More than two years after Covid began spreading around the globe, Hong Kong is experiencing one of the deadliest outbreaks of the entire pandemic. It began early this year, when the omicron variant breached the Chinese territory’s ferocious quarantine system for inbound travelers, which had previously kept cases almost at zero. Soon it became clear that the authorities had done little to prepare for the possibility that the travel restrictions wouldn’t be enough. Within weeks, parts of the health-care system had effectively collapsed, and since January there have been about 5,600 fatalities. Although there are tentative signs that the worst may be over, right now more people are dying from Covid in Hong Kong, relative to population, than anywhere else in the world. For some, the situation has engendered a sort of dazed shock. How could a wealthy, sophisticated city, with a top-notch health-care system and ample time to learn from experiences elsewhere, get its response so wrong? “During the past two years the government has done nothing,” Cheng says. “It seems like it’s never come across to them that Hong Kong may face a serious outbreak.”

Hong Kong’s situation is the product of several specific policy failures, which stem partly from Beijing’s decision to take greater control of the financial hub after 2019’s pro-democracy protests. Above all, the city’s government utterly failed at vaccinating older adults, botching public-education campaigns and allowing misinformation about the shots to run rampant among those residents. As of March 18 just 37% of people 80 and older had received at least two doses, mostly of the Chinese-made Sinovac vaccine—perhaps the lowest rate in the developed world. Other missteps resulted from the doctrinaire application of China’s Covid-zero strategy, a suite of policies designed to stamp out every outbreak the moment it’s detected. Aggressive contact tracing and mandatory hospitalization of infected people, regardless of symptoms, worked well enough with daily case counts in the single digits, but they became useless as omicron raced through densely packed high-rises. Under pressure from China’s central government, Hong Kong officials stuck to them anyway, forcing people into daylong waits for compulsory testing and dedicating precious hospital beds to patients who could have easily stayed at home. The authorities maintained, and in some cases deepened, Hong Kong’s international isolation, completely banning flights from “high-risk” countries such as the U.S. and the U.K., as though the virus was still something that could be kept out.

Hong Kong was experiencing a dark period even before the current outbreak. The government’s uncompromising enforcement of the new National Security Law, which effectively bans political opposition, had hollowed out the media and civil society, draining the vitality of a famously freewheeling place. It’s now 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 damage to the city’s reputation as a business hub may be permanent.

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. “What is happening in Hong Kong seems to vindicate their worst fears of what would happen if China were to open,” says Yanzhong Huang, a senior fellow at the Council on Foreign Relations and an expert on the Chinese health system. Outside of large cities, mainland facilities are rudimentary, and in a large outbreak, “you’re going to see hospitals quickly inundated with people seeking care. And it’s very possible the health-care system could be overwhelmed, which could lead to panic that would threaten political stability.”

Until early this year, the total number of Covid deaths in Hong Kong stood near 200—about one-fifth of the current daily total in the U.S. This remarkable record was essentially the result of a single policy, implemented consistently and remorselessly: putting everyone who wanted to enter from abroad in quarantine in a hotel room for up to 21 days. It hardly mattered that, with mandatory PCR tests before departure and again on arrival at Hong Kong International Airport, almost no one who made it as far as checking into their isolation room actually tested positive. The point was to eliminate even the tiniest risk that the virus could enter, regardless of the consequences to the economy. On the rare occasions that an infected person slipped through, contact tracers swung into action, ordering everyone they’d been in contact with to Penny’s Bay, a spartan dormitory complex on an outlying island. Sometimes all it took to be sent there was having dined at the same restaurant as a positive case. But as long as a Hong Konger didn’t travel and avoided being swept up in a contact tracing dragnet, daily life retained a reassuring normalcy, with eateries, offices, and beaches still open and busy, even as cities in the U.S. and Europe swung in and out of sweeping social distancing campaigns.

