China’s “zero-COVID” policy, which aimed at stopping the spread of the disease, was one of the strictest, longest-lasting policies in the world. Citizens were subjected to mandatory testing, protracted quarantines and city lockdowns for nearly three years. However, on December 7, 2022, the Chinese government provided 10 new guidelines for relaxing its zero-COVID policy. People infected with COVID-19 who have minor to no symptoms are now permitted to isolate at home rather than in centrally controlled facilities, and testing procedures and travel restrictions have been loosened. These sudden policy changes, which were meant for a transition back to normalcy, have resulted in a sharp increase in COVID-19 cases.
As a nation directly bordering China to the east, the Democratic People’s Republic of Korea (DPRK or North Korea) is well aware of the threat this upsurge poses to its national health security. The North Korean government has maintained its zero-COVID policy through border closures, and recent reports suggest Pyongyang may have reinstated its own five-day-long lockdown for the first time in eight months. While it remains to be seen whether North Korea will follow China’s lead in further relaxing its coronavirus restrictions, Pyongyang should be taking measures now—such as increasing vaccination rates, improving intensive care units (ICU) capabilities and personnel, and strengthening testing capacity—to avoid the pitfalls Beijing encountered in its attempt to transition to life after COVID-19.
Why Did China End Its Zero-COVID Policy?
There appear to be two main reasons why the Chinese government decided to ease its zero-COVID policy. The first is the catastrophic economic loss. The regions that were under heavy restrictions account for one-third of China’s total economy, and consequently, the estimated monthly loss has been $46 billion USD, or 3.1 percent of China’s GDP. If China maintained its zero-COVID policy, it could have incurred additional losses of 0.6 percent to 1.5 percent of its annual GDP. Moreover, according to a survey conducted with 167 manufacturers in China in early 2022, 20 percent of overseas manufacturers indicated that they would move their operations out of China if COVID-19 restrictions were further extended.
The second reason is thought to be a change in public sentiment, especially after the 2022 Qatar Football World Cup. Several Chinese people complained as they watched tens of thousands of spectators from all over the world freely cheering for football matches. Then on November 24, 2022, 10 deaths in an apartment fire in Urumqui, Xinjiang, where strong restrictions had been in place for more than two months, sparked widescale civil dissatisfaction. On November 26 and 27, massive rallies were held in Shanghai and Beijing. These ultimately developed into protests against the government’s COVID containment policy on a scale not seen since the 1989 Tiananmen Square pro-democracy movement.
What Happened in China After the Zero-COVID Policy Ended?
Since China’s “zero-COVID” policy was relaxed, the number of COVID-19 infections has risen at an explosive rate. An increase in the number of infections was somewhat expected, especially given the fast spreading nature of the Omicron variant. Yet, immediately after easing the zero-COVID policy, the surge of cases was greater than what China’s health system could handle and overloaded it. For example, there was a lack of available hospital beds, and people were not able to get drugs for fever. The result was a large number of deaths, as many as roughly 60,000 in a day.
A few factors may have contributed to this phenomenon. Due to the zero-COVID policy, Chinese citizens most likely did not have an opportunity to build up their natural immunity. In addition, high-risk groups, such as the elderly—those over 60–who account for nearly 17 percent of the country’s population—have low vaccination rates, which increases the risk of a rapid uptick in deaths in a short period of time. A US-China joint research team predicted that the number of deaths could exceed 1.5 million in six months if strict quarantine measures were withdrawn without a “safety device,” such as increasing vaccination rates or expanding the medical system.
The Chinese government cited the low fatality rate of the Omicron strain as a basis for easing the quarantine policy. However, Professor of public health, Linda Bauld of the University of Edinburgh emphasized that Omicron has a low fatality rate only if a person has sufficient antibodies, which would only have been acquired through high-efficacy vaccines, such as mRNA vaccines. Meanwhile, Chinese-made vaccines have a relatively low two-dose efficacy rate. For example, CoronaVac is 51 percent effective, and Sinopharm is 79 percent effective, much lower than mRNA vaccines from Pfizer and Moderna, which both had over 90 percent efficacy rates. That said, it is also worth pointing out that the COVID-19 disease itself has a nature of spreading incredibly fast, especially as the Omicron variant began to dominate.
