China Stands (Almost) Alone: Zero-COVID Lessons for America and the World, Part 3

Part 1

Part 2

5 Conclusions

China stands nearly alone in having successfully implemented and sustained, for nearly two years, a zero-COVID policy. Although this is being tested by the omicron variant, it is very likely to be sustained, in part because the capability exists to do so, but largely because it is hard to imagine decision makers in China deciding that the alternative — conditions in the EU, the United States, and elsewhere — are preferable [141].

It is, rather, societies and leaders outside China that could benefit from China’s example. This is not only because China has suffered far less illness and loss of life, and done much better economically, during the pandemic. In addition, and critically, had the world possessed the capacity and political will to employ a zero-COVID strategy like China’s, there would probably be no omicron variant today, and COVID would not continue to ravage human societies. The inability or unwillingness of most other nations to adopt a zero-COVID policy has had far-reaching consequences, but these have been limited by COVID’s relatively low case fatality rate (CFR) as well as by the development of vaccines and, soon, anti-viral drugs. A future pandemic could be worse [130].

In the sections above I’ve tried to characterize the chief factors — governmental, technical, and social — that account for the continued success of China’s pandemic strategy. These factors, summarized below, are interdependent; suppressing COVID requires integrated use of them.

National commitment, mobilization, and coordination. Government must provide visionary leadership. In China’s case, the early articulation of a “people first” commitment was essential. First, it oriented the entire subsequent effort. Second, it clearly conveyed to the governmental, party, and corporate leadership that a temporary failure to achieve economic goals was acceptable (this was also spelled-out in other ways). Third, it constituted a promise to the Chinese people and staked the government’s — and more the party’s — continued legitimacy on the success of a zero-COVID policy. This reassured and engaged citizens and was a pervasive reminder that the impositions of the policy served a critical collective purpose. The extraordinary mobilization that began with the rescue of Wuhan was based on the policy commitment but was also, of course, both a test of and a demonstration of it. It proved that the government’s — and the healthcare system’s, as well as ordinary citizens’ — commitment was both real and effective and could be counted on. Lastly, varied resources from every sector and throughout the country were coordinated to achieve and sustain success. Coordination has not been perfect, but it has been encompassing, and it has improved over time.

An important element of the zero-COVID policy, and a major factor in its acceptance, were the many measures taken to reorient and expand social welfare programs to aid people and small- and medium-sized businesses.

Existing social insurance programs, the MLSS, and some special temporary policy arrangements have been combined to circumvent the sharp increase in social suffering. [These include] (1) cash payments such as unemployment allowances and unemployment subsidies, benefits from the Chinese social assistance program (MLSS), ensuring the material security of millions of people and employees who have suffered from temporary layoffs, shortened workhours, or mandatory breaks imposed by employers; (2) benefits in kind, including service programs like testing, diagnosis, and therapy for Covid-19 patients, free of charge, either financed by health insurance programs or subsidized by state revenues. Also included are special social protection and social services for elderly people in nursing homes and social welfare units who constitute one of thehighly vulnerable groups exposed to the virus; (3) favorable policy measures, such as the alleviation of income tax burdens and the granting of special loans for small- and medium-sized enterprises who face challenges in existential survival owing to a lack of liquidity because of the drastic freeze in economic and commercial activities?[131].

Lastly, and important to note, is that the Chinese public has “paid unprecedented attention to self-protection”, including masking, social distancing, use of sanitizers, and limitations on social gatherings where warranted. “Hence, even for regions where the government did not strictly impose face masks, people would wear a face-mask and use sanitisers in public” [135].

Social solidarity and institutional trust.?The essential role of solidarity was recognized very early in the pandemic response. As Bruce Aylward, Senior Advisor to the WHO’s Director-General, noted at the press conference reporting on the results of the Joint Mission on February 24, pandemic control “can’t work without the collective will of the population contributing to it” [50]. It is, in this respect, instructive that Taiwan, rated one of the world’s most democratic countries, provides another example of a successful zero COVID strategy [23, 24, 25]. Solidarity has specific practical implications, as Yasheng Huang and his collaborators noted:

What, then, do the countries that have so far been effectively flattening the curve have in common? Part of the answer is that they tend to be in East Asia — China, South Korea, Taiwan, Singapore and to a lesser extent Japan — where a collectivist spirit may encourage civic-minded embrace of and a more willing compliance with governments’ infection control. In addition, these countries tend to be actively deploying technology to collect data on the virus’s progress and efforts to contain it, including tracking those who are infected and their contacts. These two aspects of East Asian societies do not work independently; they reinforce each other?[59].

