今早為Asian Medical Students Association Hong Kong (AMSAHK)的新一屆執行委員會就職典禮作致詞分享嘉賓,題目為「疫情中的健康不公平」。
感謝他們的熱情款待以及為整段致詞拍了影片。以下我附上致詞的英文原稿:
It's been my honor to be invited to give the closing remarks for the Inauguration Ceremony for the incoming executive committee of the Asian Medical Students' Association Hong Kong (AMSAHK) this morning. A video has been taken for the remarks I made regarding health inequalities during the COVID-19 pandemic (big thanks to the student who withstood the soreness of her arm for holding the camera up for 15 minutes straight), and here's the transcript of the main body of the speech that goes with this video:
//The coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, continues to be rampant around the world since early 2020, resulting in more than 55 million cases and 1.3 million deaths worldwide as of today. (So no! It’s not a hoax for those conspiracy theorists out there!) A higher rate of incidence and deaths, as well as worse health-related quality of life have been widely observed in the socially disadvantaged groups, including people of lower socioeconomic position, older persons, migrants, ethnic minority and communities of color, etc. While epidemiologists and scientists around the world are dedicated in gathering scientific evidence on the specific causes and determinants of the health inequalities observed in different countries and regions, we can apply the Social Determinants of Health Conceptual Framework developed by the World Health Organization team led by the eminent Prof Sir Michael Marmot, world’s leading social epidemiologist, to understand and delineate these social determinants of health inequalities related to the COVID-19 pandemic.
According to this framework, social determinants of health can be largely categorized into two types – 1) the lower stream, intermediary determinants, and 2) the upper stream, structural and macro-environmental determinants. For the COVID-19 pandemic, we realized that the lower stream factors may include material circumstances, such as people’s living and working conditions. For instance, the nature of the occupations of these people of lower socioeconomic position tends to require them to travel outside to work, i.e., they cannot work from home, which is a luxury for people who can afford to do it. This lack of choice in the location of occupation may expose them to greater risk of infection through more transportation and interactions with strangers. We have also seen infection clusters among crowded places like elderly homes, public housing estates, and boarding houses for foreign domestic helpers. Moreover, these socially disadvantaged people tend to have lower financial and social capital – it can be observed that they were more likely to be deprived of personal protective equipment like face masks and hand sanitizers, especially during the earlier days of the pandemic. On the other hand, the upper stream, structural determinants of health may include policies related to public health, education, macroeconomics, social protection and welfare, as well as our governance… and last, but not least, our culture and values. If the socioeconomic and political contexts are not favorable to the socially disadvantaged, their health and well-being will be disproportionately affected by the pandemic. Therefore, if we, as a society, espouse to address and reduce the problem of health inequalities, social determinants of health cannot be overlooked in devising and designing any public health-related strategies, measures and policies.
Although a higher rate of incidence and deaths have been widely observed in the socially disadvantaged groups, especially in countries with severe COVID-19 outbreaks, this phenomenon seems to be less discussed and less covered by media in Hong Kong, where the disease incidence is relatively low when compared with other countries around the world. Before the resurgence of local cases in early July, local spread of COVID-19 was sporadic and most cases were imported. In the earlier days of the pandemic, most cases were primarily imported by travelers and return-students studying overseas, leading to a minor surge between mid-March and mid-April of 874 new cases. Most of these cases during Spring were people who could afford to travel and study abroad, and thus tended to be more well-off. Therefore, some would say the expected social gradient in health impact did not seem to exist in Hong Kong, but may I remind you that, it is only the case when we focus on COVID-19-specific incidence and mortality alone. But can we really deduce from this that COVID-19-related health inequality does not exist in Hong Kong? According to the Social Determinants of Health Framework mentioned earlier, the obvious answer is “No, of course not.” And here’s why…
In addition to the direct disease burden, the COVID-19 outbreak and its associated containment measures (such as economic lockdown, mandatory social distancing, and change of work arrangements) could have unequal wider socioeconomic impacts on the general population, especially in regions with pervasive existing social inequalities. Given the limited resources and capacity of the socioeconomically disadvantaged to respond to emergency and adverse events, their general health and well-being are likely to be unduly and inordinately affected by the abrupt changes in their daily economic and social conditions, like job loss and insecurity, brought about by the COVID-19 outbreak and the corresponding containment and mitigation measures of which the main purpose was supposedly disease prevention and health protection at the first place. As such, focusing only on COVID-19 incidence or mortality as the outcomes of concern to address health inequalities may leave out important aspects of life that contributes significantly to people’s health. Recently, my research team and I collaborated with Sir Michael Marmot in a Hong Kong study, and found that the poor people in Hong Kong fared worse in every aspects of life than their richer counterparts in terms of economic activity, personal protective equipment, personal hygiene practice, as well as well-being and health after the COVID-19 outbreak. We also found that part of the observed health inequality can be attributed to the pandemic and its related containment measures via people’s concerns over their own and their families’ livelihood and economic activity. In other words, health inequalities were contributed by the pandemic even in a city where incidence is relatively low through other social determinants of health that directly concerned the livelihood and economic activity of the people. So in this study, we confirmed that focusing only on the incident and death cases as the outcomes of concern to address health inequalities is like a story half-told, and would severely truncate and distort the reality.
