How China's vaccine strategy stoked its looming 'zero covid' crisis
China's zero-covid pandemic strategy may have saved millions of lives and postponed an inevitable reckoning with the coronavirus. But now the country is staring into the face of a crisis: an implacable virus, an under-immunized population, a stubborn political system locked into vaccine nationalism and a restive citizenry tired of lockdowns.
China's decision to stick with its own domestically produced vaccines means it has not availed itself of what many experts believe is the most effective and flexible vaccine technology - a potentially consequential move in a country with large numbers of vulnerable people who have never had a booster shot.
President Xi Jinping and his advisers have so far shunned the messenger RNA vaccines developed in the West. Experts are divided on the full implications of China's vaccine nationalism. But most agree that bringing in a foreign booster now - even one tailored to target omicron in addition to the original strain of the virus - would not address the core problem China faces, which is a large population of older people who have resisted a third shot of any vaccine.
"China merely adopting mRNA covid vaccines will not solve their covid problem," said Celine Gounder, a senior fellow at the Kaiser Family Foundation and an infectious-disease specialist. "The real question is how to get China's elderly vaccinated." That is a huge challenge, she adds, because trust in the government's covid policies is at an all-time low.
China is now an outlier among developed nations because of its refusal to use the two most popular mRNA vaccines, one developed by Moderna and the other by Pfizer and its German partner, BioNTech. The lower efficacy of the two key Chinese-made vaccines became a concern early in the pandemic, when global health experts suggested adding a third shot to protect older people. Vaccines from two companies, Sinovac and Sinopharm, are based on an inactivated form of the virus. The mRNA vaccines, by contrast, instruct the body's own cells to build a replica of a key coronavirus protein to trigger an immune response.
Still, based on numbers alone, Beijing's pandemic strategy, including a "zero covid" tolerance, might look like a tremendous success: China has had a tiny fraction of the deaths and illnesses that the coronavirus has inflicted on the rest of the world. The country's ability to suppress the virus is particularly striking compared with the United States, which has one of the highest per capita death tolls in the world.
The challenge now is finding the off-ramp.
China's strategic gambles during the pandemic were once a point of pride for Xi, because they have suppressed viral transmission and greatly reduced the level of sickness and death. The government officially counts just over 5,200 total deaths from covid - an astonishingly low figure. But the earlier successes in crushing the outbreak may have come with a cost. The country is dealing with an angry citizenry, a population with low natural immunity and a virus that has become even more transmissible as it has mutated.
Throughout much of the pandemic, Beijing touted its tight controls and low fatality rates as proof of the success of Chinese-style governance, which stood in sharp contrast to the looser, scattershot U.S. response that was largely controlled at the state and local level. In America, the pandemic incited protracted political and cultural rancor and left a lot of empty chairs at holiday dinner tables in the wake of more than a million deaths.
Even with access to mRNA shots, and with a layer of underlying natural immunity from infections, the omicron variant last winter arrived like a hurricane and caused a major surge of infections that clogged hospitals and led to more than 2,000 deaths every day for roughly four weeks.
Beijing's messaging about zero covid was well received domestically and proved critical in cementing public support in the lead-up to the 20th National Party Congress, where Xi grabbed a norm-breaking third term. But frustration with continued draconian lockdowns has been building among the Chinese public, particularly as a largely maskless world returns to normal. That has increased pressure on Chinese officials to engineer a nimble exit from zero covid. Those pressures have intensified amid unprecedented hot spots of unrest across the country.
Zero covid "was one of the best strategies at the beginning of the pandemic," said Xi Chen, an associate professor of public health at the Yale School of Public Health. The extreme restrictions reflected unknowns about the new virus at the time. But the policy did not evolve - unlike the virus - and officials "were not adapting to these new variants," he said.
News of protests of the zero-covid policy is strictly censored inside China. The nation's leaders have loosened restrictions in multiple cities, but have been careful not to link the changes to the unrest.
Health officials on Tuesday also announced a new plan to address lagging rates of booster vaccinations among the elderly. Only about 40 percent of people 80 and older have received a booster, while about 69 percent of people 60 and older are boosted.
On Thursday the Chinese newspaper Caixin reported that local officials have been directed to ensure 90 percent of people ages 80 and older have at least a first shot. Officials have also been asked to ensure that 95 percent of people ages 60 to 79 have boosters by the end of January.
Older people are most likely to suffer severe illness. But unlike in other nations, China put people in this age bracket at the back of the line when vaccines rolled out. People older than 60 were barred from receiving the vaccines in China until March 2021, and uptake was initially sluggish.
Older people were also underrepresented in key clinical trials that demonstrated the efficacy and safety of vaccines. That made some doctors hesitant to recommend them to their elderly patients, Chen said.
Many of these patients were already wary of the government's vaccines for other diseases. Studies conducted before the pandemic found that only 6.6 percent of older Chinese people received influenza shots, and just 1.2 percent received pneumonia shots.
"When I took the first [covid] vaccine, I had some symptoms, like I felt faint, so I will not do it again unless I understand more about the risks," 73-year-old Chen Zhigang, a Beijing resident, told The Washington Post. He has turned down additional doses of the vaccine despite being part of a government-organized volunteer group that went door to door urging people to get vaccinated in early 2021.
