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Transcript of press conference on SARS Expert Committee report

Following is a transcript of remarks made by the Co-chairpersons of the SARS Expert Committee, Sir Cyril Chantler and Professor Sian Griffiths, and two local members, Professor Rosie Young and Professor Lee Shiu-hung, at a press conference to release the report today (October 2):

Sir Cyril Chantler: I want to introduce the report to you. In the letter which my co-chair and I wrote to the Chief Executive, we made a number of points. The first and most important is that we wish, on behalf of all members of our committee, to express our admiration to the people of Hong Kong for the way they coped with what was a very severe and very dangerous outbreak.

We would particularly like to express our condolences to the families of those who died and, in a very real sense, we believe that our task over the last four months has been to do the very best we can to ensure that their sacrifice has not been in vain.

There have been questions asked about the nature of our constitution and our independence. All I can say is that each and every member of this committee believes that they are independent. I personally can see no reason why I and other members should not be regarded as independent. We all have our own roles and responsibilities in our own country and our integrity actually matters to us.

We have endeavoured to learn the lessons and to pass them on to you, because there are important lessons to be learnt to protect this society in the future, and to protect the world in the future. We have been very clear, and I said so back in August, that we would examine the actions of individuals as well as the system and that if we deemed any individual to be culpable in terms of negligence, non-diligence, or maladministration, we would draw their names to your attention in our report. We have not found any individuals culpable in that sense and, as far as I am concerned, that is how I define accountability. It will be for others to decide whether they define it in a similar fashion.

If I could have the second of our slides, please. Who are we? Who were we? Well, there are 11 of us, and we come from a range of different countries and continents. But the one point I want to make to you is that on this committee, there are some world experts in public health and epidemiology. I can say that because I am actually not one of them. That's not my particular expertise.

But we do have such expertise available and we believe that we have produced a professional report. That has certainly been our intention. We cannot do justice to it in a short press conference so I would ask you to read all 279 pages, or, if not that, at least chapters 4, 17 and 18, which comprise a summary.

Prof Sian Griffiths: I'm just going to describe for you the context and the process. I just want to start again by expressing my admiration and respect for people of Hong Kong during the SARS epidemic and also my sympathy for the relatives of those who tragically died.

As you can see from this slide, we're talking about a period from the 10th March to the 23rd June during which time there were 1,755 cases of SARS and 300 deaths. Twenty per cent of the cases were in health care workers, around 20 per cent were amongst the elderly, and 63 per cent of those who died were in that elderly group.

I stress this because SARS was a new and emerging disease, a disease that we knew nothing about as it emerged, and a disease we learnt about as we went through the course, as it carried out through its course. Over time our understanding of the disease changed and when you think about this report, what I'd urge you to do is to understand that there was a changing picture. This means there's always some uncertainty about the disease, within Hong Kong at the beginning of the epidemic, and by the end a different understanding. So it makes international comparison quite difficult because there was also different understanding as the story unfolded in other countries.

Against this epidemic, when we've been here what we've done is that we have listened, we've met a lot of people, we've read a lot, we've interviewed people at all levels of Hong Kong society, including the Secretary for Health, Welfare and Food.

We want to stress that this report that we've produced is produced simultaneously to the public and to the Chief Executive and Government, and that we are, as Sir Cyril has said, independent. If you want to find out about the evidence that we have received and the discussions that we've had, there is a website which we particularly asked to be established which enables you to find out in more detail, but with due respect to the confidentiality of the individuals named in the correspondence and the criticisms we received.

Sir Cyril Chantler: We're going to, before we stop talking, do two things -- we're going to review very quickly the eight key issues which we've considered in detail in chapter 4, and then we're going through a few -- the recommendations that are the backbone, if you like, of this report.

So we take the eight key issues. The first concerns the early events before the 10th March, mainly what happened in Guangdong. We believe that probably the first human case of corona virus infection of this virulent form, which came to be known as SARS, occurred in Guangdong, probably in November.

By January the 23rd, when a detailed report was written by one of our members, Professor Zhong (Nanshan), the epidemic had been characterised to some extent. That information was not made available to the authorities in Hong Kong and we are satisfied that they had no way of accessing it. If it had been available, we believe the epidemic in Hong Kong would have been ameliorated.

The second key event concerns the events at the Prince of Wales Hospital, the explosive outbreak of the epidemic in Hong Kong between the 10th and the 24th of March. We have concluded that the response in the early phase of the management of the epidemic was inadequate. There was a lack of knowledge of the nature of the condition, the disease, which was all too understandable, the scale of the outbreak, its explosive nature was huge, but the lack of a pre?determined hospital outbreak control plan did make the handling of it less than ideal.

