China’s Strategies and Actions Against COVID-19 and Key Insights
Liu Chen Chen Xiao
Working Paper CIKD-WP-2020-006 EN
China’s Strategies and Actions Against COVID-19 and Key Insights
Liu Chen Chen Xiao
Author Bios Liu Chen is a Project Officer of China Center for International Knowledge on Development (CIKD). Chen Xiao is an Assistant Research Fellow of CIKD.
Acknowledgement Many thanks to the colleagues in CIKD who provided very good suggestions and comments during the research.
Disclaimer The findings, interpretations and conclusions expressed in this report do not necessarily reflect the views of CIKD.
Contents
Executive Summary ...... i 1. Overall Strategy ...... 2 1) Constantly refine the strategies based on the latest risk assessment and development trend of the epidemic ...... 2 2) Adhere to the people-centered concept, prioritize the protection of people’s right to life and health in a major epidemic, ensure the public’s right to know, and mobilize the people to participate widely ...... 9 3) Adopt the most rigorous, most comprehensive, and most complete principles and objectives ...... 11 2. Key Measures ...... 12 1) Establish national-level command and decision-making institutions for emergency management and a cross-department coordination mechanism ...... 12 2) Promptly disseminate accurate information and relevant prevention knowledge via various channels ...... 13 3) Close public places, pause most economic and social activities and require to wear masks in public, to reduce the risk of social clustered transmission ...... 16 4) Take rigorous lock-down measures in multiple levels of cities and communities to break transmission chain ...... 18 5) Strive to test everyone who should be tested and separate the potential virus carriers from the healthy population, mainly through nucleic acid testing facilitated by CT scanning ...... 23 6) Combine tracking and epidemiological investigation, meticulously track all close contacts through various ways ...... 26 7) Isolate all infected patients and close contacts ...... 28
8) Increase the supply of medical resources by diverse ways, treat all ...... 29 9) Provide comprehensive support to the control and containment measures through a mix of policies ...... 33 10) Protect the elderly and other groups with high risk of infection ... 35 11) Prepare for the potential rebound of COVID-19 ...... 37 3. Impact and International Critique ...... 38 1) Impact on public health ...... 39 2) Impact on Chinese economy ...... 44 3) Impact on Chinese society ...... 47 4) Impact on the international community ...... 48 4. Insights for Other Developing Countries ...... 49 1) Under state emergency, the national government should be granted power to intervene in the country’s economic and social activities and the power to mobilize and allocate resources ...... 49 2) When facing public emergencies with great uncertainties, national governments should adopt reasonably strict and swift strategies with ...... 50 3) The national strategy should be aligned with the national basic conditions ...... 51 4) Scientists and professionals should be widely consulted throughout ...... 52 5) Adopt policy combinations and use whatever accessible. Combine traditional containment measures with modern technologies ...... 53 6) Emphasize supervision and accountability mechanisms to ensure local policy enforcement ...... 53
Executive Summary
As the outbreak of COVID-19 evolved into a global pandemic, how to effectively tackle the disease has become the most serious challenge for most countries. Under the strong leadership of the Chinese government and the active participation of all sectors of Chinese society, the spread of COVID-19 is mostly under control within China. Many international organizations, national leaders, and world-renowned scholars commended China’s tremendous efforts, and they believe that lessons from China’s experiences can be beneficial to other countries.
In China’s overall strategy against COVID-19, the Chinese government insists on putting people’s right to life and health at its first priority. By mobilizing all sectors of Chinese society to take the responsibility of fighting against the pandemic, the government implemented the most comprehensive, rigorous and complete measures. China’s public health system not only focuses on treating patients, but also puts heavy emphasis on contain and control the spread of the virus. The following three characteristics were key to China’s relatively successful strategy. Firstly, constantly making adjustments based on the updated risk assessment and development trend of the pandemic. Secondly, based on the people- centered concept, the Chinese government not only puts people’s wellbeing at the top priority but also depends on the people by making them a major force and an essential part of the effort to tackle the pandemic, which could significantly increase the efficiency of the containment measures. Thirdly, following the basic principles of public health of “controlling the source, cutting transmission chain, and protecting the
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susceptible population”. The Chinese government uses whatever available including comprehensive measures that combine traditional approaches with modern science and technology to prevent the spread of the virus and save life.
As for the key measures, aiming at preventing the spread of the virus, lowering the fatality rate of infected patients as fast as possible, Chinese government has taken the traditional methods of social distancing and quarantine, along with providing treatment for all patients. The Chinese government also made great effort to mobilize the entire nation and coordinate resources at the national level, while encouraging medical professionals to play a significant role in the process and utilizing latest technologies whenever applicable. Additionally, enhancing information release and the supervision and accountability system also helped all the measures to be fully implemented. There are 10 major measures that the Chinese government took during the outbreak.
Establish national-level command and decision-making institutions for emergency management and a cross-department coordination mechanism Promptly disseminate accurate information and relevant prevention knowledge via various channels. Close public places, pause most economic and social activities and require to wear masks in public, to reduce the risk of social clustered transmission. Take rigorous lock-down measures in multiple levels of cities and communities to break transmission chain. Strive to test everyone who should be tested and separate the potential
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virus carriers from the healthy population, mainly through nucleic acid testing facilitated by CT scanning. Combine tracking and epidemiological investigation, meticulously track all close contacts through various ways. Isolate all infected patients and close contacts. Increase the supply of medical resources by diverse ways, treat all patients while prioritizing the severe cases. Provide comprehensive support to the control and containment measures through a mix of policies. Protect the elderly and other groups with high risk of infection. Prepare for the potential rebound of COVID-19.
Facing this sudden outbreak of COVD-19, the Chinese Government has adapted strategies and measures to the changing epidemic situation, and it also made sure to fully implement and enforce all the methods of containing respiratory infectious disease. China’s way to fight against COVID-19 successfully stopped the domestic spread of the virus within a short period of time and saved hundreds of thousands of people’s lives, as well as created the window of opportunity for the world. Though, this outbreak results in shocks to Chinese economy in short term. After a one- month break, the work and production resumption are now in progress in an orderly manner. This outbreak has also some social impacts. China’s rigorous and strict containment measures successfully protected the health and safety of the people and secured their awareness about the epidemic situation in their neighborhood. But some measures have a negative impact on people’s freedom of movement and privacy.
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China’s way of tackling the pandemic can offer valuable insights to other countries. Firstly, under state emergency, the national government should be granted power to intervene in the country’s economic and social activities and the power to mobilize and allocate resources. Secondly, when facing public emergencies with great uncertainties, national governments should adopt reasonably strict and swift strategies with great caution. Politicians should lead the country to reach a consensus and be willing to take necessary tradeoffs. Thirdly, the national strategy should be aligned with the national basic conditions. Fourthly, scientists and professionals should be widely consulted throughout the policy process. Fifthly, adopt policy combinations and use whatever accessible, and combine traditional containment measures with modern technologies. Lastly, emphasize supervision and accountability mechanisms to ensure local policy enforcement.
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As of April 9th, 2020, the novel coronavirus spread to 211 countries and regions around the world, and there were 1.44 million confirmed cases and more than 850,000 deaths in total. This worrying situation means that stopping the transmission of COVID-19 has become the most serious challenge to the future of mankind across all countries at the moment.
In late December, 2019, a local hospital in Wuhan, Hubei reported cases of pneumonia with unknown etiology. In the following 20 days, Chinese scientists discovered that the pathogen is a new coronavirus and it has a feature of sustained “human-to-human transmission”. On January 20th, the Chinese government began to mobilize all sectors of the society and took firm measures of prevention and control. It took China more than a month to initially curb the spread of the epidemic and about two months to control the daily number of domestic new cases under 10. In early April, the spread of COVID-19 was mostly under control within the Chinese border, although China was still facing the risk of sporadic cases and considerable pressure from cross-border spread.
Many international organizations, including the World Health Organization (WHO), national leaders, world-renowned scholars praised the measures taken by the Chinese government in tackling the spread of the novel coronavirus, and many believed other countries can benefit from China’s experiences when formulating their own strategies and action plans. Under this context, this report seeks to summarize the fundamental strategies and key measures adopted by the Chinese government to fight against COVID- 19, after it recognized the risk of sustained “human-to-human transmission”, and hopefully provide meaningful and useful insights to
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help other developing countries make their decisions. The report will not discuss the strategies and measures related to the resumption of work, which were adopted after the epidemic was contained.
1. Overall Strategy
Based on the advice from the third group of senior experts from the National Health Commission of China and the risk assessment of COVID- 19 on public health, the Chinese government proposed on January 20th, 2020 to adopt the most comprehensive, the most rigorous, and the most complete measures to control its spread, with an all-of-government and all- of-society approach. The Chinese government put the people’s right to life and health first and termed the battle against COVID-19 a people’s war, and a total war, demonstrating the level of seriousness in the attitude of the Chinese authority. According to the “Report of the WHO-China Joint Mission on Coronavirus Disease 2019”, China’s containment measures were considered as “the most ambitious, agile, and aggressive” in recent history of public health, that were clearly effective in slowing down the spread of the coronavirus. The following three characteristics were key to China’s relatively successful strategy.
