As patients with COVID-19 crowd hospitals throughout the world, the pandemic is exposing weaknesses in the healthcare systems of many countries. Will governments learn from these failings and make improvements in the years to come? And, if they do, what far-reaching benefits could those improvements have? Hong Kong offers answers to both questions. A study of Hong Kong before and after the 2003 SARS epidemic finds that cardio-respiratory deaths caused by heavy air pollution dropped significantly after the epidemic, even as pollution levels remained largely unchanged. The authors of the study, in the May issue of the Journal of Environmental Economics and Management, attribute the improvement to major healthcare reforms made in the wake of the SARS crisis.

“It can take a new magnitude of tragedy to expose failings in our healthcare systems, but these moments also shed light on opportunities to improve, having results that can multiply many times over,” says Guojun He, research director at the Energy Policy Institute at the University of Chicago in China (EPIC China) and a professor at the Hong Kong University of Science and Technology.

In 2003, nearly three hundred people in Hong Kong died of the Severe Acute Respiratory Syndrome (SARS) brought on by the emergence of a novel coronavirus. During the SARS epidemic, daily life changed significantly. Most people avoided going outside, and those who did donned a mask. Hospitals became overcrowded and lacked much of what was needed to keep people safe. This experience is eerily familiar to life for billions of people today.

When the COVID-19 pandemic emerged in late 2019, Hong Kong fared relatively well. Similar in population to New York City—and with 50 times more travelers from mainland China each year—Hong Kong had about 1,040 cases of COVID-19 and just 4 deaths as of May 1, 2020. New York City had 169,690 cases about 18,400 deaths.

Hong Kong’s success stems largely from the numerous improvements it made to its healthcare system following SARS: It revamped intensive care units, adopted improved infection control practices, launched massive staff training programs, and enhanced community-based services, among other changes. Meanwhile, Hong Kong residents became used to wearing masks to travel and live, which can greatly reduce the infectivity of the virus.

“These improvements in our healthcare system don’t just help in times of epidemics, they help every day, and that’s clear when studying what—in many cities—is an everyday killer: air pollution,” He says. “We were curious how it could be that people living in Hong Kong had the longest life expectancy in the world, and yet air pollution was still a problem here. We discovered that it was because people were getting a better standard of care. They were living through strokes and heart attacks—cardio-respiratory diseases that can kill within an hour—because they were getting to the hospital in time and being treated in revamped facilities.”

He and his co-authors found that while there were no dramatic improvements in air quality in Hong Kong after SARS, the amount of cardio-respiratory deaths linked to air pollution declined. Pre-SARS, a 10-unit increase in the Air Pollution Index led to a 3 percent increase in cardio-respiratory deaths. During the post-SARS periods, that same air pollution increase led to fewer cardio-respiratory deaths. The number of deaths became statistically insignificant using more recent data. Meanwhile, other factors that could have prevented cardio-respiratory diseases—such as fewer people smoking or more people using masks and air purifiers—remained largely constant.

As another way to check the importance of high-quality medical service, He and his co-authors further compared the impacts of air pollution on cardio-respiratory deaths that occurred to people living close to hospitals versus those living further away from hospitals, and found those living close to a hospital had a much smaller risk.

The study—the first to show that improving healthcare systems can mitigate the impacts of air pollution—offers a roadmap for cities around the world that are experiencing the rising air pollution that so often accompanies rising incomes. Even in places like Hong Kong, where local governments do not have jurisdiction over the most important sources of local pollution, they can still take steps to mitigate its effects on their people.

“There are many tools governments should use to reduce pollution and the impacts of that pollution on citizens’ health,” He says. “Improving healthcare systems is another tool to add to the arsenal, and one that can deliver far-reaching benefits.”