26 Jun 2023
Dr PANG Fei-chau
Commissioner for Primary Healthcare, Health Bureau
Dear Dr Pang,
I want to begin this letter by acknowledging the work you have been doing on geriatric and community medicine and congratulating you on your new position as primary healthcare commissioner to lead the Primary Healthcare Office in Hong Kong. It is delightful to know that the Government aims to shift the healthcare system’s focus to a community-based one and pay more attention to prevention (HKSAR press release,2022). However, as a former frontline healthcare provider with over ten years of experience in local hospitals and communities, I am deeply concerned about the missing link and discussion on understanding chronic disease distribution and reviewing strategies in providing personalised care. With the motivation to learn how sociocultural processes affect health, I am studying for a postgraduate degree in anthropology at University College London. It has been a learning journey to reflect on the biomedicine approach and think beyond the individualised and risk identification in the continuity of care. I hope to offer additional insights and propose recommendations for understanding the relationships between individual illness experience and disease epidemiology, which would benefit in-service planning and implementation.
Hong Kong primary healthcare
In your recent article, you highlighted the importance of multidimensional development to have prevention-focused care (Pang et al., 2023). Undoubtedly, prevention-focused care is a strategy for tackling the challenges of the ageing population. In 2039, 3 million people are expected to live with chronic diseases such as hypertension, diabetes, and obesity (Health Bureau, 2022). The report emphasises the need for primary healthcare and the roles of communities in chronic disease prevention, early identification, and timely intervention. The government had sped up the development, such as establishing district health centres. However, there have been criticisms regarding the unsatisfactory performance and utilisation of District Health Centres (DHCs), with calls for a more transparent review and evaluation of service data. There is concern whether the health system can provide sustainable care to the population (Lai, 2023).
In the Primary Healthcare Blueprint, your authority highlighted the significance of having a systematic and coherent platform to motivate the community to manage their health. Through promoting “Family Doctor for all”, your team aims to cultivate a sustainable care relationship between patients and their family doctors by reinforcing protocol-driven care pathways, strategic purchasing, and health screening service promotion. Undoubtedly, these may facilitate affordable and accessible healthcare services. However, the current strategies neglect the important lessons learnt in the past 30 years of primary care development. The proposed primary healthcare blueprint also overlooks the biosocial perspective, which helps us understand the countless facets of people’s social lives that impact their health and wellbeing. Without a biosocial perspective, a holistic analysis of the person and their conditions is lost. I have identified the opportunities to consider extra strategies before launching the “Chronic Disease Co-care Scheme” and strengthen the existing medical-social collaboration. I urge you to:
- Evaluate the current population health methodology, explore the social roots of chronic disease distribution and include the biosocial approach in studying chronic disease distribution patterns.
- Review and strengthen the competency of care workers in formulating care plans.
Without using a biosocial lens to understand the whole picture of a patient’s life, we risk falling back into failures of the past and ineffective prevention-focused care strategies. In the following sections of this letter, I provide examples and case studies to demonstrate the effectiveness of an anthropology-informed biosocial approach and how it can be adopted in Hong Kong.
Addressing Syndemics will contribute to the knowledge of chronic disease in the HK context
The syndemics approach offers an anthropological perspective to investigate how social, cultural, political, and economic environments impacting health (Singer 2017). Universalised scientific models and evidence construct knowledge in biomedicine. Traditionally, health improvement emphasises using a behavioural approach and transtheoretical model of change (Sporakowski, 1986). However, a more comprehensive approach to understand how social and environmental factors impact lifestyle and pose obstacles in managing the disease. Anthropology provides an interpretative approach and discusses how the local context and developmental history might shape different biological presentations. Singer (2017) further supports this, stating that a biosocial framework may facilitate the understanding of the intensity and relationship between disease and adverse social environments. While the field of biomedicine has long studied comorbidity and multimorbidity on a population level, it falls short in explaining the social causes, individual-level experience and distribution across the population.
In Hong Kong, health inequalities have been studied under social determinants of health in recent years. The Primary Healthcare Blueprint also acknowledged the correlation between chronic disease and wider determinants of health (Health Bureau, 2022). Led by Sir Michael Mammot, the Institute of Health Equity identified that health inequalities in Hong Kong may be exaggerated by long working hours, lower socioeconomic backgrounds, and loneliness (Institute of Health Equity & CUHK Institute of Health Equity, 2022). Public health research attempted to study the relationship of objective socioeconomic factors, health, and quality of life (Ko et al., 2006). However, most studies have only explored the differences in the prevalence of singular diseases or access to service among vulnerable groups but have yet to find the relationship between the social factors and multiple diseases themselves (Tan et al., 2021). Moreover, the current methodology in official government reports provides only a limiting perspective of population health, potentially resulting in ineffective and mismatched intervention planning.
