Shanghai in Disaster Shock: Where Will China Go After Omicron?
Medical workers conduct PCR tests for Shanghai Residence in Luwan Gymnasium on Mar. 14, 2022./ photo by Yin Liqin via Getty Images
Since the outbreak of the COVID-19 pandemic, there has been a dominating opinion in Chinese public discourse that life is priceless, so preventing the spread of the virus at all costs is totally worth it. Indeed, for each individual, one's own life is priceless. However, the reality of macro policy is less tender: life has a price, and can even be quantified fairly accurately. A basic premise of public health is that human societies have limited resources to devote to prolonging life and improving health. When the costs of public resources are equal, well-designed public health policies become the crucial factor that may lead to a better quality of life for more citizens.
If Chinese society truly believed that life and health were paramount in its list of values, China would spend far more on health care than on public utilities. But in reality, China spent just over 2 billion RMB on basic health care in 2020, less than 2 percent of total GDP in the same year, and ranked outside the top five categories of government spending. At the same time, the human value of China's medical staff has long been underestimated. To a rational society, "life is priceless" is probably just a big and unproductive emotional statement. Any sustainable public health policy requires an analysis of its costs and benefits.
Before Shanghai entered into lockdown, there were two representative models of China’s COVID-19 strategy: Shanghai's laxer "targeted prevention" model and Xi 'an's stringent "lockdown" model. Before Omicron was transmitted to the Chinese mainland, both models achieved "zero Covid." The fundamental difference between the "Shanghai Model" and the "Xi 'an Model" before the end of March 2022 lies in that the "Shanghai Model" clearly recognizes Zero Covid Policy’s enormous costs for people's livelihood, including economic stagnation, increased unemployment, material shortage, and psychological trauma for the general public. These costs should be calculated in different parts of the decision-making process. However, in reality, the difference in value leads to drastically different outcomes.
The Failings of Targeted Prevention
The most important parameter for understanding the spread of a virus is the basic reproductive number, or R0, which is the average number of people each patient will infect during the course of their sickness. The spread of the virus follows an exponential pattern. When R0 is greater than 1, the number of newly infected people increases, and the total number of infected people increases exponentially. Without intervention, the spread of the virus slows and stops until most, if not all people are infected. When R0 is less than 1, the number of newly infected people in the population decreases. Even without intervention, the total number of infections stagnates at a plateau. The targeted prevention policies in mainland China are essentially efforts to compress the R0 by means of social engineering.
Before the omicron outbreak, the Shanghai government was clearly managing the disease better than other local governments: it managed to compress R0 with less cost. However, the exponential spread of the virus means that, if R0 is not compressed below 1 to stop the spread of viruses. Until the critical point is reached, the social cost would continue to rise, but the effect of lockdown is limited. Once the threshold is crossed, the effectiveness of lockdown increases rapidly. Another way to read the cost-benefit curve is: if R0 is not squeezed below 1, it is only a matter of time before the virus spreads out of control, and all the social controls and inconveniences endured by the citizens are futile.
Therefore, when a society takes social control as the central means of epidemic prevention, the rational policy choice is to make enough efforts to cross the threshold of R0 below 1. This is why the United States failed miserably to contain COVID-19 in 2020: it lacked the tolerance for social regulation to keep the spread of the virus at a low level, but was not sufficiently comfortable enough to allow the virus to spread unchecked and claim lives, resulting in a public health and economic disaster. Before the advent of vaccines, the number of COVID-19 deaths in the United States was high. Now, a year after the vaccine emerged, Covid-19 in the United States has largely become an epidemic among unvaccinated people.
Why did Shanghai's targeted prevention model fail when the Omicron variant struck? This is because tracing and screening of epidemic investigations all require response time. The more virulent the virus, the slower the response and the more omissions. The R0 of the original SARS-COV-2 strain is thought to be around 3, the R0 of the Delta variant around 5, and the R0 of omicron over 10. Assuming that the Shanghai government had been able to compress R0 by more than six times (not empirical data, just for illustration), this is still not enough to stop Omicron from spreading. In addition, migration requires specialized human resources. If the virus continues to spread exponentially through the population, the accumulation of cases will soon exceed the capacity of the response team. So in a sense, Shanghai’s strategy, while used to be a success in combating previous strains, cannot adequately handle the extraordinary infectious Omicron variant.
