Following is speech by the Secretary for Health and Welfare, Dr E K Yeoh, at the General Meeting of the Zonta Club of Hong Kong today (Wednesday):-
Dear Dr Cheung, distinguished guests, ladies and gentlemen,
I am most delighted to be invited to address this distinguished gathering today.
Rising living standard locally, coupled with advancement in medical science and technology worldwide, have led the local community to harbour high expectation for healthcare in the new millennium. It is true that new technologies have brought new leases of life to many, with the many exciting technological breakthroughs which promised health. Nevertheless, I would like to caution that this is not a given and several pre-requisites need to be in place. Whether further improvement in the same direction can be sustained is yet uncertain. I will examine the issues under the following categories -
(1) Health and changing health need
(2) New technologies; and
(3) Application of technologies
(1) Health and changing health need
First of all, let's look at the healthcare problems and issues that we will face in the new millennium.
The burden of disease in society will change. Some of the healthcare needs will not be new but will derive from those already familiar but compounded by emerging variables. New health needs will also emerge, arising from changing lifestyles and altered environmental conditions.
The aging population is one of the key factors in determining the future disease burden. We project that by the year 2016, there will be 8.2 million people in Hong Kong, of which 13% will be aged 65 or above. We further project that the percentage will increase to 19% by 2026. Compared with the figure of 10% in 1996, it is obvious that people will live longer. While they may enjoy active lives post-retirement, they will also be in more susceptible conditions prevalent to the elderly, such as stroke, heart disease and cancer.
Changing lifestyles and deteriorating environmental conditions, like air pollution, will also play a key part in the health needs of the community. Diets, stress, smoking, air and water pollution may predispose the community to many diseases, some of which are pre-existing, some of which will be new. We will have leading diseases such as diabetes, hypertension, stroke, respiratory diseases, and even cancer. These will form the bulk of the burden of healthcare services in the future.
Tobacco will remain the single biggest risk factor in health, accounting for 9% of global disease burden by the year 2020, as projected by the World Health Organisation (WHO). Infectious diseases will continue to rank among the top killers. Tuberculosis, our old enemy, will still be around, despite being potentially controllable. According to WHO, Southeast Asia is the worst affected region in the world, experiencing nearly 3 million cases a year. Locally, the new case notification rate is accelerating despite a very sophisticated healthcare system, because we have new strains occurring which are resistant to standard drug regiments. Globally, tuberculosis still remains the single biggest killer among all infectious diseases.
We are also faced with new diseases like AIDS. We also experienced the Avian Influenza Virus, H5N1. Variant Creutzfeldt-Jacob Disease, more widely known as CJD or mad cow disease, has appeared in some countries. As the world gets smaller and people travel faster with improved communication, our contacts with animals multiply and the likelihood of totally new diseases and even current diseases spreading more rapidly will occur, as was experienced with Sydney Flu. In the past, we saw outbreaks of influenza spreading from country to country over a period of months, but now we see these big epidemics spreading from country to country in a matter of days or weeks.
Despite all the medical breakthroughs, preventing people from being ill is a far better way of ensuring health than curing them. Therefore the focus of future health direction should be on health and quality of life, instead of healthcare, emphasizing not just prevention of disease, but also prediction of disease.
As the type of care to be given is going to be different, the caregivers will change too. The role of healthcare providers will change, and as we direct our attention to health rather than healthcare, we expect the public to look for quality of life rather than freedom from disease.
In future we expect the individuals to take ownership of their own health. It is essential that the public are involved and participate fully in decisions about their health and healthcare.
Many of our health problems, such as coronary heart disease, stroke and cancers, are related to lifestyle. Therefore perceptions of health may be one of the most important barriers to its improvement. How patients and the public perceive health is a first step in ensuring their involvement in decision making.
I must admit that to change the perception of health is not easy. It may require the individual to change personally, but it may also necessitate social and political changes. The individual must feel involved and feel that it is valuable to change.
I do not mean to flatter you ladies, but I must say that the role of women is crucial in terms of involvement in health. It is generally the women who look after the family, take children to the health services and make most use of social care. Most of all, they make decisions within the family about lifestyle, food and health. It is this role which makes their perception of health and assessment of risks so important.
(2) New technologies
Other than these different and new health needs, the other scientific equation will be the ability of medical science and technology to deal with them. The advances in medical science and technology will offer exciting new possibilities, for treating diseases which were hitherto incurable and more effective treatment options will be developed in place of those currently available.
I think the single most exciting project is the Human Genome Project, which maps out the DNA of human genomes and then the progress in molecular biology will radically change the whole basis and practice of medicine. We will be able to shed light on the development of cures for hereditary diseases. There will be gene and immuno-therapy for cancers and even individualised therapy, because as we understand more about human genomes, we will understand more in terms of how individuals react to diseases. And we will be able to predict how individuals will react to different insults in the environment and how they will react to different drugs.