1) Constantly refine the strategies based on the latest risk assessment and development trend of the epidemic
China’s response to COVID-19 can be divided into three main phases, as displayed in Figure 1. During each phase, China faced vastly different challenges and therefore adopted measures that were specific to address the key challenges of that phase, which indicated the learning and adaptive
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capabilities of the Chinese government and the society in responding to the outbreak.
Figure 1: Timeline of China’s COVID-19 Epidemic and Intervention
Source: the authors’ compilation
Phase I: Launch total war against COVID-19, as the risk of rapid spread increased substantially
On January 20th, 2020, the Chinese government declared that the novel coronavirus-caused pneumonia is a Class B statutory infectious disease to be treated with control measures applicable to Class A diseases. This marked the beginning of the first phase, which lasted till February 23rd, when the Chinese government held the national meeting on coordinating COVID-19 control with economic and social development. This phase saw China’s total war against COVID-19 and was the most critical period for China to contain the spread of the epidemic. Aiming to eliminate the virus transmission, the Chinese government established the Joint Prevention and Control Mechanism of the State Council and launched the public prevention and control system, to better coordinate resources and efforts and facilitate the process of “early detection, early reporting, early isolation, and early treatment” as well as
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“gathering patients, gathering experts, pooling resources, and treating patients collectively”. China identified two battlegrounds, a main one in Hubei Province and Wuhan City, whose key objective was to prevent the virus from spreading to other places, control the escalation of the pandemic within Hubei, and treat as many patients as possible. And the second one was outside of Hubei, whose main goal was to prevent incoming cases from Hubei and Wuhan and provide assistance to Hubei and Wuhan.
Medical experts such as Zhong Nanshan played a significant role in providing recommendations to China’s decision-making process during this phase. In particular, after their investigation in Wuhan from January 18th, the group of experts headed by Zhong corrected some inaccurate judgments made by previous groups and pointed out that COVID-19 can be transmitted from human to human. Based on their assessment of the situation in Wuhan at the time, they made the advice to the central government that “people from other places should not travel to Wuhan, and people inside Wuhan should not leave”. This piece of advice was an important consideration for the central government’s decision to lock down Wuhan. The group of experts realized that China was at the brink of a large- scale outbreak, as fever clinics were overcrowded in Wuhan, hospitals were full, and cases that could be traced to Wuhan appeared in many places in China that led to local community transmission. More importantly, the Spring Festival was approaching, which was the most celebrated festival and longest national holiday in China, similar to Christmas in western countries. During the Spring Festival break, most Chinese would return to their hometown to be with their family and friends, and thus, China usually sees a tremendous increase in the volume of traffic within and between
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regions. Hubei, and Wuhan in particular, is one of the busiest traffic hubs in China. Each year, more than 10 million passengers transit from Wuhan through various forms of public transportations to all parts of China. If left uncontrolled, the huge traffic volume will greatly accelerate the spread of COVID-19. Some experts predicted that, in closed environments, the effective reproduction number of COVID-19 could increase from averaging two to three people to five to six people. China has suffered from this in the past. During the 1960s, huge population flows through a very crowded railway system within a short period of time resulted in the transmission of epidemic cerebrospinal meningitis to over 3 million people, causing approximately 160,000 fatalities.
Under this circumstance, the Chinese Government determined to launch the all-of-government and all-of-society approach. As the public health system itself is incapable of dealing with huge movement of population, the Chinese Government had to mobilize the entire nation and pool resources together to tackle the situation. This means that all ministries must be involved to coordinate actions to ensure all containment measures are correctly and promptly implemented. Moreover, the government must send out a strongest and clearest signal to the public to show the seriousness of the situation, so that the public will be willing to form a social consensus, which is absolutely required to suspend the ancient tradition of celebrating the Spring Festival.
After the COVID-19 outbreak, the rapid increase in patients put considerable pressure on medical resources. In the first ten days of lockdown, most mild and suspected cases were quarantined at home. This arrangement still failed to stop confirmed and suspected cases from
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infecting family members and neighbors during home isolation. The Chinese government immediately adjusted its prevention and control strategy to “hospitalization of all who need to be hospitalized, treating all who need to be treated, testing all who need to be tested and isolating all who need to be isolated.” While tapping potential in Wuhan City and Hubei Province to increase the supply of medical and health resources, the central government encouraged medical facilities from all parts of China to provide medical assistance to Hubei and Wuhan, including hundreds of public health workers for epidemiological survey. The decision to treat all confirmed patients and isolate all suspected patients and close contacts was based on the less than ideal results of household isolation, which led to clustered transmission in many communities, and also under professional advice. For example, Wang Chen, President of the Chinese Academy of Medical Sciences suggested that China should set up temporary makeshift hospitals to take in all confirmed patients for treatment.
China was able to execute these policies because it has the capabilities to do so. On one hand, the Chinese government has relatively greater capabilities of social mobilization, and China has a well-established industrial basis, contributing to the increase of PPE production in a short period of time. On the other hand, the active participation of Chinese people is also crucial for China’s strategy to work. As the Head of WHO, Tedros Adhanom, pointed out, the commitment from government and the participation of the public are necessary for successfully tackling the spread of COVID-19. The active participation of Chinese people is the reflection of their support to the Chinese government’s measures, and also the reflection of social consensus and traditional Chinese values of collectivism.
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Phase II: Coordinate the containment measures with restoring the normal economic and social order, as the spread of COVID-19 was mostly contained
On February 23rd, the Chinese government held the meeting to advance the work on coordinating the containment and control of the COVID-19 and economic and social development. This marked the beginning of the second phase, which lasted until late March, when the Chinese government announced its border control measures. During this phase, the primary focus of the Chinese government shifted from tackling the spread of COVID-19 to balancing the need to contain the risk of further spreading and the need to restore normal order to Chinese society. As shown in Figure 2, since February 21st, the daily number of new suspected cases in China dropped below 1,000. On the containment side, a more or less unified national strategy was replaced by regional strategies based on various levels of risk in different regions. On restoring order side, the nation-wide suspension of economic and social activities was gradually lifted, and the Chinese government wish to lead the country back to normal as soon as possible and try to achieve the annual goals of development.
Figure 2: Daily Numbers of New Suspected Cases in China
Source: National Health Commission of China
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Phase III: Shift focus to accelerate work resumption and prevent imported of cases, as domestic spread mostly stopped and the risk of cross-border transmission significantly increased
The third phase started when China announced its decision to reduce the number of international flights and temporarily halt foreigners from entering China in late March. China adopted the strategy of preventing imported cases from other countries and preventing the resurgence of the pandemic domestically. Within China, the Chinese government declared that domestic transmission had been mostly stopped, and the lockdown of Hubei was lifted since March 25th, 2020, while the lockdown of Wuhan was lifted on April 8th, 2020. As the normal economic and social order gradually restored, many local governments were trying to speed up this process with different policy combinations.
Globally, many countries and regions are now tackling the outbreak of COVID-19, and the WHO made the assessment that COVID-19 could be characterized as a pandemic on March 11th, 2020. As the situation escalates quickly across the globe, China is now facing new challenges of increasing cases flowing in from other countries. Beijing, the capital of China and an international metropolitan, became the main battle ground for China’s war against COVID-19 as it is a main destination for international travelers. On March 19th and 26th, the Chinese government announced twice that international flights going to Beijing will be diverted to nearby cities to reduce the risk and pressure of the capital city. On March 28th, under the tremendous pressure of fast-growing imported cases, the Chinese government had to reduce the number of international flights into and out
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of China and temporarily ban foreigners from entering.
During this phase, China paid great attention to advancing international cooperation for fighting COVID-19 by sharing useful information and donating much needed medical supplies and sending out medical experts to other countries, in the hope that the world would stand together and defeat the pandemic. To this end, the Chinese government also established a dedicated online knowledge hub, available for all countries. China also organized multiple sessions of online seminar for the Chinese experts to share their experience and insights with their colleagues in other countries, including 7 editions of diagnosis and treatment plan, 6 editions of containment guidelines, the standard of 14-day latent period, and other useful information.
As of April 10th, the Chinese government pledged to provide medical assistance to 127 countries and 4 international organizations including the WHO and the African Union. The Chinese government also firmly supports the important work done by the WHO and contributed 20 million US dollar to help its operation.
2) Adhere to the people-centered concept, prioritize the protection of people’s right to life and health in a major epidemic, ensure the public’s right to know, and mobilize the people to participate widely
In its daily work, the Chinese government adheres to people-centered concept, and always regards the right to life and development as the primary basic human rights, coordinating to increase the rights of all people and striving to promote the comprehensive development of human beings. When facing natural disasters, the Chinese government always puts the
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safety of the people first and uses every possible way to minimize their losses and casualty. After the outbreak of COVID-19, the Chinese government stressed once again that people’s safety and health must be the top priority, and the Chinese government mobilized all possible means to contain the spread of the virus and save every patient, regardless the cost.
The right to survive, particularly the right to life and health, is the most basic human right as it is the basis for all other aspects of human development. All of the measures implemented by the Chinese government in combating COVID-19 were oriented towards protecting people’s right to survive, while following the basic epidemiology principles and practices.
After the spread was mostly under control and the risk to people’s health and safety was greatly reduced, the Chinese government quickly decided to restore its focus on economic and social development to protect people’s right of development, while maintaining its focus on containing the pandemic.
