A Medical History of Hong Kong: 1942–2015 9789882370852, 9882370853

This book gives an account of Hong Kong’s medical and health development from the Second World War to the present day, i

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A Medical History of Hong Kong: 1942–2015
 9789882370852, 9882370853

Table of contents :
Title Page
Copyright
Dedication
Table of Contents
Foreword
Preface
Acknowledgements
1. Overview: Socioeconomic and Medical Developments in Hong Kong from Japanese Occupation to Special Administrative Region
2. Medical and Health Services during Japanese Occupation (1941-1945)
3. Battle against Infections and Communicable Diseases
4. Blue Death and White Plague
5. Pandemics of the Twenty-First Century—Lifestyle Diseases
6. The Modern Scourge—Cancers
7. Emerging Infectious Diseases
8. The Graying Population
9. A Tale of Two Schools—Medical Education
10. Hospitals and the Hospital Authority
11. Healthcare Reform
12. Embracing the Future and Learning from the Past: Primary Care and Traditional Chinese Medicine
13. Conclusion
Appendix 1. Timeline of Medical Development in the World and in Hong Kong
Appendix 2. Heads of Medical or Health Departments in Hong Kong from 1945 to Present
Notes
Glossary
Bibliography
Index
Back Cover

Citation preview

A Medical History of Hong Kong 1942–2015

By Moira M. W. Chan-Yeung

THE CHINESE UNIVERSITY OF HONG KONG PRESS

A Medical History of Hong Kong: 1942–2015 By Moira M. W. Chan-Yeung © The Chinese University of Hong Kong 2019 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from The Chinese University of Hong Kong. ISBN: 978-988-237-085-2 The Chinese University of Hong Kong Press The Chinese University of Hong Kong Sha Tin, N.T., Hong Kong Fax: +852 2603 7355 Email: [email protected] Website: cup.cuhk.edu.hk Printed in Hong Kong

To my teachers, colleagues, and students

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Contents

Foreword 

/ vii

Preface / ix Acknowledgements / xi Chapter 1  Overview: Socioeconomic and Medical Developments in Hong Kong from Japanese Occupation to Special Administrative Region / 1 Chapter 2  Medical and Health Services during Japanese Occupation (1941–1945) / 21 Chapter 3  Battle against Infections and Communicable Diseases / 39 Chapter 4  Blue Death and White Plague / 63 Chapter 5  Pandemics of the Twenty-First Century— Lifestyle Diseases / 85 Chapter 6  The Modern Scourge—Cancers / 113 Chapter 7  Emerging Infectious Diseases / 139 Chapter 8  The Graying Population / 167 Chapter 9  A Tale of Two Schools—Medical Education / 187 Chapter 10  Hospitals and the Hospital Authority / 217

Chapter 11  Healthcare Reform / 243 Chapter 12  Embracing the Future and Learning from the Past:   Primary Care and Traditional Chinese Medicine / 267 Chapter 13  Conclusion / 295 Appendices  Appendix 1 Timeline of Medical Development in the World and   in Hong Kong / 303 Appendix 2 Heads of Medical or Health Departments in Hong Kong   from 1945 to Present / 311 Notes / 313 Glossary / 353 Bibliography / 355 Index / 371

Foreword

The author Professor Moira Chan-Yeung is a Hong Kong educated clinical scientist who has been working in academic institutions and public hospitals for most of her professional career. Her writing is therefore based on her first-hand knowledge of the changes in the Hong Kong medical and healthcare scene during the period 1942–2015 and has also been enriched by her meticulous research via the archives of available government publications, other literature, and media reports. Her choice to arrange the chapters by themes rather than chronologically is a wise one. Doing so captures the reader’s continued attention and interest on the topic and makes the entire book more reader friendly. Today Hong Kong’s health indices, such as infant mortality and life expectancies are among the best in the world. Much of the credit must be given to how the city has embraced the remarkable scientific advances in medicine and technology since the Second World War as well as to socioeconomic improvements in recent years. But we should also recognize that several new initiatives and incremental reforms in our healthcare system have played a pivotal role in making this a reality. We have succeeded in preventing and eradicating infectious diseases such as cholera, smallpox, and poliomyelitis, which accounted for an alarmingly high childhood mortality in the early years of the last century. We have won worldwide acclaim for our research into the control of emerging infectious diseases such as SARS. We have upheld the humanistic principle that no one is denied basic medical care because of lack of means. But not all is smooth sailing. This book presents an unbiased and scientific analysis of events which prompted the authorities and the public to consider, evaluate, and ultimately implement policies that resulted in the gradual improvement of the healthcare system in Hong Kong. Medicine is a timeless art and an evolving science. Rosie T. T. Young The University of Hong Kong November 2017

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Preface

As I am a clinician-scientist rather than a social scientist, this book, A Medical History of Hong Kong, will invariably differ somewhat from other accounts of Hong Kong written by historians. In two volumes, it presents a broad, sweeping view of the development and evolution of medical and health services in Hong Kong in the context of its historical, social, cultural, political, and economic circumstances. My hope is that this work will serve as an impetus for others to do further research in this field, starting from any one of its inviting entry points. The first volume gives an account of Hong Kong’s medical and health development from its establishment as a British colony in 1842 to the beginning of the Second World War. The second volume, which carries on from that point to 2015, investigates how medical and health services grew and adapted as Hong Kong’s political and the socioeconomic landscape—and the world beyond it—changed, and continued changing. It does not explore the social philosophies of medicine, the economics of healthcare financing, or the healthcare policy of Hong Kong as other books have ably done. Among them are J. Hay’s Health Care in Hong Kong: An Economic Policy Assessment; R. Gauld and D. Gould’s The Hong Kong Health Sector: Development and Change; and G. Leung and J. Bacon-Shone’s Hong Kong’s Health System: Reflections, Perspectives and Visions. Thoughtful observers and students of Hong Kong medicine will find in these pages the map of the city that has been pulled at and stepped on, and yet risen again. In their inquiries, they would do well to look backwards as well as forwards; to know where we are going, we must also know where we came from. Hence, Chapter 1 of the second volume introduces the political, social, economic, and medical landscape of Hong Kong since the Second World War. Chapter 2 begins with the description of the lack of medical services for the population, prisoners-of-war camps, and Stanley camp for foreign civilians during the brutal Japanese occupation.

x   |   P reface

Chapter 3 and 4 relate the story of the valiant efforts of the Medical and Health Department and the people of Hong Kong in successfully combatting the infectious diseases and infections that overwhelmed the poverty-stricken, overcrowded postwar conditions. The following two chapters, 5 and 6, describe the inevitable fallout from improved standards of living, as Hong Kong evolved into a high-income region—the rise of non-communicable chronic diseases such as cancers, heart diseases, cerebrovascular diseases, diabetes, and obesity, and how the medical profession and Hong Kong citizenry coped with the situation. Chapters 7 and 8 discuss Hong Kong’s preparedness for medical and health emergencies such as outbreaks of emerging infectious diseases and issues associated with an aging population—challenges confronted by Western countries. Chapters 9 through 12 document medical education and changes in health-services delivery and healthcare reform in Hong Kong—efforts of the government to deal with the constantly changing socioeconomic and demographic landscape. Although Hong Kong has no long-term healthcare policy, the medical and health development since the 1970s had been guided by the principle that no citizen should be denied medical care for lack of means. The establishment of the Hospital Authority placed Hong Kong’s hospital care at par with those of countries with advanced economies. However, the rising demands for high-technology, advanced treatment, new expensive drugs, and the health needs of an ever increasing, aging population threaten the financial sustainability of the current healthcare system. The last two chapters cover the progress of healthcare reform in Hong Kong with emphasis on primary care, disease prevention, and health promotion, together with the development and modernization of traditional Chinese medicine. The chapters recount key events in the medical history of Hong Kong as its status toggled from a British colony to an occupied territory under Japanese administration, back to a British colony, and finally to a Special Administrative Region of China. Because the chapters are arranged by theme, there is chronological overlap. Between them, they tell a story of medical and health services in Hong Kong. This book draws on a wide array of archival materials, government publications, scholarly literature, newspapers, and multiple websites. A detailed breakdown can be found in Bibliography.

Moira M. W. Chan-Yeung June 2017

Acknowledgements

I wish to express my gratitude to Professor S. C. Tso and the late Professor Sir David Todd for their encouragement and valuable advice in the preparation of the manuscript. I am particularly beholden to Dr. Kenneth Suen for his careful reading of the manuscript on several occasions to ensure the accuracy of the contents, to Professor Y. W. Fung for his most helpful counsel and suggestions, Dr. Felix Chan for his invaluable advice on medical services in the elderly population, and Dr. Alice S. S. Ho for her unfailing assistance in my research. My sincere appreciation goes to Mr. Bruce Grierson for his editing, Anne DyBuncio and Stanley Yeung for their help with preparation of graphs and photographs, and Miranda Ho for her secretarial assistance. I would like to gratefully acknowledge the Hospital Authority, the Department of Health, the Water Supplies Department, the Hong Kong Museum of Medical Sciences, The University of Hong Kong Archive, Hong Kong University Li Ka Shing Faculty of Medicine, Departments of Surgery, Obstetrics and Gynecology, Medicine, Pathology, and Orthopedics of the University of Hong Kong, the Chinese University of Hong Kong, the Faculty of Medicine of the Chinese University of Hong Kong, South China Morning Post, Hong Kong Anti-Cancer Society, Hong Kong Council on Smoking and Health (COSH), the late Sir C. Y. Chung, and the family of Professor John H. C. Ho for their kind permission to reproduce photographs, Drs. Julie Wang and C. L. Lam for contributing the chest radiograph, Dr. C. M. Tam and Dr. C. C. Leung for the use the graph on BCG vaccination and Mr. Keith Poon for his photographs and his permission to use the pictures of the artefacts that he has donated to the Hong Kong Museum of Medical Sciences. My thanks also go to the editors of the Chinese University of Hong Kong Press, especially to Rachel Pang, and Angelina Wong for their patience in helping me in the preparation and publication of this manuscript.

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1. Overview: Socioeconomic and Medical Developments in Hong Kong from Japanese Occupation to Special Administrative Region Emerging from Japanese Occupation On Christmas Day 1941, when Japanese powers seized Hong Kong, a pall descended on the city. Instead of the cries of the morning hawkers selling congee, fruits, vegetables, bamboo brooms, and mats that enlivened most mornings, there was an eerie silence in the Western District. The city was a ghost of its former self. During the following three years and eight months of Japanese occupation, most of the infrastructure, including critical medical and health services in Hong Kong, would be destroyed. The story of the renaissance of Hong Kong’s medical and health services is inseparable from the larger narrative of how Hong Kong emerged from an occupied war zone to become a gleaming, modern metropolis. Once the Japanese government was in power, it became apparent that the government was unable to feed a swollen population of around 1.7 million. The Japanese solution was to actively repatriate people who were refugees from China. Countless other Hong Kong residents also trooped back to Free China, trying to escape hunger as well as Japanese brutality, but many of them died from starvation and disease along the way. The Japanese government did apply public health measures, such as vaccinations and inoculations, more vigorously than the British administration as epidemics of infectious diseases, such as smallpox and cholera, took hold. The population had dwindled to just around 600,000 by the time the Japanese surrendered on 15 August 1945 when Admiral Harcourt reclaimed Hong Kong and set up a military government. Although hindered by a scarcity of resources, this government nevertheless worked with remarkable efficiency to maintain stability in Hong Kong. While beginning to restore the economy, it was also able to begin the slow process of rebuilding the public health sector.

2  |  A MEDICAL HISTORY OF HONG KONG: 1942–2015

As the reconstruction of Hong Kong began, the lack of housing was an immediate and glaring problem. Returning residents found their properties had been destroyed by bombing during the war. Overcrowding was worsened by the influx of refugees into Hong Kong from the mainland, fleeing the devastation wrought by the civil war between the Communist Party and Guomindang. The establishment of the People’s Republic of China on 1 October 1949 further accelerated the torrent of refugees until finally, in 1951, the border was sealed. Imagine the social disruption in a city that was still in shambles after the Second World War, now bulging with desperate, hungry refugees. Then in 1950, the Korean War broke out. The entrepot trade of Hong Kong was shattered by the embargo imposed on China and North Korea by the United States and its allies; thus, with the loss of this main source of revenue, the Hong Kong government was unable to cope with the unprecedented refugee problem. It seems almost incredible that Hong Kong would emerge, as often described, like “a phoenix rising from the ashes,” during the two to three decades after the Second World War. Hong Kong’s economy improved and began to soar. By the 1960s and 1970s, annual GDP was increasing by double-digits, and by the 1980s its standard of living would equal those of countries with advanced economies. When Hong Kong was returned to China in 1997, its GDP was higher than Britain’s.

Economic and Sociopolitical Transition From an Entrepot to an International Financial Hub As the US embargo persisted after the Korean War (1950–1953), Hong Kong, although lacking in natural resources, turned to industrialization to replace the decimated entrepot trade. Primary industry had been almost non-existent, but the large numbers of migrants from China, first seen as a severe financial strain on limited resources, became the resources. The entrepreneurial immigrants brought capital and technology, while the refugees brought a seemingly endless supply of cheap labor. Within a few years, Hong Kong was emerging as a major manufacturing center. Textiles and clothing took off as major industries; light industries such as metal products, electrical appliances, furniture, plastics, and artificial jewellery

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were rapidly growing. 1 Between 1954 and 1971, employment in the manufacturing sector expanded at an annual average rate of 13%, much faster than population growth of 3% to 4%. From 1961 to 1971, women’s (age 15–64) participation in the labor force rose from 39% to 46%.2 Hong Kong’s economic ascent seemed unstoppable. By 1956 the export-led economy was already booming. Between 1960 and 1973, Hong Kong’s GDP increased at an average rate of 10.8 % (Figure 1.1). By the early 1970s, its per capita income was highest among all developing countries in Southeast Asia, ranking second only to Japan in all of Asia. The high economic growth, uninterrupted since 1960, was sustained into the 1980s and accelerated even more so after the 1980s. Initially remaining stagnant after the war, wages began to edge up noticeably for skilled workers starting in 1957, followed by wages of the semi-skilled the following year. In 1960, wages for all grades of workers rose sharply—a sign of full employment in a laissez faire labor market.3 Proportionately the largest income gain went to the two poorest quintiles with an increase of 76% in average household income, compared with an overall gain of 40% for all households. The level of inequality between the rich and the poor fell.4 Figure 1.1  Revenue, expenditure and GDP per capita in Hong Kong, 1950–2015

Source: Hong Kong Annual Reports 1950–1980 and Hong Kong Annual Digest of Statistics, 1981–2015.

4  |  A MEDICAL HISTORY OF HONG KONG: 1942–2015

Despite years of political turmoil in mainland China, Yet, against the odds, the overall performance of Hong Kong’s economy, averaging 8.1% growth during the decade from 1973 to 1982,5 Hong Kong was well equipped by then to evolve into something better. Its solid industrial base, excellent trade network, modern banking, insurance, and other business services, vibrant domestically driven economy, and an increasingly educated workforce, all helped transform it into a regional hub for business services and a leading international financial center.6

Engine of Growth for Southern China After US President Richard Nixon’s 1972 visit to China and resumption of harmonious relations between the two countries, China was rapidly developing and modernizing. With the signing of the Sino-British Joint Declaration in 1984, enterprising Hong Kong entrepreneurs began to transfer manufacturing production to the Pearl River Delta region in the south China coast, taking advantage of its low labor cost. In 1988 Hong Kong companies employed two million workers in southern China, and by 1997 the number increased to five million.7 Even before the handover, a mutually beneficial economic nexus had already developed between Hong Kong and mainland China. As Hong Kong continued to advance its economy to become a financial center, it relied on Guangdong and southern China for their manufacture. As a result, China’s development in industry and its economy were fast-tracked. As 1997 drew near, Deng Xiaoping, the paramount leader of the People’s Republic of China, who had been advocating “socialism with Chinese characteristics” devised an ingenious formula—one country, two systems—to preserve the spectacular success of Hong Kong by creating a new set of laws to protect the freedom and rights of the Hong Kong citizens and maintaining their way of life. Hong Kong, as Deng envisioned, would serve as the engine of growth to bring China rapidly into the twenty-first century.

Challenges to the Hong Kong Special Administrative Region (HKSAR) While the transfer of sovereignty of Hong Kong from Britain to China in 1997 was smooth, the immediate post-handover period in the HKSAR was nothing but turbulence. The day after the handover of Hong Kong, the Asian financial crisis, precipitated by the devaluation of the Thai baht,

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punctured the economy of many countries in the region, Hong Kong included. Unlike the previous two downturns caused by the problematic Sino-British negotiation in 1984 and the Tiananmen Square Incident in 1989, when the turnarounds were swift, on this occasion the economic depression lasted for more than two years. A series of unfortunate events occurring after 1997 battered Hong Kong and deepened the depression, including the collapse of the buoyant housing market and the attacks on its currency. Within months of the handover, a hitherto unknown biological organism—the deadly avian influenza—assailed the people of Hong Kong and its economy. Even more deadly than the avian influenza of 1997 was the mysterious epidemic that struck Hong Kong in March 2003. Originating from Foshan, Guangdong, this disease, which became known as Severe Acute Respiratory Syndrome (SARS), rapidly spread throughout this international city. The epidemic challenged not only the medical and health profession, but all aspects of life—especially the economy. Still weakened by the Asian financial crisis, Hong Kong’s financial troubles began to cascade. The “Lehman Brothers’ collapse” in 2008, which crashed financial markets worldwide, further undermined Hong Kong’s fragile economy. Hong Kong was losing its international financial edge, as other cities, some in China, began to crowd it off the stage. During this period, the gap between rich and poor of the Special Administrative Region widened. For more than a decade real wages had been flat. Young people, who believed they would never achieve the standard of living their parents had enjoyed, grew unhappy. The control of the housing supply by a small group of real estate companies, combined with the high cost of land, effectively priced this group out of the housing market. This growing wealth gap and inability to own a home, stirred discontent in the community, causing social disharmony, and instability.

Changing Government Attitudes and Policies In the 1950s, life was hard, but people did not complain. There were no large-scale protests or unrests. Despite its economic improvements from the late 1950s toward the end of the 1960s, the government had remained conservative in its financial and economic policies. It was allocating less than 10% of its budget on combined social services (education, medical and health, social welfare and housing) and the very minimum

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needed to maintain reasonably sanitary conditions. This economic and housing laissez-faire policy resulted in tremendous overcrowding and the mushrooming of squatter huts in many parts of Hong Kong and Kowloon.8 Social welfare was left mostly in the hands of local and international voluntary agencies. In 1966, a young man protested a fivecent fare hike for a ferry ride and the Star Ferry Riots ensued. Most of the protesters were manual workers, young people and students who felt that they had no prospect for future advancement. A year later in 1967, agitation from the Cultural Revolution on the mainland spilled over into Hong Kong. For six months, communism inspired violent protests led to riots in the streets. Many Hong Kong residents who had fled from the mainland were wary of the communist regime and supported the Hong Kong government’s firm stand against the protesters. The 1966 and 1967 riots jolted the government into action. The following two decades (1970s, 1980s) were characterized by increased spending on social services, including housing, health services, education, and civil service on a scale which would have been unimaginable a decade earlier (Figure 1.2).9 Figure 1.2 Percentage of total expenditure on medical and health, education, and all social services, 1946–2015

Source: Hong Kong Annual Reports 1946–1980 and Hong Kong Annual Digest of Statistics 1981–2015.

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Sir Murray MacLehose, the 25th governor of Hong Kong from 1971 to 1982, realized that while the 1967 riots were triggered by a labor dispute, backed by communist sympathizers, the public’s bigger grievance about life in Hong Kong was against harsh housing conditions that many low-income residents had to endure. In 1972 Governor MacLehose announced the ambitious Ten Years Housing Program to resettle 1.9 million people in 10 years—by constructing 35,000 new flats a year for low-income families, developing new towns in remote sites in the New Territories, building a network of new roads and highways to reach the new developments, and clearing actively the slums. The government’s policy of affordable housing for the working class reduced pressure for wage increases and it, in turn, cut labor costs and inflationary pressure, allowing goods to be competitively priced. The government also initiated infrastructural projects such as the first cross-harbor tunnel and the mass underground transit railway (MTR) system. Extra funding was allotted to social welfare, with a substantial share devoted to services to youths and school children. 10 Various legislative amendments were enacted to reduce industrial working hours. MacLehose also founded the Independent Commission Against Corruption (ICAC) which quickly won a reputation for probity. All the above measures improved quality of life and inspired confidence and social stability in Hong Kong, resulting in continuous economic growth over the next two decades. For the first time, Hong Kong people had a sense of belonging to the place and they were proud to be “Hong Kongers.” In the late 1980s, it became apparent that wealth and power were concentrated in relatively few hands while the number of people below the poverty line burgeoned. Yet the government made little effort to reduce the inequalities in income, designing economic policies that encouraged the accumulation of wealth by a small number of people. It did not seek to redistribute income by increasing taxation which was kept at a maximum of 15%, nor did it introduce social benefits along welfare state lines. The labor force was inadequately protected; while working conditions had improved, long work hours were the norm and there was no minimum wage. The provision of some social services, rapid economic growth, and occupational mobility pre-empted overt class struggle in Hong Kong.11 At the same time, a sizable middle class had also emerged and they wanted guarantees that their gains in economy,

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personal liberties, and lifestyles would be protected and preserved. The British, Chinese, and Hong Kong governments were unwilling to incorporate the middle class into the political system. Instead, the Hong Kong government pacified them through improvements in the quality and quantity of various services, such as more universities, more homeownership schemes, and better medical facilities. These services are costly and would only work when the economy continued to perform well in Hong Kong.12 The Asian financial crisis, however, struck a serious blow to Hong Kong’s economy. During this period spending for social welfare services and medical services was slashed (Figure 1.2).13 Tung Chee-hwa, the first chief executive of the HKSAR had to cancel a home ownership plan that promised to build 80,000 residential flats a year to help people buy their first home. As the economic downturn intensified, the middle class without a political voice had only two options: to protest or to emigrate. They did both, adding further socioeconomic instability to the HKSAR. In 1999, the economy began to show some signs of recovery and in 2005, it became robust enough to have a healthy government reserve, but social spending was still at a lower level than that in 1997. Recent expenditures on social services (medical and health, education, social welfare) and housing had declined from close to 70% of the total budget in 1997 to about 50% (Figure 1.2), and spending on public works increased from 11% to 18% in 2017–18.14 While the number of people struggling to live below the poverty line continued to grow steadily, there appeared to be no longterm plan to relieve their suffering. In addition to political, social, and economic transformations, Hong Kong’s demographic, health and disease patterns also underwent huge changes. Medical and health services would evolve accordingly.

Demographic Evolution Population Growth The demography of the population underwent changes. As residents returned to Hong Kong from the mainland after the war, the population, which had fallen to 600,000 during the war, reached the prewar level of 1.6 million by 1948. Even before the work of rehabilitation had

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been completed, civil war on the mainland brought thousands of refugees to Hong Kong once again, so that by 1951 its population had ballooned to 2.1 million (Figure 1.3). 15 Even though Hong Kong closed the border at Lo Wu in 1952 to stop the flow of illegal immigrants, the population continued to grow, adding one million each decade for the next thirty years. This phenomenal growth placed tremendous stress on all sectors: housing, water supply, education, and medical services. The male to female ratio of the population also changed (Figure 1.3). When the colony was founded in 1842, most Chinese men seeking opportunity in Hong Kong left their wives and children at home, in their native villages in mainland China. At the turn of the twentieth century, famine, unrest, and wars in China sent hundreds of thousands of refugees to Hong Kong, increasing the number of women and children. Still, there were considerably more men than women in Hong Kong before the Second World War. At the turn of the twenty-first century, however, for the first time there were more women than men in Hong Kong. Figure 1.3  Population and male to female ratio in Hong Kong, 1920–2013

Source: Hong Kong Blue Books 1920–1940 and Hong Kong Annual Reports 1946–2013.

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The dramatic population increase in Hong Kong after the Second World War was not only due to the massive influx of refugees from the mainland, but also to the postwar baby boom. The crude birth rate increased rapidly and peaked at 39/1,000 persons in 1958; thereafter it declined, dipping below 20/1,000 by 1968 (Figure 1.4).16 Better nutrition and sanitation, improved immunity, and the availability of antibiotics lowered the crude death rate for the whole population, which peaked in 1946 at 14/1,000, to around 5/1,000 by the end of the 1960s. Infant mortality was very high immediately after the war, at around 100/1,000 live births. This number dropped precipitously to around 20/1,000 by the end of the 1960s, thanks to improved hygiene, obstetrical care, and the use of antibiotics in addition to better nutrition. Professors Gordon King and Daphne Chun were the driving force behind the improvement of maternity services and family planning in Hong Kong. They helped reduce the neonatal and maternal mortality rates to such an extent that Hong Kong became one of the safest places in the world to give birth. Figure 1.4 Crude birth rate (live births/1,000) and crude death rate (deaths/1,000) in Hong Kong, 1945–2015

Source: Hong Kong Medical and Health Department Annual Reports 1946–1980 and Hong Kong Annual Digest of Statistics 1981–2015.

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In 1961 life expectancy was about 63.5 years for men and 70.5 years for women. By 2016 these life expectancies increased to 81.3 and 87.3 respectively—a gain of almost sixteen years for both men and women in just five decades (Table 1.1).17 The high birth rate, along with a simultaneous fall in death rates and long life expectancy, resulted in a dramatic rise in population. Something had to be done to slow this rate of growth. Table 1.1 Life expectancy (years) of men and women at birth in Hong Kong, 1961–2016 Year

Men

Women

1961

63.6

70.5

1971

67.4

75.0

1981

72.1

78.2

1991

74.8

80.4

2001

78.0

84.5

2011

80.0

86.5

2016

81.0

87.3

Source: “Vital Statistics,” Centre for Health Protection, Department of Health, HKSAR, accessed on 28 March 2018, http://www.chp.gov.hk/en/vital/10/27.html.

The Family Planning Association Intervenes The Family Planning Association of Hong Kong was established as the Hong Kong Eugenics League in 1936 by Professor W. C. W. Nixon of the University of Hong Kong to help reduce the birth rate. The league, affiliated with international organizations in London and New York, began its work in a single clinic at the Violet Peel Maternity and Child Welfare Center. More clinics were subsequently established in Kowloon and in Tsan Yuk Hospital. Though the government allowed the league to use space in its clinics and hospital, it officially had nothing to do with its activities, for fear of offending the Catholic Church.18 By 1940, the league ran five clinics, staffed by several part-time female doctors and nurses. Its work was discontinued during Japanese occupation.19 In November 1952, the Eugenics League reopened at the Violet Peel Clinic as the Family Planning Association of Hong Kong. Incorporated in 1955, it was granted a piece of land and with a donation from the Royal

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Jockey Club, construction of headquarters began behind the clinic on Hennessy Road. During the same year, the government, recognizing the importance of the work of the association, awarded it an annual grant of $5,000. In 1960, a second center was opened in Ma Tau Chung in Kowloon, followed in 1973 by a third center in Yuen Long. Hong Kong residents initially rejected the idea of birth control because traditional Chinese culture favored large families. Over the years, the Family Planning Association tried to overcome this resistance by utilizing every conceivable communication channel: freely distributed booklets and pamphlets, and advertisements in newspapers, magazines, and radio. Talks, radio plays and interviews were eventually broadcast on television to bring the message home. Social workers visited families in their homes to motivate women to practice contraception. In 1964–65 the association introduced the intrauterine device and in 1968 the oral pill. These two methods, together with postpartum sterilization, which was more commonly adopted by older women, have been the main accepted methods of contraception. After the 1960s, socioeconomic changes in Hong Kong gradually increased receptivity of these messages. High female employment and increasing opportunities for girls’ education made contraception more desirable. The services provided by the Family Planning Association and the slogan “Two is Enough” became highly popular. 20 The association developed special clinics, such as a vasectomy clinic and turned its attention to childless couples by establishing a subfertility clinic and a semen bank. Artificial insemination became available when indicated. 21 In 1974, the government decided to amalgamate the 32 Family Planning Association clinics into its Maternal and Child Health Centers.

Reduction in Fertility Rate The decline in crude birth rate continued in the 1960s, slowing somewhat after 1970, helped not only by the commendable work of the Family Planning Association, but also by several other factors. There were fewer women of child-bearing age (15–24 years) in the 1960s because fewer children were born during the war years and infant mortality was high. Also, a rapid expansion of education, first at the primary level and then at the secondary level,22 exposed young females

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to knowledge of family planning. Perhaps the most significant cause of the decline in the birth rate was that women were increasingly employed in a wide variety of occupations while Hong Kong was undergoing industrialization and modernization. 23 The surge of the female workforce was particularly high in the younger age groups (15–19 and 20–24), and this meant delaying marriage and, consequently, childbirth. Most women’s attitudes to family size also changed. In the 1970s, the majority of mothers preferred to have only two children—smaller families than their mothers.24

Changes in Population-Age Structure Changes in life expectancy and fertility rate altered the populationage structure of Hong Kong from 1961 to 2001. In the 1970s and 1980s the high postwar birth rate had led to a disproportionate number of people in their peak reproductive years (20–30 years old). However, the marked decline in birth rate in subsequent years resulted in a higher proportion of people in the 40–50 age range in 2001. Projection into 2021 indicates a much higher proportion of people in the 60–70 age range, relative to the younger age groups (Figure 1.5).25 Hong Kong’s population is aging rapidly. By 2020, 17.4% of the population will be over the age of 65. Figure 1.5  Population-age structure in Hong Kong 1961, 1981, 2001, and 2021 (projected) Age group

Number of people in thousands

1961

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Cont’d Figure 1.5 Age group

Number of people in thousands

1981 Age group

Number of people in thousands Age group

2001

Number of people in thousands

2021 Source: Data on population by age groups were obtained from Hong Kong Medical and Health Department Annual Reports of respective years while projected population data from “Information Note. Population Profile of Hong Kong,” Research Office, Legislative Council Secretariat, accessed on 11 March 2019, https://www.legco.gov.hk/researchpublications/english/1415in07-population-profile-of-hong-kong-20150416-e.pdf.

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In 1971, the fertility rate had already dropped to 1.63 births per woman, well below the rate of 2.1 which is necessary for population maintenance. By 2010, it fell further, to 1.1 births per woman. The dependent population percentage (those under 15 and those over 65 years of age) diminished gradually from the end of World War II to a low point in the early 2000s, when it began to increase. Demographers have warned the government of the dire consequences of low fertility rate, as they estimated that by 2021 the dependent population in Hong Kong will reach 30.9 % (Table 1.2),26 and that it will continue to rise if the fertility rate remains the same or falls further. The shrinking labor force will strain future healthcare financing as the elderly consume a large chunk of healthcare resources, putting a heavy burden on the wage-earning population. The aging of the population will likely pose significant economic problems for Hong Kong in the decades ahead. Table 1.2 Percentage of dependent population in Hong Kong by decade %>=65 years Dependent%Population

Year

Total Population

% =23) for those over 18 years % *

Daily cigarette smokers %

2004

2006

2008

2010

2012

2014

2016

38.4

41.0

39.3

39.2

36.7

39.0

38.8

15.7

15.3

14.4

12.9

10.7

10.0

10.4

35.7

39.5

37.4

43.0

Physical activity meeting WHO’s recommendation† % Fruit and vegetables >= 5 servings/ day‡ % §

Daily alcohol drink %

17.7

21.6

21.0

19.0

17.1

18.7

20.5

4.0

3.3

3.4

2.7

1.9

3.3

2.8

Source: Data from 2004 to 2016 were derived from “Statistics on Behavioural Risk Factors,” Center for Health Protection, Department of Health, HKSAR, accessed on 22 Feburary 2019, http://www.chp.gov.hk/en/static/24016.html. Note: * Based on the question: Have you ever smoked cigarette? If yes, how many do you      smoke on average per day. The corresponding figures were 23.3% in 1982 and     15.9% in 1992/93. †

Adults aged 18–62 should do at least 150 minutes of moderate intensity aerobic physical activity throughout the week or at least 75 minutes of vigorous intensity physical activity throughout the week or a combination of moderate and vigorous intensity physical activity.



The average number of servings of fruits and vegetables eaten per day is equal to the sum of the average number of fruits eaten per day and twice the average of bowls of vegetable eaten per day.

§

Based on the question: During the last month, have you had at least one alcoholic drink? Is yes, on how many days per week during the last month on average, do you drink at least one alcoholic drink?

Environmental Protection Department In 2000, the Environmental Protection Department of Hong Kong introduced a comprehensive program to reduce vehicle emissions, by implementing more stringent fuel and vehicle emission standards. It also increased the frequency of vehicle emission inspections and encouraged the adoption of cleaner alternatives to diesel vehicles, such as liquefied petroleum gas for taxis and light buses. Devices to reduce emissions in old diesel vehicles were required, and the government phased out pre-Euro IV diesel commercial vehicles, offering tax incentives for environmentally-friendly commercial vehicles. It enacted the Motor

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Vehicle Idling Ordinance (Cap 611), which prohibits the idling of engine of a vehicle for more than 3 minutes in any 60-minute period.89 These measures reduced the street-level pollution of nitrogen oxides by 51%, respirable suspended particulates by 70% and sulfur dioxide by 50%, from 1999 to 2015. To reduce regional smog, in 2012, the Hong Kong SAR and the Guangdong Provincial governments endorsed a new set of regional emission reduction targets for 2015 and 2020, with a view to improving air quality and bringing the levels of air pollutants down to the World Health Organization air quality standard.90 In summary, noncommunicable or lifestyle diseases are responsible for a high proportion of DALYS and are a major burden to Hong Kong as in other parts of the world. Advances in medicine have reduced the mortality of many lifestyle diseases such as coronary heart disease and stroke. Over the recent decades the incidence of coronary heart disease has declined in the several high income countries, but increases in diabetes and hypertension and obesity could easily fuel its resurgence.91 The way forward is through primary prevention. Although lifestyle risk factors, such as a poor diet, and lack of physical exercises, are notoriously difficult to change, it can be done. The successful reduction of tobacco smoking in Hong Kong is a shining example of how this is best carried out, even though it took forty years of hard work by governmental and nongovernmental agencies, and members of the community. The battle against other risk factors of chronic noncommunicable diseases only started in earnest in the last decade or so, and there is still a lot of work to be done by the health authorities in the implementation of their policies, and in educating the public. Internationally there is a great deal of activities to fight against the noncommunicable diseases. In 2009, the 70th World Health Assembly launched the Noncommunicable Diseases Alliance under the leadership of three international NGOs: the International Diabetes Federation, the Union for International Cancer Control and the World Heart Federation. The International Union Against Tuberculosis and Lung Disease joined them the following year. They came together in recognition of a shared agenda to tackle the common risk factors, strengthen health systems and generate political priority for an issue that had long been marginalized in the global health and development agendas. 92 In 2011 the United

P andemics of the T wenty - F irst C entury   |   1 1 1

Nations made a Political Declaration on the Prevention and Control of Noncommunicable Diseases urging presidents and prime ministers to take chronic diseases much more seriously.93 The WHO produced a 2013–2020 Global Action Plan for the Prevention and Control of Noncommunicable Diseases targeting four shared behavioral risk factors—tobacco use, the harmful use of alcohol, insufficient physical activity, and unhealthy diet, with the overall aim of reducing premature mortality from cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases by 25% by 2025.94 These international efforts provide excellent opportunities for the local nongovernmental agencies to stimulate action and ensure accountability of commitments and resources from governments and communities as well as supply technical details for health departments to plan their programs to fight for a world free from preventable suffering, disability and death from noncommunicable diseases. Let us hope that Hong Kong and other communities around the world would reach the target set by the WHO by 2025.

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6. The Modern Scourge—Cancers

Cancer is increasing in incidence worldwide. The World Health Organization (WHO) reported in 2015 that roughly 14 million new cases of cancer (excluding nonmelanoma skin cancer) are diagnosed annually with over 8 million deaths a year. It ranked as the second leading cause of death globally in the same year and was responsible for one in seven human deaths. Cancer risk increases significantly with age and only about 1% of cancer diagnoses are in children under 15. Certain types of cancer are more prevalent in high-income countries while others are more prevalent in low-income countries. The incidence of cancer is increasing as the world population ages, and the types of cancer are changing as people in poor countries become more affluent and adopt the lifestyles of the rich.1 Cancers have existed since antiquity, comprising a large family of diseases caused by abnormal growth of cells that can invade ruthlessly other parts of the body. Some cancers are hereditary, but the clear majority are the result of exposure to external agents that can be divided into three categories: 1) physical carcinogens, including ultraviolet and ionizing radiation; 2) chemical carcinogens, such as components of tobacco smoke, asbestos, aflatoxin (a food contaminant), and arsenic (a drinking water contaminant); and 3) biological carcinogens, such as certain viruses, bacteria or parasites. For example: chronic infections with hepatitis B and C viruses increase the risk for hepatocellular carcinoma; human immunodeficiency virus (HIV) augments the risk for Kaposi sarcoma and several other cancers; Epstein-Barr virus (EBV) raises the risk for nasopharyngeal carcinoma (NPC) and non-Hodgkin’s lymphoma; and human papillomaviruses (HPVs) heightens the risk for several cancers including those of cervix, vulva, anus, penis, and sometimes tongue and tonsils.2 Carcinogens damage DNA in our cells and produce gene mutations. Although most gene mutations arise because of exposure to external

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carcinogens (somatic mutation), some mutated genes are inherited (germline mutation). A small but significant number of the following cancers have been found to be heritable: cancers of the breast, colon, rectum, kidney, ovary, thyroid, pancreas, and skin melanoma.3 Around 15% of cancers have proven links to heredity. There are more than 100 different types of tumors, each classified by the type of cell from which it originates. Tumors are also divided into two groups according to their behavior: benign tumors demonstrate limited growth and remain at one site, while malignant tumors or cancers contain cells that can spread to other parts of the body through the blood stream and/or lymphatic system.

Incidence and Mortality of Cancers in Hong Kong In Hong Kong, cancers, a disease predominantly of the older people, were uncommon as a cause of death before the Second World War when infectious diseases had killed so many individuals at a young age. It is possible that cancers were underdiagnosed and underreported in the past. After the war, as infectious diseases came under control, people began to live long enough for cancers and other chronic noncommunicable diseases to develop. The burden of these diseases has continued to grow as the people in Hong Kong enjoyed improved standard of living and increased longevity. Increase in cancer rate is also related to the prevalence of carcinogens in modern societies, where people are repeatedly exposed to environmental and industrial carcinogens, such as environmental tobacco smoke, benzene, benzidine, asbestos, and ionizing radiation. Since the 1970s, cancer has been the leading cause of death in Hong Kong. Although the age-standardized mortality has fallen since then, in 2015, cancer claimed 14,316 lives, accounting for nearly a third of all fatalities due to all causes. In the United States, the agestandardized mortality rates for all cancers peaked in the mid-1980s, declining slowly thereafter (Figure 6.1).4 In both Hong Kong and the United States, more men than women die of cancer. Advances in diagnosis and treatment have greatly improved the chances of survival for most cancer patients.

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Figure 6.1  Age-standardized mortality rates (no/100,000 men or women) from all cancers in Hong Kong (1965–2015) and the United States (1955–2014)

Source: Cancer mortality data for Hong Kong and United States were obtained from WHO Cancer Database of the International Agency for Research on Cancer, https:// gco.iarc.fr/databases.php. The rates were all age-standardized to a standard population in 2000 as recommended by the World Health Organization.

Changing Trends Although there are more than 100 different types of cancer, the incidence of each varies by population, and is influenced by cultural conditions. As conditions change over time, the incidence of different types of cancers in a population also change. Table 6.1 shows the ranking of the eight most common causes of cancer deaths in Hong Kong from 1949 to 2015 for both sexes combined.5 In 1949, the ranking was as follows: stomach, nasopharynx (NPC), cervix, colon, liver, breast, lung, and esophagus. Cancers of the lung and the liver moved to the top of the list by 1969 and remained there until 1997. By 2015, lung cancer was still in the top spot, but cancer of the liver had fallen to third, displaced by colorectal cancer, which had been creeping up.6 In 2015, three different cancers: prostate, pancreas, and nonHodgkin lymphoma, appeared newly on the list of leading cancer deaths of both sexes, while cancers of the nasopharynx, esophagus, and cervix disappeared. Prostate cancer held the fifth spot among men while breast cancer was third among women (Table 6.2).7

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Table 6.1  The eight leading cancer deaths in Hong Kong, both sexes 1949–2015 Rank 1949 1969 1979 1989 1997 1 Stomach Lung Lung Lung Lung 2 Nasopharynx Liver Liver Liver Liver 3 Cervix Stomach Nasopharynx Stomach Colorectal 4 Colorectal Nasopharynx Stomach Breast Breast 5 Liver Colorectal Breast Colorectal Stomach 6 Breast Esophagus Esophagus Nasopharynx Nasopharynx 7 Lung Cervix Cervix Esophagus Esophagus 8

Esophagus

Breast

Colon

Cervix

Cervix

2015 Lung Colorectal Liver Pancreas Stomach Breast Prostate Non-Hodgkin lymphoma

Source: Hong Kong Medical and Health Department Annual Report of respective years from 1949 to 1997 and those of 2015 from Hong Kong Cancer Registry, accessed on 4 March 2019, http://www3.ha.org.hk/cancereg/topten.html.

Table 6.2  Eight most common cancer deaths and their % of total in Hong Kong in 2015 Rank 1 2 3 4 5 6 7 8

Both sexes Site % Lung 28.2 Colorectum 14.5 Liver 11.0 Pancreas 4.8 Stomach 4.7 Breast 4.4 Prostate 2.98 Non-Hodgkin 2.5 lymphoma

Male Site Lung Colorectum Liver Stomach Prostate Pancreas Nasopharynx Esophagus

% 31.2 14.1 13.6 4.9 4.8 4.1 3.1 2.9

Female Site Lung Colorectum Breast Liver Pancreas Stomach Ovary Cervix

% 23.9 15.0 10.7 7.2 5.8 4.3 3.6 2.8

Note: % percent of all deaths. Source: Hong Kong Cancer Registry, accessed on 4 March 2019, http://www3.ha.org. hk/cancereg/topten.html.

Figure 6.2 and Figure 6.3 show the age-standardized mortality rates of the six most deadly cancers separately for men and for women from 1949 through 2013.8 The most striking feature is the marked increase in lung cancer deaths for both sexes from 1949 to 1980s but declined thereafter. Liver and stomach cancers in both sexes, nasopharynx and esophageal cancers in men and cervical cancer in women, showed a gradual falloff in mortality, while prostate cancer mortality in men steadily climbed. Mortality of colorectal cancer in both sexes and breast cancer in women remained essentially unchanged after the initial rise.

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Figure 6.2  Age-standardized mortality rates (no/100,000 men) of six common cancers in men, 1955–2013

Source: Data from International Agency for Research on Cancer, World Health Organization, accessed on 5 March 2019, http://www-dep.iarc.fr/WHOdb/WHOdb.htm.

Figure 6.3  Age-standardized mortality rates (no/100,000 women) of six most common cancers in women, 1955–2013

Source: Data from International Agency for Research on Cancer, World Health Organization, accessed on 5 March 2019, http://www-dep.iarc.fr/WHOdb/WHOdb.htm.

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As Hong Kong evolved from a low-income to a high-income region, the types of cancer in the population also changed. From the 1950s to the 1970s, while it was still emerging economically, Hong Kong had a relatively high incidence of cancers linked to infectious agents, such as cervical cancer (due to HPV), nasopharyngeal carcinoma (EBV), hepatocellular carcinoma (HBV) and stomach cancer (Helicobacter pylori). The age-standardized mortality rates of these tumors peaked in the 1970s and declined thereafter for several reasons: 1) advent of screening programs for early detection of cancers, such as cervical and colorectal; 2) improvement in treatment of cancers; and 3) reduction in cancer incidence. The reduction in cancer incidence is linked to less smoking and better education about risk factors. Improved sanitation, nutrition, and immunity have offered protection against infectious agents in general (e.g. H. pylori). More importantly, new drugs became available in the 1980s for eliminating most of these infectious agents and thereby helped reduce the incidence of cancers. In recent years, there has been a rise in the number of new cases of colorectal cancer in both sexes, prostate cancer in men and breast cancer in women. In 2015, colorectal cancer was the most common cancer of both sexes, prostate cancer the third most common cancer in men, and breast cancer the most common cancer in women.9 These cancers are not caused by an infectious agent, but are linked to “lifestyle” factors such as poor diet (low in fiber, fruits, and vegetables), obesity, and lack of physical exercise. Hong Kong’s adoption of rich countries’ habits has resulted not only in a rise in lifestyle diseases as discussed in the previous chapter, but an alteration in cancer profile as well. The health promotion and diseaseprevention strategies for chronic noncommunicable (lifestyle) diseases, apply equally to the prevention of these cancers.

Cancer Treatment A cancer patient’s chance of survival depends on the type of cancer and stage of cancer at diagnosis. Early diagnosis usually means that it can be removed completely by surgery. Once it has spread beyond its primary site, the cancer is often beyond the reach of surgery, and other modalities of treatment, such as radiotherapy, chemotherapy, immunotherapy, and targeted therapy are required. The development of some of these treatment modalities are discussed below.

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Radiotherapy The discovery of x-rays in 1896 by Wilhelm Conrad Roentgen, a German professor, caused worldwide excitement. Within months, they were being used for diagnosis, and within three years, radiation was being used to treat cancer.10 Radiation therapy began with radium, using relatively low-voltage machines. A breakthrough took place when it was discovered that low daily doses of radiation over several weeks rather than high doses over a few days greatly improved a patient’s chance of survival and with fewer side effects. Over the years, engineers have built ever more powerful devices, enabling x-rays to penetrate more deeply and precisely into the body without damaging the outer tissue. There are currently three main delivery systems for therapeutic radiation: 1) external beam radiation therapy (the patient lies in a linear accelerator); 2) internal radiation therapy or brachytherapy, where radiation is administered in a more focused beam; and 3) systemic radioisotope therapy or unsealed source radiotherapy, where radiation is administered by infusion or injection or by mouth as a pill.11 Radiotherapy may be used in the following situations: 1) as a standalone treatment to cure cancer; 2) to shrink a cancer before surgery; 3) to reduce the risk of cancer recurrence after surgery; 4) to complement chemotherapy; and 5) to control symptoms and improve quality of life if a cancer is too advanced to cure.

Development of Diagnostic and Therapeutic Radiology in Hong Kong X-rays are an integral part of an accurate cancer diagnosis. The first diagnostic x-ray machine in Hong Kong was installed at the Alice Memorial Hospital in 1904.12 When Queen Mary Hospital opened in 1937, it was equipped with both diagnostic and therapeutic radiology.13 As modern imag ing techniques developed, Hong Kong acquired equipment such as computerized tomography (CT) scanning, magnetic resonance imaging (MRI), and positron emission tomography (PET) scanning, soon after they became commercially available. These imaging techniques have been invaluable in the diagnosis and accurate staging of cancers, which is vital for determining the most effective mode of therapy.

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The first x-ray unit for cancer treatment installed at the Queen Mary Hospital was a GE Maximar 400 Kvp unit. At its core was a 400,000-volt shock-proof device used to treat cancer of the cervix. Patients received external deep x-ray treatment, delivered by the GE Maximar unit or radium treatment via hollow needles, delivering 7.5 mg of radium each into the uterus or cervix.14 According to the history of Queen Mary Hospital, “Twenty-one gynecological and 16 surgical cases were treated with radium” in the early months of 1938. Dr. F. J. Farr was the radiologist and Mr. Jack Skinner was the radiographer. During the Second World War, the Japanese removed the essential parts of the GE Maximar unit and shipped them to Japan. Mr. B. Y. Hon, the electrical engineer in charge at Queen Mary Hospital, refused to cooperate, resulting in his torture and subsequent disabling of his right hand.15 After the war, radiation therapy was restarted in August 1949 with the arrival of Dr. John H. C. Ho, who would become a radiodiagnostician and radiotherapist of international repute. He, along with friends and relatives, doggedly raised funds through private donations to buy a 24.9 Curie RadioCobalt Telecurie Unit, and in 1953 they renovated a room at the Queen Mary Hospital to accommodate it. This device was particularly effective in the treatment of NPC, which was a relatively common cancer in Hong Kong at that time and 31 patients with this cancer were treated that year alone.16 Figure 6.4  Professor John H. C. Ho (far right) conducting ward rounds in 1966

Photo courtesy of Hong Kong Anti-Cancer Society and Professor Ho’s family

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Professor Ho, a medical graduate of the University of Hong Kong, earned the unofficial title of Father of Radiology and Oncology of Hong Kong, and was nicknamed “Emperor Ho” by his colleagues for his extensive contributions in the field. During Japanese invasion of China in 1937, he responded to the call of Professor Robert Lim and joined the Emergency Medical Relief Corps in China. On returning to Hong Kong he was placed in charge of Lai Chi Kok Infectious Diseases Hospital. In 1946, he left for England for further studies. It was there that he found his true calling—to be a radiologist and radiotherapist. Ho headed the Medical and Health Department Institute of Radiology, which provided diagnostic services to all Hong Kong government institutions, treating more than 90% of the cases requiring radiation therapy in the entire territory. He built up the department to become a world-renowned center for radiotherapy, and patients came from all over Southeast Asia for treatment.17 Ho founded the Hong Kong AntiCancer Society in 1963 and became its first chairman. His seminal research on NPC, a common cancer in Southeast Asia, resulted in the discovery of the link between NPC and consumption of preserved food, such as salted fish and preserved vegetables. Further discovery that the earlier in life the preservatives were ingested, the greater the likelihood of NPC, led to a strategy for prevention.18 Ho advocated a staging system for NPC that was later adopted (though modified) by the International Union Against Cancer and the American Joint Committee for Cancer Staging. He also designed one of the finest two-dimensional radiotherapy techniques for treatment of NPC, which achieved a five-year survival rate of 52%.19

Chemotherapy: A Versatile Advancement Traditional standard chemotherapy involves the use of rather non-specific intracellular poisons that kill dividing cells by inhibiting cell division (mitosis). Hormonal therapy involves drugs that selectively block the growth-promoting signals originating from classic endocrine hormones, for example, an anti-estrogen drug, tamoxifen, is often used for prevention and treatment of breast cancer. Targeted therapy involves the use of drugs that block specific growth-promoting signals, such as those associated with the receptor for tyrosine kinases.20 There are many types of chemotherapy agents: alkylating agents, antimetabolites, anti-microtubule agents, topoisomerase inhibitors,

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and cytotoxic antibiotics. The first alkylating agent, nitrogen mustard, was discovered during the Second World War; the research was an offshoot of the chemistry that developed mustard gas for use in chemical warfare. Nitrogen mustard was found to work against lymphoma. In 1947, aminopterin, another alkylating agent, successfully induced remission in acute leukemia. Other drugs followed in quick succession: methotrexate in 1949, 6-mercaptopurine in 1952, and the anti-tumor antibiotic, actinomycin D in 1954. These discoveries ushered in the era of chemotherapy, and in the following two decades, more effective alkylating agents, new antimetabolites, and anti-tumor antibiotics were introduced into clinical practice. All of them have a direct effect on DNA or cell division. A major breakthrough in chemotherapy was the simultaneous use of multiple chemotherapeutic drugs. Since these drugs differ in mechanism of action and side effects, using several drugs in combination minimizes the chance of resistance and toxicity, because lower doses of each agent can be used. Some fast-growing leukemias and lymphomas respond well to combination chemotherapy. Different combinations of drugs have now been introduced for different types of tumors. For example, the combination of cyclophosphamide, doxorubicin, and vincristine is used in treating lung cancer while the combination of 5-fluorouracil, folinic acid, and oxaliplatin in colorectal cancer.21 The advent of chemotherapy greatly improved the odds of treating and curing various types of cancers. It can be used in many ways: 1) as the first-line treatment with curative intent; 2) combined with other modalities such as radiation therapy and surgery; 3) as adjuvant therapy, either before surgery, to shrink the tumor, or after, to kill off any remaining cancerous cells; 4) as combination chemotherapy as discussed above; and 5) as salvage chemotherapy, to decrease tumor load and increase life expectancy.

Development of Chemotherapy in Hong Kong In the early 1950s, Professor David Todd and his team at the University of Hong Kong began using chemotherapy to treat lymphoma and leukemia. Arsenic trioxide, in the form of Fowler’s solution (first used by Professor McFadzean), was administered orally three times a day, to treat chronic myeloid leukemias.22 In the 1960s, the team used nitrogen mustard to treat

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lymphomas. Eventually, solid tumors were treated with chemotherapy as well. Professor Daphne Chun started using methotrexate, a recently discovered drug then, for treating choriocarcinoma. When the cancer developed resistance, she switched to actinomycin D.23 In the late 1960s, cyclophosphamide was added to the treatments of hepatocellular carcinoma and lung cancer. By the 1970s many different chemotherapeutic agents, such as daunorubicin, doxorubicin, vincristine, and related alkaloids, were available to treat a large variety of cancers. Targeted therapy began in Hong Kong in the 1990s, initially for chronic myeloid leukemia and later for other cancers such as lung cancer as well. Over the years, newly developed chemotherapeutic drugs have become available in Hong Kong as soon as they were licensed for clinical use in at least two of the centers in the following regions: Europe, the United Kingdom, the United States, or Australia. If the drug has been approved in only one of these places, it could still be obtained in Hong Kong on a case-by-case basis through a temporary license issued by the Department of Health.24 Medical centers in Hong Kong have often participated in clinical trials of new chemotherapeutic agents.

The Hong Kong Anti-Cancer Society and Its Legacies In Hong Kong, the tremendous work done by the Hong Kong AntiCancer Society in combating cancer deserves special recognition and praise. The society was founded in 1963 by Professor John H. C. Ho, together with a group of dedicated cancer patients, to promote, coordinate, and organize a variety of activities aimed at fighting cancer. In 1964, the society became a full member of the Union for International Cancer Control (UICC) and in 1967 it built the first hospital, Nam Long Hospital, to provide hospice care in Hong Kong. In 1991, the management of Nam Long Hospital was transferred to the Hospital Authority. When the government decided to decentralize hospice care, the Anti-Cancer Society, with the assistance of The Hong Kong Jockey Club, converted Nam Long Hospital into a self-financiing cancer rehabilitation center—a 110-bed residential care institution providing services to cancer patients at different stages of the disease. Under the leadership of Professor Ho, the society was instrumental in conducting research on NPC and lung cancer in females. The AntiCancer Society operates the Chinese Medicine Center in collaboration

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with the Baptist University, and runs the Dr. and Mrs. Michael S. K Mak Integrated Chemotherapy Center together with the 12 charity beds which are dedicated to terminally ill patients requiring palliative end-of-life care. The society has adapted to the needs of the community, and continues its efforts toward cancer prevention and early detection, such as promoting cancer awareness and lifestyle risk factors.25

Common Cancers in Hong Kong A bounty of information on cancer causes, diagnoses, management, and prevention is readily available to health professionals and the public. In terms of prevention, the first step is to identify the factors that increase the risk of cancer. Known risk factors include older age (many cancers take decades to develop, therefore they occur often in older adults); environmental factors (such as exposure to radiation, chemicals, viruses, and tobacco smoke); family history (certain cancers are hereditary); and lifestyle and habits (heavy alcohol consumption, smoking, unhealthy diet, prolonged sun exposure, and unsafe sex). These risk factors will be further discussed below. A less well understood factor is the relationship between obesity and cancer. According to the World Cancer Research Fund and the American Institute for Cancer Research, obesity increases the risk of 11 cancers: colorectal, breast (postmenopausal), prostate (advanced), pancreatic, endometrial, kidney, liver, gall-bladder, esophageal, ovarian, and stomach.26 Some common cancers in Hong Kong are discussed below:

Lung Cancer Lung cancer is the second most common type of cancer in Hong Kong, accounting for 19.1% of all new cancer cases in 2015 and is the most common cause of cancer death in Hong Kong (Tables 6.1 and 6.2). It is more prevalent in men, though in the past two decades, lung cancer incidence and mortality in both men and women have declined.27 Tobacco smoking causes about 85% of all lung cancers worldwide. A dizzying number of carcinogens are found in cigarette smoke, including arsenic, cadmium, ammonia, formaldehyde, and benzopyrene. In Hong Kong and in China, the situation is somewhat different from other

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countries; while most men with lung cancer are current smokers or exsmokers, the clear majority of Chinese women who develop the disease (95%) are nonsmokers. Indeed, in Western countries (both sexes) and in Hong Kong (men), a decline in lung cancer followed a decline in smoking. Lung cancer in East Asian women, however, appears to be due to certain gene mutation and is not linked to smoking (see below).28 Exposure to heavy-industry carcinogens as arsenic, aluminum, asbestos, coal-tar fumes, mustard gas, soot, chloromethyl methyl ether, and vinyl chloride, usually occurs in various industries. But these contaminants cannot be implicated in Hong Kong, which has little industry to speak of. There is limited evidence to suggest that red meat, processed meat, total fat, butter, and pharmacological doses of retinol increase the risk of lung cancer. And protective foods, such as certain fruits and foods containing carotenoids, likely mitigate cancer risk.29 There are two major groups of lung cancer: 1) small-cell lung cancers, which occur almost exclusively in heavy smokers, and 2) non-small cell lung cancers, which include squamous cell carcinoma, adenocarcinoma and large-cell carcinoma. Adenocarcinoma is most common, accounting for 85% to 95% of lung cancers. Treatment of lung cancer depends on the cell type and the stage of the disease. Early (stage 1) cancer can be surgically removed and cured outright. More advanced stages may require surgery, chemotherapy, radiotherapy, or a combination of two or all three; but survival rates are poor. Targeted drug therapy is a newer form of treatment that works by zeroing in on a specific mutation in the cancer cells. For example, a proportion of adenocarcinomas of the lung exhibit epidermal growth factor receptor (EGFR) gene mutation. These tumors are more often found in East Asian women who are nonsmokers. Drugs known as EGFR inhibitors have been shown to be effective in targeting and treating these adenocarcinomas. Primary prevention lies in giving up smoking, avoiding secondhand smoke, and limiting occupational exposures. There are several strategies for early detection. While some studies have shown that screening using low-dose CT or fluorescent bronchoscopy in high-risk subjects (i.e., older patients and/or heavy smokers) may be beneficial, more research is needed to evaluate the cost-effectiveness of the various screening procedures. At present the Department of Health in Hong Kong does not recommend routine screening for lung cancer,30 and the public needs more health education on prevention.

