Grief and Bereavement in Hong Kong during the COVID-19 Pandemic ()
1. Introduction
The death of a loved one (e.g., a parent, a child, a spouse, a friend) is regarded as the most potent stressor in a person’s life and can result in an increased risk of adverse mental and physical health outcomes for the bereaved individuals (Stroebe & Schut, 2021). Researchers have voiced concerns that the outbreak of the novel coronavirus (COVID-19) and the subsequent pandemic has fundamentally impacted the experience of death, dying, and bereavement at both individual and societal levels (Mayland et al., 2020). As of 17 June 2022, the COVID-19 pandemic has accumulated more than 535.2 million confirmed cases and 6.3 million deaths globally, with a fatality rate of around 1.2 percent (World Health Organization, 2022). A recent study in the United States estimated that one COVID- 19-related death leads to grieving among nine family members (Verdery et al., 2020). The extrapolation of this estimate suggests that 56.7 million individuals worldwide may be grieving for a relative lost to COVID-19. This number will be much greater if it includes those who have lost close friends. Characteristics of morbidity associated with COVID-19 (e.g., sudden death, hospitalization of several family members, the stigma around infection) and circumstances around death, including restricted access to individuals at the end of life due to infection control regulations, can impede the grieving processes of the bereaved. Irrespective of the future course of the pandemic, concerns have been raised that in the years to come, we will see an increase in the prevalence of prolonged grief disorder (Tang & Xiang, 2021). Prolonged grief disorder has been defined as a pervasive grief response that persists for more than six months and can significantly impair the bereaved individuals’ personal, social, and occupational functioning (Tang & Xiang, 2021). Given the level and circumstances of bereavement during the pandemic, there is an urgent need to understand more about grieving so that we can find ways to support recovery from bereavement (Tang et al., 2021). It is also of note that the widespread implementation of infection control restrictions and social distancing measures have impacted the bereavement practices of those people dealing with death that is unrelated to COVID-19. If this significant need is not addressed, many individuals, families, and communities are unlikely to recover from the bereavement, which will have implications for mental health and wellbeing as well as the resilience and economic productivity of society.
Although there has been some research exploring grief and bereavement during the pandemic, the majority of these studies have been conducted in western countries and researchers have highlighted that the eastern context has remained significantly under-researched (see Tang et al., 2021; Tang & Xiang, 2021). Bereavement is a universal experience, but ways of reacting to loss and coping with the ensuing grief are shaped by culture and reflected in rituals and beliefs (Chan et al., 2005), which makes grief a culturally specific experience. At the time of writing, no study of grief and bereavement in Hong Kong during the current pandemic has been published. Hong Kong is a region with diverse religious groups (e.g., Buddhism, Confucianism, Christianity, Islam, Hinduism and Judaism (Home Affairs Bureau, 2016)) and a unique culture that has been described as a hybrid of East and West (Education Bureau, 2020). Hence, the grieving experiences of the bereaved individuals in Hong Kong warrant research attention. This article aims to contribute to this research area by highlighting how the pandemic, along with its infection control regulations, has impacted Hong Kong Chinese’s bereavement. Understanding such experiences will shed light on how local governments, relevant support associations or groups, and family members or friends can support grieving and promote wellbeing. Beyond the context of Hong Kong, this line of research will also provide an enhanced understanding of culture and identity in intercultural communication in multicultural societies with a Chinese population (e.g., sojourners, immigrants).
2. Grief and Bereavement in Hong Kong
The COVID-19 pandemic has disrupted the grieving processes of bereaved individuals and made this potentially devastating process even more difficult to cope with (Tang et al., 2021). Risk factors for adverse bereavement outcomes include, but are not limited to, sudden or unexpected death, physical absence at the end of life of the deceased, disrupted funeral practices, and low levels of social support (Tang et al., 2021; Wallace et al., 2020). In an attempt to reduce infection rates of COVID-19, governments worldwide have implemented various public health measures to reduce interactions between people, such as social distancing, restrictions on assembly and travel, and the use of personal and protective equipment in nonclinical settings. The pandemic and the associated infection control measures have complicated the circumstances around the death and imposed additional challenges for bereaved individuals seeking to make sense of their loss (Mayland et al., 2020). Many usual social and cultural practices associated with bereavement, such as social support activities, funerals, and religious rituals, have been interrupted (Mayland et al., 2020). These important practices are usually considered valuable resources that can help the bereaved cope with the grieving process (Burrell & Selman, 2020). However, many of these typical societal and cultural rituals have been altered, rushed through, or even disappeared during the pandemic (Mayland et al., 2020). For instance, as an essential component of cultural and religious mourning systems, funerals held during the pandemic have often failed to fulfill their function of providing the opportunity to convey respect and love for the deceased and afford social and psychological support to the bereaved (Burrell & Selman, 2020).
