China Has an Extraordinary Covid-19 Dilemma

More than one in six people on the planet live in China. That’s 1.4 billion people who have spent the last three years in the world’s most intrusive pandemic surveillance state, designed to limit the spread of Covid-19 at almost any cost.

Americans, particularly on the right, have spent an awful lot of time and political energy complaining about pandemic overreach for the last two years. But our restrictions had nothing on China’s. In the United States, many statewide stay-at-home orders lasted just a few weeks. None exceeded three months, and most were only sporadically enforced. As protests erupted across China last month, one-third of the country was in partial or total lockdown — workers stuck in quarantine facilities, neighborhoods sealed, businesses and schools closed.

It is too soon to say whether the protests will mark the beginning of a true phase shift in China’s pandemic policy — so far, they have produced both a dramatic police crackdown and the relaxation of restrictions in some cities. But to a worldwide audience watching China with a mix of fascination and horror, mass public protest in the world’s last large “zero Covid” holdout seems to mark a global turning point. For several years now, many public health experts have acknowledged privately that the opportunity to contain and eradicate Covid-19 might have been lost as early as the winter of 2020. And for several years now China has tried to beat the disease back at the border anyway.

Remarkably, it has basically succeeded, almost entirely suppressing disease spread within the country’s borders for three years now, an effort that has put it on an entirely different pandemic timeline from most of the rest of the world. It has also made reflexive efforts to analogize the situation in China a bit suspect. Some Americans who believed our pandemic response was excessive have treated the protests as a tacit endorsement of the more laissez-faire approach we’ve embraced post-vaccines; others who might’ve argued for doing more here are also taking the protests as a sign that, in the end, compared with China, the United States got things right.

But however it may look from outside, China’s leaders are not operating in a risk landscape like the one Americans are in today, where more than 90 percent of the country has probably gotten Covid at least once and more than 90 percent of people over age 65 are vaccinated. They are looking at one somewhat more like the one we faced years ago, when immunity from vaccines and infections was substantially lower. And Hong Kong’s deadly brush with the Omicron variant this year — death rates were about twice as bad there as in Britain or the United States — may prove to be the closest harbinger of what’s to come.

Ninety percent of people in China are now vaccinated. But many fewer infections there and a low uptake of vaccines among older people — only 65.8 percent of those over 80 are fully vaccinated — means an enormous population of vulnerable, immunologically naïve people. Considerably more could still be done to protect the population going forward, such as more fully embracing imported mRNA vaccines, which seem to offer greater protection than the vaccines produced in China, and pushing even harder to vaccinate vulnerable older people. In the meantime, the risks of reopening are still large. A true reopening, however unlikely, could lead to millions of deaths.

There is no easy or obvious resolution to that dilemma, no matter how intuitive a return to normalcy may seem to those of us living in pandemic-battered parts of the world. Here a new normal was won through vaccination, to a large degree, but also through near-universal infection and mass death. So far, American Covid mortality in 2022 is below the levels of 2020 and 2021, but not that far below, with deaths this year two-thirds of those in 2020 and half as high as those in 2021. Covid-19 is on track to be the country’s third leading cause of death for the third straight year, behind only heart disease and cancer.

Something like that could well lie ahead for China, given a vaccine rollout that prioritized uptake by the young and healthy and discouraged it by the older and more vulnerable. (At first, vaccination was only approved for the young and healthy.) Exactly why they did this is still not clear, at least to international observers, many of whom may have wondered why it is so much harder for an outwardly authoritarian regime to mandate vaccination for the old, or even very aggressively promote it, than it has been to lock down entire cities for weeks at a time.

Perhaps it is a sign, like the protests themselves, that the party’s grip is less strong than we imagine it to be; perhaps that the government missed its good-will window for pushing more aggressively for shots; or perhaps it’s an indication that bodily autonomy is a different and more deeply held kind of liberty than political autonomy. Perhaps the regime distrusted its vaccines even more than the rest of the world did, or worried more about their side effects. Perhaps it was more concerned about the accumulating effect of reinfections and was waiting for nasal spray vaccines more capable not just of limiting disease severity but of stopping transmission. (Such vaccines, stuck in bureaucratic and developmental bottlenecks here, have been approved in China, though they haven’t been rolled out at scale yet.) Perhaps it was just more confident that zero Covid could work indefinitely, or so invested in the political narrative of the country’s exceptional pandemic success that a change of course was, to Xi, unthinkable.