Since the outbreak, the Chinese government also had to think about the tradeoffs between different types of civil and political rights. After recognizing the risk of rapid and wide spread of COVID-19, the Chinese government decided to ensure people’s right to know. During the high-risk period and in the epicenter, the local government released the personal information of some high-risk individuals as required, thus fully protecting the public’s right to know. This will be explained further in later parts of the report.
On the other hand, the people-centered concept also means the government should depend on its people. China’s rapid economic and social
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development over the past decades showed that people’s active participation is the most fundamental element in realizing all development goals. Facing the serious threat of COVID-19, the Chinese people became a major force and an essential part of the effort to tackle the pandemic, significantly increasing the efficiency of the containment measures. At the same time, none of the rigorous measures would actually work if the people do not understand the necessity or do not support the government’s decision to implement those measures. Currently, many western countries are experiencing difficulties when trying to implement lockdown and quarantine measures, as the lack of public understanding and cooperation made those measures difficult to be fully executed.
3) Adopt the most rigorous, most comprehensive, and most complete principles and objectives
The history of human beings fighting viruses tells us that when faced with sudden outbreak of a pandemic, it is imperative to control the source of the disease and cut its transmission chain. China closely followed these basic principles when tackling the spread of COVID-19.
Firstly, the Chinese government declared that the spread of COVID-19 must be contained at all costs, and implemented a series of measures that paused most economic and social activities, including shutting down schools and enterprises as well as locking down cities and communities. These rigorous measures played a crucial role in containing the spread of the virus.
Secondly, China adopted the all-of-government and all-of-society approach. This approach is required to properly tackle the serious challenge
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caused by COVID-19. Besides, China has accumulated successful experience in coordinating the efforts of governmental bodies, assistance partners, and civil society organizations.
Thirdly, with a view to completely defeat the pandemic, the central government of China directed local governments at all levels to track all suspected cases and close contacts, and ensure that all confirmed cases were treated. This is different from the measures taken by many other countries aimed at flattening the pandemic curve to prevent overwhelming medical facilities.
2. Key Measures
As China’s main strategy, the Chinese government aimed at eliminating the spread of COVID-19 and lowering the fatality rate of infected patients, using traditional and rigors methods of social distancing and quarantine, with treatment for all patients. The Chinese government made great efforts to mobilize and coordinate all the national resources, while encouraging medical professionals to play a significant role in the process and facilitating the utilization of the latest technologies to facilitate all aspects of the fight against the virus. Additionally, enhancing information disclosure and the supervision and accountability system also contributed to the full implementation of the containment measures.
1) Establish national-level command and decision-making institutions for emergency management and a cross-department coordination mechanism
Under the leadership of the Standing Committee of the Central Politburo of Chinese Communist Party, the “Central Leading Group for Response to
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COVID-19 Outbreak” was established for command and decision-making, to strengthen unified leadership and command of national epidemic prevention and control. In the State Council, the “State Council’s Working Mechanism for Joint Prevention and Control of COVID-19 Outbreak” was established. A central government team was sent to guide epidemic control work in severely-hit regions. A “wartime pandemic command system” was adopted to enhance a centralized, unified and efficient leadership.
The Mechanism for Joint Prevention and Control was a multi-ministerial coordination platform, led by the National Health Commission, composed by a total of 32 departments. Under the Mechanism, there are working teams for epidemic prevention and control, medical treatment, scientific research, publicity, foreign affairs, logistics support, and frontier work. These teams were led by the chairmen of related ministries with clear responsibility. They collaborated with each other to form an effective joint force for prevention and control of the epidemic.
2) Promptly disseminate accurate information and relevant prevention knowledge via various channels
The “Central Leading Group for Response to COVID-19 Outbreak” attached great importance to information disclosure, and believed that timely and accurate release of the latest situation and relevant information of the epidemic to the society had an important impact on stabilizing public sentiment, enhancing confidence in anti-epidemic and timely adjustment of decision-making. On January 25th, 2020, the Central Politburo stressed that information must be released promptly, and more efforts should be put into answering the most frequently asked questions from the public and the
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international community and explaining the rationale behind China’s strategy and measures. The Joint Prevention and Control Mechanism of the State Council released timely information on the epidemic situation, intervention measures, and medical supplies every day.
At the legislation level, a number of laws such as the “Regulation of the People’s Republic of China on the Disclosure of Government Information”, “Law of the People’s Republic of China on the Prevention and Treatment of Infectious Diseases”, and “Regulation on the Urgent Handling of Public Health Emergencies” all require the governmental bodies in charge to release information relevant to the citizens, entities, and organizations that might be affected. Local governments at the county level and above are also legally required to release their detailed public emergency response plans. All governmental agencies should also promptly clarify any widely circulating misinformation.
To achieve these, the central government required all medical facilities and the Disease Control and Prevention branches in China to use the patient information card for epidemic cases to calculate the total number of confirmed cases, suspected cases, and close contacts and report to the local government, which then in turn report to the higher-level government after consolidating information received from various sources. This forms China’s reporting network for epidemic and public health emergencies. Within this network, municipal and provincial governments must verify the data for that day within two hours, and the national CDC must verify the data for the whole nation within four hours. After the data is verified, all local governments then publish them to various platforms such as official
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websites, local news, and online social media. In the two months after the outbreak, the Information Office of the State Council, the Joint Prevention and Control Mechanism of the State Council and Hubei province, the hardest hit area in the country, held nearly 200 press conferences. In addition, other provinces and regions, such as Beijing, also held hundreds of local press conferences.1
The Chinese government also made efforts to improve the reporting system, unifying statistical criteria and subjecting it to public supervision. Local governments in China also published the necessary details of each new case, including the residential location and recent travel history of the anonymous case, to inform the public and allow the public to be alert on the risk of possible exposure. The public could refer to the “epidemic map”, which is supported by big data technology, for the precise location and number of infection cases in a specific community to respond in quick time and promptly formulate traffic control and other measures.2 Although the information published by the local government does not include the individual’s complete name and telephone information and is anonymized and minimized as much as possible, this approach has the risk of exposing the personal privacy of residents. It should be emphasized that the publication of personal information of high-risk persons ensures the public’s right to know, facilitates the self-protection of the relevant population, and also helps the public to supervise the local government to truthfully report epidemic information.
1 China Watch Institute, China Daily Institute of Contemporary China Studies, Tsinghua University School of Health Policy and Management, Peking Union Medical College (2020), China’s Fight against COVID-19, April 21, 2020. 2 Ibid.
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Furthermore, the Chinese government also established a supervision and accountability system. On January 24th, the State Council’s official website and WeChat account added a section for the public to report problems with the information reporting system. For example, two government officials from the municipal government of Lengshuijiang in Hunan Province were suspended and put under investigation, because the inconsistency in the data they reported had negatively affected local containment efforts.
Smartphones have become the primary way for people to get information. Experts such as Zhong Nanshan and Li Lanjuan used Weibo and similar apps to publish their latest findings and recommendations so that the public could receive the information quickly. Apps such as WeChat and QQ are particularly good for organizing groups, and therefore many communities and companies use these apps to share internal information with the members. Many news apps set up dedicated sections on COVID-19 and also worked closely with government agencies to dispel rumors and misinformation online by providing accurate information. Traditional media platforms such as television also played their part, particularly in promoting public awareness and sharing information on infection prevention. Many television stations in China invited medical experts to share updates on the situation and urged all citizens to wear masks in public.
3) Close public places, pause most economic and social activities and require to wear masks in public, to reduce the risk of social clustered transmission
As we know China is very densely populated, and therefore it is necessary to shut down public places and encourage people to stay at home to prevent
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human-to-human transmission of COVID-19. Around January 24th, many places in China announced that public places such as shopping malls, restaurants, cinemas, libraries and also public transportation services would be temporarily shut down. Many places also banned public gathering and set up requirements for queuing in public places and taking elevators. Also, all people were asked to wear masks in public. People must keep social distance of at least one meter away from each other.
The outbreak of COVID-19 coincided with the Chinese Spring Festival, so most schools and enterprises were already closed. To prevent transmissions in these places, the Chinese government decided to properly extend the holiday, and encourage schools and companies to utilize online platforms to reduce the impact. Online teaching and video conferences became widely used. Currently, as the outbreak is largely brought under control, companies are gradually reopening and many schools in places with relatively lower risks also plan to reopen in mid-April.
China’s extensive digital infrastructure played a significant role in enabling all kinds of entities to utilize online platforms. According to China Internet Network Information Center, as of June 2019, China had 854 million internet users, accounting for 61.2% of its total population. A test done by Speetntest.net in February 2020 showed that mainland China ranked 11th out of 140 entities in terms of mobile network speed, and 24th out of 176 in terms of broadband network speed. Moreover, companies such as Alibaba, Tencent, and Baidu launched a series of free online tools and applications for schools and enterprises to use for their online education and communication purposes. The three main internet service providers in
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China also announced many promotional deals to lower the cost of data and internet, so that people can afford to use their services. Apart from online learning, students in remote areas can also take courses through television programs launched by local governments. These measures enabled most people in China to complete their education or work from home.
4) Take rigorous lock-down measures in multiple levels of cities and communities to break transmission chain
After the outbreak, China adopted comparatively stricter temperature detection methods with higher standards in border control and locked down cities and communities. These measures restricted Chinese citizens from traveling abroad to some extent. Besides, many countries closed their borders to China or imposed travel restrictions on Chinese nationals. This reduced the number of Chinese citizens leaving China. On March 26th, 2020, with surging COVID-19 cases coming from other countries every day, China decided to learn from other countries, and announced temporary suspension of entry by foreign nationals.