Hong Kong’s social and economic circumstances present a unique perspective on grief and bereavement during the pandemic. In the first two years of the pandemic, Hong Kong’s strict infection control regulations contributed to low levels of community transmission and low mortality rates directly attributed to COVID-19. These regulations may have been effective in terms of infection control; however, they had a significant impact on the end-of-life experiences of many people. Similar effects were observed in Australia in 2020 and 2021 where infection levels were minimized through strict social distancing policies that limited funeral sizes and the presence of family members at the end-of-life (Turnbull, 2021).
Despite the low number of deaths directly due to COVID-19 in Hong Kong in 2020 and 2021, many people have been deprived of the opportunity to be present at the moment of death of a family member or close friend. Ninety-two percent of the Hong Kong population are Chinese (Hong Kong SAR Government, 2021). In Chinese culture, families’ presence at the moment of death is critical for the bereaved to ascribe meaning to death. For example, a father dying without the spouse or son(s), especially the eldest son, at the bedside can be regarded as a curse (Chan et al., 2005). Chan et al. (2005) reported that children would regard their absence at their parents’ moment of death as a sin to themselves, which could induce intense and enduring guilt. Unexpected death, along with the restrictions associated with the infection control regulations, can deprive the families of the opportunity to be with their loved ones at the last moment of life and be reassured about the physical state of the person at the time of death. Relatedly, the bereaved are inclined to experience overwhelming self-blame and guilt if the deceased dies a “bad” death. This is evident in representations of a “bad” death which often include painful facial expressions, an open mouth with unsaid last words, incompletely closed eyes showing an unwillingness to die or unfinished business, an empty stomach without food, or an unwashed dirty body (Chan et al., 2005).
After-death rituals are important social practices in both western and Chinese cultures but the implications of practicing such rituals may differ. In Chinese culture, the funeral is a critical ritual that provides the bereaved with a final chance to fulfill their responsibilities towards the deceased and say farewell. Although in Hong Kong, funeral services were exempted from the group gathering restriction (Hong Kong Legal Information Institute, 2021), bereaved individuals often adapted funerals and associated ceremonies. Grand funerals have been rare, with smaller services becoming more common (Hong Kong Economic Times, 2021). Also, there have been increasing numbers of people choosing to use funeral services at hospitals. In these cases, mourners gather in the hospital to have a brief ceremony before the deceased is sent for cremation (Ta Kung Pao, 2020). While these adaptations have allowed some rituals to continue, it is possible that such disruption may hamper the continuing bonds between the bereaved and the deceased (Chan et al., 2005). Essential rituals that used to be practiced or organized by the bereaved to continue their bonds with the deceased and take care of the deceased’s spiritual after-death life have seldom been conducted during the pandemic. For example, offerings of paper gold/silver, paper money, paper house, paper cars, paper credit cards, and other paper-made properties are often believed to enable the deceased to live comfortably in the afterworld (Chan et al., 2005). Another crucial ritual in the Chinese culture, P’o ti yu (meaning breaking the Hell’s Gate), allows dead souls to be released from hell and go into rebirth through a series of dances. In this ritual, a Taoist priest carries a paper tablet of the deceased with a sword, dancing around a symbolic gate of hell built with two paper bridges (which leads to rebirth), boiling oil (the hell fire), tiles (the hell gate), eggs (hell soldiers), candles and joss stick, and uses a sword to break the hell gate (the tiles) to release the spirit into rebirth (Cantonese Ritual Services, 2019). These types of rituals have been limited during the pandemic and this may have impacted upon the grieving experiences of many people.
