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.

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.