Research Article Community Health Awareness Model: Discussion Revisited on How Hong Kong People Are Combating the COVID-19 Pandemic Fung Kei CHENG A

Home , Homelessness, Hospital Authority

Moroccan Journal Of Public Health Vol. 2, N° 1(2021) 9- 21 ISSN:26658-8099 Research article Community Health Awareness Model: Discussion Revisited on How Hong Kong People are Combating the COVID-19 Pandemic Fung Kei CHENG a

Independent Researcher, Hong Kong. *Corresponding Author E-mail: [email protected]

SUMMARY Article info There is a relatively low number of infections and COVID-19-incurred deaths Received : May2021 Accepted : June2021 in Hong Kong, with no city lockdown, despite unfavourable factors such as it Online July 2021 having a busy transportation centre, directly adjacent borders, a high population

density and a poor living environment. Even worse, confused, inconsistent Keywords: policies and tactics have created more difficulties for citizens to defeat this

border control; health crisis. Having experienced SARS in 2003, the Hong Kong people are face mask; self-motivated and self-empowered to adopt prevention measures, including health equity; face masks, social distancing and personal hygiene. The civic synergy between quarantine; the people, non-governmental organisations and the community forms a social distancing. community health awareness model that mitigates risks of infection and

protects residents, frontline workers, the community and the healthcare system. This compassionate and altruistic approach sheds light on the significance of humanity in coping with public health threats and attaining health equity amongst cultural diversity and social class variations. However, burnout is a potential peril in the case of long-term anti-pandemic efforts.

practitioners because of the containment strategy Hong 1. Challenges and Responses Kong imposed (Wong, Kwok et al. 2020), the news has Despite the fact that Hong Kong has had a comparatively unveiled an unopened report submitted by the Chief low number of COVID-19 infections (totalling 1085 cases Executive to the Beijing government revealing that she as of May 31, 2020 (Centre for Health Protection 2020, utilised this crisis to earn political gains (Chung and Ng May 31)), including four deaths (but no healthcare 2020, March 3). A survey conducted by a domestic workers), zero cases in elderly residential care homes and university in March indicated that 60.5% of the only one possible duty-induced case among healthcare respondents were dissatisfied with the government’s

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performance in monitoring the epidemic and 71.5% felt thwart a large scale coronavirus outbreak imported from that insufficient measures had been taken to deal with it the mainland (Parry 2020, Radio Television Hong Kong (Hong Kong Institute of Asia-Pacific Studies of The 2020, January 25). More than 77% of the public supported Chinese University of Hong Kong 2020, March 31). this request (Hong Kong Public Opinion Research Institute Similar findings were analysed in a cross-country project 2020, January 31). Having received no positive feedback showing public complaints against its poor handling from the government, more than 60 nurses in public (Blackbox Research and Toluna 2020, May 6). These hospitals took sick leave in late January to voice their studies hint at how Hong Kong citizens are alert to tackle worries (Chan 2020, January 28). Subsequently, over 2400 such hazardous public health scenarios when this “failed” healthcare workers in public hospitals underwent a 5-day (Marques 2020, February 9) government is seemingly so strike from February 3 (Lau 2020, February 3) to urge a dysfunctional. complete border closure for the purpose of fending off Border controls virus sources. Their urgent demand chiefly aimed at Rumours about the prevalence of an unknown pneumonia avoiding a collapse of the domestic healthcare system due in Wuhan flooded the community towards the end of 2019, to an uncontrollably high infection rate transpiring within a in addition to a virologist’s alarm after his visit there that short period, particularly with severely insufficient medical the spread of this mysterious illness would be far more facilities such as isolation wards, intensive care units, catastrophic than that of SARS (severe acute respiratory ventilators, personal protection equipment, and even syndrome) in 2003 (Liu 2020, January 23, Fifield and Sun surgical masks. Although more than 61% of citizens agreed 2020, January 24). Eventually the Hong Kong government with this industrial action (Hong Kong Public Opinion officially warned the public that a few viral pneumonia Research Institute 2020, January 31), strike participants cases had been reported there (Zuo, Cheng et al. 2019, will probably be penalised afterwards (Wong 2020, December 31). Suspected pneumonia patients who had February 27). Numerous professional associations, political visited Wuhan in the preceding 14 days were confirmed parties and labour unions kept up such calls to safeguard with rapid increases beginning in early January 2020. With public health. Disappointingly, the government insisted possible person-to-person transmission (Chan, Yuan et al. upon continuing to operate three immigration checkpoints, 2020), strong demands to ban non-residents from Wuhan including an international airport, since closing the border received zero government reaction until January 25, when would likely send a negative political signal that might they suspended Hong Kong-Wuhan air flights and high embarrass Beijing authority (Yeung 2020, February 16). speed railway, and disallowed non-residents from Hubei Social distancing province. Nevertheless, these measures did not suffice to Medical specialists recommended social distancing to protect the community: there was a dire need for strict prohibit virus transmission (Hong Kong Government 2020, border control, particularly against travellers coming from February 11). School classes were suspended twice after the mainland. the 2-week Chinese New Year school holiday in late Veterans of the medical field ceaselessly requested an January (Chan 2020, February 25), including in private immediate entire border shutdown and more restrictions to education centres, tutoring centres and playgroups (Zhang

