It was in 1992, after Hurricane Andrew exposed the inadequacies of the US insurance industry, that Warren Buffett coined the warning: only when the tide goes out do you discover who has been swimming naked. Sadly, it sometimes takes a catastrophe to discover the obvious. The global pandemic revealed fundamental weaknesses in our health care systems. And nowhere more so than Hong Kong, where just two months ago we were patting ourselves on the back for a “zero Covid” policy that spared us the trauma and heartbreak of so many countries. As our Covid-19 toll has since soared to exceed a million cases and 5,000 deaths – our seven-day rolling average of Covid-related deaths per million is now the highest in the world – it is important to take stock of why none of our leaders recognised that we were not wearing a swimming costume. The history books will point to hubris and procrastination, especially over the failure to use the window provided a year ago by the delivery of vaccines to ensure that we insulated our elderly and vulnerable. They will point to some spectacularly inept decision-making, in particular the combination of mass testing and compulsory quarantines. When so many other governments had encouraged testing at home and advised those with mild symptoms to isolate at home where possible, why did our government force everyone into crowded testing centres and enforce a hospital quarantine that meant beds became occupied by people either asymptomatic or suffering from symptoms most of us would describe as a mild cold? But one glaring failure stands out, and which has been hiding in plain sight for over 30 years: our failure to develop a community-based primary care health system, relying instead on hospital-based care. Back in 1990, when the Hospital Authority was launched with great fanfare, the intention was also to build a second primary-care pillar underpinning our health care system. This would have planted community health centres across Hong Kong, all within easy walking reach, and staffed by a multidisciplinary team of doctors and health care professionals focused on families’ routine and chronic health and wellness needs. Swamped hospitals show up urgent gaps in Hong Kong’s primary health care Apart from administering annual flu vaccines, guiding women through pregnancy, and overseeing the chronic but manageable needs of our fast-growing elderly population, the centres would be staffed by family doctors who would get to know the people in their community, track their medical history, encourage wellness, and help individuals take ownership of their health needs. There can be absolutely no question that if such a community-based primary care system had been in place when Covid-19 struck, Hong Kong’s tragic story of pandemic management would have been completely different. Vaccination programmes would have been administered locally. Community health centres would have distributed home test kits. Those with mild or no symptoms would have got the paracetamol they needed. Those feeling worse would have collected their first dose of Paxlovid . Pressure on our hospitals would never have emerged. Our need for a stronger community-based primary care infrastructure has been plain since the government’s visionary 1990 report “Health for All – The Way Ahead”. This launched the Hospital Authority, which has since grown into one of the world’s best inpatient care systems. But well-argued plans for a primary care authority responsible for serving the health needs in the community have been left to drift. Instead of evenly developing a right arm of inpatient hospital-based secondary care and a left arm of community-based general health care, we have grown to rely on the Hospital Authority for everything. The result is that even minor or chronic medical problems – from flu and cuts to diabetes management, depression and insomnia – are swept straight through the accident and emergency doors of our public and private hospitals. Since 1990, our government has driven several major consultations on health care reform, and think tanks like Our Hong Kong Foundation have drafted many impressive and comprehensive reports, all agreeing on the need to build primary care. The foundation’s 2018 report “Fit for Purpose: A Health System for the 21st Century”, was clear: “Our health system is fragmented with patients falling through the cracks found between our primary and hospital services.” Hong Kong’s lack of pandemic preparedness must be addressed now It noted that over half of people in hospital suffered from problems that could be dealt with in community clinics – if we had them: “Pivoting our system away from its current emphasis on hospital-based, episodic and acute care towards care in the community that is continuous, person-centred and caters for the holistic needs of individuals will transform the delivery and experience of care, and improve health outcomes and efficiency,” it said. Just three months ago, the foundation hosted a conference launching another major report, “Enabling Health for All”. Chief Executive Carrie Lam Cheng Yuet-ngor was guest of honour, and called for a shift to primary care: “I would say that my government has made some good efforts and invested more in primary health care, but definitely there is still a long way to go to deliver a system that is affordable and fit for purpose.” The embarrassing and tragic irony is that Lam, back in 1990, was the government-appointed secretary serving the “Health for All” consultation. From the highest levels of government, she has “book-ended” this procrastination. The deaths and social dislocation we suffer today are a direct result of that procrastination. It is terrible that it has taken the pandemic catastrophe to teach us what we have known for over 30 years. We don’t need more consultations. We don’t need more reports. We need a properly functioning community-based primary care system. And we needed it yesterday. David Dodwell researches and writes about global, regional and Hong Kong challenges from a Hong Kong point of view