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China’s health system isn’t ready for the end of “zero Covid”

Millions of lives are at stake as the country prepares to relax its Covid strategy.

A man holds a test tube as he and other masked residents wait in line for their routine throat swabs at a Covid-19 testing site in Beijing, China, on December 4.
Andy Wong/AP
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

China is in the midst of its largest Covid-19 wave yet after three years of a strict zero-Covid policy. But rather than impose another round of lockdowns, the national government is reportedly considering easing the Covid mitigation measures that have governed its people’s lives since January 2020.

It is an abrupt pivot for President Xi Jinping, who has prided himself on controlling the novel coronavirus’s spread compared to the United States and other Western countries. Though Xi himself hasn’t commented on the policy changes, it’s possible that he and the rest of China’s leadership may have felt they had little choice in the face of widespread protests opposing the zero-Covid rules.

But reopening the country does not mean the risk has passed. Experts anticipate an enormous so-called “exit” wave if China permits people to continue going about their lives even as Covid-19 is spreading in the community, rather than lock down entire blocks or even neighborhoods as in the past. While there is much uncertainty about how such a scenario would play out, one projection of what would happen if the strict zero-Covid rules are lifted anticipated as many as 279 million cases and 2.1 million deaths in just three months, the dead being mostly older unvaccinated adults.

The Chinese population is more vulnerable than places where the virus has spread widely for the past few years. Though vaccination rates are pretty high, around 90 percent, the vaccines China deployed are not as effective as those used in the US and Europe. And a much smaller proportion of the population has been infected by the virus, which does confer another layer of protection for people. The virus should find it easier to move from person to person.

For most people, Covid-19 will look like it has for their peers, in terms of age and health, across the rest of the world. But China has one additional vulnerability: the elderly, among whom vaccine uptake for critical booster doses has been particularly low. In most countries, vaccination rates have been lower among younger age groups. In China, the opposite has happened — and it could make the country’s exit wave out of zero Covid more dangerous and deadly.

A fair number of those elderly people with no Covid-19 immunity would end up in the hospital if the virus spreads widely. Experts fear those hospitals wouldn’t be able to handle the surge in patients while also caring for the rest of their patients who need hospital-level care. China has invested substantially in the physical infrastructure of its health system, but its workforce is still catching up. As in the US, staff shortages as much as a lack of beds or equipment could lead to the kind of crisis triaging that leads to deaths. It already happened in Wuhan’s 2020 wave.

“It’s very easy to strain resources and crash the health system,” Xi Chen, a health economist at the Yale School of Public Health, told me. “Reopening will generate a lot of stress.”

Subway riders wear masks in Nanjing, China, on December 6. Starting this week, passengers on urban public transport will no longer be required to show proof of a negative Covid-19 test, but will still be required to wear masks, maintain social distancing, and take personal protective measures.
CFOTO/Future Publishing via Getty Images

China’s zero-Covid policy up till now has arguably been a success, with one major asterisk. Outside of Wuhan, further outbreaks had been minimal until spring waves this year in Shanghai and Hong Kong that were at that point the largest of the pandemic. Jennifer Bouey, an epidemiologist who leads China studies for the Rand Corporation, told me that, aside from the large exception of the initial cover-up of Covid-19’s existence, she didn’t think China had necessarily had a bad pandemic response.

But Covid-19, especially in its evolved form, is so highly contagious that zero Covid was never going to last forever. Hundreds of millions of people are facing for the first time the possibility of widespread Covid-19 infections in their community.

“People are worried,” Bouey, who communicates with friends and relatives in China regularly over WeChat, said. They’ve asked her if they are going to experience a big wave.

“I said yes. Every country had to go through that.”

A lot of people in China could get sick with Covid-19

To date, China has reported less than 4 million Covid-19 cases and about 16,000 people have died. (Bouey said these days she tends to trust the numbers from China, subject of dispute early in the pandemic.) The US has recorded almost 99 million cases and is now approaching 1,090,000 deaths.

Even accounting for some asymptomatic cases and other undercounting, with more than 1.4 billion people, China is home to hundreds of millions of people who have not yet been exposed to the novel coronavirus.