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Colorectal Cancers Colorectal cancer is the single most common cancer in Hong Kong for both sexes, accounting for 18.8% of all new cases in 2015,31 and this disease is growing more prevalent. Its incidence has grown by 5% a year in the last decade, outpacing Hong Kong’s population growth tenfold. It is the second leading cause of cancer death for both sexes, accounting for one in seven cancer deaths. For many years starting in the mid-1970s, the agestandardized death rates for colorectal cancer for both sexes accelerated, though in recent years the growth rate has plateaued. About 5% to 10% of colorectal cancers are hereditary. The two major varieties are hereditary nonpolyposis colorectal cancer (Lynch syndrome) and the much rarer familial adenomatous polyposis. A further 20% of colorectal cancers will occur in people with a family history of colorectal cancer. Patients with chronic inflammatory bowel diseases, such as Crohn’s disease and ulcerative colitis, are predisposed to colorectal cancer. Red meat, processed meat, heavy drinking (30 gm ethanol per day), high body fat (abdominal fat in particular), poor diet (low-fiber, high-fat), smoking, sedentariness, and diabetes all increase the risk of colorectal cancer.32 Lifestyle factors are by far the biggest culprit in the rising colorectal cancer numbers in Hong Kong—the bad habits that are the trappings of Hong Kong’s evolution to a high-income economy. Diagnosing colon cancer at its earliest stage offers the greatest chance for a cure, and several screening options exist, each with benefits and drawbacks. These include stool testing for occult blood; flexible sigmoidoscopy to examine the rectum and lower part of the colon; colonoscopy, and virtual colonoscopy (examination of computer generated images of the colon obtained from an abdominal CT scan). The Hong Kong Department of Health has specific advice for people with family histories of colorectal cancer,33 including: 1) carriers of mutated gene of familial adenomatous polyposis; 2) carriers of mutated genes of hereditary nonpolyposis colon cancer; and 3) those with one first-degree relative under age 60 with colorectal cancer, or two affected first-degree relative. For these high-risk groups, regular colonoscopy screening is recommended every 3 to 5 years starting at the ages of 12, 25, and 45 for the three groups, respectively. For people considered to be at “average” risk of the disease, screening is recommended beginning at age 50 to 75 years via one of the following methods: annual or biennial fecal

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occult blood test, flexible sigmoidoscopy every five years, or colonoscopy every ten years.34

Liver Cancer Liver cancer is the fifth most common cancer in Hong Kong, and the third leading cause of cancer deaths in both sexes in 2015, accounting for 5.9% of new cancer cases and 11.0% of all cancer deaths.35 Worldwide, around 80% of all primary liver cancers are caused by chronic viral hepatitis, and individuals infected with HBV are 100 times as likely to develop liver cancer. In Hong Kong and in Southeast Asia, hepatitis B infection was rampant. The virus is transmitted through contact with blood, semen, or other body fluids of an infected person. Newborn babies of infected mothers may become infected through delivery. Hepatitis infection roared through roughly 10% of the population after WWII up to the 1980s, falling to around 5% in the 1990s.36 Hong Kong during this period produced several hepatologists of international renown, including Professors K. C. Lam, C. L. Lai, and Anna Lok. They studied the natural history of chronic hepatitis B and conducted many important drug trials on its treatment. The discovery by Professor C. L. Lai that lamivudine and other antiviral drugs could arrest the destruction of the liver by HBV, and even partially reverse the process of cirrhosis, as well as reducing the risk of hepatocellular carcinoma, has placed Hong Kong on the leading edge of liver research and treatment of hepatitis B using nucleoside/nucleotide(s) analogues.37 In the United States and other industrialized countries, primary liver cancer is more often caused by hepatitis C virus (HCV), which is introduced into the blood stream mainly by intravenous drug use or blood transfusion. Other risk factors for primary liver cancer include inherited liver diseases, such as hemochromatosis and Wilson’s disease, and other conditions such as diabetes, non-alcoholic fatty liver, and exposure to aflatoxins (which contaminate mostly cereals, grains, pulses, and legumes), and heavy alcohol consumption. In Hong Kong, infestation with liver fluke, Clonorchis sinensis, found in raw or undercooked freshwater fish, can cause cholangiocarcinoma.38 Metastatic (secondary) liver cancers, which can spread from the lung, breast, or gastrointestinal tract, are also common.

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Surgical resection is the most direct strategy for attacking primary liver cancer, but the chances of success are variable, depending on the location of the tumor within the liver, the stage of the tumor, and the status of the liver function. Liver transplant is only an option for patients in early stages. Nonsurgical localized treatments, such as radiofrequency ablation using electric current to destroy cancer cells, cryoablation (liquid nitrogen injected directly via a probe into liver tumors), or chemoembolization (chemotherapy drugs injected directly into the tumor) are current options for patients who have early, small cancers. Radiation therapy and targeted drug therapy are also employed. Liver transplantation can be used for hepatocellular carcinoma in patients with associated terminal liver disease, such as advanced cirrhosis. Professor S. T. Fan performed the first successful liver transplant in Hong Kong in 1991, and the world’s first adult-to-adult living donor liver transplantation using a right lobe liver graft in 1996.39 In 1984, to help prevent primary liver cancer, the Hong Kong government started a free vaccination program for all children of hepatitis B-infected mothers. Four years later, the vaccinations became available to everyone.40 The decline in incidence of liver cancer in more recent years in Hong Kong is likely due to the effective treatment of hepatitis B using the nucleoside analogues, such as lamivudine, rather than the vaccination program; the effect of the vaccination program would be seen later. Preventive measures include proper safety precautions against the spread of HBV and HCV through blood transfusions, contaminated needles of intravenous drug users, unprotected sex, avoidance of food items contaminated with aflatoxin (moldy peanuts and cereals), and raw or undercooked freshwater fish. To screen for liver cancer, serum alpha-fetoprotein levels are measured, and ultrasonography of the liver is performed. For high-risk groups, such as hepatitis B or C carriers, the Hong Kong Department of Health recommends that periodic screening (using both tests) be carried out in consultation with healthcare professionals. Routine screening of the general population for liver cancer is not indicated.41

Stomach Cancer Stomach or gastric cancer is the sixth most common cancer in Hong Kong, accounting for 3.8% of all new cancer cases in both sexes in 2015.

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It is the fifth leading cause of cancer deaths in Hong Kong, responsible for about 1 in 23 deaths from all cancers.42 After the initial rise in the 1950s, stomach cancer has been decreasing in both sexes since the 1970s—both in incidence and death rates. Environmental factors or mere aging can change the mucosa in the stomach, leading to chronic atrophic gastritis, a precursor of stomach cancer. Likewise, a persistent infection of the stomach by the bacterium Helicobacter pylori can also lead to cancer if left untreated. H. pylori is commonly present in poor, overcrowded communities with substandard sanitation, spreading through contaminated food and water, and by direct mouth-to-mouth contact. In most populations, the bacterium is acquired early in childhood.43 The research team, under Drs. K. C. Lam and Joseph Sung at the Chinese University of Hong Kong, was renowned for its success in the eradication of H. pylori and peptic ulcer disease by using antibacterial therapy,44 reducing the risk and the incidence of stomach cancer. In the 1990s, the prevalence of H. pylori infection was 55% among healthy blood donors in Hong Kong. Forty percent of children and teenagers, and 72% of those in the 31 to 40 age group were also found to be infected.45 The infection rate among older subjects was likely to be even higher. H. pylori infection in Hong Kong has been on the decline, and in 2008 only 13% of children between 6 and 19 years of age tested positive—comparable to the infection rate in other developed countries.46 In addition to the reduction of H. Pylori infection in childhood, several factors could explain the declining numbers of stomach cancers in recent years: fewer people smoking, fewer people eating food high in nitrates, and improvements in social factors such as lowered poverty rates and reduced instances of overcrowding.47 Exposure to EBV and industrial exposure to ethylene oxide have also been linked to stomach cancers. The World Cancer Research Fund reported that a diet heavy in salt and salt-preserved foods, chili, processed meat, smoked food, and grilled and barbecued animal foods likely also increases the risk of stomach cancer,48 while fruits and allium vegetables (garlic and onion), and non-starchy vegetables that contain large amounts of dietary fiber are protective. Treatment options for stomach cancer depend on the stage of the disease, and as for other cancers, the overall health and personal preferences of the patient. Surgical resection remains the mainstay

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of curative treatment, and nonsurgical treatments include radiation therapy, chemotherapy, and targeted drugs. The Hong Kong Department of Health, like its counterparts in other Western countries, does not recommend routine screening for stomach cancer.

Nasopharyngeal Cancer (NPC) NPC is more common in southern China than in Western countries. Tenth most common in both sexes in 2015, it was responsible for 2.9% of all new cancer diagnoses in Hong Kong.49 NPC was also the tenth most fatal cancers in both sexes in 2015, although its incidence and death rates in both sexes are decreasing. The EBV is causally linked to undifferentiated NPC, as nearly every such tumor is EBV-positive, regardless of geographical origin. Although the virus is present in more than 90% of all people, only a very small proportion develop the tumor. EBV can cause other forms of tumors, such as malignant lymphoma, and in immunocompromised individuals, leiomyosarcomas.50 Other established causes of nasopharyngeal tumors are tobacco smoking and occupational exposure to formaldehyde. In southern China, eating Cantonese-style salted fish, especially during infancy and childhood, increased one’s risk of developing NPC, as reported by Professor Ho and Dr. L. Y. Fong.51 Cooking salt-cured food such as fish and preserved vegetables released chemicals in the steam that may enter the nasal cavity and increase the risk of NPC. A family history of NPC also increases the risk for this cancer.52 These tumors have become much less of a threat in recent years as the public has learned the dangers of eating too much salted fish and other preserved foods, especially in childhood. Improvements in social factors such as poverty, undernutrition, and overcrowding, have contributed to the decline of this tumor. NPC can occur at any age, but it is more commonly diagnosed between the ages of 30 and 50. In the early stage there are often no observable symptoms. In later stages, the individual may present with a lump in the neck from a swollen lymph node, blood in the saliva, bloody discharge from the nose, nasal congestion, hearing loss, or frequent ear infections and headaches. Radiation therapy is the first line of treatment and chemotherapy may be used as a supplement before, during, or after radiation therapy.

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Surgery is not used as a first-line treatment because the anatomical location of the tumor precludes adequate surgical removal, although it is often used to remove metastatic lymph nodes in the neck. In 1989, Professor William Wei and his surgical team in Hong Kong developed the anterolateral approach, or maxillary swing procedure, for surgical removal of localized persistent or recurrent nasopharyngeal carcinoma. This procedure has been accepted globally as an approach to the surgical removal of any pathology in the central skull base.53 Because NPC is prevalent in Hong Kong and treatment of the early stage (stage 1) tumor yields an excellent five-year survival rate (90%), some recommended screening for the tumor in high-risk subjects who have a family history of NPC and are over the age of 30. NPC tends to run in families, with the risk increasing four- to sixfold for individuals with a first-degree relative with this cancer. Screening typically consists of a regular EBV serology test plus nasopharyngoscopy. These are sensitive methods, successfully detecting the disease early in 40% of patients with stage 1 disease. The Cancer Expert Working Group on Cancer Prevention and Screening in 2016 recommended that there is insufficient evidence to recommend a population-based screening program. Those with a family history are advised to consult their own physicians before making an informed decision on screening.54

Esophageal Cancer Esophageal cancer was the eighteenth most common cancer, accounting for between 1% and 2% of all new cancer cases in Hong Kong in 2015. The disease is almost five times as common among males as in women.55 It was a common cancer after the war but its incidence and death rates have declined over the years. In 2014 it was the ninth most fatal cancer in men but dropped out of the list of top ten cancer causing deaths in 2015. Chronic repetitive irritation of the esophagus may contribute to the DNA changes that lead to esophageal cancer. Factors causing esophageal inflammation include excessive alcohol consumption, bile reflux, gastroesophageal reflux, drinking very hot fluids, and achalasia—a condition characterized by difficulty in swallowing due to the esophageal sphincter failing to relax.56 The World Cancer Research Fund reported that non-starchy vegetables, fruits, and food containing carotene and/

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or vitamin C probably protect against esophageal cancer, and there is limited evidence that red meat or processed meat increase the risk for this cancer.57 Esophageal cancer’s decline has been linked to lower alcohol consumption, less tobacco smoking, and better diet, particularly more fresh vegetables and less packaged food laden with preservatives.58 The main treatment of esophageal cancer is surgical resection, though this may result in serious complications, including infection, bleeding, and leakage from the anastomotic site where the remaining esophagus is reattached. Professor G. B. Ong of the University of Hong Kong contributed much to reducing the complication rates resulting from surgical resection of this cancer.59 Prevention lies in reducing the risk factors. There is no recommended screening program for esophageal cancer in Hong Kong or other parts of the world.60

Breast Cancer Breast cancer has been the most common cancer among women in Hong Kong since the early 1970s, and its incidence is increasing. The increase in age-standardized incidence for breast cancer was 3.6% from 1973 to 1999,61 a little higher than the overall average increase of 3.1% of all cancers. Population growth during this time was much lower than cancer growth: just 0.6% per year. Breast cancer accounted for 26.1% of all new cancer cases in women in 2015. One Hong Kong woman in 17 will get breast cancer in her lifetime. Breast cancer is the third leading cause of cancer deaths among women, and it accounts for 10.7% of all cancer deaths in 2015. While more breast cancer cases have occurred in recent years, mortality rates have remained unchanged in two decades, as more effective treatment has become available.62 Breast cancer is a disease of high-income countries, where the overall incidence is nearly triple that of middle- to low-income countries. Until the 1990s, mortality rates for breast cancer in the United States was two to three times higher than those in Hong Kong,63 but that gap has closed. Hormones play an important role in breast cancer progression because they modulate the structure and growth of the tumor cells and breast cancers vary in hormone sensitivity. About 5% to 10% of breast cancers are linked to inherited mutated genes. Mutations in breast cancer

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gene 1 (BRCA1) and breast cancer gene 2 (BRCA2) increase a woman’s risk of developing breast and ovarian cancers. Other risk factors include: gender (cancer of the male breast is rare), age (risk rises with age), a personal history of breast cancer, a family history of breast cancer, radiation exposure, obesity, early menarche, late menopause, having no children, having had a first child late in life, no breastfeeding, and taking combined estrogen and progesterone hormone therapy for menopause. Behavioral or lifestyle factors such as physical inactivity, heavy alcohol consumption, and obesity (or even just a high proportion of abdominal fat) are also associated with a higher risk of postmenopausal breast cancer, while having a somewhat higher-than-average body-mass index (BMI) probably protects against premenopausal breast cancer.64 Treatment options for breast cancer depend on its stage, grade, size, and type. It also varies according to whether the cancer cells are sensitive to hormones, as well as on the overall health of the patient. Most women undergo surgery and also receive additional treatment such as chemotherapy, hormone therapy, or radiation before or after surgery. Surgery typically involves removing the cancer (lumpectomy), removing the entire breast (mastectomy), removing a limited number of lymph nodes, or removing several lymph nodes in the axilla, depending on the stage of the disease. If the cancer is in both breasts, a double-mastectomy may be called for. Some women with cancer in only one breast may choose to have the other healthy breast removed if they are, by virtue of genetic predisposition, at very high risk of eventually developing cancer in the other breast. External radiation is commonly used after a lumpectomy for earlystage breast cancer. Chemotherapy is sometimes used to shrink the size of a large tumor before surgery, or when the cancer has spread elsewhere. Hormone therapy or hormone-blocking therapy is often used to treat cancers that are sensitive to hormones, or when the tumor has spread to other parts of the body. It can also be used after surgery to help prevent recurrence. There are also several targeted treatment drugs that attack specific molecular abnormalities of cancer cells. Self-examination may help women to identify any unusual signs and symptoms early. Women with average risk of breast cancer can reduce their risk further by being physically active, avoiding alcohol, having children relatively young, breastfeeding each child for a long time, and limiting postmenopausal hormone therapy. Weight management and

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healthy diet choices (lots of fruits and vegetables) also reduce the risk of postmenopausal breast cancer. The Hong Kong Department of Health does not at present recommend mammography for women with a low-to-average risk for breast cancer.65 This is at variance with the Canadian Task Force on Preventive Health Care’s recommendation that women of average risk who are aged 50–74 have routine mammography screening every two to three years.66 Women with a higher risk who have not had genetic testing themselves, or women who had chest radiotherapy when they were between 10 and 30 years of age, should consult a doctor and assess their options. The higher risk group includes women with personal histories of breast cancer, history of breast cancer in a first-degree relative, known BRCA1/BRCA2 gene mutation, or a first-degree relative with a BRCA1/ BRCA2 mutation. The American Cancer Society recommends an annual MRI and mammogram if their lifetime risk is more than 15%, based on the risk-assessment tools published by the society. Screening with MRI and mammogram should begin at age 30 and continue for as long as a woman is in good health.67 Some options are available even to the very high-risk group to improve their odds. Estrogen-blocking drugs such as tamoxifen and others may help reduce the likelihood of contracting breast cancer. Because these so-called preventative medications carry the risk of side effects, they are typically reserved for women who are strongly genetically predisposed toward the disease. This group may also choose preventive surgery to remove healthy breasts—prophylactic mastectomy—and/or elect to have their ovaries removed to reduce the risk of both breast and ovarian cancer.

Cervical Cancer Both the incidence and mortality rates of cervical cancer, the deadliest cancer for Hong Kong women in the 1950s, have been steadily decreasing, 68 ranking seventh and eighth respectively in 2015. Agestandardized incidence and mortality rates of cervical cancer declined 4.2% and 6% per year respectively between 1997 and 2006.69 Cervical cancer is a disease of moderate to low-income countries, with overall rates nearly twice as high as in high-income countries. In the 1960s, the mortality rates of cervical cancer in women in Hong Kong

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were about one and a half times those in the United State, but by the turn of the twenty-first century the gap had closed. HPV infection is an established cause of cervical cancer. There are around 200 types of papillomavirus, but only around 40 infect human mucosal areas, and only a few are carcinogenic. HPV-16 and HPV-18 are most commonly associated with cervical cancer, while HPV-6 and HPV11 are associated with benign anogenital warts. Transmission of genital HPV infection occurs mainly through sexual contact. Smoking, weakened immunity, and lack of dietary fruits and vegetables are other risk factors.70 Treatment depends on the stage of the disease. The earliest stage, before the tumor shows stromal invasion, is known as carcinoma in situ and it can be readily treated by local ablation such as a cone biopsy. Early stage invasive cervical cancers are typically treated surgically, removing the uterus. More advanced stages require radiation, alone or with chemotherapy before surgery to shrink the tumor, or after surgery to kill any remaining cancer cells. Screening for cervical cancer is done by the cervical smear test (Pap smear), which detects abnormal cell changes of the cervix. Additionally, the HPV DNA test can be used to detect the presence of HPV in cervical cells. Organized population-based Pap smear screening has been highly effective in reducing cervical cancer incidence and deaths. Screening every three years reduces the cumulative risk of cervical cancer by more than 90%, compared with no screening. Studies have found that screening more frequently than three years provides little additional protection for women with average risk. The Hong Kong Department of Health recommends that all women between the ages of 25 and 64 who have ever had sexual intercourse get a Pap smear every three years, after two consecutive normal annual smears. Screening may be discontinued in women aged 64 or above if three previous consecutive smears within 10 years find no irregularities. Women over 65 who have never had a cervical smear should have the test, and those who have never had sexual intercourse or who have had a total hysterectomy need not have cervical screening. For the high-risk group, women under 25, and those who are immunocompromised, more frequent screening is required, as dictated by medical professionals. HPV DNA tests could be called for as an alternative to repeating a cervical smear when that test shows “atypical squamous cells of undetermined significance.”71

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To date, two prophylactic vaccines against HPV infection are available and approved for use in Hong Kong, but the duration of protection is still not known. The recommended time of vaccination is before the commencement of sexual activity. Since the HPV vaccination does not provide protection against all HPV viruses, regular cervical screening is still recommended. A long-term mutually monogamous relationship with an uninfected partner, the practice of safe sex by using barrier and spermicidal contraceptives, avoidance of tobacco smoking or exposure to secondhand smoke, and having a healthy diet with fruits and vegetables are suggested measures for primary prevention of cervical cancer.

Prostate Cancer Prostate cancer is the third most common cancer in men, accounting for 11.9% of all new cancer cases in Hong Kong, and 4.8% of male cancer deaths in 2015. It is the fifth leading cause of cancer death in men, and both incidence and mortality rates of this cancer are increasing.72 Prostate cancer is mainly a disease of high-income countries, where the overall rates are nearly six times as high as those in middle- to lowincome countries. In the 1960s, the mortality rate of prostate cancer in the United States was about five times as high as that in Hong Kong, and it remained high until the 1990s, when it began to decline, due to better treatment and early detection. Those who are older, black, obese, with a family history of prostate or breast cancer, with a genetic predisposition (BRCA1 or BRCA2 in the family), or with a very strong family history of breast cancer, are at greater risk for prostate cancer. An increasingly Westernized diet has been blamed for the increase in prostate cancer in Hong Kong in the past few decades. A diet high in calcium, processed meat, milk, and dairy products increases the risk of this cancer, while foods containing lycopene or selenium are thought to protect against prostate cancer. There is some evidence that pulses (including soya products), foods containing vitamin E, and alpha-tocopherol supplements, are protective.73 High-grade prostate cancers are aggressive and spread quickly, and the prognosis is best when this type of tumor is caught early and is still contained within the prostate gland. Most prostate cancers, however, are slow-growing and locally confined, and they may need minimal or

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even no treatment. For the low-grade, early-stage cancers, some doctors recommend active surveillance, which involves regular follow-up with blood tests, rectal examinations, and possibly repeated biopsies, to assess the progression of the cancer. If tests indicate growth, surgery, or radiation or hormonal therapy will be required. Digital rectal examinations and measurements of prostate specific antigen (PSA) levels in the blood, once routine procedures in screening prostate cancer, are falling out of favor, as they tend to produce falsepositives and have not been shown to reduce the risk of death. PSA testing for prostate cancer is controversial and not recommended by the Department of Health in Hong Kong. Evidence suggests that the risk of prostate cancer may be reduced by several preventive measures: a healthy diet of fruits and vegetables, exercise most days of the week, and maintaining a normal weight.

Prevention of Cancers While advances in radiotherapy and chemotherapy together with surgery reduced mortality of cancers and prolonged the life of many cancer victims, there is nothing better than prevention. Recent studies have shown that over half of cancers can be prevented by applying our current knowledge. In addition to smoke cessation which decreases risk of cancer in most organs, the following measures have also been found to be effective: • lung cancer: smoke cessation at the age of 50 has resulted in a 62% reduction in lung-cancer mortality;74 • uterine cervical cancer: vaccination against human papillomavirus is associated with a 90% reduction in mortality;75 • liver cancer from hepatitis B infection: treatment with antiviral drugs and prevention of infection by vaccination against hepatitis B virus has led to a 90% reduction in mortality;76 • liver cancer from hepatitis C infection: treatment of hepatitis C virus infection with antiviral drugs has led to reduction in mortality;77 • colorectal cancer: early diagnosis by following screening program and the use of anti-inflammatory aspirin reduces the mortality from colorectal cancer;78

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• breast cancer: treatment with selective estrogen-receptor modulators reduces the incidence of breast cancer by 50% among high-risk women;79 and prophylactic salpingo-oophorectomy reduces the risk of breast and ovarian cancer in women with a BRCA1/2 mutation;80 • skin cancer and melanoma: protect oneself from the midday sun, use of sunscreen and avoidance of tanning beds and sunlamps; • stomach cancer: adequate treatment of H. pylori infection. In Hong Kong, among the strategies for cancer prevention, smoking cessation, cervical cancer screening, NPC screening, hepatitis B vaccination and treatment of HBV and H. pylori have been most successful. Prevention programs, which focus on modifying other lifestyle risk factors other than smoke cessation, such as obesity, healthy diet, and physical inactivity, have not yet been effectively carried out. Cancers have been the leading cause of death in Hong Kong since the 1970s. The high rates of cancer morbidity and mortality translate into huge healthcare costs and a heavy burden to patients, their families, and the government. It is imperative that more emphasis should be placed on cancer prevention by disseminating the results of research on cancer prevention, implementing policies that are evidence-based, and that all residents should be given equal access to cancer prevention and screening programs—strategies that Hong Kong should be more active in pursuing.

7. Emerging Infectious Diseases

Infectious diseases that have either appeared within the past two decades or become more prevalent in that time are considered “emerging” diseases. They can be caused by newly identified infectious agents, such as the viruses in severe acute respiratory syndrome (SARS) and acquired immune deficiency syndrome (AIDS); by reemerging infections, such as drug-resistant tuberculosis; or by nosocomial infections, such as methicillin-resistant Staphylococcus aureus, which often develop antibiotic resistance in hospitals. It is interesting to note that many emerging diseases are zoonotic, meaning the organism incubates inside of an animal, with only occasional transmission into human population: notable examples are avian influenza and swine influenza. Several factors contribute to outbreaks of emerging infectious diseases: genetic drift of microbial adaption, such as in influenza A; changing human susceptibility as seen in immunocompromised conditions; varying weather and climate as seen in diseases with zoonotic vectors; the use of antibiotics to increase meat yield; war and famine; the breakdown of public health; or poverty. In southern China, the dense population and close proximity of people to animals enable viruses to jump the species barrier and become pathogenic in humans. Globalization and rapid air travel allow microbes to propagate rapidly around the globe. SARS is a vivid case in point. Hong Kong has experienced several emerging or reemerging infections in recent decades. AIDS, avian influenza, and SARS are the most prominent. These deadly epidemics, especially SARS, severely tested Hong Kong’s ability to tackle a medical crisis.

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Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) Epidemic The US Centers for Disease Control and Prevention (CDC) reported that in the spring of 1981 in Los Angeles, California, five previously healthy young men between 29 and 36 years of age had contracted pneumocystis pneumonia (PCP), a rare form of fungal pneumonia. PCP typically only occurs in people who are severely immunocompromised—for example, patients who have been taking powerful immunosuppressive drugs for medical problems. The only feature the patients had in common in this puzzling outbreak was that they were all young gay men. In July of the same year, 26 men developed Kaposi’s sarcoma, a rare form of cancer caused by a virus that typically produces flat purple tumors of the blood vessels, visible on the skin and invisible elsewhere. All the men lost weight, developed swollen lymph glands, and soon died. Again, the disease seemed to affect only homosexual men.1 The two outbreaks marked the beginning of the AIDS epidemic in the West. These two clusters of patients died from multiple infections, due to a depletion of infection-fighting CD4 lymphocytes. Soon other groups, such as drug users who shared needles, and hemophiliacs who required frequent blood transfusions, developed the same symptoms of marked weight loss and unusual infections. The disease was no longer limited to homosexual men. The new disease swept through the United States and, in November 1982, the CDC reported 788 cases in 33 states. By then it was formally named acquired immune deficiency syndrome (AIDS), and the race was on to isolate the causal agent. In May 1983, a French group, led by Luc Montagnier and Francoise Barré-Sinoussi, discovered a new retrovirus that they suspected of causing AIDS. They called it lymphadenopathyassociated virus. At around the same time an American group led by Peter Gallo found a virus that they believed to be the culprit. The two groups of scientists were, in fact, looking at the same organism. Since the French group discovered the virus first, they were honored with the Nobel Prize in Physiology/Medicine in 2008.2 In 2011, there were roughly one million cases of HIV infection in the United States, and 56,000 or so new cases continue to be recorded each year—a remarkably high number given the enormous effort spent on sexual education. HIV affects nearly every country. In 2015, 36.7 million people worldwide were living with HIV, of whom 17.8 million

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were women and 1.8 million were children, while 2.1 million were newly infected cases. In some southern African countries, as high as 70% of hospitalized patients were HIV-infected, and in certain populations the prevalence of infection exceeded 45%. HIV infection created the greatest orphan crisis in the world—in 2006, more than 13 million children were orphaned by HIV, most of them in the poverty stricken sub-Sahara Africa where most AID-related deaths occurred.3

Origin of HIV Infection The early cases reported in the United States in 1981 were not the first cases of AIDS. Missionary doctors had described similar symptom profiles in Central African patients almost a decade earlier. Research suggests that the most common form of HIV probably originated when simian immunodeficiency virus passed from chimpanzees to humans in Central Africa between 1902 and 1921. There are two strains of HIV: HIV-1 and HIV-2. The former, generally more virulent and dangerous, is found mostly in the United States and the rest of the world; the latter is less aggressive and found mostly in West Africa. HIV-1 reached Haiti in 1966 and arrived in the United States about four years later. There it quietly spread for a decade before fully manifesting in the early 1980s.4 As a retrovirus, HIV is remarkably delicate. It needs a human host and does not survive well outside the body. It is usually transmitted through exposure to infected blood or bodily fluids such as semen, genital secretions or breast milk. Transfusions of contaminated blood or blood products carried the highest risk of infection until a screening method for detecting HIV in blood became available in 1985. Other high risks of HIV transmission include pricks from contaminated needles, needle-sharing among intravenous drug addicts, and anal sex. HIV may be transmitted from mother to child during pregnancy, delivery, and breast feeding. The risk is highest during labor and delivery, and can be drastically reduced by the use of antiviral drugs and delivery by Caesarean section.5

How Does the Virus Cause Disease? The virus’s sole mission is to replicate itself by multiplying. HIV does so by attaching itself to a specific receptor (CD4) on the cell membrane of a host lymphocyte, which is a white blood cell of the lymphatic system

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that plays a pivotal role in the body’s defense system. Once attached, it destabilizes the surface of the CD4 lymphocyte cell and enables it to pass into the cytoplasm of the infected cell. Inside the cell, the virus moves to the nucleus where its two viral enzymes, reverse transcriptase and integrase, begin their work. The former starts copying the HIV RNA into HIV DNA, and the latter integrates the HIV DNA into the host cell’s DNA. The HIV virus remains in the cell, and the infection can stay dormant until the infected cell is activated when a favorable environment presents itself. The infected cell then begins to produce not only its own proteins, but many HIV proteins. To carry on their single mission, the newly formed HIV viruses break off from the surface of the cell to infect other lymphocytes. When the CD4 cell dies and ruptures, millions of viruses are released to infect other cells.6 If the disease is untreated, over the course of several years, the number of CD4 cells will decline, and dwindle to 200 cells per microliter (μL).

Clinical Course of HIV Infection Once the HIV particles are ingested by the CD4 lymphocytes and macrophages, the immune system is activated. The patient in this early stage may have fever, diffuse pain, and fatigue as the immune system fights the infection. Usually these symptoms are self-limiting. The diagnosis of HIV infection is made by demonstrating the presence of HIV antibodies in the blood using one of two blood tests: the enzyme immunoassay (EIA) or enzyme-linked immunosorbent assay (ELISA). As both techniques can give rise to a false-positive result, a highly specific western blot assay is performed to confirm a positive test. Routine testing for HIV antibodies in donors’ blood has led to effective identification of contaminated blood and increasing confidence in the safety of blood supplied for transfusions.7 A normal, immunocompetent person has anywhere from 500 to 1500 CD4 cells per μL of blood. It is only when the number of CD4 cells drops to 200 per μL that an infected person is considered to have the disease AIDS, which represents the last stage of the HIV infection.8 By destroying the CD4 lymphocytes, the virus markedly weakens the immune system and the body loses its ability to fight off opportunist infections. At that point, the patient frequently presents with opportunistic viral, fungal,

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Figure 7.1  Chest X-ray of a patient with pneumocystis pneumonia showing bilateral diffuse ground glass shadows

Photo courtesy of Drs. Julie Wang and C. L. Lam

or bacterial infection, alone or in any combination. Examples are PCP, cryptococcosis, mycobacteria avium intracellulare, and reactivation of toxoplasmosis or cytomegalovirus infections. HIV infection can coexist with other non-opportunistic infections such as hepatitis B or C, tuberculosis, or syphilis, and may worsen these infections. Tuberculosis, in the presence HIV coinfection, can be difficult to diagnose. The presence of syphilis increases the risk of HIV infection.9 Immunocompromised AIDS patients are also prone to developing various types of unusual tumors, most notably Kaposi’s sarcoma, a malignant form of vascular tumor, and lymphoma. These lymphomas frequently appear in unconventional extra-nodal sites, such as the central nervous system and the body cavity. Anti-HIV medications have developed and evolved at an amazingly rapid pace. In the quarter-century since the discovery of nucleoside reverse transcriptase inhibitors (NRTIs), and azidothymidine (AZT) in 1990, more than 30 drugs in five different classes have been developed, tested and approved for use. The enzyme reverse transcriptase of the HIV virus is often capable of causing mutation by making changes in the viral genome, allowing it to evade the immune system or to develop

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resistance to the anti-viral drug. The drugs for HIV treatment should be used in combination to increase their effectiveness, reduce side effects and the likelihood of viral resistance. A cocktail of two or even three HIV drugs can reduce the number of pills to be taken each day. In the past, medications were usually only given when the CD4 cell count dropped to 200 per μL, but now they are given much earlier—even for those with CD4 cell counts above 500 per μL—in order to prevent the long-term problems of HIV infection.10 HIV/AIDS is no longer a fatal disease. Patients enjoy long and active lives if they take their medications regularly and have regular health check-ups.

HIV Epidemic in Hong Kong In the 1980s, Hong Kong—a cosmopolitan city of more than six million with a highly mobile population, tolerant attitudes and flourishing commercial sex industry—was a prime incubator for HIV. Anticipating the coming epidemic, the Medical and Health Department set up an Expert Committee and a Scientific Working Group on AIDS in 1984. The first case of HIV infection was diagnosed shortly thereafter, and the first case of AIDS was reported the following year.11 The Queen Elizabeth Hospital set up a counseling clinic for those who feared that they might have contracted the virus. A doctor and a health nurse followed up those who tested HIV positive with treatment and counseling. The AIDS program was not under the administration of the Hospital Authority but remained a centralized government operation under the Department of Health. Queen Elizabeth Hospital was the designated hospital for treating AIDS patients due to its proximity to the HIV clinic.12 The Hong Kong Red Cross Blood Transfusion Service began screening all donated blood for HIV in August 1985 when the ELISA test for HIV antibodies had become available. The government also procured safer, heat-treated blood products. During the early phase of the outbreak, most government-initiated efforts did not involve the community, but when the number of cases reached 107 in 1987, the government began to enlist the public in the fight against AIDS. A Committee on Education and Publicity was set up to undertake AIDS public education and prevention, and organized many AIDS-related educational activities, including an awareness campaign

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focusing on safer sex and drug abuse. The Government Information Service produced the first televised public-service announcement,13 published the first book on HIV/AIDS for doctors and dentists, and, together with the Education Department, produced “Guidelines on Prevention of Bloodborne Diseases in Schools.”14 The Hong Kong Medical and Health Department set up an AIDS Counseling Service in 1985 to provide telephone consultations, HIV testing, and clinical follow-up. The government organized seminars for doctors, nurses, and paramedical personnel during this period, and in 1987, the AIDS Counseling Service brought educational talks on AIDS into secondary schools.15 Despite all the above effort, the number of cases of HIV infection and AIDS continued to rise (Figure 7.2). In 1990, the governor, recognizing that a more comprehensive strategy was needed, appointed an Advisory Council on AIDS to assist the Director of Health in all aspects of the AIDS program. The council published a policy paper called “Strategies for AIDS Prevention, Care and Control in Hong Kong” in 1994 and met every five years thereafter, to review the status of AIDS in Hong Kong and to recommend new strategies based on the latest findings. The government also established an AIDS Trust Fund to support AIDS programs and services, and to cover payment to HIV-infected hemophiliacs and transfusion recipients.16 Several AIDS-specific NGOs also emerged. The AIDS Concern Foundation began working with the gay community in 1990,17 and is the first NGO in Hong Kong committed to AIDS care and consultation. Its mission is to suppress HIV prevalence in Hong Kong through targeted prevention and care programs for vulnerable communities, and to eliminate the stigma attached to those suffering from HIV and AIDS. Their most successful campaign, “Protect our People,” aims to promote sexual health by encouraging safe-sex practices and promote early and regular testing through the participation of community members and LGBT (lesbian, gay, bisexual and transgender)–friendly merchants. The Hong Kong AIDS Foundation was established in 1991, with a goal of limiting the spread of HIV infection in the community by enhancing public knowledge of HIV/AIDS. The foundation provides a wide range of support services for AIDS patients and their families including an AIDS hotline, an HIV antibodies test, referral services to different specialists, financial assistance, and a mutual-support network with organized outings for AIDS patients.18

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The AIDS Memorial Quilt Project was founded in 1994 to recognize men and women who have died of AIDS. Established in November 1994, the Society for AIDS Care was the first NGO in Asia to provide high-quality direct patient-care services to children, adults, and elderly people living with HIV/AIDS, as well as their caregivers in the community. With a professional team consisting of nurses, social workers, counselors, and physiotherapists, the Society provides outreach services and center-based services, including drug supervision, therapeutic counseling, and psychological support.19 The government’s Center for Health Protection, established in 2004, organized the HIV Surveillance Program with a five-point agenda: voluntary HIV/AIDS case-based reporting, HIV prevalence surveys, sexually transmitted-infection monitoring, behavior studies, and HIV-1 genotyping studies. The data are collected, analyzed, and disseminated regularly. With the plethora of programs organized by the government and the community, one would expect the epidemic to be fully under control, but it is not. In recent years the number of AIDS cases has climbed steadily, with the number of HIV infections rising steeply (Figure 7.2). In 2015 alone, the Department of Health received 725 HIV and 110 AIDS case reports—a record one-year high—bringing cumulative totals to 6,993 and 1,545, respectively.20 Figure 7.2  Cumulative number of cases of HIV and AIDS, 1985–2015

Source: Modified from HIV Surveillance Report- 2015 update, Special Preventive Program, Center for Health Protection, Department of Health, HKSAR, 2016, accessed on 6 March 2019, https://www.aids.gov.hk/english/surveillance/sur_report/hiv15.pdf.

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In 2015, 86.1% of Hong Kong’s reported HIV cases were male, with 74% Chinese and 11% non-Chinese Asians. The mean age was 34 years. Nearly 85% of the HIV-positive acquired the virus through sexual transmission, including homosexual/bisexual (64.0%), and heterosexual (20.3%). Intravenous drug use accounted for 2.1% and in about 13.4% the mode of transmission was undetermined.21 Since 2004, there has been a rising trend of sexual transmission of HIV among gay men, especially Chinese in their twenties. The prevalence of HIV among local gay men was around 5.85% in 2015,22 higher than reported in previous years (around 4%),23 and higher than other at-risk populations such as female sex workers and drug users. Heterosexual transmission has remained relatively stable, with around 130 cases per year, as have the number of cases in drug users. Condom use among gay men with different partners has increased, and the rates of HIV testing has also grown, which may partly explain why the number of new infections detected in the community remains high and is indeed climbing. But among subgroups such as young gay males who find sexual partners through the internet, underground sex workers, ethnic-minority drug users, and people who travel overseas for sex, risky behavior remains high and levels of condom use low. The AIDS Advisory Council has recently undertaken special efforts to ensure that sex education, and increased awareness of AIDS and the importance of condom use, reach as many individuals in these at-risk populations as possible.24 HIV reached Hong Kong three years after the United States. The city had time to be prepared. Despite this, once the disease had a foothold, it spread slowly but surely. As in other parts of the world, the disease became endemic. It seems that the HIV prevention programs failed to reach the whole targeted constituency where risky sex behavior persists. There remains a considerable amount of health education work to be done.

Avian Influenza (1997)—It’s Not Just Birds Avian influenza was once strictly a disease of birds and waterfowl. The occasional pig would sometimes be infected. Most cases of avian influenza are mild, but the avian influenza virus H5N1 is highly pathogenic. Avian influenza has killed countless numbers of birds since its outbreak in 1997.

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Migratory birds that carry the virus but remain asymptomatic are responsible for the spread of avian influenza. In their travels, they come into contact with other wild birds or domestic or industrial poultry. In the latter, the disease becomes lethal. In the poultry industry, thousands of chickens are kept in cramped conditions, literally walking on each other’s contaminated feces, and being sneezed upon by other contaminated captives. In Southeast Asia, teeming chicken coops are often found alongside overcrowded human dwellings, and one can imagine how easily the virus can jump species.25 In March 1997 in Hong Kong, several outbreaks of influenza swept through industrial poultry operations, resulting in the death of some 7,000 chickens. In May, a three-year-old boy died of what was later diagnosed as the H5N1 virus. The boy’s school had housed live chickens, some of which also died. At that time Hong Kong was busily preparing for the handover ceremony marking the official 1 July transfer of Hong Kong from the United Kingdom to the People’s Republic of China. Understandably little attention was paid to the case of a small boy who died of pneumonia from an influenza virus, especially no new cases appeared since. In November, a two-year-old became sick with pneumonia due to H5N1 virus. In the ensuing month, 17 new cases raised the alarm. The patients presented with fever and in some cases symptoms of pneumonia. All were infected with H5N1 and had been exposed to live poultry in the week before the onset of illness. Six died.26 Large-scale outbreaks of fatal avian influenza had occurred in chicken farms in the northwestern part of Hong Kong in March and April of 1997 and recurred between October and December of that year. The virus, in each case, was discovered to be same as those found in the humans.27 The virological findings and the temporal relationship between avian and human outbreaks strongly suggested that, for the first time, a direct chicken-to-human cross-species transmission of the virus had taken place.28 By late December, almost 20% of chickens in the markets were infected with this virus, and the government had no choice but to order the slaughter of all the poultry in farms and markets (Figure 7.3). Some 1.5 million chickens were culled, and the import of live poultry from mainland China was suspended. The government spent a total of HK$246 million on the 1997 epidemic, for compensation and ex gratia allowances to live poultry traders.

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Figure 7.3  Culling of chickens during the 1977 epidemic of avian influenza

The chickens were collected by Agriculture, Fisheries and Conservation Department in Cheung Sha Wan wholesale market. Photo courtesy of South China Morning Post, 31 December 2014.

Even though mainland China regarded the avian flu as a local disease originating in Hong Kong, most scientists believed that the source of the lethal H5N1 virus had probably originated in Guangdong. The H5N1 strains that caused the 1997 outbreak were reassortants from multiple cocirculating avian influenza strains and the transmission from chicken to human happened directly, without passing through swine as a “mixing vessel.”29 The Chinese traditionally prefer chicken to beef, and freshly slaughtered chicken to frozen. Around 100,000 birds are consumed in Hong Kong each day, and that number triples during festivals. The daily exposure of the general public to chicken during transportation, and at wholesale and retail outlets, is an ongoing concern. This risk is further aggravated by the propensity of the H5N1 virus to mutate and reassort with genes of other species. After the 1997 outbreak, the government put in place a comprehensive prevention and surveillance program to reduce the likelihood of another avian influenza outbreak. But in February 2001, H5N1 was again detected, this time in fecal samples taken at a retail market in the western district, although no poultry deaths were reported. In May 2001, clusters of chicken deaths were reported in retail markets throughout Hong Kong and the H5N1 virus was found. The government had to carry out a second territory-

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wide slaughter of poultry, and another suspension of the importation of live birds.30 Acknowledging that the H5N1 influenza has the potential to become a fatal disease in humans—with huge attendant social and financial costs—the government has, since 2003, launched more stringent preventive measures. The Ag riculture, Fisheries and Conservation Department (AFCD) introduced a vaccination program for all local chicken farms. The government also secured the mainland’s agreement and cooperation in vaccinating all chickens to be exported to Hong Kong. This means every chicken available at market has been vaccinated against H5N1 avian influenza. For local farms, AFCD also tests the antibody levels of vaccinated chickens to ensure that the vaccine is working. Prior to sale, each batch of chickens is also inspected and tested. Imported chickens must come from registered farms recognized by the mainland authority, and each consignment must be accompanied by a health certificate. The Food and Environmental Hygiene Department tests the antibody levels for the H5 virus, in all imported chickens. It also monitors all sick and dead poultry. All waterfowl in Hong Kong must be centrally slaughtered, as they are natural carriers of avian influenza virus. At both the retail and the wholesale levels the government imposed two rest days per month to reduce the viral load in the markets. Stringent hygiene measures were introduced, such as thorough daily cleansing and disinfecting of transport cages, and no overcrowding of chickens in cages. If a single dead bird was detected with H5 virus, all live poultry had to be surrendered and destroyed. In the wet markets, the poultry stalls were enlarged and air-conditioned, with properly ventilated holding areas for live poultry. A transparent floor-to-ceiling acrylic/glass panel was installed to separate the live poultry holding area from the customers. Limits on the number of live poultry permitted to be stocked in each stall were strictly enforced. These measures will hopefully stop the H5N1 virus from infiltrating the poultry populations through the supply chains and will prevent the avian influenza viruses from mutating and reassorting into lethal strains. The budget for the program in 2003 was HK$39 million.31 From time to time there have been calls to replace the practice of killing birds in retail outlets with centralized slaughter in Hong Kong, to minimize the close contact between the public and live poultry. However,

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such calls routinely meet stiff resistance from those in the poultry trade, the transportation trade, and the public at large. A centuries-old habit of consuming freshly slaughtered chickens dies hard, and in Hong Kong, the pleasure of the palate trumps common sense.

The Influenza Virus The avian influenza virus (H5N1) is a RNA virus of the Orthomyxoviridae family. There are three main types of influenza virus: A, B, and C. Influenza A viruses are the most widespread and significant, infecting many different avian and mammalian species (including humans). Influenza B and C viruses are chiefly human pathogens that rarely infect other species. There are many proteins on the surface of the mature virion that determine the antigenic subtypes and the pathogenicity of the virus. Influenza A has 16 different HA antigens (H1 to H16) and nine different NA antigens (N1 to N9). Each subtype has mutated into a variety of strains with differing pathogenic profiles. Some are pathogenic only to a single species, while others are pathogenic to multiple species and can wreak enormous havoc very quickly.32 In humans, “the flu” presents with fever, sore throat, muscle pains, severe headache, cough, fatigue and, in severe cases, pneumonia. Typically, influenza is transmitted from infected mammals through the air by way of coughing or sneezing, and from infected birds through their droppings. It can also be transmitted by saliva, nasal secretions, feces, and blood. The influenza virus remains infectious for about a week at human body temperature, and for a full month at 0°C. Vaccinations against influenza are most often given to high-risk people in industrialized countries, and to farmed poultry. The most common human vaccine is the trivalent influenza vaccine, which contains two influenza A virus subtypes and one influenza B virus strain. A vaccine formulated for any one year may become ineffective the following year, as the influenza virus mutates constantly while replicating itself. The virus can change little by little, through small copying errors during replication (antigenic drift), with a variant of the virus emerging every two to three years. The virus can also change abruptly (antigenic shift), creating a completely new virus. Scientists believe that such antigenic shifts resulted in the pandemics of 1957 and 1968 in the twentieth century.

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Pandemic Influenza The avian influenza A (H5N1) outbreak of 1997 did not, fortunately, lead to a pandemic, but seasonal influenza is a frequent occurrence in Hong Kong. Southeast Asia—especially the Pearl River Delta region, where the densely packed population and the close habitat of humans and their domestic animals has served as an incubator for the influenza virus for decades. The 1957 and 1968 influenza pandemics appeared first in Southeast Asia and spread to Hong Kong. From there the virus disseminated rapidly to other parts of the world through hundreds of daily international flights. Hong Kong and other global-crossroads cities, such as London and New York, are particularly likely to be hubs of influenza pandemics. Given antigenic shifts, and increasing international air travel, it is highly possible that there will be influenza pandemics in the future. The three pandemics of influenza in the twentieth century (1918, 1957, and 1968) were named after their presumed place of origin: Spain, Asia, and Hong Kong. They were caused by three different antigenic subtypes of influenza A virus (Table 7.1.) after an existing influenza virus jumped the species barrier. The fourth pandemic, the “swine flu” pandemic, occurred in 2009 (see below). Table 7.1  Four influenza pandemics since 1918 Pandemic 1918 Spanish Flu Asian Flu Hong Kong Flu 2009 Swine Flu

Year

Deaths

1918–1920 1957–1958 1968–1969 2009–2010

20 to 100 million 1 to 1.5 million 0.75 to 1 million 18,000 to 284,000

Case fatality rate 2% 0.13% =65) % Overall % 931 60 17 12 30 1,204 58 12 14 26 1,285 59 12 14 25 1,124 59 12 15 27 1,235 59 12 15 27 1,177 61 12 17 29 1,191 59 12 20 32 1,191 55 12 24 36 1,190 52 11 28 39 1,164 50 10 31 41 1,151 50 10 32 42

Note: Years shaded were projected. Source: “Population Profile of Hong Kong,” Research Office, Legislative Council Secretariat IN07/14-15. The total fertility rate and dependency rate from 2016 onwards were based on data projected by the Hong Kong Census and Statistics Department published in 2015.

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Given this low fertility rate, Hong Kong has had to count on a different way to expand its population: immigration. Between 2004 and 2015, about half a million mainland residents settled in the territory. In addition, a growing number of babies had been born in Hong Kong to mainland women since 2001. Some of the fathers of these babies were Hong Kong permanent residents, but most were not, and only a small proportion of this group will remain in Hong Kong. In 2008, of the 78,822 babies born in Hong Kong, 43% had mainland mothers. To ensure that pregnant women who are Hong Kong citizens have access to hospital beds for delivery and recovery, the Hong Kong government stepped up various administrative measures in 2012—it stopped accepting delivery bookings from mainland pregnant women, and it established a delivery quota in private hospitals.2 These measures will reduce immigrants into the city.

Profile in Gray According to a survey taken in 2009, roughly 1.2 million Hong Kong residents, representing 17 percent of the population, were age 60 and over. The small majority were women (52.4%), and around five percent of this population lived in institutions.3 Of those living in domestic households, two-thirds had not even had a primary-school level education, and the vast majority of this group (86.6%) were women. Compulsory primary education in Hong Kong had begun in the 1970s, so the current cohort of older women has been largely deprived of the chance to go to school. Because salaries are usually commensurate with education, this group of elderly is left with little or no savings when they retire, and usually no pension. They are also unlikely to be able to continue working even if they want to. There is little financial security for Hong Kong’s older population, especially women. In 2006, some 40% of Hong Kong’s seniors were living below the poverty line (defined as a monthly income of less than or equal to 50% of the median income of all the households of equal size).4 Almost one in five relied on Comprehensive Social Security Assistance to meet basic needs, with many counting on the Old Age Allowance to make ends meet.5 Barely half owned their homes, and most of the homeowners lived with spouses and/or children. The vast majority of residents in nursing homes depended on disability or old-age allowance (Table 8.2).6

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Table 8.2  Profile of older population living in domestic household and those living in institutions in 2009 Residing in domestic households N (%)

1,129,900 (16.2)

Male/female

546,000/ 583,900

Marital status

%

Residing in institutions N (%) Male/female Types

58,300 (0.84) 19,000/ 39,300 %

 Married

67.5

  Private home

60.3

  Never married

2.8

  Care and attention Home

25.2

  Divorced, separated,   widowed

29.8

Educational attainment

%

  No schooling

28.8

 Primary

37.7

 Secondary

26.7

 Post-secondary

6.9

Living condition

%

  With spouse and  children

39.3

  With spouse

24.7

  With children

19.8

  With other people  Alone Monthly income

3.6 12.7 %

  one illness

81.1

Doctor consultation last month

41.1

Doctor consultation last month

62.9

Hospitalized last 12 months

13.5

Hospitalized last 12 months

33.5

Average admission last 12 months No impairment of ADL History of fall last 3 months Those required chronic medications

1.6 75.2

Average admission last 12 months No impairment of ADL

1.8 18.4

4.3 62.3

Note: ADL=Activity of Daily Living. Source: “Thematic Household Survey, no. 40,” Census and Statistics Department, Hong Kong (2009), 4, 8.

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Common Chronic Diseases in the Elderly Chronic noncommunicable diseases are the leading causes of death in the elderly, and their prevalence increase with age. In 2010, cancer, heart disease, stroke or cerebrovascular disease, chronic obstructive pulmonary disease (COPD), dementia, and diabetes were among the 10 leading causes of death. According to the Hong Kong Alzheimer’s Disease Association, roughly one in ten people over the age of 70 suffer from dementia in Hong Kong. By age 85, the proportion grows to one in three. As the elderly are not often aware of their impairment, self-reported dementia is lower than clinically-diagnosed dementia. Dementia is a disabling disease; those in its advanced stages generally require institutionalization. Within institutions, dementia is far more prevalent than it is in the community (Table 8.4). In 2015, more than half of the elderly people attending day care centers had dementia.9 Table 8.4 also shows the numbers of self-reports of diabetes were only half of the diagnosed cases. Diabetes invites multiple serious complications if left untreated, and without blood-glucose tests, roughly half of the actual cases will be missed. Type 2 diabetes often runs in families, and since the likelihood of the disease increases with age, elderly people with a family history of diabetes would benefit from having blood sugar measurements included in regular medical examinations. Detecting the disease early helps forestall complications. Older seniors also suffer disproportionately from other afflictions that reduce the quality of their lives: eye problems (25%), arthritis (17%), fractures from falls (13%), depression (8%), cancers (6%), and osteoporosis (6%).10

What Chronic Disease Really Costs Chronic noncommunicable diseases pose problems at many levels. On an impersonal public level, they stress the healthcare system in myriad ways, including the costs of hospitalization, doctor consultation, medication, emergency care, community care services, rehabilitation, and institutionalization. On a personal level, chronic diseases take a tremendous toll because they can persist over a long period of time— sufferers may get no relief, nor their caregivers. The result is enormous mental and physical strain, and the lost income from being unable to work often adds financial pressures to the mix.

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Table 8.4  Prevalence of common chronic diseases in the older population in Hong Kong Age groups Heart disease 65 and over Cerebrovascular disease (Stroke)  Self-reported 65 and over 65 and over 65 and over Chronic obstructive pulmonary disease (COPD)   Based on symptoms 65 and over 70 and over 60 and over Dementia  Self-reported 65–69 80 and over 60 and over 60 and over 70 and over   Clinical diagnosed   (DSM IV) 70 and over Diabetes  Self-reported 65 and over 65 and over 65 and over 65 and over   With blood glucose

Percent Year of study 15.8 2008

Source THS No 41,200911

4.9 6.3 4.4

2008 1998–1999 2003–2004

Yu et al 199812 Chu et al 200513 Lee et al 2006b14

10 9 8.6

1998 2003–2004 2008

HU 199815 Ko et al 200616 THS No 40 200917

0.8 5.0 32.1* 24.9* 4.5 9.3

2003–2004 2003–2004 2004 2006 1995 2005–2006

DH 200518 DH 200519 THS No 21, 200520 Chen et al 200821 Chu et al 199822 Lam et al 200823

13.5 12.4 11.7 14.5

1997 1998–1999 2001–2003 2001–2003

65–74

25.4

1995–1996

65–84

21.4

2004–2005

Chu et al 199824 Chu et al 200525 McGhee et al 200726 Lee et al 200627 CV risk factor study 199728 CHP 200729

Note: Most of the studies presented in this table had been conducted on people in the community; *those in institutions. HU=Harvard report; THS=Thematic Household survey; DH=Department of Health; CHP=Center for Health protection; CV=cardiovascular.

Researchers in Hong Kong have tried to tally the true cost of chronic illnesses that are prevalent among seniors, 65 and over (Table 8.5).30 In 2016, for patients recovering from strokes, estimates of total economic burden—including costs of hospitalization, outpatient care, rehabilitation services, and community allied health services—were around HK$1.33 billion; the indirect costs were much larger—an estimated HK$5 billion. Based on these numbers, Hong Kong can expect that, by 2036, stroke victims will cost HK$4 billion directly and HK$13.3 billion indirectly, staggering numbers indeed.

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Table 8.5  Economic burden of four common chronic diseases in older population Type

Year

Direct cost

2006 1.33 billion 2036

Indirect cost

2006

5 billion

2036

13.3 billion

Hospitalization 2010

3 billion

2036

7.8 billion

Chau 201132

Dementia Institution care 2010 1.6 billion 2036

4.2 billion

Yu 201033

Stroke COPD

Indirect cost Diabetes Direct cost

Cost

Year Projected cost 4 billion

2010 10.4 billion 2036

27 billion

2006 1.4 billion 2036

3.5 billion

Source Yu 201231

McGhee 200934

The high prevalence of chronic diseases in the elderly results in their using a disproportionate share of healthcare resources. In 2010, though constituting only about 12–14% of the population, they accounted for one half of inpatient and rehabilitation services, one third of general and specialist outpatient clinics, one quarter of A&E attendances, and one fifth of allied health outpatient services. Almost half of all elderly outpatients routinely consult more than one specialist; nearly 29% see two specialists, 12% three; and 5% four or more.35 From these numbers one can anticipate growing demand for all types of medical services, as well as increasing medical costs. Only 10% of Hong Kong’s elderly have private medical insurance coverage. 36 The rest depend on the public medical system, which is comprehensive and quite generous. Inexpensive care is available to all citizens, and fees are waived entirely for those who cannot afford to pay, but the waiting time is long for these services.

