At a bus terminus in Kennedy Town near the old abattoir, an obscure plaque provides a daily reminder of the bubonic plague of 1894, which killed 2,550 people in Hong Kong. The Black Death, spread by rats, holds a special place in the battle against infectious diseases because it was the linchpin for the development of Hong Kong's health system. More than 100 years after the epidemic, Sars, which claimed 299 lives in Hong Kong, has placed that health system in the spotlight. Dr Lo Wing-lok, legislator for the medical sector and an infectious-isease specialist, keeps at his Legco office a sepia photo of the Alice Memorial Hospital on Bonham Road. The first training hospital for local doctors, it was among five small missionary and charitable hospitals that operated during the plague. 'Hospitals had to lay out mats on floors for patients, leaving them there to die,' Dr Lo said. He uses the picture as a talking point for the major disease outbreaks that have afflicted Hong Kong, and the health systems that underpinned them. Ticking them off mentally, he lists as disease 'landmarks' not only the bubonic plague but also the cholera calamities of 1964 and 1986, the Hong Kong Flu of 1968 and the bird flu of 1997. These outbreaks will be the focus of a book the Hong Kong Museum of Medical Sciences plans to publish, in two years, tracing Hong Kong's medical history. The museum's chairman, cardiologist Tse Tak-fu, points out that Hong Kong 'went through a very difficult time' before attaining the level of medical and health services it enjoys today. The health system has undergone only one major structural reform in the past 50 years. That change was in 1990, when the Hospital Authority (HA) was set up and the former Medical and Health Department was disbanded to make way for a marginalised Department of Health (DoH). The avian flu and atypical pneumonia outbreaks - whose impacts were felt around the world - occurred after 1990 under an HA-dominated system originally intended to decentralise the all-powerful influence of the director of health and medical services in planning the direction for such services. Dissatisfaction about the quality of beds and overcrowding in hospitals were among reasons for the change. The HA receives $30 billion a year in taxpayers' money to run its 44 hospitals, compared with the DoH's $3 billion. The DoH, which is in charge of primary (general health) and preventive care, was downsized further, in July, when the government transferred its 20 general out-patient clinics to the authority. Around the fringes are 12 financially strapped private hospitals (which the DoH regulates) as well as 4,000 private doctors who are independent or in group practice providing primary and specialist healthcare. The new Director of Health, Lam Ping-yan, does not think his department has been given the rough end of the stick. 'I think we have enough resources,' he said. 'Running a hospital is, of course, a different thing altogether. If there is any need substantially to increase the provision on infectious diseases we will consider how to deploy resources.' On top of the various layers of health executors is a powerful Secretary for Health, Welfare and Food, Yeoh Eng-kiong, who sets cradle-to-grave policies for Hong Kong's seven million people. Under Dr Yeoh are the HA, DoH and four other departments - Social Welfare; Food and Environmental Hygiene; Agriculture, Fisheries and Conservation; and Government Laboratory. Post-Sars, Dr Yeoh is spending $400 million to build 1,280 more infectious-disease beds in nine major HA-run hospitals. Little is known, however, about how much will be spent on boosting disease surveillance. Late last month Hong Kong's healthcare structure - and the issue of whether it can respond swiftly and efficiently - came under scrutiny after the release of the Independent Commission of Inquiry findings relating to the atypical pneumonia outbreak at Baptist Hospital in April. Minor league in terms of numbers - 13 staff and seven patients and family members were infected - Baptist received a scathing reprimand from then director of health Margaret Chan Fung Fu-chun for delaying the reporting of cases to her and not informing patients about the cases soon enough. Because the director had regulatory powers over Hong Kong's 12 private hospitals, she could flex her muscles on the Baptist case. Despite the quarantine the director invoked at Amoy Gardens, site of a Sars community outbreak, she had no clout over the Prince of Wales Hospital (where the Sars outbreak began) or the 43 other public hospitals the HA runs. The health director does not have the power to investigate public hospitals until the HA officially informs the DoH of a problem. The former Justice of Appeal, Benjamin Liu Tze-ming, who headed the three-person Independent Commission of Inquiry, was scathing of the seeming lack of co-ordination and communication between the bodies charged with healthcare. Apart from concluding that Baptist delayed reporting of its Sars cases to the director of health and to its patients, Justice Liu also opened a can of worms when he said private hospitals were left to fend for themselves during the Sars outbreak. 'As during the Sars crisis, (private hospitals) seemed to have been regarded as an extra, unwanted problem the DoH and HA did not need,' Justice Liu concluded. Baptist is now under pressure to release the commission's full report. The details of how the outbreak spread and where it went wrong were not contained in the executive summary released to the public on August 21. Tim Pang Hung-cheong, spokesman for the Patients' Rights Association, said releasing the full report would put more pressure on Chief Executive Tung Chee-hwa's Sars Expert Committee and the HA's review panel to be frank and open about their own investigations. The Sars Expert Committee, co-chaired by Sir Cyril Chantler and Professor Sian Griffiths, both of the UK, is scheduled to release its report on October 2, while the HA has said only that its report will be submitted to the HA board this month. Although Hong Kong's health system is not a focus at this week's World Health Organisation five-day meeting in Manila, the 54th session of the WHO's regional committee for the Western Pacific - including the mainland and Hong Kong - which closes on Friday, has on its agenda future directions for public health. The 200 delegates also hope to map out regional strategies to tackle Sars, HIV and tobacco control. The authors of The Hong Kong Health Sector: Development and Change would have much to say about the seeming chaotic nature of Hong Kong's health system. In their book, published just before the Sars outbreak, they write: 'Development of the Hong Kong healthcare sector has been relatively haphazard, with services reflecting demands of the immediate circumstances and environment.' The co-authors, health-policy senior lecturer Robin Gauld of the University of Otago in New Zealand and retired Hong Kong principal assistant secretary for health and welfare Derek Gould, also argue that 'the role of the government in the provision of healthcare services has never been entirely clear'. 'The private sector, for its part, has generally been ignored in government-policy documents, with the exception of the Harvard consultancy report issued in 1999,' they added, referring to the examination by 15 Harvard academics that recommended, among other things, the adoption of two compulsory medical insurance schemes that would allow some public money to be redirected to improve primary care. Immediately after the war, Hong Kong focused on minimising the impact of communicable diseases while rebuilding its hospitals, with several private hospitals getting in on the act. Ringo Ng, a researcher at the medical museum, points out that the impact of the 1968 flu that killed 34,000 people in the US, was not severe in Hong Kong, even though the government lacked a vaccination programme. It was a different story with bird flu, he said. The H5N1 flu jumped straight from birds to humans. When bird flu hit, the Hong Kong Medical Association (HKMA) set up an advisory committee on communicable diseases. Dr Lo, who has been in private practice since 1986, and who is in his fourth year as president of the HKMA, said it was bird flu that helped modernise the DoH - which allowed it to provide up-to-date information when Sars broke out this year. 'If not for the bird flu many of the services that we have now would not have been in place. For example they have a very up-to-date website. [In 1997] we had to ask the DoH for data, which would be very difficult to come by. You wait for a week and you get incomplete data.' Bird flu also prompted the department to set up a sentinel surveillance system, comprising more than 100 doctors and clinics collecting data and specimens to be analysed and monitored. Still, he said, Sars had shown up weaknesses in a hospital-dominated system in which policies are based more on hospital need than the need for preventive or primary care, which are the responsibility of the DoH. 'We have built a huge castle on sand,' Dr Lo said. 'The foundation of healthcare should be primary and preventive care.'