Introduction

I would like to begin by thanking the Hong Kong College of Family Physicians for giving me the opportunity to address this outstanding audience. For me, this is indeed an honour to be associated with a personality of great distinction, Dr. SUN Yat Sen. For those of you who are about my age, you would recall that Dr. SUN was a name that we grew up with. I could still remember that the fatherly picture of Dr. SUN was hanging in many schools, witnessing the growth and development of many generations of students in Hong Kong.

We were taught the outstanding achievements of the father of modern China as a medical student and as a revolutionist. We were taught how he put the interest of his people before his own. There is an ancient Chinese saying - "The superior doctor treats the country. The middling doctor treats before illness occurs." It is quite obvious that Dr. SUN belonged to the category of superior doctors who, with enlightened courage and conviction, fought for the benefit of his country.

If I may return to this audience, many of you are distinguished medical specialists who, has no war to fight, but nonetheless fight to safeguard and improve the standard of medical practice and who contribute through various avenues the improvement of healthcare services in Hong Kong. Many of you even exert your influence beyond the medical sector and outside Hong Kong to take part in various philanthropic activities. Your compassion and determination equally qualify you as doctors of superior quality.

* This paper was presented at the 19th Dr Sun Yat Sen Oration on 25 May, 2008.

---

Public health challenges

When I was asked by President to deliver the Oration, I spent quite sometime contemplating the common interests of public health physicians and family physicians. In the process I noted, with some anxiety, that many of you either hold post-graduate qualifications in public health or are practicing the public health discipline in one way or another. In fact, areas that are of mutual interest to both professions are innumerable. Many public health challenges are of such gravity and severity that deserve very urgent attention. They include, just to name a few, climatic changes on health, globalisation, tobacco use, alcohol and drug abuse, etc. However, only communicable diseases appear to catch the headline.

For decades, epidemiologists have been reiterating the importance of epidemiological transition with chronic non-communicable diseases (NCD) overtaking communicable diseases as the major burden of diseases. This is aggravated by the phenomenon ageing population or demographic transition that is particularly profound in Hong Kong. Some of us thought we were relatively safe from communicable diseases until the avian influenza outbreak in 1997 in Hong Kong sent us a very clear message - communicable diseases will continue to be a major threat to public health. We are confronted with the dual threat of NCD and communicable diseases. Although the later is politically more sensitive, I think we cannot afford to give equal attention to the threat of NCD.

Basic facts on NCD

I will not go into the details of the epidemiology of NCD. I think we only need to examine a few basic facts. NCD has now become the leading causes of death, accounting for over sixty percent of all death globally.¹ Many NCD are preventable. Conditions like cardiovascular diseases, diabetes, chronic lung diseases and cancers are linked by common preventable risk factors such as tobacco, excessive use of alcohol, unhealthy diet and inadequate physical activities. But does prevention work? Do we adopt a public health approach, intervening at upstream or do we target at the high-risk individuals?

North Karelia Project

One of the most successful experiences that bear testimony to the effectiveness of prevention is the North Karelia Project which was launched in 1972 to prevent cardiovascular diseases in North Karelia, Finland. North Karelia is a region in eastern Finland. It was also a low socio-economic area, dairy farming was the major source of livelihood; people there had high-fat diet, heavy tobacco use and low fruit and vegetable intake.

In the 1970s, Finland had the world's highest death rate from cardiovascular diseases as a result of widespread and heavy smoking, high fat diet (e.g. heavy consumption of butter) and low vegetable intake. North Karelia had a heart-disease rate twice that of Finland as a whole in that time.

In response to that, the North Karelia Project, with assistance from local and international experts, was launched. It was a large-scale community-based intervention, involving non-governmental organisations (NGOs), consumers, schools, food industry, supermarkets, mass media, agriculture and social and health services. It included legislation banning tobacco advertising, the introduction of low-fat dairy and vegetable oil products, changes in farmers payment schemes (linking payment for milk to protein rather than fat content), and incentives for communities achieving the greatest cholesterol reduction. Doctors and nurses were asked to help modify risk factors of their patients and clients. Opinion leaders in various villages have become project assistants and many health promotion activities took place at workplaces. Nowadays, people know how to take responsibility for their own health, whether by watching their diet or exercising. You can see from this slide how they strive to exercise more even in cold weather.

With this project, there was significant reductions in risk factors and cardiovascular disease mortality in the region. The respective changes for the whole of Finland have been nearly as great: for example, coronary heart disease mortality went down by 65%. This is one of the most successful experiences in the world in preventing chronic diseases. In North Karelia, the coronary heart disease mortality went down by 73%.²

There were several key factors that underlined the success of the Project. The Project works with the whole community and with strong people's involvement to facilitate social and behavioural changes. Local community leaders, people from different sectors such as food industry, education, agriculture, business were engaged and they worked together for their health. The Project not just focused on management of cardiovascular diseases, but also put strong emphasis on the risk factors such as smoking and unhealthy diet. It tackled the problem at upstream of the disease pathway. Moreover, it adopted the population-based approach to promote health in the whole population and sought to achieve an overall lowering of the risk in the whole population. Furthermore, the strong commitment for changes from the whole community and the government is the fuel for its sustainability and success.

