Hong Kong caught in a zero COVID dilemma


Hong Kong is one of the last few places in the world that is still following a stringent ‘zero COVID’ policy. Ananth Krishnan reports on a populated but poorly vaccinated region that is doing all it can to keep cases at a minimum even as it becomes more and more isolated from the world

The first thing that hits travellers landing in Hong Kong’s Chek Lap Kok airport is the emptiness. Hong Kong International Airport (HKG to frequent fliers) used to be among the world’s busiest. It handled 71.5 million passengers in 2019, which is close to 2,00,000 a day. Now, a busy day means 1,500 passengers at most. On a lean day, sometimes only half that number walks through the airport’s doors.

When a passenger steps off the plane, they can walk minutes on end without seeing another passenger. The inter-terminal train, packed to capacity in pre-pandemic times, no longer takes passengers to the arrivals hall but to what is possibly one of the world’s largest testing centres. An entire terminal has been transformed into a ‘test and hold’ facility. The departure gates have been converted into massive waiting halls. This is where passengers await their results, with tests processed at an on-site laboratory.

Also read: Hong Kong to tighten COVID-19 rules, seeks to open to China

HKG may be unrecognisable, but the administrative efficiency for which Hong Kong is famous is not. On arrival, every passenger is whisked into a makeshift tent for a quick nose and throat swab. A series of desks then beckon, where passengers fill in a multitude of forms. Within an hour of landing in Hong Kong, travellers are issued a government-recognised vaccination certificate that lists the date of their doses, the type of vaccine and where they had their shots — all prepared in advance from the online health declaration that every passenger is required to fill before boarding.

The certificate comes with a QR code that can be scanned and stored on Hong Kong’s ‘Leave Home Safe’ tracing app, which many Hong Kong venues, from dining establishments to cinema halls, now require for granting entry. Finally, every traveller’s phone number is registered with the health authorities and checked to make sure they can receive test results and other public health alerts. Arrivals are also introduced to Hong Kong’s 24/7 COVID-19 hotline, which usually takes not more than two minutes to respond to any query on WhatsApp, on everything from where to get a test to whether you can open your hotel window in quarantine (the answer is unfortunately a ‘no’, at least in most designated quarantine hotels).

Once the forms are filled and Hong Kong’s bureaucratic machinery is satisfied, a surreal sight awaits passengers who are ushered, finally, into a cavernous hall filled with a sea of desks. Travellers, pilots, air crew all sit in perfect silence as though at a massive examination centre. Over a nerve-wracking five-hour wait for their test results, passengers watch anxiously as every few minutes, health personnel in full PPEs appear, march up to numbered desks, quietly ask passengers who presumably tested positive to pack their bags, and then disappear.

A positive test means a passenger can neither clear immigration nor claim their checked-in luggage. They are taken away in an ambulance, lights flashing, to a hospital in Lantau Island near Chek Lap Kok, purpose-built for international arrivals. There they have to stay for at least 24 days in hospital, while all close contacts (those they sat next to on the flight) are taken to Penny’s Bay, the government’s biggest quarantine centre, for 21 days of isolation. This centre is also located in Lantau — an island once famous for hosting Hong Kong’s “happiest place on earth”, Disneyland, but now the centre of its massive quarantine programme.

Zero COVID, zero tolerance

If this elaborate arrival procedure and the vast system that is in place to keep it running seems excessive, it has been key to ensuring Hong Kong’s extraordinary record during the pandemic. Since the COVID-19 outbreak, Hong Kong, a region of 7.5 million people, has recorded only a little over 12,000 infections and 213 deaths. Its ‘zero COVID’ strategy — an approach predicated on maintaining zero local cases by squashing every outbreak with mass testing and quarantine — certainly spared thousands of lives in a densely populated island, where public health experts say a virus left to run amok would have overwhelmed its already stressed health infrastructure.

