Quarantine Wristbands, Face Masks, and Personal Freedom in Hong Kong.

What is the relationship between freedom and health in an era of viral crisis? I write to share my perspective on responses to the Coronavirus Disease 2019 (COVID-19) pandemic as an American emergency physician living in Hong Kong who was recently required to wear a tracker wristband and subjected to mandatory home quarantine. I did my residency training in New York City and have watched with dismay as the COVID-19 pandemic has engulfed my former home and forced many colleagues to work on the frontlines with inadequate supplies of personal protective equipment. What hopes might Hong Kong's approach to infection control offer for New York and other cities in the United States?

I returned to Hong Kong on March 19, the first day of the city's mandatory 14-day home quarantine policy for all incoming travelers. This home quarantine policy was part of a broader infection control system in Hong Kong involving universal hospitalization of all positive COVID-19 cases, exhaustive social contact tracing, and selective quarantining of high-risk individuals. Despite a recent ban on face coverings enacted last October in response to political protests, wearing face masks has also become a universal social practice in Hong Kong since the first COVID-19 patient was diagnosed here on January 23 (1). Not surprisingly, everyone I encountered on my arriving flight and throughout the airport was wearing a face mask, and some even donned hazmat suits or rain ponchos. After recording my body temperature, no fewer than three different Centre for Health Protection (CHP) workers asked me about my recent travel history. Compare this with my entry into the United States a week earlier at Los Angeles International Airport (LAX), where no temperature checks or forms were provided and I was asked only a single question prior to being admitted to the country: “You haven't been to China recently, have you?” I also felt social pressure to remove my face mask to avoid attracting unwanted attention while going through passport control at LAX (over 3 weeks prior to the Centers for Disease Control's about-face recommendation on April 3 that all Americans wear cloth face masks) (2).

When I arrived in Hong Kong, all adults and children older than age 6 years who had traveled anywhere other than Taiwan, Macau, and mainland China during the standard incubation period were required to undergo a mandatory 14-day home quarantine (this has since been upgraded to include mandatory testing) (3). I was instructed to fill out a quarantine order form in duplicate, which requested a home address and mobile phone number. I was then fitted with a “quarantine tracker” wristband–a strip of waterproof paper printed with a unique serial number and matching QR code and affixed around my wrist with a plastic clasp (Figure 1 ). The CHP officer instructed me to expect a Short Message Service (SMS) notice on my mobile phone for guidance on my next steps.

Figure 1

Clockwise from top right: quarantine wristband, quarantine app detection-in-process, Short Message Service (SMS) received on the last day of quarantine, and the “Stay Home Safe.”

The SMS finally arrived on the second day, instructing me to download and install the “Stay Home Safe” application on my mobile phone. After scanning my QR code, the app then informed me I would have 1 minute to walk slowly around the perimeter of my home to mark the boundaries of my confinement in “cellular” space. Unfortunately, the app stopped tracking after 30 seconds, leaving me midway through my perambulation with my bedroom unscanned. This turned out to be quite significant: every time I ventured out of the scanned zone for the next 13 days, this triggered a loud warning and I was given 15 seconds to tap “validate” on the app and confirm my presence at the place of quarantine by scanning the QR code on my wristband. Home quarantine violators risked being sent to mandatory government quarantine camps, a maximum fine of 25,000 Hong Kong dollars (HKD), and imprisonment for 6 months (4).

Tracker wristbands, monitoring apps, and threats of law enforcement seem anathema to most Americans and other citizens of Western liberal democracies—perhaps too high a price to pay for public health. Yet I would argue that this dichotomy between freedom and health is a false one. I returned to Hong Kong knowing that I would be placed under quarantine for a defined period. I willingly accepted this mandatory confinement with the knowledge that I would be released in 14 days (or if I fell ill, that I would be guaranteed full medical treatment). People in the United States and Europe are experiencing even greater infringements on personal liberty, as national lockdowns and shelter-in-place orders continue to get extended. In Hong Kong, the quarantine wristbands are a sign of a functioning public health system—even if they are merely strips of paper. By quarantining the most at-risk individuals (including travelers and close contacts), Hong Kong's approach enables most of the population to maintain freedom of movement—including the confinees after their 14-day stint. After completing my home quarantine, I was able to venture out from my apartment (with my mask on)—confident in being disease free and that most of those around me were also disease free.

I am not saying that Hong Kong's situation is ideal, as the city faces significant political problems that are simply on hold during the pandemic. But Hong Kong's experiments with quarantine provide important lessons for other places currently facing lockdowns. The logic in the United States focuses on “flattening the curve” and avoiding overwhelming an already overburdened medical system. But this is not enough. In Hong Kong, quarantining works in tandem with a broader public health system that offers universal health care regardless of employment status, and an integrated set of infection control policies. By quarantining the few for a set period (the 14-day incubation period), the many can go about daily life with the relative assurance that they will likely not encounter someone infected by COVID-19. I hope that the extreme measures taken elsewhere will not just “flatten the curve,” but also allow time to ramp-up public health responses. I believe that a functioning public health system is what will ultimately secure both freedom and health.