In China, zero-COVID policy to zero COVID policies

As the virus spreads through China’s population, Ananth Krishnan reports on the timeline of how three years of stringent restrictions and checks suddenly gave way to an abrupt and messy end, leaving the healthcare system in chaos

Updated - January 07, 2023 09:03 am IST

Published - January 07, 2023 02:16 am IST

People receive medical attention at a fever clinic in the Changning district in Shanghai.

People receive medical attention at a fever clinic in the Changning district in Shanghai. | Photo Credit: AFP

On December 20, almost two weeks since China’s sudden and unexpected scrapping of its stringent “zero-COVID” policy, the country officially reported a little over 3,000 COVID-19 cases. The real number of cases that day, estimated the National Health Commission (NHC) in an internal meeting, was closer to 37 million.

The commission, according to notes of an internal meeting that were subsequently leaked, estimated that in the first 20 days of December, China had seen roughly 250 million COVID cases — a remarkable speed of spread in a population with low immunity that had, for three years, been sheltered from COVID by a policy that had kept China isolated from a world that had, by then, come to live with the virus.

December — China’s first post zero-COVID month — saw a hospital system completely overwhelmed, as well as a wave of deaths among elderly Chinese that has remained unrecorded, evident only in the long lines outside crematoria around the country. In Beijing and Shanghai, some families had to wait as long as 10 days to get a slot in a cremation ground.

If China had more than two years to prepare for lifting its COVID curbs, the end of zero-COVID came so suddenly and abruptly that hospitals and medical workers were left stunned. As recently as on the evening of November 30, the first clear sign of a shift in policy came when Vice Premier and “COVID czar” Sun Chunlan met NHC officials and declared that Omicron was no longer threatening because of its “decreased pathogenicity”. Yet, officials in several Chinese cities, including Beijing, were even on that same day still scrambling to build more quarantine facilities, projects that were then suddenly halted.

Doctors in Beijing told The Hindu that hospitals didn’t have time to even figure out how to deal with the influx of COVID patients and to separate them from those seeking other treatment. Some hurriedly set up makeshift fever clinics to ease the burden on emergency departments. Clinics saw long lines, because pharmacies in the city ran out of medicines within days of the policy being eased. They just had not been given time to stock up on supplies.

On December 1, authorities in Wuhan published a list of 42 fever clinics, but some closed shortly thereafter because the staff themselves became infected. Cross-infection in hospitals in Beijing and other cities spread rapidly, leading to other departments needing to close for disinfection. 

The strain on ICU beds has been the biggest worry. As of November, China had 12 million people above the age of 80 who were yet to complete three doses of Chinese vaccines needed to prevent large-scale hospitalisation and death, and 80 million above the age of 60. This is a sizeable vulnerable group in a country that had, as of 2020, 3.6 ICU beds for every 1,00,000 people, with a majority of beds concentrated in bigger cities.

Only in September, China’s Center for Disease Control and Prevention (CDC) had urged the government to carry out a vaccination booster campaign, describing it as a prerequisite for a safe exit strategy. That warning was not heeded.

Indeed, China’s vaccination campaign, from the start, had been hampered by the zero-COVID model’s focus on mass testing and quarantining of contacts, which consumed most medical resources. Contrary to popular perception, the problem was not with Chinese vaccines, which were shown to be very effective in Hong Kong after three doses in preventing hospitalisation and death. The problem was the vaccination strategy.

The vaccination campaign initially focused on the 18-59 working age population rather than the elderly. If the idea was to protect the labour force, the unintended consequence was a widespread impression that the government was not convinced about vaccine safety. And with no indication of an end to zero-COVID, the rational choice for many elderly, who saw little chance of getting infected in a country with closed borders and stringent testing, was to delay getting their shots. 

The abrupt U-turn in November, with no planning and preparation, suggested only one thing: there never was an exit strategy from a model that worked well for China, but ended up becoming a victim of its own success.

