So now we are entering the third year of this global pandemic. It is changing, evolving and is bringing out the very best and the very worst in humanity. Science and scientists have had a real bashing, but then who by? Quacks, aardvarks and gobbeldygooks. Looking back is looking forward.

It is over a year ago that I wrote my last ‘Letter from Hong Kong’, 3 November 2020. It does seem quaintly naive now but there are some points that are worth revisiting.

I began by acknowledging that things change but life goes on. I did spend a considerable amount of time and energy in 2021 witnessing firsthand the inequities of the law as practised. Anyone who has been following the absolute scandal of the perverse way in which Chris Day has been treated in the United Kingdom will understand that questioning the practice of law is essential. Chris was involved in an employment law issue. When we start to look at other aspects of law, in particular criminal law, as it applies to medical practice, the concerns are overwhelming. I have had to ask if what I witnessed firsthand in a High Court in Hong Kong in 2021 was exceptional, but the sad reality is that I do not think it was. One cannot blame judges for being incompetent when they are put in a position beyond their training and capabilities. This is the case in gross negligence manslaughter pertaining to health professionals. The need for reforms in both Medicine and the Law are matters of extreme urgency. That is the focus of the other blog series: ‘Gross Negligence Manslaughter in Healthcare: A medico-legal dilemma’. I shall be returning to that next week but for now let me continue on the theme of the pandemic.

In November 2020 I wrote:

It is seven months since I wrote the first ‘Letter from Hong Kong’. The message then was simple: “Fear is okay, panic is not and wear masks”. It is one month since I wrote the last letter and that message? “Life goes on and will go on no matter what.””

I then mused on the classic beauty of Hong Kong, saying “come to Tsim Sha Tsui, in the evening time and look over Victoria Harbour. It is magic, a magic unparalleled on this planet.”

But keeping on the theme of magic I began to describe a day in the New Territories and actually made a mistake in suggesting that there was no government mandate on mask wearing in November 2020. Indeed, very strict rules and regulations had been imposed several months earlier as the city grappled with the COVID-19 crisis.

“But we have magic in the New Territories. Sunday was such a day. There were crowds of people, cycling, walking, picnicking; there was such a sense of timelessness that I was surprised not to see children guiding rolling hoops with sticks. Then I looked again, everyone, everyone, without exception, was wearing a mask. This is not a government mandate. This is a social response from over seven million people living in one of the most densely populated parts of the world who take survival seriously.”

What was true is that society was compliant because it was informed. We had been at the forefront of SARS. The spread was rather different, with one significant outbreak involving the plumbing in a residential tower block. The mask mandate became operational on 23 July 2020 ( It was backed up by an intensive education campaign ( because there was a fear that things were getting out of control. In the first six months of the pandemic, we had just four deaths and just over one thousand infections. However, community spread, the thing the government feared the most, was beginning to happen.

There is a fascinating account of this early phase in a paper entitle, ‘COVID-19 transmission in Hong Kong despite universal masking' (Martín-Sánchez M, Lim WW, Yeung A, et al. COVID-19 transmission in Hong Kong despite universal masking. Journal of Infection 2021). Essentially masks do work in limiting community spread but do not eliminate it because there were ‘loopholes’, these were situations where masks were not worn in household and other social settings.

We, in Hong Kong, were not perfect. For six months we had just four deaths and just over one thousand infections. Now Hong Kong reports just over 12,000 cases and 213 deaths. We did well at the beginning but then COVID fatigue set in. Of note, we are one of the most densely populated parts of the world but thankfully the general culture is one that favours the health and welfare of society over the notion of personal freedoms associated with democracies. Look at the world’s leading democracy, the United States of America: 57,190,371 cases and 827,879 deaths, and in the UK, 13,640,797 cases and 150,000+ deaths (updated figures). From a virus?! How did a puny little bit of RNA outwit the most powerful people on the planet including the former, defeated, President of the USA and the elected leader of the United Kingdom?

