Coronavirus: Hong Kong has flattened the curve but can it stay the course – or will imported cases and complacency derail efforts?

For the past two months, Sunny So has put on a surgical mask, clear, non-prescription glasses and a hat every time he leaves home.

The Hong Kong resident carries with him a hygiene kit with hand sanitiser, alcohol wipes and extra masks. His fingers never touch lift buttons directly.

The checklist of precautions provides So with a sense of security amid the city’s battle with Covid-19, the coronavirus-spread disease that has criss-crossed the globe with terrifying speed.

Hongkongers and others in the region have largely acted similarly, something many now credit with slowing down the rate of infection, or “flattening the curve” of the virus’ growth.

But with a recent spike in new cases, primarily imported by an influx of returning residents, questions have been raised about the city’s ability to maintain heightened vigilance over the long haul.

Chinese University respiratory medicine expert David Hui Shu-cheong believes fatigue over social distancing and other control measures could be behind some of the new infections.

“Hongkongers might have let their guard down a bit after seeing the slow rise of infections in the first few weeks,” he said.

“I am sure they will keep up their effort when they see the recent tally shooting up rapidly.”

Hong Kong’s early acceptance of the need for social distancing, even as some countries still struggled to accept the harsh new reality, has its roots in another epidemic.

“I was very worried at the beginning of the [Covid-19] epidemic,” So said. “Would an epidemic similar to Sars happen in Hong Kong again?”

As a resident of Amoy Gardens, one of the epicentres of Hong Kong’s severe acute respiratory syndrome (Sars) outbreak of 2003, So was quick to adopt strict hygiene measures, which he admits were inconvenient. A small price to pay, he said, if it meant protecting himself and others.

The dark memory of Sars, which infected 1,755 people and killed 299, gave Hongkongers a concrete reason to take the coronavirus more seriously from the beginning.

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Before last week’s spike, Hong Kong was averaging fewer than 10 new cases a day. The incidence rate remained at steady levels through to the middle of this month, particularly in comparison with countries that have experienced more dramatic spikes.

Based on data from the World Health Organisation, Hong Kong’s number of infections per million residents was 14 on March 6. That gradually increased to 18.9 by March 15. In comparison, hard-hit Italy, where swathes of the country are experiencing overflowing hospitals and morgues, saw a drastic rise from 63.8 to 349 per million over the same period; in Britain it jumped from 1.77 infections per million to 17.2.

The dean of the University of Hong Kong’s medical school, Professor Gabriel Leung, one of four experts in the local government’s advisory group, recently said he agreed that East Asia, including Hong Kong, had “successfully brought down the epidemic curve”.

In addition to social distancing, Hongkongers have received much the same medical advice as people around the globe. They have been told to wash their hands frequently, avoid touching their faces, and cover up when coughing and sneezing to reduce the spread of germs.

But city residents have taken a decidedly different approach to their Western counterparts in one very particular area – the wearing of surgical masks.

While World Health Organisation guidelines as of Monday still recommend masks only for those caring for suspected Covid-19 patients or exhibiting symptoms themselves, Hongkongers arrived at a different conclusion two months ago.

From MTR trains to supermarkets to city pavements, the site of an uncovered face has become an increasingly rare one in the city.

Many of Hong Kong’s top health experts believe that to be the right call.

Professor Yuen Kwok-yung, HKU’s leading infectious disease expert, has advocated “universal masking” since late January, when the city began recording its first coronavirus cases.

Dr Ho Pak-leung, who works in the same department as Yuen, said Sars was the key turning point in the public’s attitude towards masks.

“Before the outbreak of Sars, even in hospitals, no one wore masks,” Ho said. “Masks available in wards were just like a piece of paper. They were paper masks only.”

He said one of the factors behind the 2003 outbreak was a simple lack of knowledge – masks were not worn at the onset and proper hygiene was not practised.

“After Sars, the public reflected deeply. That’s why this time people are more proactive in doing [preventative measures],” Ho said.

Turning to masks during times of epidemic has since become the default for many Hongkongers, not because they are sick, but because they believe it to be effective protection.

The rapid surge in demand for masks made them even harder to find. But it also prompted creativity.

