Dake Kang Profile picture
Mar 21 49 tweets 16 min read
1/When China suddenly scrapped zero-COVID in December, people were bewildered by the country's lack of preparation. Millions of elderly were unvaccinated, they hadn't stockpiled antivirals.

Why? We set out to find the answer. Our findings:
apnews.com/article/zero-c…
2/Many wondered why Beijing didn't plan for the reopening.

Actually, they did.

We discovered that as early as 2021, the State Council, China's cabinet tasked an expert committee with reviewing COVID controls. They submitted a report in March 2022 recommending exit strategies.
3/It ran over 100 pages long and was packed with proposals to boost China’s stalling vaccination campaign, increase ICU bed capacity, stock up on antivirals, and order those with mild COVID symptoms to stay at home. We're reporting the existence of this report for the first time.
4/Not only were top health experts were aware of the need to prepare, so was the government. So, what went wrong?

In short, everything.

A toxic swirl of unfortunate events, sudden outbreaks, and a tense political atmosphere derailed reopening plans.
apnews.com/article/covid-…
5/First, there was a chaotic outbreak in Hong Kong that spooked the authorities. HK racked up the highest COVID death rate in the world for weeks. Experts found that most of the people dying were unvaccinated elderly - of which there were plenty in China.
apnews.com/article/covid-…
6/Then cases began spreading in Shanghai. Shanghai's COVID response was spearheaded by Zhang Wenhong, a prominent doctor who was openly calling on the gov't to loosen controls. They pioneered "precision controls" that targeted individual buildings, not districts, for lockdowns.
6a/(Sidenote: Zhang is said to enjoy a good relationship with Li Qiang, then-Shanghai chief and now China's no. 2 official. Li was initially inclined to listen to Zhang, and it appears Li's close relationship with Xi gave Shanghai extra wiggle room to experiment with controls)
7/But Zhang's controls failed. Omicron was too infectious. Cases started arriving in other provinces, and officials complained to Beijing. They argued they lacked Shanghai’s capacity to trace the virus, risking its spread to the entire country before China was ready.
8/Shanghai officials said there would be no lockdown. But as cases rose, the authorities freaked out, worried about the deadly outbreak in Hong Kong and China's flagging elderly vaccination rate. Just days later, Beijing intervened and sealed the city.
9/The lockdown was a turning point. Shanghai wasn't ready, and residents complained loudly about brutal measures and a lack of supplies. The censors stepped in, silencing complaints - as well as debate over whether China should reopen.
apnews.com/article/covid-…
10/Views differ on who was to blame. One health official blamed Zhang & Shanghai authorities for experimenting with loose controls, calling it unscientific, a “pure disaster”. They ridiculed Shanghai's so-called "precision controls", like lockdowns of a single milk tea shop.
11/Others blame the central government, saying the Shanghai outbreak proved Omicron was impossible to contain at a reasonable cost, and that it should have spurred China to prepare faster for reopening instead.
12/Either way, the effect was the same: Xi spoke decisively in favor of zero-COVID, and everyone shut up.

Zhang disappeared from media reports and stopped posting on Weibo. Others who spoke about the need to prepare for reopening also stayed silent. Some experts were blacklisted
13/Officials tried to push the needle. But under Xi, China's most authoritarian leader in decades, the space for free discourse has narrowed considerably, with pervasive censorship & punishment for those who stray from the party line. More on that here:
14/So officials felt helpless to do much. In April, China’s State Council leaked a letter from the EU Chamber of Commerce urging relaxation of zero-COVID. They wanted to spark debate but didn’t feel empowered to raise the issue themselves.
scmp.com/economy/china-…
15/The same month, Gao Fu, then-head of the China CDC, said "omicron is not that dangerous," & that China needed to "use the current opportunity to make adjustments" ASAP.

But he made the remarks in an internal @CCG_org panel, made public only recently.
ccgupdate.substack.com/p/ccg-in-april…
16/In May, Western business associations met privately with Li Keqiang, head of the State Council and China's nominal no. 2 official. He seemed sympathetic to complaints about zero-COVID, in stark contrast to Xi's pre-recorded comments making defeating COVID the no 1 priority
17/But early in Xi's tenure, he sidelined Li, analysts say, making Li the weakest Premier in decades. Experts and businessmen say their complaints were heard by sympathetic officials high in the party, but there was little they could do.
apnews.com/article/china-…
18/Of course, there were also supporters of zero-COVID. Most prominent among them: Liang Wannian, head of the government's COVID response expert group. Many in China's public health field dislike Liang, seeing him as echoing the party line, not science-backed policies.
19/Liang defended zero-COVID publicly and internally, which detractors say prolonged an unsustainable policy. But he also has supporters, who say China had good reason to hesitate to open given worries over long-COVID and incomplete data on Omicron.
news.bjd.com.cn/2022/04/10/100…
20/Another major factor: The 20th Party Congress, China's most important political meeting in a decade, where Xi was set to be confirmed for a controversial, precedent-breaking 3rd term. Beijing needed everything to go smoothly for the sensitive meet
apnews.com/article/xi-jin…
21/As a result, everything was put on hold until the party congress. Scientists who wrote to the government advising them to adjust controls were given positive feedback, but also told to wait until after the congress was over.