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2020, March 23). They resumed conditionally and step-by- restaurants started in late March (Leung and Chung 2020, step from May 27 (Radio Television Hong Kong 2020, March 28), and then was eased to eight people in mid-April May 5), including for cross-border pupils travelling daily (Cheng 2020, May 3). However, in spite of intermittent between Hong Kong and the mainland (Cheung and Ho- confirmed cases, such a restriction to personal gatherings is him 2020, May 21). Moreover, a public examination for inconsistent and makes no sense (Radio Television Hong university entrance was postponed twice until late April Kong 2020, May 20). This restriction was not applied to (Chan 2020, April 15). many indoor premises (for instance, to religious worship Civil servants set an example for working from home; only halls, classrooms or transportation), but strictly to outdoor necessary emergency services were offered (Hong Kong gatherings or events in order to prohibit social movement Government 2020, March 22, Li January 28, 2020). Public following June 2019 (Farry 2020, May 11). This decision facilities were temporarily closed, especially cultural and has been accused of addressing a political need rather than recreational facilities such as museums, libraries, sports a health concern (Hui 2020, April 1, Cheng, Ting et al. stadiums and performance theatres (Hong Kong 2020, May 19, Grundy 2020, May 26). Government 2020, January 28). Numerous private Social distancing generates negative correlations with the companies followed this arrangement for 1-2 weeks spread of infectious diseases but positive correlations with (ejinsight 2020, January 29). emotional disorders (De Vos 2020), comprising anxiety, No policies were initially enforced but many people boredom, loneliness and depressive moods (Venkatesh and minimised unnecessary social gatherings. However, Edirappuli 2020). Employing innovative methods through infected groups, including a hot pot family (AFP 2020, online and offline channels, Hong Kong mental health February 9), a monastery (Lum 2020, March 11), bar clinicians tackled the problem of regular mental health musicians (Wong 2020, March 23) and a karaoke cluster service interruptions (Tse May 10, 2020). The bureaucracy (Radio Television Hong Kong 2020, March 31), were seemed to take little notice of this issue, whereas mental increasing. Relevant regulations were imposed beginning health would become a challenge during the economic in late March or earlier April. Restaurants were restricted difficulties post-COVID-19. to half capacity, and 1.5m of separation was kept between Quarantine tables (Hong Kong Government 2020, March 27). Fitness Beginning from February 8, a mandatory 14-day clubs, cinemas, karaoke centres, mah-jong parlours, quarantine was imposed on anyone who came from the nightclubs, bars, places selling liquors, beauty salons and mainland: home-quarantine for residents, and hotels or massage parlours were provisional closed (Hong Kong government-run camps for non-residents (Colquhoun and Government 2020, April 2, Low, Zhang et al. 2020, April 8, Smail 2020, February 17). This was extended to those from Chan and Ting 2020, March 28). They reopened with South Korea in late February (Radio Television Hong suitable control measures in early May to ensure social Kong 2020, February 24), and from overseas in mid-March distancing implementation (Shackleton 2020, May 2, (Ho 2020, March 16). It also applied to close contacts of Cheng, Lau et al. 2020, May 5). confirmed cases. Those who violated the home quarantine A four-person limit regulation in public areas and order would be sued and sent to government-run quarantine

