Why did China fail to force their elderly to get vaccinated against COVID, despite being an authoritarian state?

Question

Hong Kong has been in the news recently due to their extremely low vaccination rate for the elderly:

Just 15% of elderly residents in Hong Kong’s care homes are fully vaccinated against Covid-19, about one-sixth the coverage in the U.S., despite evidence from early in the pandemic that such facilities are hotbeds for disease and death.

This resulted in them having one of the highest death rates per capita in the world last week:

Hospitals and morgues are overflowing, with bodies left unattended in hallways and in rooms with living patients. Health care workers report burnout and low morale as they work 80 hours a week. And nursing homes are being ravaged, with low vaccination rates among older people driving Hong Kong’s Covid-19 deaths per capita to the highest in the world, according to Our World in Data.

China has been doing better but still failed to reach a 100% vaccination rate:

About 51% of over 80-year-olds have received two shots and some 20% have gotten boosters, health officials told reporters at a briefing in Beijing Friday. While 87.9% of China’s 1.4 billion people have been vaccinated with two shots -- a high percentage globally -- the numbers decline with age, with the figure dropping to 82% for those between 70 and 79.

In contrast, the UK has a 88+% vaccination rate for those aged 70+, despite being a democracy, and thus not being able to use as much coercion as an authoritarian state would.

So why didn't China use their powers to force 100% of the elderly to get vaccinated? They've enforced far worse medical procedures during the one-child-policy era, so it seems like enforcing the vaccine on those most vulnerable should've been a no-brainer. This is especially perplexing given China's insistence on following a "Zero COVID" strategy and refusing to accept even a small number of infections within their borders.

The question mentions Hong Kong as an illustration of why its important to vaccinate 100% of the elderly population - I'm primarily interested in why China didn't do it, as Hong Kong is (for now) far less authoritarian.

Answer 1

Well, this answer is probably going to sound unconvincing to many, but to reproduce here what seems to be the official line...

Compared with Australia and other Western countries, China adopted a different approach, where the elderly population was not a priority group for the vaccine in the early stages of the pandemic.

Instead, China prioritised people aged between 18 to 60 years who were working in essential services, identifying them as more likely to be infected and spread the virus. [...]

George Liu — the China health program director at La Trobe University — said China didn't prioritise elderly people in the first place, due to a lack of scientific data.

"The vaccines developed in China were only tested in some developing countries outside of China because of the low prevalence of COVID-19 in China," he said.

"Populations in those countries are relatively young, compared to Australia and other Western countries."

The other issue, which is more speculative, is that they probably didn't expect their vaccines to be as ineffective as they are in preventing new variants from spreading. i.e. they probably assumed that having a high vaccination rate among the working age (which "tops 87%") might be enough to provide herd immunity and so stop new epidemics.

Edit: I actually managed to find a CGTN article from 8 Jan 2022 specifically stating that latter point:

China has theoretically achieved herd immunity goal: Zhong Nanshan

Chinese top respiratory expert Zhong Nanshan said on Thursday that China, in theory, has built a certain level of herd immunity, as over 83 percent of the country's population has been vaccinated. [...]

China began its vaccination program starting with high-risk groups in December, 2020. According to data released by the National Health Commission, over 1.2 billion people on the Chinese mainland had been fully vaccinated as of December 28, 2021, accounting for more than 85.6 percent of the country's population.

In this case, Zhong pointed out that, theoretically speaking, China's herd immunity goal has been achieved.

Answer 2

Answering why question is usually hard but one can gather some related information and make an educated guess.

Vaccination is not mandatory in China, it is offered but at least the general population is not forced to vaccinate (I don't know whether there mandates for doctors or other at-risk grous).

Vaccinations that do happen in China are almost exclusively with Sinovac. The lower rates of protection compared to Western vaccines are known in China and hence Sinovac has a relatively bad reputation.

Most Western countries have rules that require either a vaccination or daily tests to participate in various parts of public life that encourage people to get vaccinated. As far as I know China has no such rules. As long as there are no nearby new cases there are no restrictions to public life, not even mask recommendations.

Putting things together, I think the main point is that if you believe in a Zero-Covid-strategy there is just no reason to get vaccinated. The Chinese strategy was to stop the spread by some of the most severe lockdowns in the world if there are cases and no restrictions whatsoever if there are no cases. With this strategy you don't need vaccinations.

Answer 3

Obviously, I'm not an official of PRoC so I can only reference official statements and provide speculation from their point of view. It's rather difficult of course to find any sources that don't immediately look like propaganda so a lot of this will be speculation for what can be logical reasons.

1. Logistics

First let's point out that relative to the countries that you are comparing with Chine in the OP, China has a low median age of 38.4 years. Similarly, it has low elderly dependency ratios. Compared with the rest of the world China has a low urbanization rate and furthermore (this you'll have to do some data mining for from the previous source) the urban rate is a skewed towards the younger population. That means that the elderly are relatively few and in remote regions. It's far harder to obtain vaccinations than in the city centers and the numbers many not be worth it due to the low impact of spread in remote villages and the low opportunity of spread to a remote region due to lack of traffic.

2. Statistics

Had to use US data here due to lack of Chinese sources, but it shouldn't differ worldwide unless the CDC is purposefully misrepresenting death stats. As you are doubtless already aware, death rates are higher for people with weaker immune systems (as is the case with every disease) such as elderly people. Combining with the previous point on logistics, it may not be worth the effort to address this demographic as they are high risk regardless. People with weaker immune systems (such as elderly people) tend to die quickly so have a lower opportunity to spread the disease. This can bee seen as a reasonable triage situation; if your goal is only to stop the spread of the disease, not to prevent people from getting it, then you will focus on the elderly in urban areas where they can spread it. Since the elderly are skewed towards rural areas, this means that they will have an appropriately lower proportion of vaccination.

3. Economics

As expected from a former socialist country, China does have a somewhat functioning universal healthcare system (with caveats on about every word there...). As elderly care is generally more frequent than the younger demographic, it may be in China's best interest to simply let these people die than to perform expensive treatments for long periods of time trying to keep them alive when they can no longer work to support the system at a later date. Even if China wasn't an authoritarian state™, if I were in charge of a country and my main focus was economic growth to compete with the US, I would see myself sacrificing the retired members of my country. Health care aside, funds like pensions are a drain to the state only incurred from retirees. Not to mention, when these systems were put into place, the math may have made sense (work for 40 years from 25 to 65, get 10 years of about 1/4 of your wage) but falls apart quickly when people are retired for 30 years due to increased life expectancy and turns into a Ponzi scheme. Hence, there may be economic motivation to have the elderly die off from the virus but to save the younger, working population.

I do want to point out that given the size of China (largest in the world by hundreds of millions of people) and the urbanization rate of China (relatively low), such a high vaccination rate takes a large amount of effort that doesn't scale linearly with size. Considering the massive effort already undertaken, this is likely a deliberate decision so the question

So why didn't China use their powers to force 100% of the elderly to get vaccinated?

Is based on a false premise that they want to do so or it is even in their interests to do so. In general questions like "why doesn't X use their powers to do Y" are flawed because they assume in the first place that X wants to do Y. Not to mention, the inquiry in question asked about a 100% vaccination rate which is likely an exercise in futility particularly for China. Not even taking into account the rural/urban rate the total population is extremely uncertain. The level of uncertainty between the max and minimum estimates of China is on the order of hundreds of thousands to millions (a quick look at the demographics page on Wikipedia shows 3 different numbers for total population throughout the article), so likely their own government has a bit of trouble accurately determining the size of their population so 100% anything is out of question.