Climate change and public health are interconnected; as climate-related health problems proliferate across the world, healthcare systems around the world are faced with unprecedented challenges. The problems in Hong Kong’s collapsing healthcare system today serve as a perfect lesson for the world; not only do we need to put more effort into building up the resilience of citizens, but we also need to go beyond resilience to change the very social and climate conditions that affect our public health. This article argues that governments need to put health at the centre of social and climate action.

Given the overwhelming scientific evidence today that points to the health impacts of climate change, health policy agendas around the globe are now beginning to realise how big of a public health threat climate change is to humanity. It is understandable, therefore, that health emerged as a key topic in the COP26 discussions. The COP26 Health Programme was established to “prioritise health and equity in the international climate movement and sustainable development agenda.” Within the programme, an Adaptation Research Alliance (ARA) was created to “catalyse and scale investment in action-oriented research and innovation for adaptation that strengthens resilience in communities most vulnerable to climate change.”

It is also common to find research illustrating how the health effects of climate change are worse for developing countries. However, this has unhelpfully reinforced a kind of “developed-country complacency syndrome”: able to escape the worst effects of climate change, many developed countries do not feel like they need to do much.

Hong Kong also suffers from this syndrome. With an impressive score of 0.949 on the Human Development Index (HDI), Hong Kong’s standard of living is ranked 4th in the world. Many Hongkongers really do not have to worry about the effects of climate change in this city. Although Hong Kong is experiencing stronger and stronger typhoons and record-high temperatures are broken almost every year, most people are relatively unaffected.

But one need not have experience of something as serious as the destruction of their home to feel the health effects of climate change. In fact, they do impact our everyday lives, albeit subtly.

The Everyday Effects of Climate Change on Hong Kong Public Health

In Hong Kong, for every increase of 1C above 29C, hospitalisation rate increases by almost 5% and mortality by almost 2% –  which amounts to approximately 1,000 more deaths per year. This is because temperature rise indicates rising greenhouse gas emissions and these gases have significant impacts on cardiovascular (relating to the heart), respiratory (relating to lungs), and integumentary (relating to the skin) health. During the hot summers, many people feel dizzy too.

Climate change is also facilitating the spread of communicable (infectious) diseases in Hong Kong. Changing rainfall patterns have been conducive to the transmission of vector-borne diseases such as dengue fever, hand, foot and mouth disease (HFMD), and malaria.

Rising temperatures can also affect mental health. According to a study, they can be “direct or indirect, short-term or long-term, … or even transmitted to later generations”. Consequences also vary in severity, ranging from “milder” symptoms of distress to more serious clinical disorders such as depression or even suicide. In fact, haze events (such as smoggy days) are already enough to increase mortality risk by almost 3 per cent in Hong Kong; for those with existing mental disorders, the effects are far worse.

However, while everyone is affected, certain social groups are disproportionately more affected than others.

The Health Inequalities of Climate Change in Hong Kong

As a report published by the Institute of Health Equity of the Chinese University of Hong Kong (CUHK IHE) finds, economic inequality is a huge determinant of health inequality in Hong Kong. With a striking Gini coefficient of 0.539, Hong Kong is in the top 10 in the world in terms of income inequality. As Hong Kong’s temperatures rise, the city ’s poorest suffer the most. Unable to afford quality housing, many live in terribly conditioned subdivided flats with poor air quality, hygiene and suffocating temperatures. These living spaces have also become breeding grounds for diseases as mosquitoes are found swarming them all the time.

More than 30% of Hong Kong’s elderly live in poverty; with the pandemic still in force, this figure has likely risen. Without a stable source of income and surging house prices, many have become “cardboard grannies and grandpas” with nowhere but a cardboard box to live in. Deprived of a decent environment to live in and without anyone to be looked after by, they are most vulnerable.

But these health inequalities only show half of the picture. For instance, while hospitalisation rates may be a useful indication of the severity of health problems, it fails to account for the fact that there are people who have health problems but do not/are not able to go to hospital. This is evident within ethnic minority communities, as cultural and linguistic barriers (on top of financial barriers) often hinder their ability to access local healthcare services.

climate change and public healthImage by: Hong Kong Hospital Authority

A Collapsing Hong Kong Healthcare System

Despite ranking 8th globally on the World Index of Healthcare Innovation, Hong Kong’s healthcare measurement in the “Quality” category has been labelled “poor”, as it suffers from overcrowding and a serious deficit of healthcare workers. According to local think tank Our Hong Kong Foundation (OHKF), there are less than two doctors for every 1,000 people, a statistic significantly below the Organisation for Economic Co-operation and Development (OECD) average of 3.5 and lagging way behind regional rival Singapore (2.5). Hong Kong’s healthcare expenditure levels are also low in comparison with OECD countries: total health expenditure as a percentage of GDP is around 7% (2% points below OECD average). 

