Why the race to plug China’s immunity gap is stalling

Protesters march along a street during a rally for the victims of a deadly fire as well as a protest against China's harsh Covid-19 restrictions in Beijing - NOEL CELIS/AFP via Getty Images
Protesters march along a street during a rally for the victims of a deadly fire as well as a protest against China's harsh Covid-19 restrictions in Beijing - NOEL CELIS/AFP via Getty Images

Up in the high streets of Guiyang, a city of five million people built on the rolling hills of south-east China, Mr Li is explaining his decision not to get vaccinated against Covid.

“The juweihui [local volunteers] came to my door and told me to get the vaccine, but I worried a little,” he says, perched casually next to a pile of pomelos at the end of an alleyway. “On the television news, I saw that the elderly with a certain number of basic diseases can’t get vaccinated.”

Although his own heart condition, which poses only a “slight problem”, does not apparently disqualify him from getting the Covid jab, Mr Li doesn't consider it a risk worth taking. “I live alone, so I feel like I don’t need to get vaccinated,” the 74-year-old adds.

Mr Li is one of millions of Chinese citizens who have turned their back on the Covid vaccines – a trend that is particularly acute among the elderly, with only 66 per cent of over-80s double-jabbed against the virus. In the UK, coverage among the same group is 96 per cent.

His hesitancy comes despite the country’s darkening Covid picture. China is experiencing record-high infections and outbreaks in major cities; lockdowns are being reimposed, only to be met with fierce unrest; and the nation's first Covid fatalities in six months were recorded earlier this week – developments that have reset the clock to late 2020.

Protesters hold candles as they march in Beijing - Ng Han Guan/AP
Protesters hold candles as they march in Beijing - Ng Han Guan/AP

Yet Mr Li’s views are not uncommon or unexpected in a country that has deprioritised vaccination in favour of wielding far blunter tools to eradicate Covid transmission. Even in spite of the growing frustration with zero-Covid, which has manifested in rare public protests and calls for President Xi Jinping to resign, such a policy is still embraced by millions.

Indeed, of those elderly citizens who reject the vaccines, many continue to see the virus as “life threatening and so avoid any contact”, says Xi Chen, an associate professor of health policy and economics at Yale University. “They trust in zero-Covid to protect them” – but not vaccination.

The limitations of this policy have crystallised over the past year – and in a clear sign that China’s Covid strategy has begun shifting, Chinese health authorities are now racing to increase uptake among the elderly and plug a dangerous immunity gap.

With less than four intensive care beds for every 100,000 people and so many unvaccinated or partially protected older adults, who are more vulnerable to infection, officials know that letting the virus rip is not an option.

As part of its vaccination drive, mandates and Covid passes have been enforced in multiple cities (with varying degrees of success), health insurance offered (to assure the elderly they’ll be supported if they do suffer a reaction), and western pharmaceuticals approached to share their superior mRNA technology with China.

Inadequate exit strategy

But progress in improving coverage has been slow and appears to be stalling.

Between August and November, coverage among the over-80s has increased by a few percentage points, at best. The proportion of this age group to have been boosted remains stuck at 40 per cent. And although general uptake rates are higher in the over-60s, there’s similarly been little change over the past three months.

For the younger generations desperate to return to their former lives, the future looks bleak. “I think it’s unlikely things will get better for the next half of the new year,” says Prof Chen.

“There’s little discussion about an exit strategy, not just with vaccination but preparing hospital beds, antiviral drugs, and communicating to the people that they do not need to be panicked about the virus.”

Unless coverage improves among the elderly, the need to implement controversial lockdowns and mass testing – policies that break chains of infections, but offer no long-term insurance against disease – will persist, trapping China and its economy in a damaging state of suspension.

But breaking this cycle will not be easy. Officials must first overcome a myriad of challenges, ranging from confused public communications and deep-rooted vaccine hesitancy to poor rural access.

It's hard to know what exactly it was Mr Li saw on his television in Guiyang, but there's an acknowledgement both inside and outside China that the government's mixed messaging has ingrained within many elderly citizens a hard-to-shake weariness of the vaccines.

Lingering pockets of hesitancy

At the beginning of the pandemic, as China started to roll out its Covid shots, there was little drive to inoculate the elderly, with younger citizens instead targeted.

“This was a result of the under-recruitment of the elderly in the clinical trials,” says Professor Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. This meant the government was reluctant to advocate for vaccines that hadn’t been properly tested on older people.

“Those elderly with chronic conditions, when they went to see a doctor asking them if they should get a vaccine, the doctor wouldn't give a categorical yes-no answer, because the government failed to stress they were an at-risk population and that they needed to get the vaccine,” adds Prof Huang.

