The day after the Legislative Council released its Sars report, I sat in a KCR carriage watching a woman opposite me diligently clean out both nostrils with her index finger. With all the fastidiousness of a pedigree show cat, she examined the contents then flicked them, piece by piece, on to the floor of the train.
Three reports and two resignations later, have we learned nothing about hygiene and infection control? With bird flu knocking on our door again, are we going to go through the same nightmare, only with different faces to point fingers at later? To date, much of the focus has been on revenge. But forcing resignations and removing staff does not help us prepare for the next and - many experts predict - worse epidemic.
Some suggestions made in the expert committee report into Sars have already been put in place. Most important is the setting up of the Centre for Health Protection, which departing health minister Yeoh Eng-kiong rightly cites as his most important recent contribution.
But, something very similar was proposed and implemented 100 years ago. This was the Institute of Bacteriology, set up after the plague swept through Hong Kong and rapidly got out of control. People escaped quarantine, took to boats, and officials competed, squabbled or failed to take effective action.
And where is that institute now? It is a museum. While you can change structures, remove personnel, set up new institutes, construct flashy buildings, what the fate of the institute demonstrates is that unless you change culture, and the way people think and act, nothing will be different.
And it is here that the Legco report is a most valuable tool for moving forward. Its pages are full of blow by blow descriptions of how people who encountered problems assessed them and dealt with them.
Certain things stand out. Arrogance is one, exemplified by Chief Executive Tung Chee-hwa refusing to appear publicly before the inquiry. If the boss says he does not legally have to explain what went on, why do his underlings have to?