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After three years of implementing its “zero-COVID” strategy, China has dropped all COVID restrictions. In the weeks since, COVID-19 cases, hospitalizations, and deaths have skyrocketed in a country with low immunity and limited resources to address the current surge.
In this Q&A, adapted from the January 25 episode of Public Health On Call, Stephanie Desmon talks with Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security, who explains why China’s policies were destined to fail and why China in 2023 could look a lot like the U.S. in 2020.
COVID was first found in China. It caused a lot of disruptions early on, but the country has a unique COVID policy. Can you explain how China has been dealing with the virus until recently?
China has moved from two different opposite poles of policy, neither of which was correct. Their first policy—called “COVID-zero” or “zero-COVID”—involved authoritarian measures aimed at eliminating the virus.
For a respiratory virus like SARS-CoV-2 that spreads efficiently through animal hosts, that type of containment strategy just isn’t sustainable. The COVID-zero policy simply didn’t respect the biology of the virus.
When you talk about the biology of the virus, do you mean that you can’t just lock the doors and hope it goes away?
That’s right. Certain viruses—smallpox, for example—can be eradicated from the planet. But SARS-CoV-2, the virus that causes COVID-19, comes from a family of viruses that causes about 30% of our common colds. Those relatives of SARS-CoV-2 are able to evolve and escape immunity, which they do all the time. This is a virus that cannot be removed once it has established itself in the population.
For respiratory viruses like this, rather than try to eliminate them, you have to instead fortify resiliency in the population.
And when you say fortify, you mean vaccination.
Vaccination is a major aspect of it, especially vaccinating high risk individuals with very potent vaccines that are highly effective. Other pieces of the puzzle include antiviral drugs like Paxlovid, expanding hospital capacity, and teaching the public how to calculate risk.
The virus is not something that will be eradicated or eliminated; people in China—and around the world—are going to be dealing with COVID in 2023 and in 2043. SARS-CoV-2 is going to become one of the respiratory viruses we [will always] contend with, so you have to teach people how to calculate risk.
How do you teach people how to live with a threat that they didn’t have in 2019? You have to acclimatize them to it. We have an understanding of how the virus spreads, and we’ve laid out the tools we have to mitigate it: masks, moving gatherings outdoors, vaccines and boosters, antivirals, rapid tests, etc.
China didn’t do that. Until now, they were basing their strategy on a flawed assumption that the virus could be eliminated and then everything was going to snap back to 2019, and that’s not the case.
It seems like the population was set up by three years of basically lockdowns upon lockdowns. Do we know if it worked at all by reducing the number of COVID cases and deaths?
I think in the end, they were always going to have waves of COVID. They were just kind of kicking them down the road.
The best approach for China’s lockdown strategy would have been to pair it with other tactics: vaccinating high risk populations with highly effective vaccines, making rapid tests and antivirals available, and ensuring [availability of] ICU beds and ventilators. Instead it’s like they ripped off a Band-Aid, and now they’ll likely face similar issues that other countries did in the pre-vaccine era.
So after ending lockdowns and testing, China now has a real crisis on its hands. It’s seeing a spike in infections, hospitalizations, and death. What does that mean for China? And what does it mean for the rest of the world?
In China, we’re going to see a lot of preventable deaths and a lot of preventable disruption to people’s lives and the economy. I don’t think that this changes the trajectory of the pandemic in the United States or any other place, because we have so much immunity in our population from prior infection, vaccinations, boosters, and combinations of those three.
The U.S. will probably see supply shocks and issues because much of our economy is dependent upon supply chains that extend into China. Travel restrictions could also affect people who travel to China and need a negative test to return.
Let’s talk about vaccines. China had its own vaccine. A lot of people got two doses, and it was later determined three doses were needed. So it would stand to reason that they would go back out and try to vaccinate people. Is that what’s happening?
The Chinese vaccine does have some effect, but it appears to wear off quickly if you only get two doses of it, especially if you’re at higher risk. China’s early vaccination campaign, however, did not emphasize the importance of vaccinating the elderly, many of whom are already very vaccine-hesitant and therefore have not received their third doses.
The EU has also offered free supply of the more effective Pfizer-BioNTech vaccine to China, but it’s been deemed illegal for Chinese citizens to receive it. That’s why you see people fleeing to Hong Kong and Macao to receive Western vaccines.
What do we think the numbers are going to look like in China in the coming weeks?
They are currently reporting a total of around 60,000 deaths, and they keep revising that number upward. You have to assume that with a virus like SARS-CoV-2, the more contagious omicron variants, and the lack of vaccine protection in China’s high-risk populations, that the country’s whole population will be infected.
I don’t know where China’s numbers will ultimately land, and I don’t know that we’ll actually ever get accurate numbers.
What do you see going forward in China?
Like everywhere else, COVID will come and go. We’re already seeing indications that cases may have peaked in major cities, but that’s going to happen at different times across the country. Omicron will likely leave a lot of death and destruction in its wake, and then the population will have resiliency. Unfortunately, they squandered two and a half years to build that resiliency.
Stephanie Desmon, Johns Hopkins University Bloomberg School of Public Health