Psychological Trauma:

Theory, Research, Practice, and Policy

© 2020 American Psychological Association 2020, Vol. 12, No. S1, S35–S37
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000633

Social and Psychological Consequences of the COVID-19 Outbreak:

The Experiences of Taiwan and Hong Kong
Man-Kit Lei and Eric T. Klopack
University of Georgia

This article discusses the value of studying past social and psychological responses to pandemics and
natural disasters in understanding reactions to coronavirus disease of 2019 (COVID-19). By examining
severe acute respiratory syndrome (SARS) experiences in both Taiwan and Hong Kong, we indicate that
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

psychological trauma might be a pathway whereby the COVID-19 outbreak affects long-term health and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

well-being and that psychological and collective trauma caused by the COVID-19 may relate to future
preparedness and risk awareness. We conclude with a consideration of social-psychological processes for
future research.

Keywords: SARS, COVID-19, psychological trauma, long-term health, risk awareness

The outbreak of coronavirus disease of 2019 (COVID-19) began
in Wuhan, China in late 2019 and first spread to neighboring
countries and territories, including Singapore, Thailand, South
Korea, Taiwan, and Hong Kong. Nearly 3 months later, the World
Health Organization declared COVID-19 a global pandemic on
March 11, 2020. As of May 1, the United States has more than one
million confirmed cases of the virus with about 60,000 deaths
according to the Johns Hopkins University (2020) COVID-19
database. Many European countries, including Spain, Italy, France,
Germany, and United Kingdom, have been greatly affected by
COVID-19. Conversely, Taiwan and Hong Kong have 429 con-
firmed cases and six deaths, and 1,037 confirmed cases and four
deaths, respectively. Indeed, even though both Taiwan and Hong
Kong are geographically close to mainland China, they have had
more success in battling the virus’ spread than other countries and
territories (Griffiths, 2020).
To address this paradox, a number of health and policy studies
have focused on the benefits of efficient public health response
mechanisms (e.g., travel restriction and quarantine policies) and
affordable health care systems (e.g., Taiwan’s national health
insurance and free public health care in Hong Kong; Oxford
Analytica, 2020; Wang, Ng, & Brook, 2020). For instance, all
travelers entering Hong Kong are required to be tested, to wear a
GPS tracker, and to spend 14 days in home quarantine (CNN,
2020). However, studies so far have devoted little attention to the
social-psychological processes that account for why some coun-
Editor’s Note. This commentary received rapid review due to the time-
sensitive nature of the content. It was reviewed by the Journal Editor.—KKT
This article was published Online First June 1, 2020.
X Man-Kit Lei and X Eric T. Klopack, Department of Sociology,
University of Georgia.
Correspondence concerning this article should be addressed to Man-Kit
Lei, Department of Sociology, University of Georgia, 217B Baldwin Hall,
Athens, GA 30602-4527. E-mail: karlo@uga.edu
tries and territories— especially Taiwan and Hong Kong— have a
relatively low number of confirmed cases and deaths. Further, little
is known about the long-term health consequences of psycholog-
ical trauma after the outbreak. Thus, to understanding reactions to
COVID-19, it would be helpful to assess past social-psychological
reactions to and psychological trauma resulting from past pandem-
ics.
Pandemic Outbreak and Long-Term Well-Being
To explain why Taiwan and Hong Kong are different from the
United States and European countries, we can compare this pan-
demic to the outbreak of severe acute respiratory syndrome
(SARS) in 2003. An epidemic of SARS began in Guangdong,
China in November 2002, and was brought under control in July
2003 (Drosten, Doerr, Lim, Stöhr, & Niedrig, 2004). Although
SARS has lower transmissibility than COVID-19, it has a higher
mortality rate (Niederman, Richeldi, Chotirmall, & Bai, 2020). In
contrast to the United States, both Taiwan and Hong Kong were
among the hardest-hit areas during the global outbreak of SARS.
The estimated fatality rate of SARS was 17% in Hong Kong and
21.1% in Taiwan (Chang et al., 2006; Y. Cheng et al., 2005). They
also suffered from high unemployment rates during the SARS
outbreak (Wong & Siu, 2005). As a result, social and economic
development of these areas have been seriously affected (Keogh-
Brown & Smith, 2008).
As a result of this social and economic upheaval, feelings of
alienation and hopelessness were common. Past research reports
that exposure to the SARS outbreak caused psychological and
collective trauma among people who lived in Taiwan and Hong
Kong (Bonanno et al., 2008; S. K. Cheng et al., 2006; Mak, Chu,
Pan, Yiu, & Chan, 2009). For example, Lau, Yang, Tsui, Pang, and
Wing (2006) indicated that more than 60% of respondents felt
horrified and helpless and experienced mental health problems
during and after the SARS outbreak in Hong Kong. These findings
are consistent with previous studies suggesting that psychological
trauma is a common consequence of exposure to natural disasters
such as earthquakes, floods, and epidemics (Johnsen, Eid, Løstad,