"Things just got stuck," one expert told me.
22/As the party congress approaches in October, Omicron really tests China's defenses. Officials start resorting to extreme measures. Xinjiang and Tibet were locked down for months. Workers were locked into factory compounds. Still, the virus spread.
apnews.com/article/covid-…
23/(Sidenote: Local officials were under tremendous pressure because outbreaks on their turf could mean demotion - even though viruses don't care about politics. Lots were fired or demoted, and many feel they were punished unfairly. I heard of one such official in Tibet)
24/Under this pressure, officials began resorting to secret lockdowns. The city of Zhengzhou (pop: 12 million) locked down in mid-October, but as late as early November, the gov't called talk of the lockdown "rumors" - even though the city had already been locked down for weeks!
25/The party line increasingly departs from reality. Discontent is simmering. Authorities report only a handful of cases even as whole cities go into lockdown. There's factory riots & a protester calling Xi a "dictator": "We want freedom, not COVID tests"
26/At the party congress, the new leadership is unveiled - and it's stacked with Xi loyalists. Some take this as a sign that zero-COVID will continue. Many of the business and intellectual elite lose hope.
27/With the end of the congress, some health experts finally speak up. Wu Zunyou, chief China CDC epidemiologist, writes an internal report criticizing what he calls “层层加码”, or the propensity of local gov'ts to add unnecessary restrictions, saying it was causing "discontent"
28/Still, he says: “不是中央的防控政策有问题... 是对中央“动态清零“总方针的歪曲" - "it's not that the central gov't policy has a problem... it's a distortion of zero-COVID". He is said to have felt helpless b/c he was told to support zero-COVID in public even as he had doubts
29/Also speaking up behind the scenes: Zhong Nanshan, the legendary doctor famed for raising alarms about the original COVID outbreak in 2020. He bypassed the health bureaucracy and wrote to Xi personally, urging a gradual reopening. It took someone of Zhong's stature to do so.
30/In early Nov., Sun Chunlan, China's "COVID czar", holds meetings on adjusting zero-COVID.

I have to be clear: I'm not sure what the trigger was for the meetings - the end of the congress? The health experts speaking? Petitioning from business leaders, the crumbling economy?
31/Some also say top leader Wang Huning held meetings, including Reuters and WSJ. I wasn't able to confirm this independently. I am writing here mostly from the public health perspective.
32/Whatever the reason, the meetings are held. The result is 20 measures adjusting controls. Experts described it as "window dressing", minor tweaks that kept the core of zero-COVID intact. Still, it signaled Beijing want softer policies - ones that won't cause so much grumbling
33/But it doesn't stop discontent. In fact, it gets worse. Confusion ensues, as local officials try to figure out what the central govt wants. Those in China at the time know how chaotic and uncertain this period felt. It wasn't clear where things would go
34/At the end of November, cases are spreading swiftly. It looks like the whole country might hurl into lockdown.

Then it all blows up. A fire kills 10 or more. People blame deaths on virus controls. Within days, thousands are on the streets. For more:
35/Of course, the police roll into action, quelling the biggest nationwide demonstrations since 1989. The government keeps silent on the protests. But behind the scenes, they're convening meetings. The mood on zero-COVID is changing.
36/Little is known about these meetings, but we know they took place because Xinhua wrote about them afterwards. Xinhua cites growing pressure and makes references to the virus spreading out of control in Beijing and other cities
nhc.gov.cn/wjw/mtbd/20230…
37/After the meetings take place, zero-COVID is suddenly scrapped, setting the stage for China's massive wave of COVID cases as it reopened with little preparation.
apnews.com/article/health…
38/A key mystery here is - why? Why suddenly scrap zero-COVID after clinging to it for so long?

Reuters & others report newly-appointed Premier Li Qiang (ex Shanghai chief, remember?) played a big role. I heard such rumors but wasn't able to confirm them
reuters.com/world/china/ho…
39/I also don't claim to know what was going on in Xi's mind for sure. I have no idea.

But what I can say is the decision to lift controls was very sudden - and that many within the government believe that the protests were the "trigger", accelerating Xi's decision to exit
40/At the meetings before the exit, Sun, the COVID czar, said China planned to "walk briskly" out of zero-COVID. Medical experts agreed the policy needed to go, but they were surprised by how quickly the tone shifted. "The leadership was more radical than we were," one said.
41/What role the protests played in the exit is controversial. There's more analysis of this timeline here, by Professor Minxin Pei, arguing it did play a major role. That timeline lines up with our findings.
prcleader.org/pei-spring-2023
42/And here's a piece by Christopher Johnson arguing that Xi wasn't scared of the protests, as some commentators suggested, but that he might have seen the protests as a convenient way of exiting while avoiding blame:
foreignaffairs.com/china/xi-survi…
43/We may never know the full story, or the motives for the sudden reopening. But experts agree: China wasn't ready. The consequences of the sudden U-turn were obvious, and deadly. Patients filled hospitals; crematoriums worked overtime.
44/We don't know how many people died this wave, but experts guesstimate many hundreds of thousands to almost two million deaths.

