China’s urban populations have been enduring some of the most intense infection-prevention measures of the COVID-19 pandemic. For 60 straight days, Shanghai’s 27 million residents were forced into a strict lockdown – and they were not alone. During the peak of the Omicron BA.2 wave in April and May, 45 cities with a total of 373 million people were under some sort of lockdown. That is more than the combined populations of the United States (329.5 million) and Canada (38 million), and 83% of the population of the European Union (447 million).
China’s “zero-COVID” strategy has wreaked havoc on its economy and its people. But the Omicron wave has also highlighted its elderly population’s continuing vulnerability to the virus. As of June 2, 40% of those over 60 – around 95 million people – had not received any doses of a COVID-19 vaccine, even though they are at higher risk of severe illness and death from the disease.
One reason for the low vaccination rate is that the Chinese population has simply grown accustomed to the low rates of COVID-19 infections over the past two years. Now that the Omicron wave has struck, the higher perceived risk of remaining unvaccinated should increase vaccination among the elderly somewhat.
Another reason for the low vaccination rate among the elderly, however, is that many fear the side effects. To counter this, the Chinese government recently introduced a COVID-19 vaccine insurance package for individuals over 60. Vaccine recipients who fall genuinely ill stand to receive $75,000 – more than four times the country’s average annual income ($15,950). This is a clever idea. But it will not suffice, because the bigger obstacle is the lack of trust between the Chinese public and the medical establishment.
To be sure, all countries have faced difficulties in convincing concerned populations that the benefits of vaccines outweigh the risks. In the US, 15% of people remain unvaccinated against COVID-19, and 42% of this group say they don’t trust the vaccines. Still, this is a tremendous improvement from September 2020, when 49% of American adults said they would not take a vaccine if one were available. Within that cohort, 76% of survey respondents cited concerns about side effects.
The Chinese and American vaccine-resistant populations thus share a fear of side effects. But the Chinese and US medical establishments have responded to these concerns in very different ways.
In the US, the medical establishment has tried to build trust by conducting independent and transparent medical trials, the results of which are reported in uncensored publications and subject to open deliberation at all levels – by experts, journalists, politicians, and the public. This approach builds on two well-known maxims of public health: trust in the medical establishment will increase the uptake of treatments; and such trust is built through transparency and open deliberation.
In contrast, China’s approach has been almost completely opaque. The government has released very limited data on vaccine trials, and it has censored all discussion of side effects – even common minor ones such as soreness from the injection. Chinese authorities have followed the maxim that information about controversial topics should be withheld to prevent the airing of views that might run counter to government objectives.
This strategy has proved counterproductive, because it creates an information vacuum that can be filled only by rumor, speculation, and conspiracy theories. The current failure contrasts sharply with China’s own past success with deliberative decision-making on matters of health policy. After the 2002-04 SARS outbreak, China permitted a constructive debate about problems in its health system. As many noted, over 80% of rural residents, and 40% of urban dwellers, had no health insurance of any kind at the time.
In response, the government announced in 2009 that it would invest RMB 850 billion ($127 billion at today’s exchange rate) to provide health coverage for 90% of the population. The next two years featured intensive discussions among and between national and regional policymakers, health experts, community leaders, journalists, and the public. The deliberations led to many amendments in the proposed policy. Though the final product was not perfect, it proved popular and led to widespread adoption of health insurance. By 2021, 95% of Chinese had some form of coverage.
Of course, deliberation about COVID-19 vaccines will need to be faster and will not be cost-free. The Chinese vaccines would draw criticism, and some people would still be turned off by common side effects (such as fevers) or rarer risks (such as allergic reactions). Others would criticize the government’s handling of the pandemic, if given the chance.
But these short-run costs are worth the long-term benefits of building trust in public-health authorities and increasing vaccination rates over time. As other countries have found, disclosing negative information about vaccines might increase public reluctance in the short run, but it helps to sustain trust and stymie conspiracy theories.
Battling COVID-19 effectively requires accounting for the long run, given the high likelihood of future waves and the need for additional rounds of vaccinations. For China, even more than for other countries, building trust is critical, because it is a necessary step in moving away from the zero-COVID strategy. That shift will naturally lead to more infections and deaths. But open deliberations about the vaccines can increase their uptake, help to moderate the spread of the disease, and counter the negative impact on public trust.
China urgently needs to embrace transparency on this issue. The longer it waits, the more difficult it will be to abandon its economically destructive zero-COVID policy.
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