S35
 S36 LEI AND KLOPACK
& Michelsen, 1997; Maunder, 2004; Wilson & Moran, 1998). This
trauma has important implications for a range of physical health
and mental health outcomes (Fagundes, Glaser, & Kiecolt-Glaser,
2013; Heim & Nemeroff, 2001; Kendall-Tackett, 2009). As out-
lined by Miller, Chen, and Parker (2011), exposure to social and
psychological trauma is associated with a host of detrimental
physiological responses, particularly changing activity of the hy-
pothalamus—pituitary—adrenal (HPA) axis. Importantly, trauma
related changes to HPA axis functioning impact immune response
mechanisms, including inflammation, desensitization of glucocor-
ticoid receptors to cortisol, and programming of proinflammatory
cells that allows them greater opportunity to initiate and sustain
overly prolonged inflammatory responses (Lei, Beach, & Simons,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
2018). Consistent with this perspective, Mak and colleagues
This document is copyrighted by the American Psychological Association or one of its allied publishers.
(2009) have revealed that there were long-term mental and phys-
ical health consequences among SARS survivors. Thirty months
after the initial outbreak, 25.6% of patients had posttraumatic
stress disorder and 15.6% had depressive disorders.
By contrast, the social impact of COVID-19 is significantly
larger than the impact of SARS was in 2003. In the United States,
businesses and people must follow social distancing protocol by
remaining at least 6 feet away from other people, most face-to-face
interactions have been limited, and the unemployment rate due to
the outbreak could surpass Great Depression levels (Brown &
Arnholz, 2020). Thus, the COVID-19 outbreak could potentially
negatively affect everyone’s life. Such negative experiences may
result in collective and psychological trauma. Accordingly, psy-
chological trauma might be an important pathway whereby the
COVID-19 outbreak is related to long-term health and well-being.
From an intervention standpoint, identifying such biopsychosocial
pathways of the impact of COVID-19 may help inform future
health-promoting interventions.
Psychological Trauma and Risk Awareness
On the contrary, there also is considerable evidence that prior
trauma experience with natural disasters may influence the ways in
which individuals respond to hazard risks (Loewenstein, Weber,
Hsee, & Welch, 2001). For example, psychological trauma caused
by natural disasters is associated with future preparedness and risk
awareness (Johnson & Thompson, 2008; Wachinger, Renn, Begg,
& Kuhlicke, 2013). Such preparedness and risk awareness may
enable individuals to anticipate trauma, allowing them to engage
coping mechanisms more effectively. Consistent with this line of
studies, people living in both Taiwan and Hong Kong during the
SARS outbreak in 2003 not only encountered serious psycholog-
ical trauma but also showed more risk awareness for future epi-
demics (e.g., the COVID-19 outbreak) and were better prepared
for future outbreaks. For example, almost everyone in both Taiwan
and Hong Kong was wearing a face mask during the outbreak,
suggesting that differences in confirmed and mortality rates of the
COVID-19 among countries are not entirely explained by biolog-
ical and political factors, but can also be explained by new social
norms and expectations. Future studies need to look at psycholog-
ical trauma and changing social norms during the COVID-19
outbreak and the effects of this on hazard preparedness and risk
awareness.
Conclusion
In conclusion, psychological and collective trauma might be a
pathway whereby the COVID-19 outbreak affects long-term health
and well-being and that such trauma caused by the COVID-19
outbreak may also relate to future preparedness and risk aware-
ness. Thus, future research needs to incorporate social and psy-
chological perspectives and to examine the long-term conse-
quences of the COVID-19 outbreak.
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Received April 15, 2020
Revision received April 29, 2020
Accepted April 29, 2020 䡲