Until vaccines and anti-viral medicine emerge, social control may be the only option. COVID-19 will not be the last new pandemic we will see in our lifetimes, and human society cannot afford periodic shutdowns. What we need is a normalized epidemic control system. The system needs to be flexible to respond to epidemics with different infectious characteristics, rather than having lockdowns as the default option. Chinese society should not allow one failure to erase the success of Shanghai's previous efforts to balance public health with economic well-being. The experience and lessons of targeted prevention in Shanghai deserve to be studied and utilized in the future.
This analysis assumes that allowing the virus to spread among people has serious real-world consequences. But in fact, the relationship between virus disease and human beings is not necessarily "life and death.” Adeno-associated virus (AAV), for example, is an extremely common "asymptomatic" virus that scientists estimate has infected more than 80% of the human population at one time or another. Yet no country is trying to contain AAV—only viruses that cause severe clinical symptoms are worth the effort. Social living and communication are the cornerstones of modern civilization and the hotbeds of infectious diseases. In a sense, the threat of infectious diseases is a necessary price to pay for civilization. Given the high cost of limiting communication, the priority for human control of infectious diseases will always be to reduce the harm caused by the disease itself through vaccines and anti-viral medcine.
Considering COVID-19's transmissibility, severity, and mortality, the policy of building immunity through large-scale natural infections is a grave humanitarian violation. Herd immunity must be achieved through vaccination. The development of the COVID-19 vaccine is a miracle of biomedical engineering. If the lockdown of Wuhan in January 2020 is taken as the beginning of the COVID-19 pandemic, several vaccines have already begun large-scale phase III trials by mid-2020. On the last day of 2020, the mRNA vaccine developed by BioNTech of Germany and Pfizer of the United States became the first COVID-19 vaccine to be added to the World Health Organization's list of emergency uses. At the time of writing, 10 vaccines are included in WHO's emergency use list.
Two biotech companies, BioNTech of Germany and Moderna of the United States, have developed mRNA vaccines that offer the best protection. In the first round of clinical trials, the two doses of mRNA vaccine were more than 95% effective against symptomatic infection and nearly 100% effective against severe illness and death. In mainland China, Shanghai Fosun cooperated with Germany's BioNTech to introduce the mRNA vaccine in the early days of the pandemic, but Fosun's mRNA vaccine has not yet been approved by Chinese regulators.
Residents of Xi’an lining up for PCR tests on December .21 2021./ Picture via Xinhua News.
The Logic Behind China's Early Vaccination Policy
China's mass vaccination campaign began in early 2021, adopting a herd immunity route dominated by domestically-produced inactivated vaccines. Inactivated vaccines are one of the oldestf vaccine technology, a classic in modern medical history -- the first polio vaccine (Salk vaccine) belongs to this vaccine family. Since there was almost no COVID-19 transmission in China at that time, the inactivated vaccines produced in China had to be carried out in phase III clinical trials in foreign nations where infections were present, such as Brazil and the United Arab Emirates. The two-dose inactivated vaccine proved to be 50-80% effective in preventing symptomatic infection caused by the original strain, and more than 95% effective in protecting against severe illness and death. Although this figure is not as impressive as the mRNA vaccine, at least in 2021, the immunization with the domestic inactivated vaccines is in line with the situation in China.
The reality of vaccine production in 2021 is that global vaccine production capacity is limited and "home first" vaccine nationalism is rampant. In March 2021, the EU threatened to impose an export ban after alleging that the British company AstraZeneca had prioritized supplies of vaccines to the UK. WHO has been forced to speak out repeatedly about "vaccine equity".
Amid the chaos caused by the pandemic, a good enough home-grown vaccine with a stable supply is worth far more to public health than an inferior imported vaccine. Fosun's planned mRNA vaccine production line has an annual capacity of one billion doses, and because the mRNA vaccine requires two doses to provide effective protection, it could theoretically reach no more than 500 million people in the first year. In addition, it takes time from the introduction of production lines to the formation of capacity, as well as time to distribute and administer vaccines.
