COVID-19 Consensuses in China

China faced a tough time in Dec 2019/Jan 2020 and again three year later.  The difference is that for the first one people didn’t know what to expect, but for the second one the public do, even when the loss in 2022/2023 will be much higher. 

Unlike my Nov 1, 2022 blog posited when there was no consensus on DZ at the time, in less than 2 months’ time a few consensuses have taken hold in China.  The first one is that DZ did save lives.  The contrast between Oct 2022 and Dec 2022 couldn’t have been starker in terms of infections and deaths.  But the second one is that opening up is the only way going forward.  DZ was too costly.  Even DZ supporters, a significant number, who oppose the current policy, admit that once it is opened, it is not possible to return to DZ.  The third consensus is that most people can recover at home, hence the fear factor is much diminished.  The fourth consensus is that many will die, but that is the cost of moving beyond the pandemic.

The fourth consensus is the reality nonetheless vexing the public.  Should or could the government have done anything, or done better, to prepare for the shift from DZ or to lessen the impact?  The only one definitive is that the government should have pushed vaccination harder (Dec 2, 2022 and Dec 10, 2022 blogs).  Other than this is speculative.

The biggest complaint right now it is the government moved away from DZ too quickly, without a smooth transition to opening up.  It does seem like it, but the actionable question is: what exactly can the government do to make the transition smooth besides vaccination?  There have been debates on this in the media.  A school of thought is that you have either DZ or full relaxation, but no middle ground.  If DZ is a 9, what the rest of world is doing is 1, then the current China is 2, but there is no 5 or 6, because 5/6 is not feasible to begin with.  In other words, little can the government do to satisfy those who want the safety of DZ minus the restrictions.  Just have to bite the bullet.  Short-term pain is better than long-term. 

The other position is that we should have tried 5/6.  Even if it doesn’t work, the weeks and months of trying it will soften the blow going into 2.  5/6 presumably means very limited lockdowns, less frequent RNA testing, health code requirements going into crowded places, etc, which my previous blog had hoped for.  We will never know the answer now as it was never attempted.  Still, DZ being ineffective against Omicron didn’t stop the government from doing it for most of 2022, then why did it go straight to 2 without ever trying 5/6?  

The last position is that the government failed to prepare the necessary medicines to handle the massive infections, such as ibuprofen, etc.  But this kind of situation happens all the time around the world, and no country or government can avoid it.  According to a famous US general and President, plans are useless, planning is essential.  If you want everything prepared well before you do anything, which is subjective and easily turned into circular thinking, you will never do anything since you can never prepare everything well.  China is a big country with 1.4 billion people, so bound to have shortage somewhere sometime no matter what.  The bottleneck is seldom the production but the distribution and panic buying.  Indeed, the first two weeks saw the most empty shelves, which in late Dec is far less an issue. 

Even though we now have vaccines and Omicron is less deadly, a situation better than 2020 and 2021, everything happens all at once, family members are sick altogether, creating a new danger.  While most people stay home, even 0.5% going to the hospitals will squeeze the system, leading to unnecessary deaths.  If you didn't have Omicron before you went to the hospital, once you did, you would have it.  The ventilation systems in Chinese buildings could be upgraded to avoid long distance infections, perhaps another area the government should have done better.  At this rate China appears to aim for 2-3 months to go through what the rest of the world went through in the last 2-3 years in order to move past COVID-19.  The exact infection and death numbers are impossible to come by because they are too fragmented and localized, so have to wait for months and check the excess death data for 2022 and 2023.  Local cities and provinces are giving very high numbers which are only surveys and estimates.  People use home Ag tests and don’t report their results, or have the symptoms but don’t do Ag tests, so it is impossible to tell if all with the cold/flu symptoms are Omicron infections.  This winter is cold in much of China, so a busy common cold/flu season as well, which would infect 200 million or more people.  Worse, China doesn’t have a tradition of tracking cold/flu.

There is abundance of information about COVID-19 experiences and death announcements in the Chinese media, which helps foster the consensuses and educate the public.  The only thing missing in almost all cases is that it would have been better and more informative if their vaccinated status is shared.  So far of all the dozens if not >100 death reports, I have seen only one ever mentioning vaccination status (not vaccinated).  For this round of infections vaccination is unfortunately too late for many, but 6 month from now when the immunity wanes, it will help to vaccinate and boost sooner, again.  How China recovers from these tough 2-3 months will be closely watched.     

