China’s U-turn in its COVID-19 policy

On December 7^th, 2022, the Chinese authorities decided to lift most of the restrictions which were imposed within the framework of the so-called zero Covid policy. Immediately, media reported a huge wave which overwhelmed hospitals and morgues. The narrative goes that this situation was due to the end of the Chinese elimination strategy. Reality may be another story: it might be more about the Chinese government’s total loss of control.

Let’s return to the early months of 2020 when China struggled to tackle the emerging SARS-CoV-2 outbreak in Hubei, the province around Wuhan. From the end of January, the Chinese government adopted a rigorous – although medieval – approach which proved to be effective in containing the epidemic. While the virus rapidly spread out of China and the pandemic was declared by the World Health Organization on the 11^th of March 2020 [1], a successful elimination strategy was implemented in China and other Asian and Pacific countries. At that time there was no vaccine and little treatment available. This policy was called “zero Covid”; a demanding approach which closed borders to passengers, without slowing freight transportation. It used intensive testing when detecting the virus anywhere in a country, isolating positive cases, and quarantining all contacts. During the first two years of the pandemic, the countries which adopted elimination or active suppression approaches were much more successful in their health indicators than those which only implemented mitigation strategies. Zero Covid was associated with much lower morbidity, hospitalization, and mortality. Zero Covid was also associated with a more pleasant social life, reduced school closures, fewer and shorter lockdowns, and less frequent mask mandates [2]. And zero Covid was associated with better economic indicators, such as GDP growth rates, which were less impacted than in other similar countries adopting less stringent policies [3] (i.e., mitigation strategies). Luckily, the first variants of SARS-CoV-2 proved to be controllable through these suppression or elimination policies. However, banning travelers from leaving or entering countries was painful in democratic states. When vaccines became available, a form of a social contract was set up between governments and their citizens, requiring vaccine coverage to resume freedom of movement. In China, such a contract was never evoked. In early 2022, the Omicron variant, which was much more transmissible than previous ones, was assessed as “milder” than previous variants in South Africa, Europe, and the Americas [4]. Populations were highly immunized with both prior infections and vaccines. These Western countries progressively lifted most of their – already light – measures, such as mask mandates, working from home, or vaccine passports. Taking advantage of this experience, and because of their high vaccine coverage, all countries but mainland China gave up their zero Covid policies. They progressively opened their borders and decided to live with the virus. Australia, New Zealand, Singapore, Taiwan, Japan, and South Korea faced important waves with Omicron. They experienced increases in hospitalizations and deaths, but at levels which remained close to or even below those observed in Europe or the Americas. They “normalized” their policies with full satisfaction from their citizens. Hong Kong also changed its zero Covid policy to mitigation. However, in Hong Kong, vaccine coverage was not as high in the elderly as it was in the active adult population. Less than 60% of those aged over 80 had been vaccinated, compared to over 90% in successful countries [5]. The outcome was terrible, with a huge wave of hospitalizations and deaths [6]. When mainland China observed this situation, they calculated that one to two million people would die if restrictions were lifted [7]. So, they maintained their zero Covid policy, virtually the only country in the world to continue with an elimination strategy against Covid-19 after vaccines were deployed. In March 2022, this attitude from the Chinese government seemed understandable, partly because of the Hong Kong tragedy, and partly because of the low level of vaccine coverage among the elderly in mainland China. Surprisingly, no social contract was implemented at the time between the government and its population. We would have expected that the government would have engaged in active vaccination campaigns among the most vulnerable segment of their population. We would have expected from an authoritarian regime that incentives would have been rapidly deployed to vaccinate the elderly. But the Chinese government did not seem to foresee an end to their zero Covid policy, acting as if it would be implemented forever. There was almost no progress in vaccine coverage for the elderly up to November 2022. 60% of the population aged over 80 were not fully vaccinated when the government lifted their restrictions [8]. With the Chinese vaccine, being protected means having received three doses.