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centres (Cheung and Lum 2020, March 21). the Immigration Department (Cheng 2020, February 7) and However, many people have complained of the defects in successfully monitored the travel history of suspected exercising quarantine. There was no monitoring system for patients who denied having come from restricted areas over those in quarantine. Individuals living with quarantined the preceding 14 days. Second, a major incident people still freely left their households (Abate, Tran et al. investigation and disaster support system (MIIDSS) was March 27, 2020). A digital wristband linked to a smart utilised to chase sources of infection and people who came phone application for home-stay quarantine that was into close contacts with confirmed cases (Centre for Health implemented beginning in mid-February (Radio Television Protection 2020, February 22). Notwithstanding, they Hong Kong 2020, February 18) was often faulty in various would have been more effective against the epidemic if situations (Kwan 2020, March 24). Without proper they could have been used in January. protective gear and training, hotel staff worried about Screening and testing occupational safety (Radio Television Hong Kong 2020, Saliva testing is effective in preventing community April 3) when hotels were used for quarantine. transmission (To, Tsang et al. 2020). Patients with fever Additionally, government-run quarantine centres caused and respiratory symptoms underwent a deep throat saliva concerns when placed on locations nearby residential areas test through a take-home kit beginning in mid-February (Siu and Chan 2020, February 16), resulting in (Radio Television Hong Kong 2020, February 18). demonstrations and protests. They were no medical However, invisible patients who show no respiratory facilities, but individuals were instructed to take body symptoms is a feature of COVID-19 (Guan, Ni et al. 2020); thermometer twice a day and to self report if their body therefore it was inappropriate to exclude them in testing. temperature was over 37°C (Davidson 2020, March 26). From mid-March, salvia tests were extended to senior air Such relaxed management fell apart, decreasing the inbound travellers aged 65 or above and those who lived effectiveness of quarantine (Mulholland 2020, April 9). with them (Radio Television Hong Kong 2020, March 19) Surveillance and then to all arrivals at the airport from early April Starting with the last day of December 2019, thermal (Radio Television Hong Kong 2020, April 7). Collection imaging systems at all boundary control points were spots for test kits involved public hospitals, public primary employed to check body temperatures and conduct health care clinics and private clinics, but responses from private surveillance. Self-reported health declarations started in sectors were inactive (Ting 2020, March 9). late January 2020 (Centre for Health Protection 2020, Communication with the general public January 20) for airport arrivals from Wuhan, excluding Communication is critical during a pandemic, not only for passengers on the high speed railway (Radio Television a better understanding of the disease but also to reduce Hong Kong 2020, January 20). Strong criticism was voiced anxiety and fears, resulting in lowering community concerning this inconsistent, loose and unreliable self- transmission (Yeoh 2020, February 29). Two multiple reported health declaration. lingual websites (particularly targeting languages spoken Two measures were added in February. First, electronic by Southeast Asians) supply diverse information mainly systems were linked up between the Hospital Authority and from the Centre for Health Promotion

