A Medical History of Hong Kong: The Development and Contributions of Outpatient Services 9882372201, 9789882372207

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A Medical History of Hong Kong

The Development and Contributions of Outpatient Services

By Moira M. W. Chan-Yeung

THE CHINESE UNIVERSITY OF HONG KONG PRESS

A Medical History of Hong Kong: The Development and Contributions of Outpatient Services   By Moira M. W. Chan-Yeung © The Chinese University of Hong Kong 2021 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from The Chinese University of Hong Kong. ISBN: 978-988-237-220-7 The Chinese University of Hong Kong Press The Chinese University of Hong Kong Sha Tin, N.T., Hong Kong Fax: +852 2603 7355 Email: [email protected] Website: cup.cuhk.edu.hk Printed in Hong Kong

To all healthcare workers in Hong Kong

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Contents

Foreword 

/ vii

Preface / ix Acknowledgements / xiii Abbreviations / xv Chapter 1  Introduction / 1 Chapter 2  Chinese Public Dispensaries / 11 Chapter 3  The Chinese Elite and the Chinese Public Dispensaries / 35 Chapter 4  Launching of Outpatient Services in Kowloon and the New   Territories and the Construction of the Kowloon-Canton Railway   and Shing Mun Dam / 61 Chapter 5  Post–World War II Government Outpatient Services:   The Great Expansion / 87 Chapter 6  Development of General Outpatient Clinics as Primary Care   Providers: Merits and Shortcomings / 111 Chapter 7  Midwifery Service: From Antiquity to Modernity / 129 Chapter 8  Maternal and Child Health and Family Health Service:   Healthy Mothers, Healthy Babies / 145 Chapter 9  School Health Service: Healthy Children, Better Learners / 167

Chapter 10  Ambulatory Treatment and Control of Tuberculosis / 185 Chapter 11  Sexually Transmitted Diseases:   Ancient and Emerging Diseases / 201 Chapter 12  Mental Health Service:   From Asylum to Outpatient Care / 219 Chapter 13  Substance Abuse and Drug Addiction / 237 Chapter 14  Industrial and Occupational Health:   A History of Inadequacy / 255 Chapter 15  Community Care Services and Elderly Health Centers:   Ageing in Place / 277 Chapter 16  The Private Sector: Chinese and Western Medicine / 289 Chapter 17  Conclusion / 317 Appendix 1 Lists of Clinics / 321 Appendix 2 Heads of Government Agencies / 331 Glossary / 335 Notes / 337 Bibliography / 375 Index / 387

Foreword

Professor Moira Chan-Yeung, a clinician-academic with distinguished professional life in Hong Kong and Canada, has written an insightful and fascinating account on the development and evolution of medical and health services in Hong Kong. Her first book A Medical History of Hong Kong covered the historical period 1842 to 2015 in two volumes, from the time of Hong Kong as a British administered territory to the period as a Special Administrative Region of China. In this volume covering the same historical period, she has chosen to study a critical component of health systems, ambulatory care, which is frequently relegated to a secondary role in discussions involving the dominant hospital sector. The rich and analytic discourse generated from research of the literature and archival records meticulously traces the origins of ambulatory care in Hong Kong to the establishment of Chinese Public Dispensaries in 1905 in response to the 1894 plague epidemic which recurred every summer until 1930. The sociopolitical context and the leadership from civil society in the Chinese community which was instrumental for the establishment of the dispensaries are discussed. This historical origin defined the path of the continuing role of outpatient clinics in the control of infectious diseases in the subsequent decades, covering malaria, smallpox, dysentery, cholera, tuberculosis, and in more recent decades, HIV/AIDS and SARS-CoV. The insights of why health systems need to transform in response to changing needs and the dynamic environmental context is captured in the analyses of the evolution of ambulatory care to three categories of clinics—General Outpatient Clinics providing curative and preventive care, Specialist Clinics providing specialist consultations, and Special Clinics covering a range of public health interventions ranging from maternal and child, elderly, mental, and dental health to drug abuse and venereal diseases. The changing needs arising from the demands from noncommunicable diseases and the challenges they present to the current fragmented

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and segmented healthcare delivery system where most primary care is provided in the private sector is a consequence of under-investments in the appropriate modalities of primary care in the public sector are identified and highlighted. A system response to the challenges will need to examine how to improve access to preventive care and chronic disease management in ambulatory health services, and the role of the private sector in these health services. The book is a narrative of how our past defines our present and which will inform our future, to recreate a health system fit-for-purpose for the 21st century. E. K. Yeoh Director, Centre for Health Systems and Policy Research The Chinese University of Hong Kong December 2020

Preface

There is a wealth of material on the development of medical and health services in Hong Kong. In the book A Medical History of Hong Kong, in two volumes, 1842 to 1941 and 1942 to 2015, I presented a broad sweeping view of the development and evolution of medical and health services in Hong Kong, covering key events as its status toggled from a British colony to an occupied territory under Japanese administration, back again to a British colony, and finally to a Special Administrative Region of China. Not surprisingly, the development of Hong Kong’s medical and health services is just as tumultuous. In the previously published two-volume book, A Medical History of Hong Kong, the history of development of medical and health services in Hong Kong from 1842 to 2015 was arranged by themes rather than in chronological order, so that each subject could be discussed thoroughly in a coherent manner. Such a presentation, focusing on the selected topics of interest, would necessarily leave out others perhaps equally important. The present book addresses an area that is seldom discussed, despite its immeasurable impact on the health of the citizens of Hong Kong: the development of outpatient medical services or ambulatory services and their advancement outside the hospital setting. This work highlights public health measures, implemented through general outpatient and special clinics, such as maternal and child health, school health, mental health, industrial health, and elderly health services. This book also chronicles the unique contribution of outpatient services to the control of infectious diseases such as tuberculosis and venereal diseases. Together with inpatient hospital services, outpatient services have helped improve the health indices of the people of Hong Kong to become one of the best in the world. Before 1990, under the Medical and Health Department, there were three types of outpatient clinics: general outpatient clinics, special outpatient clinics, and specialist clinics. The first two types of clinics were

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developed outside hospital settings: the general outpatient clinics were the same general outpatient clinics (GOPCs) as we know them today; the special clinics included those that dealt with maternal and child health, school health, industrial health, tuberculosis, venereal diseases, dental clinics, drug abuse, mental health, industrial health, and elderly health. The third group, the specialist clinics, was outpatient departments of hospitals, and they delivered specialists’ care of various medical specialties, such as medicine, surgery, gynecology, obstetrics, orthopedics, and others. With rapid medical advances, more specialization and subspecialization took place, and more specialist clinical services were available. Since the 1970s, polyclinics were built in different districts to accommodate specialist outpatient clinics, and later still, specialist outpatient centers were built, such as Tang Chi Ngong Specialist Clinics. Although the contribution of specialist clinics to the health of Hong Kong people is significant, it will not be discussed in this book. In 1989, the Medical and Health Department was dissolved and replaced by a new Department of Health and a Department of Hospital Services. The latter became the Hospital Authority the following year to manage all the government hospitals and subvented hospitals in Hong Kong, while a new Department of Health was formed to take responsibility for the rest of health services. Outpatient services were also restructured. The Hospital Authority would administer the specialist outpatient clinics in hospitals, polyclinics, and specialist outpatient centers. The general outpatient clinics and special clinics would remain under the jurisdiction of the Department of Health. In 2003, however, fiftyfour general outpatient clinics were transferred from the Department of Health to the Hospital Authority in order to integrate primary and secondary healthcare, thus ensuring continuity of patient care, as well as facilitating the formation of family medicine training units. The general outpatient clinics are simple and do not need high-tech equipment. They concentrate on the provision of basic curative measures and disease prevention. They have been highly cost-effective in improving Hong Kong’s health status, but their profound influence on the health of the population has often been underestimated and unappreciated. Regarding present-day pandemics of chronic noncommunicable diseases, including cancer and dementia, which carry high morbidity and mortality, the risks for these diseases can be lowered by preventive measures and their morbidity reduced by early detection. General outpatient clinics