Dynamic zero no more

Since the announcements of 20 points on Nov 11, 2022 and especially near the end of Nov, the term of COVID-19 DZ policy has totally disappeared from Chinese media reports.  While it has never been officially pronounced gone, it is 100% over.  Now the policy is not even new DZ or soft DZ.  Instead, it is called “optimization”.  DZ’s end is long overdue.  It should have been abandoned on June 1, 2022 when Shanghai emerged from its Omicron wave, if not in March or April, when the danger of Omicron was better understood.  Instead, the public and economy suffered unnecessarily for at least 6 more months.  If China had had diverted only 5% of its energy used for mass testing to vaccination, China would have been in a much better shape facing Omicron right now.  It is not that vaccination in China is bad, but it could have been much better: most Chinese could have got the 4^th shot (now only 3^rd), and elderly (>80-old now only 40%) at least three shots by Dec 2022.

Dec 7, 2022 saw 10 more official policy changes for wider opening, with the most significant one being that most infected can now isolate at home, a common sense apparent to everybody months ago.  The official media are now doing the mass education work, quoting experts saying no Omicron fear.  One has to wonder where were they during the summer? 

While it is good to follow the science, the rushes of policy changes have jolted the society, leading to much hope as well as confusion, naturally.  The official, daily infection numbers are no longer meaningful, just like the rest of the world, when many people are taking Ag tests at home and won’t report their results.  There are gushes of personal Omicron experiences on the Chinese news now, which serve good purposes.  The reality is that the public and governments haven’t found a new balance between COVID and normal lives under the so-called optimization yet, which is barely one month old.  Most old barriers against COVID-19 are dismantled overnight, but without any specific rules and safeguards for post-DZ.  For example, there are fewer RNA testing sites, and many mixed samples are tested positive, affecting a wider population of people because if one person in a 10-sample tube is positive, the other 9 people will receive an orange or red health code, must take the tests again, and can’t do anything until confirmed negative.  The outcome should have been expected, and the solution is one person, one test.  But because of the hassle, fewer people would want to take the RNA or Ag test, leading to more unknown positives and, hence, more undercurrent fear in the society.  Here lies a downward spiral dangerous for people’s health and the economy, and only time and policy adjustments will stem the chaos, naturally.

Because of the earlier and bumpy adoption of “optimization” policies in Nov and Dec, my numbers in the Dec 2, 2022 blog have become outdated.  For 2022 the real infections, reported and unreported, in China can be over 10 million, not the old 3 million.  For 2023 the number will be higher than 100 million.  But most Chinese won’t be infected in 2 months’ time as some “experts” predicted.  This is because many people are still afraid of COVID-19 and will venture out less, and other people will realize more unknown positives and danger out there and be more careful around.   It is likely that Omicron will infect and kill the same ballpark number of pre-2020 cold/flu people in China, dwarfed by the would-be excess deaths due to DZ.  China shouldn’t swing from one extreme to another.  China can’t go back to DZ, or even a soft DZ.  Instead, optimize the “optimization”.

 

2023: will it be better or worse than 2022?

Now is almost the end of 2022.  Qualitatively, 2022 is the same as 2021; quantitatively, a bit different.  Biden is still doing the same, cold/hot warmongering two years in a row as Trump, and no change of that in 2023 or beyond.  The Russia war is an escalation but also an extension of what has been going on over there since 2014.  COVID-19 is still here, albeit less deadly than in 2020 and 2021.  Thanks to vaccination and Omicron, only 0.1% or less of the infected die now.  Not an insignificant number, as 300-400 people die in the US every day, but societies around the world have decided it can stomach the loss, or it is not worth the extra measures to contain the virus.  The only standout is China and its DZ policy, but major changes have come throughout 2022 and particularly on Nov 11, 2022 (https://china.huanqiu.com/article/4AQUNteWR5p).  More opening is expected in the coming months, which will be a big positive for 2023.

The Chinese government made a big mistake of not preparing for a non-DZ policy during and after the Shanghai wave in Mar-May 2022.  For one, they should have realized long ago that DZ, defined by lockdown and mass testing, is never good: bad for the economy, for people’s life and livelihood, and bad for people’s health.  Widespread and prolonged DZ simply exchanges other deaths for COVID deaths.  Thus, lockdowns should have been reserved for the most extreme cases, yet in 2022 it was applied liberally in many cities in China.  Lockdown is no Chinese invention, for it has been used throughout human history.  But city-wide RNA testing is definitively a Chinese invention, and likely the most stupid one.  Then by May 2022 the government should have realized, based on data around the world as well as in Shanghai, that the current COVID-19 poses a lesser threat than before.  And the widely used Chinese vaccines work, and more and newer vaccines are coming up.  So at that point, China should have sped up vaccination drives.  In fact China did, during the height of Shanghai episode, but it fizzled after the Shanghai wave passed.  China also failed to educate the people no more fear of COVID.  Hence, it was a costly waste of at least 6 months’ time in 2022. 