Medical and Health Services for the Elderly Primary Care Until recently, primary-care providers in Hong Kong had mostly been private doctors who tackled health problems of their patients as they arose. There had been little emphasis on proactive management of potential geriatric health issues, little patient education and health promotion. Chronic diseases, especially dementia, were thought of as just an inevitable consequence of “normal aging,” with no further investigation of how they could be ameliorated.

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However, attitudes are changing. The Department of Health now operates 18 elderly health centers with a multidisciplinary approach in a primary care setting. Hong Kong residents 65 and over can join the Elderly Health Centre, where they are provided with health assessment, health education, and treatment services. The annual membership fee for eligible persons is HK$110 and each medical treatment visit is HK$45.37 The department also has 18 visiting health teams that provide community outreach. They teach the elderly various self-care practices and provide information on a broad variety of health issues. Using the “train the trainer” approach, visiting health professionals give free instructions to caregivers. Since the turn of the millennium, the Department of Health has periodically collected information on the health status of the elderly population in Hong Kong to obtain data on the scope of the problems and the potential impact on any intervention. In 2012 the Department of Health published a “Reference Framework for Preventive Care for Older Adults” aiming to enhance primary care for this population group.38

Secondary and Tertiary Medical Care Most hospitals in Hong Kong are designed to provide acute care. This model does not work well for patients with chronic disabilities, the majority of whom are elderly. About 70% to 80% of elderly patients have multiple chronic pathologies involving multiple systems. The goal of acute care hospitals is to treat the acute illness and move patients through quickly, freeing up beds for the next batch of acutely ill patients. The alien hospital environment is unsuitable for frail, elderly patients and can exacerbate delirium, dementia, and depression. About half of elderly patients hospitalized for acute illnesses require rehabilitation after discharge. Those with chronic diseases associated with disability— including stroke, Park inson’s disease, COPD, hip fractures, and osteoarthritis—do not receive the ongoing care that they need. Because muscular atrophy often develops after prolonged periods of confinement in hospital beds, the elderly are prone to falls and fall-related injuries. Many older patients have social, psychological, and physical needs that are best managed by comprehensive geriatric assessment.39 The emphasis on shortening hospital stays has often backfired, as many patients are often readmitted due to unresolved medical problems that were

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not detected initially. A better approach is to admit and manage frail, elderly patients in a specially designed setting with an experienced multidisciplinary team of healthcare professionals. Such a team would develop pre-discharge planning, post-discharge support, and community healthcare, to provide prompt and efficient bridging support for these patients. Although geriatric medicine with a multidisciplinary approach was introduced around 1975 in Hong Kong, it is still not routinely practiced. Multidimensional geriatric assessment is frequently offered in extended care hospitals, but not all general acute care hospitals have acute geriatric wards staffed by multidisciplinary teams. To reduce prolonged hospitalization and recurrent hospital admissions, geriatric assessment and intervention should ideally start concurrently with the treatment of acute medical diseases in the hospital.40 Elderly patients who develop acute illnesses, at times minor, in old age homes or private homes are often sent to public general hospitals for treatment. This costly practice could be avoided with upgraded medical and nursing support in residential homes. It is not uncommon for the elderly to receive multiple uncoordinated healthcare services: family doctor, visiting medical officer, cardiologist, endocrinologist, orthopedic doctor, ophthalmologist, along with other social services. There is a real risk of dangerous polypharmacy. Ready access to the Hospital Authority (HA)’s electronic case management system with medical record has been helpful.

Outreach Medical Services To help reduce pressure on hospital beds and alleviate overcrowding in public hospitals, the HA has organized several outreach medical services to reduce recurrent admissions: 1. Community Nursing Service (CNS). This service, which has been operating since 1967, is for those who no longer require hospital care but have difficulty attending outpatient clinics for follow up. It helps prevent disease relapse by organizing qualified domiciliary nursing care, such as injections, counseling, and health assessment for discharged patients. 2. Community Geriatric Assessment Teams (CGAT). Every team has one of each of the following: senior medical officer,

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registered nurse, assistant social work officer, physiotherapist, occupational therapist, and clerk, to give timely assessment and appropriate treatment for older patients in residential care homes. These patients often have complex health problems and impaired mobility. The CGAT teams collaborate with multiple organizations, both private and NGO, to enhance medical and nursing care and to strengthen infection control surveillance in residential care homes to prevent outbreaks. 3. Psychogeriatric Teams (PGT). Each PGT team consists of three senior medical officers, four medical officers, six registered nurses, one clinical psychologist, and one assistant social worker. They provide outreach service to elderly with mental health problems in residential care homes, formulate treatment plans, monitor progress, and conduct follow-up consultations. The CGAT and PGT teams, established about 20 years ago, have successfully reduced unplanned annual hospital admissions by an estimated 10%. Inadequate funding has limited the scope of the services.41 4. The Patient Support Call Center. Established in 2009, the center helps elderly patients living in the community who have been discharged from hospital but are at high risk for readmissions. It has an advanced infor mation technolog y system and automatically assesses members for levels of readmission risk using a prediction tool. There is at present a team of nurses providing 24-hour coverage for incoming calls to give clinical advice based on over 80 robust evidence-based protocols. In addition, proactive calls are being made to patients to facilitate early identification of problems and to give prompt advice on medication, community resources, and follow-up appointments.42 5. Integrated Care and Discharge Support (ICDS). This program, established in 2011, aims at improving the quality of home care by enhancing self-care, community-based rehabilitation, and support of caregivers. It organizes timely multidisciplinary interventions to reduce hospitalization by coordinating community support services, and collaborating with those provided by the NGOs. The ICDS program was found to be effective in reducing A&E use, hospital admissions and hospital bed-days, with an estimated net cost savings up to HK$22.5

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million over a period of 18 months,43 in addition to providing a much better level of care.

Institutional Care Facilities The need for nursing care increases sharply with age. In most countries, one in three persons aged 80 or over require daily attention in an institution.44 Hong Kong has a variety of facilities for the elderly, dispensing different levels of care. There are elder-only hotels, care and attention homes, self-financing homes, nursing homes, infirmaries, and private oldage homes. These facilities are managed by different sponsoring agencies with no coordination between them. As the health conditions of the elderly generally deteriorate with age, they may require different kinds of institutional care at different stages of life. The HA runs infirmaries and the Department of Health oversees nursing homes which are for those in need of full time care, while the Social Welfare Department, NGOs, and private agencies runs many of the care and attention homes. The care and attention homes provide accommodations, give general personal care and some nursing care, and cater to the more mobile elderly. The lack of continuity of institutional care may increase the burden of the secondary and tertiary healthcare services. An effective authority is required to act as the overall coordinator of these service providers and to command resources that will cater to the needs of the elderly.45 The standard of care in private homes for the elderly is not uniform. In 1993, the Social Welfare Department found 97% of private old-age homes to be substandard while the subvented homes were better.46 As a result, the Residential Care Homes Ordinance was enacted in 1996, mandating all old-age homes be licensed and meet statutory requirements for residential environments and staffing support. However, the 2014 Audit Commission found a persistent, troubling gap between conditions in government-subsidized homes and private homes. In private homes, the staff-to-client ratio was lower, around 32 staff per hundred residents, compared to 41 per hundred in the government homes; and the floor space was smaller, at around 9 square meters per resident, versus almost double that in the government-subsidized homes. The numbers of private care homes were obtained from those covered under “The Enhanced Bought Place Scheme,” a Social Welfare Department plan where the

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government purchased spaces in private homes. In homes that did not fall under the scheme, conditions were even worse—just 16 staff per 100 residents and 7.5 square meters per resident. In 2015, an outrageous report of elderly residents being forced to wait naked outdoors for showers in one of the private nursing homes demonstrated that the Residential Care Homes Ordinance and related inspection systems need to be revisited, staff and space provisions strengthened, and regulation enforced.47 There are always long waiting lists for residential homes. In 2004, there were 67,161 spaces accommodating 8% of the elderly population. By 2008 circumstances were only marginally better as the number of spaces had risen to 73,178, but there was concomitant population growth. In December 2014, there were some 32,000 elderly, who had all been screened and approved by the Social Welfare Department, waiting for various types of subsidized care homes. The waiting time for care homes was between 33 and 35 months, and for space in a private nursing home the average wait was seven months.48 In Hong Kong, the proportion of the older population who lived in institutions in 2004 was around 8%, which was nearly double that of New York City in 2000.49 Many elderly in Hong Kong would rather not be in nursing homes, preferring to live by themselves or with family members for as long as possible. Increased community care and support would help delay the need for institutionalization.50

Community Support For older people who live on their own but require daily assistance, a variety of community services are offered either through neighborhood senior centers, or directly to older people’s homes. The elderly centers provide social and recreational activities, and some offer communal meals. Older people can apply for home help and personal care services, such as meal delivery, homemaker services, and escort services to outpatient clinics. Hong Kong had 60 Integrated Home Care Services teams, 24 Enhanced Home and Community Care Services teams, and 59 Day Care Centers in 2011. Mostly run by NGOs and subsidized by the government, they provided a range of services for the elderly in the community. Despite the large number of teams to provide home services, the needs of the elderly are not met in Hong Kong.

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When older people transition to the stage where they become more dependent, yet still do not require institutional care, they may consider living in facilities with a variety of on-site care and support services. In Hong Kong, there are public rental housing units with shared facilities for the elderly, modelled on hostel-type accommodation. Means-tested individual home units for groups of six are provided, with wardens on premises for emergency situations. Such arrangements proved to be unpopular as quarrels among older people are not uncommon. There are also self-contained small flats in public rental estates, equipped with facilities for older people; however, they are not supported by warden services. Recently, new self-contained units have become available under a similar scheme. These are supported by round-the-clock professional medical and personal care services, as well as communal and recreational services. But they are expensive, and out of reach for most.51 The sad truth is that, at present, there are simply not enough care and support services for the elderly in Hong Kong to allow independent living.

Strategies for Long Term Care of the Elderly Disability is not inevitable for the elderly population—it can be delayed or even prevented by appropriate measures to improve physical function and reduce cognitive decline. Proper medical and social support can promote healthy functioning and high quality of life.

Promote Healthy Aging Major lifestyle and behavior risks for most of the chronic noncommunicable diseases include smoking, heavy alcohol consumption, sedentariness, and poor dietary habits. Hong Kong’s elderly population has certain salubrious characteristics: for example, relatively few of those over 60 years of age smoke—only 17% of men and 1% women, according to the 2015 survey.52 On the other hand, they are too sedentary, by and large, and their diet is relatively unhealthy. Roughly a third of those aged 65 and over do not exercise or perform any physical activity at all. Only 17% eat the recommended five servings of fruits and vegetables per day.53 Interestingly, even this middling performance compares favorably with many Americans, such as in New York, where only 8% of the elderly have healthy eating habits.54

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More resources need to be devoted to promoting healthy lifestyles— especially exercise and dietary habits. Efforts on the front end could bring the desirable results in terms of lengthening life, and improving overall quality of life.

Aging in Place Effective community care services can reduce or delay institutionalization, improve physical function, and reduce cognitive decline. It makes sense to keep the elderly healthy and living at home by providing them with community services, including easy access to recreational, social, medical, rehabilitative services, and in-home services—plus other necessary support as needed. Achieving this goal will depend on adequate funding not just for the needed services and facilities, but also for the staff to run them. All must be available in a package affordable by vulnerable older people. There are simply too few housing opportunities for the elderly. In 2011, there were 24,746 places in subsidized residential care homes and 7,089 places in the community, far short of demand. Moreover, the government budget in these areas is too small, HK$2,549 million and HK$381 million respectively.55 To promote the policy of aging in place, the imbalance in support of these two types of services must be addressed.

Integrate Medical and Social Services High-quality care of an aging population requires both adequate funding and integration of health and social care systems. An example of such an integrated program can be found in the United States, where the Programs of All-Inclusive Care for the Elderly (PACE) offers an integrated long-term geriatric healthcare and social care services model under a single care delivery organization, financed by the government. It provides for care in acute hospital, subacute hospital, day centers, and long-term care services, day health services, social services, medical supervision, nursing, personal care, physiotherapy, socialization, nutrition, transportation, education, group exercise, and recreation. The target clients are very frail, elderly people, with multiple medical problems. Their mean age is 80, and each has eight diseases on average. Compared with the fee-for-service model clients, the PACE clients are frailer, and yet

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they have fewer hospital days, fewer nursing home admissions, and better consumer satisfaction.56 Hong Kong currently has no integrated program that provides both medical and social care to the elderly under one roof, although the Hospital Authority and the Department of Health are trying to establish closer links with the Social Welfare Department and other related partners.

Training More Frontline Workers Though the number of service providers for the elderly has increased in Hong Kong over the past few years, the demand far outstrips the supply. Caregivers are often overworked, underpaid, and experience high stress, putting the elderly at risk for substandard services.57 Government policy fragmentation and funding rigidity remain major challenges for recruiting service providers for the elderly. Vocational education and on-the-job training have been recommended to maintain a stable supply of frontline care workers, as well as continuing professional development to have upto-date knowledge, skills, and competencies for those already in the field.58

Efforts to Provide Long-Term Care for the Elderly In 2011, recognizing the impact of a growing elderly population on healthcare expenditures, Hong Kong took a series of steps toward improving the health and quality of life of its elderly population, while at the same time reducing healthcare expenditure. In a joint venture, the Department of Social Work and Administration of the University of Hong Kong and the Sau Po Centre on Ageing conducted a study on community care services for the elderly of Hong Kong.59 The study found that because long-term care for the elderly is funded mostly by taxpayers, as the population ages and the workforce declines, the tax base will shrink. The fiscal sustainability of long-term care for the elderly will be severely tested unless something changes. The responsibility for caring for the elderly cannot fall on government alone; it needs to be shared with families, individuals, the community, and the market place. The study recommended that aging in the community be promoted over institutionalization. This would require boosting community care services, supporting family caregivers, strengthening

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human resources in long-term care and heightening public awareness of these services In 2012, the HA proposed a plan to bring together multiple partners: patients, caregivers, clinicians, professional bodies, the government and nongovernmental organizations, to improve elderly services over the next five years.60 It emphasized more integrated care through multidisciplinary approaches, enhanced patient/caregiver empowerment, and strengthening collaboration with partner organizations. The HA has drawn up five long-term objectives for elderly care, and several operational priorities for each objective. Some of these are projects in progress, but there is still a long way to go before the social and medical services for elderly long-term care are truly integrated. The strategies of HA are in line with those recommended by the WHO which published a report in 2014 on Aging and Health: A Policy Framework for Healthy Aging with a goal of maximizing functional ability for older people.61 The report identified four priority areas for action: 1) to align the health system with the older populations they now serve; with healthcare that addressed the multidimensional demands of older age in an integrated way rather than to specific diseases; 2) to develop a system to provide long-term care for older people, who have or are at high risk of substantial losses of capacity, to maintain a level of functional ability and to ensure this care and support is consistent with their basic rights, fundamental freedoms, and human dignity; 3) to provide an age-friendly environment for people to grow old; and 4) to provide improved measurement and monitoring in order to fill the major knowledge and research gaps of the older population, which has often been excluded in vital statistics and general population surveys.

End of Life Care “Good death,” something that everyone wants, but often unobtainable in Hong Kong, consists of the following: the ability to know when death is coming; retaining control of what happens; having control of symptoms such as pain; choice of where death occurs; access to information and expertise; spiritual and emotional support; hospice care; time and privacy to say goodbye; and the ability to let go instead of prolonging life pointlessly. 62 “Dying in place” would provide many elements of

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“good death,” but unfortunately it is usually unattainable in most Asian countries, particularly in Hong Kong, because of a lack of necessary medical support for the dying person at home, and living quarters are often so crammed that it is not possible for patients to be able to receive the care that they need at home. The superstition and unreasonable fear of depreciation of property value due to a death occurring in the premises results in family members rushing the deteriorating patient to a hospital. There are also other complex social, cultural, and economic factors for most elderlies in Hong Kong not to be able to have a “good death.” For most people, it is a taboo to talk about dying especially when they are sick. It is hard for the physician to bring up issues such as end of life care, or advance directive. Few physicians have been trained to communicate with patients about their goals of care for end of life. Very often physicians find themselves responding to the wishes and demands of patients’ families who want more treatment than is indicated or beneficial to the patients. In some Asian countries, an approach combining residential home and palliative care setting is being used. In Hong Kong, the legal requirement that all deaths in residential care home must be reported to the coroner and the resultant hassles of forensic investigation are deterrents for this practice being allowed. Elderly patients in residential care homes are commonly sent to A&E in ambulances when their medical conditions worsen. As a result, the acute medical and surgical wards are where the older people usually die. The setting is hardly a place for a “good death”—the elderly die in an unfamiliar environment with restricted visiting hours and little, if any, staff trained to provide adequate physical or emotional support to patients and family members. Moreover it is an inappropriate use of hospital services.63 The HA has only recently begun to pay attention to end of life care, a departure from the previous focus on curative care. It has conducted several pilot programs in different district clusters to assess feasibility and quality of end-of-life care. These programs allow the patient to die in the residential care home64 or follow the Advanced Care Plan based on a new care pathway of bypassing acute medical wards with direct clinical admission to an extended-care facility.65 In October 2015, a program to “Enhance CGAT Support to End of Life Patients in Residential Care Home for the Elderly,” was implemented by HA in four clusters, Hong Kong West and East, and New Territories West and

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East. This program enhances the usual CGAT service by collaborating with palliative care teams to provide service to those with advanced dementia approaching end of life stage. The Acute Care Plan and Do Not Attempt Cardiopulmonary Resuscitation (non-hospitalized) directives are discussed with the patients’ family members. The advanced directives will be signed if the patient is mentally sound. In Hong Kong West, Fung Yiu King Hospital, an End of Life Clinical Plan was established in 2012, when an eight-bed unit was created for elderly, dying patients to provide a peaceful environment, and foster a dignified death. Thus far, 400 patientparticipants in the program and their relatives have benefited from the plan.66 There is little doubt that any society must adopt a humane approach to end of life care to provide the elderly with dignified deaths and to establish individuals’ right to forgo life-sustaining treatments. The Institute of Medicine in the United States has published a document, “Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life” in 2014 and the full report is available at The National Academies of Sciences Engineering Medicine of the United States website (http://www.nationalacademies.org/hmd/~/ media/Files/Report%20Files/2014/EOL/Report%20Brief.pdf ). The Institute of Medicine made recommendations on the delivery of care, clinician-patient communications and advance care planning, and payment systems. It advocated professional education and development to strengthen the palliative care knowledge and skills of physicians, who care for patients with advanced serious illness and are near the end of life; it also promoted public education programs encouraging advance care planning and informed choice based on individuals’ needs and values. Hong Kong lags after other high-income countries in providing the elderly with a “good death.” Both professional and public education are greatly needed in this area.

“Apocalyptic Demography”? A fear that has originated from the United States and spread around the world is that the aging population is a kind of demographic time bomb that will wreak social and economic havoc. But some social scientists have

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found that this “apocalyptic demography” theory does not stand up to empirical examination.67 A Canadian study showed that things are trending in the opposite direction. The elderly population is healthier than ever before. Between 1981 and 1991, the number of hospitalization days fell, and hospital stays grew shorter for all age groups, including those aged 65 and above. The authors attributed this to healthier lifestyle habits in recent years, with people smoking less, exercising more regularly, and following healthier diets.68 In Hong Kong, the findings were similar. Between 1997 and 2012, the frequency of hospitalization fell. The decline applied to all ages, but the rate of decline was steepest among those aged 65 years and above (reduced from 2,796 to 1,958 admissions per 100,000 during this period) (Figure 8.1).69 This impressive result is likely to be multifactorial. We can credit healthier lifestyles of the elderly and the dedicated efforts of the outreach medical services such as the Community Nursing Service and the Psychogeriatric Team for successfully reducing multiple hospital readmissions of the elderly. Figure 8.1  Hospitalization rate (no/100,000) by age groups in 1997/98 and 2012/13

1997/98 2012/13

Source: Hospital Authority Statistical Report 1997/98 and 2012/13.

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If mortality rates decline within a given age group, one would also expect hospital morbidity to decrease. Healthy aging and better long-term care of the elderly will reduce their economic impact on the healthcare system. Of those who have predicted the dire social consequences of the aging population, many have failed to consider certain factors: the economics of domestic labor provided freely by grandparents, especially grandmothers, so that their daughters and daughters-in-law can profitably work outside the home; the many hours of volunteer activities and private assistance that are routinely offered; and transfers and bequests. In Canada about 80 percent of private cross-generational transfers occur within families and the same must be true in Hong Kong. In fact, it turns out that elders give, over the course of their lives, about 50% more than they receive.70 Contributions of the older generations to society should be duly acknowledged. This is particularly important in a society in which Confucius teaching and filial piety are still relevant. Though we live in a capitalist society, much of what transpires between individuals and across generations cannot be quantified solely in dollars and cents. How do we measure love, time, energy, kindness, and care? The Confucian ethic of care for the elderly is vital to the concept of “aging in place,” which offers a better quality of life and dignity than aging in nursing homes. Unfortunately, the Chinese tradition of “three generations under one roof,” and the strong sense of filial piety, are disappearing fast under the pressure of the rising cost of real estate and smaller and smaller sized flats in Hong Kong. The percentage of elderly living alone has gradually crept up over the years. In 2009 that number stood at just under 13%. How can we manage the effects of an aging population going forward? Improving the health status of the elderly population will not be achieved without investing more resources in health promotion. Also a broad population health framework requires more than health promotion programs. Better working and living conditions, better education, lower unemployment rates, and a more equitable distribution of wealth can positively affect health, and lower hospital admissions for all adults, including the elderly. It will also depend in part on the individual and collective willingness to adjust to social change. This cannot be accomplished without the cooperation of government, corporations, special interest groups, and individuals.

9. A Tale of Two Schools— Medical Education

Figure 9.1  University of Hong Kong c 1920s

Photo courtesy of HKU Archive

The history of medical education in Hong Kong, intimately intertwined with the development of the Hong Kong College of Medicine for Chinese, the Faculty of Medicine of the University of Hong Kong, and of the Chinese University of Hong Kong, is rich and filled with many brilliant, distinguished, courageous, and inspiring personalities whose dedication laid the foundation for modern medicine in Hong Kong as we know it today. The history of the development of College of Medicine has been covered in the first volume of A Medical History of Hong Kong 1842–1941. It is not the author’s intention to write a detailed history of two medical faculties, but rather to give an overview of their births and growth and link them with the evolution of medicine in Hong Kong.

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Readers wishing to learn more will find a complete account of the Faculty of Medicine of the University of Hong Kong in the following books: D. E. Evans, Constancy of Purpose: An Account of the Foundation and History of the Hong Kong College of Medicine and the Faculty of Medicine of the University of Hong Kong, 1887–1987 (Hong Kong: Hong Kong University Press, 1987); B. Mellor, The University of Hong Kong: An Informal History (Hong Kong: Hong Kong University Press, 1981); and P. Cunich, A History of the University of Hong Kong (Hong Kong: Hong Kong University Press, 2012). For the development of the Chinese University of Hong Kong and its Medical Faculty, the following two books are useful: A. N. H. NgLun, The Quest for Excellence: A History of the Chinese University of Hong Kong (Hong Kong: Chinese University Press, 1994), and A. E. Starling, The Chance of a Lifetime: The Birth of a New Medical School in Hong Kong (Hong Kong: Chinese University Press, 1988). The Faculty of Medicine of the University of Hong Kong will monopolize the following pages by virtue of its venerable age: it turned 130 years old in 2016.

The First Medical School— The University of Hong Kong Sir Frederick Lugard, governor of Hong Kong (1907–1912) and founder and first chancellor of the University of Hong Kong, was stirred by a grand vision. He wanted to create an “imperial” university, one to educate not just local young men, but also Chinese students from the mainland. The broader goal was to propagate British language and culture, thereby expanding British influence in China.1 To fully understand the achievements of the Faculty of Medicine of the University of Hong Kong after the Second World War, some knowledge is required of the history of the faculty since its inception. The story begins when the Hong Kong College of Medicine for the Chinese, founded in 1887, was amalgamated with the university to become the Faculty of Medicine in 1912. It was one of the three faculties of the university.

Growing Pains Because the General Medical Council (GMC) in Britain did not recognize a license conferred by the Hong Kong College of Medicine for Chinese,

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the medical graduates of the college were not allowed to practice in Hong Kong, a bona fide British Crown colony. Cognizant of this constraint, those who designed the curriculum for future medical studies at the University of Hong Kong followed closely the requirements of the GMC, and in 1913, the GMC recognized the medical degrees granted by the university. The colonial government in Hong Kong swiftly amended the Medical Registration Act of 1884 to ensure that graduates of the university would be duly registered as medical practitioners in the colony.2 Initially, the entire teaching staff of the Hong Kong College of Medicine was seconded as parttime lecturers to the new Faculty of Medicine. Francis Clark, Medical Officer of Health, was appointed the founding dean, and Gregory Jordon, a private practitioner, was made the university’s pro-vice-chancellor. The university intended to phase in fulltime staff as funds became available. The first fulltime medical faculty appointments were G. E. Malcomson, as professor of physiology in 1913, and Kenelm H. Digby, as professor of anatomy in 1914. Digby, much loved by his students, would remain at the university for more than 30 years, leaving an indelible mark on its history. When Malcolmson left for war duties, he was replaced by Herbert G. Earle. Clinical teaching in surgery began that same year, and Digby moved over to chair that department. Together, Earle and Digby provided a solid foundation upon which the Faculty of Medicine would be built. The next fulltime appointment was C. Y. Wang, a graduate of the Hong Kong College of Medicine and the first Chinese appointed as professor of pathology of the university in 1919.3 Clinical teaching was initially carried out in the Alice Memorial Hospital, where the Hong Kong College of Medicine was based, but it soon became apparent that the surgical facilities there were not up to modern hospital standards. In 1920, at the recommendation of the Sharp Commission, classes were moved to Government Civil Hospital, Tung Wah Hospital, and to government outpatient clinics. During this period, little research was conducted in the Faculty of Medicine, since there were few resources and most of the staff were still parttime.4 In the meantime, teaching in medical schools in England was evolving rapidly. Modern clinical teaching demanded small-group instruction by clinical teachers who would, in addition to teaching, devote time to research and patient care. To gain clinical experience, students needed access to patients in hospital wards, and professors needed access to hospital laboratories to conduct research. All of this required not only plenty of

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space but also plenty of fulltime staff. Unfortunately, the University of Hong Kong was poorly endowed at the time, and it soon fell into financial trouble. The Sharp Commission, which was ordered by Governor Reginald Stubbs to investigate the huge deficit accumulated by the university in the late 1910s, recommended retrenchment, which constrained any recruitment effort and seemed to seal the future of the Medical Faculty.5

The “Rockefeller Professors” At that time, the China Medical Board of the Rockefeller Foundation had established the Peking Union Medical College, but the project had proven so expensive that the foundation was unable to fund another medical school in China. It was, however, in a position to support existing institutions. When Dr. Richard Pearce, director of the foundation’s Division of Medical Education, visited Hong Kong in 1921, he was impressed with what he saw. After a great deal of negotiating, the Rockefeller Foundation agreed to endow three chairs, medicine, surgery, and obstetrics, at HKD$250,000 each. This helped secure the future of the Faculty of Medicine and raise its international profile.6 In 1922, K. H. Digby was appointed chair of surgery and John Anderson chair of medicine. Figure 9.2  The Department of Medicine 1928. J. Anderson (front center), Professor of Medicine (1923–1929), HKU

Photo courtesy of the Hong Kong Museum of Medical Sciences Society, photo donated by Dr. Andrew Hua to the Museum

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The Department of Obstetrics Figure 9.3 and Gynecology failed to meet R. E. Tottenham, professor of obstetrics and gynecology (1925–1934), HKU the Rockefeller Foundation’s requirement for the minimum number of hospital beds available for teaching purposes. The chair appointment was delayed until that quota was met in 1924, when R. E. Tottenham was appointed as professor in the department, as well as its chair. Tottenham had strong ideas about how to Photo courtesy of the Department of develop obstetrics and gynecology. Obstetrics and Gynecology, HKU He moved the teaching base from the Government Civil Hospital to Tsan Yuk Hospital and, in 1926, rearranged and modernized Tsan Yuk Hospital, according to the model of the renowned Rotunda Hospital in Ireland. New procedures at Tsan Yuk Maternity Hospital, including the use of disinfectants and antiseptics, markedly lowered both maternal and infant mortalities.7 The Rockefeller professors were, as a group, distinguished researchers. Digby had a variety of research interests, contributing to The Lancet and other medical journals on topics such as gallstones, tracheostomy, and recurrent pyogenic cholangitis (common in Hong Kong at the time). Anderson investigated dysentery and filariasis. He was appointed professor of medicine in the university in 1923, leaving in 1929 to become director of the Henry Lester Institute for Medical Research in Shanghai. Tottenham turned Tsan Yuk Maternity Hospital into a teaching and research center for treatment of eclampsia and vaginal stricture. In 1926, he became the president of the Hong Kong Medical Society. He organized an international conference in Hong Kong that burnished the profile of the university in the Far East.8 The in-house journal, The Caduceus, was established in 1922 to promote the Medical Faculty’s research; it continued publishing until 1941. The endowment from the Rockefeller Foundation transformed the Faculty of Medicine, enabling it to make significant progress in clinical teaching and research.9

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Progress in the Prewar Decade (1932–1941) The Faculty of Medicine was small, and facilities were far from adequate. In 1935 a modest building was constructed, next to the Schools of Anatomy and Physiology, to house the School of Surgery. It was cramped, and proved inconvenient when teaching was moved to the new Queen Mary Hospital in 1937.10 Several changes ensued. C. Y. Wang’s premature death in 1931 led to the appointment of Leslie Davis as professor of pathology, who would hold the post for eight years, before being succeeded by R. Cecil Robertson, a commissioner with the League of Nations Epidemic Mission to China. Tottenham returned to Ireland in 1935 and was succeeded by a brilliant young doctor, William Nixon, who in his short two-year stay revolutionized women’s medicine in Hong Kong. He established the Eugenic League, later changed to a more graceful name: the Family Planning Association. On his departure in 1937, Nixon was replaced by Professor Gordon King, a renowned missionary doctor who would keep the flame of the university burning during the years of the Second World War. The most significant events of the decade, from the faculty’s perspective, were the two visits, six years apart, of Sir Richard Arthur Needham. Needham, a general surgeon who was at one time deputy director of Indian Medical Services, came at the request of the General Medical Council in London, to evaluate the medical teaching programs in the colonies.11 During his first visit, in 1933, he conducted a thorough review of the curriculum. He found that, while it met the requirements of the GMC, there was room for improvement. He made several important recommendations, including the appointment of fulltime teachers in histology, bacteriology, pharmacology, and public health, and a closer integration between government medical services and medical faculty at the university. Needham’s first visit also spurred the government to build a new hospital, the Queen Mary Hospital, to replace the Government Civil Hospital, which was more than half a century old, overcrowded, and unsuitable for teaching. The university’s dire financial straits did not permit more fulltime appointments, but more medical officers from the Government Medical and Health Department were appointed as part-time lecturers. When Needham visited again in 1939, he was pleasantly surprised by the new Queen Mary Hospital, which was already opened and had plenty of beds assigned for teaching. He suggested that specialist teachers be hired in all branches of

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medicine and surgery, that new departments of biochemistry and public health be opened, and a public-health course be created for medical practitioners. He also recommended that a hostel be built near Queen Mary Hospital for students to meet the compulsory residency requirement, and external examiners be brought in to grade the final MBBS degrees examinations.12 Needham’s visits brought much needed improvements in the quality of the teaching programs in medicine at the university, in line with the updated standard requirements of the General Medical Council.

Preparing for a Postwar Rehabilitation Although the university suspended activities in Hong Kong during the Second World War, many students, including medical students, continued their education in universities in China (See Chapter 2). After Hong Kong’s liberation from the Japanese, Gordon King was appointed assistant director of Medical Services, and given the responsibility of reorganizing government hospitals and clinics. Since wartime graduates of Hong Kong University were qualified, they immediately filled the various positions. They formed the nucleus of the junior medical staff that was so urgently needed and played an important role in the rehabilitation of the medical services in Hong Kong. Many also became leading specialists and teachers in the university after further postgraduate training abroad.13

Reopening of the Hong Kong University: A Controversy Many schools reopened within a few months after the liberation, but the university would have to wait until 1948 to be officially reestablished. There was a great deal of controversy as to whether the university should be reopened at all. Even before the war, there were doubts about the viability of a university in Hong Kong, given that one of its objectives was “to serve the needs of mainland China”—clearly not applicable at that point. Many also felt that Hong Kong did not need a university, since only a quarter of the students were local, and their higher educational needs could be met in other ways.14 Readers interested in this controversy should consult the chapter written by Anthony Sweeting in the book Dispersal and Renewal,15 recounted briefly here. During the war, there was considerable interest in higher education in the British colonies. In 1943, the Asquith Commission was tasked

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with formulating principles to promote higher education, research and development of universities in various colonies. That same year, a small Colonial Office Committee was appointed to report on the higher educational institutions in Malaya and Hong Kong. In the winter of 1945, Duncan Sloss, the interned vice-chancellor of the Hong Kong University, returned to Britain where he played a vital role in the tortuous negotiations that eventually led to the reopening of the university. The Colonial Office sought opinions on this issue from various experts with knowledge of China and Hong Kong, and received mixed views. Some were highly critical and pessimistic, while others suggested that the reestablished university should concentrate upon those subjects in which the Chinese were not as strong. Letters of support for the reopening came from Digby, retired professor of surgery of the University of Hong Kong, as well as from graduates and past students of Hong Kong University. The Hong Kong University Advisory Committee, chaired by Mr. Christopher Cox, was finally constituted by the Colonial Office in December 1945. Convinced by the impassioned plea of Vice-Chancellor Duncan Sloss, the Cox Committee recommended that Hong Kong University be reopened as soon as possible. It should be given firm financial backing, the committee decided, because merely opening it without adequate support would ultimately be detrimental to British prestige in the Far East. If the university could not be restored to a respectable standard, the committee felt, it should not be revived at all.16 The Foreign Office supported the recommendations of the Cox Report; but the reply from the Treasury was not encouraging. Britain had its own share of reconstruction to do after a destructive war, and the fundamental question of the future of Hong Kong itself was uncertain.17 By the spring of 1948, there was a great and obvious demand in Hong Kong for university graduates in all fields. The Colonial Office finally made the decision to reopen the university when Sir Alexander Grantham (governor 1947–1957) promised a HK$4 million “reestablishment” grant, and to increase government funding to the university to HK$1.5 million annually. The British Treasury chipped in with a grant of £250,000. The era of painful uncertainty was over.18 Following the announcement by the Secretary State of the Colonies on 7 April 1948, the University of Hong Kong was formally reestablished. It is worth noting that the negotiations of the reopening were carried out in Britain; no one from the Chinese community was present. The protracted maneuverings reflected the postwar austerity in Britain, the

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lack of significance of Hong Kong within the colonial settings, and the decline of Britain as a world power.

Rehabilitation and Reconstruction Although the university was officially reopened in 1948, classes had actually been in session since October of 1946, in spite of some challenges—the Great Hall had no roof, the upper story of the Main Building had no floor, and part of the Student Union wing was missing altogether. The residences were gutted and the new Northcote Science Building, which opened just before the war, was a dilapidated mess. Students brought their own chairs, carrying them from class to class, and there was virtually no equipment for projects or laboratory work. Squatters still occupied some of the buildings on campus, and though armed guards patrolled regularly, looting was common.19 Vice-Chancellor Sloss retired after the decision to reopen the university had been made, but not before securing a million-dollar pledge from Sir Robert Ho Tung to build a women’s residence.20 Sloss was succeeded by physiology professor Lindsay Ride, who had served on three previous occasions as dean of the Faculty of Medicine and possessed a distinguished wartime record. Ride led the university through the difficult years of postwar reconstruction until his retirement in 1964. Figure 9.4  The Roofless Great Hall after the Second World War

Photo courtesy of HKU Archive

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By 1950, the university was still far from fully rehabilitated, as the limited annual government monies were spent mostly on teaching, leaving little for anything else. The teachers improvised. At the request of the Secretary of State for the Colonies, Bernard Mouat-Jones, vicechancellor of Leeds University, and Walter Adams, secretary of the InterUniversity Council, visited the university to decide how the £250,000 grant from Britain should best be spent. They were appalled that major buildings were still in massive disrepair, four years after the war. The pair recommended that Britain immediately grant another £250,000, that the Inter-University Council match that amount, and that the local government increase its annual grant to the university.21 With the population of Hong Kong reaching two million by 1952, there was a dire need for university graduates to staff the upper reaches of both public service and private enterprise. Enrollment doubled from prewar levels. Some 80% of the students were local residents, not transplants from China or Malaya. The university had become a necessity, and its standards were rising steadily. In 1953, at the request of Governor Sir Alexander Grantham, two more dignitaries were flown in to appraise the situation. Sir Ivor Jennings, vice-chancellor of the University of Ceylon and later of Cambridge, and Dr. Douglas Logan, principal of London University. Charged with assessing the financial, functional, and constitutional requirements of the university, they submitted a scathing report. The government should have an educational policy, the university’s finances should be improved, and there ought to be a separate, long-term building program for the university.22 Their report dealt separately with the needs of the Faculty of Medicine, which they felt should be given the highest priority. Their recommendations formed the blueprint for the development of the Faculty of Medicine for the next few decades.

The Blueprint of the Faculty of Medicine More doctors in Hong Kong were urgently needed, and the faculty, in its current state, would not be able to supply them, the JenningsLogan Report concluded. Deficiencies abounded, in preclinical and clinical departments alike. The Department of Pathology was located at the university main campus, nowhere near Queen Mary Hospital, the teaching hospital. There were no facilities for medical research near

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Figure 9.5  New pathology building next to Queen Mary Hospital c 1959

Photo courtesy of HKU Archive

the hospital. The university did not have a biochemistry department. The Pharmacology Department suffered from a dearth of staff and facilities. Inadequate space and a poor setup for clinical teaching plagued medicine, surgery, and gynecology/obstetrics. Only 244 out of 582 beds were under the administration of the university staff at the Queen Mary Hospital. The government’s medical officers controlled the remaining beds and they were under no obligation to teach, even though they had always taken part in teaching before the war. Moreover, Queen Mary Hospital had no outpatient department, and its casualty ward was hopelessly inadequate for teaching. The Infectious Diseases Hospital (the old Government Civil Hospital) was also wholly unsuitable for teaching. The faculty needed more money if it were to grow.23 As the economy of Hong Kong expanded in the late 1950s, the government invested more resources into the university. In 1958, a new pathology building was completed near Queen Mary Hospital. At long last, teaching and research could be carried out in a clinical setting. In 1959, the government issued an urgent request to the university to increase medical student enrollment by one third to meet urgent community need. It granted the university a subsidy, and guaranteed increasing annual funding for the next seven years. For the first time in its history, the university could embark on a program of expansion—a cause for great celebration at its golden jubilee in 1961.

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In the rich soil of that support, the Faculty of Medicine began to flourish. In 1964, Dr. Li Shu-fan generously donated a parcel of land on Sassoon Road, allowing the preclinical departments to be built near the Queen Mary Hospital. The Li Shu-fan Building, as the complex was named, began taking shape, followed the next year by a medical library and faculty administrative building right next door. In 1967, the Professorial Block amalgamated the clinical departments into a single building in the Queen Mary Hospital complex. The sagacious vision of the Jennings-Logan Report of consolidating the Faculty of Medicine in one place was being realized.

Development of Preclinical Departments Professor Francis Chang, head of the Department of Anatomy, established an excellent Anatomy Museum in 1955. Groundbreaking research would be conducted there on the developmental traits of Hong Kong schoolchildren, which would provide benchmarks for the correlation of chronological and physical age. The Anatomy Faculty also helped instruct paramedical students from the Hong Kong Polytechnic, preparing them for careers in physiotherapy and occupational therapy.24 Lindsay Ride, professor of physiology, was promoted to dean of Faculty of Medicine, and eventually vice-chancellor of the university. He would be succeeded, in sequence, by L. G. Kilborn, A. C. L. Hsieh, K. K. Cheng, and J. C. C. Hwang. Under these leaders, the department has conducted memorable research in many areas, including molecular and engineering aspects of physiology. In 1965, pharmacology broke away from the Department of Physiology and became an independent department, with R. C. Y. Lin as its first professor and head.25 The Department of Biochemistry was established in 1960 with Edward O’Farrell Walsh as its chair. Important research would be done here, too. For example, in the 1970s, L. Y. Fong, together with head of radiology John H. C. Ho, discovered a link between nasopharyngeal carcinoma, a relatively common disease in Hong Kong, and the consumption of salted fish, which contains high levels of nitrosamine, a known carcinogen.26 Hou Pao-chang was appointed the first postwar professor of pathology. A scholar locally and internationally respected for his research on the liver fluke (Clonorchis sinensis) and cancer of the bile

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ducts, Hou integrated the teaching Figure 9.6 of pathology with research. When Hou Pao-chang, professor of pathology from 1948 to 1960, HKU the new Pathology Building was constructed near the Queen Mary Hospital, he established a clinical pathology service there.27 Hou left in 1960 to become the vice-president of the Chinese Medical College in Peking, and was succeeded, first by Robert Kirk, and then James Gibson. Gibson worked tirelessly throughout his administration ( 1 9 6 3 – 1 9 8 3 ) , e s t a bl i s h i n g a n excellent pathology museum, and instituted a postgraduate training course for specialist examinations Photo courtesy of the Department of for membership of professional Pathology and the family of Professor Hou bodies, such as the Royal Colleges of Pathologists of the United Kingdom and of Australia. He negotiated an ingenious agreement with the Hong Kong government whereby the university, with government funding, would run the hospital pathology service. This enabled the Pathology Department to keep pace with modern scientific developments and meet the requirements of a modern teaching hospital of international standing. Gibson also set up a central electron-microscope unit, a new clinical pathology unit, and, in collaboration with the Department of Extra-Mural Studies, a medical laboratory technician training program. On his watch, a new clinical biochemistry unit was established, and new services, such as tissue typing and cancer screening, were implemented. Gibson retired after twenty years of distinguished service in 1983,28 and was succeeded by Faith Ho in 1985. In 1968, microbiology, separated from pathology to become an independent department, was headed by C. T. Huang and funded by government subvention.29 Apart from teaching and research, it provided a laboratory and consultative service for the Queen Mary Hospital, and a training course on infection control for nurses. One of the weaknesses of the Faculty of Medicine before the war had been the lack of systematic teaching of public health to medical

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students. That began to change in 1950, with the creation of the Department of Social Medicine. Its first professor was Sze Tsung-sing, a graduate of the university who held diplomas in tropical medicine, hygiene, and public health. He served the university for two years before joining the World Health Organization. The gap Sze left was filled by the director of Government Medical and Health Services, who chaired part-time until the arrival of P. H. Teng in 1970. Teng became fulltime professor of the department and changed its name to Department of Social and Preventive Medicine. When Teng retired in 1974, he was succeeded by M. J. Colbourne and the department was again renamed Department of Community Medicine,30 the forerunner of the present-day School of Public Health.

Development of Clinical Departments There were three clinical departments after the war: medicine, surgery, and obstetrics and gynecology. The moder n Department of Figure 9.7 Medicine began with the appointment A. J. S. McFadzean, professor of of A. J. S. McFadzean as its chair in medicine from 1948 to 1974, HKU 1948. The small department had only four wards. A single laboratory handled both routine and research work. McFadzean ran the department with the help of medical off icers assigned to the professorial units. Initially he had only one graduate student, Gerald Choa, to help him. He later recruited Stephen K. P. Chang, a professor of medicine from China who had extensive experience dealing with infectious and tropical diseases, and who would go on to become a beloved clinical teacher.31 Photo courtesy of Department of McFadzean stressed logical thinking Medicine, HKU rather than rote memorization. His passion for research on diseases of the liver, thyroid, spleen, and blood, among other subjects, led to many important publications, inspiring

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young local graduates to become not only competent clinicians but also avid investigators. Decades ahead of his time, he had the foresight to recruit a nonclinical molecular biologist in a clinical department, initiating the use of molecular medicine in the study of human diseases. His vision, dedication, and hard work paved the way for a panel of future medical leaders of Hong Kong—among them David Todd, Rosie Young, S. C. Tso, and T. K. Chan. The foundation was laid for the Hong Kong College of Physicians.32 Over the years, while providing undergraduate instruction in medicine, the department has also provided postgraduate training and subspecialty development. In 1966, it set up the first cardiorespiratory laboratory, the Lewis Laboratory, at Queen Mary Hospital. Pediatrics was initially taught as a subspecialty in the Department of Medicine. The teaching lacked formal structure and the students were not formally examined. The 1962 appointment of Elaine Field as chair of the independent department marked the beginning of the separate discipline of pediatrics. Field was succeeded as head of pediatrics by G. M. Kneebone (1971–1975), J. H. Hutchison (1977–1980), and C. Y. Yeung in 1980. As in medicine, the Department of Pediatrics eventually developed subspecialties to cover all aspects of children’s diseases. Psychiatry, like pediatrics, had been a subspecialty within the Department of Medicine, and in 1971 it became a separate department, with P. M. Yap as its first professor and department head. Yap died after only a few months in office, and K. Singer took over. The Psychiatry Department offered undergraduate and graduate instruction, but it was also a research facility. It started a sex clinic, and psychiatric services for children and the elderly. Singer’s successor, Felice Lieh-Mak, created a much-needed referral center for the systematic assessment of autistic and hyperactive children.33 In the immediate postwar years, the Department of Surgery, headed by Francis Stock, concentrated on clinical practice. Rarely was research of any depth carried out. A sea change occurred after G. B. Ong succeeded Stock in 1964. Ong, renowned for his extremely swift and bold surgery, propelled Hong Kong to the world stage, dazzling the international community with his surgical skills and ingenuity. He established visiting professorships and traveling fellowships to promote international exchanges, and invited the Royal College of

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Surgeons of Edinburgh to conduct FRCSE Figure 9.8 examinations at the university in 1965. Ong G. B. Ong, professor of surgery from 1964 to 1982, HKU also founded the Asian Surgical Society in 1976. His determination to foster links with international centers of excellence garnered global recognition and respect.34 Ong was succeeded by John Wong. Tuberculosis of the spine was common after the war, and until effective anti-tuberculosis drugs became available there had been much suffering. A. R. Hodgson, senior lecturer at the university, provided relief to many in the interim, pioneering the resection of the diseased focus of the spine by using an anterior Photo courtesy of Department of surg ical approach—a technique that Surgery, HKU became famously known as the “Hong Kong Operation.”35 He became the founding professor of the Department of Orthopedic Surgery in 1961. Harry Fang, also a specialist in spinal surgery, applied the anterior approach to correct other spinal deformities, such as scoliosis. In 1975, Arthur Yau succeeded Hodgson to become professor of orthopedic surgery, and he was followed in 1981 by John C. Y. Leong. Gordon King continued to head the Department of Obstetrics and Gynecology after the war. He left in 1957 and was succeeded by Daphne Chun, the first female Hong Kong University graduate to be appointed to a fulltime chair in the faculty. The postwar baby boom led to tremendous overcrowding of Tsan Yuk Maternity Hospital. In 1955, a spacious new Tsan Yuk Hospital opened, providing better patient care and teaching facilities. Chun improved the standard of clinical service, and the department became well-known for its pelvic surgical technique. Chun was succeeded in 1972 by H. K. Ma, a world leader in research on gestational trophoblastic neoplasia.36 Han Suyin gives a sense of the dedication of the members of the Department of Obstetrics and Gynecology: Gordon King was in love with his profession and would rear extremely good gynecologists such as the small and wonderful

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Daphne Chun. Daphne’s hands were a marvel, tiny and so able, so nimble! She was quite happy operating the whole day and I both envied and resented her enthusiasm, and the beam on her face when yet another belly had to be opened….37 Hong Kong’s economic boom of the 1980s helped the university’s Faculty of Medicine expand to 17 departments: Anesthesiology, Anatomy, Biochemistry, Clinical Oncology, Diagnostic Radiology, Family Medicine and Primary Care, Medicine, Microbiology, Obstetrics and Gynecolog y, Ophthalmolog y, Or thopedics and Tr aumatolog y, Pediatrics and Adolescent Medicine, P a t h o l o g y, P h a r m a c o l o g y a n d Pharmacy, Physiology, Psychiatry, and Surgery; and three schools: Chinese Medicine, Nursing, and Public Health. In 2012, the three main departments, Anatomy, Physiology, and Biochemistry, were amalgamated into the School of Biomedical Sciences. The clinical departments continue to thrive with successes that trace back to the prescient recommendations of the Jennings-Logan Report of 1953 to bring all preclinical and clinical facilities together at one site. This made possible the multidisciplinary research that is so vital to advances in medicine.

Figure 9.9 Daphne Chun, professor of obstetrics and gynecology from 1957 to 1972, HKU

Photo courtesy of the Department of Obstetrics and Gynecology, HKU

Figure 9.10 Daphne Chun, professor of obstetrics and gynecology from 1957 to 1972, HKU

Photo courtesy of the Department of Obstetrics and Gynecology, HKU

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Figure 9.11 HKU Faculty of Medicine Building 2015

Photo courtesy of HKU Archive

The Second Medical School— The Chinese University of Hong Kong From an Imperial Dream to Meeting Local Needs The University of Hong Kong grew out of an “imperial” dream to propagate British culture and heritage. Educating local students was of lesser concern. But Hong Kong’s second university, The Chinese University of Hong Kong, was founded on an acute and growing imperative. After the Second World War, there were two types of secondary schools in Hong Kong: the Anglo-Chinese secondary schools, which prepared students for higher education in the University of Hong Kong or universities in other parts of the British Commonwealth or the United States, and the Chinese middle schools, which prepared students for universities in China. There was no perceived demand for Hong Kong, a British crown colony, to provide its own system of university education in the Chinese language. That all changed with the establishment of the People’s Republic of China in 1949 and the closing of the border in 1952.

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Graduates from Chinese middle schools had no path to higher education, though a few might have been able to go to Taiwan. The Hong Kong government then approved a number of postsecondary colleges, to be set up in relief.38 The government appointed the Keswick Committee to investigate how to meet the needs of the Chinese middle-school graduates. The Keswick report, submitted in 1952, did not favor the establishment of another university; it suggested that a duplicate course in arts, taught in Chinese, be set up in the University of Hong Kong. The university rejected this proposal, offering instead a bridging course to provide the opportunity for Chinese middle-school graduates to enter the university. In the 1950s the government approved the founding of postsecondary colleges in Hong Kong. These colleges were registered as schools, subject to the Education Ordinance. Staffed by teachers from universities in China, the colleges were organized around Chinese rather than British curricula. Several of them received financial support from missionary organizations in the United States, and bore strong American imprints. By 1956–1957, there were seven such colleges of varying teaching standards and quality of administration. Of these, Chung Chi College, New Asia College, and United College were among the most reputable and well managed.39 Up to that time, the Hong Kong government agreed with the Keswick Committee40 that the University of Hong Kong should remain the sole institution of higher learning with degree-granting authority. By 1956, the attitude of the government had changed, and the possibility of a second university was entertained. Finally, after a great deal of discussion and input from experts outside Hong Kong, a decision was made to establish a second university in Hong Kong. In 1957, the three postsecondary colleges—Chung Chi College, New Asia College, and United College—came together to establish the Chinese Colleges Joint Council. Its purpose was to improve the standard of teaching to a level on par with that of a university. For this it sought financial help from the government of Hong Kong.41 A great deal of thought and preparation attended the creation of this second university. The government sought advice from a number of prominent visitors to Hong Kong, including: J. S. Fulton, vicechancellor of the University of Sussex; Sir James Duff, vice-chancellor

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of the University of Durham; Kenneth Mellanby, director of the Monks Wood Experimental Station of the Nature Conservancy; and F. E. Folts, professor emeritus of the Harvard School of Business Administration.42 In June of 1961, the University Preparatory Committee was appointed to advise on selecting a site for the central university buildings and accommodations. By May of 1962, the government was satisfied with the progress made on all fronts and it assembled a commission to get the project underway. Sir Charles Morris, the chairman of Inter-University Council for Higher Education Overseas, Sir Christopher Cox, J. S. Fulton, and several others supplied the guiding vision. The commission assessed whether any colleges could be upgraded to universities, and made recommendations about how a new university might be organized, and how its constitution might be drawn up. The Chinese University of Hong Kong was inaugurated in 1963 by Sir Robert Black, the then governor of Hong Kong. Its main buildings were located on Ma Liu Shui, Sha Tin, where Chung Chi College already had its campus. In the beginning, each of the three founding colleges continued to be responsible for running its own faculties. Figure 9.12  The Chinese University of Hong Kong

Photo courtesy of Dr. Alice S. S. Ho

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In the mid-1970s, new buildings were completed, and the colleges were centralized at the new Ma Liu Shui campus. For the university to be efficiently run, it quickly became clear that the administrative framework would have to be changed. Fulton submitted his recommendations in a second report in 1976, laying down a solid foundation for the new university.43

The Faculty of Medicine, Chinese University of Hong Kong (CUHK) The University of Hong Kong had Figure 9.13 been supplying most of the doctors Professor Gerald Choa, founding trained in Western medicine in Hong dean of Faculty of Medicine of CUHK Kong, but it could not meet the demand of a mushrooming postwar population. In 1974, the Legislative C o u n c i l a n d t h e g ove r n m e n t approved a second medical school at the new university.44 Plans would include an attached 1,400-bed teaching hospital, the Prince of Wales Hospital, with both teaching and service units.45 In 1976, the newly convened Medical Academic Advisory Committee outlined a curriculum and building requirements, and helped choose the medical school’s Photo courtesy of Faculty of Medicine, first cohort of senior staff. The CUHK following year, Gerald Choa, the retired government director of Medical and Health Services, took up the challenge of becoming the medical school’s founding dean. His leadership in the planning of the teaching hospital and the curriculum, as well as recruiting staff, contributed greatly to the success of the new faculty.46 Sha Tin, a brand-new town then, was chosen to be the site for the new teaching hospital. Li Choh-ming, the vice-chancellor of the Chinese University, laid the foundation stone of the preclinical building, which was named after him—a tribute to his tremendous support and interest the founding the medical school. The first class of 60 medical undergraduates,

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admitted in September 1981, would commence clinical training in July 1983. Meanwhile, the Prince of Wales Hospital was expected to be fully built and equipped with modern facilities in just 24 months. Close liaisons between many different parties would be required.47 The formidable deadline soon proved impossible to meet. By October of 1982 it was clear that, for reasons beyond the control of the contractor, the hospital was not going to be finished on time, and the estimated completion date was delayed for a year. The government had already invited the Duke and Duchess of Kent to perform the opening ceremony on November 1, 1982, so the ceremony went ahead without an actual building to crack a champagne bottle on. An alternative venue for classes in the interim was hastily arranged.48 The United Christian Hospital generously made its training school available, and clinical teaching began, with some classes also conducted at the Kowloon Hospital.49 The strong leadership of Gerald Choa, with his clear-cut policies and nononsense approach to the myriad of problems encountered by the medical school and the university, enabled the Prince of Wales Hospital to be completed by 1 November 1983. It was equipped and officially opened six months later. In 1986, members of the first class of students were conferred their MBChB degrees, and the General Medical Council recommended full registration the following year. Figure 9.14  Prince of Wales Hospital—Main teaching hospital of Faculty of Medicine, CUHK

Photo courtesy of Dr. Alice S. S. H

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The Chinese University’s Faculty of Medicine developed rapidly, leading to the establishment of 14 departments: Anesthesia and Intensive Care, Anatomical and Cellular Pathology, Chemical Pathology, Clinical Oncolog y, Imag ing and Interventional Radiolog y, Medicine and Therapeutics, Microbiology, Obstetrics and Gynecology, Ophthalmology and Visual Sciences, Orthopedics and Traumatology, Otorhinolaryngology and Head and Neck, Psychiatry, Surgery, and Pediatrics. There are differences in the organizational structure of the faculty of medicine between the two universities. There is more integration between basic science and clinical service in the Medical Faculty of the Chinese University, such as Anesthesia and Intensive Care, Anatomical and Cellular Pathology, and Medicine and Therapeutics, for example, to encourage research activities between clinical and basic disciplines.50 In Hong Kong, medical students receive clinical instruction at two main hospitals: Queen Mary Hospital for HKU students, and Prince of Wales Hospital for CUHK students. The Hospital Authority (HA) is responsible for the administration and management of both hospitals. A few other hospitals under HA are also designated for teaching of medical students. Many university teachers are recruited internationally, and English is the default language for instruction. Part-time honorary teachers are recruited from the staff at the HA, the Department of Health, and from the private sector. The standard of teaching and the quality of graduates of both universities have enjoyed strong reputations, both locally and abroad. In the 1980s, approximately 150 medical students per year were admitted to the University of Hong Kong. The enrollment of medical students at the Chinese University increased gradually until it too was admitting around 150 students per year by the late 1980s. In 2009, the two medical schools, with a total intake of around 300 students per year, increased the number of doctors to 1.8 per 1,000 population—better, but still below the 2.5 per 1,000 figure widely found in Organization for Economic Co-operation and Development countries.