Within China, especially in Hubei and Wuhan, the Chinese government adopted the most rigorous measure to control the movement of people into and out of Wuhan. On January 23rd, 2020, under the instruction from the central government, the municipal government of Wuhan declared that all forms of transportation including railway, air, ferries, and highways would be closed, and citizens should not leave the city without permission. On January 25th, the government of Wuhan announced that only authorized vehicles will be allowed to run in the city. Starting from February 14th,
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Wuhan again upgraded the control measures, aimed to lockdown all communities by February 23rd. A total of 1,501 traffic checkpoints were established in Hubei province, at highway toll gates and road crossings in cities, counties and villages, including 51 in Wuhan and 1,450 in other cities and prefectures, to stop the virus from spreading to the rest of the country and rural areas with relatively poor health infrastructure within the province.3
These strict lockdown measures were based on three main considerations. Firstly, Hubei is an important traffic hub in China. In 2019, over 14.68 million passengers passed through Wuhan during the Spring Festival holiday. Also, during early phases, most cases in places outside of Hubei can be traced back to Wuhan. Secondly, the number of patients was rapidly growing in Wuhan, making it impossible to conduct epidemiological survey. As of January 22nd, Hubei reported a total of 444 cases and 2,556 close contacts, averaging 5.8 close contacts per patient. In particular, Wuhan accounted for 408 of the cases, with 62 new cases reported on that day. These number did not include the vast number of suspected cases. Some research showed that the number of suspected cases could be four times the number of confirmed cases. 4 Thirdly, the transmission of asymptomatic and mild cases made it impossible to differentiate patients with conventional methods of detection. The speed of transmission of COVID-19 is faster than SARS. Some experts say that during this period, the doubling time of cases in Wuhan is around 7.4 days, while the doubling time for SARS was 9 days. Also, the incubation period of COVID-19 can
3 Ibid. 4 Li, R.Y., et al. (2020) “Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2)”, Science, https://science.sciencemag.org/content/early/2020/03/24/science.abb3221,16 March 2020.
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be for up to 14 days, with special cases reaching 24 days or even longer. Studies show that asymptomatic and mild patients could account for up to 50% of all cases, and the only way to confirm the diagnosis was through nucleic acid test. The study also shows that the amount of virus carried by asymptomatic patients are equivalent to normal patients, and this means conventional methods of detection could not separate these patients from the healthy population and thus not able to stop transmission.
Under these circumstances, it was necessary to implement the most rigorous and strict control measures to contain transmission. However, to lock down a mega city like Wuhan with more than 10 million residents was not an easy job, and thus, the Chinese government made tremendous efforts to ensure the lockdown would be fully implemented. On the government side, the central government sent a working group to guide and supervise the work of Wuhan, incompetent local officials were removed and replaced. Local government actively communicated with the public to seek their understanding and cooperation. On the execution level, Wuhan has 37,000 police officers, and 54% of them are auxiliary police that patrol the streets daily, so they are familiar with the local geography. During the lockdown, these people were able to man the roadblock. Wuhan also utilized CCTV cameras and cellphones to track unauthorized departing travelers. Additionally, Wuhan only has 19 main entrances, and there are roadblocks and toll booths at each entrance. These factors facilitated the execution of the lockdown, but some news reports say that some people still managed to leave the city between January 23rd and 26th, especially during the eight hours following the announcement of the lockdown, nearly 200,000 people managed to leave. As the decision to lock down Wuhan was made very
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urgently, and there was not enough time to fully prepare for the lockdown, so partial implementation at the beginning was understandable.
Other cities in Hubei Province also implemented similar lockdown measures, strictly restricting people from travelling into and out of the cities and communities. In places outside of Hubei, even though the central government did not make any specific requirements for them, many communities voluntarily implemented lockdown measures, restricting people leaving and entering the neighborhood. Many places wanted to imitate Wuhan, partially because the lockdown of Wuhan send out a strong signal to the nation revealing the seriousness of the situation, but also because some remote places are concerned about the medical capabilities of local hospitals.
The implementation of the lockdowns is greatly dependent on the involvement of all sectors and aspects of the nation. On one hand, local members of the Chinese Communist Party and civil servants worked hard to bridge the communication gaps between local governments and residents and make sure the measures are well executed and enforced. On the other hand, the public willingly became part of the enforcing body of those lockdown measures. Community workers volunteered to set up check points in their neighborhoods, registering incoming visitors and outgoing residents, checking people’s temperatures, stopping unauthorized people and vehicles from entering, and patrolling local areas to prevent social gatherings.
Public support was an essential condition for the lockdown measures to work. In China, public support came from their trust in the policies formulated by the Chinese government based on scientific evidence and
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professional recommendations. Moreover, Chinese people always had high degree of confidence in the Chinese government. According to a survey of 28 major economies about the level of people’s trust in their national government done by Edelman Public Relations Worldwide, the Chinese government achieved over 80 points among the general public for three consecutive years, topping a trust index among all surveyed economies. Especially when facing natural disasters, the good track record of the Chinese government in effectively tackling those disasters made the public deeply believe that it is the most trusted and reliable force that truly cares about the wellbeing of its people. Additionally, Chinese people always put the greater good before their own interests. Their trust in the Chinese government coupled with their care for the greater good made the Chinese people willing to endure the strict lockdown measures and sacrifice their personal short-term interests for the long-term benefit of the entire nation.
An equally important factor is that local authorities have tried their best to meet people’s basic needs for daily life. China has a relatively mature and comprehensive social management and public service system, and Chinese people also have the tradition of helping each other out during difficult times. The well-developed online shopping and logistics systems in China also made it much easier for people to agree to stay at home. It is worth noting that although the outbreak of the pandemic had affected people’s income, but the relatively high savings rate in Chinese households mitigated the impact to a certain degree. According to the IMF, China’s savings rate in 2017 was 47%, far higher than global average and OECD average. The savings provided the Chinese households with necessary means to subsist themselves during the lockdown.
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5) Strive to test everyone who should be tested and separate the potential virus carriers from the healthy population, mainly through nucleic acid testing facilitated by CT scanning
The nucleic acid testing is currently the only reliable way to diagnose COVID-19 infection, and the test results are particularly important to identify infected patients to isolate and treat them. The earlier someone is tested, the earlier he or she can be treated, and the better chance of recovery. To differentiate the infected people from the healthy population and prevent further transmission, the Chinese government made the decision that every suspected case and close contacts must be tested as soon as possible. To achieve this, the Chinese government enacted a series of policies including boosting production capabilities of testing kits, recruiting more healthcare workers to perform tests, and optimizing the testing procedures to improve the speed, efficiency, and accuracy of the tests.
Prior to January 14th, 2020, patients in Wuhan need to go to the local CDC for the test, and their samples were then sent to the National CDC in Beijing to be tested. This whole process took two days to complete. As the need for tests grew rapidly, the National CDC allowed the Provincial CDC of Hubei to perform the tests, and subsequently, Grade III Class A hospitals and professional testing facilities in Hubei were also allowed to perform tests. As of February 6th, there were 35 facilities that can perform tests for COVID-19 infection, and the time required to complete the testing process was shortened to 6 to 8 hours. At this rate, all new cases of the previous day can be completely tested. It should be noted that allowing more
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institutions to carry out the test also means the healthcare workers in those institutions will face greater risks of infection, and thus the staff should be protected with proper medical equipment. The testing agencies must have biosafety level 2 laboratories and able to conduct reverse transcription- PCR.
During the early phases, China also faced a shortage of testing kits. At the beginning of the outbreak, Wuhan could only perform 200 tests each day, which was far from enough to cover all the cases. Doctors had to use CT scans as evidence for their diagnosis, but the large number of patients even made the CT scanners overloaded. To address the shortage of testing kits, the National Medical Products Administration (NMPA) of China enacted the emergency approval procedures to accelerate the process while ensuring the safety, efficacy, and quality of the products. Under normal conditions, the time needed for nucleic acid testing kits to be approved can take 3 to 5 years or even longer. Facing the threat of COVID-19, the NMPA had approved 25 testing products for COVID-19 by the end of March, of which 17 were nucleic acid test products and 8 were antibody test products. Additionally, the Chinese government also made efforts to expand the production capabilities for testing kits. Various government bodies worked together to solve the problems preventing factories from expanding their productions, including the lack of protective equipment, lack of manpower, lack of funding, and difficulties with cold-chain transportation.
Since late February, the testing capabilities in Wuhan have reached 20,000 per day, mostly covering all the testing needs for each day. China’s daily production capability reached 2.6 million kits per day for nucleic acid test
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and 1 million kits per day for antibody tests. Currently, it only takes about 1.5 hours to complete the entire testing process from sampling to getting results, and it only takes 15 minutes for antibody tests to produce results, significantly boosting the speed for tests. It should also be noted that while the emergency approval and production procedure effectively solved the shortage of testing kits, they also led to some questionable products being released to the market. Chinese authorities are currently working closely to improve the quality of all medical products approved during this emergency period, and asking all manufacturing companies to complete all the clinical verifications required.
