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

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Policy and implications The dynamic zero-COVID-19 policy has long been criticized by European and American politicians for the issue of human rights. There are some points that need to be considered with regard to these criticisms: Firstly, the dynamic zero-COVID-19 policy protected millions of Chinese people from death, the outcomes of China’s COVID-19 response demonstrated the correctness and suitability of the dynamic zero-COVID-19 policy, and the policy benefited the world. Secondly, freedom and health were generally conflicted and extremely difficult to be compatible in the COVID-19 pandemic, and the dynamic zero-COVID-19 policy indeed exhibited several advantages in the fight against COVID-19. Thirdly, China struggled to spare no effort to save lives all the time during the COVID-19 pandemic under the dynamic zero-COVID-19 policy. Recommendations 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. Conclusions In summary, it is biased to censure the Chinese dynamic zero-COVID-19 policy or abandonment of the Chinese dynamic zero-COVID-19 policy based on human rights, and the great achievement of the policy and China’s efforts to fight against the COVID-19 pandemic should not be ignored. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-1548", "name": "Conflict between freedom and health in the COVID-19 pandemic: An appraisal..." } } ] } Home Browse Conflict between freedom and health in the COVID-19 pandemic: An appraisal... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Zhu KW. Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.12688/f1000research.157922.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Policy Brief Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] Ke-Wei Zhu https://orcid.org/0000-0002-2138-271X Ke-Wei Zhu https://orcid.org/0000-0002-2138-271X PUBLISHED 20 Dec 2024 Author details Author details Office of Pharmacovigilance, GuangZhou BaiYunShan Pharmaceutical Holdings CO.,LTD. BaiYunShan Pharmaceutical General Factory, Guangzhou, Guangdong Province, China Ke-Wei Zhu Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Coronavirus (COVID-19) collection. Abstract Background The Chinese dynamic zero-COVID-19 policy was a very strict policy for COVID-19 response in the Chinese mainland, with the overarching goal of preventing imported infections and domestic flare-ups. Policy and implications The dynamic zero-COVID-19 policy has long been criticized by European and American politicians for the issue of human rights. There are some points that need to be considered with regard to these criticisms: Firstly, the dynamic zero-COVID-19 policy protected millions of Chinese people from death, the outcomes of China’s COVID-19 response demonstrated the correctness and suitability of the dynamic zero-COVID-19 policy, and the policy benefited the world. Secondly, freedom and health were generally conflicted and extremely difficult to be compatible in the COVID-19 pandemic, and the dynamic zero-COVID-19 policy indeed exhibited several advantages in the fight against COVID-19. Thirdly, China struggled to spare no effort to save lives all the time during the COVID-19 pandemic under the dynamic zero-COVID-19 policy. Recommendations 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. Conclusions In summary, it is biased to censure the Chinese dynamic zero-COVID-19 policy or abandonment of the Chinese dynamic zero-COVID-19 policy based on human rights, and the great achievement of the policy and China’s efforts to fight against the COVID-19 pandemic should not be ignored. READ ALL READ LESS Keywords COVID-19, zero-COVID-19, China, Chinese mainland, public health, human rights Corresponding Author(s) Ke-Wei Zhu ( [email protected] ) Close Corresponding author: Ke-Wei Zhu Competing interests: Author Ke-Wei Zhu was employed by GuangZhou BaiYunShan Pharmaceutical Holdings CO.,LTD. BaiYunShan Pharmaceutical General Factory, Guangzhou, China. The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Zhu KW. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Zhu KW. Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.12688/f1000research.157922.1 ) First published: 20 Dec 2024, 13 :1548 ( https://doi.org/10.12688/f1000research.157922.1 ) Latest published: 20 Dec 2024, 13 :1548 ( https://doi.org/10.12688/f1000research.157922.1 ) 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 progress 19 ( 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. Data availability No data are associated with this article. Acknowledgements The author thanks for intense international attention to the SARS-CoV-2 Omicron wave in China by the end of 2022. References 1. China Daily: Zero-COVID policy keeps pandemic under control.2022. (Accessed January 10/2022). Reference Source 2. Xinhua: China Focus: COVID-19 response further optimized with 10 new measures.2022. (Accessed December 7/2022). Reference Source 3. Gostin LO, Friedman EA, Hossain S, et al. : Human rights and the COVID-19 pandemic: a retrospective and prospective analysis. Lancet. 2023; 401 (10371): 154–168. PubMed Abstract | Publisher Full Text 4. Zhu KW: Why is it necessary to improve COVID-19 vaccination coverage in older people? How to improve the vaccination coverage? Hum. Vaccin. Immunother. 2023; 19 (2): 2229704. PubMed Abstract | Publisher Full Text | Free Full Text 5. Xinhua News Agency: More immigrants came, and the American population grew to 333.3 million [In Chinese].2022. (Accessed December 23/2022). Reference Source 6. Xinhua News Agency: Johns Hopkins University: Cumulative American COVID-19-induced deaths exceed 1 million [In Chinese].2022. (Accessed May 18/2022). Reference Source 7. National Health Commission of the People’s Republic of China: The latest situation of COVID-19 as of 24:00 on December 7 [In Chinese].2022. (Accessed December 8/2022). Reference Source 8. China Daily: Zero COVID-19 policy helping nation, world.2022. (Accessed March 4/2022). Reference Source 9. Isaacs D: Freedom comes with responsibilities: Freedom and COVID-19. J. Paediatr. Child Health. 2022; 58 (3): 374–375. PubMed Abstract | Publisher Full Text | Free Full Text 10. Xinhua News Agency: The Joint Prevention and Control Mechanism of the State Council announces 20 measures to further optimize COVID-19 response [In Chinese].2022. (Accessed November 11/2022). Reference Source 11. Su Z, Cheshmehzangi A, McDonnell D, et al. : The Advantages of the Zero-COVID-19 Strategy. Int. J. Environ. Res. Public Health. 2022; 19 (14). Publisher Full Text 12. Zhang X, Zhang W, Chen S: Shanghai’s life-saving efforts against the current omicron wave of the COVID-19 pandemic. Lancet. 2022; 399 (10340): 2011–2012. PubMed Abstract | Publisher Full Text | Free Full Text 13. People’s Daily: Put People First and Forge Global Synergy in Fighting against COVID-19.2021. (Accessed June 10/2021). Reference Source 14. Xinhua: Xinhua Commentary_ Build a better world for all with concrete actions, true multilateralism 2021. (Accessed September 22/2021). Reference Source 15. Chadwick R: Freedom and responsibility in the COVID debate. Bioethics. 2021; 35 (7): 607–607. PubMed Abstract | Publisher Full Text | Free Full Text 16. The Lancet: The COVID-19 pandemic in 2023: far from over. Lancet. 2023; 401 (10371): 79. Publisher Full Text 17. Party history learning and education: Heroes against COVID-19: Wen-Liang Li, a whistleblower, retrograde light.2021. (Accessed April 6/2021). Reference Source 18. Xinhua: Chinese mainland reports 59,938 COVID-related deaths in past 30-plus days.2023. (Accessed January 15/2023). Reference Source 19. Chinese Center for Disease Control and Prevention: COVID-19 Clinical and Surveillance Data — December 9, 2022 to April 27, 2023, China.2023. Reference Source 20. Ioannidis JPA, Zonta F, Levitt M: Estimates of COVID-19 deaths in Mainland China after abandoning zero COVID policy. Eur. J. Clin. Investig. 