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Perspective: China’s Zero-COVID Policy Is Destructive But Reopening Without A Plan Is Even Worse


 

When I lost a parent in the waning days of 2021, the first thought that came to my mind, like most, was to book the next flight home.


That was unless your parents live in Hong Kong, China.


Flights to the Hong Kong International Airport, which ranked eighth globally in passenger traffic as recently as 2018, got slashed to roughly a third of pre-COVID levels and have barely budged since. For comparison, at around 500 flights a day, Indianapolis International Airport, the nearest commercial airport to the Indiana University School of Medicine, where I currently study, has handled more flights for the second straight year.



Making matters worse, at the time, travelers were required to undergo a self-funded three-week hotel quarantine. Travelers weren’t allowed to board a flight unless proof of a designated hotel booking was presented. While the concept of requiring everyone including citizens to pay for quarantine lodging out of pocket is legally dubious, there was a surprising shortage of quarantine hotel rooms. Compounding the issue was a “circuit breaker mechanism” which would automatically cancel flights landing with either five passengers or 5% of arrivals testing positive for COVID-19-whichever was greater.


There was no way anyone could get a flight and a hotel booking at the very last minute.


After eventually landing in Hong Kong, I ended up constrained to a 200-square-foot hotel room by myself, where I attended my dad's memorial on Zoom while being forbidden to have any face-to-face interaction or leave my room.

I desperately wished I could be there to hug my family but the policy in Hong Kong was so stringent that I could only sit and cry in front of the computer screen, alone in an unfamiliar and desolate room. I can never forget how my neighbor screamed crazily in his room in the middle of the night or his incessant punching of the wall during those 21 days.


 

My experience may be unfathomable to my American peers, but such was the day-to-day life for Chinese citizens for the three years since the first recorded case of COVID-19. However, there is light at the end of the tunnel: A year after the emergence of the more contagious and less severe Omicron variant, China has finally signaled its willingness to ease its pandemic measures. These include relaxing its mandates on mass PCR testing (until this month, citizens had to get tested as often as every other day, or else they would not be allowed to use public transport or even enter stores), ending travel tracking, and permitting those with mild symptoms to quarantine at home.


After eventually landing in Hong Kong, I ended up constrained to a 200-square-foot hotel room by myself, where I attended my dad's memorial on Zoom while being forbidden to have any face-to-face interaction or leave my room.

This is a 180-degree policy turn compared to just a few weeks ago, when a commentary in People’s Daily, the largest newspaper in China and a mouthpiece of the Chinese Communist Party, reiterated the regime’s zero-COVID commitment that “Dynamic zero is the anti-epidemic strategy with the lowest overall social cost and is the best option for the timely control of epidemics.” It is likely that the changes were in response to unprecedented protests triggered by a deadly apartment fire in Urumqi, the capital of the Uyghur region. Chinese citizens and members of the Chinese diaspora, angered that COVID restrictions may have prevented residents from leaving their burning residential compound and hampered rescue efforts, held up blank pieces of paper and chanted “We want freedom!”


The Chinese people have got what they wanted, after bearing the brunt of the ridiculously high social and economic cost of zero-COVID, just like what I had gone through that winter. However, without any science-backed guidance or attempt at transparency, this transition might turn into more chaos with a tsunami wave of COVID infections overwhelming hospitals. At this critical juncture when the Hong Kong and Mainland Chinese governments are “racing against time” to resume normal cross-border travel, I find it important to take a look at what China may learn from its own failures and other countries’ missteps to ensure that they don’t repeat the same mistakes.


 

Before the relaxation of policies, China’s zero-COVID strategy began with preventing the “import” of the virus through international air travel. The regime constantly suspended inbound international flights; even after the latest pivot, travelers are still required to undergo five days of mandatory quarantine and then spend three additional days at home. During the quarantine, individuals are not permitted to leave the room for any reason.


China’s domestic zero-COVID policy had been enforced nationally along with the “Health Code”, a mobile app that indicates the user’s risk of contracting the virus with a green, yellow, or red QR code. The color designation differed by area, with green generally equaling a pass at COVID checkpoints, and yellow and red indicating varying levels of risk and quarantine mandates.


