Public health issues in Asia

Bangkok’s transgender community finally gets the health services it wants

At a HIV conference a while ago I was chatting to one of the other participants, a transgender woman, about why in the HIV world, transgender people are typically lumped in with men who have sex with men. This makes little sense. As my coffee break companion said, with a ‘look at this’ gesture from her high heels, to her fitted dress, all the way up to her long, wavy hair: “In what way does this say I am a man, having sex with men?”

Whilst both gay men and transgender people are known to be at especially high risk of acquiring HIV, for transgender people the risk is far more extreme: 49 times higher than for the general population, in fact. Moreover, they face a degree of marginalization and exclusion from the educational and employment opportunities that men who have sex with men rarely have to grapple with. The lack of a separate ‘key population at increased risk of HIV’ category for transgender people also does nothing to address the lack of data on the HIV epidemic, and what services the transgender community needs, making it difficult to get dedicated funding for HIV programmes for transgender people.

The highly restricted work options for transgender people in many countries see a disproportionate number entering into sex work .What sexual health and HIV prevention services there are tend to focus on transgender sex workers, while stigma and discrimination make the transgender community often extremely difficult to reach with HIV testing, treatment and care services.

Until recently, folding transgender people in with men who sex with men, despite the fact that the two communities have very different needs, was what was happening in Bangkok.

In 2008 the Thai Red Cross AIDS Research Center changed its approach from offering HIV testing to offering anal cancer screening, as a way to get gay men and other men who have sex through the door, and then offer them HIV testing too. It worked: client numbers went up and 80% who came in for anal cancer screening also accepted the offer of HIV testing. Five years on, it was clear that this approach was highly successful in increasing demand for the clinic’s services, but the number of transgender people accessing the clinic remained unchanged. The clinic was missing something if it wanted to appeal to transgender people.

“Through extensive consultations with the transgender community we understood the barriers they face when accessing health services,” Nittaya Phanuphak, Chief, Prevention Department, Thai Red Cross AIDS Research Centre told me. These extensive consultations were with diverse members of the transgender community – including those working as advocates, healthcare providers, within the fashion industry, as well as those working with transgender sex workers – revealed that transgender people face obstacles in accessing hormone level testing and therapy, the most basic health services that they regularly require to affirm their gender identity. What services there are typically are not from transgender-friendly providers, or even worse are provided outside the medical profession entirely.

Hormone therapy services were identified as the entry point to make the clinic attractive to its target population. The Tangerine Community Health Centre opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. The name was carefully chosen. “We knew the clinic’s name should be one that makes everyone feel comfortable, with nothing that can be considered stigmatizing, Tangerine is a play on transgender, and was chosen because it a fruit that is not too sweet not too sour, just the right blend.

Most of the clients have since come seeking hormone level testing and injections, but they are also offered a package of services including anal and neo-vaginal pap smears, cervical smear tests for transgender men, testing for sexually transmitted infections and a free HIV test (all Thai nationals are entitled to two free HIV tests a year). The centre provides both pre and post-exposure HIV prophylaxis and harm reduction interventions for safe injection.

Funding from USAID covered the costs of the community consultation, start-up, and sensitization training for staff, but services are fee-based, with the cost set at a level that makes them affordable to most clients. As the clinic becomes established, should the fees prove to be prohibitive to some, one option is to introduce a co-pay mechanism, but the aim of the clinic is to be self-financing. A clinic that covers its own costs is a sustainable and replicable role model for other cities trying to close the gap between their transgender communities and HIV services.

Tangerine’s catchment area is Bangkok and it surrounding four provinces, although approximately a fifth of its clients so far have travelled from other provinces to access services and a handful were from overseas. The clinic has a target to see over 400 clients in the first year of operation, with at least 600 consultations. From November 27 2015 to February 23 2016, it had seen 84 male-to-female clients, of whom 61 had received HIV testing, with 11% testing positive. Of the 25 female-to-male clients, 16 had been tested for HIV. Most clients also received testing for syphilis, over half of the transgender women requested hormone level measurement, as did four out of five transgender men.

The Tangerine Community Health Center’s key strengths are its foundations built on extensive community engagement, and its model of integrated health services with a self-sustaining funding model. The clinic’s two transgender staff have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves. In time, its usage data will also become an invaluable database of the transgender community’s health profile, overcoming the current invisibility of transgender people in the national AIDS database, and this community’s unique HIV and other health-related needs will be better understood.