The Chinese government also paid attention to improving the accuracy of the tests and reduce the probability of false negative results. Some Chinese scholars5 discovered that the problem of relatively high probability of false negatives yielded by nuclei acid test at early phases can be solved by improving the quality of the testing kits, optimizing the sampling and transportation process, upgrading the medical equipment in labs, improving the skills of the healthcare workers, and optimizing the testing procedures.
For the sampling process, the healthcare workers can only complete the sampling when they are properly protected. As the sampling process requires the healthcare workers to swap the inside of the person’s nose or throat, it was common for the patients to sneeze or cough onto the healthcare worker, putting them in danger of infection. This may deter some healthcare workers from completing the sampling process properly. Thus, it is important to provide N95 masks, goggles, gloves, and protective
5 Mo, Q., et al. (2020) Understanding the Influential Factors of Nucleic Acid Detection of Novel Coronavirus, Chinese Journal of Laboratory Medicine, 43(3), 213-216.
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suits for healthcare workers to protect themselves when conducting the sampling.
For the transportation and storage of the samples, the duration between sample was taken and the actual test and the ability to store and transport the samples at low temperature could all affect the accuracy of the tests.
For the testing procedure, taking samples from different places and conducting parallel tests with different test kits could lower the possibility of false negatives. In Shanghai, when testing incoming travelers, the healthcare workers usually take two samples, one from nose and other from throat.
6) Combine tracking and epidemiological investigation, meticulously track all close contacts through various ways
Tracking all close contacts were an important part of the containment measures, as it gives the local authorities to increase their preparedness.
According to China’s “Novel Coronavirus Pneumonia Diagnosis and Treatment Plan”, a close contact is defined as any unprotected person who has been in close proximity with any suspected or confirmed patient in the past two days of patient showing symptoms, or in close proximity with any asymptomatic patient in the past two days before the patient was tested. As of March 23rd, 2020, a total of 691,185 close contacts were tracked in China, and 12,077 of them were under medical observation at the time.
In China, the job of tracking close contacts is done by professional healthcare workers who specialize in epidemiological survey. The health authority of each county or administrative district is responsible for conducting the epidemiological surveys within its respective
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administrative area. In Shanghai, for example, the municipal and district governments sent out over 550 epidemiological investigators in three groups, with one group specifically focused on tracking close contacts. Additionally, the medical teams that came to Wuhan from other places of China also included professional epidemiological investigators. During the peak of the epidemic, 1,800 epidemiological groups were set up with five members in each team to thoroughly investigate the movement history of confirmed cases and their close contacts.6
The work done by the epidemiological investigators was complemented by big data analysis and the cooperation from local communities, disease control agencies, and police departments, to confirm all close contacts. When a new case appeared, the epidemiological investigators would start their survey by first asking the doctors about the patient’s conditions, and then collect information about the patient’s recent travel history and medical history to determine the potential close contacts and generate a tracing report. If necessary, the epidemiological investigators could ask local authorities or Internet service providers to provide the CCTV footages and cell-phone locations to help identify all the close contacts.
The communities also played an important part in identifying and tracking close contacts. The community workers would survey their neighborhood, paying great attention to people who have recently traveled to Hubei, and make sure they stay at home for at least 14 days, while monitoring their health condition. If anyone shows symptoms like fever, the community workers will help them get to the hospital and closely track those who have
6 China’s Fight against COVID-19
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been in close proximity with the patient. Additionally, community workers also collect and compile the information of the local residents including the residents’ suggestions and report them to the local authority if needed.
7) Isolate all infected patients and close contacts
Quarantine was the most basic measure to break down transmission chains and prevent large-scale spread. In the early phases, the city of Wuhan advised mild cases and suspected cases to mainly stay at home. However, due to the lack of medical knowledge and the limitations of distancing within households, this led to frequent clustered transmission in households. In addition, as the patients travel between their home and hospitals, the risk of infecting other also greatly increased, which indirectly led to overcrowding in hospitals as more people became infected. To address this issue, the Chinese government decided to isolate all suspected patients and close contacts in Hubei.
Places outside Hubei also implemented regulations on quarantine. Normally, the regulations are divided into three different categories, each targeting a different group. For those who have traveled to places other than Hubei recently, they are advised to stay at home for 14 days. For those who have traveled to Hubei, they are advised to isolated at home with medical observation, meaning professional healthcare workers will visit them and check up on them twice per day, and they are not allowed to leave their houses. For suspected patients and close contacts, they are isolated at designated locations in separate rooms for 14 days and not allowed to leave during isolation while being medically observed. Local government in China would rent hotels and similar facilities as venues for quarantine,
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providing free food to all people under quarantine.
To ensure the quarantine measures are properly carried out, many places including Wuhan launched special operations to completely identify and isolate all suspected patients and close contacts. Some places even used the number of isolated people as a key performance indicator for evaluating the civil servants to make sure they do their job. In Wuhan for instance, 16,700 civil servants and state-owned enterprise employees worked together with 17,700 members of the Chinese Communist Party and covered 3,371 communities and villages, totaling 4.21 million households and 1,059 million residents.
8) Increase the supply of medical resources by diverse ways, treat all patients while prioritizing the severe cases
During the early phases, the fast spread of COVID-19 caused overcrowding in hospitals in Wuhan, and as a result, many patients could not be treated in time. This was one of the reasons for the high fatality rate and high percentage of severe cases. The untreated patients also caused greater risks of transmission as they could still infect others. To address this, the Chinese government determined to treat all patients at designated hospitals to prevent further infections. This means that places like Wuhan had to swiftly increase their supply of medical resources to accommodate all patients.
Firstly, the government of Wuhan made efforts to optimize the local public health system by expanding the scope of designated hospitals, transforming existing beds and better coordination. Health Commission of Wuhan announced the “7+7” plan on January 22nd, 2020, asking 7 large hospitals
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to assist the 7 designated hospitals for treating COVID-19 patients. This plan freed up about 3,400 beds for patients with feverish symptoms. This plan was expanded to “10+10” on the 27th, providing a total of 5,311 beds.
Secondly, Wuhan also decided to build two temporary hospitals designated to treat COVID-19 based on the model of Xiaotangshan Hospital, which played an important role in treating SARS patients in 2003. The two newly constructed hospitals, Huoshenshan and Leishenshan, were completed in just 2 weeks, providing another 2,600 beds for confirmed COVID-19 patients.
Thirdly, under the advice from Wang Chen, Wuhan turned many stadiums and exhibition centers into temporary makeshift hospitals, solved the shortage of beds in short period of time, which in turn lowered the rate of cases developing into severe cases. The conversion of the first makeshift hospital was started on February 6th, and the makeshift hospitals quickly changed the situation for the better, as more beds became available, patients do not have to wait to be treated. The makeshift hospitals operated for more than 30 days, and during this period, they treated more than 12,000 patients. Many places in Hubei also learned from Wuhan and also built makeshift hospitals. As the number of patients decreased and few new cases emerged, all makeshift hospitals in China had been closed.
As shown in Figure 3, at the end of January, the number of designated hospital beds available for the treatment of COVID-19 patients in Wuhan was around 4,000, and the number of beds on February 25th increased to about six times. In fact, there were more beds than patients in the designated hospitals in late February.
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Figure 3: Number of Beds in Designated Hospitals in Wuhan
Data source: Wuhan Municipal Health Commission
In February, a total of 16 makeshift hospitals were put into operation in Wuhan, with a total of 12,000 beds. It can be seen from Figure 4 that the bed demands from critical, severe and suspected cases were mostly satisfied since late February. Designated hospitals could treat mild patients, and the function of the makeshift hospitals was replaced. After nearly a month of operation, makeshift hospitals were all closed on March 10th.
Figure 4: Gaps of Beds in Wuhan at the Early Stage
50000 40000 30000 20000 10000
0
2/2 2/3 2/4 2/5 2/6 2/7 2/8 2/9
(10000) 2/1
2/13 2/18 1/30 1/31 2/10 2/11 2/12 2/14 2/15 2/16 2/17 2/19 2/20 2/21 2/22 2/23 2/24 2/25 (20000) Gaps of beds for critical, severe and suspected cases Gaps of beds for mild cases
Data source: Based on public data from Hubei Provincial Health Commission and Wuhan Municipal Health Commission
As more beds are created, hospitals in Wuhan were also able to increase the number of healthcare workers with the help of medical facilities in
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other places. As of March 1st, 344 medical teams consist of 42,322 healthcare workers from all over China went to Hubei to support the local hospitals. Also, 10% of China’s professionals that specialize in treating severe patients were part of these teams. China also utilized 5G and other latest telecommunication technologies to help medical experts conduct remote diagnosis. Moreover, many places also donated important medical equipment to Hubei. At the peak, 25% of China’s ECMO machines were in Hubei.
On the diagnosis and treatment side, China’s National Health Commission and National Administration of Traditional Chinese Medicine organized experts to revise the “Novel Coronavirus Pneumonia Diagnosis and Treatment Plan” based on the information gathered in early phases. The plan has been revised six times, to include the most effective treatments discovered in clinical settings. Currently, as there is no medicine and treatment proven to be completely effective against COVID-19, many experts of traditional Chinese medicine such as Zhang Boli suggested traditional Chinese medicine could be used alongside with modern medicine, depending on the specific conditions of each patient. Some evaluations show that the combination of these two types of medicine could yield better results. This combination was used to treat SARS patients in 2003 and also used on roughly 90% of COVID-19 patients. Many studies show that patients under this kind treatment recover faster than patients under only treatment with modern medicine. In particular, their symptoms disappeared faster, they were hospitalized for short period, and a higher percentage of them became negative for the nuclei acid test. The tested results proved that traditional Chinese medicine treatment a
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viable complementary option.