The Penny Bay Quarantine Center on the island of Lantau seen by drone on July 4, 2021 in Hong Kong, China. (Photo by Marc Fernandes/NurPhoto via Getty Images)
 

 

Even passengers who test negative on arrival are issued a quarantine order and taken in a government-operated shuttle to their designated quarantine hotel that has to be pre-booked, usually at least two months in advance, given the limited availability designed to cap the number of arrivals. Most passengers from countries deemed ‘high risk’ spend 21 days of quarantine in a hotel room at their own cost. The windows in these rooms are often sealed and cannot be opened. Stepping out of the room means a hefty fine, an immediate transfer to Penny’s Bay for 21 days of isolation, followed by six months in prison, reads the warning sign posted on every door.

This stringent screening of arrivals, Hong Kong’s health officials pointed out on November 29, helped Hong Kong detect its first case of the new Omicron variant, before it spread, in a traveller from South Africa who tested positive on his third day in quarantine. Every individual is tested six times during their three-week hotel stay. Hong Kong also emerged unscathed from the Delta variant, with most cases caught in quarantine and the region facing no wave. The only local spread came from an airport worker, whose close contacts were all promptly transferred to Penny’s Bay.

“A few elements have been key to ensuring that the cases were low,” explains Siddharth Sridhar, clinical virologist at the University of Hong Kong. “Border controls, 100% mask-wearing from very early on, very strictly enforced social distancing, and a highly efficient method of testing and tracing. We do a lot of contact tracing and quarantine. So, I’d say Hong Kong uses fairly traditional methods to achieve COVID-19 control and they have worked very well for us.”

Hong Kong’s sweeping testing system means that entire residential neighbourhoods are locked down and individuals tested if there is a single reported case, while hundreds of close contacts are immediately sent to quarantine at the government’s facility at Penny’s Bay.

Another major factor for low cases has been compliance from a public that lived through the SARS epidemic. If the costs of this strategy include mask-wearing and no international travel, the benefits are that people have been living largely normal lives, with open schools, for much of the past two years after an initial strict lockdown.

Hong Kong caught in a ‘zero COVID’ dilemma

 

Yet, this ‘zero COVID’ approach, in place now for close to two years, appears increasingly incongruous in a world that is gradually returning to normalcy — or was, before the emergence of Omicron. After Singapore, Australia and New Zealand opened their borders, only the Chinese mainland, Hong Kong, and Taiwan are still clinging on to a ‘zero COVID’ approach, with stringent travel restrictions meaning continued isolation from the world.

‘A victim of our own success’

A growing number of people from foreign firms who have made their base in a place that likes to call itself ‘Asia’s World City’ as well as people who haven’t seen their families overseas for months are now asking whether this strategy is sustainable. They may, however, still be in the minority, given the broad public support for a stringent approach.

Moreover, much of the debate about whether Hong Kong can — or should — re-open and follow Singapore’s path hinges on two pressing problems that complicate any decision. One involves public health — specifically, poor vaccination rates — while the other is political, with Hong Kong having to choose between the mainland — another ‘zero COVID’ region — and the rest of the world while returning to normalcy.

In Dr. Sridhar’s view, Hong Kong, at this moment, has no choice but to continue with this approach at least until it vaccinates more people. The single biggest concern is an extremely low vaccination rate among the elderly. On November 23, Hong Kong reached a milestone of vaccinating 70% of the population with one dose (67% have been given two doses). The number falls dramatically for the 80 and above population — the most vulnerable group — to just 18%.

Singapore’s example is the warning sign that gives pause for caution. Singapore, with more than 80% of the population fully vaccinated, crossed Hong Kong’s total number of deaths on October 16, mostly because of the Delta wave earlier this year. After Singapore opened its borders, it recorded more than 250 deaths in just November, which is more than what Hong Kong has seen since the start of the pandemic. Most of those deaths were among the elderly, with 95% of those who died above 60 years, and close to three-quarters of them not fully vaccinated. Given Hong Kong’s vaccination rates, opening up now would mean a wave of possibly thousands of deaths among the elderly.