Another important consideration is that the storage and transportation of mRNA vaccines require ultra-cold conditions of minus 20 degrees Celsius. Back in 2016, there was a major scandal involving vaccine spoilage caused by a break in the cold chain in Shandong, China.
When low-temperature cold chains (2-8 degrees Celsius) in mainland China have hidden problems, then the adoption of ultra-low temperature cold chains is unrealistic. This means that the mRNA vaccine is unlikely to reach China's underdeveloped regions. If China sets up a two-track system of domestic inactivated vaccines and imported mRNA vaccines based on economic conditions, it is highly likely to arouse a sense of social injustice.
Theoretically, Chinese society should balance the policy of efficiency and equity. It can consider providing basic immunity to the general populace with two inactivated vaccines and providing mRNA vaccines or booster shots to elderly/Immuno-compromised groups. There are already real-world data in some parts of the world to support the effectiveness of this mixed vaccination strategy.
In addition to the types of vaccines, there is another significant difference between vaccination in China and other developed countries: developed countries generally give priority to the elderly and high-risk groups with underlying diseases, as these people are most likely to become severely ill or even die from COVID-19 and therefore need to acquire immunity as soon as possible. China prioritizes vaccination among healthy young adults but lagged behind for those over 60 and with underlying diseases. Based on what we learned in the first half of 2021, this strategy has its own set of logic: inactivated vaccines provide immunity not only to the original strain and earlier variants but also to some extent to weaken or even block the spread of the virus. After a certain threshold is reached in the proportion of individuals with such immunity, the chain of transmission becomes unsustainable, and the risk of illness is significantly reduced even for unvaccinated individuals.In theory, the inactivated vaccine's lower protection against infection could be offset by higher vaccination rates. In general, young adults move more widely and are more likely to spread the virus. So from the point of view of preventing transmission, it is more efficient to vaccinate young and middle-aged people first.
At that time, the pandemic was effectively controlled in China. From top to bottom, many policymakers and ordinary people believed that the strict prevention and control system alone could keep the COVID-19 pandemic at a very low level for a long time. As a result, many people did not see the threat of COVID-19 to their health as imminent and felt no sense of urgency about getting vaccinated. In addition, China's pharmaceutical industry is not as mature as those in Europe and the United States. Between 2020 to 2021, there is a significant gap between the standardization and timeliness of phase-in trial data of Chinese vaccines and those of European and American counterparts. While the safety and effectiveness of domestically produced inactivated COVID-19 vaccines have since been verified in several countries around the world, the lack of popular knowledge in China, as well as a series of previous scandals involving domestically produced vaccines, may also have affected the Chinese public's confidence in the industry as a whole.
In addition, older people with underlying health problems are naturally at higher risk of adverse events due to "coupling effects" after any vaccination. There may also be socio-cultural factors that make it particularly difficult to introduce vaccines to older people. In Chinese society, the elderly are prone to the influence of pseudo-science. Retired people at home are not mandated by their employers to vaccinate. By contrast, young and middle-aged people with practical needs to go to school and work are more easily incorporated into top-down public health mobilization campaigns.
Furthermore, China's ongoing doctor-patient tensions are likely to reduce incentives for front-line doctors to promote vaccines -- families may blame doctors for adverse reactions to vaccines in older people. The combination of factors has propelled China to build herd immunity through vaccinating relatively healthy young adults in 2021.
Omicron Brings Policy Bankruptcy and an Inexplicable Protectionist Mentality
Omicron's sudden arrival has thrown this strategy into disarray. Compared with the original strain found in Wuhan, the omicron spike protein contains dozens of amino acid variations. Most vaccines are based on the original spike protein. This means omicron has a strong ability to escape existing vaccines’ protections. Even the most powerful mRNA vaccines prevent only 70% of symptomatic infections after the third dose.
In other words, there is no vaccine that effectively blocks the spread of the virus.
Fortunately, existing vaccines are still more than 95% protective against severe illness and death after three doses. This meant that after omicron became the dominant variant, the strategy of providing an immune barrier for at-risk groups through widespread vaccination of the population collapsed.
