Protesters across China have made one thing very clear: after three years of harsh restrictions, many people are tired of their government’s pursuit of an increasingly ineffective zero-Covid strategy. China once celebrated its success in containing outbreaks and keeping its economy running, but it has been slow to adapt to a world of more infective variants and mass vaccination. As life begins to feel increasingly normal in Britain and elsewhere, 49 cities – representing a third of China’s population and two-fifths of its economic output – are in partial or total lockdown.

The protests will put pressure on the regime to change its approach, but that may be easier said than done. China has been highly politically committed to its Covid policy, even as it has become less and less tenable. And the situation with its health system, population immunity and vaccine stocks is vastly different from ours, partly because of the choices it made earlier in the pandemic. China will have to face some form of living with Covid soon, and millions of lives – not to mention global economic stability – depend on how this happens.

China was an early adopter of overwhelming measures to contain Covid. This involved recurrent lockdowns affecting millions, but also building isolation centres and hospitals very quickly, mass PCR testing, intensive contact tracing and surveillance, and mandatory masking. Some of the measures were incredibly draconian. Yet, despite the cost to civil liberties, it worked in stopping Covid-19 initially.

But then in 2021, several safe and effective vaccines were approved, which meant that widespread protection could be delivered to western populations. Take-up was remarkably high, and country after country, including maximum suppression countries such as New Zealand, Australia and South Korea, pivoted from containment to mass vaccination, access to antiviral therapies and “living with Covid-19”.

China, though, stayed with its strategy of elimination within its borders. The Chinese government did roll out its homegrown vaccine but took a different approach than the west. Its vaccination priority list focused on healthy young adults, and instead noted the side-effects of the vaccine to elderly groups. It didn’t promote the vaccine to elderly groups until November 2021, but by this time considerable vaccine scepticism had built up. Rising concerns about the low effectiveness of the non-mRNA Chinese vaccines were also a concern: studies indicated that protection faded fast and was undetectable after six months.

Recent reports suggest that only about 40% of over-80s have received a booster shot, and millions still remain unvaccinated. To put this in perspective, the overall booster rate was more than 90% in Japan while only 68% in China. And the Chinese government’s efforts to push vaccination have been met by a population used to zero-Covid messaging and having a false sense of security that they won’t ever be exposed to the virus, so why get vaccinated at all?

And population exposure has been minimal in China. It has had just under 1.5m infections in a population of 1.4 billion, and the national death toll is 5229. Compare this with England where the Financial Times estimates that more than 90% of the population has had Covid at least once. This hybrid “wall of immunity” in Britain has come at a major cost: the UK death rate stands at 2,400 per million, compared with just three deaths in a million in China.

All of this means that China’s population has a lower vaccination rate, with vaccines that appear less effective, than in most other countries. And many people don’t have any immunity gained from a previous infection either. If China gives up on containment and allows a large wave of infections, the country will take a huge loss of life given current vaccination levels: they are just too low in the most at-risk groups. This would overwhelm the already fragile Chinese healthcare system with too many patients who need care.

And the 2020 playbook isn’t working in 2022 in China, with a much more infectious version of the virus – Omicron – and a population fed up and tired of restrictions and constantly changing rules. Millions of businesses have had to shut down and the country has taken a major economic hit: the World Bank forecasts GDP growth in China of just 2.8%, behind the rest of the region’s average of 5.3%. This is the first time China’s GDP growth is less than its neighbours since 1990. Yet there are few signs the government will change tack for political and health system reasons.

Politically, the president, Xi Jinping, has projected a clear narrative of protecting China’s population through a zero-Covid policy and sees it as one of his successes. He defended the strategy vigorously at the recent Communist party congress, and any sudden policy shift may be seen as an admission of failure. And while there are increasing protests against restrictions, other parts of the country are calling for authorities to do everything to protect them from Covid. They’ve heard about the death toll in the western world and don’t want to be exposed to the virus.

The other concern of Chinese scientists and politicians is long Covid, which some feel has been underestimated in western countries. And you can understand this concern. An estimated 2 million people are suffering from long Covid in Britain and it is cited as one of the major reasons for the rising number of “economically inactive” people.

No matter what approach China takes, it needs to improve its vaccines. But to do this it will need access to mRNA technology, and this has been stuck at an impasse. Moderna has refused to transfer its technology to Chinese firms for manufacturing, instead eager to sell directly to a large market. China has instead worked to develop a homegrown mRNA vaccine but this has caused delays in rollout.

The countries that dealt most successfully with the pandemic, such as New Zealand, South Korea, Japan, Denmark and others, did it by successfully moving from containment in 2020 to mass vaccination and treatments in 2021 and 2022. This is the only sustainable exit from this pandemic and we’re likely to see China take this route eventually. It will need to get mRNA vaccines to the biggest priority groups quickly, and also bring an exhausted public along through what is likely to be a jarring shift in strategy – from no Covid at all, to Covid circulation with vaccine protection.

Let’s hope China makes this transition before it is forced, regardless of what the governments wants, to live with Covid before it is ready. China buckling under a wave of Covid would affect the entire world, not just disrupting economic stability but potentially creating new variants that could set progress back everywhere.

Devi Sridhar