A version of this story appeared in CNN’s Meanwhile in China newsletter, a three-times-a-week update exploring what you need to know about the country’s rise and how it impacts the world. Sign up here.
For nearly two years, China’s daily Covid caseload rarely extended into triple digits, and often weeks went by without a single case.
Even as the rest of the world struggled to contain new, more transmissible variants, China remained an island – its borders shut and population largely untouched by the virus.
All that changed this month, as multiple outbreaks across the country saw the largest surge in China’s local infections since it brought its initial outbreak in Wuhan under control in early 2020.
Some 12,000 new cases have been reported in the past three days alone, according to health officials, who have warned the country’s defenses are facing the highly transmissible Omicron subvariant BA.2 for the first time.
These numbers may seem small in a population of 1.4 billion and when compared to the rest of the world. But to the ruling Communist Party – which has sought to promote its ability to control the virus as evidence for its superior model of governance – the outbreak represents a significant political challenge.
To respond, China has rolled out its well-worn methods for controlling the disease: placing tens of millions of residents under some form of lockdown, shuttering factories in the tech hub of Shenzhen, constructing makeshift hospitals to isolate cases in hard-hit Jilin province and rounding up “close contacts” of cases for surveillance or quarantine.
But this approach, known broadly as “zero-Covid,” is showing signs of strain.
Already authorities have moved to revise their rule for hospitalizing all patients, in a sign they are worried their own stringent measures could quickly overwhelm the health care system. And there are also indications that the patience of the general public, which has been broadly supportive of the measures, is starting to wear thin.
For now, anyway, China’s leaders may have few other options. Authorities have spent two years focused on keeping Covid-19 out of its borders and quashing its spread. But now, as more questions are raised about the sustainability of “zero-Covid,” experts say the country remains unprepared for the alternative of “living with the virus.”
Shanghai physician Zhang Wenhong – often likened to top American epidemiologist Dr. Anthony Fauci for his straight-talk and expertise – alluded to this dilemma last week, writing in the business journal Caixin: “We haven’t prepared anything of what we need to prepare. How could we possibly dare to ‘lie down’ (and allow the virus to spread)?”
To be sure, China has undertaken massive efforts to protect its people from the virus, pulling off what’s been called the largest vaccination campaign in history – developing vaccines at record speed and doling out 2.8 billion doses domestically in 2021 alone.
But despite this, there are both critical gaps in Beijing’s vaccination effort and – though the vaccines are thought to remain effective against severe disease and death from Omicron – unresolved questions about how just how well they can protect, especially for vulnerable groups. That poses significant concerns for any transition away from zero-Covid for a country that had grown used to seeing no Covid-19 deaths.
While the vast majority of China’s cases have been mild or asymptomatic, the government reported the first Covid-19 deaths in more than a year on Saturday. Health authorities said the deceased – two elderly Covid-19 patients in northeastern Jilin province, one vaccinated, one not – had mild cases and succumbed to their underlying conditions.
But experts say the risks of a more serious situation have been made starkly clear for Beijing by the events over the border in Hong Kong, where a rampant outbreak has overwhelmed hospitals and morgues, leading to more than 5,500 deaths so far this year, largely due the low vaccination rate among the elderly.
While one is a city of less than 8 million and the other a nation of 1.4 billion, experts say parallels have raised alarms in recent weeks.
“Both have pursued a ‘zero-Covid strategy,’ both have a large unvaccinated elderly population, and in addition (both) have not invested in public health surge capacity building before the Omicron wave arrived,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.
“And in China, you have a large percentage of the general population that have not been exposed to the virus, because of zero-Covid, or that are vaccinated with vaccines that (studies show) are not effective in preventing infection.”
While China’s overall vaccination rate tops 87%, immunization among the elderly, and especially the most vulnerable over 80s, lags that of countries like the US or Britain, as these groups were not originally prioritized in China’s vaccination campaigns.
An estimated 40 million Chinese over the age of 60 have yet to receive a vaccine, according to data from China’s National Health Commission. While some 80% of China’s 264 million elderly people are fully vaccinated, that percentage falls to only around half for the group most vulnerable to Covid-19, those over 80 years old.
“We have been ringing the alarm bell again and again about this – it’s a hard-learned lesson not only for Hong Kong, but also for China,” said Jin Dongyan, a professor at the University of Hong Kong’s School of Biomedical Sciences.
China’s potential problem is further compounded by its reluctance to approve a foreign mRNA vaccine, which could be used as a booster dose, despite securing an option on 100 million doses of a widely used vaccine by Germany’s BioNTech in late 2020.
“(Not approving the BioNTech shot) was also a missed opportunity for Chinese policy to out-evolve the virus,” said health security expert Nicholas Thomas, an associate professor at City University of Hong Kong, who called the decision a “clear example of vaccine nationalism” in favor of China’s domestic shots.
“Had they (approved the BioNTech vaccine last year), given the impressive resources that China deployed with their earlier vaccination program, it is unlikely that they would now be facing the same threat from the Omicron outbreak,” he said.
While several homegrown mRNA vaccines are in development – with at least one in the final phase of clinical trials – it remains unclear when or whether those doses will ultimately be approved, or if they’ll measure up the existing shots in use around the world.
Potentially compounding these risks is that many of China’s elderly live in the countryside, where health care is significantly less advanced than in cities. China’s ability to handle a crush of severe cases could also be hampered by its ICU capacity, which falls well below that of many Western countries.
There are signs that China is seeking to fill the gaps. In recent days health authorities have given updates on efforts, for example, to enlist mobile clinics to get elderly people vaccinated and stress the importance of their booster drive. They’ve also included the foreign Covid-19 antiviral pill by Pfizer in the latest guidelines – a new addition to China’s medicine cabinet – and said that Omicron-specific vaccines are in the works.
The problems that China faces are not necessarily unique: countries across the world have battled Covid-19 with low vaccination rates in the elderly and ailing health systems.
In China, because heavy-handed tactics have so far allowed the population to steer clear of the worst effects of the virus, experts say relaxing those measures could come as a shock.
“The pressure to maintain zero-Covid is not only from the central government but also the general public,” said Xi Chen, a professor at Yale School of Public Health, pointing to public support for the government’s measures in the past two years.
While there are signs that people and experts in China are beginning to look more toward policies in the rest of the world to “live with the virus,” this may also require a significant shift for official messaging that has focused on the gravity of health crises outside China’s borders, even after mass vaccination campaigns reduced deaths in developed countries.
“The problem is that if you continue to highlight the danger of the disease and demonize the pandemic response efforts of other countries, it means that the fear in the public won’t fade away, and that makes moving away from a zero-Covid strategy difficult,” said CFR’s Huang.
And even if this outbreak is brought under control, these questions will continue to rise to the fore in China, as containing Omicron amounts to a “Sisyphean effort” for China’s leaders and its people, he said.
“They are not going to eradicate all the Omicron cases in China…they are just waiting for the next round.”
Correction: A previous version of this story misidentified Nicholas Thomas' workplace.
CNN’s Beijing bureau contributed reporting.