The official media have endlessly justified DZ, leading to much of the public believing the constant danger of COVID, and the local governments strictly reinforcing DZ.  The social media have more diverse views and discussion, but no major impacts policy-wise.  Thus, when the Chinese central government relaxed DZ in the summer and again on Nov 11, 2022, there is no new public consensus, leading to confusion and uneven adoption at the local levels.   

The confusion and resistance to the new DZ is perfectly natural, as many Chinese do support the “old” DZ, or at least accept it is a necessary evil.  Only time and practice will change their mind.  The 20 points (https://china.huanqiu.com/article/4AQUNteWR5p) on Nov 11, 2022 will set in over time, and the debates and application in the next 3 months will be necessary and crucial to convince the public that a new DZ, or soft DZ, whatever it is called, is coming and will stay.  If anything, the 20 points will foster a healthy debate, and that alone would have been worthy enough.

As major and comprehensive as the Nov 11, 2022 items are, additional stipulations and loosening measures will surely follow.  One glaring blind spot so far is the lack of nation-wide position for the public what if one is tested positive in the future.  Thus, the 20 points could have been 21 points, with the 21^st point actually being the most important one.

This 21^st point should have the general public as the ultimate audience (the 20 points are mostly policy orders).  It could inform the people, through other means in detail obviously, no more fearing COVID and panicking.  It could stress the importance of vaccinations (this has been included in the other items but worth emphasizing again).  It could instruct people what to do if tested positive.  Like most people just stay home, no more isolation away; no need to rush to the hospitals unless the serious cases, which will be determined by medical professionals and hard physiological numbers.  Some of these contents will certainly be included in future government announcements, but this 21^st point has the most important task of consensus-building, and the earlier the better.

DZ has its problems, so will a new or soft DZ, which will inevitably lead to increased infections, but not the situation in the US, as China will continue to suppress COVID-19 and isolate cases, only no more widespread lockdown and testing.  Currently China reports 30-40K daily infections.  In 2022 there could be 3 million total infections, fewer than 1K deaths.  So in 2023 China may have 50-100 million infections, 50-100K deaths, part of the previously natural and most overlapping with the common cold/flu deaths (Nov 9, 2022 blog).  Hard numbers won’t lie, and nothing unusual here.  Local, sporadic reports of bad stories will emerge and be amplified if a consensus is not formed fast enough, which is the most potentially serious problem.  The bottomline is that no smooth sailing no matter what, but the ship’s got to sail.  The Chinese economy will recover.  Inflation will be higher but still much less than the US in 2022.  People will be happier.

Throughout 2022 many advanced countries, the US and in Europe, have reported excess deaths, ~ 10%, after counting COVID.  The causes are unknown, but the indirect disruptive effects by COVID may be a big factor (Nov 1, 2022 blog).  Time will tell whether excess deaths apply to countries that only report after Dec 31.  How China fares will be closely watched. 

A debate of COVID-19 dynamic zero policy in China

DZ is the official COVID-19 policy in China.   Previous blogs on 4/17/22, 7/12/22, 11/1/22, etc have argued against continuing this policy in 2022.  Here is a new one, with clear references to and point-by-point debates of the official justifications for DZ.

There have been many, uniformed, official and media documents supporting DZ, with the same, redundant talking points during the many months in 2022, so suffice to take this editorial as an example: 《“动态清零”可持续而且必须坚持》, by 仲音, published in《人民日报》on Oct 11, 2022.  Its web versions are ubiquitous, e.g., https://baijiahao.baidu.com/s?id=1746473260184521826&wfr=spider&for=pc.

