How Epidemics Shaped Hong Kong, Part I: The “Fatal City”

When you look back at early photos of Hong Kong, of gilded villas climbing up Victoria Peak, of imposing stone arcades along Queen’s Road and junks sailing in the harbour breeze, it’s easy to forget one thing: this was not a healthy place. “The Chinese look upon it as a ‘fatal’ island and have left it to be inhabited by the very refuse of their population,” declared the Illustrated London News in 1845. 

 The first British soldiers that landed on Hong Kong Island in 1840 lived in sickly squalour, riddled with syphilis and prone to dying from tropical diseases. The situation wasn’t much better for the Tanka boat people, Cantonese farmers and Hakka quarriers who had lived here for centuries. “Malaria, dysentery and typhoid were rife, but all became entangled in a web of sickness from which one disease was difficult to distinguish from another,” writes infectious disease specialist Ria Sinha in the Journal of the Royal Asiatic Society Hong Kong Branch. For most of its history, Hong Kong was a danger to its inhabitants.

Sheung Wan in 1868/1871 – original photo from the Wellcome Collection – Photo courtesy of OldHKinColour

Today, people in Hong Kong live longer than those anywhere else in the world, with an average life expectancy of just under 85 years. But it’s impossible to escape the legacy of disease, which is evident in the city’s culture, lifestyle and the very shape of its urban form. The Covid-19 pandemic is just the latest in a series of epidemics that have shaped Hong Kong. Malaria, influenza, cholera, the bubonic plague, SARS – all have left their mark on the city.

“A lot of planning regulations and building regulations were an outcome of public health and concerns about epidemics. That set an initial path of how Hong Kong developed,” says Sampson Wong, an artist and academic who has studied the link between disease and urbanism. He is echoed by Ying Kwok, who curated the Contagious Cities exhibition at Tai Kwun in 2019. “Epidemics definitely shaped the city in many ways in terms of common habits and practices,” she says.

The most notorious is probably the 1894 outbreak of bubonic plague, which killed 3,500 people that year alone – the vast majority of them in the neighbourhood of Tai Ping Shan. Its role as the epicentre of the plague was no coincidence. Tai Ping Shan was squalid and overcrowded, partly because the colonial system of racial segregation made it one of the few places where Chinese people could live. Paradoxically, one of the justifications for the various segregation laws that existed between 1888 and 1946 was that the Chinese population was inherently disease-ridden and that Europeans needed space apart from “the filthy habits of life amongst the 210,000 Chinese who reside here,” as then-Governor Sir William Robinson wrote to the British government.

Many rang a warning bell about sanitary conditions in Hong Kong’s urban areas. The territory’s chief medical officer was known as the Colonial Surgeon, and one after another warned of poor hygiene due to poorly regulated development. One, Phineas Ayres, wrote that conditions would eventually lead to an epidemic of “unenviable renown.” Some colonial bureaucrats tried to make improvements, including one instance in 1878 when Surveyor General J.M. Price rejected the building plans for a new set of tenements, insisting that they be redrawn with better ventilation in each room. Furious that such changes would eat into their profits, property owners joined forces and petitioned the governor, John Pope Hennessy, who overruled Price. 

With virtually no oversight on building quality, conditions for Hong Kong’s working class were horrendous. In 1881, a British engineer named Oswald Chadwick was hired by the government to conduct a survey of living conditions in Tai Ping Shan. He was appalled by what he found. In one building, 80 people were crammed into a single flat. Chickens and pigs roamed freely. Drains were built haphazardly, and so they would become clogged, with toxic sludge seeping into the soil. Human waste was piled up in buckets that were collected by hand and used as fertiliser. Chadwick warned that, unless living conditions and sanitation were improved, some kind of epidemic was inevitable. 

It took thousands of deaths for anyone to listen to such warnings. After the plague subsided, Tai Ping Shan was razed to the ground and rebuilt as a grid of streets surrounding Blake Garden, Hong Kong’s first public park. New building codes were finally drawn up to require minimum standards of ventilation and drainage, with a Sanitary Board given new powers to enforce rules against overcrowding. The government opened Hong Kong’s first public toilet on Pound Lane in 1904. It proved exceedingly popular, with one third of the city’s population becoming regular users in its first two decades. The plague also led to the construction of the Bacteriological Institute—today the Museum of Medical Sciences—on a hill above Tai Ping Shan, where scientists examined rats for the bacteria that causes the plague, as well as inspecting water and food for other pathogens.

