China Is Unprepared for Zero-COVID’s Sudden End

Since successfully containing the first Wuhan outbreak in April 2020, China has had more than two and a half years to prepare for the end of its zero-COVID policy, which placed strict restrictions on a public increasingly tired of life under lockdowns. But Beijing hasn’t used that time wisely. The COVID-19 wave now surging across the country is hitting a deeply underprepared health care system. Streets once empty because of lockdowns are now empty because people are only venturing out to get medicine. Other countries, such as Australia, New Zealand, and South Korea, abandoned strict containment policies but were able to contain hospitalizations and deaths because they had used the time they bought for themselves to vaccinate their citizens, educate their publics, and build up health care supply chains. These countries escaped the extremely high infection rates of the first year of the pandemic in countries such as the United States despite omicron waves, putting their decision-making in stark contrast to China’s.

China’s comparative success or failure won’t be clear for years, if ever, but the picture on the ground so far ranges from disappointing to frightening. The years of the pandemic were spent shoring up zero-COVID controls to extremes, not expanding the health care system. Overconfidence and over-investment in zero-COVID measures, combined with political demands and propaganda, have left health care workers uncertain as to what to do and the Chinese public dangerously vulnerable.

Reliable numbers are impossible to obtain. The official figures are an increasingly ludicrous fiction. The withdrawal of the onerous testing system has moved China from one extreme to another, with citizens forming social media groups to work together to find testing kits which are suddenly in short supply. China maintains that there have only been seven deaths since the zero-COVID policy effectively ended on Dec. 7, even as the bodies pile up in crematoriums and fever clinics. In part, this is because of China’s extremely narrow definition of COVID-19 deaths, a policy choice that continues the country’s past undercounting of flu deaths. Virtually any pre-existing condition is being seized on to avoid classifying a death as due to COVID-19, while other fatalities are being attributed, as with flu, to “pneumonia” or “cardiac arrest” rather than the trigger of COVID-19.

Since successfully containing the first Wuhan outbreak in April 2020, China has had more than two and a half years to prepare for the end of its zero-COVID policy, which placed strict restrictions on a public increasingly tired of life under lockdowns. But Beijing hasn’t used that time wisely. The COVID-19 wave now surging across the country is hitting a deeply underprepared health care system. Streets once empty because of lockdowns are now empty because people are only venturing out to get medicine. Other countries, such as Australia, New Zealand, and South Korea, abandoned strict containment policies but were able to contain hospitalizations and deaths because they had used the time they bought for themselves to vaccinate their citizens, educate their publics, and build up health care supply chains. These countries escaped the extremely high infection rates of the first year of the pandemic in countries such as the United States despite omicron waves, putting their decision-making in stark contrast to China’s.

China’s comparative success or failure won’t be clear for years, if ever, but the picture on the ground so far ranges from disappointing to frightening. The years of the pandemic were spent shoring up zero-COVID controls to extremes, not expanding the health care system. Overconfidence and over-investment in zero-COVID measures, combined with political demands and propaganda, have left health care workers uncertain as to what to do and the Chinese public dangerously vulnerable.

Reliable numbers are impossible to obtain. The official figures are an increasingly ludicrous fiction. The withdrawal of the onerous testing system has moved China from one extreme to another, with citizens forming social media groups to work together to find testing kits which are suddenly in short supply. China maintains that there have only been seven deaths since the zero-COVID policy effectively ended on Dec. 7, even as the bodies pile up in crematoriums and fever clinics. In part, this is because of China’s extremely narrow definition of COVID-19 deaths, a policy choice that continues the country’s past undercounting of flu deaths. Virtually any pre-existing condition is being seized on to avoid classifying a death as due to COVID-19, while other fatalities are being attributed, as with flu, to “pneumonia” or “cardiac arrest” rather than the trigger of COVID-19.