The financial burden associated with funerals is another factor that may increase the stress experienced by the bereaved. In Hong Kong, the expenses of funeral and burial arrangements can range from around HKD 10,000 (USD 1282) to over a million dollars (Investor and Financial Education Council, n.d.). The arrangement at the lower end of the range is usually very simplistic in nature, but this may be what many people can afford, given that the median monthly wage in 2020 was around HKD 18,400 (USD 2360 (Census and Statistics Department, 2021)). Also, the complete halt in producing and transporting coffins to meet the increase in deaths drove the coffin prices upward in Hong Kong (Cheung, 2020) and increased the family’s financial burden. The inability to hold an appropriate funeral and provide a nice burial site for the deceased can be of great significance, especially in Chinese culture, as the funeral ritual itself is what can allow the deceased to rest in peace. Children who fail to conduct satisfactory after-death arrangements for their parent(s) may be seen as unfilial, and parents who fail to do so may be regarded as unloving. The bereaved may be stigmatized and experience societal pressure (Zhao et al., 2021). More importantly, the bereaved may blame themselves for their incompetence and engender a lasting regret. Such social pressure, sense of blame, and regret are likely to impact upon grieving processes (Zhao et al., 2021).
In addition to rituals associated with death, traditional Chinese cultures often oppose the social sharing of grieving experiences even though social support may buffer psychological and physical consequences associated with deaths. The influences of Confucianism, Taoism, and Buddhism, the three highly influential philosophies in Chinese culture, cannot be ignored. Chow et al. (2007) described the common condolence statement jie ai shun bian, as meaning “save the tears and follow the flow” and illustrating “the cultural prescription of inhibiting grief and accepting the bereavement experience silently” (p. 602). As noted, Hong Kong Chinese tend not to converse about the grieving experience (Chan et al., 2005; Chow et al., 2007). Confucianism maintains that sharing intense emotions in relation to grief and bereavement can jeopardize the harmony of relationships, opposing the social sharing of sorrow associated with death (Chow et al., 2007). Taoism advocates for accepting death peacefully, repudiating the need to grieve (Chow et al., 2007). Buddhism believes in the cycle of death and rebirth, indicating that death is the beginning of the next life (Cheng, 2017)—death is described as the extinguishment of an oil lamp, so the bereaved should accept the death and wish the deceased a good next life (Jing, 2006). In addition, taboos in relation to death and dying also impact upon the grieving experience. The tendency not to talk about death might stem from the belief that such conversations would invite evil spirits into the lives of the bereaved, which explains why death is often used as a curse in arguments (Chow et al., 2007). These factors might account for the limited number of studies on bereavement in Hong Kong (Chow et al., 2007).
Finally, but importantly, the pandemic has also affected the working and grieving experiences of end-of-life care workers. A study conducted on the impacts of COVID-19 infection control regulations on end-of-life care in Hong Kong found that these regulations greatly restricted social workers’ capacity to fulfill service users’ wishes (Turnbull et al., 2022). These social workers believed that it was important for people at the end stage of their lives to separate themselves from the identity of being close to death and live a quality life. Prior to the pandemic, social workers would arrange activities for the service users, such as museum tours, travels, or walks on the beach. After restrictions associated with COVID-19 were introduced, these workers were creative and adapted their services but still felt that the service users were not able to enjoy the final stage of their lives as they had planned.
3. Conclusion
Grief is considered a universal but culturally-specific experience. Culture plays a significant role in shaping people’s reactions to losing a loved one and dealing with or adapting to grief. As noted above, at the time of writing, there are no published studies detailing the bereavement and grieving experiences of Hong Kong Chinese during the COVID-19 pandemic. This article addresses the gap by calling for research attention to this topic. The death of a family member or a close friend is devastating in western and Chinese cultures, and these cultures share the need and desire to practice significant rituals associated with death. However, as we have discussed, the implications of the disrupted practices during the pandemic for Chinese culture differ from those for western culture. More research attention should be directed towards understanding culturally specific features and challenges in relation to grieving and bereavement during the pandemic. Developing this knowledge will highlight how government, support groups, and health services can better support those who have been bereaved during this period of crisis. Such research will be of benefit more broadly as multicultural and multi-ethnic societies process similar experiences. The findings of such studies may lead to a better understanding of people’s grieving experiences at both the societal and individual levels. Expanding our knowledge in this way will be a critical step towards developing better support systems as well as promoting intercultural understandings of death.