Blogs posted for BMJ, Public health issues in Asia

What radiation risk? I’m going to Japan for the clean air

Chatting to fellow parents about summer holiday plans at a recent school event, I was asked by a mother whether I was worried about radiation levels in Japan. Both her family and mine are travelling to Japan this summer, neither party travelling anywhere near Fukushima. I told her that I was actually looking forward to the clean air and getting away from Hong Kong, giving us all a rest from the relentless impact of the Hong Kong’s hideous air pollution.

She, on the other hand, told me she and her friends were worried about the potential health impact of spending a week in Japan. This is a commonly held view here, and I was reminded of something I learned about risk during my MPH course: it’s not the risk, it’s the risk perception that matters.

Recently I was delighted to discover Safecast, a “global sensor network for collecting and sharing radiation measurements to empower people with data about their environments.” It is an excellent example of citizen science, created in the wake of the Fukushima nuclear power station accident after the 2011 Tohoku earthquake and tsunami in Japan. When the government and other authorities were clearly not going to provide the information people needed to determine the risk to their family and friends, a group of amateurs found each other via the Internet and did it instead. The project then grew into probably the most comprehensive source of radiation level data in the world, as Joi Ito, director of MIT’s Media Lab and co-creator of Safecast explains in this TED talk.

One of the site’s FAQs is, not surprisingly: is it safe to visit Japan? The answer might surprise some Hong Kong travellers: “Parts of Fukushima are highly contaminated, but in most of the rest of the country radiation levels are no higher and sometimes even lower than other major cities around the world. From our own measurements we can say with confidence that Tokyo and Los Angeles have similar radiation readings and that the levels in Hong Kong are even higher than those in Tokyo.” This can be partly explained by higher background levels of radiation in both LA and Hong Kong compared to Tokyo before Fukushima exploded.

So, it turns out that in Hong Kong, not only do we have pollution that is causing serious and widespread illness and shortening people’s lives (you can watch the morbidity and death toll ticking up here on the Hedley Environmental Index) but we also have radiation to contend with. Another aspect of Hong Konger’s distorted perception of risk is that the Daya Bay Nuclear Power Plant, just over the border in mainland China, has been running for nearly 30 years and scarcely gets a mention in the media or conversation about radiation risk from one year to the next. Given China’s less than stellar track record at keeping Hong Kong informed of any public health dangers emanating from across the border, we can’t assume that no news is good news. Hopefully the citizen scientists at Safecast are continuously monitoring radiation from southern China too.


Blogs posted for BMJ, Public health issues in Asia

How many cases will it take for policymakers to realize there is a HIV problem in Hong Kong?

Announcing the most recent HIV statistics for Hong Kong, the Department of Health’s Centre for Health Protection reported 154 new cases from January to March this year: in effect, almost every day two more people became infected with a preventable disease that requires lifelong adherence to a drug regimen in order to stay alive.

In my last blog post I talked about how Hong Kong’s schools are failing to teach young people even the most basic facts about safe sex, let alone giving them a forum to safely discuss and learn about sexuality. This shows in the sexual practices of young people: research by local NGO AIDS Concern last year, for example, found that among 121 young people aged 14-21, 40% did not use condoms while having sex.

Another consequence of failing to give young people proper sex and sexuality education is low awareness of the risk of HIV infection and the perpetuation of stigmatizing social attitudes towards lesbian, gay, bisexual and transgender people, and towards people living with HIV. For almost all of the new cases for which there was a confirmed transmission route, unprotected sex accounted for all but one case (which was via injecting drug use).

In a recent conversation with AIDS Concern’s chief executive Andrew Chidgey, he explained that stigma and ignorance continue to make their outreach and education work difficult. “Some people don’t want to get engaged in knowing about HIV. It’s not something they want to be associated with,” he told me. When AIDS Concern staff talk to people who get tested and to people living with HIV, they find that most got infected through unprotected sex. Chidgey attributes this to a number of reasons: people aren’t as aware as they have been in the past about the risks and dangers of unprotected sex; complacency about treatment in the era of antiretroviral therapy; and a lack of information. “The sex education that’s going on is still very limited to reproduction and not about relationships and sex,” he says.