Is it thinkable now? This week, my colleague Paul Krugman wrote that the protests were a sign that “China lost the Covid war,” emphasizing that, despite appearances early in the pandemic, democracies now seem to have definitely outperformed autocracies, and calling on Chinese leaders to recognize the error of their ways and change course. In The Guardian, Yu Jie wrote that “zero Covid can’t continue,” with reopening “the only way to quell public anger.” But personally, I would bet only on much smaller-scale adjustments, of the kind that had already been floated by Beijing in the weeks before the protests began.

That’s because the best model of what might transpire in a truly opened-up China is Hong Kong’s experience with Omicron. By mid-February 2022, there had been a reported total of just over 200 deaths in the city since the beginning of the pandemic. By mid-April, it was over 9,000. And while a much more aggressive mainland campaign to deliver mRNA vaccines to older people could lessen the death toll, the experience of other countries largely credited with doing everything right suggests that even best-case exits from the emergency phase of the pandemic can be quite messy.

Consider the experience in Japan, one of the world’s most celebrated pandemic success stories. Covid deaths there are 70 percent higher this calendar year than they were in the first two years of the pandemic combined. In Iceland, another often-cited success story, five times as many people have died from Covid in 2022 as in the first two years of the pandemic. In Australia, it is six times as many. This past January, Taiwan had registered under 1,000 deaths; today that figure is over 14,000. According to The Economist’s gold standard tracker, New Zealand is now the only nation in the world with negative excess mortality across the whole span of the pandemic — meaning that the country has had fewer deaths since 2020 than would have been expected in a world without SARS-CoV-2. And yet even there, the last year has upended some narratives: As recently as January 2022, only 52 New Zealanders had died from Covid; today the figure is above 2,000, more than 40 times as high.

In each of these countries, rapid increases in Covid mortality this year come from very low and presumably unsustainable baselines, but even so, they tell a striking story. Mitigation measures mattered, particularly until the arrival of vaccines, when vaccination mattered even more. But in any particular country the dream of actually defeating the pandemic outright — or even holding it at bay long enough to fully protect the population through universal vaccination — was no match for the disease itself. Eventually, every country got it.

Or almost every country. Throughout the pandemic, many international observers questioned the reliability of official Chinese data about the toll of the pandemic. But given the global context, that data remains pretty astonishing, even correcting for its unreliability: In January, China reported just under 5,000 total Covid deaths. Today that figure is just over 5,000. A nation of 1.4 billion registered barely 500 official deaths over the course of the year in which their pandemic policy began to crumble. In total, over three years, the country has reported only 1.6 million official infections, and while that is surely a gross underestimate, it suggests that only about one-tenth of 1 percent of the country has ever gotten sick with Covid. In the United States, a larger share of our population has died from it — nearing 1.1 million deaths in total.

That isn’t at all to suggest that China’s permanent lockdowns are a better model, or that any of the world’s major countries would or should want to trade places with China. But the binary contrast between the approaches is not as illuminating as it may seem.

In the United States, where people sometimes say “lockdowns” and mean “mask mandates” and “school closures” or sometimes just “widespread testing,” even relatively mild mitigation measures have grown politically and socially toxic. But the most obvious tools to limit ongoing spread are not especially obtrusive: investments in air quality and better workplace safety standards, paid sick leave, aggressive rollout of those nasal vaccines and an emphasis on the vulnerability of the country’s older people, who make up about 90 percent of its distressingly high ongoing deaths. In China, pandemic policy only became significantly more restrictive than it was in the United States and Britain in the summer of 2021, according to a “stringency index” calculated by the University of Oxford’s government response tracker, and the country faces tough choices now not because of how effective those restrictions have been but because of unrelated problems in vaccine rollout and efficacy.

When most of the world, armed with vaccines, pulled back from aggressive mitigation, it was in part an act of resignation — an acknowledgment that the cat was out of the bag, that the virus was irretrievably in circulation and had conferred considerable natural immunity already, and that while continuing infections were regrettable, vaccination and treatments could blunt the impact. In China, where there has been much less infection and much less death, the protests appear to express something more like pure pandemic exhaustion. By its own standards, China’s zero Covid policy didn’t really fail. But the country is running out of patience for it anyway.

David Wallace-Wells (@dwallacewells), a writer for Opinion and a columnist for The New York Times Magazine, is the author of “The Uninhabitable Earth.”