Its arguments for DZ are consistent.  1) 我国是一个有着14亿多人口的大国，加上地区发展不平衡，医疗资源总量不足，放松防控势必令易感人群感染风险加大. Meaning: China is a country with 1.4 billion people. Development is uneven across the country, with insufficient medical resources.  2) 衡量一种病毒是否严重，将传播率和致病率两者相乘，是一个重要指标。奥密克戎的传播力远大于流感和此前的新冠病毒毒株，且部分奥密克戎变异株亚分支的免疫逃逸能力出现明显增强，对老年人和基础病人群仍具较大威胁。Omicron is too infectious and still poses a threat to the elderly and sick.  3) 我国60岁及以上人口达2.67亿，老年人群体数量多，如果选择“躺平”，疫情蔓延开来势必造成人民生命、财产更严重损失，其所带来的公共卫生风险难以估量。There are over 267 million elderly Chinese, too many to relax. 4) 一方面我们不能放松防控，搞“一放了之”；另一方面我们也要警惕过度防疫，坚决防止简单化、“一刀切”和层层加码等现象。We can do better with DZ.

First, a few items must be noted.  This editorial no longer mentions that individuals infected with Omicron face more danger than with previous variants.  It also doesn’t say anything about younger people (majority of the population) at all.  Vaccines fail completely to factor in the conversation.  What it shows is that fearmongering is losing its market in China, and vaccination rates have become so high that they can no longer be used as excuses for DZ.

Now to the actual arguments.  As argued also consistently in previous blogs, while and even if these #1-4 points above are true, they still don’t lead to the conclusion that DZ is necessary.

Against Point #1: Development is uneven across the big country, and not enough medical resources, China was, is, and will always be like that. 20 years ago, China was like that.  Now, China is like that.  20 years later, China will still be the same.  Does it mean DZ for 20 years or forever?  That would be crazy.  Since it is also a subjective argument, the exact same thing can be said about every other big country in the world.  Thus, development is also uneven in the US, medical resources not enough, at least in many parts of the US as well.  That hasn’t stopped almost every country on Earth from opening up in 2022, many or most of which are actually in worse shapes than China in terms of medical infrastructure and readiness. 

Points #2 and 3: Omicron can infect too many people, and the elderly and sick will suffer.  But is DZ the only way to control Omicron?  Can we do away with DZ (its current implementation) and still limit infections, while at the same time have a safe, healthy, and working society?  China never has an open risk-reward assessment and debates, so points 2 and 3 are aimless: who doesn’t want to prevent 疫情蔓延 (pandemic spreading), but why exactly is DZ a must? 

Point 4: We can do better with DZ.  Sure, but how?  The official documents and announcements have been so vague during 2022 that nobody knows for sure.  DZ has been equaled to lockdown, mass testing, code scanning, and restriction of movement everywhere.  Local governments have the liberty to enact their own policies, and different places have different versions of DZ and implementations.  As thousands of officials have been sacked for not controlling COVID in the past 3 years, of course everyone has the incentives to do the harshest DZ possible, which does stop COVID, but also wreck the economy.  Since wrecking the economy is not a cause for dismissal, which way the officials choose is a no brainer.  People have called for the central government to publicize clear and detailed guidelines for what to do and what not to do regarding the current DZ policy, but this is impossible.  For one, impractical.  Development is uneven across China, remember?  Local situations differ, which calls for different solutions locally.  And policy must have flexibility.  Most importantly, DZ is what the central government demands, and lockdown, mass testing, etc, have been endorsed by the central government.  So whatever else the locals can do is at most adding 10 to 100.  Local governments won’t make your life easier unless DZ is relaxed from the top.  Granted, DZ in Nov 2022 is looser than in March 2022, but too many people are still suffering for too long, as the daily national infection number inches toward 10K again. 

Besides these official reasons, a significant number of Chinese do support DZ, and they have the 5^th reason for DZ: China must have DZ unless COVID-19 subsides and/or there is a cure for COVID-19 infection.  This point is based on an unfounded fear of COVID-19 and a misunderstanding of the situation and medicine.  The world (outside China) is not going to control COVID-19, so COVID-19, if it ever goes away, will go away on its own, which nobody knows when.  It could be 5 years, 10 years, or never.  In terms of medicines to treat COVID-19, outside of vaccines, few drugs have ever been developed that cure viral infections.  HCV drugs are essentially the only ones.  Despite decades of efforts no drugs can cure common cold, flu, etc, so banking on a COVID-19 cure is worse than waiting for a miracle.  Thus, point #5 is pure wishful thinking and completely untenable. 

The official debates about DZ in China have a false dichotomy, pitting DZ against “一放了之”, or doing nothing.   However, from DZ to doing nothing there is a large grey area, a huge middle ground.  So in addition to arguing against something (DZ), the blog also argues for something.  It is based on the thesis that DZ is unnecessary and does more harm than good under the present COVID-19 situation.  Further discussions about what to do require a few sets of understandings and facts be established.

