China bought valuable time to prepare for the inevitable: a variant of the coronaviruses so shifty and contagious that China would struggle to contain it.
Rather than laying the groundwork for that scenario, China stepped up its commitment to "zero Covid."
Daily vaccinations fell to a new low. Even as workers built isolation facilities, critical-care beds were in short supply. The research on the vaccine didn't keep up with the fast-changing virus.
Scientists said in interviews that China is in a bind because of the costs of that approach.
As new Covid cases have reached all-time highs, residents have taken to the streets to protest the fact that many cities have been locked down due to Covid issues. Officials have begun to ease restrictions.
Researchers are concerned that China may not be able to reopen the country in time to relieve the strain on its economy. There is a threat to the political leadership.
Dr. Siddharth Sridhar is a researcher at the University of Hong Kong. There was nothing to choose from. China isn't ready for a wave of that magnitude.
China's difficulty in immunizing older people has set back its preparation. Chinese-made vaccines offer less protection than the Pfizer-BioNTech and Moderna vaccines, which is why only 40% of people ages 80 and older have received a booster dose.
Sinovac, China's main domestic vaccine, was only 58 percent effective against severe Covid in people over the age of 80. The two Pfizer- BioNTech doses were effective in the same group. Two Sinovac doses were only effective in preventing Covid deaths.
The results have made scientists believe that the Chinese shots are a three-dose, rather than a two-dose, vaccine.
The last major vaccine push in China was in the spring, an interval of eight months or more since the last dose.
It could make a difference in their immune defenses. The effectiveness of the Sinovac vaccine against intensive-care admissions fell from 56 percent to 29 percent over the course of three to five months.
The Chinese vaccines stack up well against the world's other non-mRNA Covid shots, according to Dr. Paul Hunter. It could be damaging to reopen the country after the last vaccinations.
The quality of China's vaccines is more of an issue than the issue of vaccine quality.
The vaccine gaps in China's older population are more glaring due to the fact that the country has achieved strong coverage. A majority of the population has received at least one dose of the Sinovac or Sinopharm primary vaccine series.
Andy Chen, a Shanghai-based analyst at Trivium, said that the country could establish herd immunity if younger and more active Chinese were immunized.
Mr. Chen said that older people in China tend to avoid health risks. Other experts said that China's reluctance to give data on the efficacy and side effects of its vaccines created a vacuum in which those concerns flourished. Social media in China contains misinformation about side effects.
While health officials encourage older adults with chronic illnesses to get shots, vaccinators are hesitant to give them without access to the medical histories of more vulnerable recipients.
The vaccine drive was complicated by the zero covid strategy. By limiting infections, it saved lives, but it also made older people less interested in getting a shot.
Further attention was given to the vaccination campaign due to the emphasis on swabbing throats. In the wake of a springtime surge, China built tens of thousands of testing booths and built huge facilities to isolated millions. The rate of vaccinations remained stagnant.
There is always a shortage of staff in the health care system. The people told me that they were told to focus on mass testing.
According to a statement from the country's National Health Commission, China plans to use mobile vaccination stations, bring shots into nursing homes and go door-to-door to reach the most vulnerable in the population.
The move was seen as much more than lip service by some experts.
He said it was about tweaking the approach. That approach doesn't make sense anymore.
The authorities stopped short of mandating vaccinations, but did not provide a detailed plan. As powerful as the country's leadership is, forcing older people to get shots is seen as a potential overreach that could bring with it a public backlash.
If only one person dies from the adverse effects of vaccines, that is blood on your hands, said the analyst. It's difficult to recover from that.
Hospitals may need to contend with a winter cold and flu season if gaps in vaccine coverage continue to rise. China has less intensive care beds than other countries.
The country used to have to move health workers from one province to another when there was a shortage. That would be impossible if there were a lot of Omicron infections.
If China abandons its zero Covid policy, there would be a huge number of Covid cases and deaths. China now has more options for treatment of the disease. Ben Cowling, a professor of epidemiology at the University of Hong Kong, said that a health crisis would still occur if the restrictions were lifted suddenly.
Efforts to prepare the medical system were a priority given the inevitability that cases will surge when China reopens. There are signs that the leadership is shifting its focus to fortify its best hospitals.
New Zealand and Taiwan have made exits from the emergency phase of the Pandemic. When the measures were lifted, deaths spiked, but to levels far lower than in the United States.
Scientists said that China's strategy has limited Covid deaths but doesn't map out an exit from restrictions.
The director of the global health foundation said that restrictions and lockdowns can help buy time to get crucial public health measures in place and save lives, but they are not an exit strategy by themselves.
China, which has rejected the Pfizer and Moderna vaccines, seems to be interested in locally made alternatives. More than a dozen new vaccine candidates are being tested in a head-to-head trial.
Indonesia recently authorized China's mRNA shot, and some vaccine makers appear to be close to obtaining authorization from Chinese officials.
James Bell, a medical science expert at Rtw Investments in New York, said that early data shows that the vaccine is headed in the right direction.
China's top leadership has signaled a recognition that its blanket approach to controlling the virus is taking an increasingly large economic and social toll. Several cities have loosened some of their strictest restrictions in the last few days.
There was a debate about whether to back down from Covid restrictions. Officials in Jinzhou, in China's Liaoning province, said that they had begun to loosen some measures but still pushed back on deserting the "zero Covid" strategy.
When we can reach zero, we don't need to abandon our defense.
David was a contributor.
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