The numbers that drove China's Zero-COVID policy

The numbers that drove China’s Zero-COVID policy


December 8, 2022

The numbers that drove China’s Zero-COVID policy

Niels Graham

At the start of the pandemic, several countries pursued a zero-COVID policy. Governments like those in China, Singapore, Australia and New Zealand saw the potential of an approach that focused all resources on total control and maximum suppression of the virus. Throughout 2021, as the rest of the world suffered from the rapid spread of emerging variants, people living in countries without COVID seemed to be returning to a large semblance of normal life.

Simultaneously, their COVID-related deaths were only a fraction of those recorded in the rest of the world. However, as more infectious but less deadly variants emerged, one by one, these other countries had their own outbreaks and were eventually forced to drop the policy. China, with its immense state resources and powerful social controls, has maintained its zero COVID approach.

The successful control of the number of cases has bred complacency. In 2022, other countries have strengthened their ability to manage the virus through strong vaccination campaigns targeting the elderly, new therapies and treatments, and growing natural immunity. By contrast, China’s own policy approach, such as the lockdown of its most populous city of Shanghai, has appeared increasingly chaotic and oppressive.

Zero-COVID has also become disastrous for China’s economy. For the first time since 1989, Beijing has signaled it could miss its 5.5% annual growth target, in part because of its COVID restrictions. In recent days, the sentiments of outraged citizens have turned from waves of online anger to the biggest protests China has seen in decades in Beijing, Shanghai, Shenzhen and other cities and college campuses.

So why has Beijing maintained its zero-COVID approach that has led to historic protests and a stifled economy?


On the face of it, China has pulled off an incredibly successful vaccination campaign. As of November 11, 90% of the Chinese population had received two injections, of which 63% were also receiving a booster. The United States has only fully vaccinated about 68% of its population, 34% of whom also received a booster. China’s current vaccination rate is higher than that of any major country when they started their respective openings. However, unlike other countries, including the United States, China has not been able to encourage substantial uptake of the vaccine among its most vulnerable population groups, namely the elderly.

The vaccination status of China’s elderly population remains the main obstacle preventing a safe removal of the country’s COVID restrictions. While seniors’ vaccination rates largely match the rest of the country, their booster status continues to lag. It’s particularly treacherous for Beijing, as China resists the use of Western mRNA vaccines, the backbone of the US and European health response to COVID. Instead, they rely on less effective local Chinese vaccines. As the table below shows, vaccines made in China can only match the protection offered by mRNA vaccines such as the BioNTech-Pfizer vaccine in the elderly after three doses. To prevent soaring elderly deaths, China must roll out widespread reminder campaigns to inoculate its elderly before any reduction in its zero-COVID policies.

Beijing began taking steps to address this issue in late October. Regulators have authorized the world’s first inhalable COVID vaccine which they hope will increase uptake among vaccine hesitant older adults. Following recent widespread protests, China has stepped up efforts and its top epidemic prevention body has urged local governments to focus on vaccinating the country’s elderly against COVID. However, until China is able to inject reminders into the arms of its 254 million elderly people, and especially those over the age of eighty, Beijing risks a wave of deaths if it ease restrictions.

Healthcare infrastructure

Even with an effective vaccination campaign, China’s healthcare system is not prepared to handle the inevitable nationwide COVID outbreak that will follow any relaxation of its strict COVID restrictions. Due to Beijing’s current approach, China has focused its resources on containment and failed to build the robust defenses needed to deal with severe cases during a mass outbreak. Since the start of 2020, China has invested heavily in a colossal construction campaign to build field hospitals designed to house and treat mild and asymptomatic COVID cases. This contrasts with governments such as those of the United States and the European Union which have ordered asymptomatic and mild cases to isolate themselves at home, easing the burden on their health care systems and focusing on building infrastructure and the capacity to treat serious cases. Now, as protests force Beijing to start pivoting towards reopening, the country’s health system has been caught off guard.

China lacks both treatment capacity and personnel to handle an intense COVID surge. China has 3.1 nurses per thousand inhabitants, below developing countries such as Brazil, which has 7.4 nurses per thousand inhabitants, and far from developed countries such as Germany, which has fourteen nurses per thousand inhabitants. China also lacks the intensive care beds needed to treat a flare-up. Demand for intensive care beds could reach fifteen times current capacity during a surge, according to a study published in May. While vaccination rates have improved since then, they are still not high enough to prevent hospitals from being overwhelmed.

China’s infrastructure deficit is further complicated by the country’s urban-rural divide. Rural areas have, on average, nearly 30% fewer doctors per thousand inhabitants than Chinese cities. They also still need major infrastructure investments, as evidenced by a $300 million loan the Asian Development Bank approved earlier this fall to improve public health services in the poorest rural parts of China after the first waves of COVID revealed gaps in the state health system. Worryingly, the bank’s experts identify “surges in admissions that can negatively affect patient care and overwhelm facilities” as one of the motivating factors for investment.

China may not be able to build up the necessary staffing and processing capacity in the timeframe Beijing may meet following widespread protests. But it could still turn to stockpiling antiviral and therapeutic drugs such as the drug Paxlovid to help manage a future wave of COVID.

Towards a safer exit from zero-COVID

Next winter will be the key test for Chinese policymakers. A model from late November suggests that if China were to lift the strict restrictions now, Omicron could infect between one hundred and sixty million and two hundred and eighty million people, resulting in between 1.3 and 2.1 million deaths, mostly among unvaccinated elderly.
Despite this, Beijing seems determined to move away from its zero-COVID approach. To do this safely, it must prioritize pragmatic preparations, otherwise it risks a large, deadly wave of COVID infections like the one Hong Kong experienced in the spring of 2022. When Hong Kong began to repeal its COVID restrictions, he lacked a concrete exit plan. Its infrastructure was woefully underprepared and the policy guidance provided by its government was outdated and unrealistic. For example, even at the height of its outbreak, the city continued to isolate mild cases in hospitals, exacerbating capacity issues and leaving people with serious infections underserved, leading to a spike in deaths.

Beijing appeared to learn from the city-state’s mistakes and took some initial steps to facilitate a safer exit from zero-COVID. On Dec. 6, the CCP announced new policies to speed up vaccinations for the elderly as well as a nationwide extension of rules that allow home isolation for asymptomatic and mild infections, already allowed in Beijing after that its quarantine facilities ran out of space.

China should continue to prioritize the shift from preventing the spread of COVID to dealing with severe cases. Crucial areas to watch include Beijing’s ability to roll out an aggressive vaccination campaign focused on booster shots for vulnerable groups; the approval of new vaccines that increase absorption or are more effective, such as the first mRNA vaccine made in China; the growth of the Chinese stock of COVID treatments; and updated guidance on the health risks of COVID and how hospitals and public health officials should prioritize treatment. After 3 years of zero COVID, an increase in cases may be inevitable but, with careful policy and good preparations, an increase in deaths can still be avoided.

Niels Graham is assistant director with the Atlantic Council GeoEconomics Center which focuses on the Chinese economy.

At the crossroads of economics, finance and foreign policy, the Geoeconomics Center is a translation center whose goal is to help shape a better global economic future.

Further reading

Image: Hong Kong – Jan 7, 2022: People at a mobile COVID-19 vaccination station receiving the BioNTech Covid-19 vaccine in Wong Tai Sin, Kowloon, Hong Kong. It allows residents of the neighborhood, especially the elderly, to receive the BioNTech vaccine in a convenient way.

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