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How Hong Kong went from 'zero-Covid' to the world's highest death rate

Despite having two years to prepare, critics say the government was caught off-guard by a virus outbreak that has killed thousands of unvaccinated seniors.
A patient being transferred from Queen Elizabeth Hospital in Hong Kong on Thursday, after the government said the hospital would be used only for Covid-19 patients. Isaac Lawrence / AFP - Getty Images

HONG KONG — Hong Kong’s worst outbreak of the pandemic didn’t come until 2022, but the scenes are right out of 2020.

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

Calvin Kong, an emergency physician at a public hospital, said he and his colleagues were in a “living hell” evoking the early days of the pandemic in Wuhan, the central Chinese city where the coronavirus was first detected in late 2019. 

“We have so much lead time and experience, but still we have to suffer from a health care system breakdown,” he said. “Health authorities have not learned a lesson after two years.”

The outbreak, driven by the more transmissible omicron variant, has come as a shock to the Chinese territory, where a “zero-Covid” strategy of mass testing, contact tracing, border closures and strict quarantine requirements kept cases and deaths to a minimum for almost two years. While experts agree that approach made sense for Hong Kong early in the pandemic, critics say it also bred complacency, and the government was caught unprepared by an outbreak many had warned was inevitable.

Covid patients are kept in a holding area at Princess Margaret Hospital in Hong Kong on March 11, 2022.Dale De La Rey / AFP - Getty Images

“The ‘zero-Covid’ measures will not eventually stop the virus from getting in. They’ll only postpone it,” said Ben Cowling, chair professor of epidemiology at the University of Hong Kong School of Public Health. “In Hong Kong, we won’t be able to stop an outbreak once it gets established, and that’s exactly what’s happened now.”

Omicron is tearing through densely populated Hong Kong much the way it has elsewhere in the world. Officially, there have been more than 740,000 cases since the outbreak began in late December, out of a population of 7.4 million. But researchers at the University of Hong Kong estimate that 3.6 million people, or almost half the population, have contracted the virus in the current outbreak, and that the total will be 4.5 million. 

Only about 35 percent of residents 80 and older have received two vaccine doses, compared with more than 80 percent of those 12 and above.

Similar outbreaks are occurring in places like Singapore and New Zealand, which are transitioning away from elimination policies. The difference, critics say, is that while those countries had detailed plans for how to manage them, the Hong Kong government did not.

“The government and the Hospital Authority weren’t prepared for the outbreak,” Adrian Kwan, an internist at a public hospital, said. “They had no contingency plan until late February. They did not anticipate what they would do when there was an outbreak in institutional settings, elderly homes in this case.”

Containing the virus in Hong Kong has depended on cutting off transmission chains as soon as they appeared. Any person with a confirmed infection, even if asymptomatic, was required to be hospitalized, while close contacts were sent to a government quarantine facility for up to three weeks. But once omicron took hold, cases rose faster than officials could respond. 

Even amid mounting deaths — over 4,000, more than the toll recorded in Wuhan — the government has been slow to adjust its strategy, now called “dynamic zero Covid.” In recent weeks, officials announced plans for universal testing and scrambled to build more isolation facilities, baffling public health experts who said the priority should be saving lives. Public confusion as to when the testing would be conducted, as well as whether it would be accompanied by Hong Kong’s first real lockdown, set off rounds of panic-buying and led residents to flee the city in droves.

Last week, Chief Executive Carrie Lam announced a major shift, saying universal testing would be postponed while the government focused on reducing the number of deaths and severe infections. The change was in line with recommendations from mainland Chinese officials who have intervened after President Xi Jinping expressed his dissatisfaction with Hong Kong’s handling of the outbreak. Mainland China is also dealing with its worst outbreak in two years, with multiple cities on lockdown, including Shenzhen, a city of 17.5 million just across the border from Hong Kong.

While Lam said officials have done their best to manage the pandemic, she admitted they did not do enough to encourage older adults to get vaccinated. Only about 35 percent of residents 80 and older have received two vaccine doses, compared with more than 80 percent of those 12 and above.

A downtown street in Hong Kong, where masks are still required everywhere.Vincent Yu / AP

“We need to catch up and vaccinate every Hong Kong citizen,” she said at a news conference Friday.

The government said vaccine outreach teams will have visited every nursing home in the city by the end of this week.

Older residents, sometimes on the advice of doctors or family members, have resisted vaccination over fears of possible side effects. Others simply didn’t feel they were at risk of infection in a “zero-Covid” city.

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“The zero tolerance of having Covid in society makes you feel you have no possibility, or you shouldn’t get the disease,” said Annisa Lee, an associate professor of journalism at the Chinese University of Hong Kong who specializes in health communications. “If you do, there must be something you have done wrong.”

In January, parts of the Kwai Chung public housing estate were locked down for up to a week for mass testing after an outbreak that made headlines across the city.

“I felt alienated, even though I wasn’t infected,” resident Susan So, 31, said.

“The government made the outbreak sound so horrifying that people saw me in a different light, just because I live in that housing estate. That panic was unnecessary,” she added.

Public anxiety over the outbreak has been heightened by the stigma around Covid-19, creating intense fear of the disease itself as well as the idea of being forced into quarantine or isolation. People with mild or asymptomatic cases have swarmed hospitals and tied up ambulances, while others hoping to avoid government confinement have opted to keep their infections to themselves and quietly recover at home.

Hong Kong commuters wearing masks and other protective measures on March 2.Dale De La Rey / AFP via Getty Images

Evelyn Wong, 31, said he hesitated to report his infection after a rapid test came back positive for fear of how it would affect others.

“I’m worried all my friends will be taken to quarantine when the government decides to track down the transmission chain, and they might blame me for their ordeal,” he said.

Overwhelmed by the case numbers, the government has made some concessions, allowing close contacts to quarantine at home along with infected patients waiting to be admitted to an isolation facility or hospital. Officials have also given up on issuing electronic tracking bracelets to those quarantining at home, which Lam estimated Sunday numbered about 300,000 people. 

But for residents used to the government managing every single case, it can be disorienting to find themselves on their own.

When Justin Ho, 44, tested positive at a public hospital early last month, he wanted to go to a quarantine facility to avoid exposing his parents, with whom he shares a 500-square-foot apartment. But health authorities never followed up after telling him to go home, he said, and his parents were soon both infected, though they have all since recovered.

“I wasn’t scared of the disease,” he said, “but I felt helpless knowing I was being toyed with by the government policy.”