The OHKF has described Hong Kong’s healthcare system as “hanging on a rope stretched too thin”. The reasons show that such a claim is far from an exaggeration:

There is an increase in the attrition rate of doctors and nurses in recent years, partly because of growing emigration out of the city. As perceptions of job precarity grow (for work-related, economic and political reasons), the manpower within the healthcare sector faces more uncertainty than ever.

On one hand, this is a testament to the fact that Hong Kong has the world’s longest life expectancy of 85 years. On the other, it is projected that the proportion of citizens in Hong Kong older than 65 will be 27% by 2033 and a staggering 37% by 2066. Co-Director of PolyU’s Institute of Active Ageing under the Faculty of Health and Social Sciences Professor Teresa Tsien believes that, as people live longer, “the chances of dependency on medical, welfare and other services will be greater.”

Climate change will make things more complicated. More people today, young and old, require medical attention. Even if the number of medical staff continues to increase, it may still struggle to keep up with the rate of increase of vulnerable people in Hong Kong.

Hong Kong has a dual public-private healthcare system. However, their disparities are great. The number of doctors in private and public hospitals is approximately the same – but public hospitals provide services to 90% of in-patients in Hong Kong. It is predicted that more doctors in the public sector will “defect” to the private sector because of better pay, working hours, and conditions. With decreased manpower, the workload of those who remain in the public sector will only increase, and this will lead to even longer waiting times. This creates a vicious cycle.

Hong Kong’s public healthcare focus is weighted significantly towards curative care, which is mainly concerned with curing and rehabilitating patients. In the case of climate health, curative approaches are certainly important, but they only cure the “symptoms” and not the “disease”, i.e. climate change itself.

Although the WHO describes primary care as being “the first level of contact of individuals, the family and the community with the national health system” and therefore fundamental to any healthcare system, Hong Kong’s primary care remains inadequately provided. Most providers are private (70% of market share) and are accessed exclusively by the rich. In contrast, there are only 73 public clinics that provide primary care to a population of 7.5 million; they also tend to be underfunded. Although vouchers have been introduced to support access, a lack of publicity has deemed the programme quite ineffective

It is no surprise that Hong Kong’s curative-oriented healthcare system is collapsing. So what can be done?

Mentality Shifts Needed for Hong Kong’s Healthcare System

Today, global health policy discourses are realising the need to build “climate-resilient health systems” that can “anticipate, prepare for, and respond to hazardous events, trends, or disturbances related to climate”.

In Hong Kong, health policy discourses have recognised the need to go beyond curative approaches towards preventive and promotive approaches. For example, public health academic Emily Chan argues that the government should devote more resources to enhancing Hong Kong’s risk reduction, preparedness response and recovery abilities, which involves workforce training and promoting public health literacy in light of growing climate-induced weather events in Hong Kong.

Government and non-governmental bodies have also stepped up efforts to foster public resilience. The Hong Kong Observatory’s “MyObservatory” mobile app, for example, allows citizens to access live weather information so that they can be better prepared for weather events. Another example can be found in the development of the Hong Kong Air Quality Health Index (HK AQHI) app by the Environment Protection Department (EPD), which provides citizens with live information about air quality when they travel.

But Hong Kong’s healthcare challenges are not simply issues of manpower and literacy. Even though the government has encouraged a lot more public-private partnerships (PPPs) to improve quality and efficiency, they only upgrade Hong Kong’s “defensive capabilities”. Professor Veronika Schoeb at the Department of Rehabilitation Sciences at PolyU argues, “healthcare practitioners have only minimal control over health-related social issues such as education, work environment, or housing.” As a result, the underlying social determinants of public health remain unconsidered. In framing action only in terms of keeping pace with the rate of climate change (which is common around the world), it seems as if we are only trying to “delay the inevitable”.

Hence, healthcare systems need to be more active in other areas of policy. For Hong Kong, public health should be at the centre of different forms of social justice – which includes climate justice.

climate change and public healthImage by: GovHK

A Climate-Sensitive Healthcare System

The COP26 Special Report on Climate Change and Health provides useful suggestions for within-sector and cross-sector developments that may be appropriate for Hong Kong.

