In this Call with the Experts podcast, Jeffrey Hiday, director of Media Relations at RAND, is joined by RAND experts Jennifer Bouey, Senior Policy Researcher, Timothy Heath, Senior International/Defense Researcher, and Amanda Kerrigan, Policy Researcher. Together they discuss the risk of a rapid spread of COVID-19 Omicron variant cases in China following its easing of COVID rules, as well as potential domestic and global implications. This call was recorded on December 15, 2022.
Narrator
This audio presentation is from the RAND Corporation, a nonprofit institution that helps improve policy and decisionmaking through research and analysis.
Jeffrey Hiday
Good morning, everyone. This is Jeff Hiday, media relations at RAND. Welcome to this Call with the Experts. I am joined here by Jennifer Bouey, Tim Heath and Amanda Kerrigan. We're all coming to you from the somewhat gloomy, rainy, chilly D.C. area. Jennifer is an epidemiologist and the Tang Chair for China policies here at RAND. Tim is a senior international defense researcher and Amanda is a policy researcher who recently joined us at RAND. I'll lead a conversation for 20 minutes or so and then we'll open up to questions. Jennifer, I'll start with you with the the big question on the public health front, now that Beijing has reversed course and is moving away from a zero-COVID approach, is there going to be an Omicron tsunami in China? Is that a certainty? And if so, how big might it be?
Jennifer Bouey
Yeah, from the epidemiology perspective, I think it's pretty much a certain wave. And many of the models, the mathematical and epidemiology models showing that it will be a tsunami. So I think the the key issue here is, of course, the virus, even though the zero-dynamic control has blocked the big waves in China for the previous variants: the Alpha, the Delta. But Omicron turns out to be a really a virus that has spread really fast. And COVID zero cannot stop its spreading.
Jeffrey Hiday
And what kind of numbers are we talking about?
Jennifer Bouey
According to this? Very, I think, very nicely done mathematical modeling study that using the Hong Kong outbreak and Shanghai outbreak as the calibration of that model and using the current data of the health system in China, they predicted that if in the spring, if Shanghai's case is continuing without a lockdown, a whole city lockdown, there would be about 100 million symptomatic cases. There will be about 5 million hospital admissions, 2.7 million ICU cases, and up to 1.6 million deaths. That's only from Omicron, not including the excess of deaths that can come from the health system strain.
Jeffrey Hiday
These are huge numbers. Can the health care system cope?
Jennifer Bouey
No, that's the other problem. This article, as well as many articles, has documented that China, even though the hospital beds are plenty—they calculate about 3 million hospital beds—but the ICU beds are pretty low in terms of its density. It's about 70,000, less than 70,000 for the whole country. So that comes to 4.5 per 100,000. This is in the scale compared to, say for the U.S. it's about from 25 to 35 per 100,000. So that there you can see that even South Korea has a density of about 10 per 100,000. So China is much lower in terms of its ICU density.
Jeffrey Hiday
But if I'm doing the math right, then maybe they have about a tenth of what could be needed.
Jennifer Bouey
Yes, that's what's what has been presented. And it's also published. These are well-known facts.
Jeffrey Hiday
And is this because there aren't enough vaccines? Is it because of the zero-COVID approach? There's not enough boosters? What's causing this?
Jennifer Bouey
Yeah. So current situation, even when we talk about a summer or early fall, the situation is that this is a pretty a population with low herd immunity. So very few people has exposure to previous rounds of COVID and the vaccine overall rate is high is about 90% for the primary vaccination. However, the booster rate is quite low. To this day, it's only about 44% of the population are not boosted. And we know that the vaccine, even though it's the efficacy, is slightly lower than the mRNA—it's an inactivated virus vaccine. But the critical part is it needs to be boosted and that part is low. So I think to me, the biggest question is that given the Hong Kong outbreak, which created one of the highest mortality in January and February, and then the exponential increase of cases in Shanghai before the lockdown and all this modeling studies has showing this gap, why there was no booster campaign in the summer, why there's no stockpile of the anti-viral treatment in the summer. So even about a month ago, I think the when after the November 20th, when the 20th, the 20 points. That's when sort of a revision of the COVID policy came up. The local government are still insist on using the zero-COVID policy quarantines and and the mass testing. It's not until December 1st when the Chinese premier Sun Chunlan clearly say while this is a now, it's a different situation. We have to change the policy. So it's not until December 1st that the policy changed suddenly without, I feel that there's almost no preparation before this.