2023; 53 (4): e13956. PubMed Abstract | Publisher Full Text | Free Full Text 21. National Health Commission of the People’s Republic of China: Interpretation and reply of the notification of futher optimization and implementation of prevention and control measures against COVID-19.2022. (Accessed December 7/2022). Reference Source 22. Chinese Center for Disease Control and Prevention: COVID-19 Clinical and Surveillance Data — December 9, 2022 to January 23, 2023, China.2023. (Accessed January 26/2023). Reference Source 23. Ali KM, Rashid PMA, Ali AM, et al. : Clinical outcomes and phylogenetic analysis in reflection with three predominant clades of SARS-CoV-2 variants. Eur. J. Clin. Investig. 2023; 53 (9): e14004. PubMed Abstract | Publisher Full Text 24. Beijing Institute of Genomics, Chinese Academy of Sciences/China National Center for Bioinformation: Molecular epidemiology of the SARS-CoV-2 variant in China revealed a new Omicron BF.7 sub-lineage (proposed to be BF.7.14), October to December 2022.2023. (Accessed January 8/2023). Reference Source 25. King J, Ferraz OLM, Jones A: Mandatory COVID-19 vaccination and human rights. Lancet. 2022; 399 (10321): 220–222. PubMed Abstract | Publisher Full Text | Free Full Text 26. Giubilini A: Freedom, diseases, and public health restrictions. Bioethics. 2023; 37 (9): 886–896. PubMed Abstract | Publisher Full Text | Free Full Text 27. Ferdinand KC: COVID-19 Mitigation: Individual Freedom Should Not Impede Public Health. Am. J. Public Health. 2021; 111 (4): 592–593. PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 20 Dec 2024 ADD YOUR COMMENT Comment Author details Author details Office of Pharmacovigilance, GuangZhou BaiYunShan Pharmaceutical Holdings CO.,LTD. BaiYunShan Pharmaceutical General Factory, Guangzhou, Guangdong Province, China Ke-Wei Zhu Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests Author Ke-Wei Zhu was employed by GuangZhou BaiYunShan Pharmaceutical Holdings CO.,LTD. BaiYunShan Pharmaceutical General Factory, Guangzhou, China. The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 20 Dec 2024, 13:1548 https://doi.org/10.12688/f1000research.157922.1 Copyright © 2024 Zhu KW. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Zhu KW. Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.12688/f1000research.157922.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 20 Dec 2024 Views 0 Cite How to cite this report: Coccia M. Reviewer Report For: Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.5256/f1000research.173445.r417840 ) The direct URL for this report is: https://f1000research.com/articles/13-1548/v1#referee-response-417840 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Sep 2025 Mario Coccia , National Research Council of Italy, Turin, Italy Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.173445.r417840 Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy The topics of this paper are interesting, though well known. The content must be revised, and results have to ... Continue reading READ ALL Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy The topics of this paper are interesting, though well known. The content must be revised, and results have to be better explained by authors before to be reconsidered. The title has to be clear about implications of this zero-COVID-19 policy Abstract has to clarify the goal, methods and health and social implications of strict policy for COVID-19 response i. Authors have to structure the paper as follows. -Introduction -Study design -Results and discussion -Conclusion Introduction has to better clarify the research questions of this study, indicating the gap presents in literature that this study endeavors to cover, and provide more theoretical background about policies of prevention of COVID-19 pandemic related also vaccination. After that authors can focus on the topics of this study to provide a correct analysis for fruitful discussion (See suggested readings that must be all read and used in the text). The methods of this study are not clear. Insert a short section. Authors have to clarify if this study is: --A narrative review explains the existing knowledge on a topic based on all the published research available on the topic. --A systematic review searches for the answer to a particular question in the existing scientific literature on a topic. --A meta-analysis compares and combines the findings of previously published studies, usually to assess the effectiveness of an intervention or mode of treatment. Results and implications The study presents a detailed account of China’s dynamic zero-COVID-19 policy, portraying it as a scientifically grounded and nationally tailored strategy that helped mitigate the pandemic’s impact. However, current scientific literature reveals several limitations that challenge this narrative. One major concern is the psychological toll of prolonged lockdowns. Studies published in the Journal of Social Policy and Lancet Psychiatry highlight elevated levels of anxiety, depression, and social isolation among residents subjected to strict quarantine measures. These mental health consequences were especially pronounced in urban areas where mobility and access to care were severely restricted. Transparency remains another critical issue. Although the study emphasizes China’s efforts to publish COVID-19-related data, skepticism persists internationally. Several countries imposed travel restrictions on Chinese citizens following the policy’s repeal, citing concerns over the reliability and completeness of reported data. The early suppression of information in Wuhan, including the silencing of whistleblower Wen-Liang Li, underscores the challenges of maintaining open communication during public health crises. The policy’s adaptability has also been questioned. Research in Frontiers in Public Health suggests that the abrupt transition from strict containment to reopening in December 2022 led to a surge in infections, indicating that the healthcare system may not have been adequately prepared for such a shift. This raises concerns about the timing and scalability of the policy’s exit strategy. Economic and social trade-offs are another area of concern. While the policy may have supported global supply chains, it disrupted domestic livelihoods, particularly among migrant workers and small business owners. These groups bore the brunt of prolonged restrictions, yet their struggles are underrepresented in the study. Comparisons with the United States, used to justify the policy’s effectiveness, overlook key differences in healthcare infrastructure, governance, and public behavior. Assuming uniform infection and mortality rates across vastly different contexts risks oversimplifying complex epidemiological dynamics. Finally, the study relies heavily on anecdotal evidence, particularly the author’s volunteer experiences. While these accounts offer valuable insights into community solidarity, they cannot substitute for large-scale empirical data. Broader population-level studies are necessary to validate claims of widespread compliance and support for the policy. Taken together, these limitations suggest that while the dynamic zero-COVID-19 policy may have achieved short-term containment, its broader implications—psychological, economic, and ethical—require more nuanced evaluation within the framework of current scientific literature. Discussion. First, authors have to synthesize the main results in a simple table to be clear for readers and then show what this study adds compared to other studies. While the study offers a detailed narrative of China’s dynamic zero-COVID-19 policy and its perceived successes, it falls short in clearly articulating how it addresses existing gaps in the scientific literature surrounding pandemic response strategies. The research problem—evaluating the effectiveness and broader implications of stringent containment policies—has been widely explored