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are in a unique position in preventing these diseases. However, these general outpatient clinics in the public sector only provide 15% to 20% of all primary care services in Hong Kong. The private sector, which is responsible for the bulk of primary care will have to be engaged in the program for prevention of chronic noncommunicable diseases to be successful. This book draws on a wide array of archival materials, government publications, scholarly literature, newspapers, and online resources, the details of which can be found in Bibliography. Moira M. W. Chan-Yeung April 2020

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Acknowledgements

Throughout the process of writing this book, I have received assistance, encouragement, and support from a number of friends and colleagues, and I wish to give them special thanks here. Prof. Fung Yee-wang and Dr. Kenneth Suen reviewed the manuscript, and I am most indebted to them for their patience and advice. Dr. Wong Tai-wai graciously offered excellent ideas on various topics and generously provided materials and pictures despite his heavy workload in the hospital during this period. I am also beholden to Dr. Alice S. S. Ho, who tirelessly researched and compiled the dates of first operation of a number of outpatient clinics, and Dr. Caroline Tsang, who patiently explained the workings of Elderly Health Centers and forwarded materials on the evaluation of their performance. I wish to thank Mr. Ma Koon-yiu for generously sharing his interesting research on the Lady Ho Tung Welfare Centre; Mrs. Yvonne Cheung who revealed her inspiring experience as one of the founding members of the Youth Health Care Centre and her photographs of the center; Dr. Arthur Sham who provided information on dental clinics; Mr. Lincoln Tso for information of his celebrated grandfather Dr. Tso Seenwan, and the photographs of the Western District Public Dispensary; and Mr. Thomas Wong for the use of the image of his legendary great grandmother Wong Suet-hing. I am most fortunate to have been granted permission to reproduce a number of valuable photographs from the personal collection of my cousin, Mr. Keith Poon. I also thank Rachel Pang, editor of this book, and her several personal friends, for their kindness in volunteering to take photographs of a number of clinics and other historical sites. These photographs undoubtedly helped to illustrate my written words in a more visual and lively form. I am also grateful to the following institutions that have given their consent for reproducing their photographs: Hong Kong Medical and Health Department, Hospital Authority, Hong Kong Museum of Medical Sciences, Antiques and Monuments Office of Hong Kong, Family Planning

x i v   |   A cknowledgements

Association of Hong Kong, South China Morning Post, Hong Kong AntiTuberculosis, Chest and Heart Association, Industrial History of Hong Kong Group, Hong Kong Sanitorium and Hospital, and the editorial department of Hong Kong Open Page Publishing Company Limited. My sincere thanks go to Mr. Stanley Yeung, who kindly prepared all the maps in the manuscript. Without the encouragement and help of my friends and colleagues, the actualization of this manuscript, from start to finish, would not have been possible.

Abbreviations

ACAN AIDS BCG CAT CM CO CPDs DALYs DOT GOPCs EHC EHV ENT HA HIV HKAR HKSAR HKSP HMO HPV IL KCR KIL MCHC MDMA MRI MTR NGO PET PTSD

Action Committee Against Narcotics Acquired Immunodeficiency Syndrome Bacille Calmette-Guérin computerized tomography Chinese medicine Colonial Office Chinese Public Dispensaries disability-adjusted life year Directly Observed Therapy general outpatient clinics Elderly Health Centers Elderly Healthcare Voucher Ear Nose Throat Hospital Authority Human Immunodeficiency Virus Hong Kong Administrative Report Hong Kong Special Administrative Region Hong Kong Sessional Papers Health Maintenance Organization human papillomavirus Inland Lot Kowloon-Canton Railway Kowloon Inland Lot Maternal Child Health Center 3,4-methylenedioxymethamphetamine magnetic resonance imaging Mass Transit Railway non-governmental organization positron emission tomography Post Traumatic Stress Disorder

x v i   |   A bbreviations

SARDA SARS SCA STDs T.A.B. TCM UNICEF VDRL WHO WPPHC WWII

Society for the Aid and Rehabilitation of Drug Abusers Severe Acute Respiratory Syndrome Secretary for Chinese Affairs sexually transmitted diseases typhoid-paratyphoid A and B traditional Chinese medicine United Nations International Children’s Emergency Fund venereal disease research laboratory World Health Organization Working Party on Primary Health Care World War II

1. Introduction

When East Meets West During Hong Kong’s early years as a British colony in the 1840s, most of the Chinese in Hong Kong were laborers arriving from China to make a living. They were poor, living in congested, unhygienic tenement houses. Most of them survived on a diet of rice, vegetables, and a small amount of salted fish with occasional meat added during festivals. With such malnutrition, lack of running water, unsanitary living conditions, and no medical care, these laborers fell victim to the spread of infectious diseases, such as tuberculosis, cholera, smallpox, dysentery, and enteric fever. Their average life span was under forty years. When Western medicine was first introduced to Hong Kong in the 1840s, it was rejected by the Chinese, who firmly believed in their own ancient art of traditional Chinese medicine. They distrusted foreigners and considered surgery to be utterly barbaric. While traditional Chinese medicine may be effective in maintaining health, it was and is still incapable of treating acute infectious diseases, which were the main causes of death in those days. At that time, the Chinese did not consult foreign doctors or the Government Civil Hospital, which offered Western medicine, because of the distrust in and the high cost of Western medicine. For decades, many Chinese in Hong Kong lived in poverty and in poor health. Gradually though, their attitude toward Western medicine changed, starting with the founding of the Nethersole Dispensary in the London Missionary Society Chapel in Tai Ping Shan area in 1881, followed by the establishment of the Alice Memorial Hospital in 1887, which offered effective free consultation and Western medicine at a low cost, and the establishment of the Hong Kong College of Medicine for Chinese in the same year, training Chinese doctors to practice Western medicine. In 1896, Tung Wah Hospital, a Chinese hospital, which offered exclusively traditional Chinese medicine, introduced Western medicine

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under pressure from the government. More and more Chinese began to favor Western medicine over traditional Chinese when they discovered that those treated with Western medicine had a much better chance of surviving their illnesses.1 Additionally, further popularization of Western medicine can be attributed to the founding of Chinese Public Dispensaries (CPDs) in various districts of Hong Kong and Kowloon, which began to provide domiciliary services of midwives trained in the Western method of delivery, ultimately resulting in a higher rate of mother and infant survival. The CPDs were the forerunners of the general outpatient clinics (GOPCs) of today. These changes, together with the support of the government, allowed Western medicine to finally win the approval of the Chinese populace and become the mainstream form of medical treatment in Hong Kong since the inter-war years.