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(https://www.chp.gov.hk/en/healthtopics/content/24/10246 In contrast, owing to the painful experience of the outbreak 6.html) and a designated website for COVID-19 of SARS in 2003, the Hong Kong people understand the (https://www.coronavirus.gov.hk/eng/index.html). Lazy effectiveness of wearing face masks to combat infectious Lion, a cartoon character, helped promote health for all diseases (Cowling, Ali et al. 2010), which has been ages on televisions and radios (Hong Kong Government supported by recent investigations (Cheng, Lam et al. 2020, 2020, April 21). Cheng, Wong et al. 2020, Esposito, Principi et al. 2020, A list of buildings housing quarantined people was Howard, Huang et al. 2020). In order to protect themselves, circulated on social media in late February, which had the their families, healthcare practitioners, the community and potential to create confusion and panic among the public. the public health system, most Hong Kong citizens In response to this, the Department of Health announced an consciously put on masks in public areas. Confusion official list one day later and updated it periodically (Ting among government officials increases panic buying due to 2020, February 28). distrust of the government, and hence the price soared Daily press conferences (Cantonese-English bilingual plus sharply in the first quarter because of a mask shortage sign language) have been arranged to brief the public on (Miller 2020, February 3, Hunter and Choong Wilkins new confirmed and probable cases and relevant news. 2020, January 24). People demanded that the government Transparency tends to lessen public anxiety. stabilised the mask supply and prices. Again, rejections Wearing face masks were imposed (Hong Kong Government 2020, February Internal conflicts arose: while the Department of Health 10). District councillors, non-governmental organisations, has encouraged the public to wear masks to prevent charitable entities, and mutual help groups sourced masks pneumonia since last December through its website, many from all over the world to alleviate the panic, especially for officials (for example, the Chief Secretary for the poor and underprivileged who could not afford masks: Administration and the Secretary for Food and Health) did it would seem the government reluctantly offered not wear masks, and the Director of Health discouraged necessary administrative and financial assistance (Wong wearing them unless symptoms existed (Leung and Lum 2020, March 1). Simultaneously, people in the private and 2020, January 24). This was possibly related to an on- public medical fields cried out for masks in order to going appeal over the anti-mask law that was implemented continue their services safely, and the government failed to last October under the emergency laws against social do so. unrest (Radio Television Hong Kong October 4, 2019). Medical experts predicted that mask use would be needed Worse, a harsh order from the Chief Executive did not over a longer period of time until a vaccine becomes permit government officials to wear masks unless available (Radio Television Hong Kong 2020, May 17). A necessary, to reserve supplies for medical staff (Chung free washable mask, claiming award-winning technology, 2020, February 4), which provoked resistance from civil was given away to residents from mid-May (Zhang 2020, servants (The Standard 2020, Febrary 5). The Hospital May 6). Interestingly, its practicality is dubious (Parry Authority promptly responded that all medical supplies are 2020, Radio Television Hong Kong 2020, May 8), and it purchased through its own administration and budget. has been advised not to use it in certain circumstances