in global public health discourse. However, this study does not sufficiently engage with or differentiate itself from prior work in terms of methodology, scope, or theoretical framework. There is limited discussion of how the study builds upon or challenges existing models of pandemic control, such as mitigation versus suppression strategies. It also lacks a comparative analysis with other countries that adopted different approaches, which could have helped contextualize China’s policy within a broader scientific conversation. Although anecdotal evidence and national statistics are presented, the study does not clarify whether these sources fill a specific void in empirical data or theoretical understanding. Moreover, the study does not explicitly identify which aspects of previous research were inadequate or underexplored, nor does it explain how its findings contribute new insights. The reliance on personal volunteer experiences, while compelling, does not substitute for a rigorous engagement with peer-reviewed literature or established public health metrics. Without a clear articulation of the literature gap and how this research addresses it, the study risks being perceived as a descriptive account rather than a scholarly contribution. A more robust integration of existing research and a clearer statement of its unique contribution would strengthen its academic relevance and credibility. The discussion section has to interpret and describe the significance of your findings in relation to what was already known about the research problem being investigated and explain any new understanding or insights that emerged from your research. The discussion has better to connect to the introduction through the research questions and the literature you reviewed. The discussion clearly has to explain how this study advances these research topics. Moreover, either compare your results with the findings from other studies or use the studies to support your results. A claim for how the results can be applied more generally also beyond China. While the study provides a detailed account of China’s dynamic zero-COVID-19 policy and its domestic outcomes, it does not sufficiently explore the broader theoretical and policy implications for other countries or the nuanced consequences for individual freedom. The discussion remains largely confined to China’s national context, without extending its analysis to global public health frameworks or comparative policy models. As a result, the study misses an opportunity to contribute meaningfully to international discourse on pandemic governance. Theoretical engagement is notably limited. The study does not situate China’s approach within established paradigms of health security, biopolitics, or risk management, nor does it interrogate how the policy aligns or diverges from global norms of emergency response. Without such framing, it is difficult to assess whether China’s experience offers transferable lessons or challenges prevailing theories about state intervention and public health ethics. Moreover, the policy’s implications for individual freedom are acknowledged but not critically examined. The study mentions restrictions in high-risk areas and the public’s general compliance, yet it does not delve into the long-term societal effects of such constraints. Issues like surveillance, autonomy, and the psychological toll of prolonged lockdowns are underexplored, despite being central to debates in human rights and democratic governance. For other countries, especially those with different political systems or cultural norms, the applicability of China’s model remains unclear. The study does not address how variations in governance, public trust, or legal frameworks might influence the feasibility or desirability of similar policies elsewhere. In omitting these considerations, the study limits its relevance to international policymakers and scholars seeking to understand the broader consequences of strict containment strategies. A more robust engagement with theory and cross-national policy analysis would enhance the study’s contribution and clarify its significance beyond China’s borders. Describe lessons learned, proposing recommendations that can help improve pandemic prevention considering containment policies, vaccination and social issues related to limit to freedom, highlighting best practices to face next pandemics with bullet points, also with high investments in health sector to cope with next pandemics. Conclusion so short is useless. Conclusion has not to be a summary, but authors have to focus on manifold limitations of this study. The Conclusion does not adequately discuss the theoretical and policy implications of the study. Discuss how the gap in the literature has been addressed about the research problem. Make sure you create 3 subsections in the Conclusion: 1) Theoretical Implications, 2) Policy Implications, and 3) Ideas for Future Research. Overall, then, the paper is interesting, but the structure is confusing. Theoretical framework is weak, and some results create confusion… structure of the paper has to be improved; study design, discussion and presentation of results have to be clarified using suggested comments. I suggest improving the paper by using all comments (suggested papers included to read and use all) Suggested readings of relevant papers. Ramasamy, R., Silva, K.T. 2025. The Covid-19 pandemic and governance dimensions of crisis response in developing countries: evidence from Sri Lanka,Contemporary South Asia, 33(2), pp. 187–205 The Lancet Regional Health – Western Pacific 2023. The end of zero-COVID-19 policy is not the end of COVID-19 for China,Lancet Regional Health Western Pacific, 30, 100702 Coccia M. 2023. Sources, diffusion and prediction in COVID-19 pandemic: lessons learned to face next health emergency[J]. AIMS Public Health, 2023, 10(1): 145-168. doi: 10.3934/publichealth.2023012 Wang, Y., Qing, S., Lan, X., ... Zhang, C., Xu, C. 2024. Evaluating the long-term impact of COVID-19-associated public health interventions on zoonotic and vector-borne diseases in China: an interrupted time series analysis,Journal of Translational Medicine, 22(1), 81 Coccia M. 2022. Preparedness of countries to face COVID-19 pandemic crisis: Strategic positioning and underlying structural factors to support strategies of prevention of pandemic threats, Environmental Research, Volume 203, n. 111678, https://doi.org/10.1016/j.envres.2021.111678. Núñez-Delgado A., Bontempi E., Coccia M., Kumar M., Farkas K., Domingo, J. L. 2021. SARS-CoV-2 and other pathogenic microorganisms in the environment, Environmental Research, Volume 201, n. 111606, https://doi.org/10.1016/j.envres.2021.111606. Askitas, N., Tatsiramos, K., Verheyden, B. 2021. Estimating worldwide effects of non-pharmaceutical interventions on COVID-19 incidence and population mobility patterns using a multiple-event study (Open Access)(2021) Scientific Reports, 11 (1), art. no. 1972. Coccia M. 2022. COVID-19 pandemic over 2020 (with lockdowns) and 2021 (with vaccinations): similar effects for seasonality and environmental factors. Environmental Research, Volume 208, 15 May 2022, n. 112711. https://doi.org/10.1016/j.envres.2022.112711 Li, J., Bao, W., Zhang, X., ... Lin, Z., Zhu, H. 2023. Modelling the transmission and control of COVID-19 in Yangzhou city with the implementation of Zero-COVID policy,Mathematical Biosciences and Engineering, 20(9), pp. 15781–15808 Flaxman, S., Mishra, S., Gandy, A., Unwin, H.J.T., Mellan, T.A., Coupland, H., Whittaker, C., (...), Bhatt, S. 2020. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe (Open Access), (2020) Nature, 584 (7820), pp. 257-261. Su, Z., Cheshmehzangi, A., McDonnell, D., ... Xiang, Y.