Prof Sian Griffiths: Moving on to the question of whether there was a community outbreak in mid-March. The committee spent some time looking at this question, and we agree that there was confusion at that time. But we'd want you to think about the background of between 1,500 and 2,000 cases of pneumonia a month at that time of year. Added to this, there was a diagnosis of a single case of avian flu and the anxiety in the community about whether or not you were about to see an epidemic of avian flu.

What we found, in listening to the evidence presented, was that there was no evidence of person-to-person spread within the community. But we did find, and we discussed this with the Secretary for Health, Food and Welfare that he used technical language which was confusing and that he did manage to confuse, by this use of technical language -- and he has admitted this himself. We think it would have been better if a senior health professional had led the discussion with the public as happened later on in the epidemic in the highly acclaimed daily briefings. But overall, we don't believe that there is any evidence of intentional suppression of information about the epidemic.

Moving on then to another issue of whether SARS should have been made notifiable earlier on. Issues around notification of infectious diseases are always a matter of judgment. You stand the risk -- the positive aspects of notification are really around assisting enforcement of law; the negative are around possibly driving people who have disease underground. They don't come forward with the disease because they're worried about some of the powers that go with notification.

However, on balance, we feel it would have been more prudent to make the disease notifiable earlier because it was an unknown disease. In the event, we don't believe not making it notifiable had any impact on the epidemic. But in future we'd want this recommendation to be taken note of.

As we've told you before when we've been here, we did have the opportunity to visit Amoy Gardens, and also meet with the residents. We remain very grateful to them for the time we spent with them. It enabled us to look at the issues mentioned in the report, about three key issues. The first was the discharge of the index patient. When we looked, as a committee, at the clinical history, we believe the clinicians made a reasonable and understandable decision to discharge the patient from hospital in mid-March.

Regarding the comments about the epidemiological investigation, the initial investigation was only of those patients with a disease. We believe it would have been preferable to have had an investigation that was population based, such as the investigation that took place when the WHO (World Health Organisation) came in to help. In future, we would see the need for population based studies to help inform and decide the policy decisions around such an epidemic.

When we looked at the issues around the management of quarantine and isolation, we feel that this was well handled overall.

Sir Cyril Chantler: The next question we considered relates to the Princess Margaret Hospital and its designation to take SARS cases at the time of the outbreak at Amoy Gardens. We believe that the decision was properly made and it was a proper decision.

However, the hospital did become overwhelmed fairly quickly and we think it would have been better if the decision had been reconsidered when the scale of the outbreak of Amoy Gardens became apparent. There are lessons there for the future, which we've drawn in the report.

Next the relationship with the private sector. We do think that the private health care sector in Hong Kong was not sufficiently engaged in the management of this epidemic. We believe that they have an important function, both in surveillance and in recruiting capacity to cope with any future outbreaks, and that strenuous efforts need to be made now to develop the necessary partnerships to ensure that this happens.

Prof Sian Griffiths: The final of these issues we want to touch on today is the issue of case fatality. The question was asked about why were there more deaths in Hong Kong than in other countries.

I've already alluded to the difficulties of defining cases of SARS, but if you do compare the death rates, when they're standardised, between Hong Kong, Toronto and Singapore, there are no significant differences. There are, however, differences between all these countries and Guangdong. This is something that the international community does not yet understand. There may be factors associated with a wide variety of issues and what we've recommended is that further investigation is undertaken at this point.

Sir Cyril Chantler: Next, we're moving to our recommendations. There are 46 of them. They are grouped into three sections with 12 strategic themes. We'll just very quickly run through the themes.

First of all, the organisation of health care. For reasons which we go into in the report, we think that a summary organisation at the top of the shop, if you like, at the bureau, is necessary to merge functions between the different departments within the bureau to clarify policy making and responsibility and operational efficiency.

Prof Sian Griffiths: One of our major recommendations is the creation of a centre for health protection. We believe that Hong Kong needs a unique organisation because of the urban nature of the population and the environment, and also the position that Hong Kong occupies in terms of being a port of transit and transfer, with a lot of people coming through, and its international role.

In view of this, we think that there should be a Centre for Health Protection which takes charge of communicable disease control, the surveillance, making sure there are outbreak plans, making sure they are coordinated across Hong Kong. We have not used the phrase "CDC"; we have called it a centre for health protection, and we explain this in the report.