For obvious reasons, this put Hong Kong in a different position from most places when vaccines began to arrive in the first months of 2021. In February of that year, Chief Executive Carrie Lam, the head of Hong Kong’s government, rolled up her sleeve at a televised event to receive her first dose of the Sinovac vaccine, which was offered alongside Pfizer Inc.’s shot. But while Lam and other officials urged everyone to get vaccinated, the rollout quickly sputtered. In a population that had no direct experience of Covid’s horrors, relatively few people appeared 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 vaccinated by the end of August, compared with almost 80% in Singapore, the region’s rival financial center.

Distrust of the government certainly played a role in driving hesitancy. Although it’s now difficult to conduct reliable polls on sensitive issues in Hong Kong, Lam is widely unpopular, despised by many liberal-minded residents for her eagerness to please Beijing. Those aren’t niche sentiments: Before the security law made such gatherings illegal, pro-democracy rallies routinely drew hundreds of thousands of attendees. For some, any instructions Lam or her allies issued, on vaccination or anything else, were automatically suspect. It didn’t help that politics had crept into the vaccine drive from the start. Pro-China figures boasted proudly that they’d chosen Sinovac, and central-government officials suggested that crossing the border into the mainland would be easier for those who’d received a domestic vaccine. At one point the authorities removed a clinic from the list of authorized vaccination sites after doctors there recommended the Pfizer shot, which studies indicate is more effective at preventing infection and severe disease without a booster.

The larger problem was an unconventional philosophy of public-health communication. As in Singapore, South Korea, and other Asian countries, Hong Kong took a hypertransparent 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 in the same places to monitor their health. More unusually, it did something similar with vaccine side effects, proactively publicizing the handful of deaths and adverse events that occurred after someone had been vaccinated, whether or not there was reason to believe the shot had caused them. The result was a frenzy of anxious media coverage, with newspapers regularly speculating that the vaccines were harmful.

At the same time, official policy called for older people with existing medical problems—which was to say, almost every senior citizen—to consult a doctor before being vaccinated. This qualification, which was employed almost nowhere else in the world, led many families and even doctors to urge the elderly to err on the side of caution, as they saw it. With so little chance of catching Covid and a government that insisted it could keep the virus out indefinitely, why take the risk? “To this day, many people are talking about controlling their diseases before getting vaccinations,” says Leung Chi-chiu, a physician and former chairman of the Hong Kong Medical Commission’s advisory committee on communicable diseases. “This slowed down our vaccination program among those who most needed vaccination. And that hasn’t been solved, up until this moment.” A chart of Hong Kong’s vaccination rates, categorized by age, looks almost like the inverse of the situation in most countries, where it’s the young and healthy who tend to resist receiving shots. Among Hong Kong residents age 40 to 49, well over 90% are fully vaccinated, more than double the percentage of those 80 and older.
 

Shortly before Hong Kong’s omicron outbreak accelerated in January, the city’s senior officials held a meeting to discuss whether they were prepared for a surge of cases, according to a person with knowledge of the gathering, who asked not to be identified discussing closed-door policymaking. The group concluded that they were ready for even a large number of infections, in part because of the vast spaces available for isolation beds at AsiaWorld-Expo, a convention center by the airport. They also discussed how, 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.

But in the subsequent weeks, Hong Kong kept to its Covid-zero playbook, even as it became clear the rising number of cases was making that approach unsustainable. Tens of thousands of people were getting pings on LeaveHomeSafe, the contact tracing app that’s required to enter restaurants, malls, and other public places, instructing them to report for mandatory testing. Actually getting a test could mean lining up for several hours or more, and the results were often badly delayed, with labs overwhelmed by the volume of swabs. Meanwhile, emergency rooms were jammed with people who were worried they might have Covid—a response that may seem curious to Americans or Europeans. But in a city where even a single positive case had been treated as a severe-enough threat to justify locking down entire apartment blocks, the instinct was understandable. Even defenders of the government conceded that they underestimated how fast omicron would jump through the population. “It’s not that we didn’t have plans,” says Bernard Chan, a businessman who heads a group of Lam’s senior advisers. “It just happened faster than the system could handle.”