What Should China Have Done Before Easing Its Policy?
No country to date has been able to transition from lockdown measures to normalcy without experiencing a massive wave of COVID-19 infections. While the surge in cases upon relaxing control measures was more or less inevitable, sufficient preparation (or lack thereof) of a country’s healthcare infrastructure has been the deciding factor in how well countries have fared. For instance, South Korea and Singapore saw a sharp rise in cases after ending their zero-COVID policies and reopening borders, but on the whole, they were able to contain hospitalizations and deaths because they took measures to vaccinate their populations, educate and increase the awareness of the public, and further improve health care supply chains.
Before easing its zero-COVID policy, China should have made more efforts along these lines, especially increasing vaccination rates or administering more effective vaccines. Given the predictable spikes in coronavirus infections, hospitals should have been prepared to ensure adequate ICU beds, equipment, therapeutic medicine and healthcare personnel. In addition, as the validity of COVID-19 data from China has been questioned, there should have been transparency for epidemiological studies for better national disease control. This is not the first time China has been criticized for its obfuscation of data. Currently, China only counts deaths from pneumonia or respiratory failure toward its official COVID-19 death toll. Such narrow criteria limit rapid and robust risk assessments essential for today’s global response during health crises. For instance, the World Health Organization (WHO) guidelines for COVID-19 state that “probable” coronavirus cases and deaths where the virus was a contributing factor should be included in the tally.
Lessons for North Korea
According to North Korean state reporting, the country’s first outbreak in 2022 ended only three months after it began, seemingly due to strict lockdown and quarantine measures. It would be naïve to think that was the only outbreak the country will face, and the possibility of another variant emerging that could cause further global disruptions remains.
Pyongyang is certainly not oblivious to the economic and social impacts the country and its people have suffered as a result of its zero-COVID policy. According to one analysis, North Korea is experiencing the worst food insecurity since the devastating famine of the 1990s, known by its state-sanctioned, term the “Arduous March.” North Korea’s trade volume was slashed by 17.3 percent to $710 million USD in 2021, after its first year of closing borders. This means limited access to vital resources such as medicine and food for most North Koreans, which exacerbates health conditions for a population known for having already weakened immune systems. Additionally, China’s reopening may trigger inflation and cause food and energy prices to rise.
With some COVID restrictions easing on both sides of the China-DPRK border, trade has started to resume. Recent reports suggest that Chinese exports to North Korea more than tripled in 2022 from the previous year as freight train operations resumed. Among the goods being imported are millions of medical supplies, indicating that health conditions are of priority.
After weighing the costs and benefits, North Korea will, at some point, need to accept that COVID-19 will enter an endemic phase, as it has in most other parts of the world, and plan a transition accordingly. An initial upsurge in infections will be difficult to prevent. At best, there will be economic costs, and at worst, there will be massive casualties. Thus, North Korea and the global community should plan ahead and be prepared to take sufficient measures to mitigate the initial shock of reopening.
Avoiding China’s Pitfalls
In the case of another future outbreak, there are some concrete steps North Korea can take now to minimize the impact. The most obvious measure is to vaccinate the population. This is something that North Korea has previously demonstrated its competency to carry out. In September 2022, state media reported that a vaccination campaign was forthcoming; however, details about this campaign—what kind of vaccines and how widely they will be administered—remain unknown.
If North Korea has already secured vaccines, as some sources believe, the most probable candidate would be China’s SINOVAC, which is a traditional inactivated vaccine. Even though this particular vaccine showed inferior performance to mRNA vaccines, if vaccination is widespread with continued provision of booster doses, this may not be an entirely futile option.
