China’s aggressive “zero COVID” strategy has served it remarkably well. The country has reported fewer than 154,000 cases and 5200 deaths from COVID-19 so far, a tiny fraction of the figures in the United States. But as the highly transmissible Omicron variant seeps into the country and the social and economic costs of the zero COVID policy mount, Chinese researchers are examining options for coexisting with the virus, as the rest of the world is doing. Some think that shift may soon begin.
It will be a momentous decision, and the country is sure to proceed cautiously. China wants to avoid COVID-19 outbreaks like the one now overwhelming Hong Kong, which reported more than 34,000 new COVID-19 infections and 87 deaths on 28 February alone. Modeling by researchers at the University of Hong Kong (HKU) predicts that toll will climb rapidly. Yanzhong Huang, a global health specialist at the Council on Foreign Relations, a U.S. think tank, says until recently he believed China might introduce more flexible measures as early as this month. Now, “It is very likely that Chinese leaders may wait till the dust settles” from the Hong Kong crisis, he says. Xi Chen, a public health scientist at the Yale School of Public Health, says China needs more time—up to 1 year—to further raise vaccination and booster coverage, especially among the elderly, and bolster rural health care capabilities.
China’s zero COVID policy has relied on mass testing, contact tracing, isolating the infected, restrictions on international and domestic travel, and lockdowns of entire cities. The system has helped China stamp out every outbreak so far, including several of the Omicron variant since mid-January. But outbreaks are becoming more frequent and widespread. On 25 February, the National Health Commission reported 93 confirmed cases of local transmission in 10 provinces, despite the burdensome countermeasures. Shenzhen, which borders Hong Kong, recently closed museums, libraries, many parks, and beaches in response to an uptick in cases. Apartment compounds face lockdowns if even one resident tests positive. Most people must get tested every 48 hours.
“The huge inconveniences and difficulties imposed upon people’s livelihoods and lifestyles may be turning the wheels of the Chinese policy machinery to consider some kind of policy adjustment,” China political analyst Chen Gang of the National University of Singapore (NUS) wrote in a February commentary for Channel News Asia. And COVID-19 countermeasures started to dent China’s economic growth in the second half of 2021, says Xi Lu, an NUS specialist in Chinese economic policy. “All of the economic indices point to a continued decline,” Xi says. “There will likely come a point when the costs [of zero COVID] outweigh the benefits,” says Zhangkai Cheng, a respiratory specialist at Guangzhou Medical University. “Whether that point has arrived is up for debate.”
Under what’s now called “dynamic zero COVID,” localities have leeway to “tailor the measures to local conditions,” says HKU virologist Huachen Zhu. But the national government is pushing back at what it considers unnecessary local restrictions. On 18 February, the National Development and Reform Commission, which manages economic affairs, told local governments to avoid arbitrary lockdowns and barred unauthorized closures of restaurants, supermarkets, tourist sites, and cinemas. The Chinese Center for Disease Control and Prevention is studying changes to existing control measures to “ensure normal international exchanges and economic development,” its chief epidemiologist, Zunyou Wu, said at a 15 February forum in Beijing.
But the situation in Kong Hong shows why caution is needed. The semiautonomous city of 7.4 million followed its own zero COVID approach that eschewed citywide lockdowns. It worked relatively well through December 2021, but with the arrival of the Omicron variant, cases have soared, in a population where many vulnerable people have not been immunized. Although vaccination coverage overall is at 76%, only 46% of people in their 70s and 29% of those in their 80s were fully vaccinated. Many elderly were alarmed by early reports of side effects and felt confident in the city’s ability to keep the virus at bay. Deaths are concentrated among those who shunned vaccination, says HKU virologist Jin Dong-Yan.
The city now plans to test every resident three times in March to identify cases and may resort to limited or even citywide lockdowns. But HKU modeling suggests things will get worse before they get better. If social distancing measures stay the same—meaning restaurants stop serving after 6 p.m. and gyms, bars, and hair salons are closed—4.6 million Hong Kong residents will have been infected by mid-May, the models suggest. More than 3200 will have died.
Epidemiologists say China, too, will face a wave of infections during any transition. In places that lack community health clinics or general practitioners, even those with mild symptoms are likely to rush to hospitals, and “medical resources will quickly be exhausted,” Xi says. Although the vaccination rate now tops 87%, and more than 550 million people have received boosters, vaccination of the elderly lags, especially in rural areas. And with many Chinese vaccines relying on inactivated virus rather than the messenger RNA technology common in the West, it’s unclear how fast their protection wanes or how well they will fare against new variants, says immunologist Rustom Antia of Emory University.
Given the high stakes, many predict China’s leaders will proceed cautiously. Huang envisions steps such as reducing the length of quarantines and putting fewer contacts into isolation. Yale’s Chen thinks China might first open up one city or region as a test case.
China’s big leap may affect the rest of the world as well. Unleashing COVID-19 on a population of 1.4 billion means a lot of people “will be brewing the virus,” says Gabriel Leung, HKU’s dean of medicine. That will provide ample opportunity for new variants to emerge. “It’s not just a national problem, it’s actually a global issue,” Leung says.
With reporting by Bian Huihui.