Tai Ping Shan was razed and rebuilt after the 1894 plague. Blake Garden now stands in the centre of the photo. Photo courtesy of the Hong Kong Museum of History.

Less well known than the plague is the extent to which malaria shaped Hong Kong. Although the disease is endemic to many hot regions around the world, it was considered particularly ferocious in Hong Kong, wiping out entire British army regiments and laying waste to large parts of the population in the first years of the colonial era. The situation was so dire that colonial authorities considered abandoning their new possession. In 1845, Hong Kong’s lieutenant governor, George Charles d’Aguilar, wrote in a letter that “the utility of retaining Hong Kong as a British port” was “very doubtful.” He described the colony as “a pestiferous burden, and not a blessing” for Britain. 

One of the first courses of action was to drain the marshland of low-lying areas like Happy Valley. This helped, although it’s worth noting that nobody in the 1840s actually knew what caused malaria and other diseases collectively referred to as “fever.” Colonial Surgeon William Morrison thought that maybe the wild lightning storms that raged in the humid summer months led to electrically-charged “poisonous compounds” that made people sick. In 1880, a French doctor named Alphonse Laveran discovered that malaria was caused by parasites in the blood. Scottish surgeon Patrick Manson—the founder of Dairy Farm—hypothesised that mosquitoes were the main vectors of transmission, and after he moved to Hong Kong in 1883 he worked with another Scottish doctor, Ronald Ross, to prove his theory. (Ross ended up winning a Nobel Prize for the discovery, snubbing Manson and obscuring his role in the breakthrough.) 

Fear of malaria encouraged the expansion of urban development to the Kowloon peninsula, which was breezier and less hilly than Hong Kong Island. The government launched a campaign against stagnant water, but the public greeted it with apathy and malaria remained a constant threat. By 1930, when the Malaria Bureau was launched to fight the illness, hundreds of people were dying from it every year. By working with local communities and keeping close tabs on new infections across Hong Kong, the bureau was able to reduce—but not eliminate—the disease. Real change didn’t come until after World War II, when mosquito populations exploded amidst Hong Kong’s ruined infrastructure and a surge of malaria-infected refugees fled the devastation of mainland China. The government stepped up surveillance and mosquito control, gradually bringing malaria under control. It was finally wiped out in 1998. 

By then, Hong Kong was struggling with a new concern: the flu. As with almost everywhere around the world, influenza epidemics have been a sad reality of life in the city, including the 1918 Spanish flu pandemic, which hit Hong Kong in four waves, although not nearly as harshly as in other countries. That was also true for the influenza outbreak of 1968—the so-called Hong Kong flu—which was relatively mild and short-lived in Hong Kong, but became a deadly pandemic after it spread around the world. In 1997, a fearsome new virus became a threat: H5N1 influenza, better known as the avian flu. The name refers to the fact that the virus first emerged in birds, and while transmission from birds to humans was rare, it was often deadly, with a mortality rate that soared up to 60 percent in some countries.

19th century postcard view of the Peak, which was settled by Europeans partly to avoid disease

In Hong Kong, 18 people were infected with the avian flu in the first months of 1997 – the first known human cases of the disease. Six died. In response, the government culled 1.3 million chickens and banned the import of poultry from mainland China, where the virus had first been detected. Though this may sound inconsequential, it represented a huge change to the daily habits of many Hongkongers who were used to buying live chickens at the wet market. 

“It had a big impact on Hong Kong and its traditions,” says curator Ying Kwok. “Freshness is so important in the cuisine. When I was growing up, I would go to the wet market with my mum and she would hold my hand and ask me which chicken looked more vibrant. Anyone born in the 90s wouldn’t have the same memory. When we have no live chickens, it had a massive impact on how we cooked and how we had dinner together as a family.”

It’s this kind of small but impactful cultural change that Kwok was eager to document in Contagious Cities, the exhibition she curated for Tai Kwun. Part of the show catalogued the various epidemics that had afflicted Hong Kong, while another part featured contemporary art that reflected on the role disease has played in the city’s evolution. “Fear, trust, panic, sympathy – these were things we were interested in,” she says. 

The exhibition opened in January 2019. It made Kwok aware of just how much epidemics have shaped Hong Kong – and it made her realise that another one could hit at any moment. “Looking at the social system and how plague played such an important role in the 19th century, and how SARS had such an impact – and the density and transportation system and how it’s such an important international port. It felt possible that there would be another one. It felt very possible.”

Part II of this story examines the impact of SARS and Covid-19.