We've also explained in the report that we believe that this organisation needs to work across the Pearl River Delta. We say this because diseases don't recognise boundaries and, has been said before, local is global and global is local when it comes to communicable diseases, and there is a need to share information with Guangdong, but also internationally and to liaise with the WHO and other organisations to ensure that we detect diseases in the future.

Sir Cyril Chantler: We have quite a lot to say about coordination within the various parts of the health care system and the academic structures in Hong Kong. I won't go into the detail now, but there is a need to adopt clear ways of integrating activities between the Department of Health, the Hospital Authority, primary care sector and the universities, both separately and together.

As well as improving coordination, there needs to be greater clarity in the command structure which comes into play when the health of the population is placed at risk with an outbreak. Again, we go into details about that.

As far as communications is concerned, similarly there is much to be done to improve communications between the Hospital Authority and the patients, between the patients and their relatives when they are isolated, between the public and the Hospital Authority. We need to find better ways of communicating the nature of risk to populations.

And we do feel strongly that we need to recruit new people in the media to help and that there are ways that need to be investigated now to find out how to improve communication and coordination and co-operation with the media now, not just wait until the next outbreak.

Prof Sian Griffiths: The final group of recommendations are about management of an epidemic. As I've already said, we would expect the Centre for Health Protection to play a key role, particularly in preparedness. We're coming towards winter and we don't know when the next new emergency disease or SARS will come back.

We need to be prepared and we need to be assured that this surge capacity, that is the ability for the system to respond to such a threat -- you can use the analogy of peace of war and you need the capacity for wartime response, quick, rapid, well-informed. To do this, we also need to make sure that information systems and information flow are adequate and appropriate.

One of the things that we were very impressed by as a committee was the e-SARS database that was created, mainly at the instigation of the Secretary for Health, Welfare and Food, that brought together information from across the community. We would want to see such a system as a permanent feature linking in with primary care, the private sector and the voluntary sector and the Department of Health. So we need to see that extended.

Part of communication and information also involves having the clinical community alert and aware of what clinical protocols there are and sharing clinical protocols so that there is a concerted clinical response and treatment guidelines.

The experience of SARS showed us the need for research, ongoing research, and continued research and we make quite a few recommendations in the report about the need for research, particularly the need for quick institution of randomised control trials so that we are able to make judgments about which treatments work and what are effective measures.

Additionally, we've raised the issue of training and the essential need for training, training across the health care sector of all health care workers and also particularly those working with the elderly in social care homes. Staff need a good occupational health service to support them, and we've made a recommendation on this.

Finally, we recognise the traumatic event that SARS was for the people of Hong Kong and we have recommended not only ongoing studies so that we can understand the impact, so that we're able to offer appropriate support, but we've also recommended the establishment of a contingency fund for those in hardship.

I think that really brings us to the end of our key themes and recommendations.

Sir Cyril Chantler: Overall then, we believe that this epidemic was managed well, and that, I have to tell you, is also the opinion of senior experienced people that have spoken to us in our own countries. There were problems at an early stage, but they were overcome by a lot of hard work from a lot of people.

One of the members of our committee, Dr (Jeffrey) Koplan, was previously the Director of the Centre for Disease Control at Atlanta, which is probably the world's premier organisation in understanding these issues. He put it to the committee like this. He said, you build a wall to stop your house getting flooded, and for 50 years it keeps you safe and then you get a flood that you had not expected and you're overwhelmed. So you build a bigger wall. And what our report is designed to help you do is to build that bigger wall.

Thank you.
Question: Sir Cyril, my name is Betsy, I'm from Radio Hong Kong. The issue on blame, your 279-page report has not apportioned blame to anyone. Perhaps you can tell us why.

I'm also surprised -- not really surprised -- a whole paragraph has been set out to try and defend the Secretary for Health, Welfare and Food when he mentioned about community outbreak. How have you concluded that what he said was technically correct at the time?

And to Prof Griffiths, you mentioned that this report has been given to us and the CE (Chief Executive) simultaneously, and that is to prove that you are independent. Yet, you notice that a panel of members of your committee I think must have leaked some information to the press. So how can you convince us that the report has not been shown to the Government beforehand and adjustments have been made to the report? Thank you.

Sir Cyril Chantler: The first question was directed to me. And it was related to what I actually said in some detail at the start. You have to define -- somebody has to define in a way which is understood widely what accountability actually means. I can only define it in the way that I'm used to it in my country. To me, personal responsibility has to be measured in the terms I set out. Were you diligent? Were you negligent? Did you break the rules, which is maladministration?

