今早為Asian Medical Students Association Hong Kong (AMSAHK)的新一屆執行委員會就職典禮作致詞分享嘉賓，題目為「疫情中的健康不公平」。
感謝他們的熱情款待以及為整段致詞拍了影片。以下我附上致詞的英文原稿：

It's been my honor to be invited to give the closing remarks for the Inauguration Ceremony for the incoming executive committee of the Asian Medical Students' Association Hong Kong (AMSAHK) this morning. A video has been taken for the remarks I made regarding health inequalities during the COVID-19 pandemic (big thanks to the student who withstood the soreness of her arm for holding the camera up for 15 minutes straight), and here's the transcript of the main body of the speech that goes with this video:

//The coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, continues to be rampant around the world since early 2020, resulting in more than 55 million cases and 1.3 million deaths worldwide as of today. (So no! It’s not a hoax for those conspiracy theorists out there!) A higher rate of incidence and deaths, as well as worse health-related quality of life have been widely observed in the socially disadvantaged groups, including people of lower socioeconomic position, older persons, migrants, ethnic minority and communities of color, etc. While epidemiologists and scientists around the world are dedicated in gathering scientific evidence on the specific causes and determinants of the health inequalities observed in different countries and regions, we can apply the Social Determinants of Health Conceptual Framework developed by the World Health Organization team led by the eminent Prof Sir Michael Marmot, world’s leading social epidemiologist, to understand and delineate these social determinants of health inequalities related to the COVID-19 pandemic.

According to this framework, social determinants of health can be largely categorized into two types – 1) the lower stream, intermediary determinants, and 2) the upper stream, structural and macro-environmental determinants. For the COVID-19 pandemic, we realized that the lower stream factors may include material circumstances, such as people’s living and working conditions. For instance, the nature of the occupations of these people of lower socioeconomic position tends to require them to travel outside to work, i.e., they cannot work from home, which is a luxury for people who can afford to do it. This lack of choice in the location of occupation may expose them to greater risk of infection through more transportation and interactions with strangers. We have also seen infection clusters among crowded places like elderly homes, public housing estates, and boarding houses for foreign domestic helpers. Moreover, these socially disadvantaged people tend to have lower financial and social capital – it can be observed that they were more likely to be deprived of personal protective equipment like face masks and hand sanitizers, especially during the earlier days of the pandemic. On the other hand, the upper stream, structural determinants of health may include policies related to public health, education, macroeconomics, social protection and welfare, as well as our governance… and last, but not least, our culture and values. If the socioeconomic and political contexts are not favorable to the socially disadvantaged, their health and well-being will be disproportionately affected by the pandemic. Therefore, if we, as a society, espouse to address and reduce the problem of health inequalities, social determinants of health cannot be overlooked in devising and designing any public health-related strategies, measures and policies.

Although a higher rate of incidence and deaths have been widely observed in the socially disadvantaged groups, especially in countries with severe COVID-19 outbreaks, this phenomenon seems to be less discussed and less covered by media in Hong Kong, where the disease incidence is relatively low when compared with other countries around the world. Before the resurgence of local cases in early July, local spread of COVID-19 was sporadic and most cases were imported. In the earlier days of the pandemic, most cases were primarily imported by travelers and return-students studying overseas, leading to a minor surge between mid-March and mid-April of 874 new cases. Most of these cases during Spring were people who could afford to travel and study abroad, and thus tended to be more well-off. Therefore, some would say the expected social gradient in health impact did not seem to exist in Hong Kong, but may I remind you that, it is only the case when we focus on COVID-19-specific incidence and mortality alone. But can we really deduce from this that COVID-19-related health inequality does not exist in Hong Kong? According to the Social Determinants of Health Framework mentioned earlier, the obvious answer is “No, of course not.” And here’s why…

In addition to the direct disease burden, the COVID-19 outbreak and its associated containment measures (such as economic lockdown, mandatory social distancing, and change of work arrangements) could have unequal wider socioeconomic impacts on the general population, especially in regions with pervasive existing social inequalities. Given the limited resources and capacity of the socioeconomically disadvantaged to respond to emergency and adverse events, their general health and well-being are likely to be unduly and inordinately affected by the abrupt changes in their daily economic and social conditions, like job loss and insecurity, brought about by the COVID-19 outbreak and the corresponding containment and mitigation measures of which the main purpose was supposedly disease prevention and health protection at the first place. As such, focusing only on COVID-19 incidence or mortality as the outcomes of concern to address health inequalities may leave out important aspects of life that contributes significantly to people’s health. Recently, my research team and I collaborated with Sir Michael Marmot in a Hong Kong study, and found that the poor people in Hong Kong fared worse in every aspects of life than their richer counterparts in terms of economic activity, personal protective equipment, personal hygiene practice, as well as well-being and health after the COVID-19 outbreak. We also found that part of the observed health inequality can be attributed to the pandemic and its related containment measures via people’s concerns over their own and their families’ livelihood and economic activity. In other words, health inequalities were contributed by the pandemic even in a city where incidence is relatively low through other social determinants of health that directly concerned the livelihood and economic activity of the people. So in this study, we confirmed that focusing only on the incident and death cases as the outcomes of concern to address health inequalities is like a story half-told, and would severely truncate and distort the reality.

