From SARS to COVID-19: 3 Leadership Lessons
Hong Kong was hit hard by SARS in 2003.
Since then, the government has strengthened its preparedness greatly.[1] The public has also developed heightened awareness of viral infections, wearing masks with influenza-like illnesses, practising hand hygiene in hospitals, and reducing the potential of cross infection while using chopsticks. The preparedness and responsiveness were well tested in 2009 during the H1N1 pandemic.
Then came COVID-19.
The infectious disease alert was already in place amidst the normal flu season. The government immediately escalated the response plan to the highest Emergency level on 25 January. A 4-person scientific advisory committee was set up with world leaders in public health, infectious disease, and respiratory medicine. After Chinese New Year, schools were suspended; public facilities and major events like the Hong Kong Marathon were cancelled. The government also instituted work-from-home arrangements for civil servants and advised the community to follow. Citizens were advised to wear surgical masks when going to public places or using public transport.
But this virus is different. First, it is highly transmissible, with the Basic Reproduction Number (R0) estimated at 2-3. New evidence showed that asymptomatic infected persons could also transmit the virus. Second, consumption of PPE soared, quickly depleting the stockpile. PPE supplies could not be secured in February as China was also in high demand but short supply with factories shut down. Third, while Hong Kong only had to worry about containing community outbreak during SARS, containment from imported cases[2] became the prime agenda for COVID-19. Hong Kong introduced the policy that close contacts and everyone returning from high risk countries had to be quarantined for 14 days. As the number increased, the capacity for isolation and quarantine became a problem.
So far, Hong Kong has been doing well,[3] though it is still early to make conclusions. From our experience, there are 3 important lessons for leadership from a system perspective:
First, like all risk management in healthcare, the Swiss cheese model applies to system responses in major public health crises. Traditional responses, including social distancing, contact tracing, quarantine of close contacts, and isolation of confirmed cases, continue to play a key role in containing the disease spread. However, with a high R0 and globalised travelling, these time-tested measures were soon heavily strained and became inadequate. Speed and thoroughness are of prime importance in reducing loopholes. Hong Kong promptly introduced a geo-location map of all buildings with confirmed cases and geo-fencing with apps and bracelets for home quarantine.[4] These digital measures help reduce system loopholes, but they are not watertight. With the SARS experience, universal masking[5] is highly accepted by citizens, which probably provides the ultimate safety measure to prevent disease spread, like the role of a goalkeeper in a football match.
Second, agility is important. The SARS-CoV2 virus is new to mankind. Much remains unknown with many questions remain to be addressed.[6] Although Hong Kong set out an emergency response plan from SARS, the actual response has to be adjusted as knowledge on the virus unfolds. An example is the requirements for hospital isolation beds, intensive care, and quarantine capacities. Because of the high transmissibility of the virus, the government adopted the Modular Integrated Construction approach to build extra quarantine centres swiftly – similar to the new hospitals constructed in Wuhan, China, though not to the same scale. All digital enhancements were again developed within weeks.
Third, collective leadership requires collaborations across government, health system, businesses, NGOs, and citizens. The pandemic situation overwhelms any government, irrespective of the political system. Most leadership literature tends to impart a negative connotation on the command and control way of leadership. But this is necessary in crises, especially with leadership from the government and within the health system. Collective leadership requires connectivity and collaboration among disparate stakeholders. In Hong Kong, there was early engagement of health system leaders to control disease spread, the business sector to stock up PPE, NGOs to take care of the elderly and disadvantaged, and most importantly, citizens in social distancing, wearing masks in public places, and complying with stringent quarantine practices.
The battle is far from over. In the second wave, Hong Kong continues to see a decline in the number of confirmed cases every day. The public alert remains high. From a leadership perspective, developing awareness of the possible system loopholes, demonstrating to staff and the public on agility in addressing the system challenges, and building connectivity for collective leadership are crucial to generate positive thinking, reduce fear and helplessness, and strengthen resilience of the people and the system. The lessons learnt from SARS are being re-learnt.
[1] Since SARS, Hong Kong has strengthened its preparedness building an infectious disease block that serves the whole city, equipping all acute hospitals with isolation facilities, upgrading the ventilation systems in public hospitals, stockpiling personal protective equipment (PPE) in public hospitals at a level equivalent to 3-month consumption during SARS, increasing the compliance to hand hygiene in hospitals, developing a 3-tiered territory-wide response plan to epidemics, and conducting annual drills at different levels to rehearse responsiveness.
[2] Initially, it was just travellers across the border with the mainland; later, it was the citizens returning from the US, UK, and rest of the world as the pandemic spread.
[3] From Worldometer, as of 14 April, the number of confirmed cases and deaths in Hong Kong stood at 1,010 (135 per million population) and 4 (0.5 per million population) respectively.
[4] This is a mobile app supported by a bracelet with QR code. The mobile app detects and analyses environmental communication signals at the dwelling place of the quarantined person from Bluetooth, WiFi, and geospatial signals in the neighbourhood, and their relative strengths, to ensure that he/she stays at the dwelling place. The app does not collect personal data.
[5] The public is advised to use surgical masks (level 1) for universal masking.
[6] Such questions include how the virus infects people, why some people remain asymptomatic while others get severe illness, how the viral load affects symptomatology or immune response, what treatment works, etc.