Most of those people have been vaccinated, about 90 percent according to the official data. But there are two reasons that isn’t necessarily as much protection as it may sound like.

First, China developed its own vaccines, which rely on dead virus rather than the mRNA technology mostly used in the US and Europe. China’s vaccines have not been as effective, according to the available clinical data. Nevertheless, Xi has refused any suggestion that his country import the mRNA vaccines that are already on the market. The Chinese state media had also, earlier in the pandemic, stoked conspiracy theories about the Western mRNA vaccines, which may have made importing them a political nonstarter.

So Chinese leaders instead insisted on the country developing its own version. But shots may not be widely available in time if the country is reopening now.

People line up to be vaccinated against Covid-19 at a gymnasium in Guangzhou, China, on December 6.
Chen Jimin/China News Service via Getty Images

Making matters worse, older people have the least protection among the Chinese population. They are the age group with the lowest Covid-19 vaccination rates, and the numbers are even lower for critical booster doses. As of August, just two-thirds of people over 60 had received an additional dose, worse than even the United States’s relatively abysmal rates and significantly below countries like Germany (around 85 percent at the time) and Japan (around 90 percent). For people over 80, the most vulnerable, fewer than 40 percent received a booster shot.

China has faced a few challenges in protecting its most vulnerable. First, older Chinese people are less likely to be vaccinated in general, with many born before the country began a major childhood vaccination campaign. Fewer than 7 percent of people in this age group get their yearly flu shot and fewer than 2 percent get the pneumonia vaccine. The Chinese health system adds obstacles because it doesn’t use primary care doctors, the physicians who are seeing these patients most often, to get people vaccinated. Patients must instead go to specialized vaccination clinics, which may be more difficult for the elderly to reach.

And seniors’ low vaccine uptake is also, indirectly, a result of the zero-Covid strategy. China could not readily test its vaccines within its borders because there were not many cases. Clinical trials in the US and Europe relied on the rampant spread of Covid-19 to evaluate their vaccines’ effectiveness. But China didn’t have that opportunity and so it had to outsource those natural experiments, mostly to developing countries.

The populations in those countries are generally younger, however, so it took longer to collect data for older age groups. That is why China rolled out its vaccine in the opposite way to almost any other country: The vaccine was authorized for younger people first and then later, once the data was in, for seniors. Experts say it created some confusion among that population about whether or not they should actually get vaccinated.“The communication wasn’t that clear,” Ben Cowling, an epidemiologist at the University of Hong Kong, told me. “People thought, ‘Previously you said I didn’t need to get it.’”

For elderly people who have not gotten the booster shots, their last shot may have been a year or more ago and, based on available evidence from other countries, their immunity is likely to have waned substantially. That raises the risk that they will develop serious symptoms, end up in the hospital, and possibly die.

There are a lot of unknowns about how this reopening might look in reality, which will dictate the extent of any exit wave. Cowling pointed out that the Chinese government could quickly revert to its stricter measures if cases start to spiral out of control. But, according to the experts I spoke to and the reports they have received from people in China, Chinese hospitals are preparing for a significant wave of infections. According to a report Bouey saw over WeChat and shared with me, “the government is planning to open up and anticipating the large increase of hospitalizations.”

Patients lie in gurneys as they wait in a temporary holding area outside Caritas Medical Centre in Hong Kong on February 16.
Anthony Kwan/Getty Images

The omicron variant already sparked the kind of major wave in Hong Kong that experts fear in mainland China. Within just a few months, 10 million people there had been infected and 10,000 had died. The health care system strained under the weight.

“There was a flood of people waiting outside emergency rooms, stuck in wards shoulder to shoulder,” Cowling said. “We know in Hong Kong what the risk is for China.”

If the Chinese health system collapses, patients would pay the price

Chinese hospitals may struggle to handle the flood of Covid-19 patients they are about to see, according to the experts I spoke to. The consequences could be grave for people infected with the coronavirus as well as other people with serious medical needs.

The country’s health system relies heavily upon hospitals. General practitioners are not as prevalent as they are in the US and European health systems, Chen said. Instead, people will generally go to the hospital for most of their health care needs. In more normal times, that may be fine — but when thousands of people descend on hospitals because they are infected with Covid-19, some of them needing serious assistance, chaos could soon follow.