We looked very carefully at various senior people's roles from the Secretary for Health, Food and Welfare downwards, and asked ourselves that question. We came to the conclusion that in the light of the information which was available, in the light of the systems which were available, and in light of what we might regard as a reasonable comparitor in countries with which we are familiar, that nobody should be regarded as culpable in that respect.

That is my honest and true judgment and it's one which each individual member of our committee shares. We can't necessarily persuade others to that view, but that is our view. And, as I told you right at the beginning, even though I'm not of a background in public health, medicine and infection control, many members of the committee are, and they know what they're talking about.

The second question was for you, Sian.

Prof Sian Griffiths: The simultaneous release? Well, I can assure you that the process of putting together the report involved all the 11 members of the committee seeing the copy, commenting on all the copy, and having final say on the copy. So we knew what was in the report, and we know it wasn't altered between the final one that we've signed off and the one that you have printed here today. So all I can say is I think that the process was one where your 11 experts were involved. We had the final say and we made many, many comments between us using email and telephone and I'm content that the report hasn't been changed since the final draft that we've seen.

Question: So what about the leak?

Prof Sian Griffiths: I think that when a report goes to the press -- my colleague Rosie may want to talk. I'm not entirely clear which leak you're talking about. All I can say is that this bound version is no different. Whether bound versions were shown -- this is our report. The bound version, if that's been seen and discussed, that's not a leak. That gives no opportunity to change what we've said. I think, Rosie, you might want to say something.

Prof Rosie Young: If your leak refers to the SCMP paragraph this morning, when I was called up by the reporter I was trying to find out who leaked it, because if you read the newspapers and see the television in the past week or so, a lot has been leaked out, but it's certainly not by members of the panel, and therefore I was trying to find out from the report who leaked it. My response was to answer the questions which were asked of me, and the questions were those which had been leaked to the press. So I also was very keen, even up to this time, to find out who leaked it out, but certainly not from members of the panel.

Sir Cyril Chantler: Usually on these occasions the only people who do the leaking are members of the media themselves and you never tell us so we never find out. But none of us leaked.

Question: I'm with the Toronto Star. I wonder if you could share with us any lessons learned that you think apply overseas. Obviously SARS, as you said, knows no borders. If you were going home to your own jurisdiction what would be the advice that you give. Does it bring -- I'm trying to draw on which of your many recommendations do you think are most pertinent to other cities, not just my own, which obviously has a track record with SARS, but it could strike anywhere. So what specifically -- sorry, to be long-winded here, but so much of your efforts, obviously you were focused on procedural process, administrative stuff which applies uniquely to Hong Kong in its urban setting. What about other countries?

Sir Cyril Chantler: Well, I know that there has been a report that hasn't yet been released in Toronto which -- as far as I know, it has not yet been released, which is looking into the similar things. But I think I wouldn't be surprised if the overall message isn't the same. Prof Griffiths is the right person to tell you about that.

Prof Sian Griffiths: I think that SARS was a wake-up call for the world, as well as Hong Kong, and it was a wake-up call for public health. I think that you'll find that there are reports from Canada, from the US and from the UK, to name just three that I know of, which point to the fact that the public health system and the capacity to respond to infectious disease is not adequate in many societies because it's been an area that's been under-invested in.

We haven't been ensuring that medical students, health care workers have been educated in basic infection control measures. We need to re-emphasise that.

We need to ensure that we have identified areas such as the Centre for Health Protection, which enable us to share rapidly and quickly between different countries. If we're going to do that, we need some common definitions, some common processes and some common understanding.

For me, the big lesson from the Hong Kong SARS epidemic was that we need to be prepared. We need to look to the future and be prepared to ensure that our public health responses are adequate next time, because there's bound to be a next time, whether it's SARS or another emerging infectious disease about which we don't know much.

So it's really about all of us sharing information, the ready flow of communication , training health care workers, ensuring Government investment in public health, and raising the profile of the public health systems and the need to protect societies. Because it isn't just a health care issue. It is a social-economic issue as well, as you all well know from the impact of SARS on the community.

Sir Cyril Chantler: There's one particular issue related to this part of the world, and that is the nature of the particular risk and the need. As we say in our report, to regard the Pearl River Delta as a single system as far as the management of infectious disease, and I wonder whether Prof Lee, you might like to say a word about that.

