This is one of a series of interviews by Bloomberg Opinion columnists on how to solve the world’s most pressing policy challenges. It has been edited for length and clarity.
Clara Ferreira Marques: You were just starting your career during the severe acute respiratory syndrome (SARS) outbreak of 2003, and eventually came east to research infectious diseases and prepare for the next epidemic, at the University of Hong Kong. Your team had been expanding for years when Covid-19 hit. What was it like to realize last year that the moment you’d prepared for had come, but not all of your recommendations would be heeded?
Ben Cowling, Professor at the School of Public Health, University of Hong Kong: Mid-January is when we really started thinking that this might be a pandemic. We worked with the Chinese Center for Disease Control and Prevention on some of the earliest data and disseminated it as a warning to the world. When I talked to friends and collaborators in Europe and the U.S., they didn’t seem to think it was a big deal. They had their threat assessment, they hadn’t seen any infections domestically, so they were continuing work on the flu. At that point, we were already flat out on Covid-19, trying to understand pre-symptomatic transmission, the severity profile and more.
One of my earliest big themes was masks. I’m not saying masks make all the difference, but they do help to reduce transmission. That’s something we did very well in Hong Kong.
CFM: Yet many countries in Asia are now seeing higher case numbers than ever before. How did Asia go from early success in containing Covid to the multiple outbreaks across the region today?
BC: We did really well with our strategy of eliminating infection. If there are infections in the community, we get them down to zero with strict measures, then we keep them at zero. But as time goes on, people tire of the measures and struggle to sustain them. I am not surprised the virus is finding its way in.
The challenge now is improving Asia’s vaccine coverage. Some parts of Asia have limited supplies so far, so that’s one issue. Other parts of Asia have plenty of supply, but people have chosen not to get vaccinated. That will prolong the end of the pandemic in this part of the world.
In Europe and in North America, immunization means we are seeing the end of Covid-19 as a major threat to health, and in particular to healthcare systems. Once you have high vaccine coverage, cases may not go completely down to zero, but they are not going to overwhelm hospitals anymore, because there is enough protection for the vulnerable. That’s really when we can say the pandemic has ended. For Europe and North America that is going to be fairly soon. For Asia, it will take longer. The virus is still circulating globally, so until we have more vaccinated people, it will find its way in, whether that’s in Hong Kong, Singapore, Taiwan or mainland China.
CFM: This latest surge has affected countries up and down the income scale, with worrying outbreaks among Asia’s wealthier spots, like Taiwan — largely because of low vaccination rates. Are places like Hong Kong and Australia, where cases are still low, at risk of complacency?
BC: Complacency is an issue. Here in Hong Kong we have plenty of vaccines available. Any adult can get a shot tomorrow. But there is no sense of urgency. It’s not that people don’t want to get vaccinated, it’s that they are not in a rush. In our surveys we found that about 20% of people definitely don’t want to get vaccinated. The other 80% either are already vaccinated or are planning to at some point, they just haven’t done so yet.
One of the reasons for this hesitancy is that in Hong Kong, there is no immediate benefit to getting vaccinated today, as opposed to in a month or two’s time. We don’t have vaccine passes, used successfully in Israel. There is a short reduction in quarantine if you are vaccinated and are named as having been in contact with an infected person [compared to being unvaccinated], but it’s maybe not attractive enough to encourage people to get vaccinated now.
CFM: Another reason is fear of adverse reactions, reported assiduously in Hong Kong at least. It has not helped, given a population here that is already hardly trusting of government after the political upheaval of the last two years.
BC: I understand the need to be transparent, but when there is no evidence that there is a link between the vaccination and the event it may not help, and it gives people the idea that there are a lot of these incidents directly after shots. In fact heart attacks and strokes happen, and if we have a lot of vaccinated people, it will happen to them from time to time.
What we know from other places around the world is that there are really no serious adverse effects to be worried about. In Israel, they gave millions of doses of BioNTech, looked very carefully for evidence the vaccine was triggering something, and there is no evidence it did.
CFM: It’s curious that vaccination levels are lowest in Hong Kong among the elderly, perhaps in part because of those concerns?
BC: In Hong Kong we have about 20% of people with their first dose, but in people over 80, it’s more like 3%.
For those in the elderly community, it seems that there has been a lot of misinformation, advising people not to get vaccinated if they have even the smallest health condition. But we know from other parts of the world that vaccines have been used in people with all kinds of medical conditions, without problems. There is sensible advice in Hong Kong to ask your doctor if you are fit to get vaccinated. I would add to that that if you are not regularly seeing a doctor, there is no need to ask, as you are more than likely fit enough.
