By Jerri-Lynn Scofield, who has worked as a securities lawyer and a derivatives trader. She is currently writing a book about textile artisans.
Hong Kong hasn’t recorded a new local case of COVID -19, since April 19 – although today, it recorded one new infection, a person residing in the United States who returned to the city Monday, and is no longer showing symptoms, according to the South China Morning Post,Coronavirus: Hong Kong records one new case, imported from the US, as city eyes easing of social-distancing rules.
The city is now mulling easing its social distancing rules, after logging 1040 cases, and 4 deaths.
Hong Kong is one of the world’s most densely populated cities, with a population of roughly 7.5 million people, and is adjacent to mainland China, the place where COVID-19 originated.
Compare Hong Kong’s record with that of another densely populated city of roughly the same size, with 8.5 million residents: New York. There, the city is nowhere near being able to lift its lockdown, and has logged 168,845 cases and 18,706 deaths in the city itself – and those numbers are still climbing. (To sharpen the comparison between the two places, I’m only including cases in the five boroughs, and not including any cases in the greater NYC metropolitan area, including NJ, nor in NY state.)
What Hong Kong Did
I wrote about the different preparations the two cities making taking to the COVID-19 pandemic in March in A Tale of Two Cities: How Hong Kong Has Controlled its Coronavirus Outbreak, While New York City Scrambles. I spoke then to my old Oxford friend, Dr. Sarah Borwein, a Canadian-trained doctor who has practiced medicine in Hong kong for more than fifteeen years. Before that, she successfully ran the Infection Control program for the only expatriate hospital in Beijing during the SARS period. (For a fuller account of her career and her thoughts in March, see this interview in AD MediLink, Exclusive Interview on COVID-19 with SARS Veteran Dr. Sarah Borwein.)
I checked back in with Sarah recently, to get her latest thoughts on the COVID-19 crisis, especially in Hong Kong but also in the rest of the world. In April, she updated her AD Medilink interview, Exclusive Interview on COVID-19 with SARS Veteran Dr. Sarah Borwein (Updated), which ]I will draw upon that extensively in this post. I’ll only be able to touch on some of the points she made there, so I encourage interested readers to read the full interview: not long, clearly expressed, and certainly worth your time.
Hong Kong initially 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, as Sarah discussed in her April AD MediLink update:
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. Fingers crossed, but perhaps we are gaining some control over this second wave. 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.
Lessons Asia Learned
From its aggressive management of the outbreak of the disease, Hong Kong and Asia learned several important lessons:
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.
It all seems eerily familiar, but also oddly comforting in a “we got this” kind of way. We know how to do this. Hong Kongers seem to have just dusted off their old SARS habits and gotten on it, a bit like riding a long unused bicycle.
So, in Hong Kong, community engagement and the recent history with the 2003 SARS epidemic – when nearly 300 hundred people died – was vitally important.
Importance of Masks: Evolving Thinking
Now, 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.
Yet on the wearing of masks, Sarah admitted her thinking has evolved:
The mask issue has created a lot of confusion. My own view on this has changed as the epidemic has progressed. In the early days, I too, was tempted to listen to the advice from some authorities that masks are not helpful for the general population. I don’t like wearing a mask all the time any more than any of you and it seemed to be the prevailing expert opinion that they weren’t that helpful. However, it has become increasingly obvious that masks ARE an important part of the prevention package, something the Hong Kong authorities have always advocated.
COVID-19 is spread by respiratory droplets that are coughed, sneezed or talked out by infected people (droplet spread). It can also be spread when these infected droplets fall onto surfaces that are then touched by susceptible people who then touch their nose, eyes or mouth (contact 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 or contaminating nearby objects. 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.
Here, Hong Kong has a bit of an advantage. First, the recent history of SARS has meant that people were already conscious of infection control – and that includes wearing of masks. I’ve been struck in previous visits to the city that some people – a minority, to be sure – wear masks as a matter of course. Also, I understand that 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.
Contrast that to VP Mike Pence, who recently visited the Mayo Clinicc – and disdained to wear a mask. Not only does this send the wrong message. But it is also a deeply anti-social thing too do. Because as regular readers know, one wears ordinary masks, not to protect oneself from infection, but to prevent passing along infection to others. From spewing virus, if infected, at all and sundry. Now, to be fair, although I’m no fan of Pence, I should say, he seems to have gotten the message; And to his credit, has apologized for not wearing a mask.