Prof Lee Shiu-hung: Perhaps if I could say it in Chinese and my friend can translate it in English.

(Chinese portion)

Question: Mr Chantler, I'm from Hong Kong newspaper's Ming Pao. As in the opening you really mentioned that you would not have any pressure to pinpoint the weaknesses or the responsibilities of the departments. And also we find that the report and it's merely give us some details about, for example, the Department of Health, the Hospital Authority, their weaknesses and their structure problems.

However, in the conclusion, you mentioned that there are no departments or not anyone who is responsible for the whole outbreak. It really dissatisfies to us or we are really also confused that is it contradictory to you when you pinpoint so many problems about the departments but in the conclusion you think that no departments or no persons should take up the responsibilities?

Sir Cyril Chantler: Well, I think I've explained the nature of the judgement, the way it was reached and the fact that each of us reached that judgement independently one from the other. What caused SARS was the mutation of a corona virus, probably somewhere in the Pearl River Delta.

The next question is how well did Hong Kong respond to it, and how prepared was it. We have to put ourselves in the position of the individuals who had responsibility and authority at the time it happened. Not now, that's easy. But what was it like then?

We also had to set it against what was a reasonable expectation. Perfection is very difficult to achieve in this life. The most we can do is judge ourselves against what a reasonable competence might be regarded as, from our experience of other of other countries. We applied that standard and we reached our decision. Others may reach a different one. But we regard ourselves, as I say, independent, not just of government, but of all other special interests. I've explained that as I'm capable of doing. I don't know of any other member -- Rosie?

Prof Rosie Young: Perhaps I'll try to explain it in Chinese, Cantonese.

(Chinese portion)

Prof Sian Griffiths: You ask two questions, one about the community outbreak and the use of language. The reason we've come to the conclusion we've come to, and we've described it in the report, is that we actually looked at the transcript of what was said. We think that there is sometimes a problem for people who have scientific knowledge, translating that knowledge accurately in a way that is understandable to the population and that you can get caught up in technical phrases.

In discussing this with the Secretary, he agreed that he was so concerned to try and get the technical aspects right at a time when we still didn't know what the disease was, still didn't know the full characteristics of the disease, so we accepted that. So we accepted that as an explanation.

We also have made recommendations about the need for media training, the need for communication, the need for communication skills with the media, and for clear communication plans. So if you look within the report, this is expanded.

Your point about Amoy Gardens, we looked carefully at the course of action and the steps that were taken and we were sure that -- there is a diagram within the report which shows the course of the epidemic, and shows the sudden surge on the 24th March. It's worth looking at that to understand the nature. There were just a few cases and then suddenly a lot of cases.

If you look at the steps that were taken by the Department of Health and the (Health, Welfare and Food) Bureau during that time, they were perfectly commensurate with control of the disease. We felt that it was well handled overall.

One reason we can say that is that we have discussed this with the residents of Amoy Gardens in our visits here and I think what we're all concerned to do is to look forward to the future and make sure that we are prepared for any future outbreak should it occur.

We don't feel that it would have made any difference overall if there had been any acceleration of the isolation and evacuation, given the course of the disease. We've explained this fully in the report.

Prof Rosie Young: Perhaps I'll do the first bit, you do Amoy Gardens.

(Chinese portion)

Question: ATV Christine. Can you tell us from your report on the question on hospital closure. You said in the report that it is appropriate that at that time Prince of Wales Hospital -- the Government decision, it is appropriate that they don't close the hospital. But then you quote the example, the Taiwan experience.

But we can tell from Vietnam, they closed the hospital in Vietnam in a very early stage and they confine that virus there very successfully.

Why do you think that it is appropriate at that time for the Hong Kong Government to do so?

Sir Cyril Chantler: You have to define by what you mean by "hospital closure" and that's all in chapter 4 and also in the description of chapter 3 of the epidemic. You don't just close a hospital. If you do, there are people inside it, and they can't get out and that caused great problems in another epidemic in another country, as you probably know.

The question is whether you actually manage the flows properly. At one point they closed the ward to all visitors, but that created another set of problems. I mean, medicine and life tends to be like that. You solve one problem, and another problem arises. So they quite reasonably allowed visitors to come in but under very controlled conditions. So it's not a straightforward decision of 'I'm going to close a hospital'.

An American writer many years ago wrote that to every complicated problem there's a simple and obvious solution, which is wrong. Say you're going to close a hospital in an epidemic -- I mean, as I understand it there are other people who know more about this than I do -- is a simple obvious solution which would, in this instance, in our view, have been wrong.

