China’s low Covid-19 vaccination rate – especially among the elderly – has been a big hurdle for the country’s reopening, but authorities have refrained from introducing a mandate in a new drive to get more shots in arms.
A plan unveiled by health officials on Tuesday calls for a stronger push to get the older population inoculated by targeting places such as nursing homes and by making it easier for people to access vaccinations.
Public health experts say while the plan does not go far enough, it would be difficult to introduce a vaccine mandate in China.
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“We’ve seen attempts by local governments to introduce a vaccine pass on public transport or to enter shopping malls, but they all backed down after strong resistance,” said Jin Dongyan, a virologist at the University of Hong Kong. “The central government seems to have neither the will nor the proper measures to introduce a vaccine pass.”
Although there have been administrative orders for government workers, calling on those in state-owned enterprises and areas like the service sector to get vaccinated against Covid-19, there has never been a broader vaccine mandate in China.
There was strong public opposition last year when provinces including Zhejiang, Guangxi and Hunan tried to require people to be vaccinated to enter places such as office buildings, supermarkets and subways. National health authorities responded by urging local governments to “correct” the move and calling for vaccination to be “informed, voluntary and carried out with consent”.
In the capital Beijing, authorities sought to introduce a mandate in July to require people to show proof of vaccination to enter public places such as cinemas, libraries, museums, gyms, stadiums and training centres. But it also met with resistance from the public and was scrapped a day after it was announced, before it officially took effect.
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A vaccine expert in Shanghai, who declined to be named due to the sensitivity of the matter, said attempts to introduce mandates had failed because of a lack of engagement with the public.
“There was too much publicity around the side effects of the vaccines, when actually they are very safe,” the expert said. “They should have anticipated there would be pushback and taken the initiative with an education campaign before any mandate was announced.”
According to Wang Guisong, a law professor at Renmin University of China in Beijing, there is no legal grounds for a mandate.
“It’s about a citizen’s freedom of movement and access to public places,” Wang said. “An individual’s movement must not be restricted by means of non-compulsory obligations.”
Under China’s Vaccine Administration Law and its Basic Healthcare and Health Promotion Law, it is a civic duty to be vaccinated. But this only applies to vaccines covered by the national immunisation programme – mainly those for children such as the polio jab. While Covid-19 vaccines are provided for free, they are not officially part of that programme.
Health officials want more older people to get vaccinated against the virus – 68.7 per cent of those aged 60 and over have had three shots, while the rate is just 40.4 per cent of those aged 80 and above, according to official figures.
Maxwell Smith, an assistant professor in health sciences at the University of Western Ontario who has written policy briefs on the ethical considerations of mandatory vaccination for the World Health Organization, said it would be unwise to introduce a mandate if the law did not support it.
But he said the fundamental question was whether Chinese authorities were willing to remove other public health measures, such as lockdowns, if a high vaccination uptake could be achieved – even if this trade-off resulted in more infections.
“Vaccination mandates may be viewed by some as an infringement on their autonomy, but so are lockdowns and other measures,” Smith said. “Perhaps many would be willing to be vaccinated if this were an avenue to remove other public health measures that are seen as even less tolerable.
“If framed in this way, people may opt to be vaccinated voluntarily if this means the removal of other measures. In that case, a mandate wouldn’t be necessary,” he added.
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While there is no vaccine mandate, millions of people in China must undergo frequent compulsory PCR testing for the virus – enduring long queues and inconvenience. Depending on where they are, this can mean a negative test result valid for 24 hours is required to enter an office building, or a result from the past 48 hours must be shown to leave the city.
Smith said there was more tolerance for PCR testing mandates since no biological materials were being introduced to a person’s body and there were no lasting effects, whereas there was some level of risk to vaccination.
“The key ethical question is whether the intervention is ‘necessary’ to achieve stated population health objectives and whether it is proportional to the threat,” he said. “If we can use a less intrusive intervention to achieve the same objective, we generally ought, ethically, to choose that intervention.”
China has run a successful inoculation campaign in the past without a mandate – its drive back in 2010 to get 100 million children vaccinated against measles in 10 days.
“It’s all about implementation,” said Jin from HKU. “And whether the Chinese government has set its mind to do it.”
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