Blogs posted for Asian Development Bank (ADB)

Without incentives, health data sharing systems don’t work for patients

Published July 1 2016

In the multi-payer systems that characterize primary health care in Asia and the Pacific, both developed and developing countries suffer a way of delivering care that works against data sharing.

Even in Hong Kong, China—which has one of the highest standards of health care in the region—services are rendered without a sharable electronic medical records system, as I witnessed in a recent encounter with the medical profession that gave me first-hand insight into the matter.

Like 70% of Hong Kong’s population, I get my primary health care in the private sector. After a recent well-woman check-up with my family doctor, she sent me to a specialist, with a printed letter and photocopies of my test results. The specialist subsequently typed up and posted back his reply, explaining his diagnosis and course of action. Now both doctors had the same sheets of paper in my medical records. Meanwhile, the specialist my doctor recommended was not the same one who had provided my obstetric care, as well as periodic check-ups, over the past 17 years.

Now there were three doctors, with consulting rooms within walking distance of each other, all of who know me, and had important information about my reproductive health (and illness)… and no formal way to share the data with each other.

So I shared the data myself – I delivered the referral specialist’s handwritten notes to my longstanding gynecological care provider so he could put them in his paper records. This is what happens in Hong Kong’s private medical sector, which delivers the most expensive—and arguably the most patient-centric—primary care in the territory. The only reason all three of these doctors are now up to speed on my health is because I took it upon myself to make that happen. This is not a typical way that patients in Hong Kong deal with their health records, if they even see them at all. Usually this data is simply not shared with them or anyone else because there is no mechanism for that to happen.

Had I been part of the minority who access primary care at a Hospital Authority (HA) outpatient facility, every encounter with any health worker would have been logged in the HA’s excellent electronic medical records system. My health data would be available for easy retrieval at any point in the future. What the HA’s system can’t do, though, is tap into private sector medical records, where the vast majority of primary care happens in Hong Kong.

In March 2016 the Hong Kong, China government launched its Electronic Health Record Sharing System. It didn’t seem to create much of a splash, so I was intrigued. There is a system for data sharing after all. But leaving aside the baffling instructions for patient registration, there is another major constraint – I can register as a patient, but there is no mechanism for me to check whether or not any of my private providers have signed up, and even participating providers may not be able to share all the data they have due to “technical constraints and readiness.”

When I asked my providers, one specialist supported the idea of patient data sharing and praised the HA system, but complained the registration process was onerous and the perceived benefit to him and his patients was minimal.

Hong Kong, China is a multi-provider, multi-payer health care environment where public hospitals compete with private primary and specialist care providers. There is thus a strong disincentive for the sectors to share patient data they consider to be their proprietary information. This lack of data sharing is one key reason why Hong Kong’s primary care financing model is poor value for money.

Patients are not in a position to drive the creation of a central medical records database. Public trust in the Hong Kong government, currently at its lowest level since the 2003 SARS outbreak, also undermines efforts to reassure patients that their data will be kept safe and confidential. Moreover, the government’s data sharing system only offers a (somewhat clunky) mechanism for sharing data, but does nothing to address the disincentives to sharing it.

A robust, genuinely population-wide medical data sharing system with strong and transparent governance helps identify patients uniquely and confidentially whenever and wherever they access health care. Providers can access the information they need–and only that information–to provide continuity of care. This has enormous positive implications for public health, and other Asian countries should be aware of this.

The problem can only be effectively addressed by government intervention that compels all public and private health service providers to share their data, promote continuity of care, and put their patients’ wellbeing first.

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.