A Glimpse of the Coronavirus’s Possible Legacy

The imprint SARS has left on Hong Kong speaks to the legacy COVID-19 may well leave on much of the world.

The burial of Dr Joanna Tse Yuen-Man, who died of SARS, at Gallant Garden, Wo Hop Shek. A relative is holding her portrait.
Dr. Tse Yuen-man, along with other public-health workers who died treating patients for SARS in 2003, is still memorialized in Hong Kong. (Martin Chan / South China Morning Post via Getty)

HONG KONG—Tucked away in a park here, near a spiraling observation tower and an aviary teeming with exotic birds, is a monument of thin white pillars, metal and glass. Beneath the memorial’s canopy, eight bronze busts sit on square concrete podiums. The faces, forward looking, gazes fixed and lips drawn in the slightest of smiles, are those of medical workers who died battling the outbreak of severe acute respiratory syndrome (SARS). The illness, which first appeared in Hong Kong in February 2003, would spread to some 1,700 people in the city and kill 299, including the nurses, doctors, and hospital workers whose lives have been commemorated at the park.

One of the busts is of Tse Yuen-man, a doctor who volunteered to treat patients who had fallen ill with the disease. By April, Tse was herself sick. She died the next month, aged 35, becoming the first public-hospital doctor to die of SARS. Tse was buried in Gallant Garden, a cemetery for members of the civil service, alongside police officers and firefighters who died in the line of duty. On top of that rare honor, she was awarded Hong Kong’s Gold Medal for Bravery. The citation reads like the retelling of a soldier’s actions in battle: “By voluntarily putting her own life in extreme danger in order to save others, Dr Tse displayed noble gallantry of the highest order in carrying out her last duties.” The monument opened two years after her death. On a recent visit, office workers on their lunch break chatted through face masks, and green signs hung in the park, carrying the government’s slogan for countering the new pandemic, “Together, We Fight the Virus!”

A health crisis similar to the one now playing out globally has unfolded in few places in recent memory, and the imprint SARS has left on this city speaks to the legacy the novel coronavirus may well leave on much of the world. The experience of SARS traumatized Hong Kong, and the memories have endured in the territory’s collective consciousness. The doctors who helped combat the virus are widely known, tales of sacrifice by medical workers are often repeated, and the city’s ability to rebound once the virus subsided is frequently invoked by leaders to show its resilience and spirit. The experience also brought about a rise in public-health awareness and a sense of civic responsibility toward preventing illness, as well as an increased investment in health care and research, factors that seem to have helped effectively contain the outbreak of the novel coronavirus here. When news emerged of a mystery outbreak in mainland China, Hong Kong residents, almost out of instinct, began taking measures that health experts credit with helping stave off the explosion of infections seen elsewhere. The government, after initial stumbles, enacted a series of regulations to slow the spread and leaned on experts, many of whom came to prominence in 2003, to assist with the new crisis.

The SARS outbreak is “remembered vividly” by people who lived through it and “in no place is this more true than in Hong Kong,” says Keiji Fukuda, the director of the University of Hong Kong’s School of Public Health, who previously held top positions at the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention. “While in many places, the general public tends to regard outbreaks, more or less, like a television fantasy or brief news item,” he told me, “in Hong Kong, the public take outbreaks, and recommendations about what to do, seriously.”

A tram driver in Hong Kong is silhouetted in front of a billboard showing medical workers wearing masks to prevent the spread of SARS in 2004. (Samantha Sin / AFP via Getty)

Well before the emergence of the coronavirus, surgical masks have been a common sight on the city’s subways and buses, as people suffering from even a mild cough or sniffles wore them as a precaution against infecting others. Small signs on elevator panels and doors indicate how often they are disinfected. Hospitals maintain separate waiting areas for those experiencing flu-like symptoms. Using a tissue or pen to press an elevator button would hardly garner a quizzical look. News of disease outbreaks in China, and Asia more broadly, receive considerable news coverage. These measures that permeate everyday life are largely linked to the lasting memory of SARS. The outbreak “facilitated the development of public health at the institutional level, but it has also enabled the Hong Kong population to become aware of the importance of personal hygiene and infection prevention at the community level,” Judy Yuen-man Siu, an assistant professor at the Hong Kong Polytechnic University’s Department of Applied Social Science, observed in a 2016 paper examining the widespread adoption of face masks during the crisis.