We may also be able to perform transplants with either artificial or genetically engineered organs, possibly farmed from animals. At present, the problem with animal transplants is the rejection problem. But people are now experimenting using trans-genic animals, to see whether we can modify the gene structure so that these organ parts can be transplanted in humans and not be rejected.
Before long there could be projections of fetuses maturing in extra-uterine incubators, so women may not need to go through pregnancy and the in-vitro fertilisation continues in a laboratory.
Many of the medications currently in use will be replaced by genetically engineered products and gene therapy is already being actively researched. There will certainly be research on how we re-programme cells so that cells that are aging can be re-programmed to be more juvenile, perhaps we may not need to die or age in the future.
In tandem with all these medical advances is the development of information technology. The use of tele-medicine is already occurring in many parts of the world, enabling patients to consult doctors by tele-conferencing. Electronic patient records and patient-held Smartcards will become common tools.
With technological advancements in medicine and information, health facilities will be very different from what we use today. There will be so-called virtual health facilities, which will be networks extended from individual homes to one-stop-shopping malls providing the most up-to-date health and care information and products. We will have ambulatory care centres where developments in anaesthesiology and surgical techniques will allow the majority of surgical operations to be done on a day basis. And hospitals will continue to remain as the only places for a very small number of patients who require highly intensive care services.
With all these changes in technology, I think the ethical issues will be very important because there will be a very liberal limit to what medical science and technology can bring. Keeping the terminally ill alive by whatever means has raised issues relating to the quality of life and dignity of individuals and personal choice. The question of euthanasia is being debated worldwide, and in Hong Kong. How hard should we try to keep terminally ill patients alive, particularly as the definition of "terminally ill" changes with each clinical development?
The cloning of human beings is fast becoming a possibility. The excitement of all these technological breakthroughs will also bring about fears over the long-term legal and ethical consequences of such leading-edge technology.
(3) Application of technologies
Healthcare can only be optimised if the intervention is efficacious, effective, ethical, accessible, economical and acceptable. While the randomised, controlled trial has been regarded as the "gold standard" to test the efficacy of medical interventions, the extent to which these carefully designed and meticulously executed clinical experiments which demonstrated efficacy can be generalised and extrapolated to effectiveness of these interventions in non-trial patients and in the setting of the average medical practice is highly contentious.
Patients in clinical trials frequently have better chance of survival, because trial eligibility criteria may restrict intake to patients with a reasonable prognosis and individuals in a clinical trial are more likely to receive optimal treatment with the risks associated with that treatment minimised.
It is important that we are able to put research into practice in real life settings. There has been considerable study mostly in other industries of four factors which are prevalent in the environment when the limitations of human performance manifest as errors. These comprise team, task, situational and organisational factors.
Studies have found that improvements to team performance could be achieved effectively at modest costs through training. Tasks vary widely in their propensity to incur errors, depending on their complexity and dexterity needed. They are however influenced by situational factors in which the task is performed. A familiar task performed by a well motivated and competent workforce in an optimal environment has a very low probability for error, whereas a novel task undertaken by an unwilling workforce in a stressed working environment is prone to error.
Situational factors fall into two broad categories. Those associated with "error" such as workload, knowledge and experience form the first and factors that promote violations such as conflict between management and staff, culture that encourages taking risks and low self esteem, form the second.
Organisational factors which promote quality and ensure safety or the converse, are the fourth of the factors influencing human performance.
Most of the medical care we provide is fragmented, not well organised and inadequately co-ordinated. Clinical guidelines and pathways are very powerful clinical tools which would assist in clinical decision making and organise a co-ordinated medical treatment and care better.
In the new era the patient-provider relationship will change. The traditional type of paternalistic relationship between patients and healthcare providers will be replaced by one of partnership.
When we talk about involving patients, we need to give them choices. This is not just about choosing the doctor or nurse to look after them, or the hospital at which they stay, but choosing about the kinds of treatment available. To do this patients need information to enable them to make choices. However, it is not always easy to present the relevant information in a manner readily understood by patients. Communication skill is one of the core competencies which must be mastered by all healthcare providers.
Communication must be seen as a two-way process. Communicating well means getting to know people and understanding them. It means refocusing the traditional "not getting involved mode" to getting involved without losing objectivity and professionalism. Healthcare professionals must possess good communication skills and caring attitude. In an alienated environment and with increasingly complex interventions offered to patients, good communication skills are not only desirable but essential.
In the new millennium, the key caregiver will not be the doctor but the individual, not the patient because individuals will be looking after their own health. It is clear that individuals can influence their health status and the burden of disease. With information empowerment, individuals can determine their own health status which they deserve and the health required.
END/Wednesday, January 26, 2000