-T., da Veiga, C.P. 2022. The Advantages of the Zero-COVID-19 Strategy,International Journal of Environmental Research and Public Health, 19(14), 8767 Coccia M. 2021. Pandemic Prevention: Lessons from COVID-19. Encyclopedia, vol. 1, n. 2, pp. 433-444. doi: 10.3390/encyclopedia1020036 Zeng, H., Cai, M., Li, S., ... Xiong, Y., Long, X. 2023. Epidemiological characteristics of seasonal influenza under implementation of zero-COVID-19 strategy in China.Journal of Infection and Public Health, 16(8), pp. 1158–1166 Wan, Z., Lu, R., Zhao, Y., Zhang, C. 2022. Diagnostic strategy of SARS-CoV-2 for containment under China's zero-COVID-19 policy,Journal of Infection, 85(1), pp. e7–e9 Coccia M. 2023. Effects of strict containment policies on COVID-19 pandemic crisis: lessons to cope with next pandemic impacts. Environmental science and pollution research international, 30(1), 2020–2028. https://doi.org/10.1007/s11356-022-22024-w Yung, L., Leung, L.Y., Lee, K.H., ... Graham, C.A., Yen, H.-L. 2023. A longitudinal environmental surveillance study for SARS-CoV-2 from the emergency department of a teaching hospital in Hong Kong,Journal of Hospital Infection, 138, pp. 34–41 Coccia M. 2022. Improving preparedness for next pandemics: Max level of COVID-19 vaccinations without social impositions to design effective health policy and avoid flawed democracies. Environmental Research, vol. 213, October 2022, n. 113566. https://doi.org/10.1016/j.envres.2022.113566 Wang, H. 2023. Reflection and Foresight on Personal Information Protection and Optimization in Public Health Emergencies in China—From the Perspective of Personal Information Collection during the Period of China’s Dynamic-Zero COVID-19 Prevention and Control Policy,International Journal of Environmental Research and Public Health, 20(2), 1290 Kargı B., Coccia M.2025. Lessons learned of COVID-19 containment policies on public health and economic growth: new perspectives to face future emergencies. Discover Public Health 22, 56 (2025). https://doi.org/10.1186/s12982-025-00442-8 Ding, Y., Shi, X., Li, G., ... Deng, H., Wang, Z. 2023. Effects of dynamic zero COVID-19 policy on anxiety status and lifestyle changes of pregnant women in rural South China: a survey-based analysis by propensity score matching method,Frontiers in Public Health, 11, 1182619 Does the paper provide a comprehensive overview of the policy and the context of its implementation in a way which is accessible to a general reader? Partly Is the discussion on the implications clearly and accurately presented and does it cite the current literature? Partly Are the recommendations made clear, balanced, and justified on the basis of the presented arguments? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pandemic prevention, vaccination policies, health investments and crisis pandemic, pollution and pandemic, containment policies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Coccia M. Reviewer Report For: Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.5256/f1000research.173445.r417840 ) The direct URL for this report is: https://f1000research.com/articles/13-1548/v1#referee-response-417840 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Rinner C. Reviewer Report For: Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.5256/f1000research.173445.r360018 ) The direct URL for this report is: https://f1000research.com/articles/13-1548/v1#referee-response-360018 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 13 Feb 2025 Claus Rinner , Toronto Metropolitan University, Toronto, Canada Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.173445.r360018 Review of Ke-Wei Zhu, “Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy” [v1] In this policy brief, Ke-Wei Zhu evaluates China’s “dynamic zero-COVID-19” policy with emphasis on the delicate balance ... Continue reading READ ALL Review of Ke-Wei Zhu, “Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy” [v1] In this policy brief, Ke-Wei Zhu evaluates China’s “dynamic zero-COVID-19” policy with emphasis on the delicate balance between public health and individual freedoms. This important issue was debated in many countries around the globe during the pandemic. The author’s overall perspective is that the Chinese approach was unfairly attacked by North-American and European politicians and scientists. On the basis of China’s official COVID-19 fatality counts, Ke-Wei Zhu concludes that severe, short-term mobility restrictions were justified in pursuing the goal to “save lives,” as long as the measures were “based on law.” A fundamental issue with this text is that the policy being assessed is not properly defined. While the end of the zero-COVID-19 policy, marked by the implementation of new measures in November and December 2022, is at least referenced through news reports, the onset of the policy “by the end of 2021” is not clearly identified and explained. What institution made this decision? What was its character: Was it a law, a decree, etc.? How were the triggers and response measures defined? When did the “policy” come into effect? Did the approach change over time? What are the most (dis)similar policies found in other countries? A second major shortcoming of this policy brief is that the core issue of “conflict between freedom and health” is not explored in depth. Ke-Wei Zhu defends China’s strict public health measures through their seemingly positive impact on one metric, the country’s COVID-19 deaths statistics. For a comprehensive analysis, broader measures such as excess mortality would have to be taken into account and one might find that countries at the opposite end of pandemic response severity, such as Sweden, had comparable, if not better, long-term outcomes (e.g. Andersson and Jonung 2024). In terms of the human rights question, legal restrictions of civil liberties are often measured by their necessity, efficacy, and proportionality. The author certainly implies answers to these tests, but they should be made explicit in order to be assessed. A range of published explorations of this issue could be engaged (e.g. Schippers 2020, Tomlinson 2022), though perhaps with some limitations in the applicability of European-American considerations to a different world region. There is a suggestion in the text that the Chinese policy allowed that country to pursue a more liberal approach to vaccination. This is quite relevant and could be further supported with scholarly references questioning the ethics of vaccination mandates (e.g. Gur-Arie 2021, Kowalik 2022, Bardosh et al. 2022). However, comparing the zero-COVID-19 approach with a different, arguably unethical set of policies, does not make the former more legitimate. Instead, a comprehensive policy assessment would have to examine the unintended harms arising from lockdowns (e.g. Joffe 2021, Richardson et al. 2021, Allen 2022). The findings from a growing body of research on these harms, i.e. declining mental health, gaps in children’s education, missed medical care/prevention, as well as starvation, according to this author, could be applied to China’s contemporary political and socio-economic situation. Similar to the role of epidemiological models in pushing Western governments to (re)implement restrictions throughout the pandemic, Ke-Wei Zhu appears to suggest that in late 2021, a forecast of nearly 50 million cases and close to 1 million possible deaths was the trigger for China’s zero-COVID-19 policy. The author relies on these model results to compare the country’s de-facto COVID-19 outcomes with those of the United States, thus using the argument of hypothetical lives saved by China’s approach. However, attempts to compare reality with modelled “counter-factuals” have repeatedly been proven wrong. For example, a team of researchers including Canada’s chief medical officer of health used the approach to illustrate the effect of vaccination in limiting the pandemic (Ogden et al. 2022), yet their unrealistic assumptions would have amounted to a death rate several times greater than during the 1918 influenza pandemic or either world war (Vickers et al. 2022), illustrating how unsuitable counter-factual