What matters now is vaccine coverage among high-risk groups themselves. According to the latest population statistics, China has 264 million people over the age of 60 and 35.8 million over the age of 80. According to an article by data analyst Chenqin, only 56 percent of people over 60 on the Chinese mainland have access to a third injection (booster shot), while less than 20 percent of people over 80 have access to booster shots. That is only slightly higher than Hong Kong, which had suffered a medical system breakdownduring the Omicron pandemic earlier this year, resulting in tragic excess deaths. At the end of 2020, China had just over 9 million hospital beds. However, according to the 2017 data, the number of ICU beds was 3.6 per 100,000 people, which means that there were only a little more than 50,000 ICU beds in China. Even if the number of ICU beds in China can be greatly expanded after the outbreak in 2020, the number of trained medical personnel will not be able to keep pace with the rapid growth.
Given the huge variation in medical services across China, medical reserves in underdeveloped regions may be far below average. This means that if the epidemic gets out of control, there is indeed a high probability that China's healthcare system will be overwhelmed. Low vaccine coverage among high-risk groups is the Achilles heel of China's existing epidemic prevention system. Even if ideological and political forces did not influence the Shanghai government’s policy-making, it must choose to tighten its grip: a bitter pill to swallow for China's lack of foresight in its vaccination strategy.
The long-term weakness of “Dynamic Zero Covid” as a public-health strategy is that it has a low tolerance for error: a "lapse" in one place can cause an overall collapse. If we compare the past two years of fighting the epidemic with governing an overflowing river, the Chinese have so far focused on raising dams regardless of cost, but have not prepared to divert the flood. The priority is to develop adequate immunity in high-risk groups as soon as possible.
In the context of the omicron variant, the delayed approval of Shanghai Fosun's "Fubitai" has returned to public view. According to Hong Kong data, two doses of Fubutai and two doses of Sinovac are 84.5% and 60.2% effective in preventing severe illness and death, respectively, in people over 80 years old. Three shots of Fubitai extend the protection to more than 95%, the same as Sinovac. The key difference between the second and the third short is the time it takes to develop immunity. There is a three-week gap between the first two shots and as much as six months between the second and third needles.
Assuming that 5% of China's 35.8 million people over the age of 80 were infected with omicron, two doses of Fubuitai would reduce the number of severe cases and deaths in the population by 430,000 compared with two doses of inactivated vaccine. According to clinical studies in Brazil, a combination of two inactivated doses plus a third dose of mRNA vaccine stimulated immune formation more effectively than three inactivated doses.
For individuals in the middle of an outbreak, the best option is to get the vaccine as soon as possible, rather than waiting for the better one to become available: the type of vaccine is far less important than getting vaccinated in time. But the difference in vaccine effectiveness in the public health system cannot be ignored. If omicron gets out of control, the difference in effectiveness between the mRNA vaccine and the inactivated vaccine in the elderly population could have a decisive impact on the smooth functioning of the healthcare system. If China wants to form herd immunity as quickly as possible and reverse the passive situation before the omicron epidemic, it is urgent to introduce and promote Fubitai.
But it is puzzling that Chinese officials stalled their approval of the world's most widely used vaccine, with the best real-world data. The claim that Fubitai was not reviewed due to the lack of clinical trial data from East Asia is untenable since domestic inactivated vaccines were also initially tested outside China. At the same time, the news reported that several Chinese-made mRNA vaccines were approved for clinical trials.nThe most likely explanation is that Fubitai is being held up by protectionism against homegrown vaccines. China does not oppose the use of mRNA vaccines but excludes foreign mRNA vaccines. This protectionist mentality has put Chinese society at great risk.
BioNTech and Moderna were founded in 2008 and 2010, respectively. The two companies had been working on mRNA technology for more than a decade. According to the experience of the United States, the success rate of biotech product development from project approval to passing phase IV clinical trial is less than 20 percent. The inactivated vaccine is a mature technology for Chinese pharmaceutical companies, while the mRNA vaccine is a new attempt.
It is a “great-leap-forward” mentality to hope that the domestic mRNA vaccine will succeed in the short term. As a long-term strategy, China should develop its own mRNA vaccine technology. However, in the urgent present, reserving market space for the domestically-made mRNA vaccine means that the general public will have to endure lockdown, shortages, and poor living conditions, while high-risk groups will be more exposed to the virus.