This has now largely changed, with the elderly openly encouraged to get vaccinated. But ambiguous central statements around vaccination contraindications – a condition that prevents a patient from receiving medicine – has made it difficult for local authorities to assess the eligibility of older adults with underlying diseases.

This has helped create lingering pockets of hesitancy in the population, especially among older rural communities where there is a stubborn commitment to traditional Chinese medicine practices and general distrust of vaccines.

An elderly woman wearing a face mask walks on the street with her vegetable basket in Beijing, China, 10 November 2022 - WU HAO/EPA-EFE/Shutterstock
An elderly woman wearing a face mask walks on the street with her vegetable basket in Beijing, China, 10 November 2022 - WU HAO/EPA-EFE/Shutterstock

Zheng Yang, an assistant professor at Soochow University's School of Communication, says that limited knowledge of vaccination among these types of groups has proven detrimental, arguing that current public messaging in China does not go far enough.

“There is a lack of necessary science communication, such as why vaccines are effective,” he says. Urging the elderly to get jabbed lacks a punch without clearly conveying how the jabs actually work and explaining the risk-versus-reward pay-off, Dr Yang adds.

The Chinese Center for Disease Control and Prevention (CCDC) has itself stated that “older adults have more concerns on the effectiveness and safety of Covid-19 vaccines than other age groups”. But by failing to address these concerns in its messaging, the government is unlikely to succeed in encouraging China’s nervous elderly to get jabbed.

Prior to the pandemic, vaccination was already poorly publicised and promoted. This, coupled with the requirement that older adults pay for their jabs, has long contributed to low vaccine protection against numerous diseases.

In the case of influenza and pneumonia, just 6.6 per cent and 1.2 per cent of the population have been vaccinated against the two infections, respectively, according to the CCDC.

A resident takes inhaled COVID-19 booster vaccination on November 17, 2022 in Beijing, China - Wang Haixin/VCG via Getty Images
A resident takes inhaled COVID-19 booster vaccination on November 17, 2022 in Beijing, China - Wang Haixin/VCG via Getty Images

Recent pharmaceutical scandals have further fuelled scepticism. In October 2018, the Chinese company Changsheng Biotechnology was fined $1.3 billion after falsifying inspection data for a rabies jab and manufacturing ineffective diphtheria, pertussis, and tetanus vaccines for children and infants.

“Memories of these scandals influence people’s decisions,” says Prof Chen. He adds that the fragmented nature of the vaccine market – there are more than 200 manufacturers – makes it harder for regulators to root out lower-quality production methods, which are then pounced on and weaponised by social media conspiracists.

Back in Guiyang, the capital of Guizhou province, local health authorities are doing what they can to further improve the city’s coverage, which, at 90 per cent, already sits above the provincial average. Volunteers of the juweihui, the city’s neighbourhood committee, have been going from door to door in a bid to gently persuade the unvaccinated.

“The people who are with the community authorities came to our door,” says Mr Lao from the comfort of his home, out on the city edge where he lives with his two brothers, all of whom are nearing their seventies. “They advised us to get the jab, and so we did. It felt like it was something we had to do.”

Local health hubs are also playing a key role. On a bending road to the south of the city centre, past a row of dilapidated houses and shops selling fruit, noodles and homemade spicy crisps, the Weiqing Community Health Service Center offers care for local residents.

Inside, the entire first floor is dedicated to testing – a reminder of the city, and government’s, priorities – but messages dotted around the room encourage visitors to ask staff for information about the vaccines, should they have any questions or concerns.

Yet these types of facilities are rarely available in the more rural parts of the country, while local GPs are not typically licensed to administer jabs. As a result, out in the villages, mountains and open plains of China, where anti-vaccination sentiment is already more entrenched, access to the Covid vaccines is far more limited.

“People in the labour market can be organised and vaccinated by companies, whereas finding older people in disparate communities is much harder,” says Prof Chen. The challenge of tracking down the elderly, especially in rural China, is further complicated by the fact that most older adults live at home and only 3 per cent live in nursing homes, he adds.

As the Covid situation in China worsens – a record-high 31,527 cases were reported on Wednesday, compared with an April peak of 28,000 – the need to vaccinate the elderly intensifies with each passing day.

President Xi Jinping himself has argued that China’s strict curbs are required to protect the country's large elderly population – a tacit acknowledgement that, until uptake further increases among this group, the policy of zero-Covid is likely to persist.

Officials can certainly no longer be accused of passivity. Efforts are underway to target the unvaccinated and nudge the country closer to a scenario in which, one day, it could lift the shutters and return to the normality that so many crave. But the going will be tough, says Prof Chen. “There’s a long way to go.”

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