Does zero-COVID worsen health disparities?

By Nancy S. Jecker.

Since its inception, the novel coronavirus pandemic has prompted two distinct societal responses. Zero-Covid dominates Pacific Rim societies, such as New Zealand, Australia, Singapore, Japan, South Korea, Vietnam, mainland China, Hong Kong and Taiwan. It targets zero deaths as a goal and forcefully contains disease transmission to reach it. Mitigation dominates the U.S. and most European nations. It seeks to ‘flatten the curve,’ setting targets above zero for community transmission and lifting restrictions once targets are met.

What underlies these dissimilar approaches? One underlying factor is collectivist and individualist values, which are known to influence societal risk response. In collectivist-leaning societies, people generally regard risk as affecting everyone in their interconnected group, leading them to minimize risks on others’ behalf. Reflecting this, Zero-COVID emphasizes a duty to protect lives at all costs. By contrast, people in more individualist societies generally see themselves as independent and base choices on personal preferences, while downplaying risk-taking’s effects on society. Embodying this, mitigation allows calculated risks and accepts as ethically permissible a certain amount of disease and death.

Tight or loose attitudes toward rules are also known to affect risk-taking. Tighter societies report stronger norms and lower tolerance for deviance, while looser societies report weaker norms and higher tolerance for deviance. During the pandemic, tighter societies might be more accepting and compliant with strict rules of the sort Zero-COVID imposes. Looser societies might prefer less stringent strategies, like mitigation.

Finally, recent experiences with public health disasters shapes risk response. For example, the 2003 SARS epidemic may have led the 24 Asian societies affected to favor Zero-COVID and be generally more risk-protective during the coronavirus 2019 (COVID-19) pandemic.

Which response is best? Early in the pandemic, countries using Zero-COVID were often the most successful at preventing transmission, leading some to conclude that elimination was an optimal way to save lives and protect health. Yet, as the pandemic wore on, many, but not all, societies abandoned zero-COVID, perceiving a need to learn to live with higher background risk over the long haul.

Yet more than saving lives and protecting health are at stake. Health equity considerations lend support to loosening strict Zero-COVID policies because of the heavy burdens they place on disadvantaged people. While neither Zero-COVID nor mitigation eliminates the inequitable impact of the COVID-19 pandemic, strict Zero-COVID is the most devastating for marginalized groups.  In low-income countries, for example, lockdowns have “brutal” effects on people who rely on daily wages to survive, lack the means to purchase food in advance, and do not own refrigerators to store food. In rich and poor societies alike, Zero-COVID exacerbates structural inequalities. For example, Singapore was lauded early in the pandemic as a “gold standard,” due to its rapid response and success containing SARS-CoV-2. Yet, later on, when the virus reached migrant worker dormitories, Human Rights Watch exposed dangerous conditions, including workers “housed in crowded and unsanitary dormitories with up to 20 people sharing a room, and communal bathrooms… conditions that increased the risk of spreading Covid-19.”

Singapore is hardly alone. Many wealthy nations pursuing Zero-COVID jeopardized the health and safety of marginalized people.  For example, while Hong Kong is a wealthy city, it is among the most unequal places in the world, with 1 in 5 people living in poverty. During lockdowns, over 200,000 individuals in the city of Hong Kong were forced to retreat to spaces, locally referred to as ‘cage homes’, where the average living space is 48 square feet, less than one-third the size of a New York City parking space, with ethnic minorities disproportionately affected.

Admittedly, mitigation can also burden marginalized communities, especially when applied against a backdrop of structural racism or income inequality. For example, in the U.S., where mitigation prevails, Black and Brown communities fared worse as did people residing in areas with high social vulnerability; mitigation policies did little to alleviate these inequities.

Ethically, the best long-term response to the SARS-CoV-2 virus balances population health and health equity, considering what is owed to groups unduly burdened by COVID-19 and by societal responses to it.

Examples include requiring masks, rather than lockdowns, for low-income groups in Africa, migrant workers in Singapore, and ‘cage people’ in Hong Kong; allowing older adults ways to enjoy visitors on a limited basis outdoors; prioritizing opening schools for small children before gyms and restaurants; and enforcing restrictions in non-stigmatizing ways that avoid targeting racial and ethnic groups.

Ultimately, societies must discover ways to distribute risk equitably while protecting health and lives.


Paper title: Does Zero-COVID Neglect Health Disparities?

Authors: Nancy S. Jecker (1,2) and Derrick K S Au (2)


  1. School of Medicine, Department of Bioethics & HumanitiesUniversity of WashingtonSeattleWashington, USA
  2. CUHK Centre for BioethicsThe Chinese University of Hong Kong Faculty of MedicineShatinNew Territories, Hong Kong

Competing interests: None declared

Social media accounts of post authors: Twitter: profjecker

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