Shanghai, a national economic hub with an average daily GDP of more than 10 billion yuan, was locked down for two weeks, and China's economic losses could reach 100 billion yuan.
Moderna raised a total of $2.7 billion before the mRNA vaccine was successful. In other words, the economic loss caused by Shanghai's lockdown so far may be enough to support 5 Modernas. On March 29th, the Shanghai Municipal Government issued a number of policies that supported the importation of foreign vaccines and drugs. The position of this node is intriguing. The Shanghai government, which normally has an incentive to bring in high-tech companies, probably genuinely supports Fubitai. At the end of 2020, Li Qiang, Secretary of the Shanghai Municipal Party Committee, also spoke via video link with Ugur Sahin, founder of BioNTech, to discuss international Covid vaccine cooperation. Therefore, the Shanghai government may be sending a message to central regulators and other interested groups.
However, vaccines, as medical products, are doomed to fail without a green light from central regulators.
The False Dilemma Between "Zero Tolerance" and "Openness"
At present, the public opinion in Mainland China often regards "zero tolerance" and "openness" as opposite poles, while the "zero tolerance" often taunts "openness" as capitulation, which is a typical "false dichotomy". Giving priority to the maintenance of social mobility does not mean abandoning all public health interventions. A sound outbreak control strategy should be dynamically tailored to the nature of the virus and the health and the available public health tools, commensurate with the severity of the problem. Even if we agree that "zero tolerance" is the goal that Shanghai should pursue at this moment, it does not mean that Shanghai's means of "zero tolerance" are reasonable.
In Today's Shanghai, a big focus is the debate between "collect as many patients as you can" and "stay at home". In many people's memory, the emergence of the compartment hospital was a turning point in the outbreak in Wuhan, and it is also considered a successful example of "Chinese speed" and "national strength". Therefore, After the lockdown, Shanghai also "learned from Wuhan's experience" to promote the construction of makeshift hospitals and strive to "receive as much patinets as possible".
In reality, the circumstance in Wuhan is drastically different from that in Shanghai. The compartment hospitals in Wuhan only take in confirmed patients with mild symptoms. At that time, the capacity of CPR testing was limited, and it was unimaginable to conduct CPR testing all over the city like today. So the only people who can get in are patients who are already showing symptoms. According to news reports, the compartment hospital in Wuhan treated about 12,000 patients. Wuhan, which had a population of about 9 million at the time of lockdown, had a local infection rate of 4.43% according to a serological survey conducted in mid-April 2020. The actual number of infections is closer to 400,000. Apparently, most of the patients have recovered at home.
In other words, the main role of uhan's compartment hospitals is not to isolate sources of infection as is commonly believed. So why did compartment hospitals become a key facility in Wuhan's fight against the epidemic? Because in the outbreak in the spring of 2020, the most serious problem was the medical-system breakdown caused by COVID-19. Hospital capacity has not kept pace with the rapid increase in COVID-19 cases, and many patients are dying at home before they can be admitted. One characteristic of the symptoms of the original Covid is the rapid progression of the disease, from mild to severe and severe to incurable in just a few hours. At that time, the emergency vehicle resources available for transporting patients were also extremely tight, and it was inevitable that the patients scattered in the vast city of Wuhan would be inefficient and lagging. It is too late to send patients with mild symptoms to hospital beds when they become seriously ill.
The emergence of compartment hospitals allows patients with mild diseases to be placed under medical observation at an early stage of the disease. At the first sign of a worsening condition, the transfer from a designated shelter to a hospital is far more efficient than the transfer from a patient's home. The success of the Wuhan compartment hospital lies in the establishment of a rational and efficient medical triage process, which determines the priority of treating patients based on the severity of COVID-19. The emergence of this triage system had helped the citizens regain hope, who otherwise would have no access to medical treatment.