The end of zero-COVID

For almost three years, China’s zero-COVID model had insulated the country and its population from a virus that had swept the world and claimed millions of lives. Throughout 2020 and 2021, China was largely a COVID-free bubble. Schools in China remained open, factories hummed to supply the world, and domestic tourism boomed. China’s external trade reached record figures in 2021.

In March 2022, Shanghai provided a warning sign of the increasing difficulties of maintaining zero-COVID in the face of new variants that were highly transmissible, even if less lethal, particularly for vaccinated individuals. Shanghai’s COVID wave, the biggest in China since the pandemic began, had triggered a debate among Chinese health experts. Some in Shanghai advocated a shift away from zero-COVID, and the city initially avoided locking down and focused only on the elderly. Reports at the time suggested Beijing was angered by the softer approach and directly intervened, imposing a harsh two-month lockdown on the city. Tens of thousands of Shanghai residents were taken to central quarantine, while the separation of COVID-positive children from their parents triggered an outcry.

The Shanghai lockdown had brought out the first cracks in China’s COVID response, but the message from Beijing at the time was unambiguous — there was to be no questioning of the zero-COVID approach, on which the Chinese Communist Party leadership had staked so much.

China’s leaders were well aware that no country in the world had managed a transition to living with COVID without huge costs. These costs had been used to justify continuation of the zero-COVID approach. The question of continuing with it had also become intensely political, seen as a key achievement of the Party during President Xi Jinping’s second term, which was to conclude in October at the once-in-five-years Party Congress

The message from Beijing to all local governments was that there would be no relenting on zero-COVID especially until the Congress was held, so as to ensure a grand celebration of Xi’s decade at the helm and a smooth transition for the start of his third term.

The Communist Party’s official People’s Daily, in the lead-up to the Congress, published three editorials on consecutive days, calling for “patience with current policies” and warning that “zero COVID must be adhered to”. It slammed those who advocated for “lying flat” and living with the virus.

When Xi opened the Congress on October 16, he defended zero-COVID as the right choice for China that showed the government “put people’s lives first”. For months, Party media had criticised the West — particularly the U.S. — for its lax approach to COVID and the millions of deaths. That emphasis had led to its own narrative trap – moving away from the policy would be, for the Party, difficult to explain after three years of criticising countries that did so. 

The problem for the leadership was that public tolerance for a policy that many initially supported was declining rapidly. As lockdowns grew harsher to control new variants, the broad expectation was that the conclusion of the Congress would herald an easing and China would finally catch up with the world. However, in 2022, faced with increasingly transmissible variants, China imposed more lockdowns than in the previous two years. Economic costs were rising. In July 2022, youth unemployment soared to a record 19.9%.

In an apparent nod to those public frustrations, the government announced, on November 11, 20 measures to ease restrictions once the all-important Congress had been concluded.

For local authorities, the new measures caused confusion; they called for a shortened period of quarantine, and secondary contacts did not need to be traced. Yet for all the emphasis on easing, the very first of those measures demanded “adhering unwaveringly to dynamic zero-COVID” and eliminating infections as soon as possible. Local governments, however, continued to lock down at will. With the expectations of a move away from zero-COVID after the Congress now belied, public frustration continued to swell.

The spark that lit the fire

On November 24, those frustrations turned to anger. That evening, news broke of a fire in an apartment complex in Urumqi, in the western Xinjiang region, that killed at least 10 people. Overnight, videos went viral of firetrucks trying to douse the fire by spraying from outside the gates of the compound. From that distance, as an anguished observer remarked in one video, the water barely touched the raging fire, leaving those inside, including children, to burn to death.

For millions similarly locked down in their apartments, the Urumqi tragedy touched a raw nerve. On the weekend of November 26, Shanghai residents gathered in the city’s Urumqi Road, for a spontaneous memorial to those who died in the fire. The memorial turned into a protest, calling for an end to lockdowns.