Funding for Research One of the functions of a university is to advance learning through research and scholarship. After the Second World War there was a great demand for individuals with higher education to develop Hong Kong

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into an industrial and later financial center. In 1965, the University Grants Committee (UGC) was established as an advisory committee responsible for advising the government of Hong Kong on the development and funding needs of higher education institutions within Hong Kong. As a result, there are six more universities in Hong Kong which were founded or conferred with university status after the 1980s. Despite the enthusiastic support for the founding of these institutes of higher learning, very little support had been given to research and development in these institutions. The general debate in most advanced economies, including Hong Kong, seemed to center on how the universities could contribute to economic growth rather than how they could contribute to advancement of knowledge. Research funding through the 1980s came mostly from private donations. For the medical faculties, donations also came from grateful patients. The first private foundation was established by the late Noel Croucher in 1979 to promote the standard of natural sciences, technology, and medicine in Hong Kong. This was followed in 1983 by the S. K. Yee Medical Foundation, to promote medical education and to provide medical services for the poor. It was not until 1991 that the Research Grants Council (RGC)—an advisory group on research matters that operates within the UGC—was established. The funding it received from the government has been appalling over the years. Hong Kong’s most lavish research and development budget to date, in 2015, amounted to only 0.7% of the GDP (compared with 2.1% in China, 2.7% in the United States, and 3.6% in Japan) despite its surplus in most years.51 It is such a shame that the government still fails to recognize the importance of research and development.

Postgraduate Medical Education and Training In pursuing a postgraduate education in the 1950s, medical graduates fresh out of a first-year internship, would spend the next three or four years gaining local clinical and research experience under the guidance of their seniors. There was no formal, coordinated local postgraduate training, and the opportunities were usually only available to the cream of the student body.52 After this local apprenticeship, trainees had to go to the United Kingdom for further postgraduate training and, if needed, acquire even more research experience in their field of interest. To be eligible

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to practice as specialists in the British Commonwealth, candidates had to pass Royal College examinations in their respective specialties. A few returned with university doctorates as well. At that time, the Sino-British Fellowship Trust and the Commonwealth Scholarship Scheme provided some sponsorship to help alleviate the graduates’ financial burden. Later, graduates could also apply for overseas training at various prestigious medical centers in the United States, Australia, and Canada. With rapid advances in medicine and technolog y, medical subspecialization becomes inevitable. Trainees returning with higher qualifications and research experience in their areas of study developed various subspecialties, which were later organized into divisions within each department. In the Department of Medicine, the University of Hong Kong, there are now 13 divisions: cardiology, clinical pharmacology, dermatology, endocrinology and metabolic diseases, gastroenterology and hepatology, geriatrics, hematology/medical oncology/bone marrow transplantation, molecular medicine and genetics, nephrology, neurology, rehabilitative medicine, respiratory medicine, and rheumatology/immunology.53 After rotating through some of these specialties, trainees can choose a specialty and receive excellent basic training before, or even instead of, going overseas for further study. From the late 1960s through the early 1980s, the Department of Surgery of the University of Hong Kong expanded rapidly under the direction of Professor G. B. Ong, developing such specialties as ophthalmology, ENT (ear, nose, throat) surgery, and plastic and reconstructive Surgery. Until the 1980s, graduates who had completed postgraduate training in either of the two medical schools or the Medical and Health Department had to travel to the United Kingdom to sit for professional specialist qualification examinations of the Royal Colleges. However, several events in the 1970s and 1980s transformed postgraduate medical training in Hong Kong. The United Kingdom changed its rules on awarding higher diplomas in the 1970s. The membership examination of the Royal Colleges became merely an entry qualification to the higher training required to become a specialist. In 1979, the Hong Kong Medical Council formed the “Working Party on a Specialist Register in Hong Kong,” which ultimately decided that postgraduate medical training in Hong Kong, based on an apprentice system of practical learning, was unstructured and inadequate. The working party found that such training was often squeezed in during

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doctors’ off hours, and it relied on the commitment and goodwill of the preceptors, and that the facilities in hospital and funds were insufficient to accommodate postgraduate trainees. The working party recommended that “the professional training of doctors intending to specialize be improved as a necessary step towards the setting up of a Specialist Register.”54 With the signing of the Sino-British Joint Declaration in 1984, and the irrevocable retrocession of the British Crown colony of Hong Kong to the People’s Republic of China on July 1, 1997, Hong Kong was no longer part of the British Commonwealth. That meant that Hong Kong’s medical establishment would stand on its own, in terms of administration, monitoring, and certifying its own performance. It would also need to conduct its own postgraduate teaching and examinations.55 There was a growing demand for a properly structured and supervised postgraduate training program in Hong Kong, one open to doctors from all sectors of the medical community. An institution that could confer internationally recognized medical specialist qualifications was clearly needed. Preferably, this new body would be constituted by statute to provide the legal basis for the administration of medical standards in Hong Kong in all areas of medicine.

The Founding of Specialist Colleges Before the founding of a new body to be the conscience of the medical profession in Hong Kong, there was a need to found colleges in various branches of medicine, such as internal medicine, surgery, obstetrics/ g ynecolog y, and others. Their function would be to determine professional standards and training accreditation, and to that end they would collaborate closely with the Hospital Authority through a joint committee on training, and a subspecialty advisory committee. The establishment of the Hong Kong College of Physicians in 1988 is described briefly here as an example. Its Education and Accreditation Committee, to raise and maintain the standards of postgraduate physician training, developed strict guidelines and accreditation criteria for trainers, publishing the first Guidelines on Postgraduate Training in Internal Medicine in 1993.56 The committee also formulated that trainees need to take an examination the midpoint of their programs before being able to proceed to higher levels of training and specialization. This so-called “intermediate

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examination” is conducted jointly with the Membership of the Royal Colleges of Physicians (MRCP) in the United Kingdom. Three years into their training of specialization, candidates undergo an “exit” assessment, administered by the relevant specialty board, and they must also produce a dissertation.57 Initially, the Hong Kong College of Physicians established 12 subspecialty boards: internal medicine, cardiology, clinical pharmacology and therapeutics, critical care medicine, dermatology and venereology, endocrinology, diabetes and metabolism, gastroenterology and hepatology, hematology and hematological oncology, nephrology, neurology, respiratory medicine, and rheumatology/ immunology and allergy. Later, in anticipation of future needs, the college added more specialties: infectious diseases, geriatrics, medical oncology, palliative medicine and rehabilitation. The guidelines were revised in 1998, 2002, 2007, and 2010, in step with scientific progress and changing community needs.58 In the late 1980s and early 1990s, several colleges were formed in different areas of medicine, following the example of the Hong Kong College of Physicians. They established their own guidelines and accreditation criteria for trainers, as well as developing guidelines for their own subspecialty training, and the examinations required for a professional degree.

The Hong Kong Academy of Medicine By late 1986, the need for postgraduate medical education in Hong Kong had become apparent, and the government appointed a working party to begin this process. The eventual result, after years of hard work by Professor Sir David Todd and a few other dedicated individuals, was the formation of the Academy of Medicine in 1993. This body would shape postgraduate training and continuing medical education, but more important, it would serve as the conscience of the profession. The academy has established guidelines to ensure integrity and ethical behavior among doctors, within the broader mandate of safeguarding healthcare in Hong Kong.59

Figure 9.15 Professor Sir David Todd, founding president of the Hong Kong Academy of Medicine from 1992 to 1996

Photo courtesy of the Hong Kong Academy of Medicine

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The Hong Kong Academy of Medicine Ordinance was enacted in December of 1991, and by 1993 the academy was officially up and running with 11 founding colleges: Anesthesiology, Community Medicine, General Practice, Medicine, Obstetrics and Gynecology, Orthopedics, Pathology, Pediatrics, Psychiatry, Radiology, and Surgery. Three more—Dentistry, Ophthalmology, and Otorhinolaryngology—would later be added.60 The academy has several committees. The education committee is tasked with drawing up general guidelines for the recognition of academy colleges, specialist training, recognition and visitation of local training units, and the training of units outside Hong Kong. These guidelines were endorsed by the academy council, and soon each college drafted its own training programs based on them. The education committee also produced a document “Principles and Guidelines on Continuing Medical Education (CME)”—in effect, the committee had created the CME blueprint. From it, individual colleges could fashion up-to-date CME programs to meet their own needs.61 On 3 May 1996, the Medical Registration Ordinance (Cap 161) was amended to introduce a Specialist Register. Starting 24 January 1997, doctors could apply to have their names included in the Specialist Register of the Medical Council, if they had been awarded fellowships of the academy. By law, a registered medical practitioner whose name is included in the Specialist Register must receive CME in his or her area of specialty. This important ordinance, enforced by the academy, ensures a high standard of medical practice in Hong Kong. Moreover, to remain in the Specialist Register, the practitioner is required to satisfy the CME requirement as stipulated by the Medical Registration Ordinance (Cap 161)—a minimum CME requirement of 90 points or 90 hours in a 3-year cycle, with passive CME points (points obtained through attending lectures or talks) making up no more than 75 per cycle. Shortly after the establishment of the academy, Hong Kong’s medical establishment faced close global scrutiny. Several major disease outbreaks occurred one after another: avian influenza, severe acute respiratory syndrome (SARS), and swine influenza. The medical profession rose to each challenge, caring for the sick despite the danger to themselves. They cracked the deadly mystery of SARS by identifying the causative coronavirus, and sequenced the genes of that virus within a few weeks of the outbreak. SARS seemed to have the potential of becoming another bubonic plague, which had descended on Hong Kong in 1894, more than

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Figure 9.16  Hong Kong Academy of Medicine building in Wong Chuk Hang

Photo courtesy of the Hong Kong Academy of Medicine

a century earlier, raged on for months, and then returned almost every summer for the next 30 years. Instead, Hong Kong was out of the SARSwoods within just three months. The establishment of the Hong Kong Academy of Medicine enabled the medical profession to set its own guidelines for training of local medical graduates in all specialties and subspecialties and to provide the examinations necessary to ensure the trainees meet the high professional standards, commensurate with those in other advanced economies. It also safeguards the standard of practice of doctors during their professional life by demanding regular continuing medical education. The founding of the Academy of Medicine signaled the coming of age of the Hong Kong medical profession.

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10. Hospitals and the Hospital Authority

In lockstep with the rise of Christianity came the emergence of hospitals to care for the sick. The first recorded hospital was founded in Rome in 390 C.E. by Fabiola, a convert to Christianity, who dedicated her life to charity. By the Middle Ages, thousands of early hospitals had been established under religious orders by pious requests. These institutions were modest, often with only a dozen beds under the care of a couple of brethren. By the seventh century some hospitals in Constantinople were large enough to have separate wards for men and women. In the twelfth and thirteenth centuries hundreds of leper asylums were built and, when bubonic plague struck Europe, the leprosaria were converted to plague hospitals. By the close of the fourteenth century, hundreds of small hospitals were operating in England; two of significance in London were St. Bartholomew’s Hospital and St. Thomas’ Hospital. During the Age of Enlightenment, more hospitals were added for the benefit of the poor: Westminster, Guy’s, St. George’s, the London, and the Middlesex. By 1800, all sizable English towns had a hospital. There were specialty hospitals, such as mental hospitals, lying-in hospitals (maternity hospitals), and fever hospitals for the extremely infectious, as well as comprehensive general hospitals that provided treatment, food, shelter, and opportunities for convalescence.1 Hospital nursing had long been provided by religious orders, and left much to be desired. Hospitals became places of disease and death. In the eighteenth century, campaigns began to reform the hospitals. During this period, hospitals were increasingly opened to medical students and their patients for hands-on teaching. Students followed their teachers around the wards to patients’ bedsides and into operating theaters. By the latter half of the nineteenth century, as medicine was becoming more scientific, some hospitals evolved from places of charity and convalescence into institutions for healing and teaching.2 The twentieth century marked the beginning of a wave of technological advancements that would radically change medicine, and ensure the

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permanent place of hospitals in healthcare. A “golden age of surgery” was also emerging. The discovery of anesthesia, along with new antiseptic and aseptic techniques, made surgery safer, more reliable, and more humane. As surgery’s horizons broadened and many surgical innovations, such as open-heart surgery, transplant surgery, and reproductive technology were developed, more sophisticated diagnostic techniques were required. Electronic microscopes, computerized tomography (CT) and positron emission tomography (PET) scanners, and magnetic resonance imaging (MRI) machines were created to this end. These expensive machines were usually housed in hospitals, as the evolution of the hospital from poorhouse to medical powerhouse continued. Hospitals in Hong Kong also underwent rapid changes after the Second World War. During the immediate postwar period, Hong Kong relied mostly on hospitals sponsored by nongovernmental organizations (NGOs). The government would soon build its own hospitals, though not enough to meet the demand of the growing population. With advanced medical technology driving up costs, the traditional NGO hospitals could no longer support the budgets required for modern hospitals. They became subvented hospitals, receiving subsidies from the government. At the same time the Medical and Health Department, which oversaw the administration of the large number of public hospitals and clinics, had turned into a big bureaucracy. The dramatic rise in population in Hong Kong was accompanied by overcrowding of the public hospitals and outpatient clinics, and inadequate medical staff and facilities in the 1970s and 1980s. How did Hong Kong solve the problem of hospital congestion, long wait times, poor services, high turnover of medical and nursing staff and at the same time to keep up with the constantly advancing medical technology, administered by an institution which had become highly bureaucratic and too rigid to change?

Hospitals in Hong Kong 1945–1963 Dr. Selwyn-Clarke reestablished the Medical and Health Department and reopened as many hospitals as possible to serve the stricken population as soon as he left the prison in Stanley. Some of the hospitals that had been taken over by the Japanese military were returned to civilian use, while others were badly damaged and in need of repair. Because of a limited budget, the government offered minimal curative care and had no plans

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on expanding clinics and hospitals. The sick was often left to fend for themselves. Instead, the government concentrated on the cheapest yet the best course of action: prevention of infectious diseases which were rampant in Hong Kong as discussed in Chapter 3. Table 10.1 shows the hospitals operating during this period: nine public hospitals (three general and community, one maternity, one psychiatric, three infectious disease hospitals, one prison hospital); five hospitals operated by NGOs; and five private hospitals.3 They were mostly general or community hospitals. Table 10.1  Hospitals in Hong Kong during the immediate postwar decade Hospital

Year of Founding

Nature

No of Beds in 1946

Public   Tsan Yuk Hospital

1922

Maternity

28

  Kowloon Hospital

1925

General

167

  Victoria Mental Hospital*

1928

Psychiatric

123

  St. John Hospital

1934

Community

NA

  Queen Mary Hospital

1937

General, teaching

400

  Lai Chi Kok Hospital*

1937

Infectious diseases

NA

  Sai Ying Pun Hospital*

1938

Infectious diseases

100

?

Infectious diseases

197

1842

General

47

1870

General

467

1887/1893/1906

General

129

  Wan Chai Infectious Disease  Hospital* *

  Hong Kong Prison Hospital NGO   Tung Wah Hospital

  Alice, Nethersole Ho Miu Ling,  Hospital   Kwong Wah Hospital

1911

General

340

  Tung Wah Eastern Hospital

1929

Community

230

  Pok Oi Hospital

1919

Community

39

  St. Paul’s Hospital

1898

General

NA

  Matilda Hospital

1907

General

NA

  Yeung Wo Hospital (Hong Kong   Sanatorium and Hospital)

1910

General

NA

  Canossa Hospital

1929

General

NA

  Precious Blood Hospital (Caritas)

1936

General

NA

Private

*

Note: closed; NA- not available Source: Medical and Health Department Annual Report 1946.

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As the population mushroomed, the hospitals became desperately overcrowded. In 1953, there were only 4,695 hospital beds for a population of 2.28 million—around two beds per 1,000 people. In public hospitals, camp beds were squeezed between regular hospital beds, and they also lined hospital corridors. Nurses and doctors had to trek through a maze of canvas to reach patients. Kwong Wah Hospital was so short of space, one of the nursing sisters recalled, that patients were often loaded two to a bed. There were so few stretchers that patients who were too frail to walk had to be carried by the elderly Chinese nursemaids, known also as “amahs,” whose other responsibility was to carry mothers who had just given birth back from delivery rooms. Everyone was overworked. Patients often had to pay tips (essentially small bribes) for basic services, such as being washed and turned, to avoid bed sores and ulcers, and having their water thermoses filled.4 The wealthy often sidestepped this grief by gaining admission to private hospitals. Civil servants and their dependents were entitled to free healthcare, and by 1958 they occupied roughly 20% of beds in government hospitals, further reducing the supply for the public.5 As hospital occupancy tightened, waiting times for nonurgent treatment grew. Only critically ill patients were guaranteed prompt attention at government hospitals. It was the poor, the deprived, and refugees who deluged the healthcare system when they became sick, and they in turn became the targets of abuse, rudeness, and intolerance. In her acclaimed memoir, My House Has Two Doors, Dr. Han Suyin, who faced a continuous flood tide of patients at the Casualty Department at the Queen Mary Hospital after the war, provides a glimpse of the chaotic scene and assortment of diseases seen in those days: … Everything came to Casualty. Rare cases of leprosy, lupus, tetanus, enlarged spleens from long-term malaria, syphilitics, tuberculous meningitis (mostly children and very common in Hong Kong), accidents, suicides, homicides, fishermen blown up by the dynamite they used for fishing, early cancers and late cancers, pneumonias, and jaundices and brain abscesses and the insane. A suicide who had swallowed 180 sewing needles came, was operated on, and then recovered in the Casualty jail (there were four cells in which would-be suicides were placed, since suicide was a crime in Hong Kong). I had an advanced leukemia presenting as a swollen knee; a woman of sixty-five

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without any fever but with a board-hard stomach; I diagnosed her as peritonitis and though I was jeered at, she was an aseptic peritonitis. She had swallowed an aspirin which had gone through her stomach and lodged outside her intestines. I had a ruptured esophagus and several ruptured livers and spleens, and a fulminating cancer of the retina (the patient came in with a story of two days of blurred vision); he died nine days later. Everything uncanny, impossible and fantastic came to Casualty.6 Back then, the government had no long-term policies for the health and well-being of the citizenry. It aimed at providing medical care at low cost for the poorest of the poor, but beyond that there was no plan for more comprehensive public healthcare services. “Though hospitals certainly rank high in our list of priorities, there are other problems which would appear to be just as pressing,” the Financial Secretary reported in 1957, “… Government could, however, ease the strain by encouraging voluntary agencies to build hospitals. Voluntary societies have already shown that they can erect a hospital more cheaply than the Government can, and they have also proved that they can run hospitals more economically and just as efficiently.”7 Strapped for cash, the government encouraged NGOs and the private sector to step in, and the response was impressive, as eleven new hospitals appeared between 1946 and 1963 (Table 10.2). Some were disease-specific: Ruttonjee Sanatorium for tuberculosis patients opened in 1949, a leprosarium in Hay Ling Chau in 1951, Haven of Hope Hospital and the Grantham Hospital for tuberculosis in 1953 and 1957 respectively. Nearly half of them were general hospitals. The government built seven hospitals during this period, including the new Tsan Yuk (maternity) Hospital, completed in 1954.8 The 1,641-bed Castle Peak Hospital was created to provide general psychiatric treatment and rehabilitation services.9 It also served as a center for postgraduate training, public education, and research in mental health. Although mental health services have gradually expanded in some general hospitals, Castle Peak Hospital has remained the key psychiatric institution in Hong Kong.10 The Queen Elizabeth Hospital, completed in 1963 and located in King’s Park, Kowloon, has around 1,850 beds and remains the largest acute general hospital in Hong Kong. It has a staff of 4,600, a full range of specialist services, and an emergency department that opens 24 hours a day, serving Kowloon with a population of about 900,000. The hospital’s

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Table 10.2  Hospitals in Hong Kong built between 1946 and 1963 Year Public 1946 1954 1956 1960 1961 1961 1963 NGO 1947 1949 1949 1951 1953 1957 1961 1962 Private 1957 1960 1963

Hospital

Nature

North Point Convalescent Home* New Tsan Yuk Hospital Duchess of Kent Children’s Hospital South Lantau Hospital* Castle Peak Hospital Cheshire Home, Chung Hom Kok Queen Elizabeth Hospital

Rehabilitation Maternity Disabled Children General Psychiatric Rehabilitation General

Felix Villa TB sanatorium* Ruttonjee Sanatorium Central Hospital* Hay Ling Chau Leprosarium* Haven of Hope Hospital Grantham Hospital Our Lady of Maryknoll Hospital New Canossa Hospital

TB TB General Leprosy TB TB General General

Lock Tao Maternity Home and Clinic* St. Teresa’s Hospital Hong Kong Baptist Hospital

Maternity General General

Note: * Closed Source: Hong Kong Museum of Medical Science Society, Plague, SARS and the Story of Medicine in Hong Kong (Hong Kong: Hong Kong University Press, 2006),144–145.

Figure 10.1  The 200-bed new Tsan Yuk Maternity Hospital in 1954

Source: Hong Kong Medical and Health Department Annual Report, 1954, 31. Photo courtesy of the Hong Kong Department of Health.

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Figure 10.2  Queen Elizabeth Hospital opened on 10 June 1963

Source: Hong Kong Medical and Health Department Annual Report, 1963–1964 opposite front page. Photo courtesy of the Hong Kong Department of Health.

Radiology Institute, which was inaugurated in June of 1964, offers upto-date radiotherapy, and provides basic and postgraduate training of doctors, nurses, and allied professionals.11 In 1957 the government issued a 15-year strategic plan for health services development, but due to uncertainty over long-term population demographics and economic projects, no immediate action was taken.12

Building More Hospitals 1964–1984 In 1964, as Hong Kong was turning into a regional manufacturing center and its economy flourishing, the government published a White Paper “Development of Medical Services in Hong Kong.” It outlined the current state of health and hospital services, as well as the services that would be needed over the next decade to meet the expected rising demand. For the first time the government set a target in the provision of medical services: to provide free outpatient care for the 50% of the population who could not afford to see private general practitioners, and inpatient care for the 80% of the population who could not afford hospital care. The goal was to offer one standard urban outpatient clinic for every 100,000 residents, one rural clinic per 50,000, and one polyclinic for every 500,000 people. The government also pledged to provide more hospital beds within a decade—boosting the ratio from 2.91 beds to 4.25 beds per 1,000 residents.13

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Guided by this development plan, and bolstered by a robust economy, medical services in Hong Kong expanded rapidly between 1964 and 1984. The Star Ferry riots in 1966, and the “leftist-inspired” riots in 1967 softened the government’s resistance to social spending. In the first decade, 13 hospitals were built: two public, one military, seven NGO, and three private (Table 10.3). The United Christian Hospital, a product of the joint efforts of the Hong Kong Christian Council and Alice Ho Miu Ling Nethersole Hospital, was built in Kwun Tong, a new industrial town with a half-million residents crammed into resettlement estates and highrise apartments. The United Christian Hospital pioneered the practice of “community health and medicine” during the 1970s. It would become the focal point for development of healthcare centers, industrial clinics, school and pre-school health schemes, and mental-healthcare plans, with a major emphasis on health education and voluntary services.14 By 1973, these new facilities helped the government reach its goal of 4.25 beds per 1,000 people, and the 1964 plan was hailed as a great success. A Medical Development Advisory Committee was formed that year. On its recommendation, a second White Paper, entitled “The Further Development of Medical and Health Services in Hong Kong,” was presented in the Legislative Council in July 1974.15 The main theme was the same as the previous White Paper: more beds were needed to meet growing demand. The new target was 5.5 beds per 1,000 people by the end of the next decade. One new proposal was to divide Hong Kong into five regions to facilitate the delivery of medical services: Hong Kong Island, East Kowloon, West Kowloon, East New Territories, and West New Territories. Each region would have one acute hospital for specialized care, and a number of smaller hospitals and clinics to provide basic services. The other new proposal of note was the establishment of a second medical school to address the troublingly low doctor-people ratio (0.6/1,000) in the community in 1973.16 By 1984, the end of the second 10-year period of the original government plan, five more public hospitals had been built: two general hospitals, one rehabilitation center, one dental hospital, and one psychiatric hospital, increasing the hospital bed ratio to 4.64 per 1,000 people (Table 10.3). The two general hospitals were Princess Margaret Hospital (1,753 beds) opened in 197517 and the Prince of Wales Hospital (1,518 beds) opened in 1984. Serving the 630,000 residents of the town of Sha Tin, the Prince of Wales Hospital is the teaching hospital of the Medical School of the Chinese University of Hong Kong. (See Chapter 9).

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Table 10.3  Hospitals in Hong Kong built between 1964 and 1984 Year Public 1972 1973 1973 1975 1981 1981 1984 1984 NGO 1964 1965 1967 1967 1969 1970 1973 Private 1964

Hospital

Nature

Siu Lam Hospital Fanling Hospital/Chien Ai Hospital* Yan Chai Hospital Princess Margaret Hospital Kwai Chung Hospital Prince Philip Dental Hospital MacLehose Medical Rehabilitation Centre Prince of Wales Hospital

Psychiatry Community General General Psychiatric Dental Rehabilitation, teaching General, teaching

Caritas Medical Centre Wong Tai Sin Hospital (Tung Wah Group of Hospitals) Nam Long Hospital† Fung Yiu King (Tung Wah Group of Hospitals) Tang Shiu Kin Hospital‡ Hong Kong Buddhist Hospital United Christian Hospital

General TB and chest

Tsuen Wan Adventist Hospital

General

1965 Evangel Hospital 1971 Hong Kong Adventist Hospital Military 1967 British Military Hospital (King’s Park)†

Cancer Rehabilitation Community Community General

General General

Note: * became a rehabilitation centre; † Closed; ‡ merged with Ruttonjee Hospital in 1998. Source: Hong Kong Museum of Medical Science Society, Plague, SARS and the Story of Medicine in Hong Kong (Hong Kong: Hong Kong University Press, 2006), 144–145.

The Hong Kong Council of Social Service criticized the 1974 White Paper for its failure to address the overall quality of medicine and medical facilities being provided and demanded a review of the entire health system. Upon the release of the second White Paper, Dr. Gerald Choa, Director of Medical and Health Services, noted that the Medical and Health Department had expanded so much and the administration had become so complex that it was impractical to maintain the Medical and Health Divisions under one roof. He suggested that the Medical and Health Department be divided into functional units, and that a Planning and Development Division be formed to guide the implementation of the government’s 10-year plan.18

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Dr. Choa’s suggestion, however, was not acted on. The idea of restructuring the Medical and Health Department did not surface again for another decade. In 1984, at the end of the period covered by the second White Paper, the Government Secretariat was finally stirred into action. Aware of the mounting criticism of the administration of the health services, it began to consider revamping the outmoded, overly bureaucratic Medical and Health Department which had remained unchanged since the 1930s.

Mounting Criticism and Discontent As Hong Kong moved into the 1970s, the economic boom improved the standards of living, housing, and education considerably. Many families could now afford to have air-conditioning, refrigerators, and televisions in their homes. More children entered primary and secondary schools, while some even found places in the university. Transportation grew increasingly efficient: the cross-harbor tunnel, the MTR (Mass Transit Railway) system, and several bus companies connecting different parts of Hong Kong, Kowloon, and the New Territories. Only the Medical and Health Department bucked the trend—for most people, going to the hospital was a horrific experience. Services had failed to appreciably improve, despite more and more money being poured into the Medical and Health Department. The shortcomings were both structural and personal. Response times for calls for help were slow, waits for bedpans long, visits by doctors infrequent. Patients complained that nurses were rude and amahs were indifferent. Hospital food was invariably poor and always cold by the time it arrived at bedside. Although the number of hospital beds relative to the population rose from 1950s to 1980s (Figure 10.5), hospital overcrowding and congestion remained serious issue. Many of the new towns in the New Territories benefited from the new hospitals, but outpatient queues began to grow. Like arterial plaques, beds again started clogging up hospital corridors. Visitors had trouble finding the patients they were visiting. Overstressed staff forgot bedside manners, becoming mere dispensers of pills and potions. Patients bore the brunt of these failings, and although this was hardly a healing environment, many survived.19

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Figure 10.3  Number of hospital beds and doctors per 1,000 people, 1955–2015

Source: Medical and Health Department Annual Reports, 1955–1980; and Hong Kong Annual Digest of Statistics, 1981–2015.

Patients attending government outpatient clinics often had to wait for several hours just to spend three-to-five minutes with a doctor. Many had to make two trips to the clinic: one in the early morning to obtain a visit ticket, and a second during consultation hours to receive care. Because it was not possible to have simple laboratory tests or other routine diagnostics done in outpatient clinics, doctors often sent patients to the Accident and Emergency Department (A&E). Many patients who did not want to wait their turn in outpatient clinics showed up at A&E after office hours, further burdening its staff. Elective surgeries and some diagnostic tests often took months or years to complete. Medical care was “free” only in a technical sense—patients paid dearly in the less tangible currencies of wasted time, inconvenience, and stress. Doctors were in great demand and treated like gods; and some responded by behaving like them. The lack of resources after the war meant that medical schools in Hong Kong admitted only about 50 students per year, and graduated even fewer. In the 1970s, the number of enrollees had almost tripled, but a sudden surge in refugees from Vietnam worsened the situation. Doctors and nurses were sometimes forced to abandon their normal shifts to cope with the ever-increasing patient load. Sporadic demonstrations and industrial labor actions ensued.20

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Turnover was frequent among government staff in all fields of the medical and health profession, including doctors, nurses, and allied health workers. In 1988, the monthly salary of a government doctor ranged from HK$15,000 to HK$55,000—very low by international standards. Annual turnover of doctors hovered around 10% at government hospitals and 20% at subvented hospitals.21 Many government doctors clocked 60- to 80hour work weeks, with little chance of promotion. They worked in poor conditions, often attending patients in camp beds in corridors. Most did not have offices or desks, and there was no secretarial help.22 In the end, many doctors simply left the Medical Department for greener pastures. In 1988, 8% of the nurses in government hospitals resigned, with an even higher percentage of nurses abandoning subvented hospitals. Nearly half of the training slots in many nurses’ training programs went unfilled. Government student nurses received monthly salaries of between HK$2,850 to HK$3,405 for general nursing, and HK$3,405 to HK$4,000 for psychiatric nursing. Long working hours, low pay, low professional work status, and insufficient opportunities for professional advancement all contributed to this nursing turnover.23

A Case of Management Disaster Why did the Hong Kong public medical and health system fail so badly at that time when many modern newly and well-equipped hospitals were being built? The first reason was stasis. The postwar organization of the Medical and Health Department, consisting of medical and health divisions each divided into sections, remained unchanged until 1989. Figure 10.4 shows the organizational structure in 1950–1951.24 Each section of the department was governed by a set of regulations that determined both procedures and the roles of employees, but decision-making was highly centralized. This was a sound strategy when the department was small, but it proved inadequate as it expanded into the 1980s. By then, the Medical and Health Department had become highly bureaucratic and inefficient, and the organizational structure no longer worked. Divisional lines became blurred, and it was less apparent how and by whom certain tasks were to be performed. This huge bureaucratic structure failed to pick up on the need for change. Even when the 1974 White Paper proposed regionalization as a solution, the Medical and Health Department, instead, created additional subbranches.25

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Figure 10.4  Organizational structure of the Medical and Health Department in 1950–1951

Source: Hong Kong Medical and Health Department Annual Report 1950–1951, 63. Photo courtesy of the Hong Kong Department of Health.

Second, inequalities existed between government and subvented hospitals. The government had encouraged NGOs (religious missions and community groups) to establish hospitals and clinics after WWII. As medical care became more expensive, these institutions received government financial support (subvention), which was crucial for their survival, while also retaining their autonomy. Before the 1980s, subvented hospitals provided more than half of all the hospital beds in Hong Kong. Each was governed by an independent board of directors, and managed by a medical superintendent, who oversaw all hospital operations and was responsible for daily decision-making. There was little or no effective coordination between subvented hospitals and public hospitals. When the subvented hospitals were filled, patients were redirected to the nearest government hospital, which was effectively forced to accept all acute and emergency cases. The government claimed that subvented hospitals offered better services and were more efficiently run, yet patients perceived them as “second best.” Staff at these hospitals were jealous of the higher salaries enjoyed by government hospital employees doing the same work. However, their morale was generally higher, chiefly because they did not have to deal with the same severe overcrowding.26

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Third, within a government hospital, 100 or more camp beds might fill the corridors while as many as 300 beds sat empty elsewhere. The camp beds were mostly in the medical and surgical departments, while the empty beds tended to be in obstetrics and gynecology and pediatrics because by the 1970s less babies were born and children were healthier. The hospital’s medical superintendent was in no position to force the consultants to give up any beds because the number of doctors and nurses allocated to a department depended not on the number of patients but on the number of beds, occupied or not. This problem was exacerbated by years of entrenched bureaucracy.27 In the late 1970s, members of the Legislative Council grew increasingly concerned with the mounting number of complaints about the shortage of hospital beds, failures of planning and provision, declining service standards, and the inequalities between the government and subvented hospitals. The complaints were coming not just from the medical staff but even from within the hierarchy of the Medical and Health Department itself. While acknowledging that Hong Kong’s health indicators were among the world’s best, the council members questioned the inefficiency of a highly centralized health bureaucracy that seemed resistant to change. It blamed the lack of a clearly defined and manageable policy, the ever-expanding health budget, and the persistent low morale among the staff caused by excessive working hours and poor working environments.28 In 1979, the Management Services Division of the Government Secretariat undertook a comprehensive review of the Medical and Health Department. It recommended that the department be regionalized because of its sheer size and complexities.29 Although Dr. K. L. Thong, the director, accepted the recommendations, the anticipated restructuring never happened. The Medical and Health Department had become so politically powerful that the director was able to resist all calls for change.30 In 1983, Hong Kong appointed its first-ever Secretary for Health and Welfare, Henry Ching, who called for a full review of the Medical and Health Department. The review would cover the management of the medical division with particular focus on hospitals, their organization, and their administration. Ching introduced the concept of a “hospital authority” to address the problems that existed across the different types of hospitals (government and subvented) and their funding arrangements.31

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The Scott Review and Report The decision to go ahead with the review came a year after Ching’s call. The Australian consultant W. D. Scott and Co., an affiliate of the British accounting firm Coopers & Lybrand, would conduct the review over a period of nine months, at a cost of HK$4.5 million. They were given a narrow mandate: review the organizational structure of the government and subvented hospitals, assess the potential for achieving integration between them, and advise on changes needed to strengthen hospital administration. They were to consider the training that would be required, cost-control strategies and ways to better use existing resources, and other problems related to hospital administration. The consultants were not asked to review the structure, organization, and administration of the Medical and Health Department as a whole.32 The Scott Report was submitted to the government in December of 1985 and released on 25 March 1986. The major recommendations were: • a statutory Hospital Authority (HA), independent of the civil service, to be established to integrate the top-management structures and the hospitals; • HA to be funded largely by the government and report through its own board, the chair of which was independent from the government; • a separate central governing body to be responsible for the public health functions; • the existing reg ional off ices to be replaced by boards of management with independent chairs; • a chief executive to be selected for managerial acumen and supported by appropriate staff, and each hospital to appoint staff to strengthen managerial functions and be accountable for overall hospital performance; and • all staff to be employed on comparable terms.33 The Scott Report was critical of the appointments of medical superintendents at government hospitals, especially in teaching hospitals, where consultants were often prima donnas, and many superintendents had great difficulty in filling administrative positions. The report was also highly critical of the lack of a uniform medical records system in hospitals. Records

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were fragmented, dispersed throughout the hospitals, and often inaccessible. In some situations, records were kept under lock and key in the consultant’s unit. Not only did such practices lead to poor patient care, it also exposed hospitals to legal actions brought by patients who were harmed because doctors lacked access to their medical histories. There was a need to free up nurses in the wards so that they could perform the work that they were trained to do, while leaving lesser duties to nonprofessional assistants. The Scott Report described the situations at A&E departments of public hospitals, where the policy of free after-hour treatment had created insufferable overcrowding. A&E medical officers were reluctant to send patients away without proper diagnosis and treatment, so they admitted more patients than they could be expected to handle. The report recommended that additional beds be created near A&E departments for patient observation, and that these departments be supported by 24-hour pathology and radiology services. It also suggested several options for cost recovery, such as A&E user charges to discourage unnecessary afterhours visits, charges for major procedures and drugs, and the introduction of fee-paying beds.34 The Scott Report was fair, giving credit where credit was due. It did not avoid sensitive political issues such as the inequalities between the two hospital systems, the abuses of hospital facilities by the public, a need for a realistic fee system, and the deficiencies and failures of the current hospital structure. Responses to the Scott Report were mixed, but generally good. Some refused to believe that the establishment of the HA would solve problems such as the provision of adequate primary care, 35 but in general, both the community and the subvented hospital staff welcomed the recommendations.36 The Office of the Unofficial Members of the Executive and Legislative Councils (OMELCO) agreed on the need to improve medical services, but indicated that the establishment of an independent HA required careful consideration.37 The Standing Panel on Health Service studied the report and expressed a few specific concerns: the review’s terms of reference were too limited; health workers needed assurance that hospitals would not be required to be independent, and that government and subvented hospitals should be integrated.38 With this positive feedback, the Secretary of Health and Welfare announced that the issues of setting up a hospital authority, the procedure of integration of subvented and government hospitals, and new non-civil terms of employment, would all be studied further.39

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While the debates were in progress, the press continued to expose other problems. For instance, the acute shortage of staff and specialists meant that waiting times for elective surgery were growing unacceptably long, and expensive x-ray equipment and operating theaters were too often idling.40 High staff turnover (and excessively long working hours),41 as well as shortages of qualified obstetricians and gynecologists in public hospitals, was shown to be contributing to an unacceptably high risk of birth-related complications. Patient care was being further compromised by an exodus of senior doctors to the private sector.42 All these problems pointed to the incredibly poor management of the Medical and Health Department.

The Provisional Hospital Authority (PHA) Hong Kong’s great achievements after the Second World War have often been seen as a triumph of laissez-faire economic policy. A strategy of “positive nonintervention” allowed private initiatives and market forces to contrive solutions, unimpeded. It is a city where all the major utilities except water supply are in the hands of the private sector, and public transportation, such as harbor crossings and mass-transit railway, were built and operated by private enterprises. An independent hospital authority fitted the government and the community’s political temperament. In September 1987, following a period of extensive consultation with all stakeholders, then-Governor Sir David Wilson announced the formation of a Provisional Hospital Authority (PHA). It would have the following mandate: develop proposals for a new management structure, produce strategies for integrating government and subvented hospitals, work out staff terms, conditions, and organizational structure, and construct a legislative framework for the proposed HA.43 In anticipation of the development of the HA, in March 1989, the Secretary for Health and Welfare announced that the Medical and Health Department would be dissolved and replaced by two new agencies: a Department of Health and a Department of Hospital Services. The Department of Hospital Services, in this interim arrangement, would be responsible for the management of government and subvented hospitals, and specialist clinics, until they were eventually taken over by the HA.44 The PHA was formed with Sir S. Y. Chung, (Figure 10.5) a former Senior Executive Councilor, as its chair, and 24 constituents, including

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government officials and members of the Figure 10.5 business and health communities. 45 The Sir S. Y. Chung, chairman of Provisional Hospital Authority PHA conducted its own review of the and Hospital Authority medical and health system, implicating Standing Committee poor management as the source of the medical system’s inefficiencies, and citing the lack of community involvement in the public hospital system as another major defect. The PHA report contained most of the recommendations for management and organization structures for the HA and its hospitals.46 It also made recommendations for staff terms and conditions, the scheme for hospital integ ration, and a set of guidelines for legislation. During its 14 months of existence, the Photo courtesy of Sir S. Y. Chung PHA employed six firms of consultants to consider specific issues and to ensure that there were no legal barriers to the establishment of the new HA. It addressed problems related to teaching hospitals, such as territoriality between the university and the government—where each oversees parallel specialty departments, with each unit head jealously guarding his or her “fiefdom.” The professors, who had previously enjoyed a great deal of independence from the mainstream administration, would be represented on selection boards and governing committees to oversee the management of teaching hospitals. The PHA suggested a new hospital complaint system, which would include a patient relations officer appointed to each hospital, and a mechanism for investigating complaints. Patients would be asked to describe and rate their hospital stays, and the data would be published, as proof that patients’ concerns and criticisms were being taken seriously. The PHA made every effort to meet and answer staff concerns and to provide an acceptable set of terms for the majority in subvented and government hospitals. As a result of this demonstration of good faith, 100% of subvented hospital staff, 94% of government hospital doctors, 67% of nurses, 70% of allied staff, and 76% of administrative staff signed their agreements.47

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Establishment of the Hospital Authority (HA) The HA Bill received almost unanimous support during its passage through the Legislative Council on 25 July 1990. The government determined that it would take at least three years for the HA to be fully functional.48 The three principal HA officers: director of operations, chief development officer, and secretary general, and the governing committee of each hospital, were to be appointed even before the inauguration of the HA. The staff unions opposed the financial investment on management rather than on patients, the possibility of increase of bed charges, and the prospect that those who did not opt for employment by the HA would be less likely to receive promotions. Dr. E. K. Yeoh, who was appointed Director of Operations, acted as the “troubleshooter.”49 He conducted 31 briefing sessions at 27 hospitals and was able to allay some fears and concerns. To convince the unconvinced, he held another 43 briefing sessions. As a result of his hard work, 70% of total staff signed on to the new terms of employment. Figure 10.6  Members of the first Hospital Authority Board, 1999. Sir S. Y. sitting at the center

Photo courtesy of Sir S. Y. Chung

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The HA was inaugurated on 1 December 1990.50 The HA Standing Committee had a membership profile similar to that of the PHA, and it too was chaired by Sir S. Y. Chung. Hospital integration commenced in May 1991, when the HA gained control of all 15 former government hospitals and 23 former subvented hospitals. 51 This necessitated the transfer of about 37,000 employees from 24 separate employers to the HA, which allowed three years for the staff to decide whether to transfer to HA employment terms, or remain on existing government or subvented terms. Some 76% of government employees chose to stay with the civil service, while 10% of subvented employees opted for the existing terms. The integration was considered a major achievement, as it was accomplished with no strikes and no disruption of hospital service.52 The process of integration was very complicated. A great deal of negotiation and work was necessary to unify 16 different methods of paying employees, assembling staff records, and managing financial information. Each hospital also had its own methods of ordering, storing, and distributing supplies.53 Dr. E. K. Yeoh (Figure 10.7) was appointed chief executive of the HA in December 1993.54 On April 1, 1995, the founding Chair of the HA Board, Sir S. Y. Chung, was replaced by a fellow founding member, Peter Woo (Figure 10.8). The coordinating executive committee was then dissolved.55 When Mr. Peter Woo (Figure Figure 10.7 10.8) was appointed chair of the Dr. E. K. Yeoh, founding chief Hospital Management Committee, executive of Hospital Authority he laid down four guiding principles: 1) adoption of modern management principles and practice; 2) a line of accountability from the wards up (with one person deemed responsible for results and decision making); 3) a strong chain of command; and 4) a decentralization policy with a small head office that controls policies, standards, integrity, and ethics but entrusts the day-to-day operations to the hospitals and their departments.56 As few people in the health sector knew much about management, Source: Tksteven via Wikipedia

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they were sent in groups for training, Figure 10.8 for periods ranging from five days to six Peter Woo, second chairman of the standing committee of weeks. More than 3,000 HA employees Hospital Authority, 21 May 2008. would eventually receive this training. The HA’s vision and mission are simple and spelled out in detail on its website: the vision is “Healthy people, healthy staff, trusted by the community,” the mission is “Helping people stay healthy.” The concept of “total quality management” transformed the thinking of the staff, from the highest to the lowest HA employees, Taken on 21 May 2008 during the to regard patients as “customers.” annual general meeting of Wheelock Properties Ltd., and Peter Woo was An important strategy was to chairman of the company then. Photo change the doctor-centered culture courtesy of South China Morning Post. to a patient-centered culture in the hospitals. In the past, doctors looked upon patients in public hospitals as Figure 10.9 receivers of charity, adopting a “doctor- Logo of Hospital Authority knows-best” attitude. This mentality would not be changed overnight. The HA’s corporate logo adopts the twin themes of “people” and “heart,” (Figure 10.9) symbolizing care and dedication, and the HA needs to nurture a patient-oriented service and aims at attracting, motivating, and retaining the best possible employees at all levels.57 Another public relations innovation was the design of the HA management Photo courtesy of Dr. Alice S. S. Ho as an inverted pyramid, with the front line staff on top, and the hospital chief executive and hospital governing committee at the bottom, supporting the services of the front line workers.58 After the establishment of the HA, more hospitals were built to replace some of the old hospitals, bucking the growing international trend. They were all public hospitals except for one, the Union Hospital, which is a private hospital (Table 10.4).

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Table 10.4  Hospitals in Hong Kong built between 1990 and 2013 Year Public 1990 1991 1991 1992 1992 1993 1995 1998 1998 1999 2013 Private 1994

Hospital

Nature of Hospital

Tuen Mun Hospital Cheshire Home Shatin Shatin Hospital Bradbury Hospice Hong Kong Eye Hospital Pamela Youde Nethersole Eastern Hospital Wong Chuk Hang Hospital North District Hospital Tai Po Hospital Tseung Kwan O Hospital North Lantau Hospital

General Extended care Rehabilitation Hospice Eye General teaching Geriatrics General Rehabilitation, psychiatry Community Community

Union Hospital

General

Source: Hong Kong Museum of Medical Science Society, Plague, SARS and the Story of Medicine in Hong Kong (Hong Kong: Hong Kong University Press, 2006), 44–145.

In 2013, the 41 HA hospitals were divided into seven geographical clusters: Hong Kong East, Hong Kong West, Kowloon Central, Kowloon East, Kowloon West, New Territories East, and New Territories West (Table 10.5). Each cluster offers a balance of different services, skills, facilities, and specialist treatment, and is governed by a regional advisory committee. The new hospital management system requires that each hospital have a chief executive and a hospital governing committee, and that each also contains five administrative divisions: clinical service, nursing, allied health, administration, and finance, each with a general manager selected by and responsible to the hospital chief executive.

Metamorphosis of Hong Kong Public Hospitals There have been remarkable changes within the Hong Kong public hospital system in the few short years since the establishment of the HA. With management techniques and skills brought to bear on a multitude of problems, the efficiency of day-to-day operations of hospitals has improved greatly. Information systems in management areas such as performance standards, cost accounting, and uniform clinical records, have gradually been instituted.

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Table 10.5  Hospitals in Hong Kong by clusters in 2013/14 Hong Kong East

Hong Kong West

Kowloon Central

Pamela Youde Nethersole Eastern Hospital

Queen Mary Hospital

Queen Elizabeth Hospital

Ruttonjee and Tang Shiu Kin Tsan Yuk Hospital Hospital

Kowloon Hospital

Tung Wah Eastern Hospital Tung Wah Hospital

Hong Kong Buddhist Hospital

Wong Chuk Hang Hospital Fung Yiu King Hospital (TW group)

Hong Kong Eye Hospital

Cheshire Home, Chung Hom Kok

Grantham Hospital Children’s Hospital (under construction) MacLehose Medical Rehabilitation

Hong Kong Red Cross Transfusion Service Rehabaid Centre

St. John Hospital

Duchess of Kent Children’s Hospital

3,031 beds

3,142 beds

Kowloon East

Kowloon West

United Christian Princess Margaret Hospital Hospital

3,548 beds

New Territories East New Territories West Prince of Wales Hospital

Tuen Mun Hospital

Tseung Kwan O Kwai Chung Hospital Cheshire Home, Hospital Shatin

Castle Peak Hospital

Haven of Hope Yan Chai Hospital

Siu Lam Hospital

North District Hospital

Wong Tai Sin Hospital Alice Ho Miu Ling Pok Oi Hospital Nethersole Hospital Our Lady of Maryknoll Hospital

Tai Po Hospital

Tin Shui Wai Hospital (under construction)

Caritas Medical Centre Shatin Hospital Kwong Wah Hospital Bradbury Hospice North Lantau Hospital 2,487 beds

6,629 beds

4,518 beds

Source: Hospital Authority Annual Report 2013/14

4,085 beds

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The duration of a typical hospital stay has been reduced, by speeding up a single pathology test, for example, or by using a more streamlined culture procedure. Other important quality improvements are the use of day surgeries and examinations, and reduced waiting times for elective procedures. It has been possible to achieve both savings and improvements. By 1994, the “productivity gains” were worth US$30 million, which was reinvested in improved services and programs to enhance the quality of patient care.59 The wards are now air-conditioned and roomy, with more restful colors, better quality beds, and upgraded equipment and monitors. Waiting rooms have pictures on walls and more comfortable chairs. The lobbies of some hospitals even resemble those of hotels, with granite floors, shelves filled with books, entertainment centers, activity rooms, and play areas for children. The HA has strived to make hospitals friendlier spaces, more welcoming to visitors, with polite staffs that are less stressed. By reducing the average number of patients under the care of one consultant from 100 to around 60, new positions have been created, increasing opportunities for promotion and career advancement. Due recognition for outstanding achievement, both individually and for teams, is given to staff each year. Morale has risen considerably. At every level, employees seem to have embraced the ethos of change and emphasis on respecting, treating, and saving lives as proclaimed in the mission and vision statements. Lower-level staff are polite, smoking less, speaking without swearing, and working much harder. Teamwork has improved; barriers between groups have been dismantled. There is greater flexibility in the system for doctors wishing to conduct research to switch to the university stream, and vice versa. In 2014/2015, there were 27,648 beds in HA hospitals, and about 65,760 staff. The same year saw roughly 1.63 million hospital discharges and deaths, 2.22 million A&E attendances, 7.19 million specialist outpatients, and 5.9 million general outpatient attendances. As the number of admissions has increased over the years while the relative number of hospital beds has fallen (from 5.36/1,000 in 2000 to 5.1/1,000 in 2014), few hospitals resort to camp beds in the hallways. Hospitals in the same cluster now help one another out; resources are better used, patients are more carefully screened before admission, hospital wards are better managed, and home care is more widely practiced.60

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The establishment of the HA brought the standard of public hospitals in Hong Kong to a par with those in other Western countries. This, however, did not solve other intrinsic weaknesses within the public medical and healthcare system. In emphasizing curative care and trying to provide the newest medical technologies and treatments, the government spent 90% of its healthcare budget on the HA. This left only 10% for the more cost-effective preventive services offered by the Department of Health, at a time when most high-income countries have begun to reform healthcare by emphasizing disease prevention and health promotion. Despite the vast improvement in administration in public hospitals, the unresolved problems of the healthcare system in Hong Kong would emerge within a decade of the formation of HA and this will be the topic of discussion in the next chapter. Figure 10.10  Hospital Authority building in Kowloon

Photo courtesy of Hospital Authority

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11. Healthcare Reform

In the quarter century following the Second World War, most Western countries devoted increasingly large shares of their national incomes to social programs. It was an era of widespread state welfare. Then came the oil crisis of the 1970s, when new economic pressures, including doubledigit unemployment loomed in many of these countries. They spent the next decade or more on belt-tightening, trying to avoid radical reform, only to find that strategy unsustainable. In the 1980s, some governments began to initiate healthcare reform. Hong Kong’s public medical and health system also experienced a period of turbulence in the 1970s and 1980s. There were inefficiencies in the delivery of basic care, severe overcrowding in hospitals and clinics, and long queues and waiting time for outpatient services. Overworked and underpaid medical and nursing staff left in scores for greener pasture—the private sector. In 1990, the government established the Hospital Authority (HA), and while many of the issues in hospitals were addressed, it did not solve the multitude problems lurking elsewhere in the medical health system. What was the provision of healthcare in Hong Kong when the call for reform began? What were the weaknesses in the system and how were they addressed?

Healthcare Systems in Hong Kong Healthcare System and Policy Healthcare policy and its implementation is a major responsibility of every developed country. Hong Kong has until recently lagged after other Western countries. The government has generally taken a bandaid approach to healthcare, one based on immediate needs rather than broader social principles.

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The massive influx of Chinese refugees after the Second World War overloaded every system in the colony, including healthcare. When Hong Kong’s economy expanded in the 1960s and 1970s, government policy was “that no one should be denied adequate medical treatment through lack of means.” The 1964 and 1974 White Papers on the Development of Medical Services in Hong Kong suggested medical service should commensurate with need. The aim was to provide clinics for 50% of the population who could not afford outpatient care, and hospitals for 80% of the population who could not afford inpatient care.1

Public Medical and Healthcare System Hong Kong has two medical systems: public and private. The public system was operated until 1989 by the Medical and Health Department. While the Medical Division or the Medical Department was responsible for curative care in all public hospitals and clinics, the Division of Health, or the Department of Health, was responsible for prevention of diseases, such as childhood infectious diseases, tuberculosis and HIV infection, and for maternal and child health, school health, port health, and other services. The administrative structure of the Medical and Health Department remained essentially unchanged from the 1930s through the 1980s. Decades of postwar growth in medical services resulted in a huge, inefficient, bureaucratic department incapable of change. Despite their importance, medical and health services had not been represented by a secretary in the government organizational structure until 1983, when the Medical and Health Department was placed under the Health and Welfare Bureau. In 1989, following the recommendations of the Scott Review, the Health and Welfare Bureau dissolved the Medical and Health Department and formed in its place a Department of Hospital Services and a new Department of Health. The Department of Hospital Services would be responsible for the management of government and subvented hospitals, and specialist clinics until 1 December 1990, when the Department of Hospital Services was replaced the newly established Hospital Authority (HA). At the time of the handover of Hong Kong to China in 1997, total healthcare spending was 4.8% of GDP, 52.1% of which was accounted for by public healthcare. There were 44 public hospitals and institutions managed by the HA and 11 hospitals managed by the private sector.

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There were 30,329 hospital beds in Hong Kong (4.7 beds /1,000 residents): 25,974 were in HA hospitals, 3,514 in private hospitals, 769 in correctional institutions, and 72 operated by the Department of Health. The public sector provided roughly 90% of total hospital-bed days, the private sector the remaining 10%.2 The marked improvement in public hospitals in Hong Kong as a result of the establishment of the HA has drawn more patients from the private sector, creating problems of overloading in the public sector once again.3 During the same year, the Department of Health operated 60 general outpatient clinics, which had 4.3 million patient attendances, while HA provided 49 specialist outpatient clinics and had 5.5 million specialist outpatient visits. The public sector accounted for only 15% to 20% of all the ambulatory care, while the private sector supplied the rest.4 Patients pay a fixed flat rate for hospital and specialist services. Public hospital fees, in 2004, which were very low and heavily subsidized, are listed in Table 11.1 and remained unchanged until 2017. 5 Drugs are supplied at HK$10 ($15 in 2017) per medicinal item for specialist outpatients. As some drugs are very expensive, and many elderly patients have multiple diseases, cost to the government for each patient for just three- to six-month courses can easily reach several thousand dollars. The Social Welfare Department is authorized to waive medical fees for those with genuine financial hardship. Medical care is provided to eligible residents: any holder of a Hong Kong Identity Card and any child under 11 years of age with Hong Kong resident status. Many services offered by the Department of Health are completely free of charge for Hong Kong residents. Table 11.1  Fees charged by Hong Kong public hospitals as of 2004 Service Accident & Emergency Inpatient (general acute beds) Inpatient (convalescent) Specialist outpatient General outpatient

Public fees (HKD) $100 per attendance

Cost to government % Subsidized $700

86

$100 per day; $50 for admission

$3,790

97

$68

$1,460

95

$100 for first attendance; $60 subsequent visits; $45 per attendance

$530

81–89

$250

82

Source: Fees and Charges for Health-Care Services. http://www.ha.org.hk/upload/ publication_14/105.pdf, accessed on 15 October 2016.

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Private Medical System In 1997, private healthcare expenditure accounted for 2.3% of GDP (47.9% of total healthcare spending), financed mostly by out-of-pocket household expenditures. The balance was funded by privately purchased health insurance and medical benefits provided by employers. Private individual insurance consisted mainly of medical insurance policies that paid providers on a fee-for-service basis, with limits on maximum amounts of reimbursement. Employer-provided medical benefits included the following: indemnity insurance policies purchased from private insurance companies, “contract medicine” where employers directly contracted with physician groups to provide services to employees at a negotiated fee schedule, and prepaid coverage where employers directly contracted with physician groups to provide service to employees by capitation. The fees and charges of Hong Kong Sanatorium and Hospital (HKSH), a private hospital, are shown in Table 11.2.6 The charges of doctors and laboratory tests are separate. Private consultation fees vary from doctor to doctor, depending on professional credentials and experience, location of practice, and treatments provided. Routine office visits to general practitioners cost HK$300, on average. Table 11.2  Fees and charges (HKD) of Hong Kong Sanatorium and Hospital in 2017 Services Inpatient (acute hospitals)  1st class (per day)  2nd class (per day)   Nursery (per day) Intensive care ward/unit (per day)

HKSH $5,700–$6,700 $2,400–$3,500 $750 $12,500

Note: HKSH=Hong Kong Sanatorium and Hospital; doctors’ fees and medications are separately charged. Source: “Price List,” Hong Kong Sanatorium and Hospital, accessed on 12 April 2019, http://www.hksh-hospital.com/en/fees-and-charges/price-list.

