The city was able to keep the Pandemic at bay for two years. Why didn't it take measures that would help in an inevitable outbreak?

Patients wait outdoors for available beds at Hong Kong’s Princess Margaret Hospital on March 16. 

Patients wait outside for beds at Hong Kong's Princess Margaret Hospital on March 16.

An elderly man in a Hong Kong nursing home was struggling to breathe. He was not the only one who was sick. Half of the facility's 100 residents had already tested positive for the Covid-19 virus, and an unprecedented outbreak was gathering pace. Less than a third of people had received a booster dose. It was impossible to separate the infections. The nursing home was cramped like most dwellings in the city. Each resident's space was only big enough for a small bed, separated from neighbors by thin wooden dividers. Staff called an emergency hotline as the man's condition worsened. The secretary-general of a union that represents nursing home workers said they waited more than 10 hours before an ambulance arrived to take the man to the hospital. He died on the way, one of more than 4,000 Hong Kongers age 80 and older who have succumbed to the virus in the past few months.

Hong Kong is experiencing one of the worst Covid epidemics of all time, more than two years after Covid began spreading around the globe. It began early this year, when the omicron variant broke through the Chinese territory's ferocious quarantine system for inbound travelers, which had previously kept cases almost to zero. The authorities had done little to prepare for the possibility that the travel restrictions wouldn't be enough. Since January, there have been 5,600 deaths in the health-care system. More people are dying from Covid in Hong Kong than anywhere else in the world, even though there are tentative signs that the worst may be over. The situation has caused a sort of shock for some. How could a city with a top-notch health-care system and plenty of time to learn from experience get its response so wrong?

As of March 22.

The Government of Hong Kong has a vaccine dashboard.

Beijing's decision to take greater control of the financial hub after the pro-democracy protests is one of the reasons for Hong Kong's situation. The city's government failed at vaccinating older adults, botching public-education campaigns and allowing misinformation about the shots to run rampant among those residents. The rate of people 80 and older getting at least two doses of the Sinovac vaccine is the lowest in the developed world. The application of China's Covid-zero strategy resulted in other mistakes. Aggressive contact tracing and mandatory hospitalization of people with no symptoms worked well, but they became useless as omicron raced through densely packed high-rises. Hong Kong officials were under pressure from the central government in China to stick to their guns and force people into long waits for testing and dedicating precious hospital beds to patients who could have easily stayed at home. The authorities maintained that Hong Kong's international isolation had deepened, banning flights from high-risk countries such as the U.S. and the U.K.

relates to Hong Kong’s Completely Avoidable Covid Catastrophe
A mobile testing site in Hong Kong.

Hong Kong had a dark period before the current outbreak. The media and civil society have been decimated by the government's strict enforcement of the National Security Law. It is tipped into a full-blown civic crisis, with large numbers of residents leaving and major employers scrambling to relocate operations to places that are living with Covid more successfully. The city's reputation as a business hub may be damaged permanently.

The most significant implications, however, could be felt in the rest of China, where authorities are rushing to contain the largest surge of infections since the 2020 outbreak in Wuhan. Outside of large cities, mainland facilities are rudimentary, and in a large outbreak you're going to see hospitals quickly filled with people seeking care. It is possible that the health-care system could be overwhelmed, which could lead to panic and threaten political stability.

The total number of Covid deaths in Hong Kong was about one-fifth of the total in the U.S. until early this year. Most of the people who checked into their isolation room at Hong Kong International Airport were not tested for positive. The goal was to eliminate the risk of the virus entering the economy. When an infectious person slipped through, contact tracers swung into action, ordering everyone they knew to go toPenny's Bay, a spartan dormitory complex on an outlying island. Sometimes all it took was having eaten at the same restaurant as a positive case. As long as a Hong Konger didn't travel and avoided being swept up in a contact tracing dragnet, daily life in Hong Kong remained calm, with eateries, offices, and beaches still open and busy.

Hong Kong was different from most places when vaccines began to arrive in the first months of 2021. In February of that year, the head of Hong Kong's government rolled up her sleeves at a televised event to receive her first dose of the Sinovac vaccine, which was offered alongside Pfizer Inc. The vaccine roll out quickly went awry while officials urged everyone to bevaccinated. In a population that had not experienced Covid's horrors, few people were interested. Despite a simple online sign-up, a surplus of doses, and dozens of orderly, efficient vaccination sites, just 46% of the population had been fully vaccine by the end of August, compared with 80% in Singapore, the region's rival financial center.

relates to Hong Kong’s Completely Avoidable Covid Catastrophe
Chief Executive Carrie Lam at a news conference on March 21.