While mRNA vaccines are still seen as the global gold standard for their two-dose efficacy, a Lancet journal study suggested that after three doses, SINOVAC vaccines are able to attain efficacy levels not too far behind those of the Pfizer-BioNTech and Moderna vaccines. Certainly, this is just one study and by no means reflective of a scientific consensus. North Korea may decide that increasing the number of doses of an inactivated vaccine still outweighs the burden associated with the added stringency of the cold chain requirements of mRNA vaccines.
Because the North Korean people’s immunity is deemed to be low already due to chronic malnutrition and an overall lack of access to modern medicines, Pyongyang should avoid the kind of drastic reversal of policy Beijing employed; any paths towards reopening should be gradual, and preparations need to be taken in advance. Essential supplies and necessities, such as therapeutic medicines and food, should be secured; COVID-19 testing should be capacity increased; and information and communication technologies capacity should be strengthened to facilitate disease surveillance nationwide.
Helping North Korea Transition
The international community should not expect North Korea’s borders to open up anytime soon. North Korea’s self-assessment may indicate that continued border closures remain the most realistic option for managing the pandemic. It may feel that its lack of resources in medical personnel, healthcare infrastructure and therapeutic supplies are insurmountable without significant external aid, something the country will not resort to unless absolutely necessary.
However, if the North chooses to open up to limited amounts of aid, it will only be through an apolitical channel. Any offer that does not alleviate North Korea of a bilateral, donor-recipient dynamic, such as that of the Western-manufactured Pfizer and Moderna vaccines, is likely to be rejected.
Thus, the approach to controlling any future outbreak in North Korea should not rely on supplying vaccines; instead, the priority should be long-term capacity building. The international community should focus on strengthening the country’s vaccine manufacturing capacity, including mRNA vaccines, as well as improving overall distribution, especially to the most rural regions outside Pyongyang.
Given its proven track record of implementing successful vaccination programs, North Korea has the potential to deploy vaccines throughout the entire country both effectively and efficiently if provided with the necessary resources. As long as North Korea deems humanitarian support truly beneficial for its people, it has shown its willingness to actively engage, especially during the pre-pandemic times. The Ministry of Public Health’s long-held partnership with the United Nations Children’s Fund (UNICEF) to improve children’s health is one such example.
One possible way of moving this forward is to utilize a multilateral cooperation model via the WHO vaccine technology transfer hub. Since 2021, the initiative supported by the WHO, Medicines Patents Pool and COVID-19 Vaccines Global Access (COVAX) has developed a training platform for building capacity in low- and middle-income countries for producing mRNA vaccines.
The benefits of consolidating global health security outweigh the risks of biochemical weaponization by North Korea. The mRNA is a highly unstable and fragile compound, degrading within minutes at room temperature. It is not a coincidence that the world saw its first and only set of mRNA vaccines available to the public in 2021. While international bodies should continue to do their due diligence, the safeguards of the WHO will make it extremely likely for it to be a reasonable concern.
No matter how archaic it may seem, North Korea was able to at least somewhat successfully manage the omicron variant outbreak by locking the country down. Recognizing that it is not necessarily the cumulative number of infected individuals, but rather the small portion of severe cases that tend to overwhelm the health system, increasing North Korea’s ICU supplies and trained critical care personnel are good starting points for cooperation and capacity building. The international community should also consider providing support for collateral burdens due to COVID-19, such as mental health services, basic therapeutics supplies and more.
The sharp increase in coronavirus cases in China after it eased its zero-COVID policies presents health security concerns for a second wave of COVID-19 in North Korea as well. It is also a case study that demonstrates just how difficult—if not impossible—it is to make a smooth transition into normalcy from old-fashioned measures of border closures and lockdowns. North Korea knows what has worked for them in order to contain the virus thus far, but not without the economic and human expenses that continue to accumulate. It may be a few months or a few years, but escaping the pressure to reopen will be difficult, even for North Korea. It is, therefore, in Pyongyang’s best interest to learn as much as possible from China’s experience, to avoid the same mistakes, and prepare itself to minimize the impact of a future outbreak.
Kim Gyu-cheol, “COVID-19 and North Korea’s External Trade: Evaluating North Korea’s External Trade in 2021,” North Korean Economic Review, no. 1 (2022).