What explains the low vaccination rates for a region that did almost everything else right? “We are a victim of our own success,” says Dr. Sridhar. “Because COVID-19 was so effectively controlled, many people don’t feel it is a threat at a personal level. Indeed, there is a perception that Hong Kong can maintain its current measures and keep COVID-19 out indefinitely.” Coupled with widespread misinformation about vaccines on WhatsApp groups, few older residents are seeking to get vaccinated.

Yet, the low rates also feed into a vicious cycle, a consequence of a conscious policy decision to keep Hong Kong isolated. If Hong Kong was to set a timetable for opening, it would certainly spur more people to get their shots. While Dr. Sridhar says there is “no such thing as a clean exit strategy, if you tell people that there is a deadline and you are going to have to open up eventually”, it would send a strong message to get vaccinated. “What we can do,” he says, “is mitigate the effects of a massive COVID-19 surge in the community as far as possible. And I would argue that we will be in the best position possible to make that happen only by 2022”, with a combination of more people being vaccinated and the possibility of anti-virals. “There is no other way to exit the limbo we are currently in,” he says.

The politics of opening

That is the public health argument. Then there is the politics. With the sweeping political changes introduced in Hong Kong last year, with the passing of a national security law that essentially decimated the pro-democracy opposition and gave Beijing more control than ever over its Special Administrative Region (SAR), Hong Kong’s future is more than ever before wedded to that of the mainland.

The unpopular Chief Executive Carrie Lam, embattled after months of protests calling for universal suffrage in 2019 and the clampdown in 2020 that saw Beijing essentially bypass her government to pass the national security legislation, said in October that opening up to the mainland was “far, far more important” than opening up to the rest of the world.

Lam’s government has spent months negotiating with Beijing about opening a travel bubble that will restore the once-thriving cross-border travel between Hong Kong and the Guangdong province. According to current rules, those travelling from Hong Kong across the land border have to quarantine for at least 14 days at a government-chosen hotel in Guangdong. This has hampered business activity and separated families.

At least 50% of the 1,011 Cantonese-speaking residents surveyed by the Hong Kong Public Opinion Research Institute in November said they “preferred to see the government take immediate steps to help Hongkongers travel to the mainland instead of overseas”, while “those who favoured opening international borders for outbound travel first accounted for 38 per cent of the respondents”, the Hong Kong Free Press reported.

A trial bubble is slated to begin by end-December. This will allow a very limited daily quota of not more than 1,000 travellers a day to travel without quarantine, but only to Guangdong province and not to the rest of China. Negotiations on the bubble have dragged on for a year, delayed mostly by demands from mainland authorities for even more stringent measures (although, ironically, Hong Kong has had no major local spread for most of the past year while it is the mainland that has recently seen a spread of local clusters).

Caught between opening to the mainland and to the world, Hong Kong has had no choice but to pursue ever-stricter measures in pursuit of the elusive bubble. Part of that effort has been to tighten rules for quarantine and impose tougher conditions for discharging positive cases. Most countries have now been moved to the high-risk category requiring mandatory 21 days of hotel quarantine. These rules are more stringent than those of the mainland that allow the last seven days to be spent at home.

Under earlier rules, anyone who tested positive could only be discharged after consecutive negative tests 24 hours apart and a minimum 10 days in hospital. In November, authorities said such people would also have to spend an additional 14 days in isolation, which means at least 24 days in hospital.

This also applies to ‘repositives’ — travellers who recovered from COVID-19 but tested positive on arrival in Hong Kong even if they tested negative in their home countries, which has happened in several cases because of Hong Kong’s stricter testing criteria and how it measures cycle threshold (Ct) values in its COVID-19 tests. So, even a trace of dead virus from a patient who recovered months earlier will mean a minimum 24 days in hospital. Given these rules, some experts have advised travellers to think twice about travelling to Hong Kong if they had previously contracted COVID-19 unless they were willing to spend considerable time in hospital.