Truth be told, health inequality does not only appear after the pandemic outbreak of COVID-19, it is a pre-existing condition in countries and regions around the world, including Hong Kong. My research over the years have consistently shown that people in lower socioeconomic position tend to have worse physical and mental health status. Nevertheless, precisely because health inequality is nothing new, there are always voices in our society trying to dismiss the problem, arguing that it is only natural to have wealth inequality in any capitalistic society. However, in reckoning with health inequalities, we need to go beyond just figuring out the disparities or differences in health status between the poor and the rich, and we need to raise an ethically relevant question: are these inequalities, disparities and differences remediable? Can they be fixed? Can we do something about them? If they are remediable, and we can do something about them but we haven’t, then we’d say these inequalities are ultimately unjust and unfair. In other words, a society that prides itself in pursuing justice must, and I say must, strive to address and reduce these unfair health inequalities. Borrowing the words from famed sociologist Judith Butler, “the virus alone does not discriminate,” but “social and economic inequality will make sure that it does.” With COVID-19, we learn that it is not only the individuals who are sick, but our society. And it’s time we do something about it.
Thank you very much!//
Please join me in congratulating the incoming executive committee of AMSAHK and giving them the best wishes for their future endeavor!
Roger Chung, PhD
Assistant Professor, CUHK JC School of Public Health and Primary Care, @CUHK Medicine, The Chinese University of Hong Kong 香港中文大學 - CUHK
Associate Director, CUHK Institute of Health Equity
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【最新學術文章】可能是我學術生涯其中一篇最重要的文章!我從來都認為在香港地生活,住屋負擔能力是一個很影響我們身心健康的社會因素... 一直以來都是假設的一個想法,但今天我們終於用數據證實了!
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「住屋負擔能力對身心健康的影響:全球住屋負擔最重的群體中之家庭調查」
摘要
背景︰儘管香港面對全球最嚴重的住屋負擔能力問題,相關研究鮮有針對健康風險。故此,我們探討住屋負擔能力與身心健康之間的聯繫,並考慮匱乏的潛在中介作用。
方法︰我們以分層樣本方式隨機抽出1,978位居住在香港社區的成人。住屋負擔能力是以扣除住屋成本後的剩餘收入方法定義。一般身心健康則通過標準十二題簡明健康狀況調查表第二版(SF-12v2)進行評估,從中得出生理健康領域(PCS)分數和心理健康領域(MCS)分數。我們以多元線性迴歸分析評估住屋負擔能力與PCS和MCS分數的關聯,並根據人口、社會經濟及生活方式等因素進行調整。此外,我們亦利用中介分析以評估匱乏於住屋負擔能力對PCS和MCS影響的中介作用。
結果︰住屋負擔能力與平均PCS和MCS分數均呈量效關係。與負擔能力最高的四分位數組別相比,其餘三個負擔能力最低、稍低及稍高組別的平均PCS分數差異分別為:-2.53(95%置信區間 = -4.05至 -1.01),-2.23(-3.54至 -0.92)及-0.64(-1.80至0.51)。而平均MCS分數差異則分別為:-3.87(-5.30至 -2.45),-2.35(-3.59至 -1.11)及-1.28(-2.40至 -0.17)。當中,匱乏可解釋34.3%住屋負擔能力對PCS的影響及15.8%住屋負擔能力對MCS的影響。
結論︰住屋負擔能力影響身體和精神健康,而部份影響來自匱乏。這表明針對匱乏人士的置業政策除了可紓緩住屋負擔能力問題外,還有助減少健康不平等。
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"Housing affordability effects on physical and mental health: household survey in a population with the world’s greatest housing affordability stress"
Background: We examined the association of housing affordability with physical and mental health in Hong Kong, where there is a lack of related research despite having the worst housing affordability problem in the world, considering potential mediating effect of deprivation.