Medical Specialization in the West Specialization in Western medicine occurred early. A medical specialty can be defined by the age of the patient (pediatrics or geriatrics), disease (respirology, i.e. lung diseases, or oncology, i.e. cancer), skills (radiology or pathology), or philosophy (medical humanities). In the Western world, the division of medicine into various specialties, such as medicine, surgery, gynecology, and obstetrics, can be dated to hundreds of years ago and medical practitioners have long been specialized to practice in an area of their interest. At the present, in order to become qualified as a medical specialist, further training in the specific area for a defined period of time after graduation from medical school and passing an examination after training organized by the specialist college are mandatory. In the Middle Ages, soldiers who required surgery during and after battles were operated on by barber surgeons, who had razors and possessed good manual dexterity (a quality indispensable to their trade). They were called upon for numerous tasks ranging from cutting hair to amputation of body parts. Surgical mortality was very high from blood loss and infection, and was seldom conducted by physicians, who considered themselves above surgery. The first specialist college in the United Kingdom was the Barber Surgeons of Edinburgh, which was established as early as 1505. Table 1.1 shows the development of specialist colleges in the United Kingdom in subsequent years.

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Table 1.1 Year of establishment of several specialist colleges in the United Kingdom Year 1505 1518 1540 1841 1865 1918 1926 1928 1929 1932

Specialist Colleges Barber Surgeons of Edinburgh Royal College of Physicians Company of Barber-Surgeons Association of Medical Officers of Asylums and Hospitals for the Insane Medico-Psychological Association British Orthopedic Association Royal Medico-Psychological Association British Pediatric Association British College of Obstetricians and Gynecologists Association of Anesthetists of Great Britain and Ireland

Source: From various websites

By the beginning of the twentieth century, the number of specialists had steadily increased in urban areas in the Western world. General medical practice was regarded by some as synonymous with rural practice, and perhaps “backward” compared with modern city practice. In the United States, there were more specialists than general practitioners by the 1940s, and this phenomenon persists today.2

Medical Specialization in Hong Kong Henceforth, for brevity, traditional Chinese medicine will be referred to as “Chinese medicine.” It appears that surgery was performed early in Hong Kong at the Government Civil Hospital. When it was established in 1850, the Government Civil Hospital was in an ordinary house with no facilities for operation. A proper hospital was completed with an operation theater only around 1890. Beds for confinement were introduced by Dr. P. B. C. Ayers in 1890, but only women in moribund conditions from difficult labor were admitted. When the Alice Memorial Hospital and Nethersole Hospital were founded, there were beds for women, but again, few used them for confinement until the opening of Alice Memorial Maternity Hospital and the arrival of Dr. Alice Sibree in 1904. In the early twentieth century, medical services in the Alice Memorial Hospital and Affiliated Hospitals and the Government Civil Hospital were divided into three

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basic specialties: medicine, surgery and gynecology, and obstetrics. All other doctors were called “generalists.” When the Hong Kong College of Medicine for Chinese was established in 1887, the curriculum also included different areas of Western clinic medicine: medicine, surgery, obstetrics and gynecology. Teaching of these subjects was carried out by doctors with special interest or who were working in those areas. These teachers were not usually trained as specialists but developed their skills through years of practice. Sir Patrick Manson, the Father of Tropical Medicine and the founding dean of the Hong Kong College of Medicine, functioned both as a physician and a surgeon. In 1866, he worked as a port surgeon for the Imperial Chinese Customs Service in Kaohsiung in Taiwan. Five years later, he moved across the Strait of Taiwan to Xiamen in mainland China. There, he gained wide recognition for his discovery of the role of the mosquito as the vector in the life cycle of the filarial worm, which causes elephantiasis in humans.3 In Xiamen, he removed scrotal “tumors” due to scrotal elephantiasis caused by the filarial worms. Dr. James Cantlie, who succeeded Manson as the dean of the College, was known for his skill in both medicine and surgery. The training of doctors after graduation to be specialists began with the appointment of Rockefeller professors to the founding chairs of the three clinical departments—medicine, surgery, and obstetrics and gynecology—at the University of Hong Kong in 1925. They were tasked to provide specialist care in their respective medical specialties and also to train young graduates to be future specialists, in addition to teaching medical students.4 It is interesting to note that the founding chair of the Department of Medicine, Professor John Anderson, at the start of the First World War, had practiced in several areas. He was drafted as a medical officer to Gallipoli where he demonstrated his skill as a surgeon and was regarded as a surgical specialist. On one occasion, he continued unperturbed to complete an abdominal operation while enemy bombs dropped around his operating tent, setting the neighboring structures on fire. Towards the end of the war, Dr. Anderson became keenly interested in practical bacteriology and pathology. Having already acted as a surgical and a medical specialist, he then became an expert in pathology and commanded various field laboratories until the end of the war.5 In those days, passing an examination in a special area to become a specialist was not necessary.

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In the Government Civil Hospital, each clinical department of the University of Hong Kong was assigned beds for patient care and teaching; and each department established specialist outpatient clinics in the hospital to give consultations to new patients as well as to follow-up patients discharged from their wards.6 These clinics were the beginning of the specialist outpatient clinics (SOPCs) of today. The trainees benefited greatly by attending these clinics, which were and are still attended by specialists. In general, the specialist clinics were located in hospitals, polyclinics, and specialist outpatient centers. An exception was Queen Mary Hospital because it did not have an outpatient department when it first opened in 1937. The staff conducted outpatient clinics at the outpatient department of the Government Civil Hospital (called Sai Ying Pun Outpatient Clinic after the war) until 1960, when Sai Ying Pun Polyclinic opened. Queen Mary Hospital finally obtained its own outpatient department on site in 2002 with the opening of the S Block. The delivery of special care outside the hospital setting in Hong Kong started with midwifery service offered by the Chinese Public Dispensaries (CPDs) in 1906. 7 School health clinics began in 1924 and offered treatments for students, who were found to have health problems in the medical examination program. The first infant health center, established in 1932, was the forerunner of maternal and child health centers of today.8 In 1936, gynecological clinics were established in the CPDs, opened twice weekly, and managed by female doctors. 9 These specialized clinics and health centers were not operated by specialists, as most of these areas of practice were not regarded as specialties at that time. For example, pediatrics was a branch in the Department of Medicine and became a separate department only in the 1960s in Hong Kong. Venereal diseases and tuberculosis were and are still regarded as areas within medicine at present in Hong Kong. The medical officers, who ran these special clinics then were general practitioners, although most of them are qualified internal medicine specialists or respirologists today.