Zero-COVID was designed with short-term suffering in mind: the temporary sacrifice of basic human rights and freedoms of citizens was supposed to buy time to develop an effective vaccine, get as many people vaccinated as possible, and increase resiliency and equipment within healthcare systems.

In the case of outbreaks, local authorities enforce neighborhood, district, or city-wide lockdowns, using metal fencing to block off roads, community entrances, and even emergency exits in apartment buildings. Patients that test positive and in some cases even their close contacts are transported to quarantine centers. In a two-week period leading up to the start of the 2022 school year, at least 74 cities and 313 million people were placed under full or partial lockdowns.


Zero-COVID was designed with short-term suffering in mind: the temporary sacrifice of basic human rights and freedoms of citizens was supposed to buy time to develop an effective vaccine, get as many people vaccinated as possible, and increase resiliency and equipment within healthcare systems. The policy was indeed straightforward and effective at the beginning of the pandemic and kept case and death rates to a blip compared to the U.S. and the E.U.


However, by May 2022, World Health Organization Director-General Tedros Adhanom Ghebreyesus pointed out that “the approach will not be sustainable.” During the Omicron period, zero-COVID has shown to be more destructive to the physical and mental health of citizens than the virus itself.


A recent study looking into Hong Kong’s mandatory 21-day quarantine finds a significant effect of the week of quarantine on the level of depressive symptoms The study also suggested that poor quality of sleep, a lower sense of meaning, and a longer duration of quarantine contribute to worse mental health outcomes.


During the two-month Shanghai lockdown this spring, two out of five residents reported symptoms of depression. A surge of divorcing couples after the lockdown overwhelmed local civil affairs bureaus. Cases of domestic violence rose but women seeking support were dismissed as trouble-makers. According to a crowdsourced database, more than 200 died or took their own life due to a myriad of factors related to the zero-COVID policy instead of the SARS-CoV-2 virus: delayed or denied medical care, depression, unemployment, and overwork as nonclinical pandemic response workers.


There has been a myriad of unfortunate consequences as a result of the zero-COVID policy. Foxconn’s facility in Zhengzhou, the world’s largest iPhone assembly site, went into lockdown, forcing workers to flee the factories and walk 25 miles to get home. Additionally, to kill time and cope with loneliness, there have been reports of quarantined college students walking cardboard pets on campus. And, the tragedies continued to pile up. This November, a 3-year-old boy died of carbon monoxide poisoning as emergency care was severely delayed during the city’s month-long lockdown.


As an amalgam of draconian lockdown policies stretched into months and even years, ordinary citizens, their well-being already in shambles, are further squeezed by economic hardship.



Migrant workers were hit hard during the Shanghai lockdown, with many ending up on the streets; less than half of the urban workforce has unemployment insurance. One out of six young adults aged 18-24 is jobless. Even for the relatively well-off, horror stories of white-collar workers living within office towers for weeks at a time were widespread. This is not to mention food and medication shortages that were caused by farmers being banned from harvesting their own crops or having to watch their crops rot because there was nobody to take them to the city.


On a broader scale, the country’s financial well-being is at threat. After an initial dive in the spring of 2020, China’s GDP continued to grow as the pandemic gradually came under control. However, that modest recovery got wiped out with the advent of Omicron. The World Bank Group estimated China’s real GDP growth in 2022 to be 4.3%, dropping significantly from 8.1% in 2021. Not a single car was sold this April in Shanghai, China’s largest city.



It begs the question: if Chinese laborers were unable to get work or their daily necessities, cracks are showing in the social security system, and even municipalities are running short on cash due to the high cost of enforcing pandemic controls, then how are average Chinese citizens going to fend for themselves? Would money even solve the negative impacts of zero-COVID?