The World Health Organization has called for better accounting. But China’s account is also just straightforward lying, with officials both afraid of spreading panic and worried about being blamed for the deaths. The suddenness of the switch away from zero-COVID has left local officials uncertain what numbers they should be reporting. It’s very likely, in a country whose internal data is surprisingly poor, that the central government itself doesn’t have anywhere near an accurate death count. China’s state media, especially its flagship news program, has made almost no mention of the COVID-19 wave except for brief snippets claiming everything at hospitals is fine.

As a result of both the failure to prepare and the unwillingness to publicly admit the extent of the crisis, health care workers are struggling to cope. In some cases, Chinese medical staff are calling their U.S. counterparts through personal contacts to try and determine best treatment methods. One doctor in a small northeast town with whom we spoke (who asked, like other sources, for anonymity for fear of possible political consequences) talked of soaring case numbers and hospital authorities improvising to develop triage and treatment protocols with little guidance either from government bodies or the body of literature and experience that has been developed across the world over the last three years.

She stated that the first case of the latest wave of COVID-19 she saw was on Nov. 28. Now, approximately one-third to one-half of admittees in the in-patient section of her hospital were positive for COVID-19 and about 60 percent of the staff, including herself, had caught it. “I feel like the hospital is sort of struggling because of how many workers are sick with the coronavirus,” she said.

Elective surgeries had begun to be postponed. Over the last few days, after initial attempts to divide units between COVID-19 positive and negative sections failed, hospital administrators had begun plans to empty entire units of the hospital for COVID-19 patients. These plans had accelerated not only due to the rapid spread of the virus but because government health authorities were no longer utilizing the quarantine facilities that were once central to the zero-COVID strategy. An administrative staff member at a central Beijing hospital confirmed a similar pattern, saying that since around Dec. 10, the weekend after restrictions were lifted, they struggled to find staff to cover shifts.

It is possible that the virus itself may have evolved. The doctor in the northeast said that she knew of several cases of infants less than 6 months old being infected in the last few days, and many children under 10 had been sickened. The U.S. National Institutes of Health state that COVID-19 “is generally milder in children than in adults, and a substantial proportion of children with the infection are asymptomatic.” Fever is being more commonly reported as a symptom in China than in the West, but that may be because of weaker vaccines: Unvaccinated Western patients are more likely to experience high temperatures than vaccinated ones. There are worries that the virus is becoming even more transmissible, but also hopes of it being less lethal.

It’s too early to draw firm conclusions, but that hasn’t stopped some medical authorities from trying to downplay the risk of infection. On Dec. 9, Zhong Nanshan, China’s most famous epidemiologist, said in an interview that “today’s omicron is no longer scary!” He also dismissed long COVID-19 risks, calling COVID-19 aftereffects such as fatigue, lack of strength, depression, and brain fog nothing but “subjective feelings” that would disappear over time.

That’s a contrast with the dire warnings of the zero-COVID era. In October, Liang Wannian, head of the National Health Commission’s epidemic response expert group, said that despite omicron being less lethal, it would still infect many people due to being so transmissible and cause a significant number of deaths in the same way as other virus strains. Both Liang and Wu Zunyou, the head of the Chinese Center for Disease Control and Prevention, have also emphasized the dangers of long COVID-19. Liang said that “studies have shown that a certain proportion of infected people will have various sequelae such as fatigue, dyspnea, and neurocognitive impairment.”

That’s left many people confused and uncertain as to who to trust. “I cannot believe experts and professors anymore,” commented one lay interviewee. Health care staff complained of the stress of zig-zagging policies and noted patients’ increasing fear of hospitals as sites of infection. Although it’s well-established that surface transmission is an extremely minimal risk with COVID-19, the government’s propaganda claims that COVID-19 was entering China through parcels or frozen foods from abroad have caused further confusion. On Weibo, WeChat, Zhihu, and many other Chinese social media outlets, people are posting and retweeting unverified or blatantly false information. This week, for instance, a widely circulated tip said that “many people test positive for the second time because they forgot to change their toothbrushes after they recovered, thus, they re-infected themselves.”