modeling is for important policy decision-making. It would also be helpful if the author could provide additional details supporting the validity of the Chinese government’s COVID-19 statistics. With respect to the sample of data provided for a short period around 2022/23, it is worth noting that an important distinction is made between “COVID-19-induced respiratory failure” and “Underlying issues complicated by COVID-19 infection”. Sadly, most Western public health agencies, and consequently most media outlets, did not distinguish between fatalities with COVID-19 as the primary cause and those who died for other reasons, after a positive COVID-19 test (not even necessarily a symptomatic “infection”) had also been recorded (see De-Giorgio et al. 2021). This will limit the comparability of the Chinese with the US data and should be noted. The comparison is likely also influenced by differences in age structure, overall population health, health-care infrastructure, and attitudes to personal wellbeing, which should also be discussed. Lastly, the author credits the Chinese response with helping stabilize global supply chains and fostering post-pandemic economic growth. Reading this, I wonder whether China might in turn have benefited from the rest of the world’s more open approach, which may have accelerated the emergence of the less virulent Omicron variant, making it safer for China to drop the zero-COVID-19 policy and international isolation. I recommend that the author explore some of these considerations, in particular with additional references to the developing social science literature, in order to arrive at a more nuanced assessment of China’s pandemic response. The general tone of this article is not objective enough. For example, the paragraph on policy outcomes has similarities to the news article (reference 8) in China Daily, which, according to Wikipedia, is “owned by the Central Propaganda Department of the Chinese Communist Party,” suggesting a lack of critical distance. Other areas of the policy brief could be shortened and some language and other technical issues resolved to improve the legibility of this overall interesting piece. Does the paper provide a comprehensive overview of the policy and the context of its implementation in a way which is accessible to a general reader? Partly Is the discussion on the implications clearly and accurately presented and does it cite the current literature? Partly Are the recommendations made clear, balanced, and justified on the basis of the presented arguments? Partly References 1. Allen D: Covid-19 Lockdown Cost/Benefits: A Critical Assessment of the Literature. International Journal of the Economics of Business . 2022; 29 (1): 1-32 Publisher Full Text 2. Andersson F, Jonung L: The Covid‐19 lesson from Sweden: Don't lock down. Economic Affairs . 2024; 44 (1): 3-16 Publisher Full Text 3. Bardosh K, Krug A, Jamrozik E, Lemmens T, et al.: COVID-19 vaccine boosters for young adults: a risk benefit assessment and ethical analysis of mandate policies at universities. J Med Ethics . 2024; 50 (2): 126-138 PubMed Abstract | Publisher Full Text 4. De-Giorgio F, Grassi VM, Bergamin E, Cina A, et al.: Dying "from" or "with" COVID-19 during the Pandemic: Medico-Legal Issues According to a Population Perspective. Int J Environ Res Public Health . 2021; 18 (16). PubMed Abstract | Publisher Full Text 5. Gur-Arie R, Jamrozik E, Kingori P: No Jab, No Job? Ethical Issues in Mandatory COVID-19 Vaccination of Healthcare Personnel. BMJ Glob Health . 2021; 6 (2). PubMed Abstract | Publisher Full Text 6. Joffe AR: COVID-19: Rethinking the Lockdown Groupthink. Front Public Health . 2021; 9 : 625778 PubMed Abstract | Publisher Full Text 7. Kowalik M: Ethics of vaccine refusal. J Med Ethics . 2022; 48 (4): 240-243 PubMed Abstract | Publisher Full Text 8. Ogden NH, Turgeon P, Fazil A, Clark J, et al.: Counterfactuals of effects of vaccination and public health measures on COVID-19 cases in Canada: What could have happened?. Can Commun Dis Rep . 2022; 48 (7-8): 292-302 PubMed Abstract | Publisher Full Text 9. Richardson D, Clarke N, Broom D, Tallis J, et al.: Life after lockdown: The role of sport, exercise and physical activity in ameliorating the mental health implications of COVID-19 restrictions. Journal of Sports Sciences . 2021; 39 (18): 2144-2146 Publisher Full Text 10. Schippers MC: For the Greater Good? The Devastating Ripple Effects of the Covid-19 Crisis. Front Psychol . 2020; 11 : 577740 PubMed Abstract | Publisher Full Text 11. Tomlinson, M.: Balancing the Rights of the Individual with the “Common Good”- Ethical and Policy Frameworks for Covid-19 Pandemic Management. In The COVID-19 Pandemic: Ethical Challenges and Considerations (E. Egel, C. Patton (eds). Ethics International Press. 12. Vickers DM, Hardie J, Eberspaecher S, Chaufan C, et al.: Counterfactuals of effects of vaccination and public health measures on COVID-19 cases in Canada: what could have happened?. Front Public Health . 2023; 11 : 1173673 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Data analytics, geography, public health I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Rinner C. Reviewer Report For: Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.5256/f1000research.173445.r360018 ) The direct URL for this report is: https://f1000research.com/articles/13-1548/v1#referee-response-360018 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 20 Dec 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 20 Dec 24 read read Claus Rinner , Toronto Metropolitan University, Toronto, Canada Mario Coccia , National Research Council of Italy, Turin, Italy Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Coccia M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Sep 2025 | for Version 1 Mario Coccia , National Research Council of Italy, Turin, Italy 0 Views copyright © 2025 Coccia M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy The topics of this paper are interesting, though well known. The content must be revised, and results have to be better explained by authors before to be reconsidered. The title has to be clear about implications of this zero-COVID-19 policy Abstract has to clarify the goal, methods and health and social implications of strict policy for COVID-19 response i. Authors have to structure the paper as follows. -Introduction -Study design -Results and discussion -Conclusion Introduction has to better clarify the research questions of this study, indicating the gap presents in literature that this study endeavors to cover, and provide more theoretical background about policies of prevention of COVID-19 pandemic related also vaccination. After that authors can focus on the topics of this study to provide a correct analysis for fruitful discussion (See suggested readings that must be all read and used in the text). The methods of this study are not clear. Insert a short section. Authors have to clarify if this study is: --A narrative review explains the existing knowledge on a topic based on all the published research available on the topic. --A systematic review searches for the answer to a particular question in the existing scientific literature on a topic. --A meta-analysis compares and combines the findings of previously published studies, usually to assess the effectiveness of an intervention or mode of treatment. Results and implications The study presents a detailed account of China’s dynamic zero-COVID-19 policy, portraying it as a scientifically grounded and nationally tailored strategy that helped mitigate the pandemic’s impact. However, current scientific literature reveals several limitations that challenge this narrative. One major concern is the psychological toll of prolonged lockdowns. Studies published in the Journal of Social Policy and Lancet Psychiatry highlight elevated levels of anxiety, depression, and social isolation among residents subjected to strict quarantine measures. These