Jerri-Lynn Scofield
Naked Capitalism
9 March 2020 15 minute read
Dr. Sarah Borwein [is]…a Canadian-trained doctor who has practiced family medicine for more than 15 years in Hong Kong…. Prior to commencing her practice in Hong Kong, she…ran the Infection Control program for the only expatriate hospital in Beijing during the SARS period, also serving as liaison with the World Health Organization….
The city has been in partial lockdown from the middle of January, with schools and universities shut, employees encouraged to work from home, sports facilities and museums closed down, and people told to avoid crowds….
Hongkongers are particularly compliant with public health measures because the 2002-2003 Sars outbreak, which claimed almost 300 lives in the territory, is still fresh in many people’s minds.
There has been extensive testing for the coronavirus in Hong Kong – which is free. This allows public health authories to track the spread of the disease, and see that victims get treated properly and promptly…. Hong Kong has made it a criminal offence to lie to a health care provider about one’s travel or exposure history, according to Sarah….
From a text from Sarah:
We have triage at the door. People with high-risk travel history can’t be seen, have to go directly to government hospital if symptomatic; or if just for routine care, wait 14 days after return (all of which must be healthy). Low risk people with symptoms we isolate immediately; they never enter the main clinic. And we wear PPE [i.e., personal protective equipment] to see them.
In Hong Kong, people are being told to get tested if [they may]…have been exposed, and/or are symptomatic. Anyone with a fever or respiratory symptoms is tested as a matter of course…. Hong Kong has also made it easier for patients to test themselves, without involving a health care provider. From a message from Sarah:
They also pioneered a test that patients could do themselves – ie they self-collect a “deep throat saliva” sample at home. That reduces risk of exposure to healthcare workers, as taking nasopharyngeal swabs is aerosol generating.
…After SARS, Hong Kong set up the Centre for Health Protection (CHP), which is our version of the CDC in the United States. When COVID-19 emerged, there was already an epidemic management plan in place that just had to be activated.
… medical science has advanced considerably in the 17 years since SARS. In 2003, it took months to identify the virus and develop a test. For COVID-19 that happened within a couple of weeks. That has made identifying patients a great deal easier.
…We learned from SARS…that infectious diseases do not respect borders or government edicts, and cannot be hidden. It requires international cooperation, transparency and sharing of information to control an epidemic.
We also learned the importance of providing good, balanced, reliable information to the public. In any epidemic, there is the outbreak of disease and then there is the epidemic of panic. And nowadays, there is also what the WHO has termed the Infodemic, the explosion of information about the epidemic. Some of it is good information, but some of it is rumour, myth, speculation and conspiracy theory, and those things feed the anxiety…. Panic and misinformation make controlling the outbreak more difficult.
Hong Kong…took aggressive measures in response to the initial outbreak of COVID-19, and seemed to have managed to shut it down. But then, it was faced with a second wave of COVID-19 cases….
In response, Hong Kong took aggressive measures, basically shutting down international arrivals and enforcing mandatory testing and quarantine for all those who do enter, as well as more stringent social distancing measures, a ban on public gatherings of more than 4 people and closing many venues such as bars and sports clubs. The new case numbers have started to decline again…. It is too early, however, to relax our guard, as it will take a few weeks to be sure there isn’t disease percolating quietly in the community.
Our second wave was largely unleashed by returning Hong Kongers and expatriates coming home. In part, this was because they felt safer here, due to Hong Kong’s initial success in managing the epidemic. This has caused some problems, but is also a testament to the fact that there is benefit to being in a place that not only has know-how and resolve, but also has been tested before.
Between that first and second wave, the epicenter of the disease shifted from China, to Europe, the UK, and the United States.
Several lessons are emerging from the experience of Hong Kong and other Asian countries. The first lesson is “Go hard, and go early”. How different might things might be globally if some other places had done what we did and instituted vigorous measures in January, when there were only a very few cases or none? Hong Kong response started before we had any cases at all, and kicked into high gear when we had only five. Singapore, Taiwan, Macao, Thailand, Vietnam and South Korea did the same.
When you start early, you can contact trace every case and try to contain or eliminate the disease completely by isolating sick people quickly, and quarantining their contacts before they can spread the infection. Hong Kong’s impressive contact-tracing work has helped define where the local cases are coming from, so that measures can be taken to curb community spread. As a result, even though life is not normal, we are not in complete lockdown. Countries that didn’t start taking COVID-19 seriously until they had a great many cases cannot do this. Extreme social distancing is the only tool then available; this will help reduce the impact of the disease, preventing a worst-case scenario, but a lot more people will still get sick and die than here, and the economic consequences may be more dire.
We’ve also found that quarantine and isolation must be strictly enforced in order to be effective, and unfortunately, this requires intrusive measures including tracking bracelets, fines and even jail terms. Without these, it’s far too easy for people to find reasons why they personally are different or exempt.
Community engagement is vitally important. Hong Kong people lived through SARS and understand at a visceral level how important it is to practice social distancing, wear masks, wash their hands and listen to public health advice. This epidemic happened on the back of months of civil unrest that left us with a weakened and unpopular local government. That could have been disastrous. But we do have highly respected public health authorities and infectious disease specialists, many of whom are seen as SARS heroes. Both the government and even more importantly the local population, do listen to their advice. SARS taught us that our own health is dependent on the health of the whole community, and that lesson has not been forgotten….