Particularly worrying is that 84 out of the 154 newly reported cases were among men who have sex with men, continuing a trend that has emerged in recent years. The CHPs’ Consultant (Special Preventive Programme) Dr Wong Ka-hing admitted to local media that it has so far been unable to develop an effective strategy to address the spread of HIV among the gay community. The CHP is conducting a study among gay men to try and better understand the prevalence of HIV among the gay community.

I do hope they work closely with local NGOs like AIDS Concern, which clearly have their finger more on the pulse of the LGBT community. The organization is already collaborating with the Chinese University of Hong Kong to research into stigma associated with HIV and discrimination experienced by people living with the virus in Hong Kong. Initial findings using the widely respected People Living with HIV Stigma Index found that half of the 291 survey respondents had “internalized stigmatizing beliefs about their identity as a person living with HIV.” Over a quarter had “experienced insults, avoidance or discrimination from general healthcare workers” at accident and emergency units as well as general out-patient clinics.

Clearly the Centre for Health Protection needs to pass on some basic facts about HIV infection to their colleagues on the frontline of health care delivery in Hong Kong. But if they really want to stop the upward trend of HIV infections over the longer-term, they will need to step out of the health sector and engage with their government colleagues in the Education Bureau. It’s time they pointed out the human cost of continuing to shy away from implementing proper, evidence-based sex and sexuality education in Hong Kong schools.

Public health issues in Asia

Hong Kong needs its own Conchita Wurst

I woke up today to the news that Conchita Wurst had won the 2014 Eurovision song contest, by a mile, and contrary to expectations. I was thrilled, partly because I’m a fan, she’s got a great voice and deserved to win, but mostly because it was such a strong statement from Europe about tolerance, acceptance of diversity, and reason.

Homophobic St Petersburg legislator Vitaly Milonov (the one who sponsored a local law against homosexual propaganda in 2011, which was followed by similar federal law in 2013) tried to mobilise a Russian boycott of the competition, and tried to exclude Tom Neuwirth, in his Conchita persona, from participating.

All to no avail. In fact, the extra publicity was welcomed by Conchita, it raised her public profile and probably helped her win. “I can only say thank you for your attention!” she told Associated Press. “If this is only about me and my person, I can live with it. You know, I have a very thick skin. It’s just strange that a little facial hair causes that much excitement. I also have to add that 80% of the autograph requests that I get are from Russia and eastern Europe — and that’s what is important to me,” she said “Hey, I’m just a singer in a fabulous dress, with great hair and a beard.”

As Conchita’s win, for herself, for her country and for a tolerant Europe, plays out against the backdrop of homophobia in Eastern Europe, elsewhere this year we have seen backwards steps towards institutionalized and legally sanctioned homophobia in Nigeria and Uganda, which were followed almost immediately by crackdowns on the LGBT communities in both countries.

All this might seem very distant from Hong Kong, but homophobia, although a little more low key than in Eastern Europe, is an insidious and dangerous force here too. Although Hong Kong has laws protecting the civil and employment rights of citizens, making it illegal to discriminate against someone on the basis of their gender or race, there is no such protection against sexual orientation discrimination. This is why a fundamentalist Christian international school here can blatantly make the jaw-dropping statement that it will not hire gay teachers.

Other homophobic local Christian groups are also actively lobbying against the introduction of a sexual orientation discrimination ordinance in Hong Kong. One of their insidious tactics is to make spurious links between the issue of discrimination in the public sphere and the issue of same-sex marriage.

After Hong Kong’s Court of Final Appeal ruled that “W”, a transgender woman has the right to marry her male partner, the government rushed to introduce the Marriage (Amendment) Bill that the case prompted. If passed, the bill will restrict the right to be defined as transgender only to those who have undergone full gender reassignment surgery, far from what the court recommended as a ‘compelling model” for Hong Kong: the UK’s Gender Recognition Act, and out of step not just with most Western countries but also with several in Asia Pacific. The stipulation was condemned by the chair of the Equal Opportunities Commission York Chow, as a denial of dignity that has no place in a civilized society.