What is the narrative now? That, despite knowing their elderly people are poorly protected, the Chinese government have decided to give up their zero Covid strategy previously designed to remain for eternity? Can we believe that? We don’t. Our feeling, supported by recent WHO statements [9], is that a more transmissible sub-variant of Omicron, probably BF.7, has exploded existing barriers which were put in place within the framework of the zero Covid strategy. That was at the beginning of autumn 2022. Zero Covid means zero cases. When dealing with a couple of cases, authorities can test the whole city lock it down for a couple of days, and successfully isolate infected people and quarantine contacts. It costs money. It’s tough for the population. But it is still feasible. When you experience tens of thousands of new cases each day, as was the case in early November, you quickly become lost. Without a plan B, having never considered any alternative to the zero Covid policy, authorities lose control. Political leaders have no measures to propose nor to impose. They have just failed. After hesitating, but as soon as a political window allowed for it, the Chinese government decided to announce the withdrawal of their zero Covid policy. That was on December 7th, most probably several weeks after control had been lost. Now, Chinese officials struggle with a huge, uncontrollable wave of infections. They are also struggling with the virus overwhelming their health system (mainly based on hospitals), and a tragic wave of mortality. They may ultimately have to face the loss of the people’s trust. In the meantime, they must build a narrative. Saying Omicron is mild and vaccines are effective is not so convincing when most people see crowded hospitals and morgues; when they recognize names in obituaries of people who passed away with each new day.

What will happen from now? Nobody knows. China is “normalizing” its policy, which means “Westernizing”, which is not a good narrative in the Chinese official propaganda. Firstly, they will try to avoid too much mortality, by vaccinating their elderly people (very late, but probably very actively). This new wave of infection and mortality could provoke a surge in demand for vaccines among the elderly. Hospital infrastructure is not as good in mainland China as in Hong Kong or the Western world. There are ten times more intensive care unit beds in Germany than in China [10]. They can build hospitals in ten days, but not intensive care doctors, nor nurses to work in the ICUs. This will almost inevitably result in an enormous death toll over the next couple of months across China. An avoidable tragedy, mainly due to its government’s lack of anticipation. How will authorities react? It is not our field of competence to foresee. What we can say is that in this pandemic, lack of trust in authorities has always been associated with a poor response, with higher hospitalization and fatality rates [11]. Will it lead to new emerging strains? It could be within our comfort zones to answer here, but we all learned from this pandemic that nobody can predict new variants. Will the difference in herd immunity in China in comparison with the rest of the world lead to milder variants or more severe strains? We don’t know, and furthermore, as evolutionary pressures select for transmissibility over virulence, characteristics may be randomly determined, making it harder still to foretell what might happen. That’s unfortunate, but if we want to prepare, the earlier we are informed the better. It fully justifies decisions made by many countries to test travelers on arrival from China, and to sequence all identified viruses because these represent the only reliable window the Western world has on the situation in China. Soon after the Italian government disclosed that 52% of travelers from two flights from China were positive for SARS-CoV-2, China immediately posted a thousand sequences from various origins on the open international platform GISAID. The results were in line with those found by the Italian authorities [12]. Chinese officials are upset with Western suspicions about their lack of transparency, but how should we trust official reports from a country which has declared only 25 deaths from December 7^th to the 5^th of January, with the certainty that this is misinformation? There is much evidence about the lack of reliable data from several countries, not just China, due to a lack of transparency, trust, or infrastructure and resources. We should screen passengers and sequence viruses on arrival from all these countries, not with the ambition to block the spread of new variants but to understand the prevalence and characteristics of new variants as they emerge.

Finally, if we are really upset with this long-lasting pandemic, if we want to trust our politicians when they say “the pandemic is over”, if we would like to reduce the burden of these waves, the tensions in our healthcare system, the pandemic fatigue, long covid and post-acute Covid syndromes, and the high death toll, we could try to do more. We could try to do better. We could reduce the risk of contamination by improving indoor air quality. We should check that all our close and crowded spaces in which we spend time are properly ventilated. If we successfully made indoor air the same microbiological quality as outdoor air, we could aim to dramatically reduce the burden of variants of SARS-CoV-2, regardless of their transmissibility and virulence, whatever their immunity-evading capabilities. In addition, we would reduce the risk of catching influenza, RSV, and other respiratory viruses or airborne bacteria which also take a huge toll on our health.

Disclosure of interest

The authors declare that they have no competing interest.