Firstly, consider the public fully vaccinated/boosted.  The coverage is China is over 90% now.  Chinese vaccines definitively work, and they have been free and easily accessible for almost two years, and can be boosted if needed.  No country will reach 100%; if you don’t have one now, you will never have one, and societies must move on, not waiting for everybody forever.  

Secondly, return to the pre-COVID era, not to a time when there is no risk from any infection, which doesn’t exist.  Omicron must be compared to and balanced against all other diseases.  We can’t get 100% safety, never did, never will.  

Thirdly and lastly, Omicron infection in the said population poses a very low risk.  Few people (<10%) develop serious outcomes, and vaccines reduces serious outcomes by 90% or more, and Omicron death rate is ~ 0.1% or less. This number has been verified over and over around the world for one full year by now.  Thus, much of the need for DZ rests on the fear of COVID-19 severity and Omicron infectivity, which is demonstratively outdated and false in 2022. 

Here is a helpful comparison.  In the US cold/flu typically kill 40-50K every year.  By the same standard, China loses 200K per year.  If the mortality rate is 0.1%, it means that every year 200 million Chinese get the cold/flu.  Considering the population density in China is much higher than the US, the actual infections and deaths are likely even higher in China.  In other words, hundreds of millions of Chinese got the cold/flu every year before 2019 and nobody said a word.  Then why should China do DZ now for something that is similar?  Can China survive with that many infected with Omicron, or will China ever get even close to that many infections with Omicron? 

Based on the above analyses, a starting point, away from DZ but also not doing nothing, is that China is OK if able to limit COVID-19 to 100 million per year.  This is the middle ground policy, and it is unlikely China will ever have 100 million infections per year anyway.  For 2022, with DZ and maximal efforts and resources, China still has ~ 1 million infections, hence having 10-50 million infections is a reasonable compromise.

How to achieve this middle ground policy, and why is it doable or better?  For one, the policy will keep elements of DZ.  People get tested maybe once a week, more frequently or less depending on the local infection positivity.  Positives will isolate at home and stay away from public places until negative, reinforced by health codes.  Only the seriously sick are admitted to hospitals.  Educate the elderly and sick to avoid crowds.  Lockdown will be in place for only the most extreme cases and limited in scale, place, and time by 50% or more.  Most medical resources now used for the meaningless mass testing and quarantine will return to patient care. 

The ONLY downside of this policy is that COVID-19 deaths will increase. 10 million infections could translate to 10K deaths.  But most of them will overlap with the otherwise 200K cold/flu deaths, so it is a wash.  Unless the Chinese government also declares a new war and DZ against cold/flu, this is actually the old normal.  We have never lived in a no-risk environment, right?  But the upside will be tremendous.  The economy will recover.  People will have freedom.   Patients with severe COVID or diseases other than COVID will be better served.  Overall more lives will be saved, and more will live happily.

A fear among Chinese is that if China abandons DZ and tries the middle way, the middle way won’t hold and will inevitably regress to uncontrollable COVID.  This fear can be easily swayed.   China has established a strong COVID system and standard, supported by high public vaccination rates and knowledgeable medical staff.  The most difficult part, the worst obstacle, however, is to educate the public: why DZ no longer, why the new policy, why no more fear.  If you want your freedom, get tested periodically.  No big deal if you are infected, just stay away from others until you are clear.  It will take hard work and time to pivot from DZ, and China has wasted too much time on this.  But it is much more worthy than continuing down the path of DZ.

PS: It seems that prayers have been answered, as China has just updated its DZ policy on Nov 11, 2022 (https://china.huanqiu.com/article/4AQUNteWR5p).  The changes are major, significant, and all around.  Among the most important ones, no more city-wide mass testing, and lockdown will be restricted to small areas, no more international flight suspension, and shorter isolation time.  They are much different from what are being practiced; while the new strategy is still called DZ, who cares what it is called if the changes are real and meaningful.  It remains to be seen how the local governments follow the instructions.  More importantly, how the Chinese public reacts to the sure increase in COVID-19 cases in the coming months.  The government has so far failed to educate the people the true, low risk of COVID, ensuring that there will be hard resistance to the turnaround among many Chinese.  It is certain that the official media will now change the tune, but altering perception and allaying the 3-year-old fear will take time.