Here, I will provide some examples of how syndemics approach benefit our insights. In a study on numerous chronic illnesses by Ecks (2021), multiple chronic diseases such as depression, diabetes, and gastric disorders, are found to have a connection with poverty, trauma, miscommunication, and polypharmacy. Emily Mendenhall conducted an ethnography on comorbidity in multiple countries, including India, the US, and South Africa. Her study of Mexican immigrants in Chicago illustrated that social and economic construct the epidemic of diabetes and depression (Mendenhall, 2012). Not only does this research help establish associations between diseases, but the narrative evidence also demonstrates the association with nonadherence to treatment. The application of this study is particularly relevant in examining complex topics, especially in multimorbidity. Kordowicz and Hack Polay (2021) adopted a rapid ethnography approach in studying the experiences of care providers and patients with multimorbidity and analysed the challenges and community assets. This approach presents an opportunity to align with the Blueprint’s aim of coordinating and achieving community-based care.
By gaining an understanding of the interaction between contextual factors and multiple diseases, we can plan for an effective and practical prevention-based care. Furthermore, this would help you and your team to identify the target group on a specific promotion strategy and coordinate relevant social and community resources to address the broader determinants of disease. Finally, after discussing the importance of studying the experience of comorbid conditions, I would like to emphasize the importance of reviewing and enhancing the practice of care workers.
Future possibilities in integrating biosocial approach: beyond biomedicine
The primary care blueprint mentioned the introduction of the “Chronic disease co-care scheme”, offering subsidies to the public for medical screening and treatment of hypertension and diabetes. Undeniably, this scheme improves the affordability of care. However, it is important to note that screening and treatment alone may not be sufficient to address the comorbid conditions mentioned earlier or acknowledge social suffering. As stated in your authority’s primary care framework, the clinical protocol plays a significant role in advising patients on lifestyle modifications such as diet, exercise, and weight control. While the advice in the clinical protocol is sound and evidence-based, it does not adequately address the potential limitation imposed by social and environmental factors, nor does it provide flexible alternative advice. Ecks’ ethnography on patients’ experience with general practitioners (GPs) found that patients could only inquire about some of their complex conditions when GP occasionally mentioned only a specific ailment. Consequently, individuals need to establish the connections between their physical condition, biomarkers, and diet themselves. Studies have supported the shift in clinical medical practice from focusing solely on a single disease to embracing a complementary approach (Coventry, 2015; Mercer et al., 2012).
In the current primary healthcare system model in HK, self-management is stressed in chronic disease management, implying that people shall exert control over their health. However, scholars have critiqued this focus on individual responsibility and create the risk of producing blame (Potter et al., 2017). Regarding the previous comment on the behavioural approach, it often neglects the importance of a patient’s social support and social capital. A trustworthy and approachable social support system is crucial for our well-being (Anon, 2008), while social capital encompasses the bonds within the family and the community. To achieve the community-based and family-centric approach mentioned in the Blueprint, we should start by ensuring all care providers utilise a personalised communication approach with people. Potters (2017) suggested that coping is collaborative process, and healthcare services play a crucial role in this regard. They provided examples of positive outcomes for clients under the proactive assistance of health practitioners. In these cases, health practitioners advocated for patients by discussing return-to-work plans with the employer and connecting them to social services. Doctors and nurses are typically the first point of contact for patients. In addition to addressing the physical and psychological aspects, we should introduce an enhanced approach that considers the social and cultural dimensions of the patients. Paul Farmer (2008) explained that using social interventions appropriate to address individuals’ stuggles is effective. To understand these struggles, care workers should adopt an approach that seeks to understand individuals’ lived experiences. The explanatory model approach, integrated into health mind mapping, has been reported as a useful tool in health communication (Buitron de la Vega et al., 2018). By adopting these measures, care providers can hopefully identify the causes affecting patients’ health and wellbeing during consultations, discuss emerging needs and priorities with patients, and ultimately co-produce a personalised care plan.
Primary healthcare has been developed for almost 30 years, and we should learn from past lessons and avoid repeating our mistakes. I believe anthropological approaches, such as long-term and rapid ethnography, can help address emerging needs and facilitate informed decision-making. The findings from these approaches would help us all acknowledge and understand the broader social constraints and cultural differences, which are essential in designing a complementary approach to care.
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