How China can pivot from ‘zero covid’ while preventing calamity

A woman undergoes a routine covid-19 throat swab at a testing site in Beijing on Dec. 5. (Andy Wong/AP)
A woman undergoes a routine covid-19 throat swab at a testing site in Beijing on Dec. 5. (Andy Wong/AP)

Amid growing unrest, the Chinese government last week signaled that it will ease the strict lockdown measures that have defined its covid-19 response for nearly three years. Ending “zero covid” in the world’s most populous nation is long overdue, but if rushed without safeguards, it could result in more than 1.5 million preventable deaths in the coming months.

That’s because only a small proportion of China’s population has been exposed to the coronavirus and most elderly residents are not up-to-date with their vaccines. Its domestically produced vaccines are not as effective as the Western-produced mRNA vaccines, which China has shunned, and the country is unlikely to accept any direct U.S. assistance.

So what should China’s road map look like moving forward? Here are four key steps:

Vaccinate the elderly. From the beginning, China’s vaccination strategy has been backward. Winnie Yip, a global health professor at Harvard University and my colleague from the National Committee on U.S.-China Relations health dialogue, explained that when vaccines were first made available, older individuals and people with chronic illnesses were told the vaccine was too risky for them. Whereas most countries prioritized the vulnerable for vaccines, China barred those 60 and older from being vaccinated for months, and many people with underlying conditions are still being dissuaded from the inoculation for fear of side effects.

As a result, while about 90 percent of the Chinese population received two vaccine doses, only about two-thirds of those 80 and older have. For the Chinese-made vaccines, a third dose is necessary to safeguard against severe illness, but only about 40 percent of those 80 and above have received it.

The government has already started a campaign to increase vaccine uptake. This is a tall order in a country where only 1 in 10 adults — and just 6.6 percent of those 60 and older — receive influenza shots. “China needs to use their very effective public education machine to message vaccines correctly”, Yip said.

Ease restrictions gradually. Removing the most onerous measures might quell protests while buying time to vaccinate the elderly. Yip supports ending mandatory testing and the practice of sending asymptomatic people to isolation facilities with harsh conditions, such as limited food and lack of heat. “The prospect of being forced into these facilities causes a lot of anger, frustration and fear”, she said.

Moreover, instead of easing restrictions for everyone, the government could encourage the young and healthy to return to normal activities while emphasizing that the elderly are most at risk and should take additional precautions. Chinese culture is steeped in reverence for older generations, so people will likely heed such guidance.

Change the goal from preventing infection to reducing severe illness and death. Yanzhong Huang, a senior fellow at the Council on Foreign Relations, is among many who have been calling on China to pivot from containing covid to mitigating its most harmful effects.

“The government’s focus has been on PCR tests, quarantines and lockdowns”, he told me. “Zero covid has marginalized the use of vaccines and treatments in policy implementation”.

The architect of the zero covid policy, vice premier Sun Chunlan, signaled last week that a change was coming. National leaders must be explicit that minimizing infections is no longer the target. Yip explains the most draconian zero covid policies, such as forbidding people to leave their buildings during earthquakes and fires, came from local officials trying to meet national expectations. It would help to redefine performance targets so that they no longer reference infection numbers, but rather hospitalizations and deaths from covid.

Shore up treatment capacity. China needs to rapidly scale up production of treatments that keep people out of hospitals. The highly effective antiviral pill Paxlovid is approved by Chinese regulators, but its supply remains limited. Another Chinese-developed antiviral seems promising, but has not yet received approval. China should stockpile treatments that reduce disease severity, including through importation from other countries, and mass-distribute antivirals in anticipation of the inevitable surge in infections once precautions are relaxed.

China must also prepare its hospitals for an influx of covid patients. The problem isn’t number of beds, but who is occupying them. I’ve seen from my own research in China that there is the expectation of hospitalization for ailments that wouldn’t meet inpatient criteria in the United States. “If only severe cases are hospitalized, hospitals won’t be overloaded”, Huang said. China doesn’t need to build more hospitals; instead, it must implement a triage system to limit hospitalization to those who need it.

It’s possible that even with these steps, reopening could result in a tsunami of infections and deaths, especially in rural areas where many people cannot access care. But zero covid is not a viable policy prescription. As Yip explains, “People’s lives have been completely disrupted. I think they are ready to hear and spread the message that you could get infected, but you’re protected by vaccines, there is treatment, and you can resume your normal life”.

She is right. China must join the rest of the world in learning to live with covid.

Leana S. Wen, a Washington Post contributing columnist who writes the newsletter The Checkup with Dr. Wen, is a professor at George Washington University's Milken Institute School of Public Health and author of the book "Lifelines: A Doctor's Journey in the Fight for Public Health". Previously, she served as Baltimore’s health commissioner.

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