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Zero covid cities: here’s what we need to do next

I’VE BEEN THINKING about “zero-covid” strategies, and why we don’t have a concrete roadmap to opening up. To examine the issues, let’s divide the countries of the world into three groups regarding their strategy towards COVID.


Group A have chosen to allow it in, to go through waves of lockdowns (severe social restrictions) to slow down the outbreaks so as not to overwhelm their health systems. These countries have seen infection rates of 100 to 200 per 1,000 population, and death rates around 2 per 1,000 population.

Examples include UK, Europe, and USA.


Group B have had little choice or ability to control their epidemics, as these countries are relatively poor, with limited health care systems. These countries have reported infection and death rates similar to group A countries; although limited testing means the true figures are most likely many times worse. 

Examples include India, Brazil, and most of Africa.


Group C are the “zero covid” countries. These places attempt to minimise (to drive to zero, or as close to that as possible) the number of local covid infections. They implement this via a combination of strict border control, testing, tracing, and enforced social distancing measures. 

Once a local case appears, no efforts are spared to stop the spread of that one outbreak. Infection rates in this group have typically been less than one in 1,000, and deaths a fraction of that. 

Examples include China, Macau, Taiwan, Hong Kong, Australia, and New Zealand.


Looking at the infection and death numbers, it is abundantly clear that the zero covid strategy has, until now, produced the best results in terms of infection, death rates, and rates of viral mutations. 

The zero covid strategy clearly minimises deaths: Picture by Kay Lau/ Unsplash

If the entire world had adopted that strategy, then perhaps Covid-19 could have been eliminated (as was the case with version 1 of this virus back in 2003).  However, we cannot ignore the immense social costs that this strategy has incurred. 

Looking at the internal controls, group A and B countries have seen waves of extreme lockdowns interspersed with less restrictive measures, while group C countries have seen less extreme measures applied more or less constantly. 

In particular, restrictions of movement into group C countries have been consistently and constantly extreme. This is clear from the indexes used to track such stringency and economic effects.


But what about the future? The virus is now endemic, and changing. New variants like delta are estimated to have a R0 (base reproductive factor) of 8, compared to between 2 and 3 for the original Wuhan strain; that makes them almost as infectious as Chicken Pox (and think about how few people you know who have never had chicken pox). 

We have a selection of good vaccines that are perhaps 30% effective against infection, 90% effective against serious illness, and 98+% effective against death.

‘Living with the disease brings hope but we should not minimise the suffering and deaths it also brings’


Several Group A countries (that’s the cluster which includes the UK and the USA) have vaccinated at an impressive rate, bringing their vaccine coverage up to 90%+ in their most vulnerable (elderly primarily), and 70%+ in their adult populations. Fortified by such a protected population, these countries are now opening up, in the hope that a “final” wave of Covid-19 will burn through to force herd immunity through a combination of vaccination and recovery from infection. 

Some countries are trying to “live with” the disease: Picture by Mick Haupt/ Unsplash

They are trying to live with the disease, and that should bring hope for us all. However, we should not minimise the death and suffering that is bringing; UK is the earliest example of this and currently has 30,000+ new infections, 800 hospital admissions, and 100 deaths each day.


Meanwhile, Group C countries (That’s the cluster that includes China, Hong Kong, Australia and New Zealand) are struggling to achieve high vaccination rates. Simply put, without the disease in the community, the population fear the vaccines more than the virus. 

It is said that the average person ‘knows’ about 600 others, so let’s compare rates:

In USA, the average person would know 68 infected, 13 hospitalised, and 1 dead.

In UK, the average person would know 56 infected, 11 hospitalised, and 1 dead.

In Hong Kong, just 1 in 2 would know someone infected, and 1 in 60 would know someone who died.


The path out of this is very clear now for the Group A countries, and they have enunciated that very clearly in policy speeches; vaccinate the vulnerable, vaccinate the rest of the population to high levels, gradually remove/reduce restrictions, and allow the final wave to burn through to herd immunity. 

Internal politics is getting in the way, but Darwin has a way of winning out in the end, and it is happening regardless. 