Lowering fatality rate and improving recovery rate were important targets of treating patients. In China, patients of mild cases and severe cases are treated with different methods. For mild cases, the main focus was to closely track the change in their conditions to prevent them from turning into severe cases. For severe cases, each case was treated with a personalized treatment plan to improve the efficiency of the treatment, and effective drugs and equipment were prioritized to be used on them.
9) Provide comprehensive support to the control and containment measures through a mix of policies
To guarantee all COVID-19 patients would accept treatment without worrying about the costs, the Chinese government announced at the very beginning of the outbreak, that all costs for quarantine and treatment would be covered by the government. The central government would provide financial support to local governments through payment transfer, and also implemented a series of preferential financial and tax policies. The Chinese government also established the weekly adjustment system for the national treasury to support the financial needs of Hubei. The cost for the treatment would first be paid by the patient’s basic medical insurance, the difference is then covered by government funding. According to China’s National Healthcare Security Administration, as of March 15th, 2020, 44,189 COVID-19 patients have settled their payments, which amounted to 752 million RMB, averaging 17,000 RMB per patient. Medical insurances covered 65% of this cost, and the rest was paid by the government. These policies ensured that patients and hospitals do not have to worry about the
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cost of treatment, and therefore can focus on treating every patient.
As most economic and social activities paused, it was also important to make sure people’s basic needs are met. Thus, the central government required all local governments to ensure the supply of all necessities, including medicine, protective materials, disinfectants, and other medical supplies. It was the responsibilities of local governments to be fully aware of the production, storage, and transportation capabilities of local enterprises and make sure the enterprises can operate smoothly. All kinds of goods should be first supplied to places that were most severely affected by the pandemic. Additionally, local authorities were requested to monitor the market closely to prevent businesses from driving up the prices illegally.
To guarantee the supply of necessities to people places such as Wuhan, who made huge sacrifices in the fight against COVID-19, the central government established a coordination system among nine provinces to specifically make sure the people in Wuhan and Hubei can get what they need. From January 23rd to February 19th, eight provinces had shipped over 21,000 tons of vegetables and fruits to Hubei. The Ministry of Agriculture and Rural Affairs established the daily price reporting system to keep the price of food affordable and also organized Guangxi, Hainan, Shandong, Hebei, and other provinces to set up “one to one guarantee” mechanism with cities in Hubei to ensure the supply of vegetables in those cities.
China’s well-developed digital infrastructure and e-commerce system also played an important part. The major online retailers used their supply chains and logistics networks to help allocate medical supplies and other necessities to Wuhan. These online retailers also used their online
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platforms to stabilize prices by coordinating the producers and the sellers and banning those who sell fake products and those who charge unreasonable prices. These helped China’s market to stay stable and orderly during difficult times.
Big data has been widely used in China’s fight against the pandemic. The government has used big data to trace the infected and to identify key areas that should be focused on and to predict future trends. This information would be used by the ministries and local governments to make policies that could better balance virus prevention and production resumption for the next period.
10) Protect the elderly and other groups with high risk of infection
According to many experts including Zhong Nanshan, although COVID- 19 can infect anyone, elderly people and others that have decreased immunity are more easily affected by the virus, and they are less likely to recover. Thus, the Chinese government implemented policies that specifically targeted these groups of people, to protect them from being infected.
At the beginning of the outbreak, a handful of elderly people in some nursing homes in Wuhan were infected, but they were sent to hospitals and received treatment immediately. Consequently, the Chinese government required all nursing homes in China to increase their preparedness by temporarily declining new clients and visitors, pausing all gatherings within the facilities, serving food individually, disinfecting the facility, and taking temperatures for all residents daily. Authorities in charge of civil
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affairs paid special attention to nursing homes during the outbreak, making sure all facilities following the regulations closely.
The State Council also released a series of documents to guide nursing facilities on how to prepare for the outbreak. To solve the shortage of nursing staff, the health and civil affairs departments worked closely with local governments to arrange nursing staff from other regions to support nursing facilities in Wuhan. Local authorities also organized trainings for the staff of nursing facilities by professional healthcare workers.
The Chinese government also made the efforts to educate the elderly people about the outbreak. The health department issued an open letter to all elderly people in China to ask them to respond to the outbreak rationally. The Chinese government used voice messages and comics as promotional materials to teach the elderly people about how to prevent infection. The nursing facilities also helped to provide counselling to the residents.
Apart from protecting the residents of nursing facilities, the Chinese government also paid attention to all elderly people, especially to those living alone. During the outbreak, as communities were locked down, elderly people faced more difficulties as their children could not come to visit and take care of them. Thus, it was important to make sure all elderly people are protected and cared for. The community workers helped to survey their respective neighborhoods, collecting basic information about elderly residents within the neighborhood and created records for each elderly resident. Local government officials and members of the Chinese Communist Party also worked with community workers to cover all households with elderly people to help solve their problems. Enterprises,
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NGOs, and local residents also volunteered to offer assistance. These people worked together to help the elderly people with their daily needs, such as purchasing and delivering goods and communicating with their children. China’s social grid management played an important role in securing the wellbeing of elderly people during the outbreak, as the community workers were able to quickly locate all households that need help and coordinate efforts to provide assistance.
11) Prepare for the potential rebound of COVID-19
Although there were a few days that no new cases appeared across the country, continuous inflow of infected cases from other countries demands a high alert. Due to China’s rigorous intervention, only a small percent of the population was infected, and most people are still vulnerable to COVID-19. Thus, the Chinese government have to prepare for the long run. On one hand, China has been paying attention to the research and development of vaccines and drugs against COVID-19 to tackle the virus. On the other hand, China is also trying to improve its disease control and prevention system based on the problems exposed during this outbreak.
The Chinese government put great emphasis on research and development, and created a cross-sector collaboration system among 12 governmental bodies to lead the effort, especially focusing on improving treatment and medicine, testing new drugs, etiological and epidemiological studies, as well as vaccine development. Currently, there are over 20 research institutions and companies working on the development of vaccine against COVID-19. The joint research by the Academy of Military Medical Sciences and CanSino Biologics Inc. has reached the stage of clinical trials.
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The Chinese government also encouraged the use of the latest technologies such as artificial intelligence and big data in the R&D process.
The Chinese government also insisted on using legislation to carry out containment measures. Apart from the “Law on the Prevention and Treatment of Infectious Diseases” and “Regulations on Preparedness for and Response to Emergent Public Health Hazards”, the National People’s Congress, the Supreme People’s Court, and the Supreme People’s Procuratorate passed a series of regulations to prevent creating and spreading rumors, producing and selling fake products, charging unreasonable prices, and other illegal behaviors, to protect social stability.
After the outbreak, wild animal protection became a widely discussed issue in China. On February 24th, 2020, the National People’s Congress passed the decision to completely prohibiting the illegal trade and consumption of wild animals to protect people’s safety and health, and started the process to amend related legislations. Guangdong Province became the first province to take action as the provincial government has started to amend the laws on wild animal protection. On March 9th, Guangdong released the “Regulations on Wild Animal Protection” to receive public feedback. The new legislation stated four types of prohibited wild animals and raised the punishment.
3. Impact and International Critique
China’s most rigorous, most comprehensive, and most complete strategy and measures against COVID-19 stopped the domestic spread of the virus within a short period of time, while significantly lowered the fatality rate
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of the disease. Currently, places including Wuhan are restoring their normal economic and social order, and the international community has commended China’s effort. As Richard Horton, the editor-in-chief of The Lancet magazine, pointed out in an interview, the impacts of SARS or the Ebola virus could explain the rapid response of China and other East Asian states and regions to COVID-19 and the slow response of European and American countries. The retrospective analysis made by this report also shows that the practices and response speed adopted by China and its regions indicate historical imprints.
1) Impact on public health
China’s strict measures in preventing the spread of the virus not only successful broke the transmission chain inside China, saved the lives for hundreds of thousand people, and also created a valuable window of opportunity for other countries. a) Cut transmission chain and contain the spread of COVID-19
A research team from the Chinese Academy of Engineering led by Zhong Nanshan calculated the pattern of transmission of COVID-19 in China and simulated the effects of the public health interventions in preventing the movement of people. Their result shows that if China delayed its intervention for 5 days, the number of close contacts will grow exponentially leading to a three times greater population of infected cases. A joint research by Huazhong University of Science and Technology, Fudan University, and Harvard University also shows that, as there is no effective treatment for the disease, non-medical interventions have
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successfully contained the spread of COVID-19, preventing 94.5% of potential infections.7 In February, after the Chinese government initiated its interventions, the effective reproduction number of COVID-19 has decreased from 3.8 on January 23rd to 0.3. From an epidemiological viewpoint, the disease is considered to be under control when its effective reproduction number is less than 1, meaning each patient infects less than one person on average. Before the lockdown of Wuhan (January 22nd), each suspected patient had 5.8 close contacts on average, this value was lowered to 3 after total lockdown was fully implemented on February 29th.