Truth be told, health inequality does not only appear after the pandemic outbreak of COVID-19, it is a pre-existing condition in countries and regions around the world, including Hong Kong. My research over the years have consistently shown that people in lower socioeconomic position tend to have worse physical and mental health status. Nevertheless, precisely because health inequality is nothing new, there are always voices in our society trying to dismiss the problem, arguing that it is only natural to have wealth inequality in any capitalistic society. However, in reckoning with health inequalities, we need to go beyond just figuring out the disparities or differences in health status between the poor and the rich, and we need to raise an ethically relevant question: are these inequalities, disparities and differences remediable? Can they be fixed? Can we do something about them? If they are remediable, and we can do something about them but we haven’t, then we’d say these inequalities are ultimately unjust and unfair. In other words, a society that prides itself in pursuing justice must, and I say must, strive to address and reduce these unfair health inequalities. Borrowing the words from famed sociologist Judith Butler, “the virus alone does not discriminate,” but “social and economic inequality will make sure that it does.” With COVID-19, we learn that it is not only the individuals who are sick, but our society. And it’s time we do something about it.

Thank you very much!//

Please join me in congratulating the incoming executive committee of AMSAHK and giving them the best wishes for their future endeavor!

Roger Chung, PhD
Assistant Professor, CUHK JC School of Public Health and Primary Care, @CUHK Medicine, The Chinese University of Hong Kong 香港中文大學 - CUHK
Associate Director, CUHK Institute of Health Equity

#耶魯歧視白人及亞裔 這宗可能是近年最有影響的教育公平判決，打兩年官司美國司法部終於有結果了：耶魯涉歧視白人及亞裔美國人。

申訴稱，耶魯大學的白人及亞裔入學招收標準要高於其它種族，這些大學還使用了非法的配額制度來限制白人及亞裔美國學生的數量，優惠非裔及拉丁裔等民族。過去配額制是用於鼓勵多元族裔收生，讓更多少數族裔可以以較低分數入Ivy league。

雖然美司法部判未有明言其他院校的配額制、降低門檻等做法是不合法，但看來司法部有意限制這些措施的濫用，以防歧視白人及亞裔。耶魯實踐這些措施時，應該是無限制地，多層強化了種族因素。判斷認為這些措施必須乎合以下原則：

👉要求大學僅以“靈活，非機械的方式”將種族作為“加”因素。 Grutter v. Bollinger, 539 U.S. 306, 334 (2003）
👉種族不能是“決定性的實踐”。 Gratz, 539 U.S. at 272 & n.19; accord Grutter, 539 U.S. at 337.
👉換句話說，種族不能成為申請的“定義特徵”或決定申請人是否被錄取的“主要因素”。 Grutter, 539 U.S. at 317, 320, 337.
👉此外，根據《平等保護​​條款》330條，“種族平衡”是“明顯違憲的”。 因此也違反了《民權法》第六章。
👉招生計劃不能“給不屬於偏愛的種族和族裔成員的個人造成不必要的負擔”。 最後，大學的“種族入學政策必須及時加以限制”。

判決認為

「對於絕大多數申請人而言，亞裔美國人和白人只有具有相同學術能力的非裔美國人申請錄取可能性的十分之一至四分之一。 耶魯大學每年都會根據種族來拒絕數十名亞裔和白人申請人。

儘管最高法院裁定，接受聯邦資助的大學可以會在某些有限的情況下將申請人的種族視為眾多收生因素之一，但司法部發現耶魯大學對種族因素的使用絕非限制性。 耶魯大學在錄取過程的多個步驟中都考慮到申請人的種族，這導致種族因素對申請人影響倍增，讓耶魯在種族上平衡。」

//For the great majority of applicants, Asian Americans and whites have only one-tenth to one-fourth of the likelihood of admission as African American applicants with comparable academic credentials. Yale rejects scores of Asian American and white applicants each year based on their race, whom it otherwise would admit.

Although the Supreme Court has held that colleges receiving federal funds may consider applicants’ race in certain limited circumstances as one of a number of factors, the Department of Justice found Yale’s use of race is anything but limited. Yale uses race at multiple steps of its admissions process resulting in a multiplied effect of race on an applicant’s likelihood of admission, and Yale racially balances its classes.//

//Narrow tailoring requires, among other things, that a university use race only as a “plus” factor “in a flexible, nonmechanical way.” Grutter v. Bollinger, 539 U.S. 306, 334 (2003). Race cannot be “decisive in practice.” Gratz, 539 U.S. at 272 & n.19; accord Grutter, 539 U.S. at 337. In other words, narrow tailoring requires that race cannot be “the defining feature” of the application or “the predominant factor” that decides an applicant’s admission. Grutter, 539 U.S. at 317, 320, 337. Additionally, “racial balancing” is “patently unconstitutional” under the Equal Protection Clause, id. at 330, and thus also violates Title VI. In addition, an admissions program cannot “unduly burden individuals who are not members of the favored racial and ethnic groups.” Id. at 341 (citation omitted). Finally, a university’s “race-conscious admissions policies must be limited in time.” Id. at 342.//

https://www.justice.gov/opa/pr/justice-department-finds-yale-illegally-discriminates-against-asians-and-whites-undergraduate

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