Another widely circulated online statement concerns different strains: Many netizens believe that the virus strain spreading in Hebei, Beijing, and other northern regions is stronger and could lead to more severe symptoms, while the strain spreading in southern regions like Guangdong usually causes milder symptoms. On Dec. 15, Zhong denied this, saying: “I am afraid there is no basis for saying where the virus strain is weaker and where the virus strain is stronger. This is only identified by looking at individual cases.”

Pharmaceutical shortages have reached critical levels, with a failure to stockpile or prepare despite the country being the largest pharmaceutical manufacturer in the world. Zero-COVID policies, which often shut down shipping, rail, and trucking, had already badly affected the pharmaceutical supply chain as well as manufacturing. There’s been almost no supply of antivirals such as Paxlovid and Remdesivir, which are not manufactured in China; there’s also been very little awareness or discussion of them until recently. A doctor we spoke with said that while her hospital was still adequately provisioned, community members were less so and were relying on social media to learn where to procure common medicines for their families. China imported a small stack of Paxlovid in March, but a Chinese firm has only just signed a deal for regular imports.

Chinese President Xi Jinping’s fixation on traditional Chinese medicine (TCM)—a pseudoscience with poor pharmaceutical safety controls—has also resulted in TCM drugs and techniques being pushed for COVID-19 treatment. While Chinese papers claim success in treatment, TCM studies are of notoriously poor quality and generated largely for commercial or propaganda purposes.

With supplies of Lianhua Qingwen, the most well-known TCM drug promoted for treating COVID-19, running low, people are turning to other types of TCM such as “anti-epidemic soup” and “Qingfei Paidu soup,” a compound that was endorsed by the National Health Commission and the State Administration of Traditional Chinese Medicine, and which won a silver prize in the 23rd China Patent Awards earlier this year.

On Dec. 10, authorities issued “Guidelines for home-based traditional Chinese medicine intervention for patients infected with COVID-19.” The guidelines not only recommend dozens of different TCM drugs for COVID-19 treatment and prevention but also suggest TCM therapeutic techniques, such as moxibustion therapy, acupuncture, and cupping, for recovery. In the past few days, the price of moxa, a material used in moxibustion, increased several times; and so has the price of canned peach, which according to some widely spread rumors can cure COVID-19.

Underlying the outbreak is a spotty vaccination record. The two-dose rate is more than 90 percent but much lower among older Chinese, especially the over-80s. Only around 40 percent of the public has received a booster shot. While some analysts have blamed the government for not pushing vaccinations more heavily, resistance to vaccination among the public is strong, despite repeated persuasive efforts by local authorities. Thanks to safety scandals in the past, China’s health care system suffers from a long-time crisis of trust.

The fragmented nature of government in a huge nation has also contributed. Older Chinese tend to live in more rural areas, and COVID-19 measures have been far tougher in the cities than in the countryside. Rather than demanding vaccination directly, city authorities, with some exceptions, have normally required proof of vaccination as part of the ubiquitous (until recently) health-code app system. Even that usually only required the first round of vaccination, not boosters. And older people who live in rural areas have often avoided the health-code app system altogether since they don’t travel.

The government has also failed to approve or import the more effective mRNA vaccines. Part of this may be the desire to promote domestic solutions and technology. But biological paranoia may have played a role too. Since well before the pandemic, Chinese military academics and other public figures have promoted the idea that the United States is developing viruses to genetically target Han Chinese. Far-right anti-vaccine conspiracy theories and Russian propaganda about biowarfare in Ukraine have also widely circulated in China. One idea commonly heard from ordinary Chinese people is that the mRNA vaccine will alter your DNA. While much of this is deliberate propaganda, people in parts of the Chinese government may also sincerely believe in such ideas.

The end of zero-COVID came rapidly and unexpectedly, and the government is clearly uncertain about how to handle the next steps. A reconfiguration of the Chinese health care system toward providing genuine information and updated care could potentially save many lives. But for the moment, chaos reigns. Chinese health care staff are as confused and worried as the public.