Methods: A stratified random sample of 1978 Hong Kong adults were surveyed. Housing affordability was defined using the residual-income (after housing costs) approach. Health-related quality of life was assessed by the Short-Form Health Survey version 2 (SF-12v2), from which the physical component summary (PCS) and mental component summary (MCS) measures were derived. Multivariable linear regressions were performed to assess associations of housing affordability with PCS and MCS scores, adjusting for sociodemographic, socioeconomic and lifestyle factors. Mediation analyses were also conducted to assess the mediating role of deprivation on the effect of housing affordability on PCS or MCS.
Results: Dose–response relationships were observed between housing affordability and mean PCS score (β (95% CI) compared with the highest affordable fourth quartile: −2.53 (−4.05 to −1.01), −2.23 (−3.54 to −0.92), −0.64 (−1.80 to 0.51) for the first, second and third quartiles, respectively) and mean MCS score (β (95% CI): −3.87 (−5.30 to –2.45), −2.35 (−3.59 to −1.11), −1.28 (−2.40 to –0.17) for the first, second and third quartiles, respectively). Deprivation mediated 34.3% of the impact of housing unaffordability on PCS and 15.8% of that on MCS.
Conclusions: Housing affordability affects physical and mental health, partially through deprivation, suggesting that housing policies targeting deprived individuals may help reduce health inequality in addition to targeting the housing affordability problem
health-related quality of life 在 Roger Chung 鍾一諾 Facebook 的最佳解答
【最新學術文章】雖然香港政府的官方醫療政策是「確保市民不會因經濟困難而無法獲得適當的醫療服務」,我們的研究發現8.4%的受訪者因缺乏經濟能力而未在過去一年中尋求醫療服務!
標題:貧窮、患病、殘疾人士在香港獲取醫療服務的過程中,有甚麼經濟障礙呢?
摘要
雖然香港是世界上最富裕的城市之一,並擁有一些全球最佳的健康結果,如最長預期壽命,但目前對於因缺乏經濟能力而無法獲取醫療服務的人知之甚少。從第一波「香港貧窮與社會弱勢的趨勢及影響」問卷調查中,我們收集了2,233名18歲或以上參加者的橫斷面數據,並利用前向逐步邏輯回歸分析,評估了社會人口因素、生活模式、以及生理和心理健康,與因為缺乏經濟能力而無法獲取醫療服務的相關性。在2,233名受訪者當中,8.4%因缺乏經濟能力而未在過去一年中尋求醫療服務,而且這些人較大機會是貧窮人士。在生理和心理健康方面,與香港普遍人群相比,儘管他們患有多重病症的可能性較小,但他們的焦慮和壓力水平都較高,生理和心理健康相關的生活質素也較差,並且患有更嚴重的殘疾和的疼痛症狀,影響日常活動。因經濟障礙而無法獲取醫療服務的人士比香港普遍人士的生理和心理健康較差,這意味著一些有更大醫療需要的人士在接受及時和適當的醫療服務可能面對更大的經濟困難,這些研究結果顯示了香港面對醫療服務獲取不公的問題。
【New Academic Publication】Prof Samuel Wong and I along with the HK Poverty, Deprivation and Health Inequality Team has just published our new findings in Plos One -- 8.4% of people in HK did not seek medical care due to lack of financial means!!
Title: What are the financial barriers to medical care among the poor, the sick and the disabled in the Special Administrative Region of China?
Abstract
Although Hong Kong is one of the richest cities in the world and has some of the best health outcomes such as long life expectancy, little is known about the people who are unable to access healthcare due to lack of financial means. Cross-sectional data from a sample of 2,233 participants aged 18 or above was collected from the first wave of the “Trends and Implications of Poverty and Social Disadvantages in Hong Kong” survey. Socio-demographic factors, lifestyle factors, and physical and mental health conditions associated with people who were unable to seek medical services due to lack of financial means in the past year were examined using forward stepwise logistic regression analyses. Of the 2,233 participants surveyed, 8.4% did not seek medical care due to lack of financial means during the past year. They were more likely to be income-poor. With respect to physical and mental health, despite having less likelihood to have multimorbidity, they tended to have higher levels of both anxiety and stress, poorer physical and mental health-related quality of life, and suffer from more severe disability and pain symptoms affecting their daily activities, when compared to the rest of the Hong Kong population. People who were denied of medical care due to financial barriers are generally sicker than people in the general Hong Kong population, implying that those with greater healthcare needs may have financial difficulties in receiving timely and appropriate medical care. Our findings suggest that inequity in healthcare utilization remains a critical issue in Hong Kong.
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