Jeffrey Hiday
So you posed a number of big questions there. And you're essentially making a critique. What what what's the answer? Why why do you think this level of unpreparation.
Jennifer Bouey
Well, I think it's you know, there are some speculations why, you know, in November 20th, why wait till November? First of all, I think by November, it's pretty clear that even the the COVID, a dynamic COVID-zero policy is not stopping the spread of the of the disease of the virus. But that November the 20 points was relatively mild, as some of these policies are similar to what we have seen in Asia, many other Asian countries that experienced a wave, Omicron wave, earlier this year, usually in from January to March. So I think that the idea is that after the 20th People's Congress, this is a time to revise the policy. And the Twenty Points were there to prep the population. The idea is, well, if the booster starts then, then after a couple, a couple of months, maybe it's ready for opening. However, I think it's came a little bit too late and I think by then we already see over 200 cities in China has cases reporting in some of the cases, cities cases are soaring at the time. So but and at the same time, I think the local government officials were not clear, you know, is this a real change of policy or is it a just a adaptation? So many of them are afraid that they if the COVID outbreak starts in their their their area, then they will be punished. So they still very much insist that to use the very strong measure to stop the COVID. So I think that's probably what's happened.
Jeffrey Hiday
This sounds to an extent, a case of messaging. And whether the messaging is is good or bad, maybe it's good. But to turn to Tim. Tim, initially the messaging was all about potentially fake or bad vaccines and this was making everyone quite fearful it was a kind of terror in the population. How do you how do you view the messaging then and how it's shifting?
Timothy Heath
So, yes, a couple of things to bear in mind. When this pandemic emerged, there was the backdrop of a series of scandals related to the pharmaceutical industry in which vaccines were given to patients that were either fake or adulterated or otherwise not what they were supposed to be. And people would take the vaccines and they could get quite sick. And once word got out, the people who already have a high level of distrust of Chinese made food products and pharmaceutical products, it only deepened their distrust of vaccines. This is especially true among the elderly population who were given a message early in the in the pandemic that they were especially vulnerable. And when vaccines began to become available due to a lack of data on how the vaccines would affect older people, the Chinese government did not prioritize vaccinating elderly and sick people, but instead prioritized vaccinating healthy people. And this this also encouraged a belief among China's older population that the vaccines were dangerous to them, that the side effects could be have severe effects. So that message became entrenched. And it is a huge issue now as the government tries to reverse course and overcome that. Moreover, the initial messaging from the government was that this COVID is so deadly and dangerous that it is important to stop its spread. So that justified a zero-COVID approach. And ironically, initially, the Chinese did seem to score successes compared to China, America's COVID case situation was notoriously, you know, very devastating. We had a huge numbers of infections and deaths, and the Chinese propaganda machinery trumpeted this contrast as a justification for their policy. The problem is, over time, despite all of America's setbacks, we found a way out of it. Our vaccines have helped us find a way to live with COVID. And the Chinese, who are sticking with the model that brought them early success, are finding themselves increasingly imprisoned by this, you know, zero-COVID approach. And that and the propaganda bureaucracy is now trying to reverse course again per the guidance from Beijing and downplay COVID. This is going to further, I think, fuel, distrust and skepticism among many Chinese people who are not sure how much truth the government is really telling.
Jeffrey Hiday
And that has sparked protests. Amanda, I could turn to you on how the population is responding and protesting. Are the protests—do you see them ebbing or accelerating given the current dynamics?
Amanda Kerrigan
Hard to tell now. Currently they're not at the levels that they were previously. But what I might expect, based on what we've seen from China's history over the past few decades with protests, is that these protests may may come in kind of waves, fits and starts. So as the Chinese system tries to adjust to its new COVID policies and people try to adjust to them, we may see some protests throughout that adjustment process. Protest is a tool that people use when their institutions fail. So when people's frustrations hit a certain point and there are no institutions for them to project those grievances, then we can expect them to turn back to protests, assuming caveat that that people are not too afraid. There have been some reports that people have disappeared since the protests. So that's also something to watch as well.