For elderly people living in [residential care] homes, they are usually the first to get vaccinated, but not in Hong Kong. The homes were offered vaccines early on but tended to decline, at the organizational level. That’s unfortunate, because we’re at zero Covid now, but if it were to come back we would likely see outbreaks again in residential care, even deaths. And that could be avoided.
CFM: If only a minority of people are adamantly opposed to vaccines, what will work to get shots in arms, in Hong Kong and in other hesitant spots?
BC: My own recommendation would be to set a timeline to end quarantines-on-arrival [for visitors], say, after September. That means Covid-19 will find its way back into the community sooner or later — and if that happens without vaccine coverage it means more restrictions and social distancing, except for those who are vaccinated. And at the same time, we immediately allow vaccinated people to skip quarantine.
Those kinds of policy changes, with benefits for vaccinated people and a clear timeline, would stimulate vaccine uptake. Once we recognize Covid is going to make its way back in and having the vaccination will reduce the risk of catching it, that will make a big difference. But I am not sure that in Hong Kong, at least, that is the direction the government is going in. There is instead a lot of enthusiasm for the idea of maintaining zero Covid so that we can have a bubble with the mainland and quarantine-free travel in both directions. Zero Covid does not need vaccine coverage, but it does need strict measures in place for longer. There are economic advantages to having quarantine-free travel with the mainland, but there are also disadvantages that come with imposing quarantine on people coming in from the rest of the world, and restrictions every time cases flare up.
A timeline and relaxing the policies for vaccinated people, that’s our pathway back to a normal life.
CFM: And monetary incentives?
BC: I am not keen. They set a precedent to pay people to do other things. I prefer behavioral steps. I do, though, recognize that the economic costs to Hong Kong of sticking to the status quo are phenomenal — meaning there is an economic justification for paying people.
CFM: If behavioral nudges don’t prove convincing enough, what’s left for policymakers to reach for?
BC: In the U.S. and Europe, people are now treated like adults and allowed to make informed decisions. If they chose not to get vaccinated, that is their choice and we can respect that. Governments do have a responsibility to protect the community from what we have seen in India, and what we saw in Italy and New York early in the pandemic. So if vaccination coverage isn’t high enough and Covid flares up, that low level of vaccination is going to have an implication — social distancing and lockdowns might be needed again. That might well prompt hesitant people to get vaccinated.
For now, though, I don’t think there is reason to force anyone. It is only when individual decisions affect everyone else that we have to rethink, and right now that is not the case in Europe or the U.S.
For places in Asia, I’d follow the same advice.
CFM: Doesn’t that mean temporary restrictions become permanent, as they have to a degree in Hong Kong?
BC: In Hong Kong we are a little stuck, with a zero Covid approach, following mainland China. What we need to consider is that given the acceleration of the vaccination program in the mainland, if they keep going at that rate and accelerate further, they will not be thinking about zero Covid later this year. They will be thinking about going back to normal, with Covid maybe coming in, but no longer posing a major threat.
That will leave Hong Kong very isolated, still trying to keep Covid out entirely because of the risk posed by our low vaccination coverage. We will one of the few places in the world with lots of vaccines, low uptake, unable to go back to normal life.
CFM: You worked on SARS, its aftermath and now this pandemic, when so many mistakes were made in spite of what we knew. Are we better protected for the next one?
BC: If SARS had been a virus more like Covid-19, it would have been catastrophic. We did not have good preparation for what might happen, the virus would have spread, and we didn’t have technologies like mRNA.
We’ve seen rapid advances in vaccine technology — for the first time mRNA has been used in mass vaccination — and we know a lot more about how to stop an infection like this, what the feasible options are and what they cost. If we are to face another coronavirus pandemic in 5, 10, 50 years, I would say we will be much better prepared and might even try to stop it at source, recognizing the damage that Covid-19 did, with intense surveillance and by curtailing travel. Vaccines would also come online more quickly, as mRNA just requires the strain to be updated, and manufacturing capacity is now in place.
We’ve certainly learned a lot about respiratory-virus pandemics, which is part of the reason it is so sad to see the second wave in India. What we still need to worry about is a pandemic from another source. That will pose challenges just like this one posed. For Covid-19, we can see the finish line now. Just a little further to go.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
To contact the editor responsible for this story:
Romesh Ratnesar at rratnesar@bloomberg.net
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