Why Hong Kong has the highest covid death rate in the world

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Covid success to covid disaster: 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.

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Cases shot up from just a hundred per day in early February to more than 55,000 by early March. Hong Kong now has the highest death rate in the world. Hospitals have run out of space, leaving patients lying in hospital beds outside, waiting to be treated. And Hong Kong’s inequalities have been laid bare: Migrant workers from Southeast Asia who live with their employers as maids or cleaners have been fired and forced out after contracting the disease.

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

Omicron has revealed flaws in the territory’s covid strategy, which prioritized keeping the virus out over vaccinating the vulnerable. Prior to the recent outbreak, fewer than 20 percent of Hong Kong’s over-80 population was fully vaccinated.


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

Grid spoke to Dr. David Owens, founding partner of OT&P Healthcare and assistant professor of family medicine at the University of Hong Kong, about the surge in Hong Kong, how it could have been mitigated and what mainland China is learning from it. This interview has been edited for length and clarity.

Grid: What has it felt like to be a doctor in Hong Kong watching this severe covid wave unfold?

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.

G: Why did cases rise so quickly after Hong Kong had been able to successfully clamp down on prior outbreaks?


DO: The fundamental driving factor of the problem in Hong Kong is the biology of the virus. We have an epidemic with the omicron BA.2 variant, which is more transmissible, about 1.4 times as transmissible as the omicron [BA.1], which itself was more transmissible than delta, which was more transmissible than alpha.

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.

G: Why have vaccinations rates been so low among the elderly and other vulnerable groups in Hong Kong?

DO: Actually, in Hong Kong we have some similar challenges to the U.S. We know that in population terms, the factor that correlates most with high vaccination populations is trust in government and health institutions. So, as in the U.S., we have distrust in government institutions for recent historical reasons. We also have some cultural issues around acceptance of vaccination, and we have had also poor communication by the media. We’ve had a number of structural factors within policymaking, which have not helped.

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.


G: Is there a difference between how people perceive the BioNTech and Sinovac shots (the two vaccines available in Hong Kong)?

DO: I think in many ways, the debate around Sinovac versus BioNTech is it’s an example of how the process has become politicized both inside Hong Kong and also externally looking at the narrative of the international media. Sinovac is a killed vaccine [a vaccine made using an inactivated virus rather than mRNA] — it’s a vaccine that’s produced by China, and it was shown in early studies to be not as effective. Efficacy studies showed that Sinovac wasn’t as good at producing antibodies and the BioNTech vaccine was better from a scientific perspective.

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.

G: Other places, like South Korea and New Zealand, that have historically successfully contained covid have seen cases spike recently, but deaths have remained relatively low. Is the contrast explained by a difference in vaccination rates?

DO: I think this is quite an important point to get across: There’s no evidence that the omicron BA.2 virus that’s impacting Hong Kong is any different in its innate severity than it has been in other parts of the world. And we’re going to see this in the U.S. as well. This BA.2 wave is kicking off in the U.S. as well.

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.

G: What were the reasons people in Hong Kong have gone to the hospital even with very mild symptoms — is that a policy issue?

DO: In Hong Kong and in China, and in some other places, all cases were sent to hospital, whether they were sick or not, so we had lots of asymptomatic people in hospital. They were put in hospital rather like a quarantine as a compulsory admission, as a legal obligation, so people sat there for weeks with no symptoms in a hospital bed.


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.

G: What do you think the mainland is learning from this regarding their own opening-up strategy?

DO: I would be very surprised if China makes the same mistakes as Hong Kong. I think China has a very strong tradition of public health, I would say absolutely world-class public health experts. I think there is a misunderstanding about the efficacy of Chinese vaccines, as we’ve already talked about. I think they’ll be very effective. I think China has access to drugs, so they’re already beginning to distribute the drugs. China has challenges — they do have low levels of vaccination in the most vulnerable. But they do have a number of factors in their favor. They have very high trust in government. These policies are very popular and have a lot of public support in China. And they have very high capacity in the three aspects that are essential to manage an elimination strategy in the first instance, and then a mitigation strategy. That’s to test, to trace and to isolate. So I believe China will pivot by boosting vaccination rates. And by using their testing, tracing and isolation capacity to control the rate of which burns through so that the hospital systems are protected.

G: While the death rate is still high, cases are coming down now in Hong Kong. Will there be a shift toward opening up? Or do you see just further clamping down back to zero covid?

DO: In Hong Kong at the moment, that is the $64 million question. We are at herd immunity — we now have an immune population, which is why the wave is dying.


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.

G: What else is needed to prevent another serious wave in the future?

DO: You vaccinate at high levels, and then we need to have a big rethink about our hospital system. We’ve already built many isolation units, so if there was to be a variant which escaped current immunity, whether it’s covid or whether it’s something else, we’ve got the option to go back to the test and the trace and the isolate again to try to control as it came through.

  • Lili Pike
    Lili Pike

    China Reporter

    Lili Pike is a China reporter at Grid focused on climate change, technology and U.S.-China relations.