Targeted and mass testing. Testing is used promptly and at varying scales to accurately delineate the scope of outbreaks in order to precisely shape the response, resulting in faster, more effective containment while minimizing adverse impacts on people and businesses.

Beginning in Wuhan, the government has, on a number of occasions, conducted rapid testing of all residents in areas with outbreaks. As Zhongjie Li and his co-authors put it, these “risk-based, large-scale, population-wide screenings contributed to case finding and rapid control of epidemics and provided evidence for the government to reopen economic activities” [39]. There are a number of notable features of these events:

1. The purpose is clear: to establish a trustworthy, complete identification of positive cases and close contacts. This can be critical to containing an outbreak or to ensuring that it has been contained, enabling social and economic activities to fully resume while providing detailed information on where targeted quarantines and other pandemic management efforts should be focused.
2. Testing of millions — 10 million, in the case of Wuhan — within very short periods is an impressive technical and administrative accomplishment.
3. The attainment of near universal participation attests to public support for the zero-COVID policy, buttressed by the fact that a negative test contributes to a green Health Code rating, ensuring freedom of movement.

Mass testing is, however, a last resort, in cases where targeted testing and control measures have failed or are insufficient. More commonly, new outbreaks are identified and suppressed quickly. Overall, China has actually conducted far fewer tests than the United States, because it has not needed to [142].

Digital contact tracing. The high transmissibility of COVID, worsened by the delta and now omicron variants, means that traditional manual contact tracing is quickly overwhelmed during outbreaks. In addition, high transmissibility worsens the consequences people’s forgetfulness and gaps in their situational knowledge as well as the difficulties of reaching them and persuading them to participate. For all these reasons, the near universal adoption of digital contact tracing has been a lynchpin of China’s success. Tracing is much quicker and more thorough, making possible the targeted management of outbreaks that ensures responses are economical, efficient, and impose restrictions only where necessary and not society wide.

Use of Health Code apps. Swift adoption and pervasive use of the Health Code apps has been instrumental in providing a flexible, individualized framework for regulating movement to minimize the risk of transmission. They connect people dynamically with provincial and national pandemic information management systems while providing an effective way to gatekeep access to public spaces based on risk. They enable testing, contact tracing, and other health data to be integrated and to inform the key risk decisions embodied in the red-yellow-green codes.

Closed community management. Widespread use of “circle-layer” and other types of closed community management has enabled China to conduct highly circumscribed quarantines and to significantly reduce the risk of transmission. As Zhu Qingyi explains, “Urban communities and village communities are administratively defined units for social governance in China. Communities provide geographical space for residents’ daily activities. China adopted closed-off community management right after COVID-19 broke out. Common measures include but are not limited to minimizing entrance numbers, setting up checking points, issuing entry permits, supervising face mask wearing, enhancing health monitoring and registering personnel and vehicles passing through.” Closed-off management “effectively decreases people flows, protects vulnerable populations and curbs virus spread” [133].

Restrictions on inter-provincial and inter-urban movement. China first imposed restrictions on movement across provinces at the outset of the crisis in Wuhan, in part because it coincided with the start of the Spring Festival, ordinarily the time of greatest movement within the country. As the figure below shows, outflow from Wuhan was almost completely halted for a time [134].

How China Managed the COVID-19 Pandemic. Wei Tian [134].

Subsequent research has established “that secondary epicenters such as Beijing, Guangdong, and Shanghai, developed at a very early stage of the outbreak …[and] mobility restrictions across regions indeed prevented the further spread of the disease.” Indeed, if “the primary goal is to eliminate the disease entirely, the central and local governments must implement preventive measures simultaneously”. It seems important to note that, according to Tatsushi Oka and his collaborators, the decrease in cross-region mobility has been “largely due to travelers acting precautionarily and voluntarily canceling their travel plans” [135].

