Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy  

Introduction

The Chinese dynamic zero-COVID-19 policy was a very strict policy for COVID-19 response in the Chinese mainland, and it meant that measures for COVID-19 response would be taken to promptly restraint the spread of SARS-CoV-2 and clear away new infections when a new local outbreak occurred, under the overarching goal of preventing imported infections and domestic flare-ups.¹ It was first proposed by the end of 2021, and was repealed on December 7, 2022.² Noteworthily, China has long been implementing a strict quarantine policy since 2020, whereas the policy has no official name. A common misconception of the policy was that it aimed to achieve zero infections. In fact, China was unable to ensure that there would be no more new domestically transmitted infections, but China were capable and confident of stamping out local infection clusters as quickly as possible.¹ The dynamic zero-COVID-19 policy has long been criticized by European and American politicians for the issue of human rights.³ However, these criticisms ignore a basic question: what would China be without this policy? Herein, I discussed this question based on my understanding of China’s national conditions and my dozens of volunteer service experiences in the fight against COVID-19.⁴

Policy outcomes and implications

In late November 2021, a Chinese expert forecasted that there would be 47.8 million infections and 950,000 COVID-19-related deaths in the Chinese mainland without the stringent policy if the infection and death rates were on par with the global average.¹ In addition, China and the United States were taken as examples. The national territorial areas of the Chinese mainland and the United States of America (USA) were 9.6 million and 9.37 million square kilometers, respectively. The population sizes of the Chinese mainland and the United States by the end of 2022 were 1.41 billion and 0.33 billion, respectively.⁵ In view of the fact that the Chinese actual habitable area is much lower than the national territorial area, the population density of the Chinese mainland is several times that of the USA. The accumulative COVID-19-induced deaths exceeded one million in the United States as of May 17, 2022, in accordance with the statistical data of the Johns Hopkins University (Baltimore, Maryland, USA).⁶ Therefore, there would extremely likely be millions of COVID-19-related deaths in the Chinese mainland without the dynamic zero-COVID-19 policy. In other words, the dynamic zero-COVID-19 policy protected millions of Chinese people from death.

On December 7, 2022, the State Council of the People’s Republic of China, also named as the Chinese central government, announced new 10 measures to adjust COVD-19 response. Since then, the dynamic zero-COVID-19 policy has been completely abrogated.² Noteworthily, owing to the dynamic zero-COVID-19 policy, the accumulative numbers of confirmed COVID-19 cases and COVID-19-induced deaths were 354,017 and 5,235, respectively, in the Chinese mainland as of December 7, 2022, despite the fact that the actual number of COVD-19 infections were much higher than the official number.⁷

The outcomes of China’s COVID-19 response demonstrated that the dynamic zero-COVID-19 policy was suitable to national conditions and conformed to scientific rules. Moreover, the dynamic zero-COVID-19 policy benefited the world, and it enabled China to quickly regain economic growth and help stabilize global supply chains. Meanwhile, China provided a considerable number of antivirus materials to 150 countries and 13 international organizations, dispatched 37 medical expert teams to 34 countries, and supplied over 2.1 billion COVID-19 vaccines to over 120 countries and international organizations.⁸

Freedom and health seem to be conflicted in the COVID-19 pandemic.⁹ In general, you cannot have both two things that are desirable but normally contradictory or impossible to have simultaneously. It is also extremely difficult to balance freedom and health under the COVID-19 pandemic in practice.³ Before the announcement of new 10 measures, the State Council issued 20 measures to optimize COVID-19 response on November 11, 2022.¹⁰ However, the State Council found that the implementation effects of the 20 measures were poor, meaning the difficulty to balance freedom and health. Thus, the new 10 measures were put forward to further optimize COVID-19 response 27 days later.^2,4

The dynamic zero-COVID-19 policy exhibited several advantages in the fight against COVID-19. For instance, the policy markedly reduced COVID-19 infections, hospitalizations, and deaths for the short term, retarded the spread of other infectious diseases for the medium term, and lowered the incidence of long COVID-19 for the long term.¹¹ Undoubtedly, the Chinese dynamic zero-COVID-19 policy greatly restricted people’s freedom, especially in high-risk areas, during the COVID-19 pandemic.¹² The Chinese government consistently adheres to putting people and their lives first, namely “people first, life first”. In other words, life and health rights are the most important human rights.^13,14 For instance, a patient with COVID-19 socializes as usual, does not wear a mask, and does not distance himself from others, will spread COVID-19 to others, and may even cause hospitalization or death among older people around him. In this respect, the patient’s freedom violates the right to life and health of others. In contrast, a healthy person could be infected with SARS-CoV-2 due to social activities without a mask in the COVID-19 pandemic.¹⁵ In fact, the vast majority of Chinese people hold similar viewpoints. As a result, most of Chinese people choose to cooperate unconditionally with the government’s strict quarantine policy rather than protest the government by large-scale demonstrations, even in the absence of food.¹²

The Chinese government has struggled to supply food to residents in high-risk areas during the COVID-19 pandemic. A large number of volunteers were assigned to assist the residents, and the main tasks of the volunteers were food delivery, mass nucleic acid testing, gatekeepers, and information consultation.¹² The author participated in dozens of volunteer activities from 2020 to 2022, and all of the activities were unremunerative. The volunteers dressed in sealed protective suits and endured heat, rain, thirst, and starvation to deliver food as well as medical supplies while residents starved. The author witnessed the solidarity among volunteers, residents, polices, medical workers, and the government in these volunteer activities. In mass nucleic acid testing, neither violence events nor violent quarrels were observed, and resident processions were well-regulated all the time. The author always believes that the key to China’s victories in fights against COVID-19 is solidarity, instead of abundant medical resources, advanced medical technology, effective anti-SARS-CoV-2 agents, or an optimalizing quarantine policy, and the solidarity continued after the end of the zero-COVID-19.