Medical Subspecialization Medicine advances rapidly with new discoveries in diagnostic techniques and treatment modalities. Subspecialization in medicine in Hong Kong

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occurred after the Second World War as a result of the efforts of the heads of the different departments. The most prominent leader of the medical community, A. J. S. McFadzean, Professor of Medicine in the University of Hong Kong, who recognized the importance of the role of teaching and research in the university, ensured that the department would provide state-of-the-art clinical services in patient care and research, commensurate with advances in medicine and medical technology. In order to keep abreast of all new medical innovations, McFadzean demanded each of his staff to be trained in a subspecialty of medicine and to pass on the knowledge to his or her respective trainees. Since the 1960s, various subspecialties have been established in Hong Kong. In the late 1940s and 1950s, pediatrics and psychiatry were taught within the Department of Medicine. McFadzean persuaded the university to provide adequate resources to establish separate departments, and in 1962, Elaine Field joined the university as professor of pediatrics.10 A separate department for psychiatry was established in 1972 when P. M. Yap was appointed to the chair of psychiatry.11 These two departments were able to grow independently and more adequately to address the needs of patients in Hong Kong. With frequent changes in disease patterns and complexity of chronic diseases, McFadzean recognized and constantly emphasized the importance of postgraduate professional training by sending members of his junior staff abroad for training—Joseph Pan to the United States to specialize in cardiology, David Todd and Rosie Young to Scotland to specialize in hematology, although Young later turned to endocrinology and metabolism. Cardiology, hematology, endocrinology, and metabolic diseases would become established subspecialties in the Department of Medicine. Other subspecialties, such as gastroenterology, respirology, nephrology, clinical pharmacology, rheumatology, geriatrics, infectious disease, and dermatology followed suit.12 In the same way, orthopedics/trauma and otorhinolaryngology became separated from the Department of Surgery to become independent departments. Subspecialties in surgery, such as general surgery, plastic surgery, urology, and pediatric surgery also developed. Meanwhile, psychiatry also developed its own subspecialties: adult psychiatry, child psychiatry, psychogeriatrics, perinatal psychiatry, and alcohol and substance abuse problems.

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Specialization of Chinese Medicine In traditional Chinese medicine, specialization also took place. There were the herbalists, the acupuncturists, and the bonesetters. Chinese women had their confinement at home attended by their older female relatives or by traditional Chinese midwives, wan po. With no formal education, a wan po would learn midwifery from an oral tradition that was passed down from one generation to another, and from attending childbirths with another older wan po, a practice similar to that of their Western counterparts before the late-nineteenth century.13

Development of Clinical Outpatient Services This book focuses on the development of clinical outpatient services in Hong Kong. These services are independent of hospitals and comprise general outpatient services and special outpatient services. Specialist outpatient clinics in hospitals, polyclinics, and specialist outpatient centers will not be covered in this book. Generally, the word “clinic” is often used in two settings: 1) the establishments or buildings where outpatient services are being carried out and 2) the particular type of outpatient service that is being delivered, such as a general medical clinic, eye clinic, tuberculosis clinic, and other special clinics. To avoid confusion, in this book, “center,” “health center,” and “dispensary” refer to the first category—the establishments, except for establishments that have been known as clinics for a long time, for example, Wan Chai Clinic, which is a health center for both chest services and dental services; and “service” and “clinic” are used for the second category. The chapters are arranged in chronological order as much as possible. Chapters 2, 3, and 4 describe the development of outpatient services before the Second World War. Chapters 2 and 3 also tell the story of how the Chinese elite founded and financially supported Chinese Public Dispensaries (CPDs), which were the forerunners of present-day general outpatient clinics. These dispensaries offered outpatient services to the Chinese community in Hong Kong and Kowloon before the War. Chapter 4 additionally recounts how the development of outpatient services in

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the New Territories began with the construction of the Kowloon-Canton Railway. Voluntary agencies also contributed extensively to the outpatient services in the New Territories. During the Japanese Occupation, most of these outpatient clinics were closed and left in dilapidated states. Chapters 5 and 6 address the development of outpatient services after the Second World War, although many of them already had their origins before the war. These two chapters relate the struggle of the Hong Kong government to rebuild outpatient medical services after the War with a meager budget for a burgeoning population. Putting emphasis on the provision of cost-effective public health services, with minimal basic curative care, resulted in reducing maternal and infant mortality, increasing life expectancy, and, by 1970, raising the health status of the people of Hong Kong on par with that of a developed nation. Only later, with the economic rise of Hong Kong, did the government channel more of its resources into curative medicine, building more hospitals and investing in more high-tech equipment. The success of preventive medicine spearheaded by the outpatient clinics cannot be overemphasized. The years of plenty eventually gave way to years of want, which were brought about by the Asian financial crisis (1997–1999). At the same time, the high disability and mortality arising from chronic noncommunicable diseases as a result of the adoption of the Western style of living since the 1970s was compounded by a rising aging population where these diseases occurred most. The government had no choice but to reform the healthcare system, putting emphasis once again on prevention in the primary care setting. Primary care doctors in general outpatient services (GOPC), who had barely been able to cope with the basic curative services for the ever-expanding population, found themselves inadequately prepared for the new challenges. Chapters 7 and 8 tell the story of the development of midwifery service and maternal and child health service. The provision of antenatal and postnatal care and free immunization against childhood diseases contributed greatly to reducing maternal and infant mortalities. Chapter 9 discusses school hygiene service. Freedom from hunger and from common diseases of childhood enabled school children to participate fully in their school program, leading to academic successes. Chapters 10 and 11 address tuberculosis and venereal diseases, which flourished in Hong Kong before and after the Second World War. Free diagnosis and treatment were offered by special outpatient services for

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these two ancient diseases. Chapters 12 and 13 deal with the development of services for mental health and drug abuse that require prolonged rehabilitation to enable patients to return to the community after institutionalization. The social stigma associated with these two diseases is a challenging barrier to successful rehabilitation. Most of the above services had been initiated before the Second World War and greatly expanded after the War due to demand and advances in medicine. Chapter 14 is a brief chronicle of industrial health in Hong Kong, which was inaugurated in the late 1950s when Hong Kong grew into a manufacturing center. The exodus of factories from Hong Kong to South China, where labor and land were readily available, began in the 1970s and was completed by the 1990s, leaving behind only the construction trade. The short duration of industrial development and the capitalistic environment under which it grew stifled the advancement of industrial health in Hong Kong. Chapter 15 focuses on elderly health service, a relatively new service, which was established in the 1990s, when Hong Kong’s population was turning gray. Only a small fraction of the elderly population receives this service, and it has a long waiting list. To a certain extent, there is duplication of work between the general outpatient clinics, which have a large elderly clientele, and the elderly health centers. Coordination of the two services may reduce the long waiting time of both. Much less has been written about the development of the private sector of medical care in Hong Kong. Chapter 16 summarizes what is available in the literature on the private sector, including Chinese medicine practitioners who are now regulated by the Chinese Medicine Council. The private practitioners of Western medicine and Chinese medicine are responsible for 85% of primary care in Hong Kong, while the government general outpatient clinics (GOPC) account for the remaining 15%. In 1979, the World Health Organization (WHO) advocated a primary care approach as a global strategy for its campaign of “Health for All” by the year 2000. Primary care provided by the GOPCs in Hong Kong has been shown to be cost-effective. The GOPCs do not need hightech equipment or highly trained personnel to operate them. Their work in basic curative care and disease prevention has significantly improved Hong Kong’s health status during the postwar decades. Chronic noncommunicable diseases, including cancer and dementia, are the pandemics of the twenty-first century. The risks for most of these

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diseases can be reduced by a change in lifestyle, and their morbidities can be lowered by early detection and treatment. The preventive measures are simple and easily carried out in any general outpatient clinic, elderly health center, and general practitioners’ private offices. In order for the prevention of chronic noncommunicable diseases to be successful, it would require the efforts and collaboration of the private sector, which has been responsible for the lion’s share (about 80%) of primary care in Hong Kong.