What was right was the actions they took within the context of the emerging epidemic and they facilities they actually had.

(Chinese portion)

Question: South China Morning Post. Your recommendations focus on systemic and structure problems of the health care system in Hong Kong and you said that there is a lesson to be learned which is to be prepared for any outbreak of infectious disease. What I'm curious about is that these recommendations of forming a Centre for Health Protection, and also that the HA (Hospital Authority) should be renamed as Health Services Authority. It is more of a long-term solution, right, and this outbreak for us it was an emotional time for Hong Kong. How would you be able to explain that these sort of -- it's not a direct response to what we need. If you say that no one is culpable for the outbreak, how come your recommendations -- you look at the long-term emotional view of the health care circumstances rather than what should be happening during the outbreak.

My second question is if there are calls for an independent enquiry, would you see it as a personal slap in your face, that people aren't confident about your report?

Sir Cyril Chantler: Well, as far as the second question is concerned, it is up to your systems, your people, what you do. The only bit of it I don't appreciate is the suggestion which is inherent in your question that in some way I am not independent. There is no point in me going on saying it, but if there are any other inquiries people want to start, that's their affair. You have to ask yourself what the purpose is and what you hope to get out of it.

Justice is important. If I had lost someone I loved, and many people did in Hong Kong, I can understand the need for justice. All human beings who have lost someone they love, and that includes me, know that there is nothing as painful in life as that. I am a doctor, and I have been with death very often, so I can understand that.

But justice isn't served by blame. If somebody should be blamed, they should be called to account, but justice is also served by ensuring that if and when another epidemic occurs, and I have to say it probably is "when", that the system is in place to deal with it as well as possible, and that has been our focus.

We have a lot of recommendations in our report. Some of them seem relatively trivial. Some are very important and will take a long time to build to their final state, like the Centre for Health Protection. Some are immediate. There are a number of things that can be done immediately and we hope will be and we have every reason to suppose will be. But we are also doing our best to keep an eye on things on your behalf to ensure that they are.

Prof Sian Griffiths: Just to re-emphasise that last point. Our report is called, "SARS in Hong Kong: from Experience to Action", and we've tried to give a detailed picture of the experience, but also to look at what lessons should be learnt for the future. We've built into the process a recommendation that there should be an annual review that's published, that's an open and public review of the progress, so that this report just doesn't come out and we're all interested in it today and it disappears, because we are very serious about the need to learn lessons. Really, because I think that the people of Hong Kong deserve to have a better future and not to have a SARS event again. I think it's on that basis we've asked for a public report on an annual basis to monitor progress.

In our deliberations, we did identify things that could be done very quickly and we would expect them to be in place in time for this coming winter. I think, as Sir Cyril has said, it isn't about saying what happened does not count. What happened deserves to have a better future.

Question: Sunny Lim from Reuters. Much has happened after the event. How confident are you that Hong Kong will be better prepared when SARS comes the second time around?

My second question is you mentioned earlier about this report on SARS in January from Guangdong. During your probe, did you think that Hong Kong did enough at all in trying to learn more about the disease in China before it invaded the territory?

Sir Cyril Chantler: It's a jolly difficult question, the second one. We did ask ourselves that, all of us, and we debated it and said, you know, would we have done more in the light of the circumstances that existed. One has got to understand, as Professor Griffiths said, the context of the number of cases of interstitial pneumonia that occur every year in this society, and in this part of the world and the systems that existed. We were also helped by our colleagues from Guangdong and the judgement we came to, as I said, and is set out in our report, is that it's easy in hindsight, but if we put ourselves in the position that you were all in between November and the beginning of March, we think that they did everything that could reasonably have been expected of them.

As far as your first question is concerned, which is are you better prepared? I think probably it's best if I ask Prof Young and Prof Lee to answer that because they are more familiar than Professor Griffiths and I can be with what's been going on, particularly recently, because I know certain reports and actions have been taken.

Prof Rosie Young: If you ask me I will say that given the scenario is the same, in other words SARS comes to attack us in the same way, then I'm confident that Hong Kong as a whole will be much better prepared than we were last time, given we get the efforts, the unity of the profession and the community as a whole to fight SARS, because, as you know, to prevent another epidemic coming depends not only on the medical profession, health care profession, which is very important. It also depends a lot on the community including personal hygiene, environmental hygiene, etc.