Conditions inside health-care facilities quickly grew chaotic. A nurse at one public hospital, who asked to remain anonymous because he feared retaliation for speaking to the media, recalls how he and his colleagues stuffed gurneys into corridors and behind doors, parking emergency patients anywhere they could find space. A substantial percentage of those admitted with the virus had no reason to be there. “Many Covid patients didn’t even have serious symptoms,” the nurse says, “and there was little we as health-care workers could do to help them medically.” But government policy stated that they had to be in the hospital. The crowding made it harder to deliver decent care to those who really needed it. Meanwhile, hospital morgues were filling to capacity—some were so overwhelmed that corpses, zipped into gray body bags, were placed in the same rooms as living patients. The nurse says that at his hospital, staff had to beg government officials to cart bodies away faster.

Their response was obviously failing, but Lam and her subordinates had little ability to deviate from Chinese pandemic orthodoxy. On Feb. 16 two pro-Beijing newspapers carried comments from President Xi Jinping 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. Later that month, Lam announced that her administration would try a tactic that had successfully tamed outbreaks across the border: a blitz of mandatory testing for all residents. She was vague on how exactly this was supposed to work. Mainland cities that had completed such mass testing, including Wuhan, had done so with far lower case counts. They could also draw on the essentially unlimited manpower of the Chinese state, something Hong Kong’s modest bureaucracy could never replicate.

It also wasn’t clear what would happen to those who tested positive, who’d surely be too numerous for the already-overwhelmed quarantine facilities. Many feared the testing campaign would be accompanied by a citywide lockdown, and Lam’s announcement prompted a rush to supermarkets, where panicked shoppers cleared out stocks of meat and fresh produce. She denied that a lockdown was planned, acknowledging that such a blunt ban on movement was inconceivable in Hong Kong. The city’s housing is the most expensive in the world, and large numbers of people live in micro-dwellings known as “cage” or “coffin homes,” which can be as small as a single enclosed bed, with the tenant’s belongings kept in bags strung overhead. Even some regular apartments have a hot plate and bar fridge instead of a kitchen. Confining people to those residences seemed beyond what officials were willing to contemplate.

After two weeks of confusion, Liang Wannian, a Chinese health expert tasked by Xi’s administration with advising Hong Kong, gave Lam an opening to change course, publicly instructing the city’s leaders to shift their focus to reducing the sky-high death rate. She shelved the mass-testing plan on March 9, in tandem with a series of measures intended to improve vaccination rates among older people—though by the time a significant number of those residents receive two or three doses, many more will have died. The shift in strategy also included allowing home quarantines for people with mild illness for the first time, easing some of the pressure on hospitals.

Hong Kong is still reporting hundreds of Covid deaths each day, overwhelmingly among unvaccinated older people. The number of fatalities per million residents since the start of the pandemic now stands at more than 800, far higher than in South Korea, Japan, or Singapore and closing in on 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 infuriating for their families, who are watching their loved ones die unnecessarily from a disease they could well have been protected from if they’d lived elsewhere.
 

The effects of the outbreak are being felt across the economic spectrum. Mary Wan, 34, lives with her husband and their two children in Sham Shui Po, one of Hong Kong’s poorest districts. As neither has a job, they rely on modest social security payments to survive, squeezing into a 150-square-foot, one-room apartment. All four of them sleep in a single bunk bed, jammed against the only window: Wan’s husband on top and her on the bottom with her 4-year-old daughter and 5-year-old son. Worried that it would be impossible to shield her children if someone in the family got infected, Wan sent her daughter to stay with her parents in early March. Her son tested positive soon after, followed by his father; Wan was infected a couple of days later.

The boy, who struggled with asthma and hadn’t yet received his second dose of the Sinovac vaccine, was running a fever that wouldn’t break, and Wan’s husband brought him to a hospital. But staff there said it could take days to find a bed and instructed them to go home. Desperate, they stayed in the emergency room, waiting 12 hours before the boy was finally admitted. With so little space available, Hong Kong hospitals were largely forbidding parents from accompanying Covid-infected children, and he had to be treated alone. Wan’s husband returned to their apartment, where the couple isolated until a government agency moved them to a comparatively spacious room in a quarantine center. Her son eventually recovered, but Wan found the experience terrifying. “I missed him so much, but there was nothing I could do,” she says. “I felt really helpless.”