Apart from curative care, the best healthcare systems in the world have a robust primary healthcare infrastructure. Beyond expanding the capacity of hospitals or upgrading medical equipment, Hong Kong needs to diversify its healthcare services beyond curative care. It can learn from countries such as Canada and Finland in expanding and strengthening primary care services. The benefits are profound: as the OECD argues in a report published in 2020, Realising the Potential of Primary Care, “[p]rimary health care can save lives and money while levelling the playing field to achieve more equal access to medical treatment”.

For healthcare services to be used wisely, community engagement, which is found to be quite poor in recent years (because of politics and the pandemic), is important. The majority of community engagement today are organised by non-governmental organisations. Taking a backseat, the government has failed to create a coherent vision and provide appropriate support to these programmes. This might also explain Hong Kong’s poor health literacy.

A way to foster engagement is to increase involvement of health professionals, who often command more respect from the public (than the government) “to communicate the health risks of climate change, and to promote policies that protect public health from climate impacts”. Actions can be as simple as providing educational materials to patients or visiting vulnerable households. On a larger scale, health talks and forums can be organised within communities.

Hong Kong’s healthcare sector is often also criticised for its lack of coordination: services are often set up only reactively, resulting in a lot of redundancy. To improve governance within the healthcare sector, communication is important. A starting point, for example, is to develop health data harmonisation, which involves data sharing between health departments. This can improve the efficiency and quality of services by making the whole process a lot smoother for both the staff and the patient.

While within-sector changes are important, they are insufficient. As we have seen, (climate) health is very much socially determined. This is why the COP26 Special Report resolutely argues that we need to “include health in all policies”. Hence, in the words of IHE CUHK, “[t]he government should work with other sectors, including academia, social care and healthcare, professional bodies, businesses, charities and voluntary organisations, in developing policies across the board to mitigate the social determinants of [climate] health inequalities.”

Hong Kong needs a constructive approach to climate change-related public health. Apart from enhancing health resilience, how can we make our city a greener and more liveable place?

It is good to know that concepts of liveability are being recognised in Hong Kong’s newest Clean Air Plan 2035 and are increasingly connected to health and wellbeing. For example, the government has been trying to promote a low-carbon transport infrastructure by installing roadside air quality detectors and financially incentivising the use of electrical vehicles and public transport.

However, housing has been overlooked in the plans. As we have seen, the government needs to improve the living conditions of public housing in many areas such as by installing or updating their cooling and ventilation systems. To ensure continued accountability, assessment tools such as the Hong Kong Green Building Council’s BEAM Plus New Buildings should be actively employed to crucially ensure that future construction projects are “human-centric”, green, and practical.

Furthermore, according to a report by local think tank Civic Exchange, urban development is not just about infrastructural improvement but also about discovering their “vibrancy”. In a densely populated city like Hong Kong, this is not going to be easy. But as the authors Carine Lai and Antonio Da Roza show, vibrancy need not be about developing extravagant spaces such as shopping malls (which are also energy-intensive) but can also be achieved through the creation of accessible, green, open and user-friendly spaces for public activities such as street hawking and performance. As such, they can be enjoyable spaces – as the evidence shows, they are also opportunities for enhancing mental and physical health – without necessarily being environmentally damaging.

In line with global discourses on sustainability, talk of green and just transitions to renewable energy in Hong Kong have grown. However, discussions have primarily framed relevant strategies of decarbonisation or energy diversification only in economic or environmental terms, where public health is only of secondary importance.

Hong Kong’s climate action needs to be “people-centred”. The medical sector should be a bigger stakeholder in Hong Kong’s power discussions, so that future decisions and investments can be improved: they should consider not only the scarcity of natural resources – that humans can only exploit so much of – but also the potential health ramifications of such initiatives.

Finally, to sustain climate action, climate education needs to be transformed. Apart from learning about the adverse health effects associated with climate change so that people can protect themselves better, the education system should focus on cultivating sustainable mindsets and lifestyles that will enable future generations to imagine different pathways to a healthier Hong Kong.

Overcoming Hong Kong’s Healthcare Crisis: Lessons for the World

Hong Kong has all the expertise and resources it needs to make those changes possible – it has access to a remarkable pool of professional talent that not every country can boast of. However, Hong Kong’s poor management of the healthcare sector and its failure to situate health issues within climate discussions (and vice versa) are lessons that healthcare systems around the world can draw on.

The COP was created in 1992 with the noble aim of creating a globally coordinated strategy to tackle climate change and governments around the world will continue to bear this in mind and harness the opportunities provided by COP26 to develop more cross-regional collaborations to help improve public health around the world together.

Featured image by: Shutterstock