2. Chinese Public Dispensaries

Much has been written about Chinese hospitals (Tung Wah, Kwong Wah, and Tung Wah Eastern Hospitals) in Hong Kong, where initially only traditional Chinese medicine (TCM) had been practiced, while little attention has been paid to Chinese Public Dispensaries (CPDs), where, for decades, outpatient medical services based on Western medicine were provided to the impoverished Chinese free of charge or for a small fee. The CPDs in Hong Kong were more than conventional dispensaries. In addition to delivering the much-needed Western medical services, including midwifery, to the population during the first half of the twentieth century, CPDs played a crucial role in providing public health services to Hong Kong, including free vaccinations and inoculations, and education of the public in basic hygiene and sanitation. The earliest CPD in Hong Kong was founded in 1905. Over the next two decades nine more were established. Their services were disrupted during the Japanese occupation (December 1941 to August 1945) and resumed after the Second World War under a different name— government outpatient clinics. Although the idea of having district dispensaries had come from the Colonial Surgeon as early as 1892, it was the Chinese elite who founded the CPDs and financially supported them. The CPDs were staffed by Chinese medical licentiates trained in Western medicine. Given the background of distrust of Western medicine among the Chinese in Hong Kong, the story of the CPDs is a fascinating one, reflecting the progressive changes in the attitude and culture of a people brought about by the westernization of its elite.

Historical Background The social unrest and political instability in China arising from the Taiping Rebellion (1850–1864) brought more and more people to Hong

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Kong, and this considerable influx of newcomers consequently impacted the area’s already-poor sanitary and living conditions. Sanitation, which was inadequate, because of the lack of proper sewerage and clean water, especially in the Tai Ping Shan district where the Chinese densely congregated, deteriorated further. During the mid-to-late 1800s, Hong Kong became infamous for its blatantly miserable sanitary conditions brought on by overcrowding and deficient infrastructure. Finally, in 1882, the Secretary of State for the colonies requested Osbert Chadwick, a British sanitary engineer, to assess the sanitation conditions, or lack thereof, in Hong Kong. Chadwick, highly critical of the area’s unhygienic conditions, submitted a blueprint for developing proper sanitation to the Hong Kong government.1 Unfortunately, the subsequent frequent changes of Hong Kong governors led to delays in implementing Chadwick’s recommendations,2 and ultimately, very little was carried out to correct the unhealthy conditions in Hong Kong and the overcrowding in Tai Ping Shan area. 3 The government’s lack of funding and the resistance of owners to spend money on improving their properties stalled housing reforms, and therefore allowed sanitation to continue its decline. Since death rates from infectious diseases had always appeared to be low among the Chinese compared with the Europeans in Hong Kong, Chinese property owners were reluctant to spend money to improve housing conditions, which they perceived as only beneficial for foreigners.4 However, Chadwick pointed out that the low death rate among the Chinese was based on flawed statistics: although the government published population figures every year, an accurate population census was virtually impossible because of the constant movement of people to and from the Chinese mainland.5 According to ancient customs, most Chinese returned to their native village to die when they were old or became sick, resulting in a deceivingly low death rate compared with the Europeans.6 In the 1870s, Hong Kong was the only British colony without proper birth and death registration. When MacDonnell (governor of Hong Kong, 1866 to 1872) was asked by the Colonial Office in Britain to set up such a registration in Hong Kong, he declined for fear of upsetting the Chinese, who were against any kind of interference from the government.7 Moreover, and perhaps more importantly for the British colonial administration, the cost for the registration could not be covered by the government’s limited budget.

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The Colonial Surgeon’s Proposal In the early 1890s, the Colonial Office in London raised the issue of birth and death registration again and the need for providing medical services to the Chinese community. Sir William Robinson, the governor of Hong Kong, sought the opinion of his officers, the Colonial Surgeon and the Registrar General, on these issues. The Colonial Surgeon, Dr. P. B. C. Ayres, indicated that the Chinese should not be compelled to do anything against their will. Favoring a less intrusive approach, he proposed to establish several dispensaries in different parts of the colony, each to be staffed by licentiates from the Hong Kong College of Medicine for Chinese, who were not permitted to practice medicine in Hong Kong because their licenses were not recognized by the General Medical Council in Britain.8 Their first duty would be to obtain accurate information on the cause of death of those who died without being attended to by a registered practitioner. Noting the high prevalence of diseases among the impoverished Chinese and the lack of medical care, Ayres suggested that the second duty of the licentiates would be to provide free consultation and medicine to the Chinese. For patients who could afford to pay, the licentiates were permitted to charge a small fee to supplement their meager salary of HKD 30 per month. Together with the wage of a clerk who could speak English, wages of two coolies, and the cost of drugs, the expense of running such a dispensary would come to around HKD 660 per year. Ayres suggested a trial of such a scheme for three years.9 Stewart Lockhart, the Registrar General, agreed with the Colonial Surgeon that enquiry into causes of death would be considered by the Chinese an invasion of their privacy and should be carried out with sensitivity and care. In general, the Chinese were opposed to Western medicine, and it would be advisable to establish only two such dispensaries in the beginning, one in the City of Victoria, located on Hong Kong Island, and one in Kowloon, across the Victoria Harbor. The government should be responsible entirely for their management and expenditures. After all, the Chinese were responsible for a huge proportion of the tax revenue and yet had not received much from the government in return. Lockhart suggested to run the clinics for one year and if they worked out well, more clinics could be established.10 These clinics would be a sensible

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way to introduce and popularize Western medicine to the Chinese and to gain their acceptance and confidence. Governor William Robinson agreed with the proposals of his two officers, but he was reluctant to pay for the expense of the dispensaries for lack of funds. He would try to put this proposal into next year’s budget.11 Before the government had the opportunity to put this proposal into action, plague struck Hong Kong in 1894, killing over 2,500 people. Tai Ping Shan, the epicenter of the epidemic, accounted for over 50% of all cases. After the appalling plague epidemic of 1894, Governor Robinson appointed a Committee of Inquiry into the Medical Department of the Colony and other related matters.12 In addition to a prolonged discussion on the workings of the Medical Department, the lack of staff to deal with the epidemic, the Committee also discussed the feasibility of establishing three dispensaries to sell European drugs at nominal prices to the Chinese and employing licentiates of the Hong Kong College of Medicine to introduce Western medicine. Their duties included treating povertystricken Chinese patients, dispensing medications, and performing vaccinations.13 However, no further action was taken on the proposal of dispensaries until 2 May 1902, when it was recorded in the annual medical report of the government that Dr. Lau Lai, Licentiate of the College of Medicine for Chinese, was appointed resident medical officer and public vaccinator at the Government Dispensary at Wan Chai.14 Seven months later, in January 1903, Lau Lai was transferred to Tai Po Dispensary, replacing Dr. Ho Nai-hop as the Chinese Medical Officer to the New Territories.15 It is not clear what happened to the Government Wan Chai Dispensary after the departure of Lau Lai. The opening of the Eastern District Chinese Public Dispensary might have led to its closure. In the end, it was the Chinese elite, not the government, who established and funded the CPDs for an entirely different reason—to deal with the problem of “dumped bodies” on the streets, rather than for birth and death registration and to determine the cause of death of those who died without being attended to by a registered practitioner.