 

Moving away from zero-COVID may be a welcome sight for Chinese citizens; now that the time bought is running out though, China still appears to be wholly unprepared for what’s next. New cases of infections skyrocketed in the spring of 2022 before the most recent rounds of lockdowns, and have sharply increased right after the announced end of zero-COVID. Bloomberg reports that the Chinese National Health Commission NHC) internally estimated as many as 37 million citizens being infected with COVID-19 in a single day. An unprecedented increase in COVID infections in China gives ample opportunities for the virus to mutate, which may result in an emergence of a brand new and potentially more dangerous variant that could pose a threat to people everywhere. Not only do China’s homegrown COVID vaccines fail to provide enough protection, but the vaccination rate in China is also low when compared to other countries. Beijing not only left its people vulnerable but also the whole world.



mRNA vaccines have been proven strongly effective against the Omicron variant with effectiveness as high as 86% for three doses. In the US, people older than 50 that are completely boosted have a much lower chance of dying from COVID compared to those unvaccinated. That protection further increases with the bivalent booster which was recommended by the U.S. Centers for Disease Control and Prevention (CDC) in September. However, the two Chinese homegrown jabs, Sinovac and Sinopharm, are both based on inactivated viruses and designed to target the original COVID strain. They were pretty much useless against Omicron among participants who received two Sinopharm COVID jabs. The country has yet to approve foreign-developed mRNA vaccines for use by its own citizens or roll out its own mRNA shots, prompting concerned citizens to head to Macau, a semi-autonomous city administered by China, to get mRNA boosters targeting the original strain. Curiously, Beijing has repeatedly refused offers of Pfizer/BioNTech mRNA vaccines from the U.S. or Germany.


Not only do China’s homegrown COVID vaccines fail to provide enough protection, but the vaccination rate in China is also low when compared to other countries. Beijing not only left its people vulnerable but also the whole world.

Although the NHC claims that more than 90% of individuals aged 60 or above have received the first COVID shot, only 40% of those aged 80 or older have received an inactivated virus booster shot. Scientists have raised their major concern - dropping Zero-COVID abruptly will have little time to ramp up vaccination among older people and mass infection among old people would overwhelm national healthcare capacity. China is pushing elderly vaccination aggressively these days but they can’t ditch the deep-seated vaccine hesitancy in the elderly in a day or two, which traced back to product quality scandals from tainted infant milk formula to contaminated blood thinners, and even — you guessed it — a vaccine scandal just a few years ago affecting nearly a quarter million children in China.



Recent modeling has shown that with low levels of immunity in China, this winter wave will cause 1.55 million deaths and inundate the critical care capacity with a tsunami wave of COVID cases. Other than COVID, health experts have warned on state-run media about the circulation of flu in China this winter. The dual impact of a surge in COVID cases due to reopening and the seasonal flu peak will, no doubt, cause significant additional deaths and hospital admissions. Chinese citizens are now in pain because they have nothing to alleviate the symptoms of flu and COVID due to a national shortage of painkillers and vitamin C. China isn’t ready for reopening that soon.


And to make things worse, China has a history of opaqueness or flat-out fudging of official figures: Although the unemployment rate in China has hovered around levels comparable to that of the E.U., economists have always suspected that this has been a gross underestimate. Analysts have been sounding alarm bells about the underreporting of recent and past cases and death data. That is not to mention the regime’s outright hostility to allow impartial, independent investigations that could piece together how the initial COVID-19 outbreak spiraled out of control.


How can science-backed decisions be made if there is nothing to back up the numbers? If they had never been made with numbers in mind, then how would one know if those approaches were effective, if at all? How would anyone learn from their mistakes by eschewing a quantitative approach?


How can science-backed decisions be made if there is nothing to back up the numbers?

There’s no easy off-ramp from the zero-COVID policy, a clear exit plan is certainly needed to avoid chaos and confusion. Some epidemiologists have discussed the exit plan step by step: Approve and import foreign-developed mRNA vaccines. Raise the vaccination rate, especially for boosters among the elderly. Continue masking and social distancing. And oh, “Either report real figures or stop publishing them.” But most importantly, China should treat the pandemic as a pandemic, and treat its citizens as citizens.


 

Yezi Yang contributed research to the essay.

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Cherry Cheuk-lam Cheung

From Hong Kong, Cherry is a Ph.D. Candidate in Microbiology and Immunology at the Indiana University School of Medicine, with a minor in Policy Analysis. She has a BSc degree in Biology from Imperial College London and an MSc degree in Infection and Immunity from University College London. Cherry is a volunteer at Engineers & Scientists Acting Locally (ESAL), a national organization dedicated to increasing local civic engagement by people with STEM backgrounds, and is affiliated with the National Science Policy Network. Not only has her work been published in Nature Communications, but she also has a patent on a next-generation hair conditioner.

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