What worries me at this point in time is that there may be factors which are beyond our control, and what worries me at this point in time is the occurrence of cryptic cases, because the cryptic cases, when they come, they do not present themselves as SARS. Therefore the community and the medical profession may have overlooked the one or two cryptic cases. I think this is a hidden danger and this is something we have to keep watching out for the occurrence of.

Prof Lee Shiu-hung: Well, if I could say it now in English. Because I like to quote what the Director General of World Health Organisation Dr Lee (Jong-woon) has said. Now SARS is the first epidemic in the twenty-first century but it will not be the last. So we have to maintain a high level of vigilance and preparedness to face another epidemic. Whether there will be another epidemic in Hong Kong in winter, really it all depends on you as well as the Government and the community, because to fight against infectious disease, SARS, is really a partnership. It's a Government, community, individuals, NGOs (non-governmental organisations), academic bodies, everybody has to be involved. So really the future depends on all our efforts.

Now, as far as HA is concerned, I understand they already have taken steps to provide additional isolation facilities in hospitals with acute A&E Departments. This has already been taken up by the Hospital Authority and also prepare contingency plans in the respective hospitals.

Secondly, I'm sure you all know recently the Health, Welfare & Food Bureau, together with DH (Department of Health) and HA (Hospital Authority) has introduced these measures against SARS. Now this is an immediate thing. So really, with this action and with the support of Government and everybody we are confident that we are ready to fight for the next epidemic.

Of course, it is difficult to say whether or not it will occur. It all depends on us and we have to maintain a high level of vigilance as well as close collaboration with our friends across the border in Mainland China.

(Chinese portion)

Sir Cyril Chantler: I'll answer and then everybody else will answer. I'll answer the first question and the answer is very clear, it is no. Now, the second question concerned whether or not the misunderstanding over community outbreak ?? Rosie.

(Chinese portion)

Question: I am a reporter from Sing Pao. I want to know more details about the outbreak in Prince of Wales Hospital. The report said that there is an inadequate involvement of DH staff in critical decisions, like the closure of the hospital. So I want to know what are problems caused by that and who should be responsible for the decision of closing the hospital.

Second question is, before the report is released, the Hospital Authority and the Government have set some contingency plan already. So would you have any comment on that because you also have a set of recommendations on what improvements should be done. So do you think that's enough up to this moment?

Sir Cyril Chantler: I'll ask my colleagues to answer the second question because most of my time over the last few months has been spent with this report, not just when I'm here but when I've been in London and so I haven't actually been able to read the documents that came out recently from here.

What I do expect, what we expect and what we actually understand is going to happen is that the Government will go through our report now and look at the advice that they have developed and make sure that there is no conflict if any conflict exists, or misunderstanding. So that's the second question.

As far as the Prince of Wales Hospital is concerned, it gets to the heart of whether or not you have in place a proper pre?outbreak control plan. I'll ask Prof Griffiths to expand on this in a minute.

What we found which, as I say, is not that unusual, but it's inadequate, is that responsibilities were compartmentalised. Hospital Authority had some responsibility, the university had some responsibility, the Department of Health had some responsibility. Under these conditions there has to be clarity about who is responsible for what and what you absolutely require is the primacy of people who are expert in the management of epidemics. In many instances around the world, we've lowered our game on that one and it's time we raised it again. Hong Kong is not different from anywhere else, and it was that discordance which was the heart of the problems early on at the Prince of Wales Hospital.

Prof Sian Griffiths: Just one of the comments about DH involvement, that's DH at different levels. In any outbreak ?? I think what had happened in Hong Kong, things were characterised not from a population perspective but from either a hospital or a community outbreak. One of the big lessons that we think we've learnt from the report is that you need to see outbreaks in the context of the population, not just where the patient happens to be at that time, but the total population. Because people come in and out of hospitals, they go in and out of the community. So in terms of -- our big lesson there was about population perspective.

We've made a recommendation about embedding epidemiologists in the health care -- into the hospital system to rotate between the Department of Health and the private sector as well, so that we increase the understanding of the relative roles. Because there's also some comments in the report about how public health systems are seen by hospital colleagues and vice versa. It's the compartmentalisation and it's the separation of public health from the main health care initiatives. So I think that's what was behind some of those comments.

So it is important that you take a population perspective of an epidemic and that everybody has a clear role to play. That's when it comes to Cyril's point about outbreak control plan. What you need is to have clear plans with clear roles for people with clear lines of command and control, particularly at a time of an emerging epidemic, so you're absolutely clear who is taking what decisions and playing which roles. I think we felt that this was not really in place at the time because there had been the separation and it hadn't received much attention, and this, as Cyril says, is not just a lesson for Hong Kong. It is certainly a lesson for other countries.

