Can China’s zero-COVID Policy Stand Up to the Test?

Virologist Feng Gao is head of the Institute of Molecular and Medical Virology at Jinan University in southern China’s Guangzhou, and an emeritus professor at Duke University in Durham in the United States.

Gao has been researching pathogens for nearly 40 years and is currently working on vaccine development for the coronavirus and HIV. Here he discusses his experiences with COVID-19 in China and the United States*.

Interview by Yvaine Ye

How has the outbreak of the Omicron variant affected you?

I came back to China from the States in February 2022 after visiting family for a few months. After landing in Shanghai, I was taken to a hotel for a mandatory two-week hotel quarantine, a measure that continues to be imposed on all international travellers to China. At that time, the Omicron variant started hitting multiple cities across the country. I then returned to Guangzhou, and so far haven’t faced any lockdowns. Although the situation is dire in other cities, such as Shanghai.

Mass testing has helped limit the spread of Omicron. My university organises PCR tests for teachers at least once a week.

Shanghai continues to face lockdowns. Did you expect this situation to have lasted so long? 

I absolutely didn’t anticipate that there would be such a massive and long-lasting lockdown in Shanghai, and I’m very curious to understand why it happened. Shutting down activities and restricting people’s movements should prevent the virus from spreading. But that didn’t happen.

Some people speculate that it was spread via delivery packages, but research shows that SARS-CoV-2 doesn’t survive well on surfaces such as cardboard. Also, there is no strong evidence that it would still be infectious. Now the lockdown is over, we’re probably never able to find out exactly what happened during that period, because a lot of important evidence is no longer available, such as environmental samples.

What are some advantages to China’s zero-COVID policy?

China’s strict COVID-19 prevention measures, especially those imposed on international travellers, managed to limit the spread of the virus within the country over the past year. China saw only occasional flare-ups while the rest of the world battled waves of COVID-19. So, in that sense, the policy is successful.

This strategy has the potential to cut off transmission chains and prevent the virus from spreading. If your goal is to eliminate the pathogen, it’s the most effective method of virus control.

What about the disadvantages? 

China faces a dire problem. Even though the country has domestic outbreaks somewhat under control, the virus is still rapidly spreading in the rest of the world. This makes controlling these so-called “imported cases” extremely difficult.

Although the government has strict measures in place to reduce the risk of travellers bringing the virus in, there are always going to be some cases that slip through the net. For example, in February, a hotel staff member became infected by an international passenger who was staying there under quarantine, and it led to a community outbreak.

Why didn’t other countries opt for this approach?

I think one of the reasons why other countries around the world didn’t adopt the zero-COVID approach is largely because of the cost. Routine screening of millions of people is very expensive, and that doesn’t include the costs of having healthcare workers perform the task.

Also, when the entire city is put on pause, the national economic output will be affected. Not many countries can afford that. A zero-COVID policy will have different degrees of impact on healthcare, the economy, and psychology. The key is to find a balance when designing a public health policy.

Hong Kong’s COVID-19 control approach has become more focused on targeted vaccination. Is there a public health policy lesson here?

I think Hong Kong’s strategy is a valuable lesson for mainland China. Hong Kong experienced a sudden Omicron wave in March this year, which led to a surge in deaths, after having previous early successes in containing the virus.

Data showed that elderly people and those with underlying diseases were most at risk and so the region made the decision to change its approach and push for wider vaccination uptake, instead of a simple zero-COVID message. Mainland China and Hong Kong are two areas that are similar in many ways in terms of their demographic make-up, the types of vaccines available, and relatively low levels of vaccine uptake among the most vulnerable.

However, we do not have data from Shanghai officials as to the number of reported deaths, and so it’s difficult to know how this lesson could be applied here. We also need to reconsider the zero-COVID policy in light on lowered mortality rates across the world. When the mortality rate of SARS-CoV-2 becomes similar to that of influenza, are lockdown measures still appropriate?

In recent decades, we have been hit by several influenza epidemics and pandemics, during which many people died, but we never went into lockdowns. Lockdown is very costly, both for a country and to individuals. We need to consider what would be a better strategy to reduce loss and consider more open epidemic prevention policies.

What do you think about the different pandemic control strategies adopted by China and the United States?

During the second half of 2020, I flew to China for work. Then at the end of 2021, I felt the pandemic situation seemed to be improving, so I returned to visit my family. Then, Omicron came and everything became a mess. My experience of trying to return to China in early 2022 was dreadful. I spent a month living in hotels from before departure to landing in China because of the tightened measures, and the flight tickets were extremely difficult to secure.