China has plenty of hospital beds, experts said. Since 2010, it has built hospital buildings across the country. The problem is there are not enough people to staff them. If there isn’t a doctor on call or a nurse who can tend to patients in between doctors’ visits, the quality of care is going to suffer. Some of the hard-hit areas could live through something similar to what happened in parts of Italy in 2020, Bouey said, when people died because there was no hospital staff to treat them.

Here is the problem in crude numbers: China has more hospital beds than the United States, 4.3 versus 2.9 per 1,000 people, according to the most recent World Bank data. But China also has fewer doctors than the US (2 versus 2.6 per 1,000 people) and significantly fewer nurses (2.7 versus 14.6 per 1,000).

“You have all these hospitals, but what’s the quality of the health care?” Bouey said.

And patient care could suffer beyond the Covid-19 wards. Because the Chinese health system is so reliant on hospitals, if those facilities cannot maintain their typical standards of care, people with chronic conditions or who experience a medical emergency could end up worse off.

Customers scan their health codes before entering a supermarket in Beijing, China, on December 6. People in Beijing are no longer required to show negative Covid-19 test results before entering public places.
Jia Tianyong/China News Service via Getty Images

That is what happened in Wuhan during its initial outbreak. According to a February 2021 study published in the BMJ, people in the immediate area with diabetes and certain heart conditions (including those experiencing a heart attack) suffered higher mortality rates than patients elsewhere in China. Drugs that are critical for managing those diseases (insulin) or procedures that can avert a medical emergency (like stenting) were harder to get when the city’s hospitals were overwhelmed by Covid-19 patients.

“We saw patients waiting in long lines at the hospital, with no family doctor to call,” Chen said. “Any consideration of a quick reopening is going to give all this pressure to the health care system.”

Hospitals are doing what they can to prepare, but there are limits. Increasing the number of ICU beds by 10 percent, as the government recently ordered according to the WeChat report that Bouey shared with me, should not be a major problem. But finding the personnel for them would be. Every nurse who expected to enter the workforce through 2025 would need to work in their hospital’s ICU in order to fill the estimated 480,000 nursing positions that the country needs to staff 80,000 new ICU beds.

“This can be a major barrier,” the report concluded.

The experts I spoke to also said that adequately staffing the Chinese health system, given the recent building bonanza, would take years. While the United States has also had staffing struggles during the worst of the pandemic, Chen pointed to traveling nurses as one way the US health system could fill staffing shortages (albeit imperfectly and at significant cost).

No such reserve exists in China. They haven’t had time to build it.

There is only so much China can do to prepare for an exit wave

The country’s insistence that a zero-Covid strategy could work over the long term may end up making the exit wave worse, experts said. Countries like Australia and New Zealand that also employed zero-Covid plans were buying time to vaccinate their people and then they prepared for the reopening. But China has struggled to vaccinate its most vulnerable and it has not invested enough in building up its health system’s capacity in the meantime.

“The government was so convinced zero Covid would work, so focused on measures necessary to sustain that, that not enough investment and preparation and planning” were put into a scenario in which it failed, Cowling said.

Security guards wearing PPE stand guard outside a community in an area with residents under health monitoring or lockdown for Covid-19 in Beijing, China, on December 4.
Kevin Frayer/Getty Images

More vaccinations would help, and the government recently announced that it would particularly target people over 80 in the weeks ahead. Cowling told me that, in an ideal world, China would try to maintain its zero-Covid strategy for three more months and go on a massive vaccination campaign. But the social and political climate may not allow that.

The national government is trying to make the new normal more manageable and less disruptive for people and for the health care system. One of the changes it is expected to make is that, instead of locking down an entire apartment building or neighborhood when an infection is found, a person could quarantine at home.

But a huge number of infections appears inevitable and a small but significant share of them will turn serious. As Cowling put it to me, even a small fraction becomes a problem if the denominator gets big enough.

So the world’s most populous country faces an uncertain future. It has spent three years holding Covid-19 back, but the virus is on the precipice of breaking through. Their health care system may not be ready. The stakes are high.

“I know the wave will come once they open up,” Bouey said in our interview. When it does, Chen told me, “the health care system is not ready.”