mental health consequences were especially pronounced in urban areas where mobility and access to care were severely restricted. Transparency remains another critical issue. Although the study emphasizes China’s efforts to publish COVID-19-related data, skepticism persists internationally. Several countries imposed travel restrictions on Chinese citizens following the policy’s repeal, citing concerns over the reliability and completeness of reported data. The early suppression of information in Wuhan, including the silencing of whistleblower Wen-Liang Li, underscores the challenges of maintaining open communication during public health crises. The policy’s adaptability has also been questioned. Research in Frontiers in Public Health suggests that the abrupt transition from strict containment to reopening in December 2022 led to a surge in infections, indicating that the healthcare system may not have been adequately prepared for such a shift. This raises concerns about the timing and scalability of the policy’s exit strategy. Economic and social trade-offs are another area of concern. While the policy may have supported global supply chains, it disrupted domestic livelihoods, particularly among migrant workers and small business owners. These groups bore the brunt of prolonged restrictions, yet their struggles are underrepresented in the study. Comparisons with the United States, used to justify the policy’s effectiveness, overlook key differences in healthcare infrastructure, governance, and public behavior. Assuming uniform infection and mortality rates across vastly different contexts risks oversimplifying complex epidemiological dynamics. Finally, the study relies heavily on anecdotal evidence, particularly the author’s volunteer experiences. While these accounts offer valuable insights into community solidarity, they cannot substitute for large-scale empirical data. Broader population-level studies are necessary to validate claims of widespread compliance and support for the policy. Taken together, these limitations suggest that while the dynamic zero-COVID-19 policy may have achieved short-term containment, its broader implications—psychological, economic, and ethical—require more nuanced evaluation within the framework of current scientific literature. Discussion. First, authors have to synthesize the main results in a simple table to be clear for readers and then show what this study adds compared to other studies. While the study offers a detailed narrative of China’s dynamic zero-COVID-19 policy and its perceived successes, it falls short in clearly articulating how it addresses existing gaps in the scientific literature surrounding pandemic response strategies. The research problem—evaluating the effectiveness and broader implications of stringent containment policies—has been widely explored in global public health discourse. However, this study does not sufficiently engage with or differentiate itself from prior work in terms of methodology, scope, or theoretical framework. There is limited discussion of how the study builds upon or challenges existing models of pandemic control, such as mitigation versus suppression strategies. It also lacks a comparative analysis with other countries that adopted different approaches, which could have helped contextualize China’s policy within a broader scientific conversation. Although anecdotal evidence and national statistics are presented, the study does not clarify whether these sources fill a specific void in empirical data or theoretical understanding. Moreover, the study does not explicitly identify which aspects of previous research were inadequate or underexplored, nor does it explain how its findings contribute new insights. The reliance on personal volunteer experiences, while compelling, does not substitute for a rigorous engagement with peer-reviewed literature or established public health metrics. Without a clear articulation of the literature gap and how this research addresses it, the study risks being perceived as a descriptive account rather than a scholarly contribution. A more robust integration of existing research and a clearer statement of its unique contribution would strengthen its academic relevance and credibility. The discussion section has to interpret and describe the significance of your findings in relation to what was already known about the research problem being investigated and explain any new understanding or insights that emerged from your research. The discussion has better to connect to the introduction through the research questions and the literature you reviewed. The discussion clearly has to explain how this study advances these research topics. Moreover, either compare your results with the findings from other studies or use the studies to support your results. A claim for how the results can be applied more generally also beyond China. While the study provides a detailed account of China’s dynamic zero-COVID-19 policy and its domestic outcomes, it does not sufficiently explore the broader theoretical and policy implications for other countries or the nuanced consequences for individual freedom. The discussion remains largely confined to China’s national context, without extending its analysis to global public health frameworks or comparative policy models. As a result, the study misses an opportunity to contribute meaningfully to international discourse on pandemic governance. Theoretical engagement is notably limited. The study does not situate China’s approach within established paradigms of health security, biopolitics, or risk management, nor does it interrogate how the policy aligns or diverges from global norms of emergency response. Without such framing, it is difficult to assess whether China’s experience offers transferable lessons or challenges prevailing theories about state intervention and public health ethics. Moreover, the policy’s implications for individual freedom are acknowledged but not critically examined. The study mentions restrictions in high-risk areas and the public’s general compliance, yet it does not delve into the long-term societal effects of such constraints. Issues like surveillance, autonomy, and the psychological toll of prolonged lockdowns are underexplored, despite being central to debates in human rights and democratic governance. For other countries, especially those with different political systems or cultural norms, the applicability of China’s model remains unclear. The study does not address how variations in governance, public trust, or legal frameworks might influence the feasibility or desirability of similar policies elsewhere. In omitting these considerations, the study limits its relevance to international policymakers and scholars seeking to understand the broader consequences of strict containment strategies. A more robust engagement with theory and cross-national policy analysis would enhance the study’s contribution and clarify its significance beyond China’s borders. Describe lessons learned, proposing recommendations that can help improve pandemic prevention considering containment policies, vaccination and social issues related to limit to freedom, highlighting best practices to face next pandemics with bullet points, also with high investments in health sector to cope with next pandemics. Conclusion so short is useless. Conclusion has not to be a summary, but authors have to focus on manifold limitations of this study. The Conclusion does not adequately discuss the theoretical and policy implications of the study. Discuss how the gap in the literature has been addressed about the research problem. Make sure you create 3 subsections in the Conclusion: 1) Theoretical Implications, 2) Policy Implications, and 3) Ideas for Future Research. Overall, then, the paper is interesting, but the structure is confusing. Theoretical framework is weak, and some results create confusion… structure