A home-made mask, created from common household items such as kitchen roll, strong tissue paper and pieces of plastic file folders, was devised by HKU-Shenzhen Hospital and the city’s Science Park tech hub as a temporary alternative for people who had run out.

Hats with large transparent covers – to protect from droplets carrying infection – became a fashion statement, while elbow bumps replaced handshakes as a greeting and discussions on how best to avoid touching public surfaces went viral on social media.

Social distancing measures, meanwhile, went into effect on an unprecedented scale.

Schools were suspended and government departments and private companies alike rolled out work-from-home arrangements, while churches took their weekly services online and festivals and sporting events were called off.

Travel between Hong Kong, mainland China and other parts of the world has also been greatly reduced – if in stages – a phenomenon being repeated to differing degrees all over the world.

In the past month, the government has tightened travel restrictions at least six times, first subjecting travellers from South Korea, Iran and Italy, then later the 26 countries in Europe’s Schengen zone, to a mandatory 14-day quarantine. On March 19, the policy was expanded to arrivals from all foreign countries.

The social distancing and border-control measures are part of an overall strategy of containment, which focuses on isolating those suspected or confirmed to have the virus.

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Close contacts of confirmed cases and people returning from high-risk areas, with or without symptoms, have been subject to quarantine.

Hui, from Chinese University, said containment is vital in the early stages of an epidemic.

“It aims to prevent the rapid spread of the virus in the community,” Hui said, noting the measures taken by the city had proven effective in containing the disease.

He added it was too early to abandon containment in favour of “mitigation”, a stage at which the high number of cases from unknown sources makes isolating patients pointless. The city, he said, has not yet reached that point.

“We should not surrender if we have not fallen,” he said. “Containment should continue.”

To that end, Hong Kong has continued to expand quarantine facilities at local holiday camps and an unoccupied public housing estate.

Britain, which raised the eyebrows of many medical experts when it first announced plans to beat Covid-19 by achieving so-called herd immunity, quickly abandoned that tack in favour of “suppression”.

The about-face last week came after an Imperial College London report suggested that 250,000 people in Britain could die under the mitigation scenario, even if all patients were properly treated.

Leung, from HKU, said the strategy of allowing large-scale infections to build herd immunity was “difficult to pull off’.

But while Hong Kong has avoided that misstep, HKU’s Ho had harsh words for the government’s response, which he said deserved a score of “zero”.

“I’m not saying it has not done anything, or those measures were not good. But the government has been acting too slowly in rolling out measures, and there are too many loopholes,” he said.

Ho called for the government to ban all non-residents from entering the city, pointing to similar measures already in place in Australia, New Zealand and neighbouring Macau. Others called for a stepped-up information campaign rallying the public to take more drastic social-distancing measures.

And on Monday, officials did step up measures. Amid mounting pressure for stronger action, and a day after Singapore announced border closures to foreign visitors including those transiting through the country, Chief Executive Carrie Lam Cheng Yuet-ngor announced the barring of all overseas visitors for 14 days, suspending transit services at the airport, extending testing of residents returning from virus hotspots such as Europe and America, and banning restaurants and bars from selling alcohol.

Appealing to the community to adhere to anti-epidemic measures, Lam said: “This is a long battle, and we need citizens’ help to fight it.” Experts, however, believed the government should go further, and the community was ready for more action.

“Hong Kong people are resilient. We have played a good game in the first half of the match, let’s keep it up in the second half,” medical-sector lawmaker Pierre Chan said, pleading with residents to not squander the hard-won gains of relatively low infections in the previous months.

Dr Ho was more blunt, saying the city needed “martial-law-style measures” to stop it “becoming another Wuhan or another city [like one of those] in northern Italy”. He said restaurants should provide takeaway services only, and called for returnees to be quarantined at hotels to minimise the chance of violation, after some were spotted removing their tracking wristbands and leaving their homes.

Despite differing views on the government’s performance, Leung and Ho both agreed Hongkongers, on an individual level, deserved credit for what Ho called a “great job” over the past two months.

The trick now, experts say, will be maintaining the effort.

As stepped-up measures to contain imported cases were announced last week, Leung said the city faced a “critical turning point”, one in which infection cases could reach new highs.

All the more reason, he said, for residents to “maintain their self-discipline and avoid venturing out”.