Jeffrey Hiday
But the the nature of the protests, is it is it, from what you've seen so far, is it is the dynamic what you've seen in the past? And in terms of how it might shift if if things get as bad as Jennifer was just describing, how would you expect these protests to evolve?
Amanda Kerrigan
So what we saw over the past few weeks was newer in the sense that we had multiple protests together protesting a national policy. So that that's been relatively rare in China's modern history since Tiananmen. So that's why it got so much attention. But protests happen all the time at the local levels in China. So for all sorts of grievances, whether it's an environmental grievance, a land grievance, even a health care grievance, and so something that is a common phenomenon in China's health care system is people protesting or in some in some cases resorting to violence against doctors and health care workers when they're dissatisfied with the health care system. So what may happen in this case is that as Jennifer was saying, as hospitals become overwhelmed and don't have enough ICU beds or other services for for sick patients, not just COVID patients, but other patients they might not be able to see as well. We might see some more strike and struggle between patients and families and hospitals. And so that's something to potentially watch as we go, as things go forward. It's not just the sort of anti-national-policy protest, it's also going to be kind of at the local level against hospitals, some more strife and some more protests at that level as well.
Jeffrey Hiday
Got it. Thank you. Let me let me put two questions from Barry Pavel that are in the chat to the group. The first is what are likely to be the global health implications of this Chinese COVID surge? And will this be similar to the beginning of the pandemic when Chinese cases caused mass infections in the rest of the world? It might be a good one for Jennifer.
Amanda Kerrigan
Yeah, so good question. So I think at this point, it's almost like China is catching up with the rest of the world. So I think in terms of immunity, I think China's immunity to, mainland China's immunity to, COVID-19 is lower than the other parts of the world. So I don't think that's a big concern of the cases coming out of China. However, just given that this will be a large population transmission, we have the workforce of the world population is facing this infection. So whether there will be new variants more likely to come out of this tsunami, that's possible. So I think it's really critical for China to communicate with W.H.O. and with other public health global health organizations to continue to monitor the variants coming out and to monitor for, you know, for the global health community, to monitor the symptoms and the changes of the response. Because this is a constant struggle between the virus and the immunity of the whole world.
Jeffrey Hiday
And a pretty natural follow up to that point from Barry is since the CCP often conceals or changes data to suit their propaganda purposes, how do we really know how many Chinese cases and deaths are occurring? Jennifer, do you want to start with that one? But Amanda and Tim, feel free to weigh in.
Jennifer Bouey
Yeah, I would say that when when the policy is successful, we can trust the number better. When the policy fails, that's usually when we see the number doesn't make sense. And right now, what we see is actually the COVID infection number dropped since December 1st. December 1st is the time when the China's premier said that there shouldn't be a mass testing. So I think this drop of cases definitely do not reflect what's happening in China, given the social what's on the social media, what's on the news, what's on the pictures. Actually, Beijing is the hot spot now. It's a very dystopian picture there. The streets are empty, shops are empty, the hospitals have long lines. And many of the community hospitals have actually closed. And the pharmacies are short of medicine. So I think the question is correct that I think now that the number doesn't really reflect the epidemic.
Timothy Heath
So I think in what we know, countries have followed zero-COVID type restrictions early in the pandemic, the overall death rate did seem lower. So I think that's a really good point by Jennifer that early in the crisis, the policy seemed to work and the overall death rate and infection rate in China, by all accounts, was lower than in the U.S.. But as we move forward, I think that CCP has a very strong incentive to begin suppressing information once they loosen the restrictions and they start to go through what America has already gone through. So at the end of the day, I don't think there's a way around. If you loosen up, there's going to be a soaring number of infections and deaths. It doesn't seem like there's any way around that unless you can really get 100% vaccination or really high vaccination rates, which China at this point does not seem like it will be able to do. So going forward and I agree with Jennifer, as the policy has proven more and more incapable of stopping variants like Omicron, I think doubts have been growing about the reported numbers of infections and deaths. Those doubts will only grow once they loosen even further. The restrictions and the deaths and infections will almost certainly increase to very high levels.