“Dumped Bodies,” and the Dawn of CPDs In the context of Hong Kong’s plague of 1894, “dumped bodies” refer to individuals left in public to die or human corpses that were already

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deceased discarded on the streets. The horror of the plague epidemic and its unforeseeable severity led the Sanitary Board of the Hong Kong government, under Governor William Robinson, to apply draconian measures to prevent it from spreading. In addition to isolating plague patients, a team descended on the residences of the diseased to disinfect them. The whole house was sloshed with disinfectant, all furniture placed into a huge tank of disinfectant on the street, and the walls whitewashed.16 Even the clothes that residents were wearing had to undergo sterilization. For the poor without extra, clean clothing, the government provided temporary ones. These measures of disinfecting the houses of affected individuals did not prevent the spread of plague. Anyone would consider such horrendous measures as unreasonable harassment from the government, and the Chinese dreaded such interference. As a result, when someone in a Chinese household came down with plague, family members typically would not notify the authorities as required by law, and instead hid the diseased person during the visit of a health inspector. When a person died of plague, members of the household, in fear of potential consequences for their disregard of the law, simply dumped the dead body in the street. For the same reasons, during smallpox epidemics, the numbers of “dumped bodies” also increased. During the plague epidemic of 1894, a large number of bodies were dumped in the streets, heightening the possibility of dissemination of the disease. Although the 1894 plague epidemic died down towards the fall, the disease recurred almost every year during the summer months until 1930. The problem of “dumped bodies” persisted. In 1897, 23% of all plague deaths were picked up from the streets; the percentage in the subsequent seven years from 1898 to 1905 were: 24.2, 29.5, 19.7, 34.6, 31.7, 26, and 18.4% respectively.17 The practice of abandoning dead bodies on the streets, viewed by the British as utterly indecent and repulsive, became so scandalous that the two Chinese members of the Sanitary Board, Mr. Fung Wachun and Mr. Lau Chu-pak, were compelled to devise a solution. They approached the Chairman of Tung Wah Hospital Committee to establish one office each in the City of Victoria and Kowloon, respectively, and have in attendance a licentiate of the Hong Kong College of Medicine for Chinese to identify the cause of death of the “dumped bodies.” In the case of infectious diseases, when removal of the body from the house and disinfection of the premises were deemed necessary, an interpreter,

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hired by the dispensary, would assist the relatives by telling them what needed to be done to comply with regulations and to relay their wishes to the sanitary authorities.18 The first two nascent CPD offices were opened in Hong Kong on 1 April 1905: Western District office at No. 42, First Street and Eastern District office at No. 205, Queen’s Road East—districts with the highest population density. Later in the year, a third office, together with a small adjoining plague hospital, was opened in Kowloon City. These offices were managed by a committee consisting of the Registrar General, A. W. Brewin, Fung Wa-chun, Lau Chu-pak, and the chairman of the Tung Wah Hospital.19 Although these offices were originally created to deal exclusively with “dumped bodies” on the streets and to determine cause of death, they eventually became fully-fledged CPDs, when assigned more duties.

Development of Chinese Public Dispensaries (CPDs) Soon after the founding of the first three dispensaries, the committee prepared plans for CPDs to operate independently from the Tung Wah Hospital. The committee, now called the CPDs Committee, was enlarged to include a total of nineteen people and chaired by the Registrar General.20 Because of the cost of maintaining these dispensaries, the Tung Wah Hospital Committee and the Chinese elite petitioned to the Registrar General to separate the dispensaries from the hospital for administrative, budgeting, and fundraising purposes. The success of the first three dispensaries led to the establishment of three more in the following two years. The fourth dispensary opened in Yau Ma Tei on 25 May 1906, the fifth in Hung Hom on 17 June 1906,21 and the sixth one, Central District Dispensary, opened on 1 February 1907.22 By 1907, there were altogether six dispensaries, three in the City of Victoria on Hong Kong Island and three in Kowloon. These dispensaries must have aptly fulfilled the needs of the local community, because there was a demand for more. In August 1909, all the boats gathered in the Causeway Bay Shelter, and a huge crowd attended a meeting of the boat population and those closely connected to them, such as the launch owners, merchants and shop keepers, to discuss the possibility

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of a dispensary for the floating population. During the meeting, it was resolved to open a harbor dispensary. A committee of seventeen members was elected to raise funds to purchase a hulk and to convert it into a dispensary. With the consent of the Harbormaster, a hulk was moored in Causeway Bay.23 Soon after, the large fishing population in Shau Kei Wan also demanded a similar service and in 1910, a dispensary was opened in a rented location to serve them.24 Meanwhile, new buildings were being constructed to house some of these dispensaries. In 1909, the Western District Dispensary and the Western District Plague Hospital were accommodated in a new building at No. 63, 65, Third Street, Hong Kong.25 The plague hospitals were small hospitals in communities where plague outbreaks were common. It was an idea promoted by Governor Henry Blake specifically for the convenience of the family members of the patients with plague, and for isolating the patients. It seemed popular with the Chinese for a while, but because of lack of effective treatment for plague, they fell into disfavor.26 Many patients opted to go to Guangzhou where herbal medicine was given with dubious results. Accommodation for coolies and ambulances was added to the Western District Dispensary three years later.27 The year 1910 saw a new building completed for the Hung Hom dispensary. On 7 October 1911, the Eastern District (Wan Chai) Dispensary moved into the ground floor of a new building with the Eastern District Plague Hospital on the top floor. The whole complex included a small hospital, a dispensary, waiting rooms, quarters for coolies, and parking accommodation for dead-vans.28 In the 1910s, two more dispensaries were founded: a new one in Sham Shui Po in 1915 and the Yau Ma Tei Harbor Dispensary, built on Kansu Street in 1916 to serve both the land and boat populations in the area.29 In the 1930s, two more CPDs were added to the list: Aberdeen in 1930, and Stanley in 1936. The CPD in Stanley began its operation by taking over a dispensary which had been run privately by St. Stephen’s College.30 Because of this, it was not counted as the tenth CPD by some people. The setup of each individual dispensary was quite simple: it had a waiting room, a consultation room for the doctor to see the patients, a treatment/dressing room, and a small dispensary. Each dispensary also had a room attached to it where dead bodies could be received for transportation to the mortuaries.