The role of artificial intelligence. Until now, AI’s diverse contributions to pandemic management in China appear to have assisted or enhanced efforts that would have succeeded without it. However, its importance is growing rapidly. It already plays a significant role in diagnostics and in robotics applications, and it is on the threshold of wider usage in many other areas, including triage, prognosis, epidemiological pattern recognition and prediction, virology and pathogenesis, and drug and vaccine development.

The use of AI in the containment of COVID in China is a virtuous circle. Its ability to contribute to improvements in diagnosis, robotics, drug discovery, and in other areas depends on the availability of large datasets for training and discovery. In turn, AI utilization is a learning experience that feeds improvement processes. More broadly, as Kai-Fu Lee explains, harnessing the power of AI requires four inputs: “abundant data, hungry entrepreneurs, AI scientists, and an AI-friendly policy environment” [99]. In its response to COVID, China is demonstrating that it has all of these in abundance.

5.1 Can We Learn?

The remarkably effective response of China’s State Council and Chinese society to the pandemic has been overshadowed in the US and throughout much of the world by criticism of China for mismanaging the initial outbreak and for its authoritarianism. Particularly in the case of the Trump administration, the rhetoric of blame served to distract attention from its own pandemic response failures. There is evidence for the prevalence of the same kind of rhetoric in the media of many countries.

A major study that used supervised deep learning to analyze more than 280,000 news items from 57 mainstream sources in 22 countries from December 1, 2019 to June 30, 2020 found that negative items substantially outweighed positive ones, particularly in the areas of “society”, “economy”, and “politics”. And when examining emotional tone, where emotions were categorized as “agreeable, believable, good, hated, worried, and sad”, the emotion labelled “hated” predominated in 15 of the 22 countries, often by a wide margin (see Figure 16 from the study below). In the U.S, 62% of items were in the “hated” category and only 3% were “agreeable” (the second largest category was “worried” at 32%) [153].

China in the eyes of news media: a case study under COVID-19 epidemic. Hong Huang et al [153].

Other, more narrowly focused research reached similar conclusions. A study of coverage of the earliest phase of the pandemic — January through April 2020 — by three influential papers,?The New York Times,?The Times?(of London), and?The Guardian, found that it was “dominated by negative attitudes, with 30–50 percent neutral coverage, and with relatively little positive coverage.” Even after China gained control of the epidemic, coverage remained negative, with the predominant narrative for the period that of an “epidemic paralyzed China who adopts ineffective epidemic prevention measures.” What did change is that there was simply less reporting [154]. And a frame analysis of eight U.S. news sources across the political spectrum from January through June found that three-quarters of the items were negatively framed [155].

While it is difficult to prove a causal relationship between media coverage and public attitudes and beliefs, what is certain is that “unfavorable opinion [of China] has soared”, according to a global opinion survey by Pew Research. “Across the 14 nations surveyed, a median of 61% say China has done a bad job dealing with the outbreak” [156].

Unfavorable Views of China Reach Historic Highs in Many Countries. Laura Silver et al [156].

We are unlikely to learn as long as China is blamed for the pandemic in media coverage and public opinion, and as long as the elements of its successful pandemic management are under-reported and, when covered, typically framed as examples of heavy-handed authoritarianism.

What is especially troubling about this is not only that we tolerate an enormous loss of life and substantial economic harm that we possess the technical and administrative means to avoid, but that our choice to do so is only at all viable because this pandemic is?relatively?mild. Were COVID’s case fatality rate much worse, the pandemic management policy of the US and most of the world outside East Asia would have horrific consequences. By refusing — so far — to learn from and adapt China’s approach to democracies, we render ourselves unprepared for a worse “next time”, despite the fact that a next time of some sort is likely. And we sustain the very conditions which enable SARS-CoV-2 to continue evolving and which will do the same for any future pandemic. Lastly, blaming China not only distracts from but undermines the urgent need to invest in and build a far better global system for disease monitoring and management.

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