A haunting video that went viral last week showed residents of Shanghai screaming from high-rise windows into the night—a collective complaint about the harsh COVID-19 lockdown the city’s 26 million inhabitants have been under since the end of March. Many have had trouble obtaining food, essential medicines, and daily necessities. Tens of thousands who have tested positive for SARS-CoV-2 in China’s worst surge since the start of the pandemic are isolated in crowded halls and convention centers outfitted with cots in cubicles, without showers. Authorities have separated infected children from their parents. Media have reported deaths among non–COVID-19 patients denied health care.
But the Chinese government is not budging. Although the country’s public health experts have worked quietly on steps toward coexisting with SARS-CoV-2, like much of the world has begun to do, President Xi Jinping reiterated on 13 April that the country must persist with what is now called “dynamic clearing.” “I believe China is preparing for an eventual reopening, but before the point when it is ready to relax, the best way forward remains to insist firmly on dynamic-zero [COVID-19],” says Zhangkai Cheng, a respiratory specialist at Guangzhou Medical University.
But the costs are growing, and even if they outweigh the benefits, Chinese politicians may see no way to pivot, observers say. The COVID-19 response has become “not so much a public health or public policy issue as a political issue,” says Yanzhong Huang, a global health specialist at the Council on Foreign Relations, a U.S. think tank. Minimizing cases trumps consideration of the “rapid, exponential increase in the social and economic costs,” he says. “It has become an undebatable political decision,” adds Xi Chen, a public health scientist at the Yale School of Public Health.
China’s devotion to “zero COVID” reflects a fear of an explosion of serious illness and death if Omicron variants of SARS-CoV-2, now largely one called BA.2, escape control. More than 2 years into the pandemic, the country is still not fully prepared; China’s leadership has squandered the grace period it earned with the zero COVID strategy, Huang says. “Until November last year, there was no serious effort to prioritize the vaccination of the elderly,” he says. Nor did the country use the time to improve the health infrastructure in rural areas.
But whether China can still get back to zero, as it did after the world’s first COVID-19 outbreak in Wuhan in 2020 and with every other appearance of the disease elsewhere, is uncertain given Omicron’s transmissibility. Despite the lockdown, the number of reported new cases in Shanghai has soared to a record of 28,145 cases on 13 April. (On 14 April, new cases declined to 23,072.) The lockdown has been extended indefinitely. Other cities have entered partial or complete shutdowns as well.
The good news is that Shanghai’s epidemic appears to be mild so far. Roughly 90% of cases are reportedly asymptomatic, and by 14 April, the city had reported only nine patients with severe illness and not a single death. In all of China, there have only been two reported COVID-19–related deaths so far this year, amounting to a case fatality rate lower than that for influenza, according to a 5 April letter in Nature Medicine by Ji-Ming Chen, an epidemiologist at Foshan University, and a colleague.
Whether the numbers tell an accurate story is unclear. The large number of asymptomatic cases is partly because Shanghai is testing all its residents periodically, catching many infections that would fly under the radar in other countries. But Huang suspects Shanghai officials are also counting some cases with only coldlike symptoms as asymptomatic. One incentive for doing so is that they can be sent to the makeshift isolation centers instead of hospitals. (Isolating all infected people outside their homes adds to the social and economic burdens of the lockdowns, however, and many public health experts within and outside China have urged that this requirement be relaxed.)
As to severe cases and deaths, local media have raised questions about unexplained deaths at several Shanghai nursing homes. Still, Chen believes the numbers are “largely reliable.” He says severity is low because most infections so far seem to have been in younger people and because Shanghai is still in the initial phase of its outbreak. Also, identifying infections early allows for timely treatment that can forestall serious illness. “If infections spill over to sizable older populations, the results will be very different from what we are seeing now,” and more similar to Hong Kong, Chen says. That city recorded the world’s highest death rate in mid-March, in part because many older people had foregone the vaccine.
Mainland China has a similar problem. Airfinity, a London-based health analytics firm, reported that nearly 19% of Chinese people over age 60 were unvaccinated as of mid-March. Among those in their 80s, just over 50% have gotten two shots and only 19% have received boosters, Zeng Yixin, deputy director of the National Health Commission, reported at an 18 March press briefing. (Across all ages, the picture looks much better, with 88% of the population fully vaccinated and about 51% having received boosters.)
The low vaccination rate in the elderly could spell disaster. If Omicron spreads throughout China, it could cause 1 million deaths in 3 months, Airfinity estimates. In contrast, Australia, New Zealand, and Singapore exited zero COVID after only 1.2%, 0.6%, and 0.4%, respectively, of their over-60 population were unvaccinated. They have seen relatively few deaths as a result.
Why China did so much worse is puzzling. Several observers say China’s leadership painted itself into a corner by touting the success of zero COVID and not preparing the public for a transition to living with the virus. Because of safety concerns when COVID-19 vaccines first became available, “only nonelderly adults were asked to take injections,” Cheng says. And vaccine hesitancy continues. “One question I frequently get asked is: ‘My parents are 80 years old [or] have hypertension-diabetes, is it safer for them to vaccinate or not vaccinate?’” he says.
“Hesitancy among older adults is somehow rational in the context of a zero COVID strategy,” says University of Hong Kong (HKU) epidemiologist Ben Cowling. “If a vaccine has minimal but nonzero risk, whereas the risk of COVID infection might be expected to be minimal, some may prefer to take their chances with the virus.”
Now that this calculation has changed, China is pulling out all the stops to catch up. Some communities are sending vaccination teams door to door to persuade senior citizens to get the shots. Guangzhou is giving a 500 yuan ($78) gift card as an incentive, Cheng says.
A study by an HKU group provided some reassurance about the effectiveness of the inactivated virus vaccines used in China, which has not authorized the messenger RNA (mRNA) shots used in many other countries. The team found that two shots of the BioNTech mRNA vaccine showed notably higher effectiveness than the Sinovac-CoronaVac inactivated vaccine among adults 60 and older, but that three doses of either vaccine offered very good protection against severe illness and death.
China’s plans for exiting its zero COVID stance are still in development. Among the measures China needs to make the shift this year, Chen and his colleague wrote in their Nature Medicine letter: expanding the use of online health consultations, training health care workers to better treat mild COVID-19 cases, and stockpiling antivirals.
But few are willing to wager when the transition will occur. “There is no indication that the central government has begun to prepare for a coexistence strategy,” says Xi Lu, a National University of Singapore specialist in Chinese economic policy. “I speculate that China will continue to implement the wrong policies for a long time; and with each day of delay, the transition will become more difficult.”
With reporting by Bian Huihui.