Indonesia, too, has been hard hit; picture by Mufid Majnun/ Unsplash

Group B countries (the nations such as India and the African countries) are pleading for their limited supply of vaccines, and the sad reality is that they seem to be reaching their herd immunity more through infection (and death) than vaccination.


But what now for Group C countries, the zero-covid survivors? They have a choice:

* Continue with the zero-covid approach, remaining isolated, suffering the economic and social damage, and perhaps forming bubbles with other zero-covid countries.

* Switch to a ‘living with covid’ approach, generally opening their borders and allowing the virus in (with the associated infections and deaths) but throwing away any chance of bubbles with other zero-covid countries.

‘I originally thought it was political but then what about Australia and New Zealand?’


I ask myself: “Why is Hong Kong not clearly defining a roadmap out of this?” And I come to the conclusion that none of these zero covid countries have clearly defined a roadmap. 

I originally thought it was political (given the situation here), but then what about Australia and New Zealand (both full Western-style democracies run by politicians)? 


You can argue that Singapore has a roadmap, but I would counter that Singapore (with its 11 in 1,000 infection rate) is not really group C; with 10 times the infection rate of group C countries, 1/10 the infection rate of group B, and similar high vaccination rates to group A, it sits somewhere in the middle.

Singapore doesn’t fit into the three main categories; picture by Alesia Kozik/ Pexels


Hong Kong is placed in an increasingly difficult position with these two choices.

Economically, China is by far both our largest trading customer and our largest supplier. We are dependent on China for water, food, and power to name just three, and are both socially and economically tied.

But China has clearly stated that they are maintaining their zero-Covid approach for at least the next year. 

Look at what happened when Singapore announced its ‘living with covid’ policy; the proposed travel bubble with Hong Kong burst and disappeared forever (or morphed into a one-way porous membrane allowing easy travel from Hong Kong to Singapore but not the other way).

 Just like with one-way travel to Singapore, the decision of whether to open the Hong Kong border to travellers from China is entirely in our hands, but we have little control or influence on whether China will accept travellers from Hong Kong.


So the answer I came up with is that these Group C zero-covid countries don’t / won’t announce a clear roadmap simply because they can’t. The answer is too politically unappealing. Damned if you do, damned if you don’t. 

Caught in a Catch 22 situation, these countries are a victim of their own success, and Hong Kong particularly so with the China constraint. 

Becoming increasingly isolated from a recovering Europe and USA, but with vaccination rates too low to open up, they can’t tell their population the unappealing truth that they are forced to continue with zero-covid and an indefinite future of restrictions, continued vaccine refusal, and waning vaccination immunity for those that have accepted. 

They can’t announce a roadmap, a timeline, because there are too many factors out of their control.


I heard [medical specialist] Prof Ben Cowling on the radio the other day talking about the choice of continuing with zero-covid or abandoning it, opening to China or the world, and that either choice is acceptable, but one must be made. 

I simply wonder if this hard decision could politically ever be made. Hong Kong could push hard for vaccination levels to increase, but that would increase the pressure on opening up our external borders to the world and dash any hopes of opening a two way border to China. 

Or Hong Kong could ignore the rest of the world and focus on the border to China, suffering the economic disaster of Asia’s world city remaining closed to our international markets. Even if a decision was made one way or the other, the approach could fail (as whether or not people turn up to be vaccinated is their choice, China’s borders are China’s, and none of them are under Hong Kong Government control). 


I suspect that we will bumble onwards and hope for the best. That said, the glimmer of hope I see is that, despite all the above, vaccination levels in Hong Kong continue to climb, with consistently another 1% of our population being vaccinated every 2 to 3 days. 

Zero covid nations struggle to articulate an exit strategy; picture by Mat Napo/Unsplash

Some 73% of Hong Kong people aged 40-49 (not particularly vulnerable to Covid-19) have already had their first doses, and there is no reason to think that the other age groups won’t make the same decision. 

Perhaps the decision will be taken out of Government’s hands in the end, by the vaccines. As vaccination rates increase, it becomes increasingly difficulty not to open up. 

Now more than ever, the fate of Hong Kong is in its people’s hands (and upper arms), not government.


Infections and Deaths

Stringency Index

Image at the top shows a young woman in Kennedy Town, Hong Kong: Picture by Johen Redman/ Unsplash

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