Charges for surgeries and other procedures were directly linked to the type of hospital ward that a patient chose—a private-room patient might be charged two to twenty times as much as a general-ward patient for the same procedure. A patient’s room choice is a good proxy for his or her wealth or income level, and through this mechanism, some Hong Kong surgeons extract the maximum amount that a customer can bear.7

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Some private Hong Kong hospitals have more advanced and sophisticated imaging facilities, such as computerized scanning (CT) and magnetic resonance imaging (MRI), than government hospitals. The charges for some procedures are listed in Table 11.3.8 In recent years, HA has also a list of fees and charges for visitors to Hong Kong in line with those of the private sector. Table 11.3  The cost of some common procedures in HKSH and HA hospitals for private patients Procedures CT Thorax* MRI Brain* Colonoscopy†

HKSH $4,070 $8,090 $10,420

Private service in HA hospitals $740–5,480 $3,000–20,000 $7,870–40,000‡

Note: HKSH=Hong Kong Sanatorium and Hospital; * without contrast; † Doctor’s charge included; ‡ depending on whether biopsy is needed. Source: Hong Kong Sanatorium and Hospital and Hospital Authority websites: http:// www.hksh-hospital.com/en/fees-and-charges/price-list; http://www3.ha.org.hk/fnc/ Radiology.aspx?lang=ENG; and http://www3.ha.org.hk/fnc/DiagnosticTherapeutic Procedures.aspx?lang=ENG. All accessed on 16 March 2019.

The private medical system is driven by demand and adheres to free-market principles. There is no standard or set price, and no regulation. The Hong Kong government has taken a hands-off, laissez faire approach to private medical care, partly because it has been preoccupied with more complex problems in the public health sector. Despite the high cost, there is no quality assurance of the private medical services. There are almost no data on numbers and types of services provided, prices, incidences of complication, malpractice, quality, or outcome of private practice.9

Healthcare Expenditure Between 1986 and 1997, annual total healthcare expenditure had increased fivefold, to over HK$60 billion in 1997, of which public healthcare expenditure came to about HK$32 billion and the rest accounted for by private healthcare.10 The HA consumed about 90% of public healthcare spending, while the Department of Health the remaining 10%. About 96% of the HA’s revenue came from the general government budget, with the rest coming from user fees and charges.11

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Call for Healthcare Reform The call for healthcare reform began in 1993, shortly after the establishment of the HA. Elizabeth Wong, Secretary of Health and Welfare, put forth the first consultative document, “Towards Better Health,” which reviewed the healthcare climate at the time, diagnosed some of the more pressing problems, and argued that reform was necessary.12 Hong Kong is graying rapidly. Older people are more prone to chronic illnesses and their share of healthcare expenditures is high, especially in the public sector. Since the Second World War, technologies for the diagnosis and treatment of diseases have rapidly advanced. New imaging techniques have endowed radiology with potent tools for accurate diagnosis. The use of innovative techniques for treatment has markedly improved the survival rates of patients with diseases, such as ischemic heart disease and cancer. The evolution of organ transplantation has prolonged many lives, and many powerful new drugs and potent chemotherapeutic agents have been discovered. These new inventions, technologies, and equipment are expensive to acquire and costly to maintain, and new wonder drugs are always costprohibitive. As Hong Kong’s economy flourished in the 1970s and 1980s, the populace became more educated, and demand grew for better quality and greater choice of medical services. The colonial government, in its attempt to demonstrate its productivity, continued to expand the provision of new services. People came to expect the latest advances in medical technology, the newest drugs if they got sick, and organ transplantation if indicated. After the handover of Hong Kong to the Chinese government in 1997, the weaknesses within the healthcare system were left unaddressed. The outgoing colonial government, believing that it was best not to impose radical changes during the last years of its administration, left them to the posthandover government. The HA was under pressure as more patients, who previously only attended private hospitals, flocked to the public ones because of the improvement in services. Makeshift camp beds began to appear again periodically as hospitals strove to meet demand. In the latter part of 1997, a number of highly publicized medical errors, such as transfusions of incorrect

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blood types and administration of tainted or incorrect medicines, occurred in public hospitals.13 The public doctors attributed these errors to escalating demand, manpower shortages, and the lack of a long-term policy on medical financing.14 Others alleged that the HA’s constant push for “productivity gains” had led to cutbacks in staff and services. Concern was growing over the quality of care delivered in the public system. The avian influenza that struck Hong Kong at the end of 1997 saw further criticism directed at the government for its decision to cull 1.5 million chickens, even though this was later proven to have averted a potential pandemic of H5N1 virus.15 A further outbreak of avian influenza in mid-2001 led to further questioning on the adequacy of the public health surveillance system. Hong Kong takes pride in its health indices—high life expectancy, low infant and maternal mortality rates—compared favorably with other advanced economies. Some critics argued, however, that strong scores had nothing to do with Hong Kong’s medical and health services per se; rather, they reflected the salubrious cultural characteristics of the Chinese population, such as low smoking rates (especially in women) and relatively healthy diets with more emphasis on fish, fruits, and vegetables.16

Deficiencies within the Healthcare System In October 1997, Mrs. Katherine Fok, Secretary for Health and Welfare, announced that an overseas expert would be asked to review the healthcare system.17 A team from Harvard University was invited to conduct the review and advise on healthcare reform. While complimenting Hong Kong’s remarkable health indices and equal access of medical care across demographic strata, the Harvard team identified a number of weaknesses as listed below:18

Lack of Primary Care Hong Kong has historically neglected primary healthcare. A medical system with good primary care often prevents or delays the onset of chronic disabling diseases and reduces the need for the costly secondary and tertiary medical services.

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Variability in the Quality of Care While Hong Kong had some world-class medical practitioners and facilities, the quality of care was sometimes subpar. Since Hong Kong lacked adequate statistics on outcome measures, such as treatment complication rates, disease-specific mortality rates, and functional states of patients after treatment, the Harvard team undertook several factfinding studies. They assessed the quality of medical care indirectly, by studying the drug-prescription behavior of the physicians, as well as the amount of time physicians spent on each clinical consultation. The team found that patients were often given excessive, multiple prescriptions of only two or three days’ duration, and too frequent prescription of antibiotics for too short a duration. For example, a patient with an upper respiratory tract infection was prescribed 3.89 medications, and an antibiotic was prescribed 64% of the time, for an average of 3.3 days. This pattern created antibiotic resistance. (In 2014, the percentage of patients with Streptococcus pneumoniae resistant to penicillin was as high as 70%, and those with Hemophilus influenzae resistant to ampicillin, 58%.)19 A strong incentive to overprescribe was found to exist because private-sector physicians routinely dispensed drugs in their own clinics (in the absence of a qualified pharmacist) and charged patients directly. Moreover, few patients were warned of possible side effects of the drugs.20 Public-sector doctors prescribed fewer antibiotics, and a longer course for each of them—5.2 days on average. Although drug labeling is mandatory in Hong Kong, only about half of the drugs prescribed by private practitioners were labeled, and most of the time with trade names rather than generic names. In contrast, all public-sector drugs were labeled. There have been little regulations of prescription drugs in the private sector. Many more medications are available over the counter in Hong Kong than, for example, in the United States. Antibiotics, contraceptives, analgesics, and other drugs can be purchased in Hong Kong without a prescription. Patients with chronic diseases buying these medications have often been left to decide their own dosages. This practice persists. Doctors spent little time with patients. For an upper respiratory tract infection, consultation time was usually five minutes or less. In the public sector, by contrast, physician contact time in specialty clinics was more generous. An ophthalmologist would give a patient five-and-a-half

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minutes, on average; a radiotherapist, 21 minutes. The proportion of short visits (less than 10 minutes) was greater in Hong Kong (75%) than in other parts of the world (65% in Britain, 30% in the United States). It is highly questionable whether such brief contact can provide adequate treatment. The Harvard team expressed grave concerns on the quality of care the patients were receiving from their doctors.21

Lack of Oversight and Accountability A lack of quality assurance accompanied medical practice in Hong Kong at the time of the Harvard Report. Once a practitioner obtained a license to practice, no further continuing medical education was required. There were no practice standards or guidelines, nor any peer review or regulations to improve or maintain quality of work.22 The Academy of Medicine in Hong Kong had just been established, and continuing medical education was not yet strictly enforced. Programs such as facility accreditation, which allowed some quality control over the practices of hospitals, were lacking. To maintain standards, public hospitals relied on internal audits rather than external reviews and ongoing monitoring by independent parties. Private hospitals and nursing homes were required to register with the Department of Health and had to comply with the guide to hospital standards, but the guide did not specify quality-assurance standards.23 Until the 1980s, anyone could establish a private hospital in Hong Kong with little more than the payment of a small license fee. Private hospitals functioned with little oversight, as mechanisms for private sector inspection, quality assurance, and customer complaint management were totally inadequate or absent. One of the system’s biggest failings was that government officials had focused almost exclusively on the government healthcare system, while adopting a “buyer beware” attitude, ignoring basic protection for those who received private healthcare.24 Because medical knowledge is highly specialized and technical, the role of quality assurance falls to the medical profession in Hong Kong, as it does elsewhere. The public expects the medical profession to selfregulate, yet medical professionals have traditionally been reluctant to criticize their colleagues. International experience has shown that physicians possess a natural dominance in medicine because of their superior medical knowledge and professional authority.

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Lack of an Efficient Mechanism for Handling Patients’ Complaints Patients or their families could file complaints with the Medical Council of Hong Kong or the Public Complaints Department of the Legislative Council, and a Public Complaints Committee existed under the HA to handle complaints of hospitals.25 The process of how complaints were handled was not transparent, and the public perceived the system to be unjust. This is illustrated in the way Hong Kong’s Medical Council, which was dominated by physicians, dealt with patients’ complaints. All complaints made to the Medical Council followed two main procedures. First, an initial decision on the complaint was made by the chairman and the vice-chairman of the Preliminary Investigation Committee. If prima facie evidence existed to the satisfaction of both chairpersons, the case would then be heard by the Preliminary Investigation Committee. In fact, most complaints were dismissed immediately, and never heard by the committee. Hong Kong had far less medical litigation than other Western countries. Few cases made it to a court of law and of those that did, few concluded to the patients’ satisfaction. Neither the complainants nor the respondents were informed about the process of investigation or given justifications for rulings. In 1997, of the 28 members of the complaints committee, only four were lay persons.26 The Public Complaints Committee of the HA was an internal body, established in accordance with the HA Ordinance, but it had neither statutory status nor direct investigative powers. Doctors and nurses under the HA could even refuse to attend interviews requested by the committee.27 When investigating a HA employee who was the subject of a complaint, the committee, which also fell under the HA umbrella, was in a clear conflict-ofinterest position. Moreover, since the meetings were held in private, with no channel for public participation, accountability was highly questionable. The duty of the Public Complaints Committee was restricted to uncovering the truth; it had no authority to decide whether a complainant would receive redress, or how the staff concerned would be penalized, if a defendant was found culpable. An independent, impartial complaints system is necessary.

Overloading—Long Queues and Long Wait Time The high subsidization rate and the quality of service offered by the HAmanaged public hospitals attracted patients, but at the cost of overburdening

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the facilities. Patients who were not visibly suffering often had their appointments rescheduled. Wait times were long—weeks, months, or even years—depending on the procedure and where the patient lived.28 Due to increasing demand and delays for procedures and services, the HA had put in place a triage system at specialist outpatient clinics. Medical appointments were arranged according to the urgency of a patient’s clinical condition at the time of referral and classified by category: priority 1 (urgent), priority 2 (semi-urgent), and priority 3 (routine). A patient in the “routine” category could wait up to two years for an appointment and initial treatment.

Compartmentalization of the Two Healthcare Systems Hong Kong citizens frequently engaged in “doctor shopping”—visiting two or more doctors for the same episode of illness.29 Moreover, there was little communication among doctors in the private sector, or between doctors in the private and public sector. It was not uncommon for a private physician to refer his or her patients to the public sector for specialist care; however, very few of the referring doctors received followup reports once their patients were in the public system. The referring doctor would only know the outcome if a patient returned, and if a written report was received, it was usually inadequate. There were also continuity issues: the chain of care sometimes broke down when patients were transferred from one sector to another. This compartmentalization of health services often led to duplication of investigations, polypharmacy, and waste of resources.30

Inappropriate Resource Allocation An aging population’s chronic diseases put an increasing burden on the healthcare system, and curative medical services alone are an inadequate long-term strategy. Many other countries were doing things differently. Proactive rather than reactive, they were shifting public resources toward more cost-effective primary and outpatient care, preventive measures, and patient education. In 1997, Hong Kong’s health sector, going against the trend of other Western countries, favored curative medical services over disease prevention. Ninety percent of the public healthcare budget was consumed by public hospitals under HA and the rest by the Department

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of Health where health promotion and prevention services were severely under-budgeted.

Unsustainable Healthcare Finance Hong Kong has always been proud of its efficiency in delivering healthcare. It has among the lowest total healthcare expenditure in the world and yet it has achieved one of the world’s best health indices.31 However, many healthcare costs in Hong Kong were hidden and covered by expenditures of other departments: official figures on public healthcare expenditures had not included such items as the rental value of buildings and facilities, or the services supplied gratis by other government departments.32 If all of these hidden costs were counted, Hong Kong’s total healthcare costs would be higher, indeed, comparable with Asian countries such as South Korea and Taiwan. Singapore had an even lower total healthcare expenditure than Hong Kong, and it also achieved health indices as strong as those in other advanced economies. (Figure 11.1)33 Figure 11.1  Total healthcare expenditure (% GDP) in different countries (1989–2014)

Source: OECD Health data, accessed on 11 October 2016, http://www.oecd.org/els/soc/.

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Figure 11.2  Public and private healthcare expenditure (% total healthcare expenditure) in Hong Kong, 1989–2014

Source: H. G. Ma, “Healthcare Reform and Change Management: The Practice of Health Administration” (Presentation at Hospital Authority Convention, 28 March 2015).

The total healthcare expenditure in Hong Kong had grown significantly, from 4.1% GDP in 1990 to 4.8 % GDP in 1997. Public sector healthcare expenditure had risen from 1.6% to 2.5% GDP, while private healthcare expenditure was only up slightly, from 2.2% GDP to 2.3%. During this period, the proportion of public healthcare had risen sharply— from 42.1% to 52.1% of total healthcare expenditure—while private healthcare expenditure had decreased proportionately.34 (Figure 11.2) If Hong Kong were to maintain the quality of care and timely access to public health service, its previous commitment to public healthcare expenditure had to be maintained. Assuming that GDP grew at 5% per year, the Harvard team estimated that public healthcare expenditure would need to increase from 2.4% of GDP (1996 level) to 3.4% of GDP by 2016.35 Such a growth rate would be unsustainable—gobbling up between 20% and 23% of the total government budget—unless other important public programs, such as education, social welfare, and housing, were reduced. The Harvard team predicted that the Hong Kong government could not afford to continue with the system of healthcare financing it had in place. Hong Kong has a narrow tax base that narrows further with changing demographics. When labor-force participation shrinks from the current 58.8 percent to an estimated 49.5 percent by 2041, revenue

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from direct taxation will decline and the tax dollars available to fund these services will shrink proportionately. With an aging population and increased demand for high-priced new medical technology, healthcare costs seemed sure to spiral out of control. A course-correction was clearly needed.

Healthcare Reform Proposals The Harvard Report Recommendations in 1999 The Harvard team recommended the creation of family medicine as a medical specialty and measures that would improve quality assurance in medical practice. It also proposed options to improve the financial sustainability of the system: a health security plan and a savings account for long-term care. A compulsory health security plan was deemed necessary to protect people from unexpected, large medical expenses, such as hospitalization and specialist outpatient services for serious chronic illnesses. The individual savings account was to be used to purchase longterm care insurance upon retirement or disability.36 The Harvard Report sparked extensive debate in both public and medical circles, but there was little support for compulsory health insurance. Subsequent surveys of the general public showed that only about one in four people thought it was a good idea.37

“Lifelong Investment in Health” in 2000 Because of the controversies generated by the Harvard team’s recommendations, the government prepared its own document, “Lifelong Investment in Health,”38 published in 2000 as its own proposal for change. The government would work within existing institutions rather than make a radical change and continue to be a major funder of public healthcare, safeguarding the principle that no one be denied adequate care due to insufficient means. Reforms to the healthcare delivery system would be gradual and evolutionary. The public and private systems would be maintained, with closer collaboration between the two. Primary care and preventive services would be strengthened, a communityfocused, patient centered, and knowledge-based integrated healthcare

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system would be developed, and the quality assurance program would be enhanced. The 2000 document included regulatory requirements for quality assurance, improvements in patient complaint mechanisms, and structured continuing professional development. The Harvard review had coincided with the Asian financial crisis, which crippled Hong Kong’s economy. The uncharacteristic, prolonged economic depression, lasting for several years, gave the government an opportunity to cut costs (as it had become politically acceptable) by reducing its subsidy from 97% to 95% of the total healthcare expenditure, and by introducing user fees, such as a HK$100 charge for each visit to an Accident and Emergency Department. With scant support for compulsory health insurance proposed by the Harvard team, the government proposed a personal medical savings account, known as Health Protection Account (HPA), whereby a small portion of the wages of working people (1% to 2%) would be deducted and put in a fund to pay for public health services they might require after the age of 65. The government’s HPA also did not receive support from the public and other stakeholders and was subsequently abandoned. Low-income people opposed the plan because it would further cut into their meager take-home pay, while the middle-income group felt that they were being asked to contribute to an “improved” system that offered no promise of better service or more choice in return. There were also doubts about whether 1% of the earnings of ordinary working people would make a meaningful difference in the overall healthcare financing picture. People in the higher-income bracket worried that a fairly large sum of money would be locked up in their HPA and thus unavailable for them to purchase private healthcare service, which they preferred.39

“Building a Healthy Tomorrow” in 2005 In 2005, the Health and Medical Development Advisory Committee, chaired by the Secretary for Health, Welfare and Food Bureau, issued another consultation document called “Building a Healthy Tomorrow.”40 The government emphasized the importance of primary care and the role of the family doctor as gatekeeper to secondary and tertiary health services. It highlighted the importance of care for the elderly and the chronically ill, and proposed rehabilitating patients in a well-organized,

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community-based system. It defined more clearly the roles that the public and the private sector should play. The public sector most appropriately handles emergency, acute, and catastrophic illnesses and provides services for low-income groups, and training and continuing education for healthcare professionals. The private sector best provides comprehensive, personal, and quality care to patients. The discussion paper did not receive much public attention and the government did not follow up on its proposals. By then the economy had improved and the government promised to increase funding for public healthcare starting in 2007.

“Your Health, Your Life” Consultation Document in 2008 In 2008, the government produced yet another proposal for healthcare reform, this one in the form of a document called “Your Health, Your Life,”41 and with public consultations. There were four stated aims: 1) to enhance primary care; 2) to promote public-private partnership in healthcare; 3) to develop electronic healthcare record sharing; and 4) to strengthen the public healthcare safety net. There was also a financing reform proposal for supplementary healthcare financing via six possible supplementary options. The first-stage of public consultation on healthcare reform was carried out from March to June of 2008. Most of the public supported the first three parts of the proposal as outlined in the previous paragraph. But there was no support for changing the financial model of the healthcare system. The public suspected that the government wanted simply to unload public healthcare funding onto the people themselves, even though at that time the Financial Secretary set aside HK$50 billion from the fiscal reserve to support healthcare financing reform.42

“My Health My Choice” in 2010 Following the second stage of the consultation of the 2008 document, the government published a new proposal, “My Health My Choice,” in 2010 to address healthcare finance reform.43 The new scheme was based on the following principles: 1) public funding will remain the main source of funding for healthcare, supplemented by private funding; 2) participation in a healthcare financing scheme is voluntary; 3) the

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scheme will provide consumers with a greater choice of value-formoney healthcare services with quality assurance; 4) participants will enjoy extended continuous protection into old age; and 5) the scheme will be standardized and regulated by the government to safeguard consumer interests. This voluntary supplementary scheme, plus proposals to strengthen government’s supervision and regulation of private health insurance and healthcare services, was supported by the public.

Progress in Healthcare Reform With endless, multiple consultation documents and plans since 1993, one might have expected sweeping changes to both Hong Kong’s private and public healthcare systems. So far, that has not happened. However, since the new millennium, the government and the medical profession have made significant moves to address weaknesses in several areas identified by the Harvard Report. Some of the reforms have already been implemented as discussed below, while others such as healthcare finance have yet to be agreed upon. Changes in primary care and traditional Chinese medicine (TCM) will be addressed in the next chapter.

Preparedness for Future Epidemics The SARS outbreak in 2003 revealed how vulnerable and unprepared Hong Kong was to a major medical disaster. In 2004, the Hong Kong government set up the Centre for Health Protection to prevent and control outbreaks of communicable and noncommunicable diseases.44 SARS did not return but the threat of H5N1 bird flu had lingered since 2003. There have been flu outbreaks in poultry in 12 countries in Asia, Europe, Africa, and human cases as well. The government published a preparedness plan in early 2005 and tested in simulation exercises. It is maintaining a stockpile of anti-flu drugs that is continually updated. To improve disease surveillance and control, the center is setting up a HK$100 million communicable-disease information system, aimed at creating a comprehensive database for disease analysis. HA also had enhanced the infection control facilities including ventilation and filtering provision. Some 1400 isolation beds were constructed in 14 major acute hospitals

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to upgrade their ability to handle future infectious disease outbreaks. 45 In 2009, the arrival of a Mexican traveler with swine flu provided an opportunity to showcase Hong Kong’s preparedness in preventing an outbreak of communicable disease (see Chapter 7).

Assurance of Quality of Care At present, all specialists are required by the Academy of Medicine to log a minimum of 90 hours of continuing medical education (CME) in a three-year cycle, to be included in the Specialist Register at the Medical Council of Hong Kong. CME programs are overseen by the Academy of Medicine and the various specialist colleges. For nonspecialists, enrolment into the continuing medical education program is voluntary. For those who accumulate the required credit points per year (30 hours), the Medical Council issues a certificate indicating a satisfactory level of CME activity during that period. The College of Family Physicians has actively promoted CME among its nonspecialist members.46 Several practice guidelines, for management of patients with chronic diseases such as hypertension and diabetes, and for disease prevention in the elderly and children, have been introduced by the Department of Health Primary Care Office.47 Individual colleges or societies of various subspecialties have also introduced and promoted treatment guidelines for a number of diseases; for example, the Hong Kong Thoracic Society has endorsed guidelines such as the Global Initiative for Asthma (GINA)48 for management of asthma, and Global Initiative for Chronic Obstructive Lung Disease (GOLD) 49 for management of chronic obstructive pulmonary disease (COPD). Proper clinical practices were developed to reduce risk.50

Enhancement of Staff Competency The HA initiated measures to better support human resource functions at the cluster level. New staffing structures were created for doctors, nurses, and allied health professionals. Competence enhancement programs and advanced certificate courses were organized. A framework for continuous professional development and training quality accreditation was developed to improve the quality of staff at all levels.51

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Oversight and Accountability Accreditation of public and private hospitals and institutions, to be carried out by external reviewers, has been introduced and implemented. Within each public hospital, programs to ensure the quality of care are being instituted such as clinical audits, mortality rounds, and audit for mortality of certain diseases and complications of procedures are being carried out. Evidence-based medicine is being promoted, while new medical and information technologies are being carefully and judiciously assessed.52

Access to General Outpatient Services Since August of 2003, a series of measures, including extension of opening hours, allocation of staggered appointments, extension of prescription durations for patients with chronic diseases, and automated phone appointment system, has been implemented to improve patients’ access to outpatient services.53 The public-private shared-care system in community health centers for patients with chronic diseases (Chapter 12) was designed to reduce long queues at specialty clinics.

Communication and Collaboration between the Public and the Private Sectors The HA information technology team and those in the private sector have developed an electronic health record (eHR) sharing program and this allows authorized healthcare professionals to gain and share patients’ data across all sectors. Efforts are being made to improve communication between the public and private sectors; for example, all patients discharged from public hospitals are given discharge notes with diagnoses and treatments, which they can take to their family doctors. The government has also begun to experiment with different public and private collaboration projects. Among them are: 1) a pilot program for purchasing primary medical care for elderly patients; 2) vaccination subsidy programs; and 3) partnership programs for cataract surgeries and hemodialysis.54 In addition, the HA has introduced sessional private practice in selected general outpatient clinics, and the provision of positron emission tomography services through collaboration with

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private practioners.55 Capitalizing on professional expertise and knowledge infrastructure, HA provides training and education to private practitioners to break the clinical public/private barrier.

Resource Allocation Hospitalization is the most expensive form of healthcare. There has been a sustained effort to reduce the use of beds in acute-care hospitals, and to redirect those resources into community care. 56 Initiatives include outpatient or day surgery, nurses’ clinics for diabetes patients, hotline services for old age homes, a high-risk elderly database to identify patients at risk for frequent hospitalization and to provide them with telephone nursing consultation, voluntary support upon discharge from hospitals, and physiotherapy services organized at A&E Departments to reduce the number of lower-back-pain admissions.57 Nurse-led services were expanded and outreach nursing and rehabilitation services were introduced. All these measures succeeded in keeping patients out of hospitals, and reducing admission rates from 661 per 100,000 in 1997 to 479 per 100,000 in 2012.58 The Department of Health collaborated with other NGOs to promote disease prevention, health education, and training of healthcare professionals in the welfare sector. Hospital and community-based smoking cessation programs were established in 2002–2003, with more than 4,000 smoking-cessation sessions having been conducted to date.59

Sustainability of the Public Healthcare System The government formulated its policy on fees and charges, and it was implemented in April 2004. The HA developed a model for populationbased resource allocation to clusters for 2003–2004 to encourage costeffective use of resources. In addition, the HA took great pains to improve system efficiency and generate savings, including administrative downsizing, central purchasing, and energy conservation measures in public hospitals, among others.60 However, these steps are far from addressing the underlying problem of financial sustainability of the current public healthcare system.

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Problems to Be Addressed Although progress has been made to improve many areas of weakness, the following are problems remaining within the healthcare system to be resolved:

Pharmacy Practice Despite modern high-tech facilities, pharmacy practice in Hong Kong reminds one of nineteenth century England. Doctors, their nurses, or unqualified assistants routinely dispense medication in their offices. In most high-income countries, prescribing and dispensing have become separate functions, and doctors only dispense where patients do not have easy access to a pharmacy. The doctors in Hong Kong enjoy an exemption under the Pharmacy and Poisons Ordinance which allows them to dispense their own medicines without the need to employ a pharmacist. It is also the policy of manufacturers to supply drugs at a lower cost to doctors than to pharmacists, resulting in pharmacy-filled prescriptions being more expensive. In 1979, following an industrial action by government dispensers, there was considerable public interest on the practice of pharmacy, and the need for all prescriptions to be filled by qualified persons. A government-appointed Working Party on the Practice of Pharmacy and Ancillary Matters found that the public generally had less confidence in pharmacies, and that consumers were satisfied with doctor-dispensing, recommending that there was no need for any change to the system. However, it recommended that patients had the right to request a prescription and that this should be honored.61 In addition to over-prescribing, especially antibiotics, leading to development of drug resistance as discussed in the Harvard Report, the practice of doctor-dispensing contributes to polypharmacy and dangerous drug interactions.62 This practice sometimes has disastrous consequences for patients. In 2005, for example, two elderly patients died as a result of mistakenly being given an anti-diabetic drug as stomach medication.63 The separation of the role of doctors and pharmacists is highly desirable and should be the government policy, as it is in most countries with advanced economies. No decision has yet been made.

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Quality Assurance and Transparency of Charges of Private Hospitals While a quality assurance program is being implemented in public hospitals, and is beginning to be implemented in private hospitals, issues remain. The lack of transparency in hospital charges and the lack of upfront cost certainty in the private system need to be addressed.

Patient Redress System There is still no independent complaint system at the Medical Council. The government recently proposed a Medical Registration (Amendment) Bill, which would add four appointed lay members to the council, expanding the membership to 32. This was rejected in 2016 by doctors who, despite their support for medical reform, feared that the independence of the council would be compromised by allowing the chief executive to appoint more members and thus control the body. (The Bill was finally passed at the Legislative Council in 2018.)64

Long-Term Care for the Elderly There is still no comprehensive program for long-term care for the elderly. The two problems, primary care and long-term care for the elderly, need to go hand in hand.

Financial Sustainability Due to lack of public support of various proposals, the government has done little to improve its healthcare finance model since the Harvard Report. The Asian economic crisis of 1998 sunk Hong Kong into economic depression for several years. Public spending on health during this period was necessarily curtailed. It was not until 2006 that Hong Kong’s GDP began to show signs of growth. Since then, Hong Kong has capped healthcare spending to 17% of total expenditures (Figure 11.3).65 During this period, public healthcare spending has gradually decreased, while private healthcare spending has increased (Figure 11.2). This trend can be best explained by increased user fees and growing use of private medical insurance. Despite the lack of enthusiasm in the community

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for any compulsory medical insurance program, there has been a noticeable increase in private medical insurance coverage during the past two decades, from 14% in 1993 to around 34% in 2015—a substantial improvement. This trend, most people believed, was not the result of the government’s healthcare reform, but of the people’s own volition. The percentage of healthcare expenditure contributed by the private sector in the past decade increased from 42.8% in 2003/04 to 52.4% in 2013/14. Figure 11.3  Healthcare expenditure (% of total expenditure) in Hong Kong, 1973–2015

Source: Hong Kong Annual Digest of Statistics, 1973–2015.

That Hong Kong has no savings scheme for healthcare or longterm care does not bode well for the future. According to economists, the highly tax-dependent financing model for health is unlikely to be sustainable with a declining labor force and growing number of dependent elderly persons. Hong Kong is ill-prepared to meet these serious challenges. Without an adequate and coherent plan to deal with the situation, it is certain that quality of care will decline, with the lower socioeconomic groups suffering most.66 Despite this, in 2014, a survey of randomly selected adults found that close to half of the residents disapproved of the voluntary health insurance scheme. They prefer the heavily subsidized but often crowded public healthcare services to setting aside several thousand dollars a year to buy health insurance and upgrade to private doctors.67

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In summary, although healthcare reform does not seem to have changed the public healthcare system all that much on the surface, a great deal has been accomplished. The reforms, as promised, are gradual and evolutionary. These include improved preparedness to deal with epidemics, emphasis on disease prevention and health promotion, improved quality of care and accountability, reduced waiting times in the public healthcare system, reallocation of resources from hospitals to the community for the elderly and the disabled, introduction of primary care, and enhanced communication between the private and public healthcare sectors through various programs. The mandatory CME program for specialists and voluntary CME program with strong inducement for nonspecialists, no doubt, have improved the quality of care in both the public and private sectors. Many projects are still work in progress. Very little has been done to reform the pharmacy practice and the patient redress system, or to secure more sustainable healthcare financing. The long view still eludes many people in Hong Kong. They prefer the present tax-based financing system as the major source of healthcare financing and accept charges for use of services and a voluntary medical insurance program. The incentive is inadequate to encourage the middle class to buy private insurance and to switch to the underutilized private sector, allowing the public system to serve those who truly need it. There has always been a strong tension between the view held by many in Hong Kong that private markets are the engine of strong economic performance and that a laissez faire policy is the best policy for Hong Kong, while at the same time many hold the opposite view that healthcare is a fundamental right guaranteed by the government, and that all citizens, especially the poor and the disadvantaged, should have equal access to high quality healthcare. This ideological conflict between the two opposite views is surely one of the most complicated and lasting obstacles to healthcare finance reform.

12. Embracing the Future and Learning from the Past: Primary Care and Traditional Chinese Medicine Development of Primary Care What is Primary Care? Primary healthcare is a philosophy and a strategy for promoting and protecting the health of individuals. The World Health Organization (WHO)’s 1978 Declaration of Alma-Ata defines it as “essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families through their full participation and at a cost that the community and country can afford. It is the first level of contact of individuals, the family and community with the national health system, bringing healthcare as close as possible to where people live and work, and constitutes the first element of a continuing healthcare process.”1 Primary care, in most countries, is a flexible concept. It applies to first-contact healthcare models that provide comprehensive person-centered care, and includes health promotion, community development, and coordinated intersectoral action to address the social determinants of health.

Evolution of Primary Care Practice The first primary care providers were “general practitioners” in the most literal sense. In Britain, before the Napoleonic years, medical care consisted of primitive surgery and crude pharmacy. The “medical men” who dispensed it had been trained as apprentices and had passed the examinations of the Society of Apothecaries or the Company of Surgeons. They were “medical men,” not “doctors.” The term “doctors” is reserved for members of the Royal College of Physicians of London—a tiny elite of physicians who supplied healthcare to the rich and consulted in technically difficult areas.

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In 1858, a Medical Reform Act created the General Medical Council for the entire United Kingdom. It stipulated that only universities and established corporations of England, Wales, Scotland, and Ireland could grant medical licenses, and that only those registered by the General Medical Council would be considered “qualified medical practitioners.” The act gave general practitioners the same legal (though not social) status as the elite consultant physicians of London.2 During the second half of the nineteenth century, the practice of medicine became more science-based, and general practitioners became primary care doctors or family doctors.3 Specialization in medicine began at the end of the nineteenth century and flourished on the popular demand. In Britain, specialists cared for patients in hospitals, while family doctors or general practitioners were responsible for primary care. By the turn of the twentieth century, general practitioners had lost the right to see patients in hospitals, but they maintained a gatekeeping role: before a patient could be seen by a consultant in a hospital or a hospital outpatient department, a referral letter from a general practitioner was required.4 In the United States, general practitioners are disappearing. In 1942, about half of all doctors were general practitioners; the rest were specialists. By 1989, the proportion of general practitioners had fallen to under one in nine.5 To protect their sphere of operation, general practitioners formed their own association in 1947—the American Academy of General Practice. It organized training workshops, provided continuing education to members, and demanded the right to certify its own trainees. North of the border, the College of Family Physicians of Canada was formed in 1954.6 The first residency training program in family medicine was launched at McMaster University in Hamilton, Ontario in 1967.7 Primary care in Hong Kong was slow to develop. Its evolutionary path was different from that of Western countries, in that it involved two separate cultural heritages: Western-style primary care and traditional Chinese style primary care.

Pre–World War II Era Until the late-nineteenth century, the Chinese inhabitants, when they had minor health complaints, would consult traditional Chinese medicine (TCM) practitioners or herbalists. Western-style medicine was largely

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distrusted, but in 1882 the paradigm began to shift. The Nethersole Dispensary was established, followed closely by the Alice Memorial Hospital in 1887, the Nethersole Hospital, the Alice Memorial Maternity Hospital, the Ho Miu Ling Hospital, and finally the aggregation of these facilities at a single site—the Alice Ho Miu Ling Nethersole Hospital in 1939. These hospitals offered free Western medical consultation with a small charge for medications, and many Chinese began seeking out these new treatments. In 1896 Tung Wah Hospital, which had only offered TCM since its inception, began to use Western medicine and patients could choose either TCM or Western medicine. Western medicine was perpetuated by the establishment of the Hong Kong College of Medicine for Chinese in 1887, the forerunner of the Faculty of Medicine, the University of Hong Kong. The graduates of the College of Medicine could not be registered in Hong Kong, since the degree was not recognized by the General Medical Council in Britain. However, they had received good training in Western medicine, and were hired by the government to work in the Chinese Public Dispensaries to perform birth and death registrations, send sick patients to hospitals, remove “dumped” bodies to the public mortuary. Additionally, they were permitted to treat patients and charged those who could afford to pay. There were nine Chinese Public Dispensaries opened in different parts of Hong Kong and Kowloon. A 19-person, central committee was formed to take over the responsibilities of the dispensaries, while local committees were established to manage them. Although the government paid these doctors, the expense of running the dispensaries was raised in the Chinese community by the Chinese Public Dispensaries Committee, which was chaired by the Registrar General.8 The Chinese Public Dispensaries proved to be very popular. They provided free vaccinations and cooperated with the government to educate local communities about issues such as infectious disease notifications, and the dangers of dumping dead bodies on the streets. The government also employed Western-trained midwives at these dispensaries offering home deliveries and they taught new mothers essential skills such as simple hygiene and proper feeding of their babies. In addition to the Chinese Public Dispensaries, the government established six clinics in the New Territories: Tai Po, Un Long (now Yuen Long), Fanling, Sai Kung, Tai O, and Shenzhen. These clinics were attended by medical officers either daily or three times per week depending on the demand.

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The Chinese Public Dispensaries and the government clinics provided primary care for people in the community and were the forerunners of the outpatient clinics and maternal and infant health centers that emerged after the Second World War. They enhanced the acceptance of Western medicine by the Chinese. Despite government’s efforts to suppress TCM while favoring Western medicine, TCM remained popular. TCM practitioners remained the first point of contact for many people when they became ill.

Post–World War II Era (1945–1970) After the Second World War, as before, private practitioners offered care for those who could afford it, and the poor attended the government general outpatient clinics or the Chinese Public Dispensaries. In 1946 the government took over all the Chinese Public Dispensaries and renamed them general outpatient clinics. These clinics became the backbone of local outpatient medical services, especially for the working class, providing primary care. Over the years, the government replaced most of these dispensaries with larger clinics or polyclinics and added more. In addition, many new private or charity clinics emerged especially in the new industrial towns that arose in Kowloon and the New Territories in the 1960s and 1970s, such as Tsuen Wan, Kwai Chung, and Kung Tong. During the immediate postwar years, the number of registered medical doctors failed to meet the demands of a growing population. Among the immigrants and refugees were a few doctors who had been practicing in China but were not “registrable” by the criteria of the General Medical Council. To assist them in obtaining registrations, the government invited the Society of Apothecaries of London to conduct examinations in Hong Kong in 1958, 1959, and 1960 (see Chapter 3). The 126 (out of 177) candidates who were successful were awarded the LMSSA, London (a medical qualification registrable with the General Medical Council). Some would work in the Government Medical and Health Department, others would staff government subvented hospitals, and the remainder work in private clinics. In the 1950s and early 1960s, many charity clinics, staffed by “unregistrable” doctors, sprung up in Hong Kong. The law dictated that only registered medical practitioners could practice for gain, meaning that an unregistered medical practitioner, or indeed anyone, could still

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practice medicine provided that no profit accrued. Clinics were opened by missionary societies, native-place associations, kaifong associations, trade unions, chambers of commerce, and other bodies with the stated object of providing low-cost medical attention for the sick and the poor. They were staffed mostly by “unregistrable” doctors with Chinese medical qualifications, claiming that they gave their services in an honorary capacity. It was often impossible to prove otherwise. In through this open door, came nurses, dressers, charlatans, and quacks, all claiming to be “unregistrable” doctors. However, the poor had come to rely on these charity clinics, as there were too few registered medical practitioners to meet the community’s needs, and understandably, the “unregistrable” doctors were able to command a fair degree of public sympathy.9 To ensure that patients received reasonable care from credible and accountable doctors, the government enacted the Medical Clinics Ordinance in 1963, requiring all clinics to be registered, or registered with exemption. A total of 730 applications for registrations or registrations with exemption were received in 1964. Eighty clinics employed only registered medical practitioners, 28 employed both registered and unregistered doctors, and the rest were staffed by unregistered doctors. The latter were interviewed by a panel of specialists to ensure that they were competent to practice medicine in the clinics. The standard set by the panel was very low and the interviews were brief and cursory, consisting of questions based on practice rather than theory. A number of candidates arrived with forged diplomas, and were later investigated by the police.10 Four hundred and eighty-three doctors passed the interview and were permitted to practice medicine in these clinics which could be registered with exemption under the ordinance. A total of 353 clinics were granted registrations with exemption. These clinics varied in size and standard, some were well-equipped and well-attended by patients, while others had such low patient loads that they were hardly efficient to run. The registered clinics charged HK$3 per visit with medicine for two days, while clinics registered with exemption charged HK$2.50 per visit. Unregistered practitioners earned about HK$800 to HK$1,200 per month, while their counterparts in the Government Medical and Health Department earned HK$1,700 to HK$2,600 per month for men, and HK$1,270 and HK$1,945 for women.11

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In July 1965, an advisory committee was set up to assess the clinics established under the Medical Clinics Ordinance. There was a clear need for these clinics; they had some 3,750,000 patient-visits per year. Indeed, half of the population of Hong Kong relied on low-cost clinics for general or primary medical care.12 Because the standards set at the clinical interviews by the panel of specialists were unambitious, the advisory committee decided that the 483 “unregistrable” medical practitioners should take further examinations in order to prove their competence. Held between 1967 and 1969, the examinations were mandatory for all those in government service. All who passed would be placed on a roll of assistant medical practitioners; those who failed would no longer be allowed to practice medicine, although they could still be employed as medical ancillary workers under strict supervision in hospitals.13 Since 1969 no new application for clinic registered with exemption with an unregistered doctor in-charge was considered. The existing clinics registered with exemption were allowed to reapply every year for registration. Over the years, some renewal applications were refused14 In the year 1994/95, there were still 125 such clinics in Hong Kong.15

Primary Care Services since 1970 In Hong Kong, private-sector providers of primary care services can be divided into three main groups: 1) private general practitioners with solo practice; 2) private group practices run by local companies or international companies such as Blue Cross; and 3) traditional Chinese medicine practitioners. Patients pay out of pocket for private general practitioners, which covers both consultations and medication. (Many medical specialists in private settings provide both specialty and primary care services.) Unlike the prewar era, TCM occupied a relative minor niche in the medical care system through the end of the twentieth century. In 2002, just 54 per 1,000 people visited Chinese medicine practitioners in any one-month period, compared with 440 per 1,000 who visited Western medicine doctors during the same period.16 In the public sector, primary care is provided either by general outpatient clinics operated by the Department of Health, or by general outpatient clinics run by NGOs charging nominal user fees.17 In the 1980s, the 54 general outpatient clinics operated by the Department of Health were consistently overcrowded. The waiting time for these clinics was long and the quality of

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service poor. Patients were often sent away after several hours’ wait and told to return the next day. Others, to avoid the long wait in the outpatient clinics, visited hospital Accident & Emergency (A & E) Departments in the evening, putting further pressure on those already overburdened services.18 To date, the private sector has provided about 80% of primary care in Hong Kong and government general outpatient clinics 20%. Until recently, doctors, both in private practice and in the public sector, treated patients only for acute illnesses, rarely having time for the essential work of preventive medicine and health promotion. In addition, many doctors did not have the proper training to perform these primary care services. There was no primary care network to speak of. Family medicine and general practices as specialties were underdeveloped and undervalued, and they remain so in Hong Kong.

Changing Scene In the 1970s, the medical scene in Hong Kong began to change. Communicable diseases were giving way to chronic noncommunicable diseases, with chronic conditions becoming major causes of morbidity and mortality. Hong Kong was aging, and that trend continues. (In 2015, around 15.3% of the population was 65 or older—a cohort that draws far more on healthcare. The number is expected to climb in the future.) Rapid advances in medical science and technology reduced the value of generalists. The traditional family doctor had given way to highly specialized medicine in a high-technology and hospital-based system, which proved much costlier, but not necessarily cost-effective. Moreover, research has shown that healthcare systems that rely on primary care produce better health outcomes, reduce disease mortality, and result in higher patient satisfaction and lower healthcare costs. The WHO promoted the primary healthcare approach as the key to achieving the goal of “Health for All” by the year 2000.19 A stronger primary care system is badly needed in Hong Kong to strengthen prevention and management of chronic diseases, and support elderly care. After the Scott Report of 1986, which recommended the establishment of the Hospital Authority (HA) as the principal agency to deal with the public hospital system, debates flourished in the Legislative Council around the issue of medical and health services in Hong Kong. Creating the HA alone would not and did not solve the fundamental problems of chronic overcrowding and poor conditions in the general outpatient clinics. To

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upgrade hospital standards while neglecting primary care services would create serious resource-allocation imbalances within the health system. To move things constructively forward, the government established the Working Party on Primary Health Care in 1989.

Working Party on Primary Health Care (WPPHC) 1989 The WPPHC, comprising 17 members and chaired by Professor Rosie Young, was established by the Secretary for Health and Welfare. The review and recommendations of the WPPHC were comprehensive. Since no data had been available on the primary care situation in Hong Kong, the WPPHC started by commissioning surveys of the use of healthcare services and of maternal and child care health services. It solicited submissions from interested organizations and professional bodies and invited international experts to review various primary care services, public health nursing services, and family-medicine training. A delegation was sent to study Singapore’s primary health services, because of its social and demographic similarity to Hong Kong. The WPPHC split into groups to investigate specific areas of primary care such as health promotion and disease prevention, school health services, clinic services, and community services. Finally, a coordinating group was formed to work through and finalize the various recommendations to include in the report. Released on 28 December 1990, the report did not generate debate the way the Scott Report had, nor did it receive the same degree of attention. The WPPHC noted that it had great difficulty in its review because of the lack of a clearly defined and up-to-date healthcare policy. In its view, the government had neglected to provide adequate healthcare services in Hong Kong, and that a clear commitment toward primary healthcare was badly needed. The report’s 102 recommendations were wide ranging and would require many new initiatives to implement.20 Government would need to address the important role of the occupational health service.21 It would need to provide health screening services for early disease detection, such as cervical cancer screening,22 establish a computer-based information system, which would be vital for continuation of care in general outpatient clinics under the Department of Health, and emphasize the role of rehabilitative services, especially in the delivery of home-care service.23 The general outpatient clinics, the WPPHC noted, had lacked objectives, and a new set of guidelines was needed to provide more

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effective, accessible, and higher quality services. These guidelines would act as a benchmark for the delivery of primary care that would offer preventive, curative, and rehabilitative care in Hong Kong.24 The doctors in charge of the clinics needed proper training and a clear career path. The standards of private practitioners also needed upgrading, emphasizing their role in preventive medicine and health promotion. There were criticisms that the scope of the review of the WPPHC was too narrow as it limited itself to primary care services in the public sector and neglected the predominant private sector and the practitioners of traditional Chinese medicine. Nevertheless, according to the Secretary for Health and Welfare, the 102 recommendations were swiftly executed by the Department of Health. By mid-1994, 98 of the recommendations were already implemented, and 68% of the budget of the Department of Health had been channeled into primary care services.25 Three important primary care programs had been set up at the recommendations of the WPPHC in the latter part of the 1990s: Woman Health Service, Elderly Health Service, and Student Health Service. For women aged 45 to 64, a comprehensive range of health promotion, such as healthy lifestyle, menopause, osteoporosis, and breast self-examination, and screening services such as mammographic and cervical cytology examination, are offered. The Elderly Health Service, opened to all citizens, aged 65 and above, is to promote the health and well-being of elderly persons in the community. Each participant will receive a detailed assessment of physical, mental, functional, and social health through the use of questionnaire, interview, physical examination, and investigations, The Student Health Service replaced the School Medical Service. A more comprehensive program, it promotes not only the physical but also the psychological health of school children. Participants are given an annual examination to screen for physical, psychological, or sexual problems. These services are available in a number of centres or clinics in different parts of Hong Kong. Some critics of healthcare policy, however, found the exercise inconsequential, and its results disappointing, noting that the recommendations were hardly implemented in the private sector—which provides 80% of primary care.26

Reviews and Public Consultations on Healthcare Reform Primary care reform and healthcare reform are inseparable; efforts to improve one must necessarily include the other. Since 1993, many reviews

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and consultations on medical and healthcare services in Hong Kong have been published (Chapter 11). They include “Towards Better Health”27 in 1993, the “Harvard Report”28 in 1999, “Lifelong Investment in Health”29 in 2000, “Your Health, Your Life”30 in 2008, and “My Health My Choice”31 in 2010. The last four were government consultation papers and they all identified the need to reform primary care along with changes in healthcare financing structure. While healthcare reform consultations were carrying on since 1993, little had changed in primary care services except for the HA taking over management of the general outpatient clinics from the Department of Health in 2003, to provide continuity of care to patients who were discharged from hospitals.32 In the 2008 healthcare reform consultation document “Your Health, Your Life,” several proposals were included to enhance primary care to provide a continuing, comprehensive, preventive, and holistic healthcare service. The ideas included: 1) developing basic models for primary care services; 2) establishing a registry of family doctors; 3) improving public primary care; and 4) strengthening public health functions through public-private partnership.33 As the proposals in the 2008 document received broad public support, the chief executive earmarked additional resources for the period 2009–2010 to 2012–2013 to enhance primary care development. He indicated his continuous longterm support if the overall progress of reform proved satisfactory and resources were available.

Steps in Primary Care Reform In October 2008, the Secretary for Food and Health established a new working group on primary care to advise on strategic directions for the development of primary care. Under the group, three task forces were formed: to develop conceptual models and reference frameworks, to establish a primary care directory, and to create primary care delivery models. The public and private healthcare sectors, academia, patient groups, health administrators, and other stakeholders were represented both in the working group and the task forces. The WHO report “Primary Health Care—Now More than Ever,”34 which was released in 2008, provided useful guidelines for the task forces in formulating their strategies. The important elements of primary care

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proposed by the WHO included: 1) development of a comprehensive, multidisciplinary strategy to meet the multifaceted needs of chronicdisease patients, particularly the elderly; 2) improvement in continuity and coordination of care across all healthcare providers; 3) enhancement of collaboration across different sectors for patients with chronic diseases, emphasizing a patient-centred approach and patient empowerment to improve disease monitoring, prevention of complications, and compliance; and 4) reinforcement of professional development and quality improvement. In 2010, Hong Kong’s the long-awaited primary healthcare policy was born—“Primary Care Development in Hong Kong: Strategy Document 2010,”35 based on WHO’s recommendations. The Department of Health and the Hospital Authority (HA) have initiated several projects, and some pilot programs:

Development and Dissemination of Reference Frameworks The task forces, under the auspices of the Department of Health, developed age-group, disease-specific, preventive, and basic health service models. They produced clinical protocols and guidelines known as frameworks, which followed models developed in the United States (National Service Framework) and in Australia but took into consideration local conditions and requirements. In 2015, the first two such frameworks, “Preventive Care for Older Adults in Primary Care Setting” 36 and “Preventive Care for Children in Primary Care Settings,”37 were published. They were followed by reference frameworks on hypertension care38 and diabetes care39 for adults in primary care settings. Two ongoing clinical advisory groups have been established under the task force to ensure that the latest medical developments and evidence will continue to be reflected in the frameworks. Even though the evidence-based guidelines were developed by stakeholders, putting them into practice proved to be difficult. While the dream of seamless care provided by various public sectors of the HA and Department of Health is theoretically possible, developing a partnership between the public and the private sector will be a huge challenge, considering that these groups have not collaborated well in the past. The reference frameworks were developed with the understanding that the Primary Care Office in the Department of Health would ensure the adoption and promotion of these models and frameworks

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in the community. The Primary Care Office will have to work with stakeholders to organize health-promotion activities for patients so that they can better understand each framework and assess whether it will meet their specific needs. The effectiveness of the reference frameworks will depend on support and endorsement from healthcare professionals across different sectors in Hong Kong. It will be a long-term and continuous process involving local healthcare providers in the private sector, professional organizations, NGOs, and social service agencies in the community.40

Development of a Primary Care Directory The Primary Care Office developed a Primary Care Directory41 to give public and private healthcare providers a readily accessible electronic database. This resource serves many functions. It archives practice-based information of the primary care professionals of various disciplines in the community, and it brings together different primary care providers to work as a multidisciplinary team. The directory also contains subdirectories for different primary-care professionals in the community, and includes Western medicine doctors, dentists, Chinese medicine practitioners, nurses, allied health professionals, and other healthcare service providers.

Elderly Healthcare Voucher Scheme To improve the provision of primary health service for the elderly, the Elderly Health Care Voucher Scheme was launched in 2009 by the Department of Health, for a trial period of three years. In the pilot program, each elder seventy years of age and over received five HK$50dollar vouchers annually, to be spent on whatever private healthcare services he or she wished. In addition to encouraging elders to seek consultation and establish closer relationships with private doctors who are familiar with their health conditions, the scheme also seeks to help promote the family-doctor concept. Because community feedback on the scheme was quite positive, the government increased the annual vouchers to HK$500 in January of 2012, and to HK$1,000 the following year. In 2013, the scheme was promoted from a pilot project to a recurrent elderly support program with annual vouchers provided at a very respectable HK$2,000 in 2017.42

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Vaccination Scheme The Elderly Vaccination Subsidy Scheme of the Department of Health provides subsidy to the elderly to receive seasonal influenza and pneumococcal vaccinations from their general practitioners’ clinics. The government also underwrites influenza vaccinations for children ages 6 months to 6 years through the Childhood Influenza Vaccination Subsidy Scheme. These schemes have already proven successful.

Tin Shui Wai Primary Care Public-Private Partnership Project An important primary care project of the HA was the creation of community health centers that offer one-stop, coordinated, and comprehensive primary care services, including health-risk assessment and disease identification, disease prevention and health promotion, and support for self-health awareness education. The centers are staffed by healthcare professionals from various disciplines working as teams to improve coordination of services in the community, including those provided by the private sector and NGOs. Hospital care, emergency or inpatient, and specialist consultations, will be offered only when necessary.43 Figure 12.1  Tin Shui Wai Community Health Centre

Photo courtesy of Hospital Authority

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The first such community health center, in Tin Shui Wai, (Figure 12.1) was launched in June 2012. Chronic disease patients, who are in stable condition and need long-term follow-up treatment at public general outpatient clinics, are allowed to receive treatments from private doctors, with fees partially subsidized by the government. This project encourages private practitioners and their patients to make full use of the various facilities in the Community Health Centre. Patients may seek up to 10 medical consultations with private doctors and are required to pay a standard fee of just HK$45 per consultation—the same fee the government’s general outpatient clinics charge.

Pilot Primary Care Projects of the Hospital Authority Three pilot projects have been established by the HA: 1) Nurse and Allied Health Clinics, which are run by nurses and allied health professionals. These clinics have been clustered within selected general outpatient clinics to provide more focused care for high-risk chronic disease patients. They handle chronic respiratory problems and ensure medication compliance, support mental wellness, oversee wound and continence care, and run a fall-prevention program for the elderly; 2) a Multi-disciplinary Risk Factor Assessment and Management Program where teams of healthcare professionals such as nurses, dietitians, and pharmacists are set up at designated general outpatient clinics at selected clusters to provide comprehensive health risk assessment for patients with hypertension and diabetes so that they can receive appropriate preventive and follow-up care and 3) Patient Empowerment Program by improving chronic disease patients’ knowledge of the disease and enhance their selfmanagement skills.44 All these programs aim at maintaining patients with chronic diseases stable in the community and to prevent repeated hospital admissions. These measures should decrease healthcare cost while enabling patients to remain at home and enjoy “healthier” lives—a win-win situation. Their effectiveness has yet to be evaluated.

Electronic Health Record (eHR) Sharing The eHR program which allows public and private sector physicians to share patient information was implemented in 2017 and is a significant

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advance toward improving the communication between the public and private healthcare sectors as well as reducing the risk of polypharmacy.

