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Zero COVID and health inequities: lessons from Singapore
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  1. G Owen Schaefer
  1. Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  1. Correspondence to Dr G Owen Schaefer, Yong Loo Lin School of Medicine, Singapore, Singapore; owen_schaefer{at}nus.edu.sg

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COVID-19 has stolen millions of lives and devastated livelihoods around the world and led to the exacerbation of existing inequities within and between countries. This part of a tragic pattern in catastrophes, where the most vulnerable populations are typically the ones to bear the greatest burdens. Jecker and Au1 offer a keen observation of how one particular COVID-19 response—Zero COVID—appears particularly problematic from a health equity perspective. Under Zero COVID, countries enact stringent lockdowns and movement restrictions in order to keep cases as low as possible. Yet such restrictive policies hurt disadvantaged populations (such as impoverished individuals or migrant workers) the most, by severely curtailing their ability to earn a living and forcing them to remain in cramped living spaces for potentially extended periods of time.

However, the link between Zero COVID and health inequity is more complex than it might at first appear. This is because Zero COVID is itself compatible with meaningful efforts to mitigate inequities, including those caused by Zero COVID policies themselves. Conversely, certain inequities seemingly characterised by Zero COVID may persist even when Zero COVID is abandoned, indicating their ultimate root and (purported) justification lies elsewhere. To illustrate this point, I will focus on the case example of Singapore that Jecker and Au themselves raise.

In early- tomid-2020, Singapore experienced a surge of COVID-19 cases in its migrant worker dorms. As Jecker and Au observe, this was in part the result of overcrowded facilities that were at that time not well equipped to prevent spread of a highly infectious pathogen like COVID-19.1 Among various steps taken in reaction, the government moved to alter the conditions in workers’ dorms in order to prevent further spread, setting up ‘quick-build dormitories’ that were substantially less densely packed than existing facilities. This was not a purely temporary measure, as in September 2021, new standards were promulgated to formalise many of the reformed space requirements in dormitories.2

By the end of 2020, daily case counts in the country were in the single digits, a testament to the effectiveness of various mitigation efforts, including improved dormitory conditions as well as subsidised medical care for migrant workers.3 Yet, Zero COVID remained in place as the prevailing public health strategy until late 2021. In other words, Zero COVID is compatible with conditions that exacerbate inequities, as well as conditions that seek to mitigate those inequities.

Nevertheless, migrant workers continued to face substantial inequities after the 2020 dormitory outbreak was resolved. Even though almost all are fully vaccinated (including with boosters), workers have not for the most part been allowed to leave their places of residence, except to travel to their worksite or seek health services. This has led to strain on the social and psychological well-being of workers who are essentially kept isolated from the rest of society.

Most notably for present purposes, these severe restrictions were not conditioned on a Zero COVID approach, as they have generally remained in place even when Singapore officially abandoned Zero COVID in October 2021.4 While restrictions on socialising, exercising, dining out and travelling abroad were gradually eased for the rest of the population, opening up has been much slower for workers sequestered in their dormitories. A programme to allow workers into the community has been piloted, but as of this writing, only about 1% of the total number of migrant workers are permitted to be in the community on any given day.5

This case illustrates how the most material question in relation to health equity is not whether a country is pursuing Zero COVID, mitigation or some other strategy. The question is whether, within the broad public health strategy being pursued, health equity is being prioritised and promoted. Jecker and Au outline a four-pronged approach that is very useful in this regard: (1) keep restrictions proportionate to a group’s socioeconomic status and resources; (2) stratify restrictions by risk level; (3) prioritise lifting restrictions by domain; and (4) share risks fairly.1

So, for example, a Zero COVID strategy might impose severe restrictions on certain sectors like the food and beverage industry pursuant to risk level (promoting prong 2) but at the cost that workers in that sector suffer disproportionately (inhibiting prong 4). This inequitable result can at least be partly mitigated within a Zero COVID strategy by providing substantial subsidies to help offset the economic losses restrictions impose on the most vulnerable individuals. This was part of Singapore’s strategy, through schemes like the Jobs Support Scheme to minimise layoffs in affected sectors, as well as a support grant for those nevertheless laid off or otherwise unable to support themselves. Dozens of other countries, both those pursuing Zero COVID and those pursuing mitigation, have to varying degrees also enacted subsidies to offset economic losses during COVID-19 pandemic.6 Of course, it remains an open question whether such subsidies are adequate or sufficient in the face of the inequities of relevant policies. But that question of equitability of response is to a substantial degree independent of whether a given country is pursuing Zero COVID in the first place.

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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