I think, again, the contingency planning is something that's occurred since we were last here and Rosie might want to comment.

(Chinese portion)

Sir Cyril Chantler: Well, I hope they will actually read it before they're unhappy because we put a lot of work into it and, to the very best of my knowledge, it's accurate. We were told a lot of things which weren't accurate when we started. So it is important that the people who criticise do so from a basis of knowledge.

Now, it is finally a matter of judgement, many of the things that you raise. Professor Griffiths has explained what we understand, what is generally understood, by the transmission of an infection between two people in the community. But we also understand that the way it was perceived was not what was meant. We put that to the Secretary for Health, Welfare and Food and said, "Well, whatever you meant, you were misunderstood." And he said, "Yes, and I'm sorry about that."

We then sat down and said, "Well, how can we prevent this happening in the future?" Some of it is about improving communication skills and there are ways that you can learn to do that. That is the lesson to be learnt.

I know that there were real problems for health care workers, both in terms of the risk of acquiring infection, in personal protection, and one or two areas of training. Again, all that has to be put in context. We have put it into context and we have reached a judgement. It may not be your judgement. All I can say is that it is ours and we have done our best to be -- well, really to make sure that we understand what justice requires. It does require honesty. It requires blame, culpability, where that is appropriate. But it doesn't require that where it's not appropriate.

Prof Sian Griffiths: If I just pick up the notification point. We have been through it and it is described in the report. All I would re-emphasise from a public health perspective, that making a disease notifiable does not necessarily solve all your problems. The Director of Health did have powers that were commensurate with the steps that needed to be taken for Amoy Gardens and the conclusion of our report is that this part of the epidemic was well managed.

We have said that in future we think that an emerging disease should be made notifiable immediately because it just helps in case. But in this particular instance of SARS, we feel that making SARS notifiable earlier would not have made any impact on the course of the outbreak.

Rosie, did you want to pick up that (inaudible)?

Prof Rosie Young: Yes, I'll pick up the last two questions. One is that I think it would be very unfair to compare the incident in Baptist Hospital -- not the first round of infection in Baptist Hospital, but the second round, for which the Hospital Chief Executive took responsibility and resigned. Whether he did the right thing or not is not for me to judge. It would be very unfair to compare that incident with what Dr EK Yeoh said in public which had been misunderstood. Because in the case of the Baptist Hospital, according to the newspaper, the presence of SARS patients in the ward were not related to the other patients and the relatives of the patients. So there is a kind of omission. Whether it's deliberate or not deliberate, I do not know, but there's an omission of a duty. By that time, when the second episode at Baptist Hospital appeared, I think it was in late April or early May, when we all know what SARS was. So it's very, very different.

Secondly, the health care workers, I agree with you, even I heard from the news that there are a lot of health care workers who called up the station, radio station, and said that they were not given the appropriate health care protections, personal protection.

Two things happened. We all know that this happened in the early stage. Mind you, when we saw the health care workers, they all agreed that this situation was very quickly remedied. In other words, later on they all got the gear. Two things happened. First of all, SARS was such an explosive disease that everyone was looking for masks. Even I had difficulty in getting masks, the proper kind of mask. All the masks were sold out and we had to rely on China, the factories, to produce millions and millions of masks for us to use.

Therefore, any mal-distribution of masks among the health care workers, or inadequate distribution, could be understandable at that stage. Secondly, of course, there is confusion among the public, among the health care workers, as to whether it should be N95 or whether it should be surgical masks, and whether surgical masks could be used in the general wards, non-SARS wards, and N95 should be used all over the hospital. So there is that sort of confusion.

But the situation, I understand, was rapidly remedied.

Sir Cyril Chantler: Can I end by making, on behalf of my colleagues, just one point. Infectious disease involves all of us. It is a risk to our community. It is potentially a risk to our world. Whatever the controversies that the management of any particular episode generates, it is very, very important that we try to learn the lessons and that we try to work together.

The media are a crucial part of the armament of fighting infectious disease. I shall be going back to London but I do hope that the professionals, the doctors, the nurses, the hospital managers, the general practitioners, the public health doctors, the whole health care community, and the public, and the media, will find ways of working even better together because you are part of the defence against catastrophe.

(Please also refer to the Chinese portion)

End/Thursday, October 2, 2003
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