So let me highlight his apology – which does seem a bit grudging. But it is nonetheless, an apology. As Newsweek reports, MIKE PENCE REGRETS NOT WEARING FACE MASK TO MAYO CLINIC: ‘I SHOULD HAVE’:
“I didn’t think it was necessary, but I should have worn a mask at the Mayo Clinic,” Pence said during a Fox news town hall on Sunday evening, before explaining to host Bret Baier that the Center for Disease Control and Prevention’s (CDC) guidelines provides for the use of masks to limit asymptomatic spread of the novel virus.
While the vice president admitted regret, he also defended his decision to not wear a mask, saying that because he knew he didn’t have the virus during his visit because he and President Donald Trump are now tested regularly. However, Pence noted that he did wear a mask to a visit to General Motors in Indiana two days after his appearance at the Mayo Clinic.
Wearing masks is one thing we all can do to protect each other. And I think unmasking oneself is more important than the compulsive hand washing protocol. Don’t get me wrong: attention to fomites is not wholly misplaced. But I think to some extent practicing better hygiene is the pandemic equivalent of security theater. While it certainly doesn’t hurt, it does distract attention away from the failure of many public health authorities – not including Hong Kong, of course – to prepare effectively for pandemic. It seems to shift responsibility onto individuals, and away from effective collective action on the part of public health authorities.
The New Normal
We’re moving to a new normal – but we’re far from there yet. There’s been discussion that countries that have so far controlled the disease – Hong Kong, Macao, Vietnam, Taiwan, Thailand, Australia, and New Zealand- may be the first to be able to open up some limited st=travel. I think that in the absence of a vaccine and efficacious treated, countries will be very cautious about doing so. They only have to look at the situation in Singapore, which enjoyed great success in initially managing the outbreak of COVID-19, only to see cases spike from densely-habited dormitories housing migrant labour.
Over to Sarah:
To a large extent, we are trying to predict the unknowable. This is a new virus with many uncertainties around it. It is possible that it will disappear like SARS did or dissipate when the seasons change. But it would be very foolish to count on that.
We have seen many countries be overwhelmed by a tidal wave of COVID illness and in these places some of the worst-case scenarios have played out. But elsewhere, including here, good preparedness and rapid action have been effective and shown us a way forward.
During the Spanish Flu pandemic of 1918-1919, the places that fared the best were the ones that took the disease seriously from the start, isolated sick people early, instituted comprehensive social distancing measures and continued public health measures until the epidemic was unquestionably under control. St Louis, which did this, had half the death rate of Philadelphia, which did not. Economies also recovered more quickly in places that had taken decisive early action. In a series of natural experiments in which different places did these things to various degrees, the effectiveness of simple public health measures was proven over and over again.
Here in Hong Kong, we are fortunate to have one of the best public health systems in the world, strong epidemic planning and deep experience. Hong Kong took early and vigorous action and has a population that is disciplined in mitigation measures. Several authorities have singled out Hong Kong and Singapore as examples of places where COVID-19 has been well managed to date, stating that we provide hope and many lessons to other countries. We must not relax at this point; however. It’s important that we continue our stringent public health measures and cooperate with social distancing and other measures until the epidemic is truly over globally.
Now, I should point out, that Hong Kong is not staying complacent. Just yesterday, the city’s Information and Technical Bureau announced plans to provide all residents with reusable, washable face masks, according to the South China Morning Post, Coronavirus: every Hong Kong resident to get a reusable mask as city turns corner in pandemic fight to start gradual easing of Covid-19 curbs. The city will begin to ease restrictions. But Hong Kong authorities agree with my assessment of the likelihood of near-term opening of travel and concede: border controls will be lifted last.
New York State of Mind
I’ll close with a short mention of the NYC situation. NY Governor Andrew Cuomo looks to be positioning himself for a possible dark horse Democratic presidential run based on his handling of this crisis, as Bernie has been kneecapped and Biden isolates in his own special world.,
Are you kidding me? Compare NY’s record with that of Hong Kong. Not perfect, but that’s what effective pandemic management looks like.
Cuomo only appears to be competent when compared to Trump. Which is really no comparison.