Jeffrey Hiday
Okay. A few questions from Xiaoshan at VOA. The first one is referring to a Shanghai based doctor who suggested that the COVID wave in major cities like Shanghai and Gwangju would peak in one month and take 3 to 6 months to get over. Another health expert, Zhong Nanshan, forecast China might be back to pre-COVID normal by mid-2023. So the question is when do we think the COVID peak will arrive in China? January? Spring festival? Jennifer, you want to hazard a guess?
Jennifer Bouey
Yeah. If we look at the cases earlier this year in other Asian countries that started with more of a COVID-Zero type of control. When they opened up, what we see in Singapore, in Taiwan, in Hong Kong, and in South Korea, and Japan. What happened is there will be a big wave in the first wave of Omicron, and then they will continue with a smaller, still moderate, case number reports. I think that the health care system limit will be reached very quickly, probably in the models showing about 30 to 40 days. So that would be, you know, end of January. And it happens on the Chinese New Year, too. So that is where we will see probably the first crisis relates to the health system. But I think the infection will have multiple waves in the next six months.
Jeffrey Hiday
And Barry Pavel had another question that ties into that. If that worst case scenario develops, what should the U.S. and other countries around the world be doing to protect their citizens from a China-based spread?
Jennifer Bouey
Well, I think again, this is still the Omicron wave. Unless there's a new variant coming out of it that's worse, creates more severe diseases, or spreads even faster than the current variants. Otherwise, I think right now China's reporting is that the BA.5 And maybe that the BQ.1 is starting somewhere. So these are still the known variants outside China. And I think with the U.S. personnel, if they have recently boosted and have the sufficient vaccine, then they should they have better immunity than most of the people in China.
Jeffrey Hiday
So what is the, how would you identify what the current hotspot is? Where is the current hotspot and which variant is it that we should be paying much attention to?
Jennifer Bouey
Well, right now from just from the social media. So we don't really have any reliable official numbers anymore as they stopped the testing. From the social media, observation is that Beijing and Northern China is the hotspot and the majority of the strain are the BA.5. I think the new strain, the BQ.1, they said they only in a couple of provinces outside China. So they're trying the in the social media there lots of discussion about these different strains.
Jeffrey Hiday
And Xiaoshan had a few other follow ups. One is after, whenever the cases do peak, when do we think China might go back to a pre-COVID normal? And then somewhat related to that is, do we have any specific policy or medical recommendations to the Chinese government on how to get through all this?
Jennifer Bouey
Well, I was just emphasizing I think this is really just the beginning of what we're seeing, this tsunami at the very beginning. So there will be, I expect that it will last, you know, several months and depends how the health care system stands. I think there might be a spill over to other problems. And recently, I think only yesterday, we see that many of the blood bank in China is in shortage of supply. So I think, you know, often these are the health issues we don't anticipate directly linked with COVID, but because less, much less people are donating blood in the last few months and there's concern of contamination of asymptomatic cases. So now the blood bank is low. So there are lots of uncertainties now. But again, you know, this is just the beginning. And what government can do. Again, you know, this is back to the really epi 101, is vaccine, vaccine, vaccine. And also the antiviral treatment to reduce the mortality rate for the vulnerable population. And then we see the government just starting in the last couple of days talking about booster and antiviral medicine.
Jeffrey Hiday
Amanda, the research on this question about what to do.
Amanda Kerrigan
Yes. A broad observation is, we've been talking here and there about the role of local officials and sort of the pressure they've been put upon during this pandemic. And it's actually, you know, local officials in in China actually show a very high degree of flexibility and adaptation and creativity when given the ability to do that. So, for example, in zero-COVID, if the goal is zero-COVID, they're going to do everything they can to achieve zero-COVID. But if they are given better and more flexible goals, like a certain amount of economic growth, certain health criteria that are a little bit more flexible and allow them to implement policies that fit their specific situation. We know from decades of Chinese history that local officials can do that and do show some the ability to do that. So, yes, Thanks.