Respect for basic human rights is enough to justify legal protection and full civil rights for all in Hong Kong, regardless of sexual orientation or gender identity, but there is a public health agenda to this too. The government’s rush to introduce misguided and inhumane marriage legislation, and the lack of progress on bringing in a sexual orientation discrimination law, are, at best, a sign of ignorance within the government.

This ignorance about sexuality and gender starts with the education system, and the parlous state of sex education in Hong Kong’s school system is a public health hazard in its own right. It seems we can’t rely on schools to deliver anything like the basic minimum package of youth sexuality education recommended by the UN. That package is based on evidence that has shown that “comprehensive sexuality education that is scientifically accurate, culturally and age-appropriate, gender-sensitive and life skills-based can provide young people with the knowledge, skills and efficacy to make informed decisions about their sexuality and lifestyle.” These, along with the other pressing human rights issues we are facing in Hong Kong, are issues that we will need to tackle society-wide.

Even if Conchita hadn’t won the Eurovision song contest this year, she would still have achieved one of her main goals, which was to bring the conversation, not just about gender identity, but about tolerance for difference, into family living rooms all across Europe. Maybe we need someone like Conchita here in Hong Kong, to step out of the shadows of the LGBT community and into the public arena, looking fabulous (with or without a beard), standing proud and helping to bring sexual and gender rights and legally protected tolerance for difference under the spotlight and into the public domain where they belong.




Blogs posted for BMJ, Public health issues in Asia

The disease of poverty is a doctor’s business everywhere

“If you miss the poor, you’ve missed the point,” said Dr. Margaret Mungherera in her recent inaugural speech as incoming president of the World Medical Association. She urged doctors around the world to advocate on behalf of the poor. If any delegates from the Hong Kong Medical Association, a WMA member, were present I do hope they were listening.

One fifth of Hong Kong’s population lives below the official poverty line. This was set for the first time in September 2013, at 50% of median monthly household income before tax and welfare transfers.

Hong Kong has one of the highest per capita GDPs in Asia and ranks 11th globally, yet its Gini coefficient, a measure of income inequality, indicates it has the worst income disparity in the developed world. The announcement of the poverty line and that there are 1.3 million people living below it has been big news in Hong Kong, but it hasn’t generated the sense of righteous outrage that such a statistic should.

The toxic effects of poverty on health have been widely documented. Poor housing, food insecurity, inadequate access to health care, the physical and psychological stress of coping with the daily indignities that poverty imposes: these are all well known to be associated with higher rates of all the major non-communicable diseases. The health impact on children of growing up in poverty is particularly deleterious.

Since Hong Kong’s poverty line has been announced, the social welfare sector has been very vocal and highly visible in the media, asking what action will follow. But despite the well-established links between poverty and ill-health, any organized response from the local medical community has been conspicuous by its absence.

Unless they are only treating the well-to-do and middle class patients, the medical professionals who treat Hong Kong’s sick, the doctors and dentists who routinely screen all Hong Kong children through government health clinics, must see the health effects of poverty every day, but their professional associations are saying little or nothing about it.

There are ways to tackle poverty. Toronto family physician Dr Gary Bloch treats poverty itself as a disease, for example. Physicians in some parts of the US routinely screen for poverty along with other health risk factors. On a national scale there are many societies that have successfully narrowed the inequality gap. None will say they have a perfect solution, or achieved what they have by making easy choices, but unlike Hong Kong, neither do these developed countries have people living in 20ft2 cage homes, one in five children living in poverty, and one in three elderly people struggling to survive without a pension. Nor do they have the economic and social burden of the health consequences of allowing such a shameful state of affairs to exist.

The World Medical Association may have been speaking more to developing countries in its call to doctors to advocate for the poor. Dr. Mungherera noted that almost half of the world’s population survives on less than a dollar a day, but she also pointed out that there are poor people everywhere. “As physicians, we have been given the privilege to do something about it,” she said. “And we can do so as individual physicians, but we can do even better through organized medicine, as national medical associations and as the World Medical Association.”

Hong Kong’s income disparity may be an extreme example, but how societies like Hong Kong tackle poverty holds lessons for middle-income countries climbing up the development ladder. These countries are already facing the dual burden of infectious and non-communicable diseases, but the latter are not just the diseases of affluence. They will also have to find ways to deal with the diseases of urban poverty. I hope they do a better job than Hong Kong and have a medical community more willing to stand up and be counted in the fight.