of the paper has to be improved; study design, discussion and presentation of results have to be clarified using suggested comments. I suggest improving the paper by using all comments (suggested papers included to read and use all) Suggested readings of relevant papers. Ramasamy, R., Silva, K.T. 2025. The Covid-19 pandemic and governance dimensions of crisis response in developing countries: evidence from Sri Lanka,Contemporary South Asia, 33(2), pp. 187–205 The Lancet Regional Health – Western Pacific 2023. The end of zero-COVID-19 policy is not the end of COVID-19 for China,Lancet Regional Health Western Pacific, 30, 100702 Coccia M. 2023. Sources, diffusion and prediction in COVID-19 pandemic: lessons learned to face next health emergency[J]. AIMS Public Health, 2023, 10(1): 145-168. doi: 10.3934/publichealth.2023012 Wang, Y., Qing, S., Lan, X., ... Zhang, C., Xu, C. 2024. Evaluating the long-term impact of COVID-19-associated public health interventions on zoonotic and vector-borne diseases in China: an interrupted time series analysis,Journal of Translational Medicine, 22(1), 81 Coccia M. 2022. Preparedness of countries to face COVID-19 pandemic crisis: Strategic positioning and underlying structural factors to support strategies of prevention of pandemic threats, Environmental Research, Volume 203, n. 111678, https://doi.org/10.1016/j.envres.2021.111678. Núñez-Delgado A., Bontempi E., Coccia M., Kumar M., Farkas K., Domingo, J. L. 2021. SARS-CoV-2 and other pathogenic microorganisms in the environment, Environmental Research, Volume 201, n. 111606, https://doi.org/10.1016/j.envres.2021.111606. Askitas, N., Tatsiramos, K., Verheyden, B. 2021. Estimating worldwide effects of non-pharmaceutical interventions on COVID-19 incidence and population mobility patterns using a multiple-event study (Open Access)(2021) Scientific Reports, 11 (1), art. no. 1972. Coccia M. 2022. COVID-19 pandemic over 2020 (with lockdowns) and 2021 (with vaccinations): similar effects for seasonality and environmental factors. Environmental Research, Volume 208, 15 May 2022, n. 112711. https://doi.org/10.1016/j.envres.2022.112711 Li, J., Bao, W., Zhang, X., ... Lin, Z., Zhu, H. 2023. Modelling the transmission and control of COVID-19 in Yangzhou city with the implementation of Zero-COVID policy,Mathematical Biosciences and Engineering, 20(9), pp. 15781–15808 Flaxman, S., Mishra, S., Gandy, A., Unwin, H.J.T., Mellan, T.A., Coupland, H., Whittaker, C., (...), Bhatt, S. 2020. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe (Open Access), (2020) Nature, 584 (7820), pp. 257-261. Su, Z., Cheshmehzangi, A., McDonnell, D., ... Xiang, Y.-T., da Veiga, C.P. 2022. The Advantages of the Zero-COVID-19 Strategy,International Journal of Environmental Research and Public Health, 19(14), 8767 Coccia M. 2021. Pandemic Prevention: Lessons from COVID-19. Encyclopedia, vol. 1, n. 2, pp. 433-444. doi: 10.3390/encyclopedia1020036 Zeng, H., Cai, M., Li, S., ... Xiong, Y., Long, X. 2023. Epidemiological characteristics of seasonal influenza under implementation of zero-COVID-19 strategy in China.Journal of Infection and Public Health, 16(8), pp. 1158–1166 Wan, Z., Lu, R., Zhao, Y., Zhang, C. 2022. Diagnostic strategy of SARS-CoV-2 for containment under China's zero-COVID-19 policy,Journal of Infection, 85(1), pp. e7–e9 Coccia M. 2023. Effects of strict containment policies on COVID-19 pandemic crisis: lessons to cope with next pandemic impacts. Environmental science and pollution research international, 30(1), 2020–2028. https://doi.org/10.1007/s11356-022-22024-w Yung, L., Leung, L.Y., Lee, K.H., ... Graham, C.A., Yen, H.-L. 2023. A longitudinal environmental surveillance study for SARS-CoV-2 from the emergency department of a teaching hospital in Hong Kong,Journal of Hospital Infection, 138, pp. 34–41 Coccia M. 2022. Improving preparedness for next pandemics: Max level of COVID-19 vaccinations without social impositions to design effective health policy and avoid flawed democracies. Environmental Research, vol. 213, October 2022, n. 113566. https://doi.org/10.1016/j.envres.2022.113566 Wang, H. 2023. Reflection and Foresight on Personal Information Protection and Optimization in Public Health Emergencies in China—From the Perspective of Personal Information Collection during the Period of China’s Dynamic-Zero COVID-19 Prevention and Control Policy,International Journal of Environmental Research and Public Health, 20(2), 1290 Kargı B., Coccia M.2025. Lessons learned of COVID-19 containment policies on public health and economic growth: new perspectives to face future emergencies. Discover Public Health 22, 56 (2025). https://doi.org/10.1186/s12982-025-00442-8 Ding, Y., Shi, X., Li, G., ... Deng, H., Wang, Z. 2023. Effects of dynamic zero COVID-19 policy on anxiety status and lifestyle changes of pregnant women in rural South China: a survey-based analysis by propensity score matching method,Frontiers in Public Health, 11, 1182619 Does the paper provide a comprehensive overview of the policy and the context of its implementation in a way which is accessible to a general reader? Partly Is the discussion on the implications clearly and accurately presented and does it cite the current literature? Partly Are the recommendations made clear, balanced, and justified on the basis of the presented arguments? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Pandemic prevention, vaccination policies, health investments and crisis pandemic, pollution and pandemic, containment policies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Coccia M. Peer Review Report For: Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.5256/f1000research.173445.r417840) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1548/v1#referee-response-417840 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Rinner C. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 13 Feb 2025 | for Version 1 Claus Rinner , Toronto Metropolitan University, Toronto, Canada 0 Views copyright © 2025 Rinner C. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Review of Ke-Wei Zhu, “Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy” [v1] In this policy brief, Ke-Wei Zhu evaluates China’s “dynamic zero-COVID-19” policy with emphasis on the delicate balance between public health and individual freedoms. This important issue was debated in many countries around the globe during the pandemic. The author’s overall perspective is that the Chinese approach was unfairly attacked by North-American and European politicians and scientists. On the basis of China’s official COVID-19 fatality counts, Ke-Wei Zhu concludes that severe, short-term mobility restrictions were justified in pursuing the goal to “save lives,” as long as the measures were “based on law.” A fundamental issue with this text is that the policy being assessed is not properly defined. While the end of the zero-COVID-19 policy, marked by the implementation of new measures in November and December 2022, is at least referenced through news reports, the onset of the policy “by the end of 2021” is not clearly identified and explained. What institution made this decision? What was its character: Was it a law, a decree, etc.? How were the triggers and response measures defined? When did the “policy” come into effect? Did the approach change over time? What are the most (dis)similar policies found in other countries? A second major shortcoming of this policy brief is that the core issue of “conflict between freedom and health” is not explored in depth. Ke-Wei Zhu defends China’s strict public health measures through their seemingly positive impact on one metric, the country’s COVID-19 deaths statistics. For a comprehensive analysis, broader measures such as excess mortality would have to be taken into account and one might find that countries at the opposite end of pandemic response severity, such as Sweden, had comparable, if not better, long-term outcomes (e.g. Andersson