Jeffrey Hiday
Good, thanks Amanda. This all sounds quite difficult for Chinese leadership. Maybe we could look at a few implications. Economic would be want to speak with. Of course, if we had our own Howard Schatz on here, he would be a great expert for this. But I know that you all have some insights as well. What first off, what are we seeing in terms of how this is affecting the economy, how it's affecting the number of workers who are getting to their their workplaces or not? Tim, could you start on that?
Timothy Heath
Sure. So COVID has been a hammer blow on the Chinese economy for several reasons. First off, it's worth bearing in mind the context. China has been trying for a number of years to wean itself off of dependance on export industries and investment driven growth as construction and real estate. And there have been tried to nurture a consumer driven economy. This COVID has obviously set that back. People cannot shop, or their shopping has gone way down. Their ability to eat at restaurants has gone away. And not only that, people are using up all their savings, staying at home, many unemployed or underemployed. And so the actual consumption power of the Chinese citizen has gone down, which has deepened the imbalances in the Chinese economy. Moreover, the deepening dependance on exports comes at a terrible time for China because the U.S. and Europe, which are the main markets, are expected to be headed more and more towards something resembling a recession, which means demand in the West will go down, which will add even more pressure on the Chinese economy. So what we've seen in the headlines that the real estate bubble is finally starting to pop. That is that is a major part of the Chinese economy, like almost 20 to 30% of GDPs in real estate. So we can expect that the Chinese economy will be under immense pressure. This will add further incentive for government officials to try to ease up on the COVID restrictions. But again, the drawback of that is there will almost likely be, or unavoidably be, a surge in deaths and infections as Jennifer laid out. So the Chinese government is in a terrible dilemma. It's damned if it does, it's damned if it doesn't restrictions, ease up restrictions on COVID and the economy is looking pretty grim for China, at least for the near future.
Jeffrey Hiday
Who's going to be blamed?
Timothy Heath
Well, you can expect that the Chinese government will do everything it can to deflect blame off of Xi Jinping. What we're seeing coming out in the messaging is a great deal of effort is being put into blaming the West. There is a lot of disinformation coming from the highest levels of Chinese propaganda that insinuates that America created COVID-19 at Fort Detrick and that COVID-19 was the result of some military experiment gone awry. So there is the Chinese apparently picked up this conspiracy theory idea somewhere off the Internet and are running with it. And this is one way to deflect blame. But the Chinese are also going to, I think, rely on the heavy repression of data and distortion of data that reveals the extent of sickness and death that will arise as the restrictions ease and then to the extent they have to, the Chinese central government has the long history of blaming local officials for unpleasant facts, and this is possible as well, where they feel that data cannot be suppressed and a picture of real horrors emerging. It will be convenient for Beijing to blame local officials for incompetence.
Jeffrey Hiday
I think Tim, that I'm picking up from the way you're describing this, that there have been precedents in Chinese history for handling these kinds of situations in certain ways.
Timothy Heath
There are certainly. The tension between Beijing and local officials is a longstanding one. And for years there has been this tussle between the provinces where actually where most of the money and power is is frankly located. And Beijing, which is forever trying to assert its dominance over powerful provincial officials and provincial economies.
Jeffrey Hiday
I was wondering I was wondering whether it was fair to go back to the Great Leap Forward or other really apocryphal periods for China.
Timothy Heath
Well, Great Leap Forward provides a cautionary tale for China, if the top leader takes the blame. And the Great Leap Forward, estimates of up to 30 million Chinese people died due to, you know, misguided policies initiated by Mao Zedong. He was blamed by his rivals and the elite in the lead circles and top levels of government and subsequently marginalized. And this was a massive humiliation for Mao. I think Xi Jinping is going to do everything in his power to avoid that. He's definitely not tolerating any rivals who could criticize him publicly. He's made sure those guys are locked away. And given his control of the media apparatus, I think you can be sure that blame will be deflected elsewhere to the West, to local officials. It will go somewhere else.
Jeffrey Hiday
All right. Back to the here and now. Karen Weintraub from USA Today's question. Any sense of the availability of COVID boosters, booster vaccines, antivirals such as Paxlovid or remdesivir? Are these already available or manufactured, or will China be scrambling to try to get them from elsewhere? Jennifer, that's probably best for you.