A paper published on Science on March 31st shows three main findings: the lockdown of Wuhan has postponed the spread of COVID-19 into other cities in China for 2.91 days; during the first week of the outbreak, the earlier the cities intervened with strict measures, the fewer cases these cities had; lockdown and other emergency response measures have prevented hundreds of thousand people from being infected. The paper points out that shutting down public places, prohibiting social gatherings, and stopping public transportation services also helped reduce the number of infections.8 The findings of this paper corroborates the calculations made by Chinese researchers.
Table 1 shows the infection rates of China, Singapore, South Korea and G7 countries during the same period, that is numbers of infections per million population from the report dates to the 70th day and 80th day of confirmed
7 Wang, C.L., et al. (2020) “Evolving Epidemiology and Impact of Non-pharmaceutical Interventions on the Outbreak of Coronavirus Disease 2019 in Wuhan, China”, MedRxiv, https://www.medrxiv.org/content/10.1101/2020.03.03.20030593v1, 3 March 2020. 8 Han, H.Y., et al. (2020) “An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China”, Science, https://science.sciencemag.org/content/early/2020/03/30/science.abb6105?rss=1, 31 March 2020.
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cases. China’s infection rate was lower than that of most developed countries.
Table 1: Infection Rates of China, South Korea, Singapore and G7 Countries (number of infections per million population) Date of first 70th day 80th day confirmed Infection Infection Date Date case rates rates China Dec. 27 Mar. 6 57.72 Mar. 16 57.94 South Jan. 20 Mar. 30 190.76 Apr. 9 203.70 Korea Singapore Jan. 23 Apr. 2 184.04 Apr. 12 444.21 US Jan. 20 Mar. 30 428.52 Apr. 9 1,297.65 Canada Jan. 27 Apr. 6 420.48 Apr. 16 768.40 UK Jan. 31 Apr. 10 1,054.40 Apr. 20 1,871.67 France Jan. 24 Apr. 3 948.44 Apr. 13 1,448.72 Germany Jan. 27 Apr. 6 1,195.19 Apr. 16 1,612.02 Italy Jan. 31 Apr. 10 2,444.95 Apr. 20 3,002.45 Japan Jan. 16 Mar. 26 11.03 Apr. 5 29.05
Source: WHO outbreak report
Data from many studies all demonstrated the effectiveness of the strict control over people’s movement for containing the spread of the virus. This was discussed in the “Report of the WHO-China Joint Mission on Coronavirus Disease 2019”, which points out that China’s all-of-government and all-of- society approach to contain the virus has saved numerous lives globally and protected global safety. Several foreign national leaders also commended China’s effort. Chairman of France’s National Committee of Public Health and member of the French Academy of Medicine, Dominique Bertrand, recognized China’s powerful intervention and stated that China’s measures could provide useful insights to France. Former U.S. Assistant Secretary of State Kurt Campbell stated that China’s rigorous measures have won valuable time for the U.S. to be prepared.
Some people questioned China’s decision to lock down cities and isolate
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patients. The director of the Center for Infectious Disease Research and Policy at the University of Minnesota, Michael Osterholm pointed out that the virus could spread again once China lifts the lockdowns. It has been over a month since China started to resume its economic and social activities, and we have not seen large-scale local outbreaks, only sporadic cases. b) Improve recovery rate and lower fatality rate, numerous lives saved
Under the Chinese government’s decision to treat every patient, the recovery rate gradually increased while the number of existing cases declined. As of March 31st, the cumulative recovery rate reached 93.5%. In Wuhan, the cumulative recovery rate reached 92%, which is significantly higher than the rate at the beginning of the outbreak (1.85% on January 26th).
Figure 5: Recovery Rate and Fatality Rate in China
Source: Tencent Epidemic Updates, based on the data of National Health Commission of China
Looking at the data for existing cases in Figure 6, the number reached its peak on February 18th and declined sharply since then. The peak occurred
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within one month after China implemented the lockdowns and since then, the number of existing confirmed dropped continuously, from over 58,000 cases at the peak to around 3,000 cases by the end of March.
Figure 6: Existing Confirmed Cases in China
Source: Tencent Epidemic Updates, based on the data of National Health Commission of China
China’s intensive treatment for patients also lowered the fatality rate and the percentage of severe cases. Since February, the percentage of severe cases in Wuhan reached its peak on the 11th at 31.6% to 22% on February 27th. The percentage of severe cases for other places in China remained stable since February 7th, on February 24th, the figure for cities in Hubei (excluding Wuhan) and outside Hubei were 11.8% and 10.5% respectively.9 As of the end of March, the recovery rate for severe cases increased from 14% to 88%. Additionally, according to experts such as Wang Chen and Zhang Boli, the rate of mild cases turning into severe cases is between 2% to 5% for patients in makeshift hospitals.
China managed to keep the fatality rate at a low level. Table 2 shows the case fatality rates of China, Singapore, South Korea and other countries and regions during the same period, that is the percentages of deaths from
9 China National Health Commission (2020) “The State Council Joint Prevention and Control Mechanism Press Conference introduces scientific prevention and precise implementation of policies and classification of epidemic prevention and control work”, http://www.gov.cn/xinwen/gwylflkjz30/index.htm, 17 March 2020.
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the report dates to the 70th day and 80th day of confirmed cases. Clearly, China’s fatality rate was lower than that of most developed countries.
Table 2: Case Fatality Rates of China, South Korea, Singapore and G7 Countries (%) Date of first 70th day 80th day confirmed Fatality Fatality Date Date case rates rates China (including Hubei Dec. 27 Mar.6 3.803 Mar. 16 3.983 province) China (excluding 0.867 0.901 Hubei province) South Korea Jan. 20 Mar. 30 1.655 Apr. 9 1.990 Singapore Jan. 23 Apr. 2 0.381 Apr. 12 0.316 US Jan. 20 Mar. 30 1.705 Apr. 9 3.443 Canada Jan. 27 Apr. 6 1.854 Apr. 16 3.63 UK Jan. 31 Apr. 10 12.747 Apr. 20 13.23 France Jan. 24 Apr. 3 10.219 Apr. 13 15.400 Germany Jan. 27 Apr. 6 1.620 Apr. 16 2.89 Italy Jan. 31 Apr. 10 12.774 Apr. 20 13.31 Japan Jan. 16 Mar. 26 3.317 Apr. 5 1.998
Source: WHO outbreak report, National Health Commission of China outbreak report
2) Impact on Chinese economy
Based on current assessment, the outbreak of COVID-19 would result in at least two waves of shock to the Chinese economy.10
The First Wave: the outbreak of the virus in China and China’s rigorous intervention during the first quarter negatively impacted both the demand and supply side of the economy. From the demand side, as people had to stay at home under China’s strict and comprehensive control over public places, restaurants, shops and other service providers had to temporarily close their businesses. As a result, China’s consumption and investment
10 Wang, Y.M. (2020) “The epidemic will bring ‘great impact happening once in a century’ to China and the world economy”, Sina Finance, http://finance.sina.com.cn/world/2020-03-28/doc-iimxyqwa3798239.shtm, 28 March 2020.
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during the first two months declined more than 20%, and China’s export declined around 20% while a surplus of 41.5 billion US dollar in 2019 for commodity trade became a deficit of 7.1 billion US dollars. From the supply side, the outbreak coupled with the extended Spring Festival break led most enterprises in China to suspend their activities. Consequently, China’s industry value added for January and February of 2020 fell 13.5%, and the service production index dropped 13%.
Second wave: global outbreak of COVID-19 and economic lockouts put more pressure on Chinese economic development. As COVID-19 spreads to more countries and regions, many of China’s major trade partners are heavily affected. Economies around the world are placing border controls and restricting economic activities, which inevitably lead to the stagnation of the global production system and bring systemic impact to the world’s economy. If the global economy enters recession, external demand for China’s commodities will decline sharply, causing tremendous impacts on China’s export. In the near future, Chinese companies could face large- scale order cancellations, which would in turn affect China’s employment, investment, and domestic consumption, putting considerable pressure on Chinese economy.
There have been some positive changes caused by the outbreak of COVID- 19, such as the situation created new opportunities for e-commerce and online platforms.
During the outbreak, as economic and social activities were heavily restricted, many sectors and industries began to pilot new technologies to find viable alternatives. The outbreak forced people, including the elderly
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and residents in remote places, who are not particularly familiar with modern technologies, to switch to online platforms to satisfy their basic needs, such as shopping for necessities, obtaining information, and even getting medical advice. As a result, China’s internet coverage rate could further increase from the current 61.2% to match the coverage rate in developed countries. According to the Ministry of Industry and Information Technology of China, internet usage during the Spring Festival break surged drastically, as Chinese people consumed 2,710 petabytes of mobile data, a 36.4% increase from the previous year.
On the corporate side, the outbreak accelerated the process of digitalization for many Chinese enterprises. Currently, only 20% of China’s service sector have achieved digitalization, and digital technologies only account for 10% of China’s value added in traditional industries. With the support of 5G, artificial intelligence, big data, cloud computing, and the internet of things, many new business innovations emerged and developed rapidly, including contactless delivery, online education, remote working, online community marketing, and shared employees. Many companies used the outbreak as the opportunity to embrace digitalization. Since February 3rd, more than 10 million companies in China have asked their 200 million employees to work remotely.