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Responsibilities of the CPDs The functions of pre-WWII CPDs can be grouped into two categories: medical and educational. On the medical side, each dispensary enlisted the services of a licentiate of the Hong Kong College of Medicine for Chinese. The following were the duties31 of the medical licentiate who was paid from a government grant: • To find out the cause of death of those unattended to by a licenced doctor, to issue death certificates, and to remove corpses to hospital or mortuary; • To inspect dead bodies at the request of the Sanitary Department or the Police and to determine the cause of death if possible; • To issue medical certificates on the nature of illness for those who were leaving Hong Kong; • To diagnose and treat patients who came to the dispensary, and to arrange for the seriously ill to be sent to a hospital for further treatment; • To be responsible for plague patients in the district plague hospital; • To arrange for plague patients to be sent out of Hong Kong at their request; • To arrange for the presence of a clerk during house cleaning of the dwelling of a plague patient, and to arrange for compensation when there were damages to the property from house cleaning; • To apply for coffin for the dead whose relatives could not afford to bury them; • To perform smallpox vaccinations. In each dispensary, there was a registry office for births occurring in the district.32 Coffins were provided free.33 In performing these duties, the licentiate was assisted by a clerk with a knowledge of English and coolies who used ambulances and dead-vans to remove patients and dead bodies, respectively. The clerk’s presence was required during house cleansing to communicate the wishes of the family and the residents to the Sanitary Department. Soon other duties were added. In 1906, the government hired several midwives who had been trained in Western methods of delivery, attached to some of the CPDs. Those who wished to have

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domiciliary deliveries could apply for their services through the medical licentiate of the CPDs.34 In 1930s, gynecology clinics for women with gynecological problems35 and venereal disease clinics were added to each CPD. In 1936, the Government Bacteriological Laboratory began to provide services to the CPDs, consisting largely of examinations of blood for malarial parasites.36 When the anti-cholera vaccine became available in Hong Kong in 1939, inoculation was added to the duties of the CPDs.37 Public education on hygiene, sanitation, and disease prevention constituted the second main function of the CPDs. The Chinese elite raised funds for the CPDs, and also took it upon themselves to publicize the importance of hygiene and the benefits of these dispensaries to the community. On 10 June 1907, Fung Wa-chun, one of the two Chinese members of the Sanitary Board, addressed the audience at Taiping Theatre on the criminality of dumping dead bodies and urged the community to refrain from doing it. Many Chinese dignitaries, such as Lau Chu-pak, the other Sanitary Board member, and members of the Hospital Committee of Tung Wah Hospital, were also in attendance to express their support.38 For the Registrar General to keep in touch with the Chinese on sanitary matters, a “Street Committee” in each district was appointed to advise the Registrar General on the best way to handle the Chinese in such matters and how best to send the messages of sanitation across to the community. Every CPD hired two “lecturers” whose duties were to advocate against the dumping of bodies in the streets, to point out the benefits of the dispensaries, and to explain the objectives of the sanitary laws. Fliers were issued in profusion and delivered on appropriate occasions. Photographs were taken of bodies found on the streets and were posted in the neighborhood, and enquiries were made in each case by the “Street Committee.”39

Officials behind the CPDs In 1905, the CPDs Committee, chaired by the Registrar General, Mr. A. W. Brewin, had nineteen members, consisting of two Chinese unofficial members of the Legislative Council, two Chinese members of the Sanitary Board, three chairmen of the general committee of Tung Wah Hospital, and others who were leading members of the

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Chinese community. In 1909, Dr. Ho Kai (Figure 2.1) became the vicechairman of the CPDs Committee. Over the years, prominent members of the Chinese community had been elected to the CPDs Committee, such as Sir Wei Yuk, Sir Robert Ho Tung, Ho Kam-tong, Ho Fook, Tso Seen-wan, Sir Shouson Chow, Chan Kai-ming, Lau Chu-pak, Fung Wachun, Sir Lo Man-kam, and more. Members of the 1941 Chinese Public Dispensaries Committee: Robert Kotewall, Lo Man-kam, Tso Seen-wan, Li Po-kwai, Ho U-ming, Wong Ping-sun, Li Jou-son, Ng Wah, Haung Sing-chiu, Wong Kat-shiu, Li Shu-fan, W. N. T. Tam, Lo Yuk-tong, Kwok Tam-wan, Lo Chung-wan, Lo Yuet-cho, Kwong Chun-san, Wan Shiu-po, Cheung Wa-lop. The dispensaries in Victoria (later all CPDs on Hong Kong Island) were directly managed by the CPDs Committee while each of the dispensaries in Kowloon was managed by a local committee. The ultimate aim, however, was for each dispensary, including those on Hong Kong Island, to have its own local committee to manage its own affairs.40

Finance of the CPDs Figure 2.2 shows the total annual revenue and expenditure of all the dispensaries by year up to 1937. By 1937, the annual expenditure had increased to about HKD 70,000,41 a large sum at that time (the wage of a laborer was about HKD 15 per month in the 1930s). The main source of revenue of the CPDs came from subscriptions from the Chinese elite, the Chinese community, business companies, and fees from the maternity hospitals at Eastern District and Tsan Yuk Hospital at Western District and a small grant of HKD 2,000 from the government.42 Chinese theaters (Tai Ping Theater, San Theater, and Ko Shing Theater) and temples also helped defray the expenses of the dispensaries with generous donations each year. There were special fundraising events and subscriptions for establishing new dispensaries.43 The government increased the grant over the years because of the rising workload and the increasing number of CPDs. In 1926, the grant was increased to HKD 9,000 per year, yet this constituted less than one fifth of the total expenditure of all the CPDs that year.44 The total revenue barely covered the total expenditure over the years.

Figure 2.1 Sir Kai, Ho Kai

Wikipedia photo d Sir Kai, Ho Kai (1859–1914), born in Hong Kong, was a medical doctor and a barrister educated in England. His first wife, Alice Walkden, was a British national. After his wife’s death in 1884, he donated funds for the building of Alice Memorial Hospital in her memory. He also raised funds for the operation of Alice-affiliated hospitals and CPDs every year and donated and taught in the Hong Kong College of Medicine for Chinese. Sir Kai is remembered as a teacher and mentor of his student, Sun Yatsen, who became the founding father of the Republic of China. Kai Tak Airport, Hong Kong, was named after him and one of his son’s father-inlaw, Au Tak. He served as a member of the Legislative Council of Hong Kong and a member of the Sanitary Board for years. d

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Figure 2.2 Total annual revenue and expenditure of CPDs, 1905 to 1937

Note: Revenue (thick line), expenditure (thin line). Data for revenue only available from 1912 to 1928. Source: from the Registrar General (later renamed Secretary of Chinese Affairs) Reports, 1905–1937 from HKSP or HKAR of respective years.

Several individuals deserved special mention for fundraising efforts as well as for their generous donations. In addition to Ho Kai, Ho Kam-tong, a maternal half-brother of Sir Robert Ho Tung, had been particularly enthusiastic in supporting the CPDs. Dr.  Tso  Seen-wan, a barrister, championed medical services for the Chinese. Tso’s contributions will be described in more detail in the following pages. The income and expenditure accounts of the Victoria dispensaries were kept by the Registrar General, who was also responsible for collecting the subscriptions. The Kowloon dispensaries were independent of the Registrar General, keeping their own accounts and collected subscriptions.45

Contributions of the CPDs “Dumped Bodies” One of the main reasons for the establishment of CPDs and district plague hospitals was to reduce the large number of abandoned dead bodies on the streets of Hong Kong. So, were the CPDs truly effective in reducing

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Figure 2.3 Number of “dumped” bodies and deaths from plague and smallpox per year, 1905 to 1926

Source: The number of “dumped bodies” each year were derived from the Registrar General or Secretary for Chinese Affairs 1905 to 1926; smallpox and plague deaths were obtained from Medical Department annual reports from 1905 to 1926. There were very few cases of plague after 1926.