One thing that made a huge difference in Hong Kong was the early and widespread use of masks. That measure of course cannot be separated from testing, isolation, quarantine, hygiene, and social distancing….
COVID-19 is spread by respiratory droplets that are coughed, sneezed or talked out by infected people (droplet spread)…. Plain surgical masks provide some protection against droplet spread infections. It’s hard to quantify how much, but even if the protection is only 10-20% that’s worth having, when combined with good hand hygiene and social distancing. Even more than that, this is an infection that can be spread when asymptomatic or pre-symptomatic, and we know that masks do significantly help to prevent infected people from transmitting to others…. Everyone should consider themselves potentially infectious and wear a mask to protect others.
Wearing a mask when around others is a civic responsibility and an act of solidarity: I wear a mask to protect you, you wear a mask to protect me. Everyone is protected if we all do it.
But when the epidemic ends, please stop wearing masks. They stop us from smiling at each other.
…Due to recent political unrest, some people donned masks as a way of obscuring their identities. The COVID-19 outbreak just made that behavior one of civic responsibility…. Just yesterday, the city’s Information and Technical Bureau announced plans to provide all residents with reusable, washable face masks…. The city will begin to ease restrictions…. Border controls will be lifted last.
The city of 7.5 million residents [limited]…cases to just over 1000, and deaths to four…[even though] Carrie Lam, Hong Kong’s hapless chief executive…bungled Hong Kong’s initial response…. From The Atlantic:
Lam fumbled the response to the pandemic…. Hong Kong’s first coronavirus case was reported when she was having dim sum with world leaders in Davos, Switzerland, and there was an outcry over the fact that she did not quickly return. She dragged her feet in closing the city’s borders, and never fully closed down the land border with China. The hospitals suffered from shortages of personal protective equipment. Lam wavered on masks, and even ordered civil servants not to wear them. There were shortages of crucial supplies and empty shelves in stores, as well as lines for many essentials….
And yet there is no unchecked, devastating COVID-19 epidemic in Hong Kong. The city beat back the original wave, and also beat back a second resurgence due to imported cases. But unlike in Taiwan or South Korea, this success can’t be attributed to an executive that acted early and with good governance backed by the people.
Why is Hong Kong showing such success in COVID-19 management? For starters, their public health authorities knew what to do to control a pandemic, having learned painful lessons from two previous outbreaks Hong Kong wasn’t so successful in managing: the 1968 influenza epidemic, later dubbed “the Hong Kong flu”; and the 2003 SARS episode…. [Also,] Hong Kong residents took the lead in promoting the use of masks – despite initially contrary advice from the World Health Organization and lack of support from the government…(who had banned mask wearing during the recent period of political unrest):
In response to the crisis, Hong Kongers spontaneously adopted near-universal masking on their own, defying the government’s ban on masks. When Lam oscillated between not wearing a mask in public and wearing one but incorrectly, they blasted her online and mocked her incorrect mask wearing. In response to the mask shortage, the foot soldiers of the protest movement set up mask brigades – acquiring and distributing masks, especially to the poor and elderly, who may not be able to spend hours in lines. An “army of volunteers” also spread among the intensely crowded and often decrepit tenement buildings to install and keep filled hand-sanitizer dispensers. During the protest movement, I had become accustomed to seeing shared digital maps that kept track of police blockades and clashes; now digital maps kept track of outbreaks and hand-sanitizer distribution.
Sarah described what has been undertaken as “old shoe-leather epidemiology.” No app. No technofix fairy. Just hard work. I asked her to explain what test and trace means to Hong Kong health authorities.
Sarah Borwein: So we had 21 days with no local cases and then a case was detected 2 days ago, and now her grand-daughter and husband have tested positive. What they are doing reflects their strategy:
They did extensive interviews with the index case (the 66 year old grandmother) and retraced everywhere she’d been in the 2-3 days prior to getting sick – every market stall etc. She looks after her 5 year old grand-daughter who is also positive – so they have also traced all her contacts. She attends a tutorial school, so the teachers and other kids.
And now they are conducting testing for 860 families who live in her housing block or the grand-daughter’s, or work in the market or work in or attend the tutorial center. At least 5000 people from 1 case!
They actually do something similar whenever we have a local case of dengue fever (not endemic here) – so they do have practice.
Jerri-Lynn Scofield: So, that’s what test and trace means! And not via an app.
Sarah Borwein: No, not via an app.
Although there are websites where you can see the locations of all the positive cases, and any flights etc (including seat number) they have been on – so you can self-report if you were near them. But mainly they do the shoe-leather work as the mainstay.
The work is hard, and in the most recent Hong Kong case, public health authorities are testing and tracing more than 5000 contacts of just one index case. It is this level of effort that has limited the number of deaths to just four of the 7.5 million residents of Hong Kong.
Excerpted from three articles by Jerri-Lynn Scofield on Naked Capitalism blog