The Chinese government also adopted a series of policies to ensure the orderly resumption of production and work. These policies have been successful so far. On March 17th, the National Development and Reform Commission announced that apart from Hubei, 90% of enterprises in China have resumed production and work, while Zhejiang, Jiangsu, Shanghai,
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Shandong, Guangxi, and Chongqing have reached 100%. Based on the data provided by the National Grip on the usage of electricity for various industries, medicine, pharmaceutical, and electronics have reached 90% of their normal capacity. Steel, machinery, and textile industries have reached 80% of their normal capacities.
3) Impact on Chinese society
China’s rigorous and strict containment measures succeeded in protecting the health and safety of the public and also secured their right to information and knowledge. But undeniably, some measures have compromised people’s freedom of movement and privacy.
The prevention and control measures, particularly lockdowns in Hubei, restricted people’s ability to move freely and caused some inconvenience. Some western experts stated that although China’s strict lockdown policies are effective in containing the spread of the virus, but such kind of policies may not be replicated in some countries. Apart from the lack of capabilities to enforce those measures, the governments have to deliberate the tradeoffs between the citizens’ economic, civil, and political preferences. Dr. Freddie Gomez, a famous host for medical shows on CNN Philippines maintained that lockdown can be an important step in containing the virus, but the measures implemented in China may not be accepted by the Philippine public. He stressed that the Philippine could learn from China’s lockdowns, but the public would not agree to unannounced inspections and mutual supervision among neighbors.
Additionally, using technologies to track all close contacts and suspected
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patients raised the problem of leaking people’s private information. According to a report by BBC, the “health code” has become a more important form of identification than identity card during the outbreak. And the health code led to the controversy around the right to collect the users’ personal information. To guarantee the protection of personal data and the legitimacy of the use of big data, the Cyberspace Administration of China released on February 9th the Notice on the Protection of Personal Information when Using Big Data for Joint Prevention, reinforcing the relevant legal basis and technical specifications. The principles of anonymous and minimized use of personal information are similar to what have been applied to the collection and use of personal data in countries and regions such as South Korea, EU and the UK in fighting against COVID-19. Recently, several local authorities in China have imposed administrative punishment or a fine on individuals who violated the regulations. Chinese legislative body the National People’s Congress is in the process of manipulating laws on personal information protection, for normal situation after the epidemic. It is a consensus that even when facing public health emergencies, governments still need to pay attention to balance the need to release information and the need to protect people’s privacy.
4) Impact on the international community
During the fight against COVID-19, China has devoted its utmost efforts to contain the spread in China and across the border. We really appreciate the generous help from many countries, organizations and companies during our hardest time. Since the outbreak of the epidemic in some other countries, the Chinese government and Chinese people have also tried our best to help them,
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like donate and export PPE, sharing experience and lessons. Leaders of WHO, UN, EU, and many other international organizations and several national leaders expressed appreciation of China’s effort.
China’s actions have boosted the morale for the international community, as the WHO, United Nations, African Union, and many other international organizations and several national leaders approved and praised China’s effort.
4. Insights for Other Developing Countries
As COVID-19 continues to spread globally, countries that have not seen major outbreaks should begin to increase their preparedness and formulate their strategies and actions plans as soon as possible. If the governments of other developing countries have strong credibility and hope to control the epidemic as soon as possible, and there is a consensus in the society to prioritize the public’s rights to life, to health and to know, then China’s experiences could provide useful insights for them to make response strategies and action plans.
1) Under state emergency, the national government should be granted power to intervene in the country’s economic and social activities and the power to mobilize and allocate resources.
China is a country with 1.4 billion people and complex conditions of unbalanced development. When facing severe public emergencies, the central government must be decisive and responsible to bring its people together and overcome the difficulties. Facing a new virus with great uncertainties, it was really difficult to make decisions that will have major
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impacts. However, if the government do not reach a decision in time, the country might miss the best opportunity to tackle the worrying situation. The decision to lock down Wuhan requires the national leaders of China to show great political courage and to follow the advice from the scientists and experts. As previously mentioned, if the decision to lock down Wuhan was delayed for a few days, the situation now would be much direr.
Even though China has a strong government, it is still facing the problem of insufficient manpower to implement relevant policies in time to deal with the large-scale outbreak. Therefore, taking an all-of-society approach to mobilize the entire country to fight the pandemic is very important. Through extensive social mobilization and active public communication, the government should let the public be aware of the seriousness of the epidemic, understand the national prevention and control policies, actively participate in the epidemic management and become part of the actions.
At government level, China took an all-of-government approach. It made efforts to coordinate the allocation of resources among all regions of China to prioritize the supply to Hubei and Wuhan. Additionally, as China is a vast country and different regions faced various levels of risk. The national coordination of resources could help the neediest get the resources in time and improve the efficiency of resources use, which is critical in response to the epidemic.
2) When facing public emergencies with great uncertainties, national governments should adopt reasonably strict and swift strategies with great caution.
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COVID-19 spread rapidly and affected a lot of people, and it also came with a lot of uncertainties. After the Chinese government fully grasped the seriousness of the situation within a short period of time, it immediately implemented the most rigorous, most comprehensive, and most complete measures to contain the spread. The aggressive and ambitious attitude towards the outbreak was a necessary condition for the effective implementation of all measures. The central government sent out a strong and clear signal to the entire nation, which helped to create consensus in China. With this fundamental consensus, all people and all levels of governments in China actively followed the instructions given by the central government and ensured all policies are properly carried out. Conversely, an ambiguous signal from the central government would only confuse the public and create more conflicts, preventing the synergy required to defeat the virus.
3) The national strategy should be aligned with the national basic conditions.
Combating the pandemic of COVID-19 is an enormous and complex undertaking, and therefore, the main strategy must be customized to fit the country’s major characteristics for it to be effective and viable. In China, the central government’s credibility and capability to mobilize resources, the value of “greater goods” shared by Chinese people, China’s well- developed infrastructure and industrial system, and the high savings rate of the Chinese households were all important considerations for formulating China’s overall strategy. If the strategy does not fit the country, it will make policies difficult to implement and the public unwilling to cooperate. As
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mentioned earlier, there are considerable disparities among different regions in China, specifically in terms of the governing capabilities of local governments and the level of development. For example, the lack of a hierarchical medical system in Hubei province contributed, to a certain extent, to the overwhelming of medical resources in Wuhan. Contrastingly, Guangdong province benefitted from the hierarchical medical system that was established earlier. Thus, China also implemented differentiated measures based on risk assessment of each region.
4) Scientists and professionals should be widely consulted throughout the policy process.
In China’s fight against COVID-19, public health and medical experts played a major role. Experts such as Zhong Nanshan, Wang Chen, Zhang Boli and their teams made significant contribution to the decision-making process. Collecting information in Wuhan in person, evaluating the risk of the virus, making the recommendations of lockdown, building makeshift hospitals, and adding traditional Chinese medicine into the treatment process, they made great effort to help the central government and local governments make rational and science-based policy decisions.
China also benefited from the fact that the experts learned a lot from China’s past experiences of combating infectious diseases. Through combating the epidemic of meningitis in the 1960s, SARS in 2003, and H1N1 influenza in 2009, the Chinese experts have accumulated valuable experiences. In the past two decades, the capacity of China’s healthcare workers grew continuously, as did the disease control and prevention system. The professional healthcare workers and disease control experts
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made great contributions by conducting epidemiological surveys to track close contacts and implementing quarantine. They also helped to convert information into actual policy advice.
5) Adopt policy combinations and use whatever accessible. Combine traditional containment measures with modern technologies.
The co-lead of the WHO-China Joint Mission on COVID-19, Bruce Aylward stated that China used the most ancient containment measures against epidemic, but the combination of the ancient measures and modern technologies yielded surprisingly good results. He pointed out that China used online systems to allocate medical resources in hospitals and used modern telecommunication technologies such as 5G to support remote diagnosis and treatment. These approaches increased the efficiency of using limited resources, allowing hospitals to treat more patients. Additionally, China also widely used big data and other information technologies to help tracking the spread of the virus, which made it much easier to implement the traditional measures of lockdown and quarantine. The effectiveness of traditional containment measures has been proven many times throughout human history, and China used latest technologies to make these tried-and-true methods better suited to modern society, and thereby increasing their effectiveness and viability.
6) Emphasize supervision and accountability mechanisms to ensure local policy enforcement.
Formulating a viable strategy and action plan is only the first step towards defeating the pandemic. It is equally, if not more important to ensure all
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planned actions are fully implemented. China set up a strict system consists of information sharing, supervision, reporting, and accountability to ensure all levels of government would turn the policies enacted by the central government into actions. At the beginning of the outbreak, the central government arranged the deputy prime minister to lead the central working group to guide the work in the epicenter and promptly replaced the relevant official in Hubei and Wuhan due to their incompetence. Additionally, the central government also sent out several teams of experts to different regions in China to supervise the local government and help them overcome their difficulties. The public also played an important role in keeping the governments in check by reporting any questionable actions through a dedicated channel. All these mechanisms help ensure local governments complete their jobs properly and all policies are diligently carried out.
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China’s Strategies and Actions Against COVID-19 and Key Insights
Liu Chen Chen Xiao
Working Paper CIKD-WP-2020-006 EN