On the other hand, the Shanghai compartment hospital treated any citizen who tested positive for Covid-19. Except for the elderly, other groups in Shanghai all have a high vaccination rate, and Omicron is characterized by high transmission but mild symptoms. As a result, most of these PCR-positive cases are asymptomatic infections and do not require any professional medical observation. In the Wuhan epidemic, such citizens will not get a place in makeshift hospitals at all. Most Of the Shanghai residents who entered the compartment hospital have suffered a significant deterioration of their quality of life and risk worsening their condition. However, the capacities of hospitals are not enough to receive more than 20,000 new patients per day. As a result, the policy of "collect as many patients as you can" has become a mere formality led by politics.
We often hear of medical workers arriving late to forcibly remove people who are close to self-healing from their homes. Ironically, the huge human and material cost of maintaining the shelters does not seem to have brought Shanghai any closer to “Zero Covid”. Considering that Shanghai has been under lockdown for two weeks and the only major gathering place for citizens seems to be queuing for PCR tests, Shanghai should reflect on the characteristics of Omicron, and mend its strategy accordingly instead of blindingly adopting past experience.
Inside of a makeshift hospital for COVID-19 patients in Shanghai/ picture via Xinhua News
What Can Shanghai Do at Present?
It is urgent for Shanghai to prioritize medical resources. Some of the compartment hospitals in Shanghai can follow the experience of those in Wuhan to treat mild patients with underlying diseases, who require medical observation but are not in an urgent situation. Another part of the shelter can be transformed into a voluntary quarantine point: the shelter can provide quarantine services to residents who have immo-compromised people at home or home that do not meet the quarantine standard. These shelters do not need too many medical staff on duty, and volunteers can provide basic services. For asymptomatic or very mild patients who have been vaccinated and healthy, home-based quarantine under community management should be actively explored. The resources freed up for medical care and patient transport could be used to serve those in real need and to rapidly increase vaccine coverage for vulnerable groups.
As the first omicron outbreak in China, Shanghai should carry out epidemiological research consciously. It is puzzling that the number of infected cases in Shanghai has not slowed down since the city was locked down for two weeks. We obviously can't stop all human contact and distribution activities and let people starve to death at home with the virus. Therefore, it is urgent for Shanghai to quantitatively analyze the transmission channels of Omicron in various scenarios with epidemiological methods. One of the most important issues is to determine as soon as possible whether sampling sites for mass PCR testing are a major channel of transmission. To this end, Shanghai can pilot self-testing services. The service has been available for more than a year at Boston's local colleges and universities. All students and teachers are required to register a real-name account associated with their identity. Each sampling kit has a specific QR code. Before sampling, users should associate the QR code with their accounts. After sampling, users place the swab into a plastic tube marked with the corresponding QR code and drop the plastic tube into a recycling bin similar to a mailbox.
The accumulated samples are regularly sent to the testing center. After simple video training, ordinary people can be fully competent in the task of self-help nasal sampling.
With China's logistics and PCR testing technology, it is not difficult to develop the process. Shanghai may designate a number of communities as self-help PCR sampling test groups, and the rest of the concentrated sampling communities as control groups. The inaccuracy involved in the operation of the self-test may cause certain false negatives. However, since most Shanghai citizens have been confined to their homes, PCR testing is the only channel of infection. Yet, universal PCR testing is one of the main public health tools in China. Therefore, it is important to find out as soon as possible whether the existing testing methods accelerate the spread of the virus.
In addition, China should immediately import the mRNA vaccine and start the Fubitai production line. The lesson of Shanghai is that any Chinese city is only weeks away from a public health and livelihood crisis. If widespread immunity develops even two to three months earlier among high-risk groups, China will have a bigger buffer against the epidemic.
Wuhan lockdown is an initial response in the face of the unknown. At that time, mankind had not yet given up hope of eliminating Covid once and for all, and it was understandable that people wanted to eradicate the virus at any cost. Yet as the COVID-19 pandemic enters its third year, virologists and public health experts around the world have come to a consensus that the virus will be with human society for a long time to come. In this omicron epidemic, Shanghai "zero" is only a matter of time when the cost is not considered, and there will probably be a celebration.
However, Chinese society must now think seriously: should it continue with this costly "China model" until its economy and health care system are no longer viable? Or should we break out of the political constraints of Covid-19 strategy and find a sustainable path before the next wave of variants arrives?
This piece is translated by Aowen Guan and Harry Huang