Nearly three years after the start of a pandemic that has killed more than 6.6 million people worldwide, the official death toll in mainland China stands at 5,233 – an incredibly low number for the most populated by the world.
While most countries have long since stopped trying to eliminate the coronavirus and decided to live with it, China has gone to extreme lengths to prevent it from spreading. The government is relentlessly tracking its citizens, mandating constant testing, shutting down workers inside factories and locking down entire cities under a plan known as “zero COVID”.
Now, with its economy in steep decline and protesters taking to the streets in a rare show of defiance against an authoritarian government, the country’s leaders face enormous pressure to ease those restrictions.
But there is one major problem they will have to deal with: Zero COVID has turned China into a coronavirus powder keg.
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With epidemics scrupulously suppressed and vaccination rates lagging behind, the population is likely to have little natural immunity. If the rules were relaxed too much, experts fear the country of 1.4 billion people could experience a large-scale public health emergency, which would threaten its ability to care for the sick.
“Without a coordinated and cohesive plan, it could just lead to a rapid increase in cases, and then you find the health system is quickly overwhelmed,” said Yanzhong Huang, senior researcher for global health at the Council on Foreign Relations and an expert. on public health in China. “It defeats the very purpose of China’s response to the pandemic.”
To get an idea of what that might look like, consider Hong Kong in February. That’s when the highly contagious variant of Omicron broke through the city’s zero-COVID defenses and swept through the densely populated metropolis.
Although 72% of residents had been vaccinated against COVID-19, vaccination of vulnerable seniors was significantly lower. Less than 45% of people aged 70 and over were vaccinated when the epidemic began, and among residents of assisted living facilities it was less than 20%.
Within weeks, a huge convention center was transformed into a makeshift hospital to care for elderly patients with COVID-19. Wait times for ambulances lasted up to two days. Morgues ran out of coffins as the daily death toll rose from zero to nearly 300, though the variant often appears less dangerous than its predecessors.
Public anger and frustration aside, many citizens fear a similar scenario is unfolding on the mainland.
“Society is very divided,” said Xi Chen, a health policy expert at the Yale School of Public Health. “They’re worried about the lockdown being too tough, but they’re also worried about the government easing everything.”
When the novel coronavirus first emerged in Wuhan in late 2019, Chinese authorities were slow to recognize the threat. But once the risk became clear, the country implemented sweeping measures to stamp out viral transmission. That meant canceling international flights, blocking highways and confining entire city populations to their homes.
Within months, life in China had returned to normal as countries like the United States, South Africa and Brazil struggled to control their death tolls.
President Xi Jinping has proclaimed zero COVID as one of his greatest achievements, calling it proof that China’s governance is superior to that of the West. For a long time, it seemed like he was right, said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
“Then came Omicron,” Osterholm said. “Previous variants were like severe wildfires: they were tough, but they could be controlled. Omicron is like the wind. They can deflect it. But they can’t stop it.
Chinese officials have certainly tried.
Authorities require daily or near-daily coronavirus tests to immediately identify infections. The single-digit number of cases has led to prolonged lockdowns. As new cases hit record highs, 95 of China’s top 100 cities by economic output had COVID restrictions in place as of Nov. 22, according to Beijing-based research firm Gavekal Dragonomics.
Under the most severe closures, citizens have struggled to obtain sufficient supplies of food and medicine. The measures have also weighed on the economy, closing businesses, disrupting factories and stifling consumer spending.
The government continues to tout the low death toll in the country, which does not include Hong Kong. Although the official tally is debated, experts agree that China’s COVID-19 death rate remains one of the lowest in the world.
But that success did little to quell the growing outrage. For many, the costs of such an inflexible policy have been crystallized by events such as a bus crash in the southern province of Guizhou that killed 27 people who were being transported to a subzero COVID quarantine facility. Or the fact that anxious residents of Sichuan province were banned from leaving their buildings after an earthquake that killed at least 93 people. Or the death of a 3-year-old boy in Gansu province who succumbed to carbon monoxide poisoning after lockdown health workers prevented his father from calling an ambulance.
The straw that broke the camel’s back was an apartment fire that killed 10 people last week in Urumqi, the capital of the Xinjiang region that has been in lockdown for more than three months. Angry citizens believed zero COVID checks were preventing residents from fleeing and preventing firefighters from reaching the burning building in a timely manner.
Over the weekend, vigils for victims in Urumqi erupted into mass protests across the country, with many participants complaining about China’s zero COVID policy and even the Communist Party and President Xi.
Although the government moved to quickly quell the protests, there are signs that public dissent has put more pressure on party leaders to come up with a zero COVID exit plan.
It’s unclear exactly what that would entail, but authorities reaffirmed a major priority on Tuesday: increasing vaccination rates among the elderly. While 90% of Chinese people were fully immunized in mid-November, the National Administration for Disease Prevention and Control says only 66% of people 80 and older were fully immunized, and only 40% received a reminder even if doses are widely available.
Increasing immunity in the elderly is vital as they are most vulnerable to severe COVID-related illnesses. In Singapore, for example, 99% of deaths from the pandemic have occurred in people over the age of 60. In England, this age group accounts for 92% of deaths.
Vaccine skepticism has been widespread among older people across China since the first vaccines came out, said Winnie Yip, director of the China Health Partnership at Harvard’s TH Chan School of Public Health. She attributed this to the fact that the country’s first two COVID-19 vaccines were only available to adults under the age of 60.
“The general perception that the government gave people was, ‘We’re not sure about the vaccine yet, so maybe older people shouldn’t take it,'” Yip said. “Older people in general feel that because they’re older, they shouldn’t be at risk from the vaccine.”
China also cannot rely on citizens who are highly immune to past infections. The country’s frequent coronavirus testing and use of mobile health codes that record travel history and close contacts identify people with asymptomatic infections before they have a chance to spread the virus too widely.
The upshot is that if China’s tough zero-COVID restrictions are lifted, the healthcare system could be overwhelmed with patients in need of hospital beds. The country has around 4 intensive care beds per 100,000 people, according to the study’s estimates and official comments. That compares to 27 intensive care beds per 100,000 people in the United States, according to the Kaiser Family Foundation.
Even offering a little slack in the current conditions could allow things to spiral out of control quickly. During an outbreak fueled by Omicron in Shanghai in the spring, a trial of looser restrictions led to overwhelmed hospitals and aged care facilities, prompting a two-month lockdown in the city of 25 million people. Residents confined to their homes have complained of dwindling food and medical supplies, while others have been forced to spend weeks in quarantine facilities, which has sometimes meant parents have to be separated from their children .
“Cities are now in a dilemma because they want to use a softer hand, but it’s not working,” said Ben Cowling, an epidemiologist at the University of Hong Kong.
Until China increases its immunization rate for the elderly, improves the effectiveness of its vaccines and treatments, and strengthens its medical resources, it cannot afford to loosen its grip on zero COVID.
“If they had any of these three elements in place, it would significantly change the risk calculation,” said Andy Chen, senior COVID analyst at Beijing-based consultancy Trivium China.
But for now, China lacks all three.
Yang reported from Taipei and Healy reported from Fairfield, Conn. David Shen of The Times’ Taipei bureau contributed to this report.
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