Health promotion and health education

The North Karelia Project was perhaps of the best example of how health promotion works. Health promotion was defined, at the First International Conference on Health Promotion in 1986 as the process of enabling people to increase control over and to improve their health.³

Without going into the details of the Charter for Health Promotion presented at the Conference, I would like to highlight five health promotion actions mentioned in the Charter, viz, building healthy public policy, creating supportive environments, strengthening community actions, developing personals and reorienting health services. The role of the health sector must, according to the Charter, move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. The mandate should support the needs of individuals and communities for a healthier life and open channels between the health sector and the broader social, political, economic and physical environment. The Charter also mentioned the need for a change of attitude and organisation of health services on the total needs of the individual as a whole person.

In 2005, the Sixth Global Conference on Health Promotion, the participants presented the Bangkok Charter for Health Promotion in a Globalized World.⁴ While globalisation provides new opportunities, it also poses new critical factors that influence health, including increasing inequalities within and between countries, new patterns of consumption and communication, commercialisation, global environmental changes and urbanisation.

The Bangkok Charter proposes that all sectors must,

1. advocate for health based on human rights and solidarity,
2. invest in sustainable policies, actions and infrastructure to address the determinants of health,
3. build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy,
4. regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people,
5. and partner and build alliances with public private, non-governmental and international organisations and civil society to create sustainable actions.

The Bangkok Charter urges all stakeholders to join in a worldwide partnership to promote health with both global and local engagement and action. The health sector has a key leadership role in the building of policies and partnership for health promotion.

Health education has long been established means of intervention in disease prevention. It is now clear that health education, although a core and necessary element of many health promotional programme, is not sufficient by itself to bring about improvement of population health. The promotion of health calls for the collaboration of the international organisation, different levels of the Government, the private sector, community groups and the civil society. The healthcare sector is best placed to play the leadership role. We need to create a new environment that supports the adoption of healthier life style practice and the avoidance of risk factors. 

Where are we in Hong Kong?

Although the health indices of Hong Kong rank among the best in the world, we are confronted with the same challenges posed by an ageing population,⁵ sedentary lifestyles and health risk profiles not dissimilar to other advanced economies. The Behavioural Risk Factor Survey reported in 2007⁶ that about two-fifths (38.5%) of people aged 18-64 were overweight or obese. About four-fifths (81.1%) failed to meet the World Health Organization's recommendation of having at least five servings of fruit and vegetables a day. About one-fifth (18.9%) were classified as having low level of physical activity and a substantial number of daily smokers.

In so far as the Department of Health is concerned, we have been reorienting and reorganising our health promotion programme with a view to leveraging community effort in health promotion. I can assure you that there is no lack of dedicated organisations, people and resources that stand ready to contribute. However, in order for our efforts to be well spent, I suggest that we need to know where we are and where we want to go. In other words, we need a strategy to guide us along. By definition, doing more of what we are now doing or doing what we are now doing more efficiently is not a strategy. We need to make a difference; we need changes that will bring lasting benefits to Hong Kong. We have for the past two years been in dialogue with different sectors of the community on how we could collaborate to make a difference. I am pleased to announce that a framework strategy document for prevention and control of NCD is ready for launching in the middle of this year. While it may be premature for me to give you the details of the framework strategy but the rationale is largely in line with the two Charters. What is more important for Hong Kong is the high level political support for the change. The launching of the framework strategy is in the policy agenda⁷ of the Chief Executive and the Secretary for Food and Health has already committed financial support for the purpose.

The role of family physicians

I would like to suggest at this juncture that the family physicians are the best suited to take up a leading role in the prevention and control of NCD. If we take a second look at both Charters, you would have noticed that the attitude and orientation required of healthcare providers are basic to the training of family physicians. Family physicians are knowledgeable on how the family, or the immediate environment of every individual, influence his health and wellbeing. They have an intimate understanding on how to leverage the effort of family members to support healthy lifestyle practices. At the point of first contact care, they have the opportunity of taking care of clients at different stages of their life course. They are often the first persons to identify risk factors or unhealthy lifestyle practices and provide health advice that is often followed by your clients.

A couple of years ago, I was speaking to a group of healthcare profession. I asked them how often they advised their clients not to smoke and then leave them alone. There is a large demand for tobacco cessation services and the only way to meet the demand is the primary care setting. If you do not have the clinical time to run tobacco cessation service, you can at least be their resource person. The same goes for other lifestyle practices or high-risk behaviours. Statistics show that people in Hong Kong seek consultation as often as 9 times a year and they are mostly seen at the primary care setting (63%).⁸ If family physicians could be alert to unhealthy lifestyle practices and early symptoms of chronic diseases (I am sure they are) and act accordingly, the health benefit they could bring would be of a very tall order.

The influence of family physicians often goes outside his clinical practice. Have you ever thought of advising, among your clients, employers to adopt a healthy workplace policy or headmasters of schools to adopt a healthy school policy? I would also suggest that family physicians, as well trained and well informed advocates, to serve in community projects like the healthy city movement or NGO's with informed policy. You are well placed to advise on evidence based intervention rather than those that attract political mileage. I cannot be exhaustive with the opportunities of family physicians to contribute.

Conclusion

I have tried to avoid being technical in this presentation. It is clear that we have an epidemic of NCD that will be the major cause for morbidity and mortality. The family physicians are well trained and uniquely positioned in the community to contribute to the prevention and control of the epidemic. The purpose of this presentation would have been served, if I am able to share with you a glimpse of the vision ahead of us and perhaps enlist you as my key partners.

---

---

References