The hesitancy was caused by the distrust of the government. Although it's difficult to conduct reliable polls on sensitive issues in Hong Kong, it's still unpopular because of her eagerness to please Beijing. Hundreds of thousands of people attended pro-democracy rallies before the security law made them illegal. Any instructions that were given by her or her allies were suspect for some. Politics crept into the vaccine drive from the beginning. The pro-China figures boasted that they had chosen Sinovac, and the central-government officials suggested that crossing the border into the mainland would be easier for those who had received a domestic vaccine. The authorities removed a clinic from the list of authorized vaccination sites after doctors there recommended the Pfizer shot, which is more effective at preventing infections and severe disease without a booster.

An unconventional philosophy of public-health communication was the larger problem. Hong Kong took a hyper transparent approach to publishing information about Covid cases, publicly identifying every location visited by a person who later tested positive, on the theory that these details would prompt people who'd been there. It did something similar with vaccine side effects, publicly announcing the handful of deaths and adverse events that occurred after someone had been shot, whether or not there was reason to believe the shot had caused them. Newspapers speculated that the vaccines were harmful, causing a frenzy of anxious media coverage.

The official policy called for older people with existing medical problems to consult a doctor before getting a vaccine. Many families and doctors urged the elderly to be careful because of this qualification, which was almost nowhere else in the world. With so little chance of catching Covid and a government that insisted it could keep the virus out indefinitely, why take the risk? A chart of Hong Kong's vaccination rates, categorized by age, looks like it's an inverse of the situation in most countries. More than double the percentage of those 80 and older are fully vaccine free among Hong Kong residents age 40 to 49.

relates to Hong Kong’s Completely Avoidable Covid Catastrophe
An elderly woman outside her retirement home.

A person with knowledge of the gathering said that senior officials held a meeting to discuss whether they were prepared for a surge of cases. The group concluded that they were prepared for a large number of infections because of the large spaces available for isolation beds at AsiaWorld-Expo, a convention center by the airport. In a worst-case scenario, the government might abandon its insistence on hospitalizing or otherwise taking physical responsibility for every positive case, allowing those without serious symptoms to stay at home.

Hong Kong kept to its Covid-zero approach even as it became clear that the approach was unsustainable. Tens of thousands of people were getting notifications on Leave HomeSafe, the contact tracing app that requires them to report for mandatory testing in restaurants, malls, and other public places. Getting a test could take several hours or more, and the results were often badly delayed, with labs overwhelmed by the volume of samples. The emergency rooms were filled with people who were worried they might have Covid, a response that may seem strange to Americans or Europeans. In a city where a single positive case was enough to justify locking down the entire apartment blocks, the instinct was understandable. Bernard Chan, a businessman who heads a group of people who support the government, concedes that they underestimated how fast omicron would jump through the population.

There were chaotic conditions inside health-care facilities. A nurse at a public hospital who asked to remain anonymous because he was afraid of repercussions for speaking to the media recalls how he and his colleagues stuffed gurneys into corridors and behind doors to parking emergency patients. Many Covid patients didn't have serious symptoms, and there was little we as health. It was harder to deliver decent care to those who really needed it because of the crowding. The hospital morgues were so full that corpses were placed in the same rooms as living patients. At his hospital, the nurse said staff had to beg government officials to speed up the cremation process.

relates to Hong Kong’s Completely Avoidable Covid Catastrophe
Workers at a public mortuary on March 16.

Their response was a failure, but they were unable to deviate from Chinese orthodoxy. The two pro-Beijing newspapers carried comments from the President that instructed Hong Kong to take all necessary measures to get cases under control, a clear signal that the central government wouldn't tolerate major policy changes. After successfully controlling an outbreak across the border, her administration would try a tactic that would require all residents to be tested. She wasn't sure how this was supposed to work. The cities that did mass testing, including Wuhan, had lower case counts. Hong Kong's modest bureaucracy could never duplicate the Chinese state's manpower.

It wasn't clear what would happen to the people who tested positive, who would surely be too many for the already-overwhelmed facilities. panicked shoppers cleared out stocks of meat and fresh produce after the announcement of the testing campaign. She acknowledged that a ban on movement was not feasible in Hong Kong. The city's housing is the most expensive in the world, and large numbers of people live in micro-dwellings. Some apartments have a bar fridge instead of a kitchen. It seemed beyond what officials were willing to consider.

