This week, I have managed to interview Dr Loretta Chan, a family doctor in Hong Kong who I met through the WONCA Asia Pacific Young Doctor’s group called the Rajakumar Movement. We spent some time together at the WONCA conference in Kyoto last year and she is truly a vivacious positive character and an extremely talented photographer.
A post that Loretta had written a few months ago on Facebook had caught my eye where she reminisced about the challenges experienced by the Hong Kong people during the SARS outbreak in 2003. I was really interested to see how Hong Kong was managing the current outbreak and whether there were any lessons learnt from the previous tragedy. For the record, I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but that goes without saying.
SARS was another coronavirus that ravaged Hong Kong in 2003. Loretta calls it a ‘hit and run’ where 1755 were infected (including many healthcare professionals) and 299 people died in the space of two months. Isolation wards were set up, doctors stayed at work to avoid risking their families and everyone in the hospital had to wear masks, only taking them off to eat. She describes that when the COVID-19 was first described in Hong Kong two months ago, it almost triggered a PTSD amongst the Hong Kong people where SARS was still within living memory. Living in such a compact city must perpetuate some fears but what I am really struck by when talking to Loretta is the blitz spirit exhibited by her local population. Relationships with the government are still fraught following the recent Hong Kong riots and that there is still a lingering level of distrust. Loretta describes that initially there was a real sense of helplessness but then they realised that they had to change their mindset and this has fostered a real sense of camaradarie. They all follow the advice of a respected microbiologist Prof Kwok-Yung Yuen from the University of Hong Kong who was active in the H1N1 outbreak of 1997 and the SARS outbreak of 2003 and is now part of the working party managing COVID-19. There are announcements on the radio and the newspapers and, although I didn’t ask directly, it doesn’t appear to be much misinformation as there is in the West. Schools were closed promptly and employees were encouraged to work from home. Social gatherings were discouraged and health staff tentatively started by using SARS precautions whilst more was being found out about the new coronavirus. In the initial period, like in the UK, only those with a fever and a travel history were tested. As with everywhere, the guidance has been dynamic and there are daily changes even today.
Now, it seems like the Hong Kong Department of Health are in full flow. There are specialist clinics for those with fevers to segregate potential COVID-19 patients from everyone else. Everyone is encouraged to receive testing and Loretta says that if they test positive even if asymptomatic, they get a phone-call directly from the Department of Health and have an ambulance dispatched to their house where the patient is picked up and carted to hospital whilst your household members are sent to quarantine camps (holiday campsites with facilities outside of town converted for this purpose). Well, that’s one way to minimise transmission! We talk about how mortifying it must be to have an ambulance arrive at your house in this way announcing to your neighbours your viral status and we wonder whether that might put some people off from presenting. For the record, this can happen in epidemic surveillance which was seen in the Ebola crisis in West Africa in 2016. It seems unacceptable from a medical perspective not to get tested but, for patients, the stigma can be a real thing.
Contact-tracing appears to be very important in the HK policy and Loretta has some concerns on the asymptomatic carriers or those who are shedding the virus before they develop symptoms. Loretta wears full gear when seeing any of her patients, fever or not, which includes a gown, eye protection, mask and a face shield, all funded out-of-pocket at her clinic and not by the government. It makes my Personal Protection Mask shrivel in comparison but the cautiousness is palpable when nine healthcare professionals died in SARS which had a mortality rate of 15%. I ask her if there is any guidance for frontline staff exposed to the virus. If a doctor has been in contact with a confirmed case of COVID-19 and both patient and doctor had been wearing masks and the consultation was less than 15 minutes, the doctor can just be under medical surveillance. However, if one was not wearing a mask or the face-to-face time was more than 15 minutes, they would have to present themselves to A&E to get tested. Some clinics have prophylactically closed its doors and Loretta describes that less people are coming to hers. Although things are better now, there was a point last month where they were only open for half-days due to the lack of patients.
In hospitals, all elective operations have been cancelled and only emergency and cancer surgery is allowed. The need for this was highlighted following an incident where a woman who had surgery for a fractured neck of femur tested positive which meant that the whole ward had to be contact-traced and decontaminated. I also wonder if this is a way of keeping ITU beds open just in case.
Out on the streets, Hong Kong is less of the hustling and bustling city that it is known for. Everyone is expected to wear a mask when they are outside and, if you don’t, you may get some funny looks. In fact, people might offer you one nervously. Being Japanese, I love a mask when I’m in Japan where it is less associated with serious illness than it is in the UK. It is pretty normal to wear one in the Far East to avoid spreading colds to others, to avoid catching colds around important events like exam time, to avoid pollen in hayfever season, to keep the face warm in winter (they are amazing for this), and even so that you can pop to the shops when you’re not looking your best. It’s part of Far Eastern culture so I am not that surprised that the people of Hong Kong have adopted this as part of their policy which is not in line with World Health Organisation (WHO) advice. The underprivileged are struggling to get hold of these masks that there has been some charities who are distributing to those who cannot afford them. As with everything, there is always a health gap associated with wealth inequality.
On the social scene, Loretta describes that many restaurants are suffering because of less customers but the plus side is that the takeaway business is booming. Social gatherings are discouraged because the clusters of positive cases has generally arisen from social events such as a hot-pot dinner for Chinese New Year or a religious event. Interestingly, the cinemas are selling alternate row tickets which means that people can still enjoy a good film whilst maintaining distance from other cinema-goers. Very nifty. But overall, it sounds like HK is waking up from its period of isolation and people are tentatively returning to work and social situations. I’m very impressed as Loretta is recounting this at how stoical the population are. She says that everyone accepts these rules in order to help everyone else out. I can imagine this. Having lived in London for the majority of my life, I am always pleasantly surprised at how people come together in a crisis even in this huge unfriendly city. We’ve had to get on with every day life following multiple horrific terrorist attacks but only time will tell how we are in the face of a true epidemic. But also this may be a reflection that the Far East has a more collectivist culture where the greater good is more important than the self compared to the Western individualist ideals.
However, just because the Hong Kong people seem well-versed in an epidemic, it doesn’t mean that panic buying is not also a feature. I am truly baffled by the current toilet roll shortage in the UK and the bulk-buying of pasta. However, this was also true in Loretta’s local supermarket last month but, instead of pasta, there is a shortage of rice. She describes a local news item at the end of February where some men were arrested for armed robbery of toilet paper which was met with some bemusement from me. I feel like I’m missing a trick here and I might check my own toilet roll supplies just in case. But Loretta reassures me that things are ok now and the supermarket hysteria has since settled and I do not need to buy my five packs of spaghetti from Tesco tomorrow.
And finally we talk about the future of COVID-19. I suppose that a lot of this is still conjecture as we are still learning about the virus but Loretta is pretty resigned to the fact that it will spread and that it will come back next winter even if the warmer temperatures make transmission less effective. The word on the Hong Kong street is that once temperatures hit 25 degrees to 30 degrees, the virus will be less active although I did point out to her that for most parts of the UK, that may never happen so perhaps we need to be braced for an all-year round flu epidemic! Her concerns lie in the fact that the southern hemisphere will have their winter soon and that COVID-19 will just cycle back to the northern hemisphere later in the year. At least it will buy us some time to have developed some herd immunity and also to try and develop some treatment and vaccine options.
Interview date: 9th March 2020
Hong Kong WHO stats at time of interview: 109 confirmed cases and 2 deaths
Population: 7.4 million