Training of Primary Care Physicians Until the 1980s there was no primary care teaching in the medical curriculum for undergraduates, and no postgraduate training program for family physicians in Hong Kong. Most private practitioners treated acute illnesses without identifying risk factors or initiating any preventive measures for their patients. In many parts of the world, general practitioners have their own professional colleges. The Hong Kong College of Family Physicians was inaugurated in 1979 through the hard work of Dr. Peter Lee. Admittance to the Hong Kong College of Family Physicians requires passing a fellowship examination, and in 1984, candidates had to satisfy the following prerequisites in order to take the exams: they had to have been in practice for more than 10 years, have accumulated 400 hours of CME credit, and have attended three two-week refresher courses per year. Only 15 out of 29 individuals satisfied the examiners that year. The Hong Kong College of Family Physicians became one of the foundation colleges of the Academy of Medicine when it was established in 1993, but the college had certified only 149 fellows by 2004. Several factors, not least of which is the huge time commitment, with no obvious commensurate return in either salary or status. The six years of family practice training required by the college to become a specialist in family medicine is one of the longest in the world—in other countries the training period is usually two to four years.45 The unique skills of a family doctor cannot be acquired in a specified period, it is reasoned, but are accrued on the job, throughout a lifetime of active participation in continuous professional development. Young graduates in Hong Kong lacked the incentive to become certified family physicians, since the prolonged training does not lead to higher patient volume, more professional prestige, or higher salaries. In addition, the HA, which provides doctor training and is the most important employer of physicians in Hong Kong, had no clear policy on recruitment or a retention program for family medicine.46 In 2004, the academic family medicine units in the two medical schools were staffed by just three faculty members and were subsumed

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under the specialty departments of internal medicine and community medicine. There was but one consultant in family medicine in the Department of Health, and two in the HA—compared to more than 500 in other medical and surgical specialties.47 Primary care reform is happening in Hong Kong, but slowly. Most of the projects at present are still in progress. While changes are taking place in primary care in the public healthcare system, reforms in the private system are much more difficult to enforce. It is hoped that compulsory continuing medical education, the elderly vouchers scheme, the vaccination program, the shared care programs, and electronic health record sharing organized by the Department of Health and HA will help change the attitudes of private practitioners to proactively tackle disease prevention and health promotion. If the city wants, as proposed by Professor Gabriel Leung and John Bacon-Shone, a primary care-led health system with family medicine at its core, much more work has yet to be carried out.48

Development of Traditional Chinese Medicine Pre–World War II Era When Hong Kong became a British colony in 1842, the Chinese inhabitants, distrusting Western medicine, continued to seek medical help from TCM practitioners. At that time, many TCM practitioners set up their businesses in the streets, alongside hawkers.49 They were the first and possibly only contact for medical care for many Chinese at the time. Tung Wah Hospital, the first hospital that practiced only TCM, was founded in 1872 by Chinese elite with a grant from the Hong Kong government. The Tung Wah Hospital Committee, consisting mostly of wealthy Chinese with no medical backgrounds, was preoccupied with activities such as charity and politics. The hospital committee became the mouthpiece for the Chinese community, playing a crucial political role in negotiations between the colonial government and the Chinese populace. The hospital practiced only TCM and was staffed by TCM practitioners who had no experience running hospitals. The mortality rate of the hospital’s inpatients reached about 50%—five to ten times that of the Government Civil Hospital. Overcrowding, poor sanitation, lack of

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knowledge, and the failure to use disinfectants were constant sources of concern for the colonial surgeon. When bubonic plague erupted in 1894 and 20 undiagnosed cases were discovered in the Tung Wah Hospital (with no isolation precautions in place), the hospital naturally became a target of blame for the epidemic. The government held an inquiry in 1896 and seized the opportunity not only to introduce Western medicine to the hospital—a move that the hospital committee had steadfastly resisted in the past—but also to stop future political activities, curbing the power of the hospital committee over the Chinese population. The government appointed Chung King-ue, a Chinese doctor trained in Western medicine, to be the resident surgeon of the hospital and Dr. J. C. Thomson, former superintendent of the Alice Memorial Hospital, to oversee Tung Wah Hospital. Patients were to be given the choice of either TCM or Western medicine, and more patients opted for treatment by Western medicine when they learned of its superior survival statistics. By 1915, more inpatients preferred Western medical care then TCM, but for outpatient treatment of minor complaints, the majority of patients still preferred TCM.50 Since the government inquiry of 1896, the Tung Wah Hospital Committee focused on providing medical care, expanding its medical services to meet the changing needs of the population, and founding more clinics and subsidiary hospitals. In 1911, the committee established Kwong Wah Hospital in Kowloon, and in 1929, the Tung Wah Eastern Hospital. The Medical Ordinance of 1884 required all practitioners of Western medicine to be registered in Hong Kong, but TCM practitioners were exempted. Anyone could practice TCM as long as they had a commercial registration license, and as long as they did not call themselves “doctors.”51 Many under-qualified TCM practitioners hung out their shingles, with the result that some patients were harmed and the reputation of the profession as a whole was tarnished. When the Sino-Japanese War was declared in 1937, thousands of refugees flooded into Hong Kong. The number of patients requiring outpatient treatment increased markedly. Tung Wah Hospital was attending to over 10,000 patients daily in 1940.52 This placed a great strain on the hospital, and it began to dispense herbal medicine for certain diseases in powder form—a break from the tradition of requiring that herbs be boiled for long periods, in accordance with each individual prescription. This prefigured the modernization of TCM.

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Since the government did not legally recognize TCM, there was no government sponsored or subsidized training for TCM practitioners. However, a few practitioners took in apprentices, and some set up evening schools. In 1938, with the fall of Guangzhou to the Japanese, the Hon Hing Chinese Medicine School moved, together with its staff, to Hong Kong. The school lasted until the Japanese occupation in December 1941.53 During Japanese occupation, Western medicine received preferential attention even though TCM practitioners underwent the same registration procedures as Western doctors. In the Tung Wah group of hospitals, the practice of Chinese medicine was terminated when funds ran low.54 Figure 12.2  TCM prescription

Photo courtesy of the Hong Kong Museum of Medical Sciences Society, item donated by Mr. Keith Poon. The notation in the top right-hand corner indicates that this is for half-portion. In the lower left corner are instructions to prepare the medicine.

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Figure 12.3  Various herbal medicines in powder or pill form to be taken orally, or in paste or liquid form for external use

Photo courtesy of the Hong Kong Museum of Medical Sciences Society, and Mr. Keith Poon who donated the artefact.

Post–World War II Decline of TCM After the Second World War, the advent of antibiotics and the discovery of various drugs for the treatment of chronic diseases, such as arthritis and high blood pressure, gave Western medicine powerful weapons that almost wiped out TCM practice in Hong Kong. At the same time, the price of Chinese medicinal herbs had risen more than tenfold. Many people in Hong Kong could afford neither the cost of TCM nor the time necessary for preparing the herbs when they were sick, and Chinese medicine declined in popularity. High rents discouraged small businesses of all types, let alone expensive training schools for TCM. During the 1960s, the number of Chinese herbal stores in Hong Kong declined, even as the number of pharmacies for Western medicine grew.55

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Postwar developments in the public medical and health services concentrated solely on Western medicine. No attempt was made to train practitioners of TCM. One had to either pursue an apprenticeship with a TCM practitioner or enroll in one of the private Chinese-medicine training schools in Hong Kong or mainland China. There are three main types of TCM practitioners in Hong Kong: herbalists, acupuncturists, and bonesetters, who treat sprains and contusions. A 1969 survey conducted by the Hong Kong Medical Association found that there were 4,506 Chinese TCM practitioners of various kinds and only 2,317 Western trained doctors56 All TCM practitioners were in private practice. In 1971–1972, a survey on the use of health services in Kwun Tong, a township with a population of around one-half million, found that there were 174 TCM practitioners and 101 Western medicine clinics. Of those who participated in the study, an overwhelming majority (84%) believed that Western medicine was more effective than TCM in treatment of infectious diseases; however, most (70%) still preferred Chinese medicine for promotion and maintenance of good health. For treatment of acute conditions such as tuberculosis, fever, heart diseases, mental illness, skin diseases, diarrhea, whooping cough, and anemia, 65% of respondents were more confident in Western medicine, while most favored TCM for rheumatism, sprains, and fractures. About 83% reported that they had visited Western medicine doctors in the previous three years, while only 11% had consulted TCM practitioners. Among parents of children who had fallen ill, 92% took them to Western-medicine doctors. Western medicine was the clear preference in the 1970s, carrying higher social prestige and legitimacy than the “unscientific” TCM.57 Over the years, TCM practitioners became more and more constrained. They were not permitted to practice surgery, to undertake treatment of eye diseases, to possess antibiotics and/or dangerous drugs, to sign death certificates, to give inoculations, or to use such modern technologies as x-rays. On the surface, these measures were aimed at curtailing quackery; but of course they also protected the economic interests of the modern Western medical profession.58 The TCM profession did not take this rejection lying down. When the bill to prohibit TCM doctors from treating eye disease was read the first time in April 1958 in the Legislative Council, TCM doctors were alarmed. The Hong Kong Chinese Medicine Practitioners’ Association

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organized a meeting of all the members of various TCM organizations in Hong Kong. They mobilized the media and appealed to the Legislative Council. In the end, the Director of Medical and Health Services clarified (effectively reversing) the government’s position. Trained TCM practitioners were not meant to be prevented from treating eye diseases, he explained, only prohibited from advertising treatment of eye diseases.59

Revival of TCM In the 1970s and 1980s, a TCM revival movement emerged in Hong Kong. An increasing number of medical elite—including leading members of TCM, some university faculty members, and Western trained doctors— were concerned about the lack of rigor around the education, licensing, and practice of TCM. They pushed for improvements in the social organization and technical content of Chinese medical practice. Some felt that the University of Hong Kong should establish an accredited school for TCM. Others recommended that scientific methods be used to routinely evaluate traditional treatments (especially acupuncture), and that pharmacological actions of herbal medicines be thoroughly investigated. However, the most powerful force for change came from outside. Since the founding of the People’s Republic of China, the Chinese government has placed much weight on developing the legacy of traditional Chinese medicine and pharmacology. In 1950 China adopted an important policy to foster a close working relationship between doctors trained at Western medical schools and TCM schools. Since then, there has been a great deal of research done in China to systematize the basic theory of acupuncture and moxibustion, and to evaluate its clinical effects. Enthusiasm over the use of acupuncture and moxibustion in treatment readily spread to Hong Kong during this period. The signing of the Sino-British agreement in 1984 hastened the plan to develop TCM in Hong Kong. In August of 1989, the Hong Kong government commissioned a Working Party on Chinese Medicine, comprised of government representatives and academics with expertise in TCM, to collect information and recommend a course of action. The working party undertook a number of surveys of the TCM industry in Hong Kong, and sent deputations to China and Taiwan to obtain more information.60

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They found that in 1990 there were about 7,000 TCM practitioners in Hong Kong, roughly the same number as registered Westernmedicine doctors. Around 60% of the population had consulted a TCM practitioner at some time, but self-medication with herbal medicine was far more common.61 The self-prescribing phenomenon presented problems, since there was no regulation of the TCM industry, and deaths from the use of some herbal medicine had been reported. There was a general lack of knowledge of herbal medicines being sold over the counter.62 An interim report was released in January 1992, recommending that a new TCM professional organization be established. It would be responsible for registration of all TCM practitioners, and would control and monitor the TCM industry, especially the use of the herbs that were restricted in China and Taiwan, but freely available in Hong Kong. It also recommended that the implementation of regulatory measures be gradual, to avoid disruption of the TCM industry and allow time for practitioners to prepare themselves for the registration process. Following the release of this interim report, the working party received more than 182 submissions, including recommendations from the OMELCO (Office of Members of the Executive and Legislative Councils) Standing Committee on Health Services. In 1994, the final report was released with more detailed recommendations, including: 1) preparatory committees be established to develop a framework for regulation of TCM; 2) a list of active TCM practitioners be compiled for eventual registration; 3) criteria and procedures be determined for registration of practitioners; 4) a list of toxic herbs be published; 5) health and sanitary standards of TCM manufacturing plants be subjected to strict regulation; 6) a TCM training school be established; and 7) research and teaching programs in TCM be developed in local tertiary institutions.63

Regulation of TCM In 1995, a 21-member Preparatory Committee on Chinese Medicine was convened, with a mandate to implement the specific recommendations proposed by the Working Party on Chinese Medicine. It contained a mix of academics, TCM practitioners, community leaders, and civil servants. In April 1997, the committee approved the specific recommendation for

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the establishment of a statutory council on Chinese medicine, which would be responsible for regulating the practice of TCM and the use, manufacture, and distribution of medicinal materials. On 1 July 1997, with handover of Hong Kong by the British to the Chinese government as a Special Administrative Region, the development of TCM was written into the Basic Law as Article 138. In his first policy address, the first chief executive announced the formal regulation and registration of Chinese medicine practitioners, the establishment of the Chinese Medicine Council of Hong Kong, and the enactment of the Chinese Medicine Ordinance.64 Two years later, on 14 July 1999, the Chinese Medicine Ordinance, which provided the legal framework for regulating Chinese medicine in Hong Kong, was enacted. This was followed by the establishment of an 18-member Chinese Medicine Council to develop sublegislation to govern the TCM sector, and to establish the code of ethics and standards, which would guide practitioners in areas such as keeping patient records, writing legible prescriptions, and labeling dispensed medicines. Following consultation with the profession, the government granted a number of concessions to TCM practitioners, and exempting the following from the licensing examination: 1) those who had been practicing for 15 or more years, or who otherwise had significant experience and a recognized TCM qualification in Hong Kong; 2) those who had 10–15 years of practice with a qualification acceptable to the Chinese Medicine Council; and 3) those who had 10–15 years of experience but without acceptable qualification or those with less than 10 years of experience but with acceptable qualification, provided they passed an assessment by the council. This resulted in only those practitioners with less than 10 years of experience and without formal qualifications having to sit for the examination.65 Practitioners were given until 30 December 2000 to apply for registration with the Chinese Medicine Council. Training programs for TCM have been available in Hong Kong since 1998. Three local universities—the University of Hong Kong, Chinese University of Hong Kong, and the Baptist University—offer part-time, non-degree extramural TCM courses. Students must complete five formal undergraduate training courses and pass the licensing examinations before they can be registered as TCM practitioners. Registered Chinese medicine practitioners must also satisfy continuing education requirements,

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as set by the Chinese Medicine Practitioners Board according to the Chinese Medicine Ordinance.66 The Hong Kong University of Science and Technology established a research laboratory aimed at developing hybrid TCM-Western medicine, while the Chinese University founded the Chinese Medicinal Material Research Centre. In 2000, the Baptist University created an Institute for the Advancement of Chinese Medicine, aimed at integrating Western medical sciences and TCM. The facility is now housed within its School of Chinese Medicine, which operates two public clinics. In 2002, the University of Hong Kong restructured its School of Chinese Medicine and incorporated it under the Li Ka Shing Faculty of Medicine.

TCM Development in the New Millennium Hong Kong was not the only place to struggle with the regulation of traditional medicine; most WHO member states have encountered the same problem. In 1998, the WHO Congress of Traditional Medicine found that 51 out of 96 member states were planning a national policy, while the rest already had them in place. In 2001, the WHO published “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine: A World View.” 67 National recognition and regulation of traditional and complementary/alternative medicine vary considerably, and the WHO planned to work with countries to develop policies appropriate to their particular circumstances. It indicated that governments of member states should increase their support for traditional complementary/alternative medicine, and promote the integration of traditional complementary/alternative medicine in national healthcare systems.68 In 2006, Hong Kong incorporated TCM into the public healthcare system and legally recognized TCM practitioners’ rights to sign sick leave and death certificates. In 2009, 14 out of 18 planned TCM outpatient clinics opened under tripartite management: NGO, university, and HA. The number of TCM practitioners increased with these training programs in place. In 2014 there were 9,492 TCM practitioners in Hong Kong. Of those, 6,726 (71%) were registered TCM practitioners, 63 (0.7%) had limited registration, and 2,702 (28.5%) were listed TCM practitioners. Of 2,087 who responded to a survey, 89% reported that they were economically active.69

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Public TCM clinics under the HA are currently employing new graduates of degree courses in Chinese medicine as junior TCM practitioners and providing them with up to three years of postgraduate training. TCM use appears to be increasing. In the 2014/2015 Population Health Survey published by Department of Health, among those aged 15 and above who had experienced health problems 30 days preceding the survey, 47.9% received treatment from Western medicine practitioners while 11.1% consulted Chinese medicine practitioners. TCM users were usually older and female, and often suffering from one or more chronic diseases. Interestingly, and for the first time, TCM use fell bimodally among the lowest and highest education and income groups.70 Another study found that double consultations with TCM and Western medicine doctors were common among those with chronic noncommunicable diseases. Around 17% of those who responded to the question “Have you visited a healthcare professional in the past 12 months?” reported double consultations. Government initiatives in TCM development have led to increasing patient choice for TCM and Western medicine care; but corresponding inter-professional affiliations between Western medicine and TCM has yet to be realized.71 TCM development has advanced considerably in the last two decades. With proper registration of TCM practitioners and regulation of Chinese medicine industry, TCM may become an important component of primary care in Hong Kong.

Herbal Medicine Industry Herbal medicine has deep roots in Hong Kong. Nam Pak Hong (now Bonham Strand), which handled north and south trade, once teemed with herbal medicine stores. They imported various Chinese delicacies such as shark’s fin, swallow’s nests, and abalone, as well as medicinal products such as ginseng and deer tail. 72 Yau Wing Hong, one of the earliest herbal medicine stores, opened in this neighborhood in the 1850s. Activities in the Nam Pak Hong region had declined since the strikeboycott of 1925/26. Trade, including trade in Chinese herbal medicine, ground to a near halt during the Japanese occupation of Hong Kong. Despite this, it is still an area where Chinese herbal medicine stores aggregate at present.

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Figure 12.4  Three TCM stores next to each other on Ko Shing Street

Photo courtesy of Mr. Keith Poon. Photo taken in 2016. Most of the large herbal medicine stores were situated at Ko Shing Street and Bonham Strand before the war and even now.

The herbal medicine trade returned in earnest. In 1988, an estimated HK$160 million worth of Chinese herbal medicine was imported, mainly from China, and just two years later the figure had climbed to HK$200 million.73 When Prince Charles visited Hong Kong in 1989, he toured one of the oldest drug stores on Bonham Strand, in Hong Kong, Pak Cheong Tong (Figure 12.5), which was 100 years old, but impressively well preserved. A typical narrow Chinese tenement building, the store is 15 feet wide by 120 feet deep and boasts three skylights. It remains structurally solid despite its age.74 The development of Chinese medicine industry in Hong Kong is well described in Xie Yongguang’s book Xianggang zhongyiyao shihua (A history of Chinese medicine in Hong Kong). Despite reports of poisoning from Chinese herbs containing heavy metals and arsenic, there were no laws regulating the sale of Chinese medicine until after Hong Kong’s handover to China in 1997.75 The Chinese Medicine Council has a mandate to regulate all aspects of Chinese medicine, and in 2003, the council began to accept applications

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Figure 12.5  Pak Cheong Tong, one of the oldest herbal stores in Hong Kong

Photo courtesy of Mr. Keith Poon, picture taken in 2016.

for license from Chinese medicine traders, and applications for registration of proprietary Chinese medicines. The safety, efficacy, and quality of proprietary Chinese medicines were assessed before allowing the products to be registered. The dispensation, storage, and labeling of Chinese herbal medicines were also regulated. In 2008, regulations on the import and export of Chinese medicines came into effect. By 2010, legislative provisions specifying that proprietary Chinese medicines should be registered, and clinical trials conducted on proprietary Chinese medicines, became effective. By 2016, the Chinese Medicine Ordinance relating to the regulation of Chinese medicine had been fully implemented.76 In 2012, there were 4,371 Chinese herbal medicines retailers, 847 Chinese herbal medicines wholesalers, 295 manufacturers of proprietary Chinese medicines, and 1,108 wholesalers of proprietary Chinese medicine in Hong Kong. Following consultations with Chinese medicine practitioners, most patients received TCM prescriptions, which they obtained from herbal medicine retailers. Hong Kong has become an international center for trade in Chinese medicines. Ninety percent of more than 2,000 Chinese-medicine

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ingredients are imported from mainland China for reprocessing. After reprocessing, 90% are exported. In 2010, the total revenue from exported herbal medicine materials amounted to HK$856.7 million. The process of registering Chinese medicine, and legislating its preparation and storage for import and export, has undoubtedly helped the industry.77

Modernization of TCM Although TCM is an integral part of mainstream medicine in China today, it is also widely used by many Chinese immigrants in their adopted countries. Such is its status, that it now has an impact on global healthcare and new drug development. In the 1990s, in randomized controlled clinical trials, investigators found that several TCM drugs were more effective than placebos in the treatment of several diseases. In Japan, two kampo drugs (TCM drugs) were found to be safe and efficacious in the treatment of constipation and perennial nasal allergy. In Australia, two TCM drugs were shown to be effective in treatment of irritable bowel syndrome and hepatitis C. In the United States, Dantonic for chronic stable angina, Fuzheng huayu for liver fibrosis, and PHY906 as an adjuvant cancer drug, have been approved for clinical trials.78 For TCM to be acceptable to developed countries, genuine reform must be undertaken to bring it in line with contemporary standards. In the mid-2000s China took the step of joining the international community in promoting evidence-based medicine and clinical trials. For the future development of TCM, raw herbal materials must be produced in a sustainable way, and cultivated using good agricultural practices, to safeguard the quality of the TCM raw materials. Modernization of TCM will provide opportunities for it to consolidate its scientific base, following the principles of integrity, integration, and innovation. Thus, might ancient medicine play a larger role in the future medical health system.

13. Conclusion

The public medical and health system in Hong Kong, prior to the Second World War, was developed on an ad hoc basis and steered solely by need. During the first two to three decades after the war, infectious diseases had been rampant. As Hong Kong’s economic growth gradually caught up with that of a developed region, together with better nutrition and the strong focus of the Medical and Health Department on preventive measures, including immunization programs, and improved sanitation, infectious diseases were finally brought under control. Hong Kong’s health indices became one of the best in the world. However, the departure of these communicable diseases was inevitably replaced by chronic noncommunicable diseases brought about by improvement in the standard of living and adoption of the Western lifestyle. Despite the brisk expansion of medical and health services in Hong Kong from the 1960s to 1980s, the rapid population growth during this period overwhelmed the medical facilities. By establishing a new Department of Health in 1989 and creating the Hospital Authority the following year, the government brought about a dramatic improvement in public hospital services, but other basic problems, such as healthcare financing, lack of primary care, and lack of supervision of the private sector, remained relatively unchanged. Moreover, new problems arose, such as those associated with an aging population, emerging novel infections, and the rising costs of medical care due to advances in medical technology and their demand. After several public consultations and external expert reviews, Hong Kong has finally embarked slowly on healthcare reforms in recent years.

Hong Kong’s Healthcare System Today From the perspective of one who has lived in both Hong Kong and North America, I can say that Hong Kong today has a reasonably good

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healthcare setup despite its weaknesses. Hong Kong has two medical systems, offering its residents the choice of public or private medical care. In the United States, there is costly but quality private medical care for the rich, who can afford it, and for those employed in firms that provide medical benefits. The very poor are enrolled in the Medicaid program. Quality private healthcare is denied to the lower-income population that is above the poverty threshold and yet not qualified for Medicaid coverage, and to a substantial segment of the younger population who cannot afford private insurance. In Canada, where privatization of hospitals and medical services is prohibited, there is only one medical system—the public one. It offers up-to-date medical services to all citizens who pay into the national medical services plan, but for elective procedures, such as hip replacement and cataract surgery, a long waiting list is the norm. The public medical healthcare system in Hong Kong, heavily government-subsidized, has committed to ensuring every resident access to adequate healthcare, including hospitalization when needed. It delivers advanced medical services, comparable to those offered in advanced Western countries, for only a small fraction of the actual cost. True, the wait list for specialist consultation or elective surgery is long, as it is in any universal public system. The private system in Hong Kong offers timely, but expensive medical services to the wealthy and to those with medical insurance. But, according to the Harvard Team Report in 1998, the rich and the poor spent a similar proportion of their household income on healthcare and were similarly within reach of a healthcare provider— quite an enviable achievement. A unique feature of healthcare delivery in Hong Kong is the easy availability of both advanced Western medicine and traditional Chinese medicine (TCM). While many Western medical practitioners are skeptical of TCM, some are beginning to appreciate the fact that it can provide relief in cases where Western medicine has failed, most often in treating chronic pain using alternative modalities, such as acupuncture and Chinese herbal medicine. The Hong Kong medical profession is uniquely qualified to help the city become a regional or global center for future integration of Western medicine and TCM.

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Its Accomplishments Since the Second World War, Hong Kong has excelled in many areas of Western medicine, and it had contributed significantly to medical science even when resources were scarce. The World Health Organization pronounced Hong Kong’s method of cholera surveillance a model for other developing nations. The current standard regimen of tuberculosis recommended by the WHO of using four drugs for two months followed by two drugs for four months, was demonstrated to be highly effective from numerous drug trials carried out in Hong Kong in partnership with the British Medical Research Council in the 1960s and 1970s. This combination drug therapy for tuberculosis was the forerunner of the use of multiple drugs in cancer chemotherapy and in treatment of HIV. The direct observed therapy (DOT) used by the Hong Kong Anti-Tuberculosis Unit in the 1950s and 1960s has also been recommended by the WHO as the standard method to ensure compliance for tuberculosis treatment. There are also other areas in public health that Hong Kong should be proud of. It has, at present, one of the longest life expectancy—81.4 years for men and 87.3 years for women.1 Infant and maternal mortality rates in Hong Kong are among the lowest in the world.2 The Family Planning Association and the Obstetrics and Gynaecology Department of the University of Hong Kong have been so successful in family planning that Hong Kong now needs more babies. There are fewer smokers in Hong Kong than in almost any other country,3 thanks in part to public-education efforts of the Council of Smoking and Health and the Community Health Department of the University of Hong Kong (now School of Public Health). Hong Kong surgeons have been remarkably innovative. The anterior surgical approach to the spine, fondly known as the “Hong Kong Operation,” was introduced for debridement and stabilization of a spine rendered unstable by tuberculosis. The maxillary swing approach, which is now the preferred method for removal of tumors in the base of the brain and in the nasopharynx, was pioneered in Hong Kong. The world’s first microsurgical thumb replant in 19774 and the first adult-to-adult living donor liver transplantation in 19965 were performed in Hong Kong. Over the years the medical profession has advanced knowledge to help tackle diseases prevalent in Hong Kong and South China. The discovery of the common occurrence of α and β thalassemia and G6PD deficiency among the Chinese population, and the innovation of prenatal

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diagnosis of hemoglobinopathies, reduced their occurrence. It provides an excellent example of the relevance of the use of molecular techniques in the study of diseases leading to their prevention. The coordination of bone marrow transplantation locally, and the establishment of the world’s first all-Chinese bone marrow donor registry, the Hong Kong Bone Marrow Match Foundation Registry, are major achievements. The registry has been a source of unrelated donors for bone marrow transplant, not only for patients in Hong Kong, but also for patients in Southeast Asia. The finding that a high intake of salted fish is a risk factor for nasopharyngeal cancer, the causal link between chronic hepatitis B infection and liver cancer, and between H. pylori infection and stomach cancer, are major breakthroughs that identified risk factors for the effective prevention of these cancers and facilitated their treatment. The discovery of the coronavirus as the agent of the disease, and the sequencing of the genome of the SARS virus within weeks of its isolation by scientists in the local university, were monumental events. However, neither arguably matched the bravery with which the medical profession fought the disease, the lives lost in combatting the epidemic.

Its Weaknesses Not everything is rosy in Hong Kong’s healthcare picture. The SARS outbreak had caught Hong Kong unprepared and revealed the healthcare system’s vulnerabilities to such threats. The city had learned its lessons the hard way. In addition to other measures to increase the city’s preparedness to medical emergencies, it now has founded an excellent Centre for Health Protection with a reasonable budget allowing it to function properly to prevent communicable diseases, including emerging novel infections— especially the ever-changing influenza virus which can cause pandemics. The 1998 Harvard Report 6 identified many areas of healthcare deficiencies, and the government has responded with several reform proposals. Special emphasis has been placed on advancing primary care and preventive measures, and improving communication among various healthcare sectors by establishing an electronic clinical management system. Reforms have been initiated to address the quality of care, quality assurance, and accountability. The Hong Kong Academy of Medicine currently requires all specialist doctors to have 90 hours of

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continuing medical education over a three years period as a prerequisite for remaining in the Specialist Register. Steps are being taken to improve primary care, but there is still a long way to go to involve all private sector doctors in the reform. The old problem of private doctors prescribing and dispensing medication in their own offices instead of sending prescription to pharmacies has yet to be addressed. With the graying of the population, the public’s increasing demand for modern treatment and the escalating costs of healthcare delivery, the percentage of public healthcare expenditure for Hong Kong has risen dramatically in recent years—from 1.7% of the GDP in 1989 to 2.7% in 2004. The projected public healthcare expenditure by 2033 is 9.2% of GDP, or 20% of total public spending.7 Even though the government has capped healthcare expenditure at 17% of the total budget, it is not clear whether it is feasible to maintain the same standard of care in the years ahead. Efforts to reform healthcare finance have met with resistance from the middle class who prefer public over private healthcare, because the former has provided good service at a cheaper price. The ideological conflict—private markets are the engine of economic growth and a laissez faire policy is the best policy for Hong Kong, as opposed to the view that healthcare is a fundamental right that should be guaranteed by government—is, indeed, an impediment to healthcare financial reform in Hong Kong. There is still no plan for long-term care for the growing numbers of the elderly who will require both social and medical assistance. Let us hope that Confucian ethics and filial piety are still relevant in Hong Kong to allow the elderly to “age in place.” Such a program will be costly, and unless Hong Kong finds a way to spread the costs across all sectors, taxes will have to increase. The deficiencies of the public system are equally observable in the private system. The quality of care in the private sector is highly variable and quality assurance procedures are lacking. Additionally, the high costs and the lack of transparency in cost-calculation are the main reasons for the private system to be underused. If this sector wishes to have a larger share of the healthcare market in Hong Kong, it needs to address these concerns. Doing so would also relieve the pressure on the public system. The Hong Kong government, in its short-sightedness, has spent very little on research and development over the years. In 2015, Hong Kong’s research and development budget, the most lavish to date, still amounted to only 0.7% of the GDP, when China spent three times as

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much on R&D.8 Hong Kong has a population of more than 7 million; imagine what potential it could unleash if young people were educated and incentivized to innovate, and more funding were allocated to research and development.

Other Challenges Ahead Good health is much more than prevention and treatment of diseases. It is an expression of a delicately balanced process of physical and mental wellbeing that is intimately linked to social factors, such as housing, nutrition, education, and gender equality; to economic factors, such as employment opportunities, technological advances, freedom of international trade and movement; and to cultural influences, such as health and religious beliefs, parenting, family cohesiveness, and food habits and choices. Hong Kong’s economic success and prosperity in the 1970s and 1980s were attributable to the strong work ethic of the population and the social stability safeguarded by the principles of rule of law, and freedom of expression and movement under the colonial administration. These values instilled in the people of Hong Kong a deep sense of civic pride. Like any other metropolitan city, however, Hong Kong faces many socioeconomic and political issues that can undermine the health of the people in the years ahead. Air pollution, poverty, and housing scarcity are the three most significant ones. Air pollution is responsible for 2,000 to 3,000 deaths a year in Hong Kong, and untold respiratory damage. Its impact is not only physiological but economical: the poor air quality drives away international companies and tourists.9 In recent years, improved vehicle emission-control standards have cut street-level pollution, but the problem of cross-border pollution from factories and vehicles from mainland China remains. Since the handover of Hong Kong to China, the wealth gap between rich and poor has increased, as has the proportion of people living below the poverty line.10 At the same time government’s spending on social services has declined from 70% to about 50% of total expenditure— especially on housing and education. 11 Poverty is toxic. This fact was recognized almost two centuries earlier by the great Victorian social reformer Sir Edwin Chadwick, who identified the direct relationship between low income and filth, high-risk behavior, disease prevalence,

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and mortality. 12 A more recent study showed that people of low socioeconomic status had a greater mortality rate compared with those of high socioeconomic status with a hazard ratio of 1.42.13 Overcrowding is another important social determinant of health. The expanding population and land scarcity in Hong Kong have created an ongoing housing shortage. Housing has become so expensive that it is out of reach for most young people; this has generated a great deal of discontent and social unrest. Some housing developers have recently produced mini flats just 50% bigger than Hong Kong prison cells. These micro units—many with less than 200 square feet of usable space—are greedily priced at HK$1.94 to 2 million. Such “nano” homes will account for half of all newly completed housing in 2017.14 History teaches us that high population density heightens the risk of spreading any infectious disease. Those with vested interests, landowners and developers, have not learned the lessons from the plague epidemic or from the SARS scourge that beset Hong Kong more recently. The stark warning of the civil engineering visionary and sanitarian, Osbert Chadwick, son of the eminent social reformer Sir Edwin Chadwick, still rings true: prevention must be taken seriously before the “irresistible logic of a severe epidemic” compels action.15 The time is now for public health advocates to confront these issues head on. Just as access to medical care is not a luxury but an ethical imperative, so too should be affordable housing. Ready access to space, to light, and to clean breathable air should be the right of every citizen of Hong Kong in the twenty-first century and beyond.

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Sociopolitical Events in Hong Kong

Ruttonjee Sanatorium built for TB patients

Closure of the border at Shenzhen

Founding of People’s Republic of China

End of Japanese occupation, Sir Cecil Harcourt, Provisional Governor Britain re-established civil government; Sir Mark Young Dr. Selwyn-Clarke re-established Medical and returned as governor; civil war in China between Health Department Guomindang and the Communist Party Government Tuberculosis Service established; Sir Alexander Grantham became governor First Casualty Department at QMH Hong Kong Anti-tuberculosis Association Social Welfare Office established founded; HKU officially reopened

Medical Developments in Hong Kong

Jonas Salk developed the first polio vaccine; First postwar group of 22 medical students 1952 Rosalind Franklin used X-ray diffraction to study graduated; BCG vaccination program started the structure of DNA Francis Crick and James Watson discovered 1953 double helical structure of DNA; first heart-lung Shek Kip Mei fire, about 53,000 homeless machine built; medical ultrasound developed. First successful kidney transplant between Housing Authority created; 7- year plan for expansion of 1954 New Tsan Yuk (Maternity) Hospital identical twins primary education

1951 Isoniazid discovered

1950 John Hopps invented the first cardiac pacemaker

1949 First implant of intraocular lens

1948

1947 Defibrillator introduced

1946 Acetaminophen introduced

1945 First vaccine for influenza

1944 Disposable catheter discovered

1943 Streptomycin discovered

Year Global Medical Advances

Timeline of Medical Development in the World and in Hong Kong

Appendix 1

1964

1963

1962

1961

1960

1959

1958

1957

1956

1955

Medical Developments in Hong Kong

Sociopolitical Events in Hong Kong

Hodgson pioneered anterior spinal fusion; Tetracycline first used Haven of Hope Hospital First cardiorespiratory laboratory at Queen Metered dose inhaler introduced; first successful Mary Hospital; Duchess of Kent Children’s 1956 riots in Kowloon bone marrow transplant Hospital Daphne Chun appointed professor obstetrics and gynecology, HKU; Influenza epidemic First TV station; Tai Lam Chung Reservoir completed Type A/Asian/57; Grantham Hospital opened for tuberculosis patients Sir Robert Black became governor; Social Welfare Rune Elmqvist invented cardiac pacemaker Department established New Pathology Building at Queen May First in vitro fertilization successful Hospital Cardiopulmonary resuscitation invented; first South Lantau Hospital combined oral contraceptive Cholera epidemic; Castle Peak Hospital, Cheshire Home at Chung Hom Kok and Our Lady of Maryknoll Hospital John Charnley performed hip replacement; First hemodialysis using artificial kidney Typhoon Wanda killed 130 people Albert Sabin introduced oral polio vaccine First human lung transplant; first human liver Severe drought; White Paper on Reorganization of transplant; use of steroids and azathioprine as Cholera revisited; Queen Elizabeth Hospital Education; Marsh Samson Report on Education; Chinese immunosuppressant; use of anti-lymphocyte University founded; Shek Pik Reservoir completed serum for treatment of rejection First open-heart surgery; first description of Sir David Trench appointed governor; White Paper on “Aims First vaccine for measles thalassemia and G6PD deficiency in Chinese; and Policy for Social Welfare”; White Paper on “Medical Caritas Medical Centre Development in Hong Kong”

Year Global Medical Advances

Cont’d Appendix 1

3 0 4   |   A ppendix 1

1974 First vaccine for chicken pox

1973

1972

1971

1970

1969

1968

1967

1966

1965

Medical Developments in Hong Kong

Sociopolitical Events in Hong Kong

Li Shu Fan Building for preclinical departments built; medical students First commercial ultrasound enrollment increased to 120; Wong Tai Sin Hospital New medical library built in HKU; the first The first human pancreas allograph for diabetes Primary Fellowship Examination of the Royal 1966 “Star Ferry Riots” mellitus; rubella vaccine first introduced College of Surgeons of Edinburgh held in Hong Kong; The Professorial Block opened at Queen Mary First successful human heart transplant in South Hospital; first intensive care unit at Nethersole 1967 “Leftist inspired” Riots Africa; first vaccine for mumps Hospital; Nam Long Hospital and Fung Yiu King Hospital First open-heart surgery in Grantham First powered prosthesis Hospital; influenza epidemic (HK Flu) Introduction of internet; first cochlear implant; First cadaveric renal transplant at Queen Mary balloon catheter introduced Hospital; Tang Siu Kin Hospital Cycloserine introduced for immunosuppression; Medical students increased to 150 at HKU first vaccine developed for rubella Magnetic resonance imaging (MRI) and first Sir Murray MacLehose became governor; 6 year compulsory commercial computer tomography (CAT) free primary education scanner introduced Opening of Hunghom Cross Harbor Tunnel; President Insulin pump introduced Siu Lam Hospital Nixon’s visit to China First living-related renal transplant; Yan White Paper on “Further Development in Medical Services Laser eye surgery first performed Chai Hospital and United Christian Hospital in HK”; Plover Cove Reservoir in service opened

Year Global Medical Advances

Cont’d Appendix 1

A ppendix 1   |   3 0 5

Automated DNA sequencer; polymerase chain 1985 reaction (PCR) technique; artificial kidney dialysis and surgical robot introduced

1984

Sino-British Joint Declaration—proposal of “one country two systems”

Si Edward Youde, governor; Britain and China began talks on the future of Hong Kong Henry Ching appointed the first Secretary of Health and Welfare Bureau; Black Saturday

First Mass Transit Railway (MTR) operational

High Island Reservoir completed; economic reforms began in China

First overseas center for the entire MRCP (UK) First Legislative Council election including medical examination in Hong Kong constituency representative

Peritoneal dialysis service established; antenatal screening for thalassemia; Prince of Wales Hospital and McLehose Medical Rehab-ilitation Centre; first case of AIDS

First palliative care team

1982 Human insulin available

1983 HIV, the virus that causes AIDS, identified

CUHK admitted the first batch of medical students; Professor Rosie Young appointed dean of the Faculty of Medicine; DNA diagnostic laboratory at Queen Mary Hospital; Kwai Chung Hospital and Prince Philip Dental Hospital

Tacrolimus, Sirolimus and mycophenolate 1981 mofetil (MMF) introduced for immunosuppression; first vaccine for hepatitis B

First microsurgical thumb implant Master of Medical Sciences introduced in HKU HKU Laboratory Animal Unit building opened

Home ownership scheme introduced

Influx of Vietnamese refugees began

First test-tube baby born; last fatal case of 1978 smallpox; prenatal DNA sequencing Introduction of short course chemotherapy for 1979 TB; first anti-viral drugs First vaccine for hepatitis B; lithotripter invented; 1980 WHO announced smallpox eradicated

First positron emission tomography (PET) scanner built

Sociopolitical Events in Hong Kong

Medical Developments in Hong Kong Part 1 MRCP examination held in Hong Kong; Princess Margaret Hospital opened with the first infection unit

1977 First vaccine for pneumococcal pneumonia

1976

1975

Year Global Medical Advances

Cont’d Appendix 1

3 0 6   |   A ppendix 1

1986 Human Genome Project began

Statins commercially available; discovery of first HKU Centenary; Hong Kong College of 1987 gene associated with early onset Alzheimer's Orthopedic Surgeons founded disease Establishment of Provisional Hospital Authority; Halnan report on Postgraduate 1988 Intravascular stents; laser cataract surgery Medical Education and Training; Hepatitis B virus inoculation for neonates; College of Obstetricians and Gynecologists formed Working Party on Primary Health Care Cystic fibrosis gene discovered; DNA microarray (WPPHC) and Working Party on Traditional 1989 technique introduced Chinese Medicine (WPTCM); Departments of Health and Hospital Services established Hospital Authority and Hong Kong College 1990 of Surgeons founded; preliminary Report of WPPHC; Tuen Mun Hospital First successful liver transplant; Ruttonjee 1991 Sanatorium converted into a general hospital; Shatin Hospital and Cheshire Home in Shatin First heart transplant and first bone marrow 1992 First vaccine for Hepatitis A transplant; Hong Kong Eye Hospital and Bradbury Hospice First living-related pediatric liver transplant; Hong Kong Academy of Medicine 1993 inauguration ; “Towards Better Health” published; Pamela Youde Nethersole Eastern Hospital

Medical Developments in Hong Kong Scott’s Report released; Hong Kong College of Physicians formed

Year Global Medical Advances

Cont’d Appendix 1

Tobacco advertisement on television banned; Cable TV Hong Kong, a first pay television station

Chris Patten, the last governor of Hong Kong to oversee the handover

Hong Kong Basic Law adopted by the National People’s Congress of China

Tiananmen Square pro-democracy protests

Sir David Wilson became Governor

Sociopolitical Events in Hong Kong

A ppendix 1   |   3 0 7

2001 First telesurgery

2000 Human Genome Project completed

1999

1998 Stem cell therapy

1997

1996 Dolly the Sheep cloned

1995

1994

Year Global Medical Advances

Cont’d Appendix 1 Medical Developments in Hong Kong First living unrelated liver transplant; training center for A&E Medicine in Tang Shiu Kin Hospital; cord blood transplant service began; first Geriatric Community Assessment Team (CGAT) First lung transplant; undergraduate training for nurses began; Hong Kong Renal Registry established; Hong Kong Society of Transplantation formed; Wong Chuk Hang Hospital First adult-adult right lobe liver live donor transplant; Education and Accreditation Committee formed; 12 specialty boards in the Hong Kong Academy of Medicine established Outbreak of avian (H5N1) influenza; Alice Ho Miu Ling Nethersole Hospital opened in Tai Po Degree course in TCM launched in three local universities; North District Hospital Chinese Medicine Ordinance enacted; Chinese Medicine Council formed; Harvard Report “Improving Hong Kong’s Health Care System”; Tseung Kwan O Hospital Registration of TCM practitioners; “Lifelong Investment in Health” healthcare reform document Tobacco sponsorship for sports banned

New Hong Kong International Airport at Chek Lap Kok

HKSAR established; Tsing Ma bridge opened; Tung Cheehwa as first chief executive; Asian financial crisis

Disability Discrimination Ordinance enacted; first satellite TV in Hong Kong

Personal Data Ordinance enacted

Sociopolitical Events in Hong Kong

3 0 8   |   A ppendix 1

2013

2012

2011

2010

2009

First kidney grown in vitro; first human liver grown in vitro

First successful uterus transplant from a deceased donor

2008 First full face transplant

2007

2006 First HPV vaccine approved

2005 First partial face transplant

2004

2003 Identification of SARS coronavirus

Year Global Medical Advances

Cont’d Appendix 1 Medical Developments in Hong Kong

Sociopolitical Events in Hong Kong

17 people quarantined after confirmation of H7N9 avian flu

C. Y. Leung became the third chief executive; protests Leung being in office

SARS outbreak; SARS coronavirus identified; July 1 march against Article 23 Genome Research Centre established Closer Economic Partnership Agreement with China (CEPA) Centre for Health Protection established implemented The State Key Laboratories of Emerging Infectious Diseases and of Brain and Cognitive Donald Tsang replaced Tung as chief executive; Hong Kong Sciences established in HK; “Building a Poison Information Centre and Centre for Food and Drug Healthy Tomorrow” healthcare reform Safety established document HKU Faculty of Medicine renamed Li Ka Shing Faculty of Medicine; TCM introduced to the public health system Smoking indoor in workplace, restaurants, and in public places banned “Your Health, Your Life” healthcare reform Hong Kong held 2008 Olympic Equestrian event document Working Party on Primary Health Care recommendation published; H1N1 flu pandemic (swine flu); Smoking ban in public 2009 East Asian Games entertainment venues and all public indoor areas “My Health, My Choice” healthcare consultation document published

A ppendix 1   |   3 0 9

Source: “Hong Kong Profile, Timeline,” BBC News, https://www.bbc.com/news/world-asia-pacific-16526765;“Hong Kong History Timeline,” Worldatlas, https://www.worldatlas.com/webimage/countrys/asia/hongkong/hktimeln.htm; Rachel Hajar, “History of Medicine Timeline,” National Center for Biotechnology Information, USA, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4379645/; “History of Medicine: Timeline of History of Medicine,” http://historymedicine.blogspot.com/2015/03/timeline-of-history-of-medicine.html; “Timeline of Discovery,” Harvard Medical School, https://hms.harvard.edu/about-hms/history-hms/timeline-discovery. All accessed on 16 March 2019.

2015 A 3D printer is used for first ever skull transplant Heavy metal in drinking water

2014

Sociopolitical Events in Hong Kong

Medical Developments in Hong Kong Culling of 20,000 imported chicken from the 2014 protests (Umbrella Revolution) and “Occupy Central” mainland to avert H7N9 avian flu movement

Year Global Medical Advances

Cont’d Appendix 1

3 1 0   |   A ppendix 1

Appendix 2 Heads of Medical or Health Departments in Hong Kong from 1945 to Present

Table 1  Directors of Medical and Health Department (1945–1988) Director P. Selwyn-Clarke L. Newton K. C. Yeo D. J. M. MacKenzie P. H. Teng G. Choa K. L. Thong

Year 1945–1947 1947–1951 1952–1957 1958–1963 1964–1971 1972–1976 1977–1988

Table 2  Directors of Department of Health (1989–present) Director Lee Shiu-hung Margaret Chan Fung Fu-chun P. Y. Lam Constance Chan Hon-yee

Year 1989–1993 1994–2003 2004–2013 2014–present

Table 3  Chairmen of Hospital Authority Board and Hospital Authority Chief Executives (1990–present) Chairman of HA board Sir Sze-yuen Chung Peter Woo Lo Ka-shui Edward Leong, Che-hung Anthony Wu John Leong, Chi-yan Henry Fan Hung-ling

Year 1990–1995 1995–2000 2000–2002 2002–2004 2004–2013 2013–2019 2019–present

Chief executive of HA Eng-kiong Yeoh William Ho, Shiu-wei Vivian Wong (interim) Shane Solomon Leung Pak-yin Tony Ko Pat-sing

Year 1990–1999 1999–2005 2005 2006–2010 2010–2019 2019–present

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Notes

Chapter 1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

L. C. Chau, “Economic Growth and Income Distribution in Hong Kong,” In 25 Years of Social and Economic Development in Hong Kong, ed. Benjamin K. P. Leung and T. Wong (Hong Kong: Hong Kong University Press, 1994), 94–95. Ibid., 503. Ibid., 494. Ibid., 501. Revenue and Expenditure for each year obtained from Hong Kong Annual Reports, 1950–2010, Hong Kong Government. S. Tsang, A Modern History of Hong Kong (Hong Kong: Hong Kong University Press, 2006), 174. Ibid., 171–172. M. Castells, The Shek Kip Mei Syndrome: Economic Development and Public Housing in Hong Kong (London: Pions Ltd, 1990), 136. Expenditure for each year obtained from Hong Kong Annual Reports, 1946–2010, Hong Kong Government. Hong Kong Annual Report, 1968, Hong Kong Government, 10. I. Scott, Political Change and the Crisis of Legitimacy (Hong Kong: Oxford University Press, 1989), 236–239. Ibid., 246–247. L. Goodstedt, Poverty in the Midst of Affluence: How Hong Kong Mismanaged Its Prosperity (Hong Kong: Hong Kong University Press, 2013), 30. “The Madness at the Heart of Hong Kong’s Public Spending,” South China Morning Post, 15 April 2017. “Population,” Annual Reports of Medical and Health Department, 1950–1980; Hong Kong Annual Digest of Statistics, 1981–2011, Hong Kong Government. “Crude Birth Rate and Crude Death Rate,” Annual Reports of Medical and Health Department, 1946–1980; Hong Kong Annual Digest of Statistics, 1981– 2011, Hong Kong Government. “Life Expectancy from Birth,” Center for Health Protection, Department of Health, Hong Kong, accessed on 7 March 2019. https://www.chp.gov.hk/en/ statistics/data/10/27/111.html Northcote to Cowell, 21 May 1938, CO 129/571/17. S. Y. S. Fan, “The Family Planning Association of Hong Kong: History and Development,” HKJGOM 3 (2002): 2–16.

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20. Family Planning Association of Hong Kong, accessed on 9 March 2019. . https:// www.famplan.org.hk/en 21. Same as note 19 22. Director of Education’s Annual Report of 1977–1978, Hong Kong Government, 32. 23. C. Y. Choi and K. C. Chan, “The Impact of Industrialization on Fertility in Hong Kong. A Demographic, Social and Economic Analysis” (Hong Kong: The Family Planning Association of Hong Kong and the Chinese University of Hong Kong Social Research Center, 1973), 21–42 24. Ibid., 50–51. 25. Population by Age, Data obtained from Medical and Health Department Annual Reports of respective years, Hong Kong Government Reports Online. Data on projected ppopulation was obtained from “Information Note. Population Profile of Hong Kong,” Research Office, Legislative Council Secretariat, accessed on 11 March 2019, https://www.legco.gov.hk/research-publications/english/1415in07population-profile-of-hong-kong-20150416-e.pdf. 26. Ibid. 27. “Hong Kong Frets Over Low Fertility Rate,” China Real Time, 27 March 2014. 28. “Hospital Books Suspended for Expectant Mainlander Mothers,” South China Morning Post, 9 October 2009 29. “Disunion. As Animosity Towards Mainland Rises, the Chief Executive Must Win Over Skeptics Who Wonder Whether He Is on the Side of Hong Kong or Beijing,” South China Morning Post, 5 November 2012. “Mainland Agency Claims It Can Beat the Zero Birth Ban,” South China Morning Post, 31 December 2012. 30. Causes of deaths in 1946, 1948, 1950 and 1936. Hong Kong Medical and Health Department Annual Report of respective years. 31. Causes of deaths 1946 to 2011. Hong Kong Medical and Health Department Annual Reports 1946–2011. 32. Causes of deaths in 1970, 1990, 2010. Hong Kong Medical and Health Department Annual Reports, 1970, 1990 and 2010. 33. B. M. Popkin, “The Shift in Stages of the Nutritional Transition in the Developing World Differs From Past Experience,” Public Health Nutrition 5(2002): 205–214.

Chapter 2 1. 2. 3. 4. 5. 6.

“Reassuring Words by Hong Kong Governor,” Hong Kong News, 21 February 1942. G. B. Endacott, Hong Kong Eclipse (Hong Kong: Oxford University Press, 1978), 120. Ibid., 126. “Full Text of Laws Promulgated by the Governor,” Hong Kong News, 13 April l 1942. J. M. Carroll, A Concise History of Hong Kong (Lanham, Maryland: Rowman and Littlefiled, Publisher Ltd, 2007), 123–129. “Reassuring Statement on Registration of Houses and Goods,” Hong Kong News, 28 August 1942.

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7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

Endacott, Hong Kong Eclipse, 149. “Repatriation of Chinese,” Hong Kong News, 2 February 1942. “Partial Hongkong Census Returns,” Hong Kong News, 10 February 1942. “Census of Population,” Hong Kong News, 30 April 1943. “Census completed in less than three hours,” Hong Kong News, 14 March 1944. “Less than One Million Residing in Hong Kong and Kowloon,” Hong Kong News, 29 September 1942. Hong Kong Medical and Health Department Annual Report 1946, 4. “57 Depots Will Handle Distribution,” Hong Kong News, 7 March 1942. Endacott, Hong Kong Eclipse, 143. “Relief Work in Hong Kong,” Hong Kong News, 15 November 1942. “Definite Measures for Relief of Destitutes in Hongkong Decided,” Hong Kong News, 22 November 1942. “Distribution of Relief in Hongkong,” Hong Kong News, 26 November 1942. F. D. Angus, Report of the Work Undertaken by Dr. P. S. Selwyn-Clarke Following the Occupation of Hong Kong by the Japanese in December 1941, 2 July 1943, CO 129/592/1. Hereafter The Angus Report. Report compiled by Direction of His Excellency Mr. F. C. Gimson CMG, Of Duties Performed by Dr. P. S. Selwyn-Clarke, Director of Medical Services, and Non-interned staff and Volunteer Helpers, During the Occupation of Hong Kong by Japanese Forces, CO 129/592/1. “City Streets Made Clean,” Hong Kong News, 15 February 1942. “Organized Plan for Removal of Night Soil,” Hong Kong News. 25 March 1942. P. S. Selwyn-Clarke, Report on Medical and Health Conditions in Hong Kong. For the period 1 January 1941 to 31 August 1945 (London: His Majesty’s Stationery Office, 1946), 8. “Hongkong Cleansing Plan,” Hong Kong News, 8 March 1942. “Cleansing Campaign,” Hong Kong News, 23 February 1943. “Health of Populace. Anti-Epidemic Bureau Opened,” Hong Kong News, 24 February 1942. “Successful Vaccination Campaign,” Hong Kong News, 1 January 1944. “Anti-cholera Inoculation Campaigns,” Hong Kong News, 18 March 1943; 30 July 1943; 3 September 1943. “Health Measures Explained,” Hong Kong News, 25 March 1942. “Safeguards for Public Health. Regulations Issued to Cafes etc,” Hong Kong News, 30 May 1943. “Progress of Anti-cholera Campaign,” Hong Kong News, 14 July 1943. “Dengue Fever,” Hong Kong News, 4 November 1942. “Precautionary Steps Against Malaria,” Hong Kong News, 31 March 1944. “Hongkong Doctors Register,” Hong Kong News, 26 May 1942. Lee Wai-shing, “Examination of Medical History Under Japanese Occupation: Using Hong Kong Nippo (Hong Kong News) as the Main Reference,” (PhD thesis, The Chinese University of Hong Kong, 2012), 53. S. C. Tso, “An Unusual Nursing Diploma,” in Footprints of Medicine: From the Collections of Hong Kong Museum of Medical Sciences (Hong Kong: Hong Kong

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Museum of Medical Science, 2016), 62–65. 36. Lee Wai-shing. “Examination of Medical History Under Japanese Occupation: Using Hong Kong Nippo (Hong Kong News) as the Main Reference,” (PhD thesis, The Chinese University of Hong Kong, 2012), 56. 37. “Treatment at Public Hospital,” Hong Kong News, 9 October 1944. 38. “Additional Anti-cholera Depot Opened,” Hong Kong News, 5 June 1943. 39. “Tung Wah Hospital Committee,” Hong Kong News, 28 March 1943. 40. Ho Pui-yin, Po yu li: Donghua sanyuan zhidu de yanbian (Get rid of the old and bring in the new: The development of the Tung Wah Group of Hospitals) (Hong Kong: Joint Publishing [H.K.], 2009), 87–88. 41. Hong Kong News (Chinese version), 8 December, 1942. 42. The Angus Report, CO 129/592/1, 59. 43. Ibid., 49. 44. Sun-pao Joseph Ting, Shan yu ren tong: Yu Xiangang tongbu chengzhang de donghua sanyuan (For the Common Good: The Tung Wah Group of Hospitals That Grows with Hong Kong) (Hong Kong: Joint Publishing, 2010), 251. 45. “Your Body and How it Works,” Hong Kong News, 8 February 1942. 46. “Exercise for Health,” Hong Kong News, 4 August 1943. 47. “Canadian Prisoners of War in Hong Kong,” Veterans Affairs Canada, accessed on 11 Novemeber 2017, http://www.veterans.gc.ca/eng/remembrance/history/ second-world-war/canadians-hong-kong. 48. C. G. Roland, Long Night’s Journey into Day: Prisoners-of-War in Hong Kong and Japan. 1941–1945 (Waterloo, Ontario: Wilfred Laurier University Press, 2001), 155. 49. Ibid., 164–167. 50. D. Bowie, “Captive Surgeon in Hong Kong,” JHKBRAS 15 (1976): 172–174. 51. Bowie, “Captive Surgeon in Hong Kong,” 172–173. 52. Roland, Long Night’s Journey into Day, 180–181. 53. Bowie, “Captive Surgeon in Hong Kong,” 172. 54. The Angus Report, CO 129/592/1, 57 55. G. C. Emerson, Hong Kong Internment 1942–1945: Life in Japanese Civilian Camp at Stanley (Hong Kong: Hong Kong University Press, 2008), 36. 56. Emerson, Hong Kong Internment, 1942–1945, 38, accessed on 15 February 2019., https://en.wikipedia.org/wiki/File:StanleyInternmentMap.jpg. 57. Emerson, Hong Kong Internment 1942–1945, 38. 58. Emerson, Hong Kong Internment 1942–1945, 23. 59. C. M. Fung, A History of Queen Mary Hospital 1937–1997 (Hong Kong: Queen Mary Hospital 1997), 34. 60. The Angus Report, CO 129/592/1, Appendix 1, 3. 61. The Angus Report, CO 129/592/1, 52–54. 62. Dr. P. S. Selwyn-Clarke’s Report on 20 October 1945, CO 129/591/1. 63. The Angus Report, CO 129/592/, 59. 64. “Stanley Internment Camp,” accessed on 15 February 2019, https://en.wikipedia. org/wiki/Stanley_Internment_Camp.

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65. L. Ride, “The Test of War,” In Dispersal and Renewal: Hong Kong University during the War Years, eds. C. Matthews and O. Cheung (Hong Kong: Hong Kong University Press, 1998), 12. 66. Ride, “The Test of War,” 14. 67. Ride, “The Test of War,” 16–17. 68. J. R. Poynter, 'Ride, Sir Lindsay Tasman (1898–1977)', Australian Dictionary of Biography, National Centre of Biography, Australian National University, http:// adb.anu.edu.au/biography/ride-sir-lindsay-tasman-11524/text20557, published first in hardcopy 2002. Accessed online 16 February 2019 69. G. King, “An Episode in the History of the University,” In Dispersal and Renewal (Hong Kong: Hong Kong University Press, 1998), 85–87. 70. King, “An Episode in the History of the University,” 93–95. 71. F. Ho, “MHIG 2. Recounting the Experience and Impact of Students Who Studied Medicine in War Time China 1942–1945” (presentation, Medical History Interest Group, Hong Kong Museum of Medical Science, 26 September 2009). 72. King, “An Episode in the History of the University,” 99. 73. D. E. Evans, Constancy of Purpose: An Account of the Foundation and History of Hong Kong College of Medicine and the Faculty of Medicine of the University of Hong Kong 1887–1987 (Hong Kong: Hong Kong University Press, 1987), 81. 74. Professor Rosie Young, “The Teacher I Remember” (presentation, Medical History Interest Group, MHIG 9, Hong Kong Museum of Medical Science, 12 October 2013).