After two weeks of confusion, a Chinese health expert gave the city's leaders an opportunity to change course and focus on reducing the death rate. She put the mass-testing plan on hold on March 9 in conjunction with a series of measures intended to improve vaccination rates among older people. The change in strategy allowed for home quaternions for people with mild illness for the first time, easing some of the pressure on hospitals.

The majority of Covid deaths in Hong Kong are among unvaccinated older people. The number of deaths per million residents in the country has risen to more than 800, far higher than in other countries and close to the figures for some European countries. Many of the victims are in their 90s or even older, people who might have been killed by the flu or some other opportunistic infection had Covid not come along. That doesn't make the situation any less frustrating for the families, who are watching their loved ones die unnecessarily from a disease they could have been protected from if they'd lived elsewhere.

The economic effects of the outbreak are being felt. One of Hong Kong's poorer districts is Sham Shui Po, where Mary Wan lives with her husband and two children. They rely on modest social security payments to survive, and they have a one-room apartment. Wan and her husband are on top of the bunk bed, while her daughter and son are on the bottom. Wan sent her daughter to stay with her parents in March because she was worried that someone in the family would get sick. Her son was the first to test positive, followed by his father.

Wan's husband brought the boy to the hospital because he was running a high fever and hadn't yet received his second dose of the Sinovac vaccine. They were told to go home because it could take days to find a bed. They were in the emergency room for 12 hours waiting for the boy to be admitted. He had to be treated alone in Hong Kong hospitals because of the lack of space. Wan and her husband were isolated until a government agency moved them to a spacious room in a Quarantine center. Wan felt helpless as her son recovered.

Hong Kong's many wealthy people are more comfortable, but life is still a long way from normal in other world cities. In part because they fear a backlash for decisions that could be seen as implicit rebukes of Chinese policy, few large employers have publicly announced plans to move roles elsewhere. About 64,000 people left Hong Kong in the first 20 days of March, while just 10,000 arrived. expats seek advice about moving companies with the shortest wait times, while others trade tips about finding short-term rentals in Singapore, which has moved away from hard-line Covid policies and substantially reopened its borders. Hong Kong's economic base is diminishing due to many departing.

After demanding for almost two years that nothing compared in importance to avoiding Covid cases, Lam recently conceded that there are limits to what the population can be asked to put up with. She said that some of our financial institutions were losing patience and that she had decided to ease restrictions.

It's not clear how Hong Kong can move toward substantially looser policies without a similar shift on the mainland. In mid-March, China's state broadcaster reported that the president instructed officials to put people and life at the forefront. 45 million people across the country were in some form of lock down at the time of his comments. In Shenzhen, which is across the border from Hong Kong, factories and schools were closed until recently, while Shanghai suspended bus services and diverted flights. In Jilin, a northeastern province experiencing a stubborn outbreak, daily life has come almost entirely to a halt.

One lesson from Hong Kong's viral surge is that even the most aggressive containment policies aren't enough to control the omicron variant, and that the only sustainable approach is to treat the most vulnerable. China's leaders may conclude that the risks of letting Covid gain a foothold in the rest of the country are not worth it. There are some dynamics on the mainland that are alarmingly similar. Only half of people 80 and older have received two vaccine doses, all with domestic shots that may not provide enough protection. In a large-scale outbreak, huge numbers of Chinese residents have no primary physician who could send them straight to hospitals to seek care. If they let go, they would have a huge wave and a large number of elderly people.

The Chinese public's attitude could be an obstacle to changing strategy. State media began hyping the dangers of the coronaviruses and accusing the U.S. and Europe of betraying their citizens by allowing it to circulate. Even in a one-party state that permits no meaningful dissent, many ordinary Chinese people are petrified of being exposed to the virus, a public opinion reality that will complicate any shift toward living with it.

The city of Hong Kong was unprepared for the current outbreak due to a lack of openness. The National Security Law was designed to criminalize a broad range of political activities, not to stifle discussion of medical policies. It has cast a chill over all public debate, with no one sure what comments might fall under the umbrella of Subversion, one of several vaguely defined offenses in the legislation. After a pro-Beijing lawmaker suggested the opposite, the government put out a statement clarifying that general remarks about its Covid strategy wouldn't violate the law. Few people in public life would dare to criticize government decision-making. Dozens of opposition politicians and activists are in jail awaiting trial on security charges, while almost every critical media outlet has been pressured into shutting down. Hong Kong's legislative council has been transformed into a rubber-stamp body after legal changes meant to ensure onlypatriot can be elected.

There is a direct line between Hong Kong's failed virus response and political oppression. With no one left to point out the loopholes, the holes just grow wider.