But throughout the pandemic, I had the opportunity to see the differences in how the Chinese and American public reacted to the crisis, a reflection of the differences between the two cultures.

The U.S. government doesn’t have as strong authority over individuals and their actions as the Chinese government. Even things like a mask mandate are difficult to enforce. The U.S. government also doesn’t have the money to pay for measures such as mass testing and strict quarantine.

Facing the pandemic, the U.S. chose a less restrictive strategy and accepted the loss of a million people. The public accepted this outcome with relative openness and lived without panic. At the same time, China has a strong government and strong economic resources at its disposal to support its strict zero-COVID policy.

I also observed a relatively stronger fear among the Chinese population toward COVID-19. This is partly because the country was the first to be hit by the then-unknown virus in 2019. During the initial outbreak, the virus was killing a lot more people. The fear then continues to this day.

I don’t think there is a right or wrong policy, just one with the least impact on the overall development of a society.

Certainly, the U.S. strategy led to a huge number of deaths. But mortality is not the only important metric in policy-making. The U.S. policy also considered factors such as the economy and social development. Humans have gone through many disease outbreaks and not panicked over a single virus.

What also puzzles me is that tobacco is far more damaging to people’s lungs than SARS-CoV-2. In China, tobacco kills over 1 million people each year and without action, the number will double by 2030. People are fine with having no strong measures to control this harmful substance but are not willing to accept the relatively small number of deaths caused by SARS-CoV-2.

We need better science and health education for the public.

How long do you predict China’s zero-COVID policy will last?

I can’t predict it. But in the long run, zero-COVID is hard to maintain when the virus widely circulates around the world. China has seen its impact on international exchanges and economic development. The government is already discussing an economic recovery plan. We should know more soon.

The country has administered more than 3 billion doses of the COVID-19 vaccine—nearly three shots per person. Data from different countries and regions show that vaccines, although not really effective in stopping infections anymore, are still very effective in preventing severe illnesses and death from COVID-19.

I think social intervention strategies should consider the power of vaccines. China still uses the same zero-Covid strategy as before the vaccines were available. By sticking to this approach, China is ignoring the protective effects of vaccines, which renders the world’s tremendous efforts in inventing the vaccines and rolling them out rather meaningless.

Last year, several public health officials talked about “co-existing with the virus” in public. With Omicron, that plan seems to be on pause.

Do you think China will coexist with the virus eventually?

In a paper published in early April in the National Science Review, Nanshan Zhong [who heads a government COVID-19 research group] pointed out the potential challenges of zero-COVID policy in the long run and the importance of having an orderly opening of the country, suggesting a possible future where we coexist with the virus.

We are coexisting with many disease-causing viruses including HIV, hepatitis viruses, herpes simplex viruses, foot-and-mouth disease viruses, and hemorrhagic fever viruses. We’ll eventually coexist with the coronavirus, but we hope to limit the viruses’ impacts on people’s health through vaccines, drugs, and other interventions.

What are some milestones China has to achieve before coexisting? 

I think we need to improve science education for the public. We need to let the public know what kind of danger a disease poses, what would be a proper strategy for facing the level of risk, and what kind of mentality we should have in facing the virus. The public needs to develop a correct understanding of the disease, as well as vaccines.

The flu vaccine uptake is at about 2% in China, even though you could get very sick and have to stay at home to isolate yourself after getting the flu, just like COVID-19. Many people in China are reluctant to get vaccinated due to fear and a lack of understanding of vaccines’ role in public health.

To better control the outbreak and hopefully return to normal, we need better COVID-19 vaccines and drugs. The current COVID-19 vaccines, either the Chinese ones or the foreign ones, are very limited in their effectiveness in stopping transmission of Omicron and likely the future variants. Many scientists, including my lab, are hoping to develop a broad-spectrum vaccine that can perhaps work on multiple coronaviruses.

As a virologist, what’s your takeaway from the pandemic?

The relationship between coronaviruses and humans is just one of the interactions between humans and pathogenic microorganisms in nature. Coronaviruses are among the most impactful on humans. We have seen outbreaks of SARS, MERS, and SARS-CoV-2  in the past two decades. As a virologist, I think we already know a lot about SARS-CoV-2, but a key challenge we face now is that we can’t predict what the next mutation will be and whether the new variants are more virulent or can escape our immune response. This is one of the questions that my lab is trying to explore, hoping to find some patterns of mutation.

Humans will likely encounter a new pathogen as we constantly interact with nature. Similar zoonotic spillover when pathogens jump from animals to humans is very unpredictable in terms of when and what pathogen will emerge, but it will happen.

*This interview has been edited for length and clarity.