For Hong Kong’s many wealthy people, circumstances are more comfortable, but life is still a long way from the relatively normal existence now on offer in other world cities. While few large employers have publicly announced plans to move roles elsewhere—in part because they fear a backlash for decisions that could be seen as implicit rebukes of Chinese policy—there’s no question that an exodus is under way. In the first 20 days of March, about 64,000 people left via Hong Kong’s air, land, and sea ports, while just 10,000 arrived. In Facebook and WhatsApp groups, expats seek advice about moving companies with the shortest waitlists, 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. Some of those departing will eventually come back, but many won’t, diminishing Hong Kong’s economic base.

After insisting 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. “I have a very strong sense that people’s tolerance is fading,” she told reporters in a briefing on March 17. In particular, she said, “some of our financial institutions are losing patience.” Several days later she announced a modest easing of restrictions, including the shortening of inbound quarantines from 14 to 7 days, as well as an earlier-than-planned end to the ban on flights from the U.S. and the U.K.—a change that will allow stranded residents, some of whom have been locked out of Hong Kong since the December holidays, to finally return.

It remains unclear, however, how Hong Kong can move toward substantially looser policies without a similar shift occurring on the mainland. In mid-March remarks reported by CCTV, China’s state broadcaster, Xi instructed officials “to put people and life at the forefront” by continuing to pursue “dynamic zero,” Beijing’s term for pouncing on each outbreak with snap lockdowns and mass testing, albeit with tweaks to reduce the policy’s economic toll. At the time of his comments, about 45 million people across the country were in some form of lockdown because of rising cases. In Shenzhen, immediately across the border from Hong Kong, factories and schools were closed until recently, while Shanghai has 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 could be that even the most aggressive containment policies aren’t sufficient to control the omicron variant, and that the only sustainable approach is to focus on vaccinating and treating the most vulnerable. But China’s leaders may well conclude the opposite: that the city’s experience proves the risks of letting Covid gain a foothold in the rest of the country are unacceptable. Some of the dynamics on the mainland are alarmingly similar, if not more worrying. Only 51% of people 80 and older have received two vaccine doses—all with domestic shots that may provide insufficient protection. Huge numbers of Chinese residents have no primary physician, which could send them straight to hospitals to seek care in a large-scale outbreak. Many of those facilities are undersized and underresourced, especially in rural areas that are likely to have the largest proportion of unvaccinated elderly. “If they let go right now, they’d have a huge wave and a very large number of fatalities,” says Ivan Hung, the head of the infectious diseases division at the University of Hong Kong’s medical school.

The attitude of the Chinese public could be an equally formidable obstacle to shifting strategy. Soon after the coronavirus was contained in Wuhan, state media began relentlessly hyping its dangers—both to justify China’s aggressive approach and to accuse the U.S. and Europe of betraying their citizens by letting it circulate. The tone of coverage has changed little since, and many ordinary Chinese people are petrified of being infected, a public opinion reality that will complicate any shift toward living with the virus, even in a one-party state that permits no meaningful dissent.

To some in Hong Kong, a similar lack of openness is a big part of why the city was so unprepared for the current outbreak. The National Security Law, which criminalized a broad range of what would be considered normal political activities in most places, was designed to kneecap opposition to the government, not to stifle discussion of medical policies. But it’s cast a broad 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. In January the government felt it necessary to put out a statement clarifying that “general remarks” about its Covid strategy wouldn’t violate the law, after a pro-Beijing lawmaker suggested the opposite. In any case, there are few people left in public life who’d 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. After legal changes intended to ensure only “patriots” can be elected, Hong Kong’s legislative council has been transformed into a rubber-stamp body.For Cheng, the union official representing nursing-home workers, there’s a direct line between this political repression and Hong Kong’s failed virus response. “If there were still pro-democratic lawmakers, they would have definitely held the government accountable and revealed the problems in the system,” he says. “And the government might have been able to fix the problems. But now there’s no one left to point out the loopholes, so the holes just grow wider.” —With Phila Siu