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(GM37 2020, May 8) because of its structural design and guidelines and offered financial assistance to care homes material (Dimsum Daily 2020, May 11). Indeed, the (Wong, Lum et al. 2020, April 27). Management of care private sectors and social enterprises have already been homes promptly suspended visitations, decreased social successfully sourcing masks (Cheng 2020, February 24) or and volunteer activities, and enforced mandatory leaves for manufacturing local products (Wong 2020, February 21, staff who had travelled abroad within 14 days, along with Yiu 2020, February 21) to fulfil community needs in late strengthening defensive tactics such as face masks and February. frequent cleaning (Chen 2020, May 9). The capability and Neglecting the homeless professionalism of frontline service providers contributed There are 7.5 million people in Hong Kong (Census and to the prevention of spread within care homes (Fallon, Statistics Department 2020, February 18) living in 1106.66 Dukelow et al. 2020), resulting in protecting not only the square kilometres (GovHK 2020). This high density pushes vulnerable but equally important medical resources (Chor rocketing housing rates; thus, subdivided flats, cubicles, 2020, May 27). cage units and homelessness continuously increase, even Notably, this pandemic affects mental health both directly producing a group known as McRefugees (those who stay and indirectly (Holmes, O’Connor et al. 2020), especially overnight in 24-hour McDonald’s restaurants) (Hincks for hospitalised patients and residents of care homes, 2018, August 23). together with their family members or caregivers because Homeless people have no access to protective equipment, of isolation from each other (Vahia, Blazer et al. 2020). In and have received support from charity bodies rather than order to deal with such frustration, technology for social the government (Lai 2020, April 14). Unfortunately, contacts was used (Lum, Shi et al. 2020) which complied McDonald’s suspended dine-in services from 6pm to 4am with the SARS review report (sections 14.9 and 18.29) on March 25 for two weeks (Radio Television Hong Kong (SARS Expert Committee 2003), but this could not replace March 26, 2020) to minimise coronavirus transmission, face-to-face visits and personal touch. For instance, causing homeless McRefugees to wander around seeking patients with terminal illnesses and their families strongly shelters (Low and Chan 2020, March 25). Non- requested ward visits from a humanity perspective through governmental bodies asked relevant departments (for which they could access the “ultimate companionship” example, the Home Affairs Department) to open (Cheng 2017) they deserved. The Hospital Authority may community halls and re-open public showering facilities, consider requests on an individual basis. but these requests were refused (Sunday Examiner 2020, April 3). They then found temporary shelters for a rising 2. Civic Synergy number of homeless when unemployment began to grow Being a busy international transportation hub, Hong Kong during the pandemic (Westbrook 2020, April 5). has directly adjacent borders to the mainland, coupled with Special arrangement for hospitals and care homes a highly dense population and a crowded living space. The Hospital Authority announced no patient visits from These result in high risks for COVID-19 transmission. January 26 (Hong Kong Government 2020, January 25) Unlike neighbouring countries or territories, in which trust while the Social Welfare Department issued special has been achieved between patients, healthcare workers

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and the community as a whole along with the government Institute 2020). Also, the net satisfaction value for the (Legido-Quigley, Asgari et al. 2020), this synergy is Secretary for Food and Health was -5.1% (a survey taken separate from government in Hong Kong. Approximately in May 4-6, 2020) (Hong Kong Public Opinion Research 72% of research respondents admitted that community Institute 2020). Such low-rated, incompetent authority vigilance and effort is necessary to avoid a large scale lacks self-reflection and a mindset of serving the Hong spread of pandemic (Cheung and Wong 2020, April 1). Kong people, and is consistently blamed for doing too little, When political considerations over public health seem to too late during this health crisis (Cheung, Sum et al. 2020, be hiding ulterior agenda, the Hong Kong people are self- January 29). In two relief packages totalling US$36.9 motivated, self-empowered and cautious of health concerns. billion (Cheng, Cheung et al. 2020, April 8), spending on When an arrogant government habitually ignores public medical expenses amounted to only US$2.1 billion opinion and even experts’ advice, Hong Kong people help (HK$16.4 billion) (Tsang 2020, February 20). In particular, one another curb pandemic outbreaks (Kammerer 2020, with official foreign currency reserve assets amounting to February 25). For instance, free sanitising services for poor US$437.5 billion at the end of March (Hong Kong residents have been continually provided by volunteers Monetary Authority 2020, April 7) with no debts, the (Tufekci 2020, May 12). In a survey taken in May 19-21, government could have gotten more extensively involved 2020, the approval ratings for the Chief Executive reached in public health expenditure in such a global health crisis. only 28.3 out of 100 marks (Hong Kong Public Opinion In spite of these unfavourable conditions, Hong Kong has Research Institute 2020), and the net satisfaction value of had no city lockdown during the pandemic, owing to the government and net trust value reached -48.8% and - decisive community leadership which should not be 35.7% respectively (Hong Kong Public Opinion Research