Keeping transparency is important in the fight against COVID-19.¹⁶ In early 2020, some officials in Wuhan (Hubei Province, China) suppressed information, silenced whistleblowers, and violated the freedom of expression for the purpose of political interests, leading to the outbreak of COVID-19 and large-scale infections in Wuhan.³ Eventually, the officials received administrative sanctions, such as removal from office, demotion, and serious warning. Wen-Liang Li, as a whistleblower, is one of the medical workers who firstly identified COVID-19 cases, and died of COVID-19 infection ultimately. He was rated as a martyr by the Chinese government, respected by all Chinese people, and became a heroic whistleblower.¹⁷ The Chinese government would not treat a person unfairly who made contributions to the fighting against COVID-19. After abolishment of the dynamic zero-COVID-19 policy, several countries announced travel restrictions and requirements of negative COVID-19 tests for Chinese people, reputedly due to non-transparent COVID-19 data.¹⁶ In order to keep the transparency, the Chinese government officially published the data for COVID-19-related deaths. A total of 59,938 COVID-19-related deaths were reported in medical institutions in the Chinese mainland between December 8, 2022 and January 12, 2023. The COVID-19-related deaths consisted of 5,503 patients who died of COVID-19-induced respiratory failure and 54,435 patients who died of underlying issues complicated by COVID-19 infection.¹⁸ In some ways, it is also the price of absolute freedom, which was achieved after the abrogation of the dynamic zero-COVID-19 policy. Thereafter, the Chinese government persistently reported COVID-19 infection surveillance data, including COVID-19 nucleic acid test data, COVID-19 antigen test data, fever clinic diagnosis and treatment data, hospitalization data containing COVID-19-related deaths in hospitals, SARS-CoV-2 variants surveillance of domestic cases in the Chinese mainland, and COVID-19 vaccination progress¹⁹ ( Figure 1). Evidently, the number of COVID-19-related deaths was much lower than the number predicted by American experts, in view of the fact that most of patients with critical COVID-19 would be sent to hospitals for emergency treatment.²⁰ The Chinese government chosen reopening when SARS-CoV-2 evolved to be a low-virulence virus, and the low virulence of current dominant SARS-CoV-2 Omicron subvariants was the main consideration for abandoning the dynamic zero-COVID-19 policy.^21,22 For instance, BA.5.2 and BF.7 accounted for 70.8% and 23.4%, respectively, in 69 Omicron sublineages based on 18,906 valid SARS-CoV-2 genome sequences from domestic cases in the Chinese mainland from September 26, 2022 to January 23, 2023.²² BF.7 (BA.5.2.1.7) is a sublineage of BA.5, Omicron BA.5.2 has notably decreased virulence compared to Omicron BA.1.17.2.²³ Of note, the BF.7 sequence in China was completely different from BF.7 sequences in other countries, and has additional five novel mutations, including V274L in ORF1a, L238F in ORF1b, C1243F in S, H47Y in ORF7a, and C29632T in ORF10, suggesting an independent BF.7 sublineage spreading in China. Recently, the BF.7 sublineage was designated as BF.7.14 by international scientists.²⁴

Figure 1. COVID-19-related deaths occurred in medical institutions in the Chinese mainland from December 9, 2022 to February 9, 2023.

The causes of death were classified as COVID-19-induced respiratory failure and underlying issues complicated by COVID-19 infection. Herein, underlying issues complicated by COVID-19 infection referred to the interaction of pre-existing comorbidities with COVID-19 infection.

Actionable recommendations

Freedom and human rights are not absolute. Appropriate restrictions on freedom and human rights are justified to protect public health and prevent harm to others in the COVID-19 pandemic, and an important premise is that the implement of these restrictions are based on law.⁹ Absolute freedom is impractical and irresponsible, freedom often comes with responsibility, and taking personal responsibility for personal health and public health is indispensable to ultimate freedom in spite of its complexity and difficulty. When defining the actual meaning of freedom, considerations should be given to different situations and different populations, especially the COVID-19 pandemic.¹⁵ From 2020 to 2022, COVID-19 vaccinations were mandatory for all residents in many countries, whereas the mandatory requirement was compatible with human rights according to the COVID-19 (LAC19) project. Immunization is recognized by WHO as an essential component of the right to health, and the mandatory COVID-19 vaccination policy will be proportional to legal principles if it serves for public health.²⁵ On the other hand, quarantine measures, such as lockdowns, could keep SARS-CoV-2 under control to achieve long-term freedom despite restrictions on short-term freedom, because an uncontrolled COVID-19 pandemic would cause large-scale infections and deaths, leading to the restrained freedom of a healthy population. From this point of view, lockdowns contribute to freedom by protecting people from COVID-19 infection and reducing relevant risks.²⁶ The respect for individual freedom should not endanger public health and give rise to more COVID-19 infections and deaths.²⁷

Conclusion/Discussion

In summary, it is biased to censure the Chinese dynamic zero-COVID-19 policy or abandonment of the Chinese dynamic zero-COVID-19 policy on the basis of violating human rights, and it neglects the solidarity and efforts of Chinese people to fight against the COVID-19 pandemic.

Ethics and consent

Ethical approval and consent were not required.