How indeed? I continued in November 2020:

“COVID-19 is caused by a novel coronavirus. It is predominantly a respiratory disease spread by airborne dissemination. Lives are lost whilst pedants opine and talk about aerosols and droplets and surfaces and bubbles. I still recall the surprise and disappointment when hearing the Deputy Chief Medical Officer in the UK declaring that only symptomatic people could spread the virus. No. No. No! He may be a specialist in influenza, but the coronaviruses are a different ‘animal’ altogether.

“Now I understand Mr Johnson is proposing a further ‘lockdown’ in England. I am not sure I know what a lockdown actually entails. Okay, with a respiratory disease caused by an airborne virus you want to keep unprotected social interaction to a minimum. But what is ‘social interaction’? We are not talking about healthcare professionals dealing with sick people (N95 masks, visors, gloves, gowns, etc). We are talking about going shopping, going to school, taking a walk in the park, catching a bus or train. And then there are the ‘essential workers’ who also must wear masks. Let us be clear, we are dealing with a strand of RNA, not Watson, the IBM supercomputer. This is not three-dimensional chess or Go! This virus needs human cells in order to survive. It binds to the angiotensin-converting enzyme 2 (ACE2) which occurs in a number of cells but typically on the mucous membranes of the nose, mouth, eyes and intestines. It is a sneaky virus. It happily co-exists with some humans, causing no signs or symptoms, and drifts from one human to another in respiratory droplets and aerosols. Occasionally it is transmitted by surface contamination and ‘self-inoculation’.

“So what do we do? Homo Sapiens, the most evolved life form on the planet (that we know of)? Back to basics: prevention is better than cure. Prevention? We assume that anyone, everyone, is a carrier of the virus. And, to limit spread, everyone wears a mask. Simple. So simple. We do not wear the masks all the time. In our unique social units, we take off the masks. This is our bubble, our ‘circle of trust’. When we go shopping, when we GO TO SCHOOL, COLLEGE or UNIVERSITY, we wear masks. We need to deprive this virus of hiding places.

“Mass testing, with rapid results, can enlarge our ‘circle of trust’. These bubbles can enlarge and coalesce and life, miraculously, can go on. This is a virus. It has no brain. It can be beaten without advanced therapeutics, or vaccines. But it does require society to work together. What a wonderful world this could be if people started to think as much about each other as they do about themselves! Less burns, less accidents, less trauma, less…COVID-19. Less poverty, less hunger, less fear. Less inequality. Please note, this is not communism or socialism or any ‘-ism’. It is humanity. It is caring.

“This is not going to happen overnight. It will take time but what is a short-term deprivation of perceived indulgent freedoms compared to a long-term freedom to live? I am thinking in very simple terms of the MeMes and the MeWes. Which are you? If the former, then you belong to the past. The future belongs to the MeWe people. The bridge builders, not the wall builders.

“These are exciting times. They really are. Yes, there is an election today that is going to define democracy; there is a lockdown in the UK which is going to pit individual freedoms against the good of society. Life is changing. It will never be the same again. Humility is never a bad thing and will be essential for society to survive. Take care, everyone. Keep safe, keep healthy and wear those masks! For the general population the masks are there to stop the virus dissemination at source. Oh, and whilst I think of it, children should be wearing masks as well, particularly at school.”

We can never know what the future entails and as I read that quaint sentence from 3 November 2020, “Yes there is an election today that is going to define democracy”, never would I have imagined the sheer depths of the evil entrenched in politics in the USA and how that would turn out. 2021 was a tough year but we must look forward. 2022 is here and so is the virus. As from tomorrow (7 January) in Hong Kong we have a new raft of social restrictions: Restaurants have a 6pm curfew. Fifteen types of specified premises are to shut. They are bars and pubs, nightclubs, fitness centres, theme parks, museums, party rooms, beauty parlours, swimming pools, bathhouses, game centres, karaoke rooms, sports premises, Chinese-style gambling establishments for mahjong and tin kau (dominoes), event and performance venues, and cinemas. Flights from eight countries including the UK, USA and the Philippines are banned for two weeks. Will this be enough? Only time will tell but I am cautiously optimistic.

Andrew Burd (Prof)

The Chinese University of Hong Kong.

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