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

【香港是全球最長壽人口 -- 但這是一個假象嗎？】

非常榮幸與「健康公平」一代宗師Micahel Marmot爵士合寫了這篇探討香港何以是全世界最長壽人口的文章，刊登於美國國家醫學學院(National Academy of Medicine)的官方期刊"NAM Perspectives"中。文章中，我們嘗試提出幾個主要原因，亦嘗試為某些解釋提出異議。

我們嘗試問：這是否與整體經濟發展有關？但其他經濟比香港更發達的地方也沒有香港人口那麼長壽，因此，必然有其他因素在影響港人的健康。我們亦在問：傳統的理解上，在發達國家中，貧富懸殊越厲害，整體健康越差；但這關聯亦未明顯出現於香港中，為甚麼呢？顯然有其他重要的因素向貧富懸殊對健康的負面影響作出了保護作用。我們發現明顯的分別是香港比英國及美國在主要健康及社會指標上都做得更好，包括：較低的嬰兒死亡率、較低的青少年懷孕出生率、較高的青少年就讀與就業比率、較低的兇殺與暴力比率以及較低的犯罪率（儘管香港近半年見證了歷史上最動蕩的時刻）等。一直都有人提出的可能原因包括非西方的飲食、香港較小和集中的基建環境在各式各樣日常生活中所帶來的方便、以及不極端的氣候。話雖如此，香港的人均肉類消耗量是全球之冠，而有其他擁有温和氣候的國家的人民亦不那麼長壽。亦有人提出港人長壽可以歸功於公營醫療系統的存在，但我們都知道大部份的人是病了才會出現於醫療體制之中，而且研究更指出公營醫療系統未能有效解決貧窮人得不到適切醫療的問題（因為經濟原因得不到適切醫療的香港人口高達8.4%）。換句話說，港人長壽是因為香港擁有好的醫療體制一說有欠說服力。

我們在文中再提出兩個潛在但被人忽視的原因 -- 1) 所謂的年代效應，即是現在步入人生最後階段的都是戰後生存下來的強人，他們的後代會否像他們一樣擁有那麼強的適應及生命力是一個疑問；2) 我們看到的是一個平均數，一個被一小撮極富裕的人拉高了的平均數，而事實上，在香港越貧窮的人，健康普遍來說便越差。

因此，我們要對全球最長壽人口這個美譽非常警惕，尤其確實存在於香港的多方面社會不公會累積下來，為未來的健康帶來負面的影響。

（這是中文大學成立健康公平研究所(CUHK Institute of Health Equity)後的首篇發表文章。）

Link: https://nam.edu/people-in-hong-kong-have-the-longest-life-expectancy-in-the-world-some-possible-explanations/

#SirMichaelMarmot
#HealthEquity
#HongKong
#Lifeexpectancy
#CUHKInstituteofHealthEquity

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