Blogs posted for BMJ, Public health issues in Asia

Heads: Hong Kong babies lose. Tails: the formula companies win

It’s been a busy couple of years in Hong Kong for the international baby formula companies. As soon as the Department of Health announced it had set up a Taskforce on Hong Kong Code of Marketing of Breastmilk Substitutes in June 2010, the industry quickly mobilized to get ahead of any potential for their self-interests to be threatened.

The Hong Kong Infant and Young Child Nutrition Association, set up by the industry in May 2011, may sound like it has the interests of Hong Kong’s children rather than profits at heart. But it has since harnessed every opportunity to promote its member’s interests, and this year a so-called crisis of supply for local parents has been a bonanza for the industry, giving them many opportunities to promote their products through media assurances that they will support government efforts to maintain stable supplies.

In a clear effort to get ahead of any potential restrictions on advertising, in the unlikely event that the Hong Kong Code should ever become anything more than a suggestion for voluntary action, for the past two years the international formula manufacturers have been plastering their tacky images of ‘brainy’ children across public transport and TV screens. It is impossible to watch the terrestrial TV stations or take a bus or underground train in Hong Kong without seeing their advertisements.

But overshadowing their own marketing efforts is a bigger force that as been at play this year: massive demand for their products from mainland Chinese shoppers and parallel importers who have flocked to the city to buy formula, in favour of buying home-grown brands.

Domestic Chinese manufacturers are still feeling the impact of the melamine scandal that killed six children and sickened thousands more in 2008. Freelance parallel traders look to make a bit of extra cash hauling bulging luggage trollies from Hong Kong back to the mainland, having cleared the pharmacy shelves of formula in the bordering areas. They have been a thorn in the side of local residents who bemoan the impact on their lives and there have even been tense scuffles and protests.

This demand for imported formula came on the back of equally burgeoning demand for Hong Kong’s maternity ward services. Hong Kong-born babies obtain right of abode, regardless of the abode status of their parents. Giving birth in Hong Kong was a neat way for mainland parents to circumvent the implementation of the One Child Policy or to have a back-up plan in case they don’t like the educational and health options for their children open to them back home: right of abode confers access to free, high-quality healthcare and education in Hong Kong.

The doubling of demand for maternity beds in 2011 when nearly 44,000 women mainland women gave birth in Hong Kong without any concomitant change to supply, outraged the local population, and Chief Executive C Y Leung took the arguably unconstitutional step of barring all mainland births unless the father is a Hong Kong permanent resident.

It was against this backdrop that in March 2013 the government introduced a limit on formula exports of two 900g tins with the aim of protecting supplies for local women. The government also announced it was engaging with the formula manufacturers to ensure that local demand could be met.

What a windfall for the formula industry: the fact that the Hong Kong government helping them to avoid formula sales to mainlanders in Hong Kong cannibalizing their business over the border is a side benefit. The real benefit is the tremendous endorsement of its product from the government’s top health officials.

The message they were sending to parents is: here is a product that’s so precious, so invaluable to the well-being on our Hong Kong babies, that we will guarantee your supply. All this endorsement came without a single word from either the Food and Heath Bureau or the Department of Health about the real risks associated with formula feeding. This policy was also at the expense of the government’s own evidence-based policy of promotion breastfeeding. No amount of advertising dollars can buy you that kind of credibility. And given that Hong Kong’s lifetstyle habits are often emulated over the border, the ripple effect of this credibility into the mainland market is potentially enormous.

It seems the party is coming to an end, however. Secretary for Food and Welfare Ko Wing-man, speaking on a radio show on September 24 2013, said that the government was pondering abandoning the two-tin limit, if they were reassured that there was enough supply for local mothers.

Currently the industry is required to maintain 1.65 million cans of baby formula a month for local parents: all this formula for the babies and young children of a seven-million strong population. The formula industry’s spokesperson said the industry would welcome lifting the quota and that it had no problem maintaining the required level of stock.

So for Hong Kong’s legion of formula-fed babies, it seems that it’s heads they lose, tails the formula industry wins. Meanwhile the government’s guardians of public health continue to squander the opportunity to reach out to new and prospective parents with information about breastfeeding and warnings about the risk of using formula. The government quietly ignores its own stated public health goals for the support of big business and a quiet life without complaints from parents.