Taking their cue from Shanghai, residents in cities across China began to similarly gather to pay tribute, an unprecedented movement that, for the first time in decades, saw a civil society outpouring in direct opposition to Beijing’s policies.

In central Beijing, a crowd of more than 500 people gathered. “No more lockdowns, no more testing!” was the chant. The strongest voices came from the young. One college student at the Beijing protest said three years of COVID policies had “stolen our youth”. Protests spread to more than 50 college campuses. In Tsinghua University, Xi’s alma mater, students chanted, “We need democracy, rule of law, and freedom of expression!” 

“We haven’t seen scenes like this since 1989,” a veteran Chinese journalist told The Hindu, referring to the Tiananmen Square protests that year.

People wait in a long queue to be tested for COVID-19 virus at an open testing site in Beijing.

People wait in a long queue to be tested for COVID-19 virus at an open testing site in Beijing. | Photo Credit: AFP

In Nanjing Communications University in the east, students started a “blank paper” protest that spread around the country. By holding up white sheets of paper, they were making their voices heard while pointing out the restrictions they faced in speaking out.

In Nanjing, a university official with a megaphone warned protesters they “would pay one day for what they have done” and reminded them that the COVID measures were “state policy”, according to one video. Undeterred, a student responded, “The state will also have to pay too for its actions.”

Beijing’s dilemma

The Communist Party was faced with a dilemma. As protests grew, so did cases around the country. By end-November, China was reporting close to 40,000 cases daily, the highest since the pandemic began.

Meanwhile, local officials were conveying two messages to Beijing: that the eased measures were not working to contain a highly transmissible virus, and harsh lockdowns would decimate an already wounded economy.  

By the end of November, zero-COVID had crossed the point of no return with the surge in cases. As Dr Mike Ryan of the WHO observed, the surge in China actually led to the end of restrictions, not the other way around. 

There were signs in Beijing that the test-and-trace model was near collapse. Key to the zero-COVID model was the system of pooled sampling that powered mass testing. The idea was that if a pooled sample turned a positive test, then those in the pool would be subsequently tested individually. This allowed for rapid testing on a wide scale, but only worked when most pooled samples were negative. By early December, every other pooled sample in Beijing was returning positive tests, posing enormous pressure to the test-and-trace regime. The numbers were so high that contact tracing also collapsed.

Bringing China back to “zero cases”, at this point, would have required a national lockdown even harsher than the one in Shanghai. That possibility was not off the table – even until early December, cities from Beijing to Guangzhou were hurriedly building new makeshift quarantine centres. What likely changed Beijing’s calculus was the protests, which posed a risk to the party but also gave it an opportunity, giving it the political space to climb down from its once non-negotiable position on zero-COVID. 

The first sign of a climbdown came four days later, on November 30, when Sun, the Vice Premier, met the NHC and for the first time emphasised that the current variants were mild, a sharp contrast from consistent messaging highlighting COVID as life-threatening. Then, on December 7, came the final nail in the zero-COVID coffin with 10 sweeping measures that dismantled the key elements of the policy, from ending quarantine and disabling the “travel card” app that had been used, for three years, to track the location of every person.

The end, when it came, sparked a range of emotions in China: broad relief for many at the end of lockdowns and being sent to central quarantine, optimism of an economic recovery — but also anxiety in dealing with an entirely new situation with almost no preparation.

Also read | President Xi Jinping warns of challenges in China’s ‘new phase’ of COVID-19

A three-year policy that had governed every aspect of the lives of Chinese had been overturned. Testing was also stopped. The NHC thus no longer had an accurate measure of the spread, and official daily numbers were soon rendered meaningless.

Letting the virus rip through the country and reaching herd immunity as soon as possible appears to now be the government’s thinking, with the hope that normalcy will return as cases subside by early 2023. The cost of that approach, with a sizeable unvaccinated population, is an extraordinary burden on the medical system. Hospitals, medical workers and the elderly have been left to deal with a flood of cases as China, almost overnight, went from a zero-COVID policy to what can only be described as zero COVID policies.

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