Figure 1. Community Health Awareness Model

undermined. About 80% and 33% of the population aged 15 Conflicts of Interest and over having attended secondary and post-secondary There is no conflict of interests. education correspondingly (Census and Statistics Department 2016). High education levels tend to lead to a Source of funding support mentality of self aid and mutual help among the Hong Kong Preparation of this article did not receive any funding. people, especially when they cannot rely on the government (Barron 2020, March 13), resulting in a mature civic society Author’s information in which citizens recognise that they have a stake in their Fung Kei Cheng, PhD, focuses on applying Buddhist and own community. Volunteers and non-profit, non- Chinese cultural theories to a variety of disciplines, including counselling and psychotherapy, mental health, governmental organisations have become key players in complementary and alternative medicine, conflict overcoming the threats of pandemic. Frontline health resolution, management, gender studies, and sustainable development. Her research outcomes have been published in practitioners in different levels and with various international peer-reviewed journals in English and Chinese. accountabilities have exerted professional efforts which She can be reached at [email protected]. have not only exhibited their professionalism but have also References gained public respect. Having experienced the SARS  Abate, D. A. W., et al. (March 27, 2020). "COVID-19: tragedy, Hong Kong people pay more attention to personal Quarantine arrangements in Hong Kong." Retrieved May 25, 2020, from hygiene and recommendations from medical specialists. https://www.mondaq.com/hongkong/healthcare/908176/covid- Furthermore, as a global business centre, Hong Kong 19-quarantine-arrangements-in-hong-kong.  AFP (2020, February 9). "Coronavirus: Nine members of Hong fighting this health calamity professionals retain Kong family feared infected after hotpot." Retrieved May 21, international connections that benefit through the 2020, from https://hongkongfp.com/2020/02/09/coronavirus- nine-members-hong-kong-family-feared-infected-hotpot/. acquisition of assistance from diverse regions in  Barron, L. (2020, March 13). "What we can learn from In a nutshell, the Hong Kong people are proactive and Singapore, Taiwan and Hong Kong about handling coronavirus." Retrieved May 31, 2020, from highly sensitive to their own health environment. They have https://time.com/5802293/coronavirus-covid19-singapore-hong- kong-taiwan/. compassionate and altruistic awareness to take care of  Blackbox Research and Toluna (2020, May 6). "The world in people and the healthcare system as well. Such engagement crisis: A global public opinion survey across 23 countries." Retrieved May 26, 2020, from creates a civic synergy between people, non-governmental https://blackbox.com.sg/everyone/2020/05/06/most-countries- covid-19-responses-rated-poorly-by-own-citizens-in-first-of-its- organisations and the community, forming a community kind-global-survey. health awareness model (Figure 1) that mitigates risks of  Census and Statistics Department, G. o. H. K. S. A. R. (2020, February 18). "Year-end population for 2019." Retrieved May infection. This approach reveals the significance of 27, 2020, from https://www.censtatd.gov.hk/press_release/pressReleaseDetail.js humanity itself in coping with public health threats and p?charsetID=1&pressRID=4612. attaining health equity within a context of cultural diversity  Census and Statistics Department, H. K. S. A. R. (2016). "Educational characteristics of Hong Kong population." and social class variations. Alarmingly, people may feel Retrieved May 31, 2020, from https://www.bycensus2016.gov.hk/data/snapshotPDF/Snapshot0 exhausted exercising such preventive practices to fight this 2.pdf. disease for nearly half a year, the effects of which will  Centre for Health Protection, D. o. H., The Government of the Hong Kong Special Administrative Region (2020, February 22). predictably continue for a longer period of time. Burnout "CHP investigates additional case of COVID-19." Retrieved May 21, 2020, from from prolonged anti-pandemic efforts may become a https://www.info.gov.hk/gia/general/202002/22/P20200222007 38.htm foreseeable challenge for keeping this model in good shape.

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