Public health issues in Asia

Kill a GSK chicken to frighten the monkeys

The recent revelations about fraud and corruption at GlaxoSmithKline’s China operations have thrown up more questions than answers. How much did the senior management, both in China and at corporate headquarters know? Are the four Chinese nationals currently being held by authorities the only culprits within the company? Why did the authorities zoom in on GSK? And who’s next?

On Transparency International’s Corruption Perception Index China dropped from 75th in 2011 to 80th out of 174 in 2012 and it is hard to be surprised by reports of corruption in China, at least when you are over the border here in Hong Kong where there are daily news reports of mainland Chinese corruption big and small.

Some commentators have asserted that the investment community has been too phlegmatic about the impact of corruption in China on GSK: after all, it only accounts for 3% of the firm’s global sales.  But listening in on the July 24 quarterly results investment analyst webcast, that wasn’t my impression.

In his opening remarks, chief executive officer Andrew Witty reiterated what had already been said by company spokespeople, adding his own personal sense of “deep disappointment.” Despite asking the analysts to understand that he could give no more information at this early stage, and clearly hoping to focus on the company’s earnings news and product pipeline, one after the other analysts pressed him for more colour about the implications for their China business; what it said about GSK’s control over its sales force in other emerging markets; and the earnings implications of what Witty described as potentially “changing our business model in China.”

Any international pharmaceutical industry executive engaging with China must be aware of the role that corruption plays in China’s health system. For the uninitiated, Reuters explains it well: when a fresh graduate from medical school earns the same as a taxi driver – approximately RMB3,000 a month (£317, $489, €368) – the balance needed to make a decent living has to come from somewhere.

A much-touted editorial from the state news agency Xinhua on July 24 called on international players to raise the ethical bar for China by shouldering their “due responsibilities to bid farewell to malpractice, setting a good example and serving as a wake-up call for domestic pharmaceutical companies.” That’s easier said than done when the rules of engagement are determined by the structural weaknesses of the Chinese health system itself.

My guess is that senior management at GSK were aware of the lubricating function of backhanders in China’s pharmaceutical industry but didn’t have the inside knowledge required to fully understand the mechanisms by which the transactions are conducted. Witty made an oblique reference to the peculiarities of China’s healthcare environment when he told analysts that “there are many unique characteristics, to state the obvious, about China and, therefore, some of the circumstances that may exist in China simply are not replicated elsewhere.”

So now that fraud at GSK’s China operations has been exposed, the obvious question is: who’s next? There are reports of AstraZeneca and Belgian biopharmaceuticals firm UCB receiving investigative visits from the authorities, and the Xinhua editorial warned that other domestic and international pharmaceutical firms could come under the same harsh spotlight as GSK. Not necessarily. A Chinese idiom sums up the state’s approach to keeping control: kill a chicken to frighten the monkeys. The scale of the alleged corruption (£320 million worth of cash and sexual favours), the public apology by GSK’s head of emerging markets Abbas Hussain, the sudden departure of the head of China operations Mark Reilly and his replacement by vice president for Europe Hervé Gisserot, the likelihood that GSK will lower its prices, will have focused the minds of senior management across the industry in China.

Given that corruption is so widespread in China, one may wonder why the pharmaceuticals industry has been the one in the authorities’ cross hairs. It’s not the first. Booming demand for imported infant formula (the memories of thousands of children sickened and six dead due to melamine poisoning from domestic formula in 2008 are slow to fade) prompted the National Development and Reform Commission to launch an anti-trust investigation into the infant formula sector targeting foreign companies. It was launched on July 2 and a day later Wyeth Nutrition lowered its prices for 2014 by an average of 11%. Now it’s Big Pharma’s turn.

As the income gap widens, China is facing widespread social turmoil, and public distrust of officials exposed time and again, often through social media, as corrupt. The country’s health system is going through a significant process of reform that in time should lead to universal access to healthcare. In the meantime money still talks and the pressure of out-of-pocket expenses for health services is felt across the social spectrum. What better way to unite the populace than to be seen rooting out corruption in the industry that holds the health of the nation in its hands?

Jane Parry is a Hong Kong based public health and medical journalist and researcher.