Prep ahead of time, like boosting vaccinations and stocking medication may have prevented hundreds of thousands of deaths
medrxiv.org/content/10.110…
45/Policymakers faced a genuinely tough choice, a very dicey situation. Once they started exiting, there would be no going back. They fretted about deaths, about long COVID, about so many things that could go wrong. That hesitancy, while unfortunate, is understandable
46/China's zero-COVID policy wasn't pointless. China's death rate even at the high range of estimates is still significantly lower than most Western countries.
47/But given how long China had to prepare, many experts at shocked at how badly the zero-COVID exit was fumbled. Beijing claims it was well-timed, based on "scientific calculations".

It wasn't. As a retired CDC official said, “The way this happened was just unbelievable.”
48/A shout-out to my intrepid Hong Kong reporting partner-in-crime @kanis_leung for tracking down leads there, and helping to unspool some of the backstory.

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More from @dakekang

Dec 22, 2022
I just came back from two harrowing days traveling from emergency ward to emergency ward around Baoding in Hebei, one of the first areas hit by the current wave. The situation is very grim. ICU units totally overwhelmed.
1/China is facing a medical emergency. Two harrowing days in Hebei’s ICUs shows the area’s hospitals are buckling with the spread of COVID. We saw ambulances turned away from hospitals, relatives frantically searching for beds, patients sprawled on floors
apnews.com/article/health…
2/This is Langfang No. 4 People’s Hospital in Bazhou, Hebei on Thursday. The ICU was in utter chaos when we visited. The ward was packed with patients on ventilators; lines of people seeking medicine; doctors wheeling gurneys to and fro
Read 30 tweets
Dec 17, 2022
1/COVID-linked deaths are appearing in Beijing, even as China hasn’t reported a single death from COVID since December 4. The relatives of two people who died at the Dongjiao funeral home said their loved ones had positive for the virus.
apnews.com/article/health…
2/Traffic to the funeral home is way up. One person estimated about 150 people are being cremated a day, far more than the dozens on a normal day.
3/China’s official death toll remains low, with just 5,235 deaths — compared with 1.1 million in the United States. However, public health experts caution that such statistics can’t be directly compared.
Read 15 tweets
Dec 15, 2022
1/What's going on with China's first-ever wave of mass infections? At the moment, it's too early to tell. Lots of people are infected all over the country, but we haven't yet seen large numbers of critically ill patients flooding hospitals in big cities.
apnews.com/article/politi…
2/Though anecdotal evidence suggest huge numbers are getting infected, there's now no way to track.

Cities like Beijing and Shanghai appear to be holding up so far. Some doctors back to work after infection, but hospitals are so far keeping critical non-COVID wards virus-free.
3/However, the real challenge will be in the countryside. In rural areas, the healthcare infrastructure is far poorer. @xcyale says that some counties lack a single ICU bed, raising concerns about where elderly patients with COVID will seek treatment.
Read 5 tweets
Dec 14, 2022
1/Today, I went to two more fever clinics in Beijing. This one, a children’s hospital, was considerably more crowded than the ones I went to yesterday. Maybe 50 or 60 people waiting in lines.
2/More from the fever clinic.
3/This fever clinic in another part of town had mostly elderly patients. There were perhaps one to dozen people inside. People went in and out, some to buy medicine
Read 13 tweets
Dec 13, 2022
1/Visited several fever clinics in Beijing. I saw short, orderly lines, and no signs yet of overcrowding. If the medical system here can hold up for the next couple of weeks, Beijing might just make it through without a large number of fatalities, which would be a huge relief.
2/A patient getting checked up at a fever clinic. Hospital guidelines tell patients to get a nucleic acid test and wait for results before being admitted.
3/A short line while people wait for medicine, results, to see a nurse.
Read 14 tweets
Dec 7, 2022
1/China's National Health Commission just announced 10 measures amounting to what is effectively a switch from containment (stopping the spread of covid altogether) to mitigation (trying to protect the most vulnerable while the virus rips through society)
nhc.gov.cn/xcs/gzzcwj/202…
2/To summarize:
_Risk areas further shrunk, to apartment floors and individual buildings, not districts or neighborhoods
_No more health codes, no more nucleic acid test checking (except for special organizations, like nurseries, elderly care homes, schools)...
3/
_Infected people with mild cases can isolate at home
_High risk zones can be locked down for no longer than 5 days if there’s no new cases
_No more restriction of sales of cough/cold medicine
_Accelerate elderly vaccinations
_Identify high risk populations
Read 11 tweets

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