Hong Kong: What went wrong with its Covid plan?

The scene was grim at Caritas Medical Centre last week.

Just outside the hospital's emergency room, dozens of hospital beds had been placed in an alley under makeshift tents. The air was punctuated by the moans of patients - most of whom were elderly - and cries of children. All were suspected or confirmed Covid cases waiting to be admitted.

"It felt like we were in a wartime refugee camp. It was depressing. We were tearful, but there was no more space in the ward. They could only wait and there was nothing we could do," one emergency room nurse told the BBC.

Days later the patients were moved indoors, after Chief Executive Carrie Lam said the situation was "unacceptable". But Hong Kong's hospitals still remain full as the city battles its worst wave of infections.

Hong Kong was a poster child of pandemic control success in the past two years. By the end of 2021, the city of 7.5 million had recorded only 12,650 cases and fewer than 220 deaths.

The success justified the government's adherence to the mainland's "dynamic zero Covid" strategy, which involves early testing, detailed contact tracing, strict quarantine rules, and tight travel restrictions.

But the city has been brought to its knees with the arrival of the highly transmissible Omicron variant. The number of reported cases has soared to more than 66,000 in just a couple of months.

The first local Omicron cases linked to two Cathay Pacific flight attendants who breached Covid rules were found in late December. Then a larger cluster emerged in a quarantine hotel.

According to projections by the University of Hong Kong (HKU), the city will see a peak of more than 180,000 new cases daily by mid or late March, if current social distancing measures remain in place. By mid-May, the total death toll is forecast to have topped 3,200.

"Because of our success, paradoxically, people had been lulled into a sense of false security," said Gabriel Leung, HKU's dean of medicine.

The vast majority of Omicron cases cause less severe symptoms than previous strains, meaning that many can recover on their own within days.

But health authorities are still insisting that people who test positive with no or mild symptoms isolate in quarantine facilities, which are quickly filling up.

The government has not released any clear, detailed guidelines for home isolation, and have only said people no longer need to be quarantined if they wait for 14 days and test negative.

"What we need to do is to recognise that our health system is about to implode on its own weight," Prof Leung said.

Hong Kong officials have refused to deviate from their zero Covid approach, in the hope that this would please Chinese authorities and lead to a reopening of borders between Hong Kong and the mainland.

But the consequence of this, said HKU virologist Siddharth Sridhar, is that "the narrative of living with Covid is completely absent in Hong Kong, and now everybody is panicking".

Dr Sridhar said that if Hong Kong cannot change its policy, then the government should at least improve support for patients who are self-isolating at home, ensuring that they have access to groceries, rapid tests and basic medicine.

Prof Leung also said hospitals should properly triage people who need medical care, as there are only about 2,000 acute care beds in the city's public hospitals.

But one key problem is the low vaccination rate among the elderly. Some 76.2% of those aged above 11 are fully vaccinated - but fewer than one-third of people aged 80 and above have had two jabs.

"There was very little Covid in Hong Kong all along, so very few people knew people who had Covid or had died of Covid. Automatically, a very important incentive for vaccination disappeared," Dr Sridhar said.

Vaccine hesitancy also took root in Hong Kong, in part driven by low trust in the authorities following the political unrest in recent years.

Hong Kong scored lowest in vaccine acceptance and effectiveness compared to five other territories, including Singapore, UK and the US, in a study conducted by the City University of Hong Kong last May.

At the same time, it saw the highest belief in conspiracy theories. Out of a maximum score of seven, Hong Kong respondents hit nearly four when asked if the vaccine was being used to track and control the population, would alter human DNA and was developed to make money.

For months, authorities provided little incentive for people to get vaccinated, with little difference in the way they treat vaccinated and unvaccinated people.

Currently, the strict virus rules apply to everyone: there's no dine-in service at restaurants after 6pm; venues such as gyms, cinemas and sports grounds remain shut; private gatherings of more than two families are banned.

Officials are only rolling out a vaccine pass this week, allowing vaccinated people to enter venues like restaurants and shopping malls.

Hong Kong's plight has caused deep concern in Beijing. Chinese President Xi Jinping recently told the city government that bringing the pandemic under control should be "the overwhelming priority".

Beijing is now helping to expand Hong Kong's testing and quarantine capacities, and the city government said it's planning to test the entire population, which experts say would help hasten the end of the current wave.

Kay Lam, researcher at the Hong Kong Policy Research Institute, said two possibilities would emerge afterwards.

"A lot more people will have acquired natural immunity because we never experienced such large-scale infections. Also, many more people will also get their vaccines and learn how to self-isolate," she said, adding that help from the mainland would make it easier to maintain zero Covid.

But Hong Kong cannot stay closed to the world, she said, as it has many multinational corporations: "Their workers need to go on business trips and have to return home to see their families. It is impossible for Hong Kong to not open the international border forever."

Dr Sridhar, on the other hand, doesn't believe Hong Kong will change tack any time soon, as its Omicron experience would have bolstered Beijing's belief in the need for zero Covid.

"This wave, in a way, cements the view of a lot of people in China that the mainland needs to maintain zero Covid, because you see the chaos it's causing in Hong Kong.

I would imagine that the mainland is very keen to avoid a similar scenario happening there."