From covid success to the highest covid death rate in the world: What happened in Hong Kong?

For two years, Hong Kong was known for its relative success in controlling covid. The government used strict measures including three-week quarantines for incoming travelers, lockdowns and curfews in an effort to totally eradicate covid, even after most of the world had moved toward coexisting with the virus. But starting in February, Hong Kong’s defenses faltered.

How did Hong Kong’s covid success story spiral so rapidly into a public health disaster?

Meanwhile, as cases rise in mainland China, where vaccination among the elderly has also lagged, Hong Kong offers a stark warning.

David Owens: It’s been a bit frustrating and upsetting really to see the situation evolve in the way that it has because it was predictable, and it was preventable. I think for anybody with some background or understanding of public health or medicine, the warning signs were there for many months, and suddenly the warning signs became louder and louder from early to mid-December when we first saw the seeding of the omicron wave.

In much of the world, there has been talk about the fact that the variant is milder, that it causes more mild disease, and that is true with a very important caveat that it causes mild disease in immune populations. Unfortunately, in Hong Kong, although our overall vaccination rate was not too bad, we had very low vaccination rates in the most vulnerable fragments of the population.

What happens is if you don’t have an exit plan [from zero covid], the focus on keeping this bad guy out becomes negative. It’s a negative narrative. And it triggers this, I think I may have coined this phrase, rational vaccine hesitancy. I use the analogy that maybe I’m going to go to West Africa in the next 10 years, when am I going to get my vaccination? I’m going to get it a few weeks before I go. So if you’re telling your population, the disease is never going to come in, you’re not encouraging vaccination. So that was the communication failure of focusing too much on the elimination and not enough on the preparation for the eventual inevitability of the infective wave.

The government in Hong Kong, unlike the government in Singapore and some other governments in this area, decided to roll out both vaccinations, and to some degree within Hong Kong, there was a politicization of that process. Everybody in Hong Kong had the option to take either vaccine, so it was a free choice. Vaccines were free and widely available — the government did an extraordinary job of setting up vaccine centers all over the city. You could walk in with an appointment and get the vaccine, and you can choose which vaccine you wanted.

There was something of a division — it’s not strictly true — but there was a broad division that the older members of the population, who tend to be more likely to be pro-China, pro-Beijing, were more likely to have Sinovac, and the younger members of the population were a little bit more likely to have Pfizer-BioNTech. So there was something of a divide in the way the vaccines were given.

I’m often asked by people under this assumption that this China vaccine is in some way a failed vaccine. It’s not. Sinovac is a really great vaccine, and the difference is that BioNTech is an unbelievable vaccine. So there’s a misunderstanding. Similar to what happened in the U.S., there was a failure to communicate the fact that vaccinations have their impacts in different ways. A perfect vaccine will stop transmission and stop any form of infection, and neither of the vaccines do that, but the mRNA vaccines do it a bit better — they reduce transmission. But when it comes down to stopping people dying or stopping people going to intensive care, the Sinovac vaccine is very effective.

There were three factors that drove [the surge in Hong Kong]. No. 1, we had a very low natural immunity because we’ve had zero covid, so we have no immunity in our population. No. 2, we have very low levels of vaccination in the most vulnerable fragment, so our most vulnerable were unprotected. And then No. 3, and most upsetting for those of us who predicted this process, was the nature of this very high wave with lots of infections drove lots of people to hospitals in a very short space of time, and the hospital system got overloaded. When hospital systems get overloaded, mortality rates increase significantly from all the causes.

At some point, whenever you have a strategy like that when infections start to kick off, you need to pivot because you’re going to need your hospitals. Hong Kong, strategically they were caught in the headlights — they were not yet ready to pivot from zero covid to living with covid. So they were giving a political narrative that we’re going to go back to zero covid, but that meant two things. It meant the population was frightened about this terrible disease, which was really harmful, but there wasn’t a communication: ‘This is 90 percent asymptomatic, don’t worry, you’re going be fine.’ There was no reassurance, it was all about worry and fear, on the one hand, and on the other hand, they didn’t prepare the hospital system. So when the cases arrived, we had a flood of people rushing to the hospital worried that they were sick, and this overloaded it. I think that this contributed to the crashing of the hospital system.

Any rational and logical public health analysis would be to say that we would continue with mitigation measures at a lower level for a few months, and gradually open up over the next two, three, four, maybe up to six months so that we slowly reduce public health measures and return to normal by the summer or end of the summer. We could remove our border controls immediately. There’s no need for them. And we could probably get the schools back within a couple of weeks and gradually start easing up from there.

An alternative proposal, which is discussed in the media here, and partly that is because the government hasn’t clarified exactly what the strategy is going to be. One of the narratives is a return to zero covid by doing compulsory universal testing, which there’s been some talk about. I can envisage no scenarios under any circumstances at all that makes any sense whatsoever from a public health perspective.

I think it increases risks to population health in the short term by diverting priorities in terms of resources and energy to unnecessary testing of populations rather than focusing on protecting the health system and giving out drugs and maximizing vaccination. I think in the medium to long term it damages population health by damaging the economy further. We know that poverty is the greatest correlate with poor health in populations, so damaging the economy can only be bad for health. And then finally, if we go back to zero cases, you know, what then? Immunity can wane in our population, and if a variant gets in, as it will inevitably at some point, we’d potentially face a worse wave.