Chapter 3 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Hong Kong Medical and Health Department Annual Report, 1946, 5–6. “Big Increases in Cases,” SCMP, 14 November 1946. Hong Kong Medical and Health Department Annual Report, 1946, 40. Hong Kong Annual Report, Hong Kong Government, 1946, 122–23. Hong Kong Medical and Health Department Annual Reports, 1946–1955. Hong Kong Medical and Health Department Annual Report, 1946, 4–5. S. H. Lee, Prevention and Control of Communicable Diseases in Hong Kong, 1994, 43–45. Hong Kong Medical and Health Department Annual Report, 1946. 40–41. Lee, Prevention and Control of Communicable Diseases in Hong Kong, 24–25. Ibid., 19–22. Hong Kong Medical and Health Department Annual Report, 1954, 22–23. Hong Kong Medical and Health Department Annual Report, 1955, 22. Hong Kong Medical and Health Department Annual Reports, 1947–1980, and Hong Kong Annual of Digest of Statistics, 1981–2011, Hong Kong Government. Hong Kong Medical and Health Department Annual Report, 1948, 73. Hong Kong Medical and Health Department Annual Report, 1948, 75. Hong Kong Medical and Health Department Annual Report, 1948, 76–78.

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17. Hong Kong Medical and Health Department Annual Report, 1955, 22–23. 18. Hong Kong Medical and Health Department Annual Reports, 1947–1997, and Hong Kong Annual Digest of Statistics, 1998–2010, Hong Kong Government. 19. Hong Kong Medical and Health Department Annual Report, 1952, 20–21. 20. Quarantine and Prevention of Disease Ordinance (Cap 141), 1937. 21. Lee, Prevention and Control of Communicable Diseases in Hong Kong, 11–12. 22. Hong Kong Medical and Health Department Annual Report, 1952, 37 23. Hong Kong Medical and Health Department Annual Report, 1956, 72. 24. Hong Kong Medical and Health Department Annual Report, 1956, 68–69. 25. Report of Advisory Committee on Clinics (Hong Kong: S. Young, Government Printers at the Government Press, 1966), 44–45. 26. Ibid., 40. 27. Report of Committee Appointed to Review the Doctor Problem in the Hong Kong Government Service (Hong Kong: Hong Kong Government Printers, May 1969), 15–18. 28. Hong Kong Medical and Health Department Annual Reports, 1953–1990 and Hong Kong Annual Digest of Statistics, 1991–2012. 29. The University of Hong Kong Li Ka Shing Faculty of Medicine, Shaping the Health of Hong Kong: 120 Years of Achievements (Hong Kong: Hong Kong University Press), 2006, 40–41. 30. “OECD Health Statistics 2014,” Organisation for Economic Co-operation and Development, accessed on 28 March 2015, www.oecd.org/health/healthdata. 31. “List of Gazetted Registered Nurses Training Schools,” The Nursing Council of Hong Kong, accessed on 28 March 2015, http://www.nchk.org.hk/filemanager/ en/pdf/list_gazetted_en.pdf. (The universities that offered nurses training with degrees are The Hong Kong University, The Chinese University of Hong Kong, The Hong Kong Polytechnic University, The Open University of Hong Kong, and Hong Kong University School of Professional and Continuing Education. Tung Wah College and Caritas Institute of Higher Education also offer a degree program in nursing.) 32. “List of Gazetted Enrolled Nurses Training Schools,” The Nursing Council of Hong Kong, accessed on 28 March 2015, http://www.nchk.org.hk/filemanager/ en/pdf/list_gazetted.pdf. 33. Same as note 30. 34. Hong Kong Medical and Health Department Annual Report, 1953–1990, and Hong Kong Annual Digest of Statistics, 1991–2012. 35. “Hong Kong’s Water Supplies. 1960. A Year of Decision,” Hong Kong Annual Report 1960, 1–10. 36. Hong Kong Medical and Health Department.Annual Report, 1946, 7. 37. “Shek Pik Reservoir,” Wikipedia, accessed on 29 March 2015, https:// en.wikipedia.org/wiki/Shek_Pik_Reservoir. 38. Ho Pui Yin, Water for a Barren Rock: 150 Years of Water Supply in Hong Kong (Hong Kong: The Commercial Press, 2001), 155. 39. “The High Island Reservoir,” Water Supplies Department, accessed on 13 March 2019, https://www.wsd.gov.hk/en/customer-services/other-customer-services/fishing-inreservoirs/brief-introduction-of-reservoirs/high-island-reservoir/index.html.

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40. Ho Pui Yin, Water for a Barren Rock, 156–167. 41. Ibid., 217. 42. Public Health and Buildings Ordinance, 1903, Historical Laws of Hong Kong Online, accessed on 29 March 2015, http://oelawhk.lib.hku.hk/items/ show/1209. 43. R. Hutcheon, High-Rise Society—The First 50 Years of Hong Kong Housing Society (Hong Kong: Chinese University Press, 1998), 3–4. 44. A. Smart, The Shek Kip Mei Myth: Squatters, Fires and Colonial Rule in Hong Kong 1950–1964 (Hong Kong: Hong Kong University Press, 2006), 48. K. Hopkins, “Housing the Poor,” in Hong Kong: The Industrial Colony, ed. K. Hopkins (Hong Kong: Oxford University Press, 1971), 273–305. 45. Han Suyin, A Many-Splendoured Thing (London: Jonathan Cape, 1952), 30–33. 46. M. Chan-Yeung, The Practical Prophet: Bishop Ronald O Hall of Hong Kong and His Legacies (Hong Kong: Hong Kong University Press, 2015), 94, and 121–22. Octavia principle consists of the following: The managers of the housing estate were educated women who were trained in this prinicple. They collected rents themselves as well as ensuring the premises were in good state of repair. They also acted as social workers for the families. 47. S. Y. Ho, “Public Housing,” in Hong Kong in Transition, ed. J. Y. S. Cheng (Hong Kong: Oxford University Press, 1986), 331–348. 48. In 1999, the Urban Council was abolished and the sanitary services were taken over by Food and Environment Hygiene Department and the Leisure and Cultural Services Departmemt. 49. Hong Kong Medical and Health Department Annual Report, 1946, 7. 50. “A Review of 1996,” Hong Kong Annual Report (Hong Kong: Hong Kong Government Printers, 1997), 172. 51. Hong Kong Medical and Health Department Annual Report, 1946, 8. 52. “Waste Management in Hong Kong,” Wikipedia, accessed on 1 April 2015, https://en.wikipedia.org/wiki/Waste_management_in_Hong_Kong. 53. “Hawker Control,” Food and Environmental Hygiene Department, Hong Kong, accessed on 2 March 2019. http://www.fehd.gov.hk/English/pleasant_ environment/hawker/control.html.

Chapter 4 1. 2. 3. 4. 5.

S. L. Kotar and J. E. Gessler, Cholera: A Worldwide History ( Jefferson North Carolina: McFarland & Company Inc., Publishers, 2014), 9. G. C. Cook, The Asiatic Cholera: An Historical Determinant of Human Genomic and Social Structure, Cholera and the Ecology of Vibrio Cholera (London: Chapman and Hall, 1960), 20–21. L. T. Wu, J. W. H. Chun, R. Pollitzer, and C. Y. Wu, Cholera: A Manual for the Medical Profession in China (Shanghai, National Quarantine Services, 1934), 1–16. General Board of Health, Report of the Committee of Scientific Inquiries in Relation to the Cholera Epidemic of 1854 (London: Eyre and Spottiswoode, 1855), 52. Medical and Sanitary Services Annual Report, 1937; Hong Kong Adminstrative

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6. 7. 8.

9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

24. 25. 26.

Report, 1937, M 115 and M 142. S. M. Bard, Light and Shade Sketches of an Uncommon Life (Hong Kong: Hong Kong University Press, 2008), 66–68. Hong Kong Medical and Health Department Annual Report, 1946, 5. Hong Kong Museum of Medical Sciences Society, Plague, SARS and the Story of Medicine in Hong Kong (Hong Kong: Hong Kong University Press, 2006), 40–49; Report on the Outbreak of Cholera in Hong Kong, Medical and Health Department, 1961; Lee, Shiu-Hung, Prevention and Control of Communicable Diseases in Hong Kong (Hong Kong: Government Printer, 1994), 31–39. Hong Kong Medical and Health Department Annual Reports, 1946–1997, and Hong Kong Annual Digest of Statistics, 1998–2010. Hong Kong Medical and Health Department Annual Report, 1961–1962, 21. Hong Kong Medical and Health Department Annual Report, 1962–1963, 3. Lee, Shiu-Hung, Prevention and Control of Communicable Diseases in Hong Kong, 34–35. S. H. Lee, “The History of Public Health in Hong Kong” (presentation, Medical History Interest Group of the Hong Kong Museum of Medical Sciences Society, 6 February 2010). P. A. Van de Linde and G. I. Forbes, “Observations on the Spread of Cholera in Hong Kong 1961–1963,” Bull Org Mond Santé Bull Wld Hlth Org 32 (1965): 515–530. G. J. Forbes, J. D. F. Lockhart, and R. K. Bowman, “Cholera and Night Soil Infection in Hong Kong, 1966,” Bull Org Mond Santé 36 (1967): 367–373. Report on the Outbreak of Cholera in Hong Kong, Hong Kong Medical and Health Department 1961, 7–26. Hong Kong Museum of Medical Sciences Society, Plague, SARS and the Story of Medicine in Hong Kong, 40–49. S. H. Lee, S. T. Lai, J. Y. Lai, and N. K. Keung, “Resurgence of Cholera in Hong Kong,” Epidemiol Infect 117 (1996): 43–49. J. Chretien, Tuberculosis: The Illustrated History of a Disease, Propos Volume 1 (Paris: L’Union internationale contre la tuberculose et les maladies respiratoires, 1998), 15. M. Gandy and A. Zumla, The Return of the White Plague: Global Poverty and the New Tuberculosis (London: Verso, 2003), 17. A. Rooney, The Story of Medicine: From Early Healing to the Miracles of Modern Medicine (London: Arcturus, 2009), 52. S. Keshavjee and P. E. Farmer, “Tuberculosis, Drug Resistance, and the History of Modern Medicine,” N Engl J Med 367 (2012): 931–936. W. Fox, G. A. Ellard, and D. A. Mitchison, “Studies on the Treatment of Tuberculosis Undertaken by the British Medical Research Council Tuberculosis Units, 1946–1986, with Relevant Subsequent Publications,” Int J Tuberc Lung Dis 3 Supple 2 (1999): S231–S279. Annual Reports of Medical and Sanitary Services, 1929–1938; Hong Kong Administrative Report, 1929–1938. C. M. Fung, A History of Queen Mary Hospital Hong Kong (Hong Kong: Queen Mary Hospital, 1997), 23 Tuberculosis and Chest Service Annual Report, Department of Health, 2016.

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27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55.

Hong Kong Medical and Health Department Annual Report, 1953, 26. Bard, Light and Shade, 140–142. Han Suyin, A Many Splendored Thing (London: Jonathan Cape, 1952), 219. S. M. Bard, “Pulmonary Tuberculosis in Hong Kong University Students,” The Journal of the American College of Health Association 13 (1965): 319–330. Hong Kong Medical and Health Department Annual Report, 1947, 60–72. Hong Kong Medical and Health Department Annual Report, 1959, 60. Hong Kong Annual Digest of Statistics, 1993, 228. Annual Medical Report 1931; Hong Kong Administrative Report, 1931, M 127. Hong Kong Medical and Health Department Annual Report, 1952, 30. Hong Kong Medical and Health Department Annual Report, 1960, 31. T. W. Wong, “Plomage Treatment for Pulmonary Tuberculosis,” in Footprints of Medicine: From the Collections of Hong Kong Museum of Medical Sciences (Hong Kong, Hong Kong Museum of Medical Science Society, 2016), 120–121. Hong Kong College of Surgeons, Healing with a Scalpel (Hong Kong: Hong Kong Academy of Medicine Press, 2013), 167–168. J. Murray, “A Century of Tuberculosis,” Am J Respir Crit Care Med 169 (2004): 1181–1186. Hong Kong Medical and Health Department Annual Report, 1953, 25–40. “Tuberculosis Manual 2006,” Tuberculosis and Chest Service, Public Health Service Branch, Center for Health Protection, Department of Health, Government of the HKSAR, 51. M. Humphries, Life and Times of Ruttonjee Sanatorium (Hong Kong: Wing Yiu Printing Company, 1996), 32. D. Mahler, M. Mikulencak, “What is DOTS? A Guide to Understanding the WHO-Recommended TB Control Strategy Known as DOTS,” WHO/CDS/ CPC/TB/99.270. Hong Kong Medical and Health Department Annual Report, 1960, 25. Hong Kong Medical and Health Department Annual Report, 1952–1953, 37. K. Noertjojo, C. M. Tam, S. L. Chan, J. Tan, and M. Chan-Yeung, “Contact Examination for Tuberculosis in Hong Kong is Useful,” Int J Tuberc Lung Dis 6 (2002): 19–24. S. H. Lee, “The History of Public Health in Hong Kong.” (Mobile x-ray unit) Hong Kong Medical and Health Department Annual Report, 1955, 16. Tuberculosis Manual, 2006, Tuberculosis and Chest Service, Public Health Services Branch, Center for Health Protection, Department of Health, Government of the HKSAR, 2006, 44. Medical and Health Department Annual Report 1949, Hong Kong Government, 63–64. Hong Kong Medical and Health Department Annual Report 1959, 32–33. S. H. Lee, “The History of Public Health in Hong Kong.” (BCG vaccination) Tuberculosis Manual, 2006, 105–111. Ibid., Figure 15.1. Ibid., 99–104.

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56. Humphries, Life and Times of Ruttonjee Sanatorium, 33–34. 57. Tuberculosis and Chest Service, Annual Reports 2002 and 2013, Department of Health. 58. C. W. McMillen, Discovering Tuberculosis: A Global History, 1900 to the Present (New Haven: Yale University Press, 2005), 175–179. 59. Tuberculosis Manual, 2006, 105–11. 60. Tuberculosis and Chest Service, Department of Health, Annual Report 2015, 3. 61. C. C. Leung, W. W. Yew, and C. K. Chan, “Tuberculosis in Older People: A Retrospective and Comparative Study from Hong King,” J Am Geriatr Soc 50 (2002): 1219–1226. 62. McMillen, Discovering Tuberculosis, 228. 63. “Tuberculosis,” World Health Organization Fact Sheet (18 September, 2018), accessed on 9 March 2019, https://www.who.int/en/news-room/fact-sheets/ detail/tuberculosis.

Chapter 5 1.

Hong Kong Medical and Health Department Annual Reports, 1951, 1971, 1991 and 2011, Hong Kong Government. 2. E. Nabel, E., Braunwald, “A Tale of Coronary Artery Disease and Myocardial Infarction,” N Engl J Med 366 (2012): 54–63. 3. “Health, United States, 2016,” Centre of Diseases Control and Health Promotion, US Department of Health, Centre for Disease Control and Prevention, National Centre for Health Statistics, 120, accessed on 7 March 2019, https://www.cdc. gov/nchs/data/hus/hus16.pdf. 4. T. S. Yu, S. L. Wong, O. L. Lloyd, and T. W. Wong, “Ischemic Heart Disease: Trends in Mortality in Hong Kong, 1979–89,” J Epidemiol and Community Health 49 (1995):16–21; P. H. Chau, M. Wong, and J. Woo, “Trends in Ischaemic Heart Disease Hospitalization and Case Fatality in the Hong Kong Chinese Population 2000–2009: A Secondary Analysis,” BMJ Open 3 (2013): e002963. 5. “Heart Disease,” Centre for Health Protection, Department of Health, acessed on 31 March 2016, http://www.chp.gov.hk/en/content/9/25/57.html. 6. J. F. Toole, “A History of Cerebrovascular Disease since the Renaissance,” in Cerebrovascular Disorders, 6th edition, eds. E Steve Roach, Kerstin Bettermann and Jose Biller (Cambridge: Cambridge University Press), accessed on 24 March 2016, http://www.cambridage.org. 7. “Cerebrovascular Disease,” Centre for Health Protection, Department of Health, Government of HKSAR, accessed on 4 March 2019, https://www.chp.gov.hk/ en/healthtopics/content/25/58.html. 8. “Health, United States 2016,” 120. 9. Hong Kong data from Hong Kong Medical and Health Department 1960–1980; Hong Kong Annual Digest of Statistics, 1981–2016, Hong Kong Government Reports on line; US data from “Health, United States 2016,” 120. 10. E. D. Janus, “Epidemiology of Cardiovascular Risk Factors in Hong Kong,” Clin and Exp Pharm and Physiol 24 (1997): 987–988. 11. “Report of Population Health Survey, 2003/04” and “Report of Population Health Survey, 2014/2015.” Centre for Health Protection, Department of Health,

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18. J. H. Ho, D. P. Huang, and Y. Y. Fong, “Salted Fish and Nasopharyngeal Carcinoma in Southern Chinese,” Lancet 2 (1978): 626–628. 19. Anne W. M. Lee, “A Tribute to the Father of Radiology and Oncology in Hong Kong—The Legend of John H. C. Ho, M.D. Obituray,” Int J Radiation Oncology Biol. Phys 64 (2006): 1–2. 20. V. T. DeVita and Edward Chu, “The History of Chemotherapy,” Cancer Res 68 (2008): 8643–8653. 21. “Evolution of Cancer Treatments, Chemotherapy,”American Cancer Society, acessed on 15 October 2016, http://www.cancer.org/cancer/cancerbasics/ thehistoryofcancer/the-history-of-cancer-cancer-treatment-chemotherapy. 22. Y. L. Kwong and D.Todd, “Delicious Poison: Arsenic Trioxide for the Treatment of Leukemia,” Blood 89 (1997): 3487–3488. 23. H. K. Ma, S. K. Yip, and D. Chun. “Actinomycin D in the Treatment of Methotrexate-Resistant Malignant Trophoblastic Tumours,” J Obstet Gynaecol Br Commonw 78 (1971): 166–171. 24. Personal information from Professor T. K.Chan. 25. Hong Kong Anti-Cancer Society Annual Report, 2016, accessed on 6 March 2019, https://www.hkacs.org.hk/ufiles/2016_annualreport_s1_1.pdf. 26. World Cancer Research Fund and American Institute for Cancer Research, Food Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective (2007), 322–341, accessed on 31 March 2016, http://discovery.ucl.ac.uk/4841/1/4841. pdf; B. Laub-Secretan, C. Scoccianti, D. Loomis, Y. Grosse, F. Bianchini, K. Straif, for the International Agency for Research on Cancer Handbook Working Group, “Body Fatness and Cancer–Viewpoint of the IARC Working Group,” N Engl J Med 375 (2016): 794–798. 27. “Lung Cancer,” Center for Health Protection, Department of Health, accessed on 7 March 2019, https://www.chp.gov.hk/en/healthtopics/content/25/49.html 28. Y. L. Chiu, Ignatious T. S. Yu, and T. W. Wong, “Time Trends of Female Lung Cancer in Hong Kong: Age, Period and Birth Cohort Analysis,” Int J Cancer 111 (2004): 424–430. 29. World Cancer Research Fund and American Institute for Cancer Research, Food Nutrition, Physical Activity, and the Prevention of Cancer, 259. 30. “Recommendations on Prevention and Screening for Lung Cancer,” Center for Health Protection, Department of Health, Hong Kong, accessed on 6 March 2019, http://www.chp.gov.hk/en/health_topics/9/25.html 31. “Colorectal Cancer,” Center for Health Protection, Department of Health, accessed on 7 March 2019, https://www.chp.gov.hk/en/healthtopics/content/25/51.html. 32. World Cancer Research Fund and American Institute for Cancer Research, Food Nutrition, Physical Activity, and the Prevention of Cancer, 280. 33. “Recommendations on Prevention and Screening for Colorectal Cancer,” Centre for Health Protection, Department of Health, Hong Kong. Accessed on 6 March 2019, https://www.chp.gov.hk/files/pdf/cewg_crc_professional_hp.pdf. 34. Ibid. 35. “Liver Cancer,” Center for Health Protection, Department of Health, accessed on 7 March 2019, https://www.chp.gov.hk/en/healthtopics/content/25/52.html. 36. S. L. Mak and K. Y. Leung, “Hepatitis B Carriers in Hong Kong: Prevalence and

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53. Shaping the Health of Hong Kong, 135. 54. “Recommendations on Prevention and Screening of Nasopharyngeal Cancer,” Centre for Health Protection, Department of Health, accessed on 6 March 2019, https://www.chp.gov.hk/files/pdf/npc_hp_version_hp.pdf. 55. “Oesophageal Cancer,” Center for Health Protection, Department of Health, accessed on 7 March 2019, https://www.chp.gov.hk/en/healthtopics/content/25/50.html. 56. World Cancer Research Fund and American Institute for Cancer Research, Food Nutrition, Physical Activity, and the Prevention of Cancer, 19. 57. Ibid., 253. 58. L. A. Tse, Ignatius T. A. Yu, and Oscar W. K. Mang, “Time Trends of Esophageal Cancer in Hong Kong: Age, Period and Birth Cohort Analysis,” Int J Cancer 130 (2006): 853–858. 59. Shaping the Health of Hong Kong, 136. 60. Same as note 41. 61. G. M. Leung, T. Q. Thach, T. H. Lam, A, et al “Trends in Breast Cancer Incidence in Hong Kong beween 1974 and 1999: An Age-Period-Cohort Analysis,” Brit J Cancer 87 (2002): 982–988. 62. “Breast Cancer,” Center for Health Protection, Department of Health, accessed on 6 March 2019, https://www.chp.gov.hk/en/healthtopics/content/25/53. html. 63. “Cancer Facts and Figures, 2015,” American Cancer Society Surveillance Branch, 9–10. 64. World Cancer Research Fund and American Institute for Cancer Research, Food Nutrition, Physical Activity, and the Prevention of Cancer, 289. 65. "Recommendations on Prevention and Screening for Breast Cancer." Centre for Health Protection, Department of Health, accessed on 6 March 2019, https:// www.chp.gov.hk/files/pdf/breast_cancer_professional_hp.pdf. 66. “Breast Cancer 2011.” Canadian Task Force on Preventive Health Care, accessed on 6 March 2019, https://canadiantaskforce.ca/guidelines/published-guidelines/ breast-cancer/. 67. “Breast Cancer Early detection and Diagnosis,” American Cancer Society, accssed on 26 October 2016, http://www.cancer.org/cancer/breastcancer/ moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acsrecs. 68. “Cervical Cancer,” Center for Health Protection, Department of Health, accessed on 7 March 2019, https://www.chp.gov.hk/en/healthtopics/content/25/56. html. 69. F. Y. Cheung, Oscar W. K. Mang, and S. C. K., Law, “A Population-Based Analysis of Incidence, Mortality, and Stage-specific Survival of Cervical Cancer Patients in Hogn Kong.1997–2006,” Hong Kong Med J 17 (2011): 89–95. 70. World Cancer Research Fund and American Institute for Cancer Research, Food Nutrition, Physical Activity, and the Prevention of Cancer, 302. 71. “Recommendations on Prevention and Screening for Cervical Cancer,” Centre for Health Protection, Department of Health, accessed on 6 March 2019, https:// www.chp.gov.hk/files/pdf/cervical_cancer_professional_hp.pdf. 72. “Recommendations on Prevention and Screening for Prostate Cancer,” Center

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73. 74. 75. 76. 77.

78.

79. 80.

for Health Protection, Department of Health, accessed on 5 March 2019, https:// www.chp.gov.hk/files/pdf/prostate_cancer_professional_hp.pdf. World Cancer Research Fund and American Institute for Cancer Research, Food Nutrition, Physical Activity, and the Prevention of Cancer, 305. H. K. Koh and K. G. Sebelius, “Ending the Tobacco Epidemic,” JAMA 308 (2012): 767–768. D. M. Gertig, J. M. Brotherton, A. C. Budd, K. Drennan, G. Chappell, and A. M. Saville, “Impact of a Population-Based HPV Vaccination Program on Cervical Abnormaities: A Data Linkage Study,” BMC Med 11 (2013): 227–231. C. J. Yang, S. L. You, M. S. Lai, and C. J. Chan, “Thirty Year Outcomes of the National Hepatitis B Immunization Program in Taiwan,” JAMA 310 (2013): 974– 976. CDC Facts Sheet: "Viral Hepatitis and Liver Cancer," Atlanta: Centers for Disease Control and Prevention, Departmnet of Health and Human Services, accessed on 6 March 2019, https://www.chp.gov.hk/files/pdf/prostate_cancer_professional_ hp.pdf. U. S. Preventive Services Task Force, “Screening for Colorectal Cancers: U. S. Preventive Services Task Force Recommendation Statement,” Ann Intern Med 149 (2008): 627–637; H. G. Welch and D. J. Robertson, “Colorectal Cancer on the Decline—Why Screening Can’t Explain It All,” N Engl J Med 374 (2016): 1605– 1607. G. A. Colditz, K. Y. Wolin, and S. Gehlert, “Applying What We Know to Accelerate Cancer Prevention,” Sci Transl Medicine 4 (2012): 127rv4. T. B. Bevers, J. H. Ward, B. K. Arun, et al., “Breast Cancer Risk Reduction,” Version 2.2015, J Natl Compr Canc Netw 13 (2015): 880–915.

Chapter 7 1.

“A Timeline of HIV/AIDS,” U.S. Department of Health & Human Services, accessed 6 March 2019, https://www.hiv.gov/hiv-basics/overview/history/hivand-aids-timeline. 2. S. K. Bell, C. L. McMickens, and K. L. Selby, AIDS, Biographies of Disease (Santa Barbara: Greenwood, 2011), 1–7. 3. A. Whiteside and T. Barnett, AIDS in the Twenty-First Century: Disease and Globalization (London: Palgrave MacMillan, 2006), 24. 4. Bell, McMickens, and Selby, AIDS, 4–6. 5. NIH Medline Plus, “HIV/AIDS. Symptoms, Diagnosis, Prevention and Treatment,” accessed on 1 Nov 2016, https://medlineplus.gov/magazine/issues/ summer09/articles/summer09pg13-15.html. 6. Bell, McMickens and Selby, AIDS, 18. 7. “HIV Diagnosis,” UCSF Health, accessed on 6 March 2019, https://www. ucsf health.org/conditions/hiv/diagnosis.html. 8. Bell, McMickens and Selby, AIDS, 32-35. 9. Ibid., AIDS, 70–71. 10. See note 7.

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11. Hong Kong Advisory Council on AIDS, The First Decade of AIDS in Hong Kong: A Collection of Essays (Hong Kong: Hong Kong Advisory Council on AIDS, 1999). 12. “A Review of Services Provided to the People with HIV/AIDS,” AIDS Services Development Committees of Advisory Council on AIDS Hong Kong, 1994. 13. Hong Kong Advisory Council on AIDS, The First Decade of AIDS in Hong Kong, xx. 14. “Prevention of Transmission of HIV in Health Care Setting. Guidelines and Practices,” Hong Kong Advisory Council on AIDS, AIDS Unit, Department of Health, 1994. 15. Same as note 13. 16. Hong Kong Advisory Council on AIDS, The First Decade of AIDS in Hong Kong, 24–25. 17. Hong Kong AIDS Concern Foundation, accessed on 6 March 2019, https:// apcom.org/2013/04/08/hong-kong-aids-concern-foundation/. 18. Hong Kong AIDS Foundation, accessed on 6 March 2019, https://aids.org. hk/?lang=zh. 19. The Society for AIDS Care, Hong Kong, accessed on 6 March 2019, https:// aidscare.com.hk/. 20. “HIV Surveillance Report–2015 Update,” Special Prevention Programme, Center for Health Protection, Department of Health, HKSAR, 2016, accessed on 6 March 2019, https://www.aids.gov.hk/english/surveillance/sur_report/hiv15. pdf. 21. Ibid. 22. “HARiS—HIV and AIDS Response Indicator Survey 2014 for Male-to-Female Transgender,” Special Preventive Programme Centre for Health Protection, Department of Health, HKSAR, accessed on 1 May 2016, http://www.chp.gov. hk/files/pdf/oth_rep2015_tg_e.pdf. 23. “PRiSM—HIV Prevalence and Risk Behavioural Survey of Men Who Have Sex with Men in Hong Kong 2017,” Special Preventive Programme Centre for Health Protection, Department of Health, HKSAR, accessed on 6 March 2019, https:// www.aids.gov.hk/english/surveillance/sur_report/prism2017e.pdf. 24. “Recommended HIV/AIDS Strategies for Hong Kong 2012–2016,” Hong Kong Advisory Council on AIDS, 2012. 25. Murphy Colum, Flu Action Plan: A Business Survival Guide (Singapore: John Wiley & Son Ltd, 2006), 14. 26. K. Y. Yuen, P. K. S. Chan, J. S. M. Peiris, D. N. C. Tsang, and members of the H5N1 Study group, “Clinical Features and Rapid Viral Diagnosis of Human Disease Associated with Avian Influenza A H5N1 virus,” Lancet 351 (1998): 467– 471. 27. P. K. S. Chan, “Outbreak of Avian Influenza A (H5N1) Virus Infection in Hong Kong in 1997,” CID 34 Suppl 2 (2002): 58. 28. B. C. Claas, A. D. Osterhaus, R. van Beck, et al., “Human Influenza A H5N1 Virus Related to a Highly Pathogenic Avian Influenza Virus,” Lancet 351 (1998): 472–477. 29. K. P. Shortridge, P. Gao, Y. Guan, et al., “Interspecies Transmission of Influenza Virus: H5N1 Virus and Hong Kong SAR Perspective,” Veterinary Microbiology 74 (2000): 141–147.

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30. P. K. S. Chan, “Outbreak of Avian Influenza A (H5N1) Virus Infection in Hong Kong in 1997,” CID 34 Suppl 2 (2002): 63. 31. “Prevention of Avian Influenza: Consultation on Long Term Direction to Minimise the Risk of Human Infection,” Health, Welfare and Food Bureau, HKSAR (2004), accessed on 16 March 2019, https://www.legco.gov.hk/yr03-04/ english/panels/fseh/papers/fseh0402-avian-e-scan.pdf. 32. D. Suarez, “Influenza A Virus,” in Avian Influenza, ed. D. E. Swayne (Ames, IA: John Wiley & Son Inc., 2008), 3–8. 33. E. D. Kilbourne, “Influenza Pandemics of the 20th Century,” Emerging Infectious Diseases 12 (2006): 9–14. 34. Hong Kong Medical and Health Department Annual Report, 1957, 15. 35. Hong Kong Museum of Medical Sciences, Plague, SARS, and the Story of Medicine in Hong Kong (Hong Kong: Hong Kong University Press, 2006), 55. 36. E. D. Kilbourne, “Influenza Pandemics of the 20th Century,” Emerging Infectious Diseases 12 (2006): 11. 37. Murphy, Flu Action Plan, 54–56. 38. “SARS Expert Committee Report,” SARS Expert Committee, acessed on 1 May 2016, http://www.sars-expertcom.gov.hk/english/reports/reports/reports_ fullrpt.html, 13. 39. Ibid., 19–20. 40. M. Chan-Yeung, W. H. Seto, and J. J. Y. Sung, “Severe Acute Respiratory Syndrome: Patients Were Epidemiologically Linked,” BMJ 326 (2003): 1393. 41. “SARS Expert Committee Report,” 24–35. 42. K. W. Tsang, P. L. Ho, C. Ooi, et al., “A Cluster of Cases of Severe Acute Respiratory Syndrome in Hong Kong,” N Engl J Med 348 (2003):1977–1985. 43. “SARS Expert Committee Report,” 28. 44. J. S. M. Peiris, S. T. Lai, L. L. Poon, et al., “Coronavirus as a Possible Cause of Severe Acute Respiratory Syndrome,” Lancet 361 (2003):1319–1325. 45. “Discovery of Coronavirus-Causative Agent for SARS,” South China Morning Post, 14 April 2003. 46. SARS Expert Committee Report, 40–65. 47. “Amoy Gardens Post-traumatic SARS Disorders,” South China Morning Post, 19 December 2003. 48. S. Ng, “The Mystery of Amoy Gardens,” in At the Epicenter: Hong Kong and the SARS Outbreak, ed. C. Loh (Hong Kong: Hong Kong University Press 2004), 95–116. 49. “SARS Expert Committee Report,” 46. 50. Ibid., 52–53. 51. Ibid., 50–51. 52. “Despite a Drop in the Number of New Cases, Worries about Amoy Gardens Have Prompted the Unprecedented Advice: WHO Tells Travellers to Avoid Hong Kong,” South China Morning Post, 3 April 2003. 53. “WHO Gives All Clear,” South China Morning Post, 24 June 2003; “SARS Expert Committee Report,” 65. 54. “SARS Expert Committee Report,” 5.

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55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66.

“Remembering Dr. Tse Yuen-man,” South China Morning Post, 14 May 2003. S. Brown, “The Economic Impact of SARS,” In The Epicenter, 190–91. Murphy, Flu Action Plan, 56–57. “SARS Expert Committee Report,” 85–119. Ibid., 65–72. SARS Expert Committee Report, 85–91. “Swine Flu: 300 Quarantined in Hong Kong Hotel for a Week,” The Daily Telegraph, London, 1 May 2009. “Mexican Traveler is HK’s First Swine Flu Case,” The Standard, 21 May 2009. Sophie Leung, “Hong Kong Lifts Swine Flu Quarantine on 351 People,” L. P. Bloomberg, 8 May 2009; Beatrice Siu, “Tough Action on Lessons Backed by Principals,” The Standard, 12 June 2009. “2014–2016 Ebola Outbreak in West Africa,” Centers for Disease Control and Prevention, accessed on 6 March 2019, https://www.cdc.gov/vhf/ebola/ history/2014-2016-outbreak/index.html “The Zika Virus,” World Health Organization, accessed on 6 March, https:// www.who.int/en/news-room/fact-sheets/detail/zika-virus. B. Brende, J. Farrar, D. Gashumba, et al., “CEPI—A New Global R&D Organization for Epidemic Preparedness and Response,” Lancet 389 (2017): 233–235.

Chapter 8 1.

2. 3.

4. 5. 6. 7. 8. 9.

Information Note: “Population Profile of Hong Kong,” Research Office, Legislative Council Secretariat IN07/14–15; Hong Kong Monthly Digest of Statistics December 2018, accessed on 8 March 2019, https://www.statistics.gov. hk/pub/B71812FA2018XXXXB0100.pdf. Ibid., 5–9. “Thematic Household Survey, no. 40, Socio-demographic Profile, Health Status, and self-care Capability of Older Persons,” Census and Statistics Department, Government of HKSAR, 4 (2009), https://www.statistics.gov.hk/pub/ B11302402009XXXXB0100.pdf. P. H. Chau, J. Woo, M. K. Gusmano, and V. G Rodwon, “Hong Kong and Other World Cities,” In Ageing in Hong Kong: A Comparative Perspective, International Perspective on Ageing, ed. J. Woo (New York: Springer 2013), 13. Hong Kong Poverty Situation Report 2014, Government of HKSAR, 2014, 5.4, accessed on 9 March 2019, https://www.povertyrelief.gov.hk/pdf/poverty_ report_2014_e.pdf. “Thematic Household Survey, no. 40.” 1–9. P. H. Chau, J. Woo, M. K. Gusmano, and V. G. Rodwon, “Hong Kong and Other World Cities,” In Ageing in Hong Kong: A Comparative Perspective, International Perspective on Ageing 5, 14. “Thematic Household Survey, no. 40,” 4, 8. “You Need Help to Cope—Why Greying Hong Kong Is Ill-Equipped to Deal with Global Rise in Alzheimer’s Disease Cases,” South China Morning Post, 27 August

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2015. 10. “Thematic Household Survey, no. 40,” 29. 11. Ibid., 56. 12. R. Yu, P. H. Chau S. M. McGhee, et al., “Trends of Disease Burden Consequent to Stroke in Older Persons in Hong Kong: Implications of Population Ageing," CADENZA, The Hong Kong Jockey Club, 2012, 11. accessed on 19 March 2019, http://www.cadenza.hk/research/hts/Stroke.pdf. 13. L. W. Chu, I. Chi, and A. Y. Chiu, “Incidence and Predictors of Falls in the Chinese Elderly,” Ann Acad Med Singapore 34 (2005): 60–72. 14. J. S. Lee, T. Kwok, P. C. Leung, and J. Woo, “Medical Illnesses Are More Important Than Medications as Risk Factors of Falls in Older Community Dwellers? A Cross-Sectional Study,” Age, Ageing 35 (2006): 246–251. 15. “HU Harvard Household Report 1998,” Health Services Group, Department of Community Medicine and the Social Sciences Research Center, The University of Hong Kong, 1998. 16. F. W. Ko, C. K. Lai, J. Woo, et al., “23-Year Change in Prevalene of Respiratory Symptoms in Elderly Chinese Living in Hong Kong,” Respir Med 100 (2006): 1598–1607. 17. “Thematic Household Survey, no. 40,” 79. 18. “Population Health Survey, 2003–2004,” Department of Health and Department of Community Health, the University of Hong Kong, HKSAR, 65–69, accessed on 8 March 2019, https://www.chp.gov.hk/files/pdf/report_on_population_ health_survey_2003_2004_en.pdf. 19. “Population Health Survey, 2003–2004,” 65–69. 20. “Thematic Household Survey, no. 21, Patterns of Study in Higher Education, Socio-demographic Profile, Health Status and Long Term Care Needs of Older Persons,” Census and Statistics Department, HKSAR (2005), 116, accessed on 8 March 2019, https://www.statistics.gov.hk/pub/B11302212005XXXXB0100.pdf.. 21. H. Chen, A. P. Chiu, P. S. Lam, et al., “Prevalence of Infections in Residential Care Homes for the Elderly in Hong Kong,” Hong Kong Med J. 14 (2008): 444–450. 22. Same as note 12. 23. L. C. Lam, C. W. Tam, V. W. Lui, et al., “Prevalence of Very Mild and Mild Dementia in Community Dwelling Older Chinese People in Hong Kong,” Int Pschogeriatrics 20 (2008): 135–148. 24. Same as note 12. 25. Same as note 13. 26. S. M. McGhee, L. M. Ho, A. W. Cheung, et al., “Evaluation of a Mobile Clinic for Older People in Shamshuipo,” Hong Kong Med J 13 Suppl (2007): S13–S15. 27. L C. Lee, S. W. Tang, P. C. Leung, and J. Woo, “Medical Illnesses Are More Important Than Medications as Risk Factors of Falls in Older Community Dwellers? A Cross-Sectional Study,” Age Aging 25 (2006): 246–251. 28. “The Hong Kong Cardiovascuar Risk Factor Prevalence Study 1995–1996,” Department of Clinical Biochemistry, Queen Mary Hospital, Hong Kong. 29. “Heart Health Survey 2004–2005,” Centre for Health Protection, Department of Health, HKSAR, accessed on 8 March 2019, https://www.chp.gov.hk/files/pdf/ heart_health_survey_eng.pdf.

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30. R. Yu, P. H. Chau, S. M. McGhee, et al.,“Trends of Disease Burden Consequent to Stroke in Older Persons in Hong Kong: Implictions of Population Ageing,” 96 31. R. Yu, P. H. Chau, S. M. McGhee, et al.,“Trends of Disease Burden Consequent to Stroke in Older Persons in Hong Kong: Implictions of Population Ageing,”100. 32. P. H. Chau, J. Chen, J. Woo, et al., “Trends of Disese Burden Consequent to Chronic Lung Disease in Older Persons in Hong Kong: Implications of Population Aging,” in Aging in Hong Kong: A Comparative Perspective, International Perspectve on Aging, 137. 33. R. Yu, P. H. Chau, S. M. McGhee, et al, “Dementia Trends: Impact of the Aging Population and Social Implications for Hong Kong,” in Aging in Hong Kong: A Comparative Perspective, International Perspectve on Aging, 132–136. 34. S. M. McGhee, W. L. Cheung, J, Woo, et al.,”Trends of Disease Burden Consquent to Diabetes in Older Persons in Hong Kong: Implications of Population Aging,” accessed on 8 March 2019, https://www.hkjc.com/english/ news/images/260209%20CADENZA%20Executive%20summary-e_final.pdf. 35. “Hospital Authority Strategic Service Framework for Elderly Patients 2012,” Hospital Authority, HKSAR, accessed on 8 March 2019, http://www.ha.org.hk/ ho/corpcomm/Strategic%20Service%20Framework/Elderly%20Patients.pdf. 36. “Thematic Household Survey Report, no 45, Health Status of Hong Kong Residents, Doctor Consultation, Hospitalization,” Census and Statistics Department, HKSAR, (2010) 129, accessed on 8 March 2019, https://www. statistics.gov.hk/pub/B11302452010XXXXB0100.pdf. 37. “Elderly Health Centre,” Elderly Health Service, Department of Health, HKSAR, accessed on 8 March 2019, https://www.elderly.gov.hk/english/contactus/ elderly_health_centres.html. 38. “Hong Kong Reference Framework for Preventive Care of Older Adults in Primary Care Settings, 2012,” accessed on 8 March 2019, https://www.pco.gov. hk/english/resource/files/ref_framework_adults.pdf.. 39. L. W. Chu and I. Chi, “Long-Term Care and Hospital Care for the Elderly,” In Hong Kong’s Health System: Reflections, Perspectives and Visions, eds. G. Leung and J. Bacon-Shone (Hong Kong: Hong Kong University Press, 2006), 223–255. 40. Ibid., 238. 41. E. Lin and E. Wong, “Health Care for the Elderly People,” Research and Library Services Division, Provisional Legislative Council Secretariat, 25 October 1997, 31, accessed on 9 March 2019, http://ebook.lib.hku.hk/HKG/B36230704.pdf. 42. F. H. W. Chan, “Person-Centred Care for the Older Persons through MedicalSocial Collaborations” (Presentation at the Hospital Authority Convention, 17 May 2017). 43. F. O. Y. Lin, J. K. H. Luk, T. C. Chan, et al., “Effectiveness of a Discharge Planning and Community Support Programme in Preventing Readmission of High-Risk Older Patients,” Hong Kong Med J 21 (2015): 208–216. 44. E. M. F. Leung, A. C. M. Chan, J. J. Lee, and S. T. Cheng, “Residential Care Policy for Elderly People in Hong Kong,” Asian J of Public Administration 15 (1993):10–14. 45. E. Lin and E. Wong, “Health Care for the Elderly People,” 39–40. 46. S. T. Cheng and A. C. M. Chan, “The Future of Private Elderly Home in Hong Kong: An Ecological Analysis,” Hong Kong J Gerontology 7 (1993): 29–33. 47. “Hong Kong’s Elderly Deserves Better,” South China Morning Post, 5 June 2015.

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48. “Hong Kong Struggles to Cope with Its Rapidly Ageing Population,” South China Morning Post, 14 February 2015. 49. P. H. Chau, M. Wong, and J. Woo, “Living Environment,” In Ageing in Hong Kong. A Comparative Persepctive. International Perspective on Ageing 5, 24. 50. Same as note 47. 51. P. H. Chau, M. Wong, and J. Woo, “Living Environment,” 23. 52. “Thematic Household Survey, no. 59, Patterns of smoking,” Census and Statistics Department, HKSAR (2016), 23, accessed on 8 March 2019, https://www.statistics. gov.hk/pub/B11302592016XXXXB0100.pdf. 53. “Population Health Survey, 2003–2004. 54. P. H. Chau, J. Woo, M. K. Gusmano, and V. G. Rodwon, “Hong Kong and Other World Cities,” In Ageing in Hong Kong. A Compaarative Perspective, International Perspective on Ageing 5, 16. 55. “Consultancy Study on Community Care Services for the Elderly” (Final Report Submitted by Sau Po Centre on Ageing and Department of Social Work and Social Administration, The University of Hong Kong, June 2011), 6, accessed on 8 March 2019, https://www.elderlycommission.gov.hk/en/download/library/ Community Care Services Report 2011_eng.pdf. 56. L. W. Chu and I. Chi, “Long-Term Care and Hospital Care for the Elderly,” 245. 57. Same as note 47. 58. S. S. T. Kwok, K. W. N. Wong, and S. L Yang, Challenges Facing the Elderly Care Industry in Hong Kong: The Shortage of Frontline Workers, Practical Social and Industrial Research Symposium, Hong Kong, 5 December 2014, Open access SpringerOpen. 59. Same as note 53. 60. Same as note 35. 61. J. R. Beard, I. A. de Carvalho, J. A. Thiyagarajan, et al., “The World Report on Aging and Health: A Policy Framework for Healthy Aging,” Lancet 387 (2017): 2145–2154. 62. R. A. A. Smith, “A Good Death,” BMJ 320 (2000): 129–130. 63. J. K. H. Luk and F. H. W. Chan. “End-of-life Care for Advanced Dementia Patients in Residential Care Home—A Hong Kong Perspective,” Ann Pallia Med 7 (3) (2018): 359–364, accessed on 8 March 2019, http://apm.amegroups.com/article/ view/16270/20139. 64. W. W. C. Chu, A. C. T. Leung, C. Y. T. Lam, et al., “An Evaluation of a Shared Care Program and End of Life Care Service in a Subvented Nursing Home in Hong Kong” (Presentation at the Hospital Authority Convention, 2004). 65. E. Hui, H. M. Ma, W. H. Tang, et al., “A New Model for End-of-Life Care in Nursing Homes,” J Am Med Dir Assoc 15 (2014): 287–289. 66. J. K. H. Luk, W. W. Y. Mok, T. C. Chan, et al., “End of Life Clinical Plan in a Geriatric Stepdown Hopsital,” Asian J Gerontol Geriatr 11 (2016): 42–47. 67. E. M. Gee, “Population and Politics: Voodoo Demography, Population Aging and Canadian Social Policy,” in The Overselling of Population Ageing, eds. E. M. Gee and G. M. Gutman (Toronto: Oxford University Press, 2000), 3–22. 68. Y. Carriere, “The Impact of Population Ageing and Hospital Days,” in The

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Overselling of Population Aging, 33. 69. Hospital Authority Statistical Report 1997–1998, accessed on 28 March 2016, http://www.ha.org.hk/visitor/ha_view_content.asp?Content_ID=224151&La ng=ENG&Dimension=100&Ver=HTML; Hospital Authority Statistical Report 2012–2013, accessed on 8 March 2019, http://www3.ha.org.hk/data/doc/ HAStatReport/HASR_2012_2013.pdf. 70. K. Kronebusch and M, Scheisinger, “Intergenerational transfers,” In Intergenerational Linkages: Hidden Connections in American Society, eds. V. Bengtson and R. A. Harootyan (New York: Springer Publishing Company, 1994), 12–51.

Chapter 9 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

D. E. Evans, Constancy of Purpose: An Account of the Foundation and History of Hong Kong College of Medicine and the Faculty of Medicine of the University of Hong Kong 1887–1987 (Hong Kong: Hong Kong University Press, 1987), 38. P. Cunich, A History of the University of Hong Kong (Hong Kong: Hong Kong University Press, 2012), 176. L. Ride, “The Faculty of Medicine,” in University of Hong Kong: The First 50 Years, 1911–1961, ed. B. Harrison (Hong Kong: Hong Kong University Press, 1962), 104–107. Cunich, A History of the University of Hong Kong, 217–220. Ibid., 23–31. Evans, Constancy of Purpose, 51–60. Cunich, A History of the University of Hong Kong, 273. Ibid., 274. Ibid., 274. Ibid., 319–321. “Needham, Sir Richard Arthur (1877–1949),” Biographical Entry, Plarr’s Lives of Fellows, Royal College of Surgeons website. Ride, “The Faculty of Medicine,” 109–111. G. King, “An Episode in the History of the University of Hong Kong,” in Dispersal and Renewal: Hong Kong University during the War Years, eds. C. Matthews and O. Cheung (Hong Kong: Hong Kong University Press, 1998). Cunich, A History of the University of Hong Kong, 362–363. A. Sweeting, “Controversy over the re-opening of the University of Hong Kong 1942–1948,” in Dispersal and Renewal, Hong Kong University during the War Years, 397–424. Ibid., 410. J. I. C. Crombie, Treasury to Sir Thomas Lloyd, Colonial Office, 9 May 1947, CO 129/610/1. Colonial Office, Note on Present Position Regarding Hong Kong University, 20 December 1947, CO 129/610/1. B. Mellor, The University of Hong Kong: An Informal History (Hong Kong: Hong Kong University Press, 1981), 111.

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20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47.

Ibid., 114. Ibid., 115. Ibid., 122–124. Evans, Constancy of Purpose, 87–100. Ibid., 93–94. Ibid., 114–115. L. Y. Fong, J. H. Ho, and D. P. Huang, “Preserved Foods as Possible Cancer Hazards: WA Rats Fed Salted Fish Have Mutagenic Urine,” Int J Cancer 23 (1979): 542–546. Lau Chi-pang and Liu Shu-yong, Hou Po Chang jiazu shi (A family history of Prof. Hou Po Chang) (Hong Kong: Peace Book Company Ltd., 2012), 18–22. Evans, Constancy of Purpose, 111–115. Ibid., 102–103. Ibid., 98–99. “Occasional Article. Reminiscences of Three Former Teachers: Prof. A. J. S. McFadzean, Dr. Stephen Chang, and Prof. Geral Choa. An Abridged Version of the Talk Given by Professor Sir David Todd at the Inauguration of the Medical History Interest Group Held at the Hong Kong Museum of Medical Science on 17 January 2009,” Hong Kong Medical Journal 15 (2009): 315–318. Richard Yu, Centenary Tribute to Professor A. J. S. McFadzean: A Legacy for Medicine in Hong Kong (Hong Kong: Hong Kong Academy of Medicine Press, 2015), 8–11. Evans, Constancy of Purpose, 117–118. Hong Kong College of Surgeons, Healing with the Scalpel: From the First Colonial Surgeon to the College of Surgeons of Hong Kong (Hong Kong: Hong Kong Academy of Medicine Press, 2013) 97. Ibid., 99–100. Evans, Constancy of Purpose, 104–105. Han Suyin, My House Has Two Doors (London: Triad Grafton Books, 1988), 19. D. J. S. Crozier to Colonial Office 26 May 1957, The Post-secondary Colleges of Hong Kong. CO 1030/571, 286–289. Far East Department, Colonial Office 2 November 1962, Hong Kong PostSecondary Colleges. CO 1030/1094, 24–27. Report of the Committee on Higher Education 1952 (The Keswick Report), Hong Kong Government Printers, 1952. Same note as 39. Ibid. A. N. H. Ng-Lun, Quest for Excellence: A History of the Chinese University of Hogn Kong (Hong Kong Chinese University Press of Hong Kong, 1994), xx. A. E. Starling, The Chance of a Life Time: The Birth of a New Medical School in Hong Kong (Hong Kong: Chinese University Press of Hong Kong, 1988), 33. Ibid., 14–15. Same as note 31. Starling, The Chance of a Life Time: The Birth of a New Medical School in Hong Kong,

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53–54. 48. Ibid., 65–69. 49. Ibid., 72–73. 50. “Faculty of Medicine,” Chinese University of Hong Kong, accessed on 7 August 2016, https://www.med.cuhk.edu.hk/eng/main/index.jsp. 51. Hong Kong Annual Digest of Statistics, 2017 and OECD Health Data, “Better Policies, Better Lives,” accessed on 11 October 2016, http://www.oecd.org/els/ soc/ 52. D. Todd, “Recent Developments in Medical Education in Hong Kong,” in Plague, SARS and the Story of Medicine in Hong Kong, Hong Kong Museum of Medical Sciences Society (Hong Kong: Hong Kong University Press, 2006), 288–289. 53. The University of Hong Kong Li Ka Shing Faculty of Medicine, Shaping the Health of Hong Kong: 120 Years of Achievements (Hong Kong: The University of Hong Kong, 2006). 54. Hong Kong Academy of Medicine, In Pursuit of Excellence: The First 10 Years 1993– 2003 (Hong Kong: Hong Kong Academy of Medicine Press, 2003), 4–5. 55. Ibid., 11. 56. Joint Committee on Internal Medicine Training ( JCIMT), Guidelines on Postgraduate Training in Internal Medicine (Hong Kong: Hong Kong College of Physicians, 1 July 1993). 57. L. Yam, “Education and Accreditation,” in Sapientia et Humanitas—A History of Medicine in Hong Kong (Hong Kong: Hong Kong Academy of Medicine Press, 2011), 69–70. 58. R. Yu and K. N. Lai, “The Story of the Hong Kong College of Physicians,” in Sapientia et Humanitas, 58–60. 59. Hong Kong Academy of Medicine, In Pursuit of Excellence, 52–54. 60. Ibid., 15–16. 61. Ibid., 58–59.

Chapter 10 1. 2. 3. 4. 5. 6. 7. 8.

R. Porter, The Cambridge History of Medicine (Cambridge: Cambridge University Press, 2006), 181–186. Ibid., 189. Hong Kong Medical and Health Department Annual Report, 1946, 18–21. R. Hutcheon, Bedside Manners: Health & Health Care in Hong Kong (Hong Kong: The Chinese University Press, 1999), 35. G. B. Endacott and A. Hinton, Fragrant Harbour: A Short History of Hong Kong (Hong Kong: Oxford University Press, 1968), 167. Han Suyin, My House Has Two Doors (London: Triad Grafton Books, 1988), 48. Hong Kong Hansard, 1957, 53. “The New Tsan Yuk Maternity Hospital of 200 Beds in 1954,” Hong Kong Medical and Health Department Annual Report, Hong Kong Government, 1954, 31.

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9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.

“Castle Peak Hospital,” Hong Kong Medical and Health Department Annual Report, Hong Kong Government, 1963, 61. Hong Kong Museum of Medicial Science Society, Plague, SARS and the Story of Medicine in Hong Kong (Hong Kong: Hong Kong University Press, 2006), 138–142. Ibid., 118–121; Hong Kong Medical and Health Department Annual Report, 1964, 65. R. Gauld and D. Gould, The Hong Kong Health Sector: Development and Changes (Hong Kong: The Chinese University Press, 2002). 48. Hong Kong Government, “Development of Medical Services in Hong Kong,” Hong Kong Government Printers, 1964. Hong Kong Museum of Medical Sciences Society, Plague, SARS and the Story of Medicine in Hong Kong, 121–122. Hong Kong Government, “The Further Development of Medical and Health Services in Hong Kong,” Hong Kong Government Printers, 1974. Hong Kong Annual Digest of Statistics, 1973, compiled by Richard Butler, Commissioners for Census and Statistics, November 1987. “Princess Margaret Hospital at Lai Chi Kok to be Opened in 1975,” Hong Kong Medical and Health Department Annual Report, 1974. Gauld and Gould, The Hong Kong Health Sector, 47–48. Hutcheon, Bedside Manners, 42. Ibid., 43. “Curing the Doctors’ Ills,” South China Morning Post, 2 September 1988. “Doctors in Mass Protest at Condition,” South China Morning Post, 6 September 1988. “Shortage of Nurses Near Crisis Point,” South China Morning Post, 24 April 1989. Hong Kong Medical and Health Department Annual Departmental Report, Hong Kong Government, 1950/51, 63. Gauld and Gould, The Hong Kong Health Sector, 55–56. Hutcheon, Bedside Manners, 39. Ibid., 113. Hong Kong Hansard, 1 Nov 1978: 99. Hong Kong Hansard, 1 Oct 1980,19–20; Hong Kong Hansard, 27 Oct 1983, 139. G. Leung and J. Bacon-Shone, Hong Kong’s Health System: Reflections, Perspectives and Visions (Hong Kong: Hong Kong University Press, 2006), 21. Hong Kong Hansard, 9 Nov 1983, 174–183. Gauld and Gould. The Hong Kong Health Sector, 58–60. W. D. Scott, “The Delivery of Medical Service in Hospitals: A Report for the Hong Kong Government,” Hong Kong Government Printers, 1985. Same as note 33. “Many Patients Should be Charged More,” South China Morning Post, 29 March 1986. “Hospital Group to Get $14 m for Subsidy,” South China Morning Post, 27 March 1986.

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37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60.

“Panels Seek Second Opinion,” South China Morning Post, 21 May 1986. Hong Kong Hansard, 15 October 1986, 114–119. Hong Kong Hansard, 15 October 1986, 154–158. “Under Use of Hospital Eqipment Criticised,” South China Morning Post, 20 November 1987. “Delay Reduced Survival Odds,” South China Morning Post, 1 November 1986. “Acute Shortage of Top Doctors for Delivery,” South China Morning Post, 7 December 1987. Hong Kong Hansard, 7 Oct 1987, 33. Gauld and Gould, The Hong Kong Health Sector, 65. Gauld and Gould, The Hong Kong Health Sector. Development and Changes, 64. Sir S. Y. Chung, “Report of the Provisional Hospital Authority,” Hong Kong Government, December 1989. Hutcheon, Bedside Manners, 97. Hong Kong Hansard, 2 May 1990, 1438. Hong Kong Hansard, 25 Oct 1990, 209. Yilu: Shengming shi mei (Life is Beautiful—Our Way) (Hong Kong: Cogizance Publishing, 2012), 25. “Doctors Pledged on New Posts,” South China Morning Post, 25 May 1991. Gauld and Gould, The Hong Kong Health Sector, 67–68. Yilu, 66. Ibid., 64. Gauld and Gould, The Hong Kong Health Sector, 70; “Timeline,” Yilu. 30. Yilu, 32–37; Hutcheon, Bedside Manners, 131. Yilu, 135. Ibid., 37; Hutcheon, Bedside Manners, 120–121. Hutcheon, Bedside Manners. Health & Health Care in Hong Kong, 147. Hong Kong Hospital Authority Report, 2013, Appendix 9, 214–215.