He added that two of his elderly relatives in rural Hubei, the province where the virus was first detected, were offered coupons for discounted groceries in return for taking the vaccine, as local officials faced pressure to meet quotas.
This distrust of vaccines has put China in a precarious situation. Many of the most vulnerable people are under-vaccinated, and with a somewhat less effective vaccine than Western options. China's 1.4 billion inhabitants are desperate to return to normal life, but a sudden move to lift all restrictions could unleash a wave of infections.
"China has painted itself into a corner," Andrew Noymer, an epidemiologist at the University of California at Irvine, said in an email. "The idea that the covid pandemic will be the 1918 flu, and that countries can just 'hunker down for a year,' has proven to be a mirage."
What happens next is unclear, but most experts agree that suddenly loosening restrictions would result in a public health disaster.
A research paper published in the journal Nature Medicine in May warned of a "tsunami" of infections from an omicron variant if China's stringent restrictions were relaxed. The scientists projected that, based on the vaccination rate in March 2022, there would be a need for more than 15 times the number of intensive care beds in the country at the omicron peak. They projected that a bed shortage could last 44 days. Modeling showed that such a wave would result in about 1.55 million deaths.
A Chinese official, speaking on the condition of anonymity because of the sensitivity of the matter, told The Washington Post that confidence nonetheless remains high in Beijing.
"The trust in our country's strategy is the same. There's no fundamental change in this dynamic strategy. It has proven successful for the health and well-being of all Chinese people," the official said, while declining to comment on recent protests in the capital.
The government's strategy has in part been affected by the experience of Hong Kong, which - like mainland China - cemented a formidable zero-covid strategy early in the pandemic, enjoying few cases despite relatively low vaccination rates among the elderly. But when the city's defenses were breached in late 2021 by a spiraling outbreak, hospitals were slammed and fatality rates shot to one of the highest levels in the world at the time.
"Especially for the elderly, the epidemic in Hong Kong has taught us a particularly profound lesson," Wang Hesheng, vice minister of China's National Health Commission, said in March, when authorities began a fresh push to vaccinate people older than 60.
In the United States, public health experts and Biden administration officials are cautiously optimistic that a winter surge will not reach the severity experienced in previous years. Most people are vaccinated, and many have recovered from a bout with covid. The overall level of immunity in the population reduces the chance of a dramatic spike in hospitalizations and deaths.
This contrast between the West and China has led some experts to focus on the differences between the vaccines available in each nation.
Many countries that started out with Chinese-made vaccines have since added mRNA shots to their arsenal. The underlying technology is flexible and fast and can be rapidly updated to match circulating variants.
Moderna and BioNTech have both been in negotiations to provide vaccines to China. BioNTech has an agreement from December 2020 to provide 100 million doses through a partnership with Shanghai Fosun Pharmaceutical Group. But that vaccine has never received Chinese regulatory approval. BioNTech spokeswoman Jasmina Alatovic said that BioNTech's chief executive, Ugur Sahin, visited China in November and discussed allowing the vaccine for foreigners living in China, but that no formal authorization has yet occurred.
The Financial Times reported that Moderna's talks broke down because Chinese officials wanted the company to not only provide doses, but hand over intellectual property - the know-how to make the vaccine. Moderna officials did not respond to requests for comment.
Many experts think it is unlikely that President Xi, who has invested so much in a nationalist vaccine strategy, will allow Western vaccines to be used. Less clear is whether the difference in effectiveness would even help China climb out of this hole, given that new boosters designed to target omicron appear to offer only modest protection against infection.
No currently available vaccine anywhere on the planet provides a robust shield against mild infections. Vaccines cannot stop the virus from spreading, and when it does, it finds vulnerable people. Infectious-disease experts may disagree on many elements of pandemic strategy, but they agree this virus is not going to be eradicated.
"I don't think [making foreign mRNA vaccines available] would make a difference in uptake, and the difference in efficacy is not that great," Ben Cowling, an epidemiologist at the University of Hong Kong's School of Public Health, said in an email.
A study published in July in Lancet Infectious Diseases suggested that with three shots, protection with the Pfizer-BioNTech shot or the Sinovac vaccine was extremely high against severe illness or death. But another study in Brazil found that protection against severe illness eroded after three months in people who received a Chinese booster.
Kathleen Neuzil, a member of the expert group that advises the World Health Organization on immunization strategy, said there has not been enough data on the real-world performance of the vaccines from China over time to determine whether messenger RNA vaccines would offer a significant benefit over additional shots of already available vaccines. She called it "an unanswerable question at this point."
Infectious-disease experts agree that China cannot safely exit from its zero-covid policy until it manages to greatly increase its rate of booster shots.
"We have to admit that the policy was a success early on and saved lives, but it cannot be sustained, and they do not have a plan B," said epidemiologist Ali Mokdad of the University of Washington's Institute for Health Metrics and Evaluation. "The government did not plan for a move out of this policy, so they are stuck with it. If they open up, they will have lots of deaths and hospitalizations."
"Literally, there's only one way out," said Lawrence Gostin, a global health law expert at Georgetown University. "That way out is highly effective vaccinations, with a wide uptake among elderly populations. Right now, [Xi] has neither."
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The Washington Post's Christian Shepherd contributed to this report.
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