Amanda Kerrigan
China produces its own boosters and has shipped many of its vaccine to many parts of the world. So I think they do have the capacity to create their own boosters. In terms of the antiviral, Paxlovid was approved by China FDA in July this year. However, there's a company, Zhejiang Huahai, that has been the designated company to work with Pfizer on that. However, there hasn't been any sale on the market until the last couple of days. They're talking about allowing sale of the Paxlovid. China also approved, another anti-HIV virus medicine that can be used as antiviral. So that also is showing up in the last couple of days. And I think Merck is talking about a deal with China. It's antiviral molnupiravir as a potential. But as you can see, the medicine has not been on the market and no one knows how how much you know, these medicines are available here in China. China has been promoting its own medicine, Chinese herb medicine. But so far we really haven't seen any clinical trials on its efficiency.
Jeffrey Hiday
Sticking with the vaccines for a moment, so are the Sinovac and Sinopharm vaccines the only ones that are still available.
Jennifer Bouey
Yeah. Those two are the main. Initially, China started on the approving for the vaccines created by the country, but Sinovac and Sinopharm were the ones that are in mass production. So there was also the I think the Pfizer's mRNA vaccine has been approved by the China FDA. But and it has been shipped and manufactured in China, but only I think it was only used in Hong Kong. Only the citizens in Hong Kong can have the choice of either the Pfizer vaccine or the Chinese Sinopharm vaccine. Most of the people in mainland China does not have that choice.
Jeffrey Hiday
Is this a pure case of nationalism or was there some other reason for this?
Jennifer Bouey
My suspicion is so. I think China was there early on in 2020, they are very keen on being the first to have a effective vaccine. They did have the first vaccine started the clinical trials, I think it was in March 2020, although that one didn't, it was not Sinovac. So I think they they really want to build a national pride on this vaccine.
Jeffrey Hiday
Thank you, Amanda or Tim, anything you want to add here?
Timothy Heath
I will add that politics has definitely been a big part of China's management of the vaccine from the very beginning. One example is the reluctance of the Chinese government to change course once Xi Jinping declared, this is the way we're going to handle it. The government refused to budge. Right up through the party Congress. And only when the protests broke out did the government start to bend. Moreover, we've seen a narrative that frequently contrasts China and success as defined by the CCP with what is going on in the West, and this disparagement and criticism of Western countries, their vaccines, their failures, actually is making it has made it harder for China to turn to the West for help. People have often asked why isn't China simply bought mRNA vaccines from the West? And if you read their media and their frequent disparagement and criticism and belittling of the West, you could see that politically, it is a very tough pill for for for those folks in Beijing to swallow, to to denounce the West on the one hand and turn to them to save China on the other. So I think the political angle should not be ignored when we are trying to understand China's approach to managing COVID.
Jeffrey Hiday
Are there neighboring countries that obviously have taken different approaches but that have taken approaches that China either might or should draw from?
Jennifer Bouey
But I studied South Korea's response to COVID. And I think at the very beginning of the pandemic, they did a almost perfect case. They had the testing kits very early on, before their first epidemic in February 2020. And then, you know, the whole system has we have published that research. Many of the Asian country has to import the mRNA technology, but they have built a very strong regional hub for production. So that's why we see the uptake of vaccine was slower than the Western countries, but they have caught up very quickly last year in the second half of the 2021 and beginning of this year. I think that really helps them quite a lot with the the Omicron. As you can see that New Zealand only had about two per million deaths rate, mortality rate at the beginning of the Omicron, whereas Hong Kong was very low vaccination rate in January, had multiple times, 38 per million mortality of that. So that you can see the difference of the vaccination impact. So I think if China are looking for models, there are plenty of models they can follow.
Jeffrey Hiday
Fair enough. Amanda. Tim, Jennifer, thanks for joining us. If anyone has follow up questions, send a note to media@rand.org. And appreciate everyone joining. Have a great day. All right.
Timothy Heath
Thanks.
Amanda Kerrigan
Thank you.
Amanda Kerrigan
Thank you.
Narrator
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