Chapter 11 1. 2. 3. 4. 5.

Hong Kong Government, Development of Medical Services in Hong Kong (Hong Kong: Government Printers, 1964). The Harvard Team, “Improving Hong Kong’s Healthcare System: Why and for Whom?” accessed on 14 March 2019, https://www.f hb.gov.hk/en/press_and_ publications/consultation/HCS.HTM, 22–29. Yilu: Shengming shi mei (Life is Beautiful—Our Way) (Hong Kong: Cogizance Publishing, 2012), 144. A. Ng, “Medical and Health,” in The Other Hong Kong Report, eds. Richard Y. C. Wong and Joseph Y. S. Cheng (Hong Kong: The Chinese University Press, 1990), 395–427. Fees and Charges for Health Care Services. Accessed on 15 October 2016. http:// www.ha.org.hk/upload/publication_14/105.pdf.

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6. 7. 8.

9. 10. 11.

12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

Hong Kong Sanatorium and Hospital, accessed on 16 March 2019, http://www. hksh-hospital.com/en/fees-and-charges/price-list. J. Hay, Healthcare in Hong Kong: An Economic Policy Assessment (Hong Kong: Hong Kong University Press, 1992), 22–24. Hong Kong Sanatorium and Hospital, http://www.hksh-hospital.com/en/feesand-charges/price-list; data for private patients in HA hospitals from http:// www3.ha.org.hk/fnc/Radiology.aspx?lang=ENG and http://www3,ha,org.hk/ fnc/Operations.aspx?lang=ENG. All accessed on 16 March 2019. Hay, Healthcare in Hong Kong, 42. R. Gauld and D. Gould, The Hong Kong Health Sector (Hong Kong: The Chinese University Press, 2002), 142–143. E. Liu and S. Y. Yue, “Healthcare Expenditure and Financing in Hong Kong,” Research and Library Division, Provisional Legislative Council Secretariat, 22 January 1998, accessed on 15 October 2016, www.legco.gov.hk/yr97-98/english/ sec/library/06plc.pdf. “Towards Better Health: A Consultation Document,” Health and Welfare Branch, Hong Kong Government, 1993, accessed on 11 October 2016, http://ebook.lib. hku.hk/CADAL/B38633516.pdf. “Activitists Lash Out at Lack of Monitoring, South China Morning Post, 21 August 1998; “Catalogue of Errors,” South China Morning Post, 21 August 1998. “Overseas Expert Sought Amid Service-Cost Fears: Consultant to Probe Healthcare System,” South China Morning Post, 11 October 1997. “After the Anguish and Recrimination Which Punctuated the Avian Flu,” South China Morning Post, 4 February 1998; “Bird Flu Pandemic Averted,” South China Morning Post, 31 August 1998. Hay, Healthcare in Hong Kong, 3–4. Same as note 14. The Harvard Team, “Improving Hong Kong’s Healthcare System: Why and for Whom?” 22–23. “Bacterial Pathogen Isolation and Percentage of Antimicrobial Resistance, OutPatient Setting, 2014,” Centre for Health Protection,HKSAR, accessed on 15 March 2019, https://www.chp.gov.hk/en/statistics/data/10/641/697/3346.html. The Harvard Team, “Improving Hong Kong’s Healthcare System: Why and for Whom?” 60–61. Ibid., 68. Ibid., 57. Ibid., 58. Hay, Healthcare in Hong Kong, 42–43. F. Lieh-Mak, “Quality of Care and Patient Redress: A Professional Perspective,” in Hong Kong’s Health System: Reflections, Perspectives and Visions, eds. G. Leung and J. Bacon-Shone (Hong Kong: Hong Kong University Press, 2006), 261–268. The Harvard Team, “Improving Hong Kong’s Healthcare System: Why and for Whom?” 56–58. Chu Yiu-ming, “Quality of Care and Patient Redress: A Patient Perspective,” in Hong Kong’s Health System, 280

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28. P. P. Yuen, “Financing Healthcare and Long-Term Care in a Rapidly Ageing Context: Assessing Hong Kong’s Readiness,” PAAP 17 (2014): 56–64. 29. A. Y. Lo, A. J. Hedley, G. K. Pei, et al., “Doctor-Shopping in Hong Kong: Implications for Quality of Care,” Int J Qual Health Care 6 (1994): 371–381. 30. The Harvard Team, “Improving Hong Kong’s Healthcare System: Why and for Whom?” 79–80. 31. “Social Policy Data,” Organisation for Economic Co-operation and Development, accessed on 11 October 2016, http://www.oecd.org/els/soc/. 32. Hay, Healthcare in Hong Kong, 10. 33. Same as note 9. 34. H. G. Ma, “Healthcare Reform and Change Management: The Practice of Health Administration” (Presentation at Hospital Authority Convention on 28 March 2016). 35. The Harvard Team, “Improving Hong Kong’s Healthcare System: Why and for Whom?” 73–75. 36. Ibid., 10–13. 37. Gauld and Gould, The Hong Kong Health Sector, 134–138. 38. “Lifelong Investment in Health, 2000.” Health and Welfare Bureau, HKSAR, accessed on 14 March 2019, https://www.vhis.gov.hk/doc/en/public_ consultation/lifelong_investment_in_health_eng.pdf 39. The Bauhinia Foundation Research Centre Health Care Study Group, “Development and Financing of Hong Kong’s Future Health Care: Report on Preliminary Findings, 2007,” LC paper No CB(2)2460/06-07(01), accessed on 11 October 2016, http://www.legco.gov.hk/yr06-07/english/panels/hs/papers/ hs0717cb2-2460-1-e.pdf. 40. “Building a Healthy Tomorrow,” Health and Medical Department Advisory Committee, 2005, HKSAR, accessed on 14 March 2019, https://www.info.gov. hk/archive/consult/2005/hmdac_paper_e.pdf 41. “Your Health, Your Life: Healthcare Reform Consultation Document,” Food and Health Bureau, HKSAR (2008), accessed on 11 October 2016, http://www.f hb. gov.hk/beStrong/files/consultation/exsummary_eng.pdf. 42. “Hong Kong $50 Billion Set Aside for Health-Care Reform,” South China Morning Post, 28 February 2008. 43. “Healthcare Reform Second Stage Public Consultation,” Food and Health Bureau, HKSAR, accessed on 11 October 2016, http://www.Myhealthmychoice. gov.hk/en/consulDoc.html. 44. K. H. Wong, “Message from the Controller,” Centre for Health Protection, Department of Health, HKSAR, Accessed on 14 March 2019. https://www.chp. gov.hk/en/static/23993.html 45. Hospital Authority Annual Report. 2003–2004. Hospital Authority, HKSAR, 54–60; “Medicine in Intensive Care—Medical History 1997–2007,” South China Morning Post, 1 July 2007; 46. Hong Kong Academy of Medicine, In Pursuit of Excellence, 52–60; Gauld and Gould, The Hong Kong Health Sector, 102. 47. “Hong Kong Reference Framework for Hypertension Care in the Primary Settings,” Department of Health, HKSAR (2016), accessed on 11 October 2016,

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48. 49. 50. 51. 52. 53. 54.

55. 56. 57. 58. 59. 60. 61. 62. 63. 64.

65. 66. 67.

www.pco.gov.hk/english/resource/professionals_hypertension_pdf.html; “Hong Kong Reference Framework for Diabetes Care in the Primary Settings,” Department of Health, HKSAR (2016), accesssd on 11 October 2016, www.pco. gov.hk/english/resource/professionals_diabetes_pdf.html. Global Initiatives for Asthma website, accessed on 11 October 2016, http://www. ginasthma.org/. Global Initiatives for Chronic Obstructive Lung Disease webiste, accessed on 11 October 2016, www.goldcopd.org. Hospital Authority Report 2001–2002, 15. Hospital Authority Report 2003–2004, 23; Hospital Authority Report 2004–2005, 11. Hospital Authority Report 2000–2001, 15–17. Hospital Authority Report 2005–2006, 320. Keynote Address by the Secretary of SFH at World Health Summit Regional Meeting, GIS 9 April 2013, accessed on 14 March 2019, https://www.info.gov.hk/ gia/general/201304/09/P201304090492.htm.; Hospital Authority Report 2002–2003, 19; Hospital Authority Report 2004–2005, 13; Hospital Authority Report 2007–2008, 22, 24. Hospital Authority in Focus, 2002–2003, 46–47. Hospital Authority Report 2006–2007, 18. Ibid., 19; Hospital Authority Report 2007–2008, 18–19. Hospital Authority Statistical Reports 1997, 2012. Hospital Authority Report 2003–2004, 16. Ibid., 19. Gauld and Gould, The Hong Kong Health Sector, 106. Ibid., 107. “Patients Die after Drug Blunder,” South China Morning Post, 31 May 2005. “Carrie Lam Can’t Get Hong Kong Pan-Democrats’ Support on Health Watchdog Reform,” South China Morning Post, 6 July 2016; “Medical Bill Passed,” Hong Kong Government News, 28 March 2018, accessed on 16 March 2019, https://www.news.gov.hk/eng/2018/03/20180328/20180328_195044_752.html. Hong Kong Annual Digest of Statistics, 1973–2014. Same as note 22. “Give Hong Kong People More Incentives to Switch to Private Health-Care,” South China Morning Post, 28 December 2014.

Chapter 12 1. 2. 3.

Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978, accessed on 14 March 2019, http:// www.who.int/publications/almaata_declaration_en.pdf ?ua=1. R. Porter, The Cambridge History of Medicine (Cambridge: Cambridge University Press, 2006), 110–111. Ibid., 114–115.

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4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

Ibid., 126. Ibid., 127–128. J. Duffin, History of Medicine: A Scandalously Short Introduction (Toronto: University of Toronto Press, 1999), 346. Ibid., 355. Registrar General’s Report for 1907; Hong Kong Sessional Papers 1908, 191–192. Report of Advisory Committee on Clinics (Hong Kong: Government Printers, 1966), 41. Report of Advisory Committee on Clinics, 6–7. Ibid., 15. Ibid., 27. Ibid., 51. Hong Kong Medical and Health Department Annual Report 1980/1981, Table 63. Hong Kong Department of Health Annual Report 1994/1995, Table 59, 101. G. Leung, W. S. Chan, S. Choi, et al., “The Ecology of Health-Care in Hong Kong,” Soc Sci Med 61 (2005): 577–590. S. Little, J. Woo, C. Lam, et al., “Primary Care in Hong Kong: A Lesson about Competition,” Brit J of General Practice 60 (2010):142–143. R. Gauld and D. Gould, The Hong Kong Health Sector (Hong Kong: The Chinese University Press, 2002), 75. “Global Strateg y for Health for All by the Year 2000,” World Health Organization, accessed on 14 March 2019, https://iris.wpro.who.int/bitstream/ handle/10665.1/6967/WPR_RC032_GlobalStrategy_1981_en.pdf . “Health for All, The Way Ahead: Report of the Working Party on Primary Health Care,” Working Party on Primary Health Care, 1990, 8. Ibid., 65–70. Ibid., 79. Ibid., 148. Ibid., 143. Gauld and Gould, The Hong Kong Health Sector, 83. G. Leung and J. Bacon-Shone, Hong Kong’s Health System: Reflections, Perspectives and Visions (Hong Kong: Hong Kong University Press, 2006), 145. “Towards Better Health: A Consultation Document,” Health and Welfare Branch, Hong Kong Government, 1993. The Harvard Team, “Improving Hong Kong’s Health-Care System: Why and for Whom?” 1999, accessed on 14 March 2019, https://www.f hb.gov.hk/en/press_ and_publications/consultation/HCS.HTM, 22–29. “Life Long Investment in Health,” Health and Welfare Bureau, Hong Kong Government, accessed on 14 March 2019, https://www.vhis.gov.hk/doc/en/ public_consultation/lifelong_investment_in_health_eng.pdf. “Your Health Your Life: Healthcare Reform Consultation Document,” Health and Welfare Bureau, Hong Kong Government, 2008, accessed on 8 August 2016, http://www.f hb.gov.hk/beStrong/files/consultation/exsummary_eng.pdf. “Healthcare Reform Second Stage Public Consultation,” Food and Health

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37.

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44. 45. 46. 47.

Bureau, HKSAR, accessed on 8 August 2016, http://www.Myhealthmychoice. gov.hk/en/consulDoc.html. Hospital Authority Annual Report 2003–2004, Hospital Authority HKSAR, 46. Same as note 30. “Primary Health Care: Now More than Ever,” The World Health Report 2008, World Health Organization, accessed on 8 August 2016, http://www.who.int/ whr/2008/whr08_en.pdf “Primary Care Development in Hong Kong. Strategy Document 2010,” Primary Care Office Department of Health, HKSAR, accessed on 14 March 2019, https:// www.pco.gov.hk/english/strategy/index.html “Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings,” Primary Care Office, Department of Health, accessed on 14 March 2019, https://www.pco.gov.hk/english/resource/professionals_ preventive_older_pdf.html. “Hong Kong Reference Framework for Preventive Care for Children in Primary Care Settings,” Primary Care Office, Department of Health, HKSAR, accessed on 14 March 2019, www.pco.gov.hk/english/resource/files/ref_framework_ children.pdf. “Hong Kong Reference Framework for Hypertension Care for Adults in Primary Care Settings,” Primary Care Office, Department of Health, HKSAR, 2016, accessed on 14 March 2019, http://www.pco.gov.hk/english/resource/ professionals_hypertension_pdf.html. “Hong Kong Reference Framework for Diabetes Care for Adults in Primary Care Settings,” Primary Care Office, Department of Health, HKSAR, 2016, accessed on 6 June 2016, http://www.pco.gov.hk/english/resource/professionals_ diabetes_pdf.html. S. M. Griffiths and J. P. Lee, “Developing Primary Care in Hong Kong: Evidence into Practice and the Development of Reference Frameworks,” Hong Kong Med J 18 (2012): 429–434. “Primary Care Directory,” Department of Health, HKSAR, accessed on 19 September 2016, http://www.pco.gov.hk/english/initiatives/directory.html. “Health Care Voucher,” Department of Health, HKSAR, accessed on 14 March 2019, https://www.hcv.gov.hk/eng/pub_background.htm “Tin Shui Wai Primary Care Partnership Project,” Primary Care Intiatives, Hospital Authority, HKSAR, accessed on 14 March 2019, https://www.pco.gov. hk/textonly/english/initiatives/projects.html; Hospital Authority Report, 2008– 2009, 37–38. “Primary Care Initiatives, Hospital Authority Pilot Projects,” Hospital Authority, HKSAR, accessed on 14 March 2019, https://www.pco.gov.hk/textonly/english/ initiatives/projects.html. Eligibiity and Requirements for the Clinical Examination, Hong Kong College of Family Physicians, accessed on 19 March, 2019, http://www.hkcfp.org.hk/ pages_87_275.html. Leung and Bacon-Shone, Hong Kong’s Health System, 151. “Lack of Family Doctors Threatens Health Problems,” South China Morning Post, 18 November 2009; Leung and Bacon-Shone, Hong Kong’s Health System, 149

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48. Leung and Bacon-Shone, Hong Kong’s Health System, 152. 49. Xie Yongguang, Xianggang zhongyiyao shihua (A history of Chinese medicine in Hong Kong) (Hong Kong: Joint Publishing Ltd., 1998), 1. 50. M. Chan-Yeung, A Medical History of Hong Kong: 1842–1941 (Hong Kong: The Chinese University Press, 2018). 75. 51. Xie, Xianggang zhongyiyao shihua, 2. 52. Ibid., 7. 53. Ibid., 105. 54. Ibid., 8. 55. “A New Era of Chinese Medicine in Hong Kong,” accessed on 8 August 2016, www.cmd.gov.hk/html/b5/health_info/doc/A_New_Era_of_Chinese_ Medicine_in_Hong_Kong_(2007).pdf. 56. Rance P. L. Lee, “Chinese and Western Health Care Systems: Professional Stratification in a Modernizing Society,” in Social Life and Development in Hong Kong, eds. Ambrose King and Rance Lee (Hong Kong: Chinese University Press, 1981), 260–261. 57. Ibid., 264. 58. Ibid., 270. 59. Xie, Xianggang zhongyiyao shihua, 217–227. 60. Gauld and Gould, The Hong Kong Health Sector, 85–86. 61. “Public View Sought on Chinese Medicine Report,” South China Morning Post, 11 January 1992. 62. Gauld and Gould, The Hong Kong Health Sector, 86. 63. Same as note 55. 64. Gauld and Gould, The Hong Kong Health Sector, 90 65. Gauld and Gould, The Hong Kong Health Sector, 91. 66. “Chinese Medicine,” Department of Health, HKSAR, accessed on 19 September 2016, http://www.dh.gov.hk/english/main/main_cm/main_cm.html. 67. “Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A World View,” World Health Orgaization, accessed on 19 September 2016, http://apps.who.int/medicinedocs/pdf/h2943e/h2943e.pdf. 68. “WHO Traditional Medicine Strategy 2002–2005,” World Health Organization, accessed on 19 September 2016, http://www.wpro.who.int/health_technology/ book_who_traditional_medicine_strategy_2002_2005.pdf. 69. “2014 Health Manpower Survey: Summary of the Characteristics of Chinese Medicine Practitioners Enumerated,” Department of Health, HKSAR, accessed on 14 March 2019, https://www.dh.gov.hk/english/statistics/statistics_hms/sumcmp14.html 70. “Population Health Survey 2014/2015,” Department of Health, HKSAR, accessed on 15 March 2019, https://www.chp.gov.hk/en/static/51256.html, 243; V. Chung, E. Wong, J. Woo, et al., “Use of Traditional Chinese Medicine in Hong Kong Special Administrative Region,” J Alternative and Complementary Medicine 13 (2007): 361–367. 71. V. Chung, C. H Lau, E. K. Yeoh, et al., “Age, Chronic Disease Status and the Choice of Western and Chinese Medicine in a Chinese Population,” BMC Health Service Research 9 (2009): 207.

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72. 73. 74. 75. 76.

Xie, Xianggang zhongyiyao shihua, 45–47. Ibid., 51. Ibid., 52. Ibid., 213. “Regulation of Chinese Medicines,” Chinese Medicine Council of Hong Kong, accessed on 14 March 2019, http://www.cmchk.org.hk/pcm/eng/#../../eng/ main_deve.htm. 77. WHO and Department of Health, Hong Kong, “Hong Kong (China): Health Service Delivery Profile, 2012,”World Health Organization, accessed on 14 March 2019, http://www.wpro.who.int/health_services/service_delivery_profile_ hong_kong_(china).pdf. 78. Q. Xu, R. Bauer, B. M. Hendry, et al., “The Quest for Modernization of Traditional Chinese Medicine,” Complementary and Alternative Medicine 13 (2013) 132–142.

Conclusion 1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13.

“Life Expectancy at Birth (Male and Female), 1971–2017,”Center for Health Protection, Department of Health, HKSAR, accessed on 5 January 2017. http:// www.chp.gov.hk/en/data/4/10/27/111.html. Ibid. “Statistics: Smoking Trend,” Hong Kong Council on Smoking and Health, accessed on 5 January 2017, http://smokefree.hk/en/content/web.do?page=SmokingTrend. The University of Hong Kong Li Ka Shing Faculty of Medicine, Shaping the Health of Hong Kong: 120 Years of Achievements (Hong Kong: Hong Kong University Press, 2006,) 41. Ibid., 43. The Harvard Team, “Improving Hong Kong’s Healthcare System: Why and for Whom?” accessed on 14 March 2019, https://www.f hb.gov.hk/en/press_and_ publications/consultation/HCS.HTM, Executive Summary 3–4. The Harvard Team, “Improving Hong Kong’s Health Care System,” 73–75. “Perceived Health Status by Socio-economic Status,” OECD Health Statistics 2016, accessed on 15 March 2019, https://www.oecd.org/els/health-systems/ Table-of-Content-Metadata-OECD-Health-Statistics-2016.pdf. A. Hedley, “The Role of Public Health in Social Justice: The Next Steps in Hong Kong,” in Hong Kong’s Health System: Reflections, Perspectives and Vision , eds. G. Leung and J. Bacon-Shone (Hong Kong: Hong Kong University Press, 2006), 128–129. L. F. Goodstadt, Poverty in the Midst of Affluence (Hong Kong: Hong Kong Univeristy Press, 2013), 8–9. “The Madness at the Heart of Hong Kong’s Public Spending,” South China Morning Post, 15 April 2017. A. Hedley, “The Role of Public Health in Social Justice,” 118–119. S. Stringhini, C. Carmeli, M. Jokela, et al. for the LIFEPATH consortium, “Socioeconomic Status and the 25 x 25 Risk Factors as Determinants of

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Premature Mortality: A Multicohort Study and Meta-analysis of 1.7 million Men and Women,” Lancet 389 (2017): 1229–1237. 14. “Nano Flats on the Rise as Hong Kong Homes Shrink Amid High Property Prices,” South China Morning Post, 17 April 2017. 15. O. Chadwick, Report on the Sanitary Condition of Hong Kong, CO 882/4, Hong Kong Government, 1882, A3.

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Glossary

catty Changsha Cheeloo Chengdu Chongqing Geleshan Guilin Guiyang Hon Hing Chinese Medicine School Huizhou huoluan Lingnan Nam Pak Hong National Hsiang-Ya Medical College Pak Cheong Tong Qujiang “Two is Enough” Shangdong Shaoguan Yau Wing Hong Xianggang zhongyiyao shihua (A history of Chinese medicine in Hong Kong) Xie Yongguang

斤 長沙 齊魯 成都 重慶 高樂山 桂林 貴楊 漢興中醫學院 惠州 霍亂 嶺南 南北行 國立湘雅醫學院 百昌堂 曲江 「兩個就夠晒數」 山東 韶關 祐榮行 《香港中醫藥史話》 謝永光

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Index

5-fluorouracil, 122 6-mercaptopurine, 122 A History of Chinese Medicine in Hong Kong, 292 A Many-Splendored Thing, 56, 73 Abraham, G. M., Dr., 35 acquired immune deficiency syndrome (AIDS), 82, 139–147, 306 AIDS Advisory Council, 147 AIDS Concern Foundation, 145 AIDS Counseling Service, 145 AIDS Memorial Quilt Project, 146 AIDS Trust Fund, 145 actinomycin D, 122–123 acupuncture, 287, 296 Adams, Walter (Secretary of the InterUniversity Council), 196 adenocarcinoma (of the lung), 125 Advisory Committee on Immunization, 42 aflatoxin, 113, 127, 128 age-standardized mortality rate, 89, 95, 115–118 “aging in place,” 180, 186 Agriculture, Fisheries and Conservation Department (AFCD), the, 149–150 air pollution, 20, 95, 100–102, 300 alcohol consumption, 90–91, 95, 100, 124, 127, 131–133, 179 Alice Memorial Hospital, 119, 189, 269 Alzheimer disease, 170 American Academy of General Practice, 268

American Joint Committee for Cancer Staging, 121 American Red Cross, 33–34 aminopterin, 122 Amoy Gardens, 158–159, 161 Anatomy Museum, 198 Anderson, John, Professor, 190–191 Anti-Epidemic Bureau, 26 antigenic drift, 151 antigenic shift, 151, 152 Aquinas, Mary, Sister, 81–82 artificial pneumothorax, 70, 75 artificial pneumoperitoneum, 75 Asian Association for the Study of Diabetes, 106 Asian financial crisis, 4–5, 8, 161, 257, 308 Asian Influenza, 153–154 Asquith Commission, 193 Association of Hong Kong Diabetes Nurses, 106, avian influenza, 5, 20, 139, 147–152, 154, 164, 214, 249 azidothymidine (AZT), 143 Bacillus Calmette–Guerin (BCG) vaccination, xi, 42–43, 48, 71, 77–81, 303 Bacteriology Institute, 36 Baptist University, 124, 289–290 Bard, Solomon, Dr., 64, 72–73 Barré-Sinoussi, Francoise, 140 beriberi, 17, 28–29, 97

3 7 2   |   I ndex

Black, Sir Robert (Governor), 206, 304 Bonham Strand, 291–292 breast cancer, 97, 115–116, 118, 121, 132–134, 136, 138 BRCA1 (breast cancer gene 1), 133, 134, 136, 138 BRCA2 (breast cancer gene 2), 133, 134, 136, 138 British Army Aid Group (BAAG), 36 British Medical Research Council, 76, 81, 297 British Medical Research Council Tuberculosis Unit, 84 British Military Hospital at Bowen Road, 30–31, 225 “Bunker C” Fuel, 101 Bureau of Public Health in Guangdong Province, 47 Caesarean section, 141 Canadian Prisoners-of-War (POWs), 29–30 Canadian Task Force on Preventive Health Care, 134 cancer (malignant neoplasm), x, 16–19, 85–87, 93, 95–97, 99–100, 102, 105, 111, Chapter 6, 140, 171, 198–199, 220–221, 225, 248, 274, 294, 297–298 Canossa Convent and Hospital, Canossa Hospital, 28–29, 222 Caritas Medical Centre, 225, 239, 304 Castle Peak Hospital, 50, 221–222, 239, 304 Center for Health Protection, 107, 146, 163 Central Hospital, 222 cerebrovascular diseases (stroke), x, 16–19, 85–86, 88–91, 93, 95–96, 100, 105, 110, 170–174 cervical cancer, 116, 118, 134–138, 274 Chadwick, Edwin, 300, 301 Chadwick, Osbert, 301

Chan, T. K., Professor, 201 Chang, Francis, Professor, 198, Chang, Stephen, K. P., Dr., 200 Changsha, 37 Chatham Road Camp, 66 Chemotherapy, 118–119, 121–123, 125, 128, 130, 133, 135, 137, 297, 306 Cheng, Kwok Kew, Dr., 35, 198 Chengdu, 37 Cheung Sha Wan, 61, 149 China Eastern Airlines, 164 Chief Executive, 8, 15, 16, 164–165, 264, 276, 289, 308–309 Chinese Communist Party, 2, 303 Chinese Co-operative Council, 22 Chinese Medicine Council of Hong Kong, 289 Chinese Medicinal Material Research Centre, 290 Chinese Medicine Ordinance, 289–290, 293, 308 Chinese Red Cross Medical Relief Corps, 35 Chinese Representative Council, 22 Chinese University of Hong Kong, xi, 19, 49–50, 106, 129, 157, 187–188, 204, 206–207, 209, 224, 289– 290, 318n31 Ching, Henry (Secretary for Health and Welfare), 230, 306 Chung King Ue, Dr., 283 Chung, Sir S. Y., 233 choriocarcinoma, 123 Choa, Gerald, Professor, 200, 207–208, 225–226, 311 cholera (Blue Death), vii, 1, 19, 26, 39, 41, 63–67, 69, 297, 304 cholangiocarcinoma, 127 Chongqing, 36–37, Chow, Sir Shouson, 22,

I ndex   |   3 7 3

chronic non-communicable diseases or “lifestyle diseases,” 16–17, 19, 85, 87–88, 95–96, 100–102, 105–107, 110–111, 114, 118, 171, 179, 259, 273, 291, 295 chronic obstructive pulmonary disease (COPD), 94–96, 171–174, 260 Chun, Daphne, Professor, 10, 36, 123, 202–203, 304 Chung Chi College, 205–206 Clark, Francis (Medical Officer of Health), 189 Clonorchis sinensis, 127, 198 Colbourne, M. J., Professor, 200 College of Family Physicians of Canada, 268 colorectal cancer, 97, 115–116, 118, 122, 126, 137 Columban Sisters, 80, 82–83 Commonwealth Scholarship, 211 communicable diseases, 47, 56, 106, 163, 259–260, 273, 295, 298 Community Geriatric Assessment Teams (CGAT), 175–176, 183–184, 308 community health centers, 261, 279–280 Community Health Department, HKU, 297 Community Nursing Service (CNS), 175, 185 Comprehensive Social Security Assistance, 168 Computerized Tomography (CT), 119, 125–126, 218, 247 coronary heart disease, 85, 87–88, 90, 93, 96–97, 99–100, 105, 110 coronavirus, 157–158, 214, 298, 309 Cox, Sir Christopher, 194, 206 crude birth rate, 10, 12, 16 crude death rate, 10, 16, 17 cruciferous vegetables, 97

cryoablation, 128 Cunich, Peter, Professor, 188 Cultural Revolution, 6 cyclophosphamide, 122, 123 DNA adducts, 97 Dantonic, 294 daunorubicin, 123 Davis, Leslie, Professor, 192 Declaration of Alma-Ata, 1978, 267 Department of Community Medicine, 200 Department of Extra-Mural Studies, 199 Department of Social and Preventive Medicine, 200 Department of Social Work and Administration, HKU, 181 Deng Xiaoping, 4 “Development of Medical Services in Hong Kong, 1964,” 223, 244 diabetes center, 106 Diabetes Hong Kong, 106 diabetes, Type 1, 92 diabetes, Type 2, 85, 92, 100, 171 dichlorodiphenyltrichloroethane (DDT), 42, 60 dietary fiber, 96–97 Digby, Kenelm H., Professor, 33, 189– 191, 194 Diocesan Boys’ School, 27 diphtheria, 19, 28–31, 33, 42, 43, 48 diphtheria anti-toxin, 30 Direct Observed Therapy (DOT), 76–77, 297 Disability Adjusted Life Years (DALYs), 91, 96, 101, 110 District Affairs Bureau, 22 Dongjiang, 55 doxorubicin, 122, 123 Dr. and Mrs. Michael S. K Mak Integrated Chemotherapy Center, 124

3 7 4   |   I ndex

drug labeling, 250 drug-resistant tuberculosis, 139 Duff, Sir James (Vice Chancellor of the University of Durham), 205 Duke and Duchess of Kent, 208 Duchess of Kent Children’s Hospital, 222, 239, 304 El Tor cholera, 65–66, 69 Elderly Health Care Voucher Scheme, 278 Elderly Health Centre, 174 electronic health record (eHR), 261, 280, 282 Emergency Medical Relief Corps, 121 “Enhanced Bought Place Scheme,” 177 Enhanced Home and Community Care Service teams, 178 enzyme immunoassay (EIA), 142 enzyme-linked immunosorbent assay (ELISA), 142, 144 epidermal growth factor receptor (EGFR), 125 Epstein-Barr virus (EBV), 113, 118, 129–131 esophageal cancer, 116, 131–132 ethambutal, 76 Evans, D. E., 188 Eugenic League, 192 Expert Committee on AIDs, 144 Family Planning Association, 11–12, 192, 297 Fan, S. T., Professor, 128 Fang, Harry, Professor, 202 Farr, F. J., Dr., 120 fertility rate, 13, 15, 167–168 Field, Elaine, Professor, 201 filariasis, 191 fluorescent bronchoscopy, 125

Food and Environmental Hygiene Department, 150 Fong, L. Y., Dr., 130, 198 folinic acid, 122 Foshan, 5 Folts, F. E. (Professor Emeritus of the Harvard School of Business Administration), 206 Fox, Wallace, Dr., 84 Fracastoro, Girolamo, 70 Free China, 1, 36–37 Freni Memorial Convalescent Home, 74 Fulton, J. S. (Vice Chancellor of the University of Sussex), 205 Fuzheng huayu, 294 Gabriel, M., Sister, 81 Gallo, Peter, Dr., 140 GE Maximar unit, 120 Geleshan, 37 General Medical Council (of Britain), 37, 49, 188–189, 192–193, 208, 268–270 Gibson, A. W., 33 Gibson, James, Professor, 199 Gimson, F. C. (Colonial Secretary), 34 Global Burden of Disease Study, 91, 101 Global Influenza Surveillance Network, 153 Global Initiative for Asthma (GINA), 260 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 260 glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency), 297, 304 Government Civil Hospital, 27, 75, 189, 191–192, 197, 282 Government Tuberculosis Service, 74, 76, 80–82, 303 Grantham, Sir Alexander (Governor), 48, 194, 196

I ndex   |   3 7 5

Grantham Hospital, 74, 82–83, 105, 221–222, 239, 304–305 Grayburn, Sir Vandeleur, 34 Greater East Asia Co-Prosperity Scheme, 21 Gross Domestic Product (GDP), 2–3, 19, 93–94, 154, 162, 210, 244, 246, 254–255, 264, 299 Guangdong, 4–5, 37, 47, 66, 110, 149, 155, 162 “Guidelines on Prevention of Bloodborne Diseases in Schools,” 145 Guilin, 36, 37 Guiyang, 36, 37 Guomindang, 2, 303 Guy’s Hospital, 217 H5N1 virus, 147–152, 249, 259, 308 Hall, R. O., Bishop, 58 Han Suyin, 58, 73–74, 202, 220 Hanyang, 80 Hou Pao-Chang, Professor, 198–199 Harcourt, Sir Cecil, Admiral, 1, 37, 303 Harvard Report, 172, 249, 250–251, 256–257, 259, 263–264, 276, 296, 298, 308 Haven of Hope Hospital, 81, 221–222, 239, 304 Hawker Control Squad, 61 Hay, J., ix Hay Ling Chau Leprosarium, 221–222 Health and Welfare Bureau, 244, 306 Health Protection Account (HPA), 257 Health Security Plan, 256 Health, Welfare and Food Bureau, 257 “Heart Week,” 105 Hedley, Anthony, Professor, 103 Helicobacter pylori, 118, 129 heliotherapy (sunbathing), 70

Hemophilus influenzae, 250 Hemorrhagic stroke, 89 hemoglobinopathies, 298 Henry Lester Institute for Medical Research, 191 hepatitis B virus (HBV), 42, 113, 118, 127–128, 137–138, 143, 298, 306–307 hepatitis C virus (HCV), 113, 127–128, 137, 143, 294 hepatocellular carcinoma, 113, 118, 123, 127–128 hereditary nonpolyposis colorectal cancer (Lynch Syndrome), 126 High Island Reservoir, 52, 54, 306 high density lipoprotein (HDL), 106 Hill, Octavia, 58 Hippocrates, 63, 69 Ho, Faith, Professor, 199 Ho, Hung Chiu, John, Professor, 35 Ho Tung, Eva, Dr., 35 Ho Tung, Sir Robert, 35, 195 Hodgson, A. R., Dr., 75, 202, 304 Hon, B. Y., Mr., 120 Hon Hing Chinese Medicine School, 284 Hong Kong Academy of Medicine, 213–215, 298, 307–308 Hong Kong Academy of Medicine Ordinance, 214 Hong Kong Academy for Performing Arts, 51 Hong Kong Adventist Hospital, 225 Hong Kong Alzheimer’s Disease Association, 171 Hong Kong Anti-Cancer Society, xi, 121, 123 Hong Kong Anti-Tuberculosis Association, 74, 78, 80–82, 105, 303 Hong Kong Association for the Study of Obesity, 106 Hong Kong Baptist Hospital, 222

3 7 6   |   I ndex

Hong Kong Buddhist Hospital, 225, 239 Hong Kong Chinese Medicine Practitioners’ Association, 286 Hong Kong Christian Council, 224 Hong Kong College of Family Physicians, 260, 281 Hong Kong College of Physicians, 201, 212–213, 307 Hong Kong Council on Smoking and Health (COSH), xi, 103, 108, 297 Hong Kong Housing Society, 58–59 Hong Kong Influenza, 153 Hong Kong Institute of Diabetes and Obesity, 106 Hong Kong Juvenile Diabetes Association, 106 Hong Kong News, 22, 29 “Hong Kong Operation,” 75, 202, 297 Hong Kong Polytechnic University, 50, 318n31 Hong Kong Red Cross Blood Transfusion Service, 144, 239 “Hong Kong Reference Framework for Diabetes Care in the Primary Settings,” 277 “Hong Kong Reference Framework for Hypertension Care in the Primary Settings,” 277 Hong Kong Society for Diabetic Limb Care, 106 Hong Kong Society of Endocrinology, Metabolism and Reproduction, 106 Hong Kong Stroke Society, 105 Hong Kong Tuberculosis, Chest and Heart Diseases Association, 82, 105 Hospital Authority (HA), x, xi, 16, 19, 123, 144, 157, 175, 177, 181–183, 209, 212, Chapter 10, 243–245, 247–248, 252–253, 259–262, 273, 276–277, 279–282, 290, 295, 307, 311

Hsieh, A. C. L., Professor, 198 Huangdi, Yellow Emperor, 63 Huizhou, 36–37 Human Immunodeficiency Virus (HIV), 79, 82–84, 113, 140–147, 244, 297, 306 Human Immunodeficiency Virus-1 (HIV-1), 141, 146 Human Immunodeficiency Virus-2 (HIV-2), 141 HIV DNA, 142 HIV RNA, 142 Human papilloma virus (HPV), 113, 118, 135–136, 309 huoluan, 63 Huang, C. T., Professor, 199 Hutchison, J. H., Professor, 201 Hwang, J. C. C., 198 hyperlipidemia, 88, 90, 97 hypertension, 85, 88–93, 95, 99–100, 110, 170, 260, 277, 280 immunocompromised conditions, 139 immunotherapy, 118 Independent Commission Against Corruption (ICAC), 7 infant mortality, vii, 10, 12, 16, 44–46, 80 infectious diseases, vii, x, 1, 16, 19–20, 23–24, 26, 29–31, 33, 39–45, 47, 65–66, 71, 85, 87, 114, 139, 162, 166–167, 213, 219, 244, 260, 269, 286, 295, 301 influenza A, 139, 151–153, 159, 163–164 Institute for the Advancement of Chinese Medicine, 290 Institute of Radiology, Medical and Health Department, 121 Integrated Home Care Services teams, 178 “International Classification of Diseases” (ICD), 85–86

I ndex   |   3 7 7

International Diabetes Federation, 106, 110 International Office of Public Health and the Health Organization of the League of Nations, 48 International Union Against Cancer, 121 Inter-University Council for Higher Education Overseas, 206 isatis root (banlangen), 155 Isogai, Rensuke, Lt-General, 21–22 Ischemic stroke, 88–90 Isoniazid, 76, 79, 83, 303 Jackson, R. B., Dr., 41 Japanese Civil Administration, 21 Japanese Civil Affairs Bureau, 22 Japanese Imperial Army, 21, 24, 35 Japanese occupation, 21, 23, 26, 28, 39, 51, 284, 291, 303 Jennings, Sir Ivor (Vice-Chancellor of the University of Ceylon and later of Cambridge), 196 Jennings-Logan Report, 196, 198, 203 Jordon, Gregory, 189 Kai Tak Airport, 40 Kaposi sarcoma, 113 Kempeitai, 22 Kennedy Town Infectious Diseases Hospital, 27 Keswick Committee, 205 Kilborn, L. G., Dr., 198 King, Gordon, Professor, 10, 35–37, 48, 192–193, 202 King’s Park, 221, 225 Kirk, Robert, Professor, 199 Kiyoshi, Watanabe, the Reverend, 28 Kneebone, G. M., Professor, 201 Koch, Robert, Dr., 70 Kotewall, Sir Robert, 22 Kowloon Hospital, 27, 33, 208, 219, 239 Kwai Chung Hospital, 50, 225, 239, 306

Kwong Wah Hospital, 26–28, 155, 219–220, 239, 283 Lai Chi Kok Infectious Diseases Hospital, 27, 121 Lai, C. L., Professor, 127 Lam, K. C., Dr., 127, 129 Lam, T. H., Professor, 103 Lancet, The, 191 Lantau Island, 53 large-cell carcinoma (of the lung), 125 latent tuberculosis, 79 “Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A World View,” 290 Leong, John C. Y., Professor, 202, 311 LGBT (lesbian, gay, bisexual and transgender), 145 leukemia, 122–123, 220 Li Choh-ming, (Vice-Chancellor of the Chinese University), 207 Li Ka Shing Faculty of Medicine, xi, 290, 309 Lieh-Mak, Felice, Professor, 201 “Lifelong Investment in Health,” 256, 276, 308 Lim, Robert, Professor, 121 Lin, R. C. Y., Professor, 198 Lingnan University, 37 Lok, Anna, Professor, 127 Logan, Douglas, Dr. (Principal of London University), 196 logo, Hospital Authority, 237 Loke Yew Hall (Great Hall), 35, 38, 195 London Hospital, 217 long-term care for the elderly, 181, 264 life expectancy, 11, 13, 16–17, 85, 122, 167, 249, 297 low density lipoprotein (LDL), 106

3 7 8   |   I ndex

Lugard, Sir Frederick (Governor), 188 lung cancer, 115 lymphoma, 122–123, 130, 143 Ma, H. K., Professor, 202 Ma Liu Shui, 206–207 Ma Tau Chung, 12, 29 Macao or Macau, 47 McFadzean, A. J. S., Professor, 122, 200 Mackay, J., Dr., 103 MacLehose Medical Rehabilitation Centre, 225, 239 MacLehose, Sir Murray (Governor), 7, 59, 305 McMaster University, 268 magnetic resonance imaging (MRI), 119, 218, 247, 305 malaria, 17, 26, 29–30, 37, 39–42, 220 Malaria Bureau, 26, 40 Malcomson, G. E., Professor, 189 malignant neoplasm, 17–18, 85–86 Mao, Philip, Dr., 35 mass radiography, 77 Mass Transit Railway (MTR), 7, 226, 233, 306 Maternal and Child Health Centers, 12, 19, 42, 45–46 maternal mortality, 10, 44, 249, 297 maxillary swing procedure, 131 MMR vaccine (against measles, mumps and rubella), 42 Medicaid Program, 296 Medical Clinics Ordinance in 1963, 271–272 Medical College of Cheeloo University, 37 Medical Council of Hong Kong, 49, 211, 214, 252, 260, 264 Medical Reform Act, 1858, 268 Medical Registration Act of 1884, 189

Mellanby, Kenneth (Director of the Monk’s Wood Experimental Station of the Nature Conservancy), 206 Mellor, B., 188 methicillin-resistant Staphylococcus aureus, 139 methotrexate, 122 Metropark Hotel, 164 Metropole Hotel, 155–156 Middlesex Hospital, 217 military yen (MY), 22, 24–25, 27 Mirs Bay, 36 Moodie, A. S., Dr., 76 Morris, Sir Charles, 206 Montagnier, Luc, Dr., 140 Mouat-Jones, Bernard (Vice-Chancellor of Leeds University), 196 Moxibustion, 287 “My Health, My Choice,” 258, 276, 309 My House Has Two Doors, 220 Nam Long Hospital, 123, 225, 305 Nam Pak Hong, 291 nasopharyngeal carcinoma (NPC), 113, 115, 118, 120–121, 123, 130–131, 138, 198 nasopharyngoscopy, 131 National Hsiang-Ya Medical College, 37 National Shanghai Medical College, 37 Neijing, 63 Needham, Sir Richard Arthur, 192–193 Nethersole Hospital, 27, 224, 239, 269, 305, 308 neuraminidases (NA), 151 New Asia College, 205 New Pathology Building, 197, 199, 304 Ng-Lun, A. N. H., 188 Nippon-Chinese Medical Association, 27 Nippon-Chinese Dentist Association, 27 nitrogen mustard, 122

I ndex   |   3 7 9

Nixon, William C. W., Professor, 11, 192 Nobel Prize in Physiology or Medicine, 140 nongovernmental organization (NGO), 58, 60, 145–146, 176, 182, 218–219, 222, 224–225, 290 non-Hodgkin’s lymphoma, 113, 115–116 non-small cell lung cancers, 125 North District Hospital, 238–239, 308 North Lantau Hospital, 238–239 Northcote Science Building, 195 nucleoside reverse transcriptase inhibitors (NRTIs), 143 No. 1 Japanese Civil Hospital (Nethersole Hospital), 27 No. 2 Japanese Civil Hospital (Government Civil Hospital), 27 Nurse and Allied Health Clinics, 280 obesity, x, 85, 88, 90–95, 99–100, 106, 108, 110, 118, 124, 133, 138 Office of the Unofficial Members of the Executive and Legislative Councils (OMELCO), 232 Ong, G. B., Professor, 132, 201–202, 211 Open University of Hong Kong, 50, 318n31 Organization for Economic Cooperation and Development (OECD) countries, 49, 51 Orthomyxoviridae virus, 151 osteoarthritis, 93, 174 overweight, 93–94, 108–109 oxaliplatin, 122 Pacini, Filippo, Dr., 64 Pak Cheong Tong, 292–293 Pamela Youde Nethersole Eastern Hospital, 238–239, 307 pandemic influenza, 152–154, 164 panel of specialists, 271–272 Parkinson’s disease, 174

Pearce, Richard, Dr., 190 Pearl River Delta Region, 4, 152, 163 Peiris, J. S. M., Professor, 157 People’s Republic of China (PRC), 2, 4, 55, 80, 148, 204, 212, 287, 303 plombage, 75 Plover Cove Reservoir, 54, 305 Pokfulam, 71 polypharmacy, 175, 253, 263, 281 positron emission tomography (PET), 119, 218, 261, 306 pneumocystis pneumonia (PCP), 140, 143 pneumonia, 17, 85–86, 140, 148, 151, 156, 159, 162, 220, 306 Preliminary Investigation Committee (of Patient Complaints), 252 Preparatory Committee on Chinese Medicine, 288 “Preventive Care for Children in Primary Care Settings,” 277 “Preventive Care for Older Adults in Primary Care Setting,” 277 primary care, x, 173–174, 203, 232, 249, 256–260, 264, 266, Chapter 12, 295, 298–299 Primary Care Directory, 278 “Primary Health Care—Now More than Ever,” 276 primary care reform, 275–276, 282 Princess Margaret Hospital, 164, 224– 225, 306 Prince of Wales Hospital, 155–156, 159, 163, 207–209, 224–225, 306 Prince Philip Dental Hospital, 225, 306 prisoners-of-war (POWs), 25, 29–31, 36 processed meat, 97, 125–126, 129, 132, 136 Programs of All-Inclusive Care for the Elderly (PACE), 180 prostate cancer, 115–116, 118, 136–137

3 8 0   |   I ndex

prostate specific antigen (PSA), 137 Provisional Hospital Authority (PHA), 233–234, 236, 307 Psychogeriatric Teams (PGT), 176 Public Complaints Committee, 252 pyrazinamide, 76 Quarantine and Prevention of Disease Ordinance (CAP 141), 47 Queen Mary Hospital, 27, 35–36, 48, 50, 56, 71, 106, 119–120, 192–193, 196–199, 201, 209, 219–220, 239, 304–306 Queen Elizabeth Hospital, 144, 221–223, 239, 304 Qujiang, now Shaoguan, 36–37 reassortment, 164 “Reference Framework for Preventive Care for Older Adults,” 174 Repatriation Bureau, 22 Resettlement Department, 59 resettlement estates, 58, 224 Residential Care Homes Ordinance, 177–178 Ride, Sir Lindsay, Professor, 195, 198 Rockefeller Foundation, 190–191 Rockefeller Professors, 190–191 Romantic Movement, 70 Robertson, R. Cecil, Professor, 36, 192 Royal Colleges of Pathologists of the United Kingdom, 199 Royal Colleges of Pathologists of Australia, 199 Royal College of Physicians of London, 267 Royal Hong Kong Defense Force, 36 Royal Jockey Club, 11–12 Rowell, T. R. (Director of Education), 38 Ruttonjee, Jehangir, 80

Ruttonjee Sanatorium, 80–83, 221–222, 239, 303, 307 St. Bartholomew’s Hospital, 217 St. Francis’ Foundling Home, 28 St. George’s Hospital, 217 St. Paul’s Convent School, 165 St. Stephen’s Preparatory School, 32 St. Teresa’s Hospital, 222 St. Thomas’ Hospital, 217 Sanitary Department, 39, 60 sanatoria, 70, 73–74, 82 Sassoon Road, 198 Sau Po Centre on Ageing, 181 School Health Program, 47 School of Public Health, Hong Kong University, 200, 297 Scientific Working Group on AIDS, 144 Scott Review/Report, 231–232, 244, 273–274 Second World War, vii, ix, 2, 9–10, 16, 52, 64, 71, 83, 106, 114, 120, 122, 127, 188, 192–193, 195, 204, 209, 218, 229, 233, 243–244, 248, 270, 285, 295, 297 Secretary for Food and Health, 164, 276 Selwyn-Clarke, Hilda, 33 Selwyn-Clarke, P. S., Dr. (Director of Medical Services), 23–25, 28, 31, 33–34, 39–40, 218, 303, 311 Severe Acute Respiratory Syndrome (SARS), vii, 5, 20, 139, 154–163, 165, 214–215, 259, 298, 301, 309 SARS Experts Committee, 162 Sham Shui Po, 28–30, 31, 58 Shangdong, 37 Sharp Commission, 189–190 Shatin Hospital, 238–239, 307 Shaw, G. I., Dr, 64 Shek Kip Mei, 58–59, 303 Shek Pik Reservoir, 53, 304

I ndex   |   3 8 1

Sherriff-Baker tanker, 67–68 Sheung Li Uk Estate, 58 Shing Mun Reservoir, 25, 51 Sino-British Agreement (Sino-British Joint Declaration), 4–5, 212, 287, 306 Sino-British Fellowship, 211 Skinner, Jack, 120 slaughterhouses, 61 Sloss, Duncan, (Vice-Chancellor, HKU), 35, 194–195 small-cell lung cancers, 125 smallpox, vii, 1, 17, 26, 39, 41, 306 Smoking (Pubic Health) Ordinance (Cap 371), 103 Snow, John, Dr., 64 Society of Apothecaries of London, 49, 267, 270 Social Hygiene Program, 40 Social Welfare Department, 177–178, 181, 245, 304 Society for AIDS Care, 146 southern China, 4, 48, 130, 139, 155 Spanish Influenza, 152–154 Special Administrative region (SAR), x, 4–5, 289 Specialist Register, 211–212, 214, 260, 299 squamous cell carcinoma (of the lung), 125, Stanley Camp or Stanley Internment Camp, ix, 29, 32–34, 36 Stanley Prison, 32, 34 Star Ferry Riots, 6, 224, 305 Starling, A. E., 188 Streptococcus pneumoniae, 250 Stock, F. E., Professor, 201 stomach cancer, 99, 116, 118, 128–130, 138, 298 streptomycin, 71–74, 76, 303 “Stop TB in the Western Pacific Region,” 84 “Stop TB Initiative,” 84

subvented hospitals, 218, 228–233, 236, 244, 270 Sung, Joseph, Professor, 129 Sweeting, Anthony, Professor, 193 swine Influenza, 139, 152, 163–165, 214, 260, 309 syphilis, 44–45, 143 Sze, Tung Sing, Professor, 200 Tai Lam Chung Reservoir, 52, 304 Tai Po, 25, 28, 269, 308 Tai Po Hospital, 238–239 Tamiflu, 165 Tang Shiu Kin Hospital, 225, 239, 308 Temple Street Outbreak, 65, 67 “Ten Years Housing Program,” 7, 59 Teng, P. H., Professor, 200, 311 “The Further Development of Medical and Health Services in Hong Kong,” 1974, 224 Thong, K. L., Dr. (Director, Medical and Health Department), 230, 311 thoracoplasty, 75 Tiananmen Square, 5, 307 Tin Shui Wai, 280 Tin Shui Wai Community Health Centre, 279 Tin Shui Wai Primary Care PublicPrivate Partnership Project, 279 Tobacco Control Office, 105 tobacco smoking, 95–96, 101–103, 110, 124, 130, 132, 136 Todd, Sir David, Professor, 122, 201, 213 Tottenham, R. E., Professor, 191–192 “Towards Better Health,” 248, 276, 307 triglycerides, 107 Tsan Yuk Hospital, 11, 27, 36, 191, 202, 219, 222, 239 Tsang, Donald (Chief Executive), 15, 164, 309 Tse, Yuen Man, Dr., 161

3 8 2   |   I ndex

Tsuen Wan, 25, 52, 270 Tseung Kwan O Hospital, 238–239, 308 Tuberculosis (White Plague), 17, 19, 37, 39, 41, 45, 63, 69–86, 105, 139, 143, 202, 221, 244, 286, 297, 303–304 Tuen Mun Hospital, 161, 238–239, 307 Tung, Chee Hua, 8, 308–309 Tung Wah Hospital, 24, 26–29, 189, 219, 239, 269, 282–283 Tung Wah Eastern Hospital, 27, 283 Tweed Bay Hospital, 32 “Two is Enough,” 12 U-trap tube, 160 Union for International Cancer Control (UICC), 110, 123 Union Hospital, 237, 238 United Christian Hospital, 158, 208, 224–225, 305 United College, 205 United States embargo, 2 United States (US) Centers for Disease Control and Prevention (CDC), 140 United States (US) Surgeon General, 102 United Nations Children’s Emergency Fund (UNICEF), 45, 48, 78 University of Hong Kong, the, xi, 11, 19, 24, 26, 33, 35–37, 48–49, 64, 73, 75, 81, 103, 121–122, 132, 157–158, 181, 187–190, 193–194, 202, 204–205, 207, 209, 211, 269, 287, 289–290, 297, 318n31 University of Science and Technology, 290 “Unregistrable” doctors, 49, 270–272 Uttley, K. H., Dr, 33 Urban Council, 60–61, 319n48 Urban Services Department, 60–61 ulcerative colitis, 126 Vietnamese refugees, 306 vincristine, 122–123

Violet Peel Maternity and Child Welfare Center, 11 Wan Chai, 28, 80 Wang, C. Y. (Professor of Pathology), 189, 192 Waterworks Department, 25 Wei, William, Professor, 131 Wellington, A. R., Dr., 71 Westminster Hospital, 217 Wong Chuk Hang, 26, 215 Wong Chuk Hang Hospital, 238–239, 308 Wong, Elizabeth (Secretary for Health and Welfare), 248 Wong, John, Professor, 202 Wong Tai Sin Infirmary, 81, 225, 239, 305 Woo, Peter (Chairman of Standing Committee of HA), 236–237, 311 Working Party on Chinese Medicine, 287–288, 307 Working Party on Primary Health Care (WPPHC) of 1989, 274, 307, 309 World Cancer Research Fund, 124, 129, 131 World Health Organization (WHO), 18, 42, 47–48, 50, 63, 69, 76, 78, 84, 88, 96, 99–100, 107, 110–111, 113, 153, 157, 160, 162, 166, 200, 267, 273, 277, 290, 297, 306 WHO’s Epidemiological Intelligence Station in Singapore, 48 Wuhan, 80 Yan Chai Hospital, 225, 239, 305 Yap, P. M., Professor, 201 Yau, Arthur, Dr., 202 Yau Wing Hong, 291 Yau Ma Ti, 28, 67 Yeung, C. Y., Professor, 201 Yeoh, E. K. Dr., 235–236, 311

I ndex   |   3 8 3

Young, Sir Mark (Governor), 21, 303 “Your Health, Your Life,” 258, 276, 309 Youth Diabetes Action, 106 Young, Rosie, Professor, vii, 201, 274, 306 Yuen Long, 12, 28, 61, 269 “Zero-Quota,” 16

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HISTORY

—Rosie T. T. Young, The University of Hong Kong

—Peter Cunich, The University of Hong Kong

A MEDICAL HISTORY OF

HONG KONG 1942-2015

Moira M. W. Chan-Yeung

“Hong Kong earned a reputation as one of the deadliest places on earth by the end of the nineteenth century, but in the five decades after the Second World War the British colony rapidly became one of the healthiest cities in Asia. This remarkable transformation in medical and health conditions is explored by Moira Chan-Yeung in this second volume of her medical history of Hong Kong. From cholera and tuberculosis in the 1940s to AIDS and SARS more recently, the major communicable and noncommunicable diseases are surveyed with admirable clarity and directness, even for the general reader, with valuable statistical data supporting her enlightening conclusions. More importantly, Chan-Yeung brings a lifetime of service to medical science in assessing the most pressing medical and health threats facing twentyfirst-century Hong Kong, while also suggesting ways of ameliorating the impacts of lifestyle diseases within our aging community.”

A MEDICAL HISTORY OF

“This book presents an unbiased and scientific analysis of events which prompted the authorities and the public to consider, evaluate, and ultimately implement policies that resulted in the gradual improvement of the healthcare system in Hong Kong.”

1942 2015

HONG KONG

This book gives an account of Hong Kong’s medical and health development from the Second World War to the present day, investigates how medical and health ser vices grew and adapted as Hong Kong’s political and the socio-economic landscape—and the world beyond it— changed, and continued changing. The author is a clinician-scientist rather than a social scientist, her writing is therefore based on her first-hand knowledge of the changes in the Hong Kong medical and healthcare scene during the period 1942– 2015, and the book has also been enriched by her meticulous research via the archives of available government publications, other literature, and media reports. This book is a sequel to A Medical History of Hong Kong: 1842–1941.



Dr. Moira M. W. Chan-Yeung has over 40 years of experience in research and scholarship, having published about 400 peer-reviewed articles, numerous book chapters and several books. A world authority on occupational asthma, she was instrumental in having it recognized as a compensable disease and setting up criteria for assessing respiratory impairment/ disability in patients with asthma. She was given the Alice Hamilton Award for “Major and Lasting Contribution in Occupational Health” from the American Industrial Hygiene Association and the prestigious Distinguished Achievement Award f rom t he Amer ican Thoracic Society in recognition of her contributions. Dr. Moira M. W. Chan-Yeung is Professor Emeritus of Medicine at the University of British Columbia and Honorary Clinical Professor of Medicine at the University of Hong Kong. This book is her fifth work on history after her retirement.

COVER IMAGE

Moira M. W. Chan-Yeung

Sheng Kung Hui St. Peter’s Primary School’s students, in Shek Tong Tsui, 23 June 2003, ready to rip off their facemasks after WHO’s announcement on the removal of Hong Kong from the list of SARS affected areas. Oliver Tsang / SCMP