and Jonung 2024). In terms of the human rights question, legal restrictions of civil liberties are often measured by their necessity, efficacy, and proportionality. The author certainly implies answers to these tests, but they should be made explicit in order to be assessed. A range of published explorations of this issue could be engaged (e.g. Schippers 2020, Tomlinson 2022), though perhaps with some limitations in the applicability of European-American considerations to a different world region. There is a suggestion in the text that the Chinese policy allowed that country to pursue a more liberal approach to vaccination. This is quite relevant and could be further supported with scholarly references questioning the ethics of vaccination mandates (e.g. Gur-Arie 2021, Kowalik 2022, Bardosh et al. 2022). However, comparing the zero-COVID-19 approach with a different, arguably unethical set of policies, does not make the former more legitimate. Instead, a comprehensive policy assessment would have to examine the unintended harms arising from lockdowns (e.g. Joffe 2021, Richardson et al. 2021, Allen 2022). The findings from a growing body of research on these harms, i.e. declining mental health, gaps in children’s education, missed medical care/prevention, as well as starvation, according to this author, could be applied to China’s contemporary political and socio-economic situation. Similar to the role of epidemiological models in pushing Western governments to (re)implement restrictions throughout the pandemic, Ke-Wei Zhu appears to suggest that in late 2021, a forecast of nearly 50 million cases and close to 1 million possible deaths was the trigger for China’s zero-COVID-19 policy. The author relies on these model results to compare the country’s de-facto COVID-19 outcomes with those of the United States, thus using the argument of hypothetical lives saved by China’s approach. However, attempts to compare reality with modelled “counter-factuals” have repeatedly been proven wrong. For example, a team of researchers including Canada’s chief medical officer of health used the approach to illustrate the effect of vaccination in limiting the pandemic (Ogden et al. 2022), yet their unrealistic assumptions would have amounted to a death rate several times greater than during the 1918 influenza pandemic or either world war (Vickers et al. 2022), illustrating how unsuitable counter-factual modeling is for important policy decision-making. It would also be helpful if the author could provide additional details supporting the validity of the Chinese government’s COVID-19 statistics. With respect to the sample of data provided for a short period around 2022/23, it is worth noting that an important distinction is made between “COVID-19-induced respiratory failure” and “Underlying issues complicated by COVID-19 infection”. Sadly, most Western public health agencies, and consequently most media outlets, did not distinguish between fatalities with COVID-19 as the primary cause and those who died for other reasons, after a positive COVID-19 test (not even necessarily a symptomatic “infection”) had also been recorded (see De-Giorgio et al. 2021). This will limit the comparability of the Chinese with the US data and should be noted. The comparison is likely also influenced by differences in age structure, overall population health, health-care infrastructure, and attitudes to personal wellbeing, which should also be discussed. Lastly, the author credits the Chinese response with helping stabilize global supply chains and fostering post-pandemic economic growth. Reading this, I wonder whether China might in turn have benefited from the rest of the world’s more open approach, which may have accelerated the emergence of the less virulent Omicron variant, making it safer for China to drop the zero-COVID-19 policy and international isolation. I recommend that the author explore some of these considerations, in particular with additional references to the developing social science literature, in order to arrive at a more nuanced assessment of China’s pandemic response. The general tone of this article is not objective enough. For example, the paragraph on policy outcomes has similarities to the news article (reference 8) in China Daily, which, according to Wikipedia, is “owned by the Central Propaganda Department of the Chinese Communist Party,” suggesting a lack of critical distance. Other areas of the policy brief could be shortened and some language and other technical issues resolved to improve the legibility of this overall interesting piece. Does the paper provide a comprehensive overview of the policy and the context of its implementation in a way which is accessible to a general reader? Partly Is the discussion on the implications clearly and accurately presented and does it cite the current literature? Partly Are the recommendations made clear, balanced, and justified on the basis of the presented arguments? Partly References 1. Allen D: Covid-19 Lockdown Cost/Benefits: A Critical Assessment of the Literature. International Journal of the Economics of Business . 2022; 29 (1): 1-32 Publisher Full Text 2. Andersson F, Jonung L: The Covid‐19 lesson from Sweden: Don't lock down. Economic Affairs . 2024; 44 (1): 3-16 Publisher Full Text 3. Bardosh K, Krug A, Jamrozik E, Lemmens T, et al.: COVID-19 vaccine boosters for young adults: a risk benefit assessment and ethical analysis of mandate policies at universities. J Med Ethics . 2024; 50 (2): 126-138 PubMed Abstract | Publisher Full Text 4. De-Giorgio F, Grassi VM, Bergamin E, Cina A, et al.: Dying "from" or "with" COVID-19 during the Pandemic: Medico-Legal Issues According to a Population Perspective. Int J Environ Res Public Health . 2021; 18 (16). PubMed Abstract | Publisher Full Text 5. Gur-Arie R, Jamrozik E, Kingori P: No Jab, No Job? Ethical Issues in Mandatory COVID-19 Vaccination of Healthcare Personnel. BMJ Glob Health . 2021; 6 (2). PubMed Abstract | Publisher Full Text 6. Joffe AR: COVID-19: Rethinking the Lockdown Groupthink. Front Public Health . 2021; 9 : 625778 PubMed Abstract | Publisher Full Text 7. Kowalik M: Ethics of vaccine refusal. J Med Ethics . 2022; 48 (4): 240-243 PubMed Abstract | Publisher Full Text 8. Ogden NH, Turgeon P, Fazil A, Clark J, et al.: Counterfactuals of effects of vaccination and public health measures on COVID-19 cases in Canada: What could have happened?. Can Commun Dis Rep . 2022; 48 (7-8): 292-302 PubMed Abstract | Publisher Full Text 9. Richardson D, Clarke N, Broom D, Tallis J, et al.: Life after lockdown: The role of sport, exercise and physical activity in ameliorating the mental health implications of COVID-19 restrictions. Journal of Sports Sciences . 2021; 39 (18): 2144-2146 Publisher Full Text 10. Schippers MC: For the Greater Good? The Devastating Ripple Effects of the Covid-19 Crisis. Front Psychol . 2020; 11 : 577740 PubMed Abstract | Publisher Full Text 11. Tomlinson, M.: Balancing the Rights of the Individual with the “Common Good”- Ethical and Policy Frameworks for Covid-19 Pandemic Management. In The COVID-19 Pandemic: Ethical Challenges and Considerations (E. Egel, C. Patton (eds). Ethics International Press. 12. Vickers DM, Hardie J, Eberspaecher S, Chaufan C, et al.: Counterfactuals of effects of vaccination and public health measures on COVID-19 cases in Canada: what could have happened?. Front Public Health . 2023; 11 : 1173673 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Data analytics, geography, public health I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Rinner C. Peer Review Report For: Conflict between freedom and health in the COVID-19 pandemic: An appraisal of China's zero-COVID-19 policy [version 1; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 13 :1548 ( https://doi.org/10.5256/f1000research.173445.r360018) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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