Since the outbreak of the coronavirus began, the community response here has been robust, undoubtedly colored by the city’s experience of SARS. Social-distancing guidelines were followed, and companies quickly switched to work-from-home schedules. Face masks are ubiquitous. Moving through the city without seeing, or hearing, numerous reminders on hand-washing technique, how to wear a mask, and what number to dial if you exhibit symptoms of the virus is nearly impossible. Now, in what seems to be a sanitization arms race, all manner of surfaces bear signs detailing how frequently they have been cleaned—two times a day, four times a day, hourly. Hand-sanitizer dispensers sit on the counters of most shops. Others have warnings in the window saying patrons will be refused entry if they are not wearing a mask. The front page of a local newspaper recently called out Westerners for going without them. (Last month, I was barred from entering an office to conduct an interview for a story until I procured a mask.) Temperature checks and health questionnaires at malls, restaurants, and the post office have become a routine part of life.

These measures, according to experts, coupled with border controls implemented by the government, as well as rapid testing and tracing of infections, have helped stem the spread of the disease here. The number of confirmed cases stands at about 160, and though four people have died, more people have been discharged from the hospital than remain under care. Carrie Lam, the city’s chief executive, said yesterday of the 57 most recent infections, 50 were imported by visitors or people returning home from abroad. To counter this, sweeping travel restrictions were announced stipulating that any person arriving in Hong Kong will be put under home quarantine, with the exception of arrivals from mainland China, Macau and Taiwan. (Some experts have said that the measures do not go far enough.) While schools, which closed in January, will likely not fully reopen next month as was tentatively planned, government offices have begun resuming work. Some private offices have followed the government’s lead.

“The temporary success of virus control in Hong Kong this time is not only due to population controls, but also … the early advocacy for mask-wearing, hand-washing, and social distancing,” Yuen Kwok-yung, the chairman of the University of Hong Kong’s infectious diseases department, who played a leading role in the discovery of the agent causing SARS, said in an interview with Caixin, a Chinese magazine. “Otherwise, with such a dense population in Hong Kong, the epidemic would very likely have spread the same way as in Italy or … South Korea.”

Members of Hong Kong's Health Department wear protective suits during an exercise held at Hong Kong International Airport. (Alex Hofford / AFP via Getty)

The public experience and knowledge of SARS, Fukuda explained, make it easier to enact these types of measures because people need little prodding to undertake them. This creates a “major advantage for the officials dealing with the outbreak because you can expend less effort convincing people to help, and the strategies can be more effective,” he said.

That advantage was very much needed: After months of prodemocracy protests, the government here is deeply disliked. A run on face masks and hand sanitizer led to panic buying, with many citizens leveling the blame at the government for being unprepared. Grocery stores were briefly wiped out of some staples.

Other efforts, however, were under way as well. University of Hong Kong researchers sounded an early alarm, saying in January that the number of cases of the virus in China were likely many times higher than what was officially being reported. They called for tougher measures to be implemented in Hong Kong and said that the virus risked becoming a global epidemic, even before the WHO declared a global health emergency. Activist groups began procuring and distributing hundreds of thousands of masks. Smaller measures popped up too: Posters describing the symptoms of COVID-19 were stuck to the few remaining parts of the Lennon Wall constructed during the protests, and the messaging app Telegram, used to push out demonstration-related updates, circulated flyers on proper hygiene techniques to channels with tens of thousands of followers. Hospital workers went on strike in early February hoping to force Lam to close the border with mainland China. Although Lam refused to fully do so, she did drastically reduce the number of entry and exit points. Overall visitor arrivals in February were down more than 96 percent from the same time last year, according to the Hong Kong Tourism Board.

Supplies have now largely returned to stores. Authorities have cracked down on counterfeit medical goods. Press briefings and detailed updates on new patients are delivered daily. Lam has mostly stuck to goodwill visits, allowing health officials and respected experts to explain the situation. A second batch of government-funded evacuation flights are being planned for Hong Kong residents in Hubei province, the coronavirus’s epicenter in China. The city is now testing about 1,000 people a day, though Yuen has said this number should be increased.

The government’s interventions and individuals’ change of behavior have been significant. The results of two surveys carried out by researchers in Hong Kong in January and February, published Monday, estimated that the large majority of the adult population wore masks when going out, while most avoided going to crowded places, and reported washing or sanitizing their hands more frequently. Not only have measures been effective in preventing the spread of COVID-19 but the transmission of influenza has also “declined substantially” as a result, the researchers found. Researchers added that if their findings were borne out elsewhere, “they support the perspective that COVID-19 can be meaningfully controlled, or at least mitigated, by familiar social distancing and population behavioral changes short of the draconian measures introduced in mainland Chinese cities.”

When the SARS outbreak eventually eased, a report detailing the numerous failures of the government’s response led to the resignation of the secretary for health, welfare and food at the time. In the years that followed, the government undertook measures to strengthen its preparedness in case of another outbreak, developing Hong Kong’s Centre for Health Protection and bolstering infectious-disease research at local universities, Fukuda said. “None of these types of structural improvements can be done overnight. All of them took leadership, legislative support and time,” he told me. “But it is what distinguishes places that improve and those that don’t.”