The new 14-day rule was criticised by several health experts as being unscientific. They pointed out that there is no evidence to suggest that such repositives are infectious or that a 14-day isolation is needed even after testing negative. Hong Kong authorities have been sensitive to criticism of these measures. When epidemiologist Ben Cowling at the University of Hong Kong in November criticised the extended quarantine as a “waste of resources and actively harming the patient with no community benefit to offset against” as well as being “unethical”, Health Secretary Sophia Chan shot back saying while “it is understandable that they perceive our stringent but necessary measures to maintain zero COVID as harsh, zero COVID is our best strategy not only on public health but also social and economic considerations, and is in line with the aspirations of our community.”

The second much-debated move, which officials say is needed to open the mainland bubble, is to adopt a mainland-style Health Code app. This is a significant step up from Hong Kong’s Leave Home Safe app, which only requires users to sign in when they enter a venue. The mainland’s Health Code app, in contrast, tracks movements 24/7 and allows authorities to easily contact, trace and quarantine people based on their geo-locations. In Hong Kong, however, there are concerns over both privacy and sharing individuals’ data with mainland authorities when they cross the border. In preparation for the bubble, the new Hong Kong health code was launched on December 10. It is not mandatory for residents, but those who want to travel to the mainland will be required to register.

Impact of policy

That Hong Kong has decided to prioritise opening to the mainland leaves little prospect of any move away from zero COVID for the time being, regardless of the impact it may have on foreign firms and Hong Kong’s status as a financial centre for Asia.

Indeed, many foreign firms are already relocating to Singapore, while expatriates are either returning home or shifting to other destinations. Tara Joseph, president of the powerful American Chamber of Commerce in Hong Kong, told Reuters in November that she would quit her post and leave Hong Kong because of its 21-day quarantine policy for overseas arrivals. “It is not in my nature to advocate on something and then embark on quarantine like a stooge,” she said. She later qualified those remarks saying this was only one of several reasons for her departure. Some international airlines are reconsidering their Hong Kong routes too, and asking if the stringent testing and quarantining is worth the risk for their air crew. In late November, British Airways said it had suspended flights to Hong Kong after several of its crew were sent to quarantine at Penny’s Bay after one crew member had tested positive. The airline said it was “reviewing operational requirements” for this route. Last month, after a Cathay Pacific pilot tested positive upon returning to Hong Kong, his entire family, along with more than 100 children in the kindergarten and primary school that the pilot’s child was studying at, were sent to quarantine at Penny’s Bay. Parents criticised this move as excessive and harsh as the children in the school were not even close contacts of the pilot, but secondary contacts.

Tens of thousands of Hongkongers have also already moved to the U.K. in recent months in response to Beijing’s tightening control under a new visa programme launched by London that offers a pathway to citizenship for Hongkongers. London introduced the initiative in response to last year’s national security law, which was seen as violating Beijing’s commitments under the 1997 handover treaty.

As a result of these measures, Hong Kong’s economy is beset by many challenges. More than ever, it is banking on the mainland and on closer integration with the Greater Bay Area (Guangdong-Hong Kong-Macau) to keep its economy afloat. However, the relative normalcy of the last two zero-COVID years has also to some extent helped local businesses avoid the fate of those in other countries that struggled under the cycle of COVID-19 waves and lockdowns.

Hong Kong lawmaker Regina Ip, the outspoken founder of the pro-Beijing New People’s Party, says the current strategy is justified, especially in the light of the emergence of new variants, and has helped Hong Kong avoid the fate of much of the rest of the world over the past year.

“Our 21-day quarantine requirements with regard to travellers from most countries are a function of their COVID-19 situations,” she says. “The U.K. was in our Group B requiring 14-day quarantine but upgraded to Group A because of the surge of their cases involving the Delta variant. We have to stop flights from Africa because of the import of a new, dangerous strain identified by the WHO. Our priority must be to keep the 7.4 million people in our city safe, and we have done well in this respect.”

Ip says Hong Kong doesn’t have to choose between mainland China and the world. “Ideally,” she says, “we want to have the best of both worlds”. That is, of course, easier said than done. For now at least, it appears, Hong Kong has already made its choice.



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