the number of “dumped bodies”? The following section will explore the answer to this question through a historical lens. In the early-twentieth century, plague and smallpox, the two main recurrent epidemic diseases in Hong Kong, accounted for a high proportion of the “dumped bodies.” Figure 2.3 shows that from 1905 to 1910 and from 1916 to 1926, there was a direct relationship between the number of “dumped” bodies and the number of deaths from smallpox and plague.46 However, during the period from 1910 to 1915, there were two years (1912 and 1914) in which deaths from plague and smallpox were high, and yet the number of dumped bodies was low, suggesting that during those two periods, the anti-dumping messages disseminated by the Street Committee had been working. Recognizing that the stringent sanitary regulations, along with the hassle and inconvenience imposed on the patients and their families following the diagnosis of plague or smallpox, were responsible for concealment and dumping of bodies, the government relaxed the rules somewhat in 1912. Patients were allowed to be treated in their own homes provided: 1) the Medical Officer of Health had been notified; 2) all

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other occupants of the floor had been vaccinated in the case of smallpox and other floors vacated; 3) the disinfecting required by the regulations was carried out; and 4) recognized treatment was given and the patient not allowed out until certified by the Sanitary Department as free from infection. Patients could be removed from their home to other facilities in the colony for treatment, if 1) under the permit from the Medical Officer of Health; 2) removal carried out in special conveyances provided by Tung Wah Hospital or the CPD; 3) the house where the disease first appeared was disinfected under the existing regulations; and 4) the house to which the patient was removed had complied with government regulations on the treatment of existing disease.47 The CPD was able to reduce “dumped bodies” only up to a point. It is apparent that the government regulations were not relaxed sufficiently enough to ensure all cases of infectious diseases were reported to the authorities. Dumping of bodies persisted in subsequent epidemics, albeit to a lesser degree. It is not clear why these various measures failed to work after 1921. Perhaps the increase in dumped bodies during this time can be attributed to the political and economic turmoil taking place in Hong Kong, as the 1920s were characterized by a series of labor unrests and strikes. The strike-boycott of 1925, ignited by the May Thirtieth Incident,48 lasted for almost one year and completely destroyed Hong Kong’s entrepôt trade and bankrupted its economy. During this period, anti-British and antiforeigner sentiments soared, with political fervor and emotional tension running at fever pitch. This atmosphere of instability and crisis probably affected the potency of any message the government wanted to deliver, sanitary and anti-dumping messages included.

Advocacy for Western Medicine CPDs were instrumental in popularizing Western medicine. In 1936, the number of CPDs rose to ten, six on Hong Kong Island and four in Kowloon. The total number of patients treated also increased progressively over the years. The rate of increase in the number of patients treated in the CPDs after 1933 was slightly steeper than the rise in population in Hong Kong (Figure 2.4), suggesting the progressive rise in acceptance of Western medicine by the Chinese community.

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Figure 2.4 Population in Hong Kong versus total patient treated in all CPDs per year, 1905 to 1939

Source: Population data from Hong Kong Blue Book and new patients seen from annual reports of the Registrar General or Secretary for Chinese Affairs during the period.

With regard to small children, the CPDs treated few below the age of five, while receiving frequently dead infants. Gradually, more children were brought in for treatment, reaching 13% of the total number seen in the clinics in 1910. From then on, the proportion fluctuated between 11% and 13% each year. 49 This steady increase in care of children again suggests that Western medicine had earned the trust of the Chinese community. In 1906, the government sent trained midwives to affiliate themselves with some of the CPDs where women in the neighborhood could apply through the licentiate doctor in-charge for domiciliary delivery. These CPDs included Western District, Eastern District, Shau Kei Wan, and Kowloon City Dispensaries. The number of domiciliary deliveries by the government increased from the year 1908 to 1917, as shown in Table 2.1.50 Their Western method of delivery with aseptic technique reduced maternal mortality and morbidity and became increasingly popular among the Chinese women.

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Table 2.1 Number of domiciliary deliveries by government midwives from CPDs, 1908 to 1917 Year

No. of Deliveries

1908

99

1909

148

1910

165

1911

172

1912

117

1913

135

1914

228

1915

138

1916

172

1917

182

Source: Annual Medical Reports for the years 1908 to 1917, HKAR 1908 to 1917.

In 1919, the Eastern (Wan Chai) District Plague Hospital, having no plague patients, was converted into a maternity hospital under the supervision of Dr. Ho Ko-tsun and Dr. Alice Hickling (nee Sibree).51 The Eastern District Maternity Hospital became very popular and successful, and the number of deliveries exceeded 1,000 by 1927. The success of the Eastern District Maternity Hospital led Dr. Tso Seen-wan to plan for a maternity hospital in the Western district, to be financed by subscriptions from the local community. However, the Western District Plague Hospital was far too small to be converted into a maternity hospital for the amount of work anticipated. Tsan Yuk Hospital was built on a nearby lot and opened in 1922. It was the first hospital with a Chinese doctor and a Chinese matron, and Dr. Hickling acted as its consultant. 52 The hospital served all women from the Western District. In 1930, gynecology clinics were set up in the CPDs attended by a female doctor. Initially, gynecological services were only offered once a week, but in some CPDs, because the waiting list was long, two clinics were held each week. The tremendous need for such a service was reflected by the huge number of patients seen in these clinics. In 1931, 5,966 patients were seen, and the number climbed by more than threefold in 1939 to 18,370 (Table 2.2).53 Since Chinese women were quite

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Table 2.2 Total annual attendance of the CPDs’ gynecology clinics Year

No. of Deliveries

1930

5,966

1931

8,094

1932

7,403

1933

9,658

1934

10,258

1935

13,348

1936

13,126

1937

13,636

1938

15,378

1939

18,937

Source: Medical Reports for the years 1930 to 1939, HKAR 1930 to 1939.

modest about any symptoms related to their sexual health, they had been reluctant to share their symptoms with a male doctor. The attendance of these clinics by a female doctor enabled Chinese women to discuss their symptoms more openly and to receive both a sympathetic ear and appropriate treatment. For the first time, women’s diseases were cared for suitably by female doctors, and Chinese women were converted to Western medicine. The services offered by CPDs played a major role in providing the basic medical care for the community. The free midwifery services reduced maternal and infant mortality. Mothers and babies benefitted enormously due to the availability of domiciliary deliveries by midwives trained in Western methods using antiseptic techniques, and education on basic hygiene and child nutrition. Thus, the CPDs helped propagate Western medicine among the Chinese and eventually make it the mainstream form of medicine in Hong Kong.

Vaccinations It is not surprising that smallpox vaccination became an important part of the routine work of the CPDs. The Chinese had long embraced the idea of smallpox vaccination long before Edward Jenner introduced cowpox vaccination. It was usually carried out by blowing powdered smallpox

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scabs or placing a pledget of cotton impregnated with smallpox scabs into the nose of a child to induce a mild disease. At first, cowpox vaccinations were carried out by licentiates visiting the homes of the individuals, especially those with children. With the increasing number of patients attending the CPDs, vaccinations had to be performed in the clinics. Figure 2.5 shows that the total number of smallpox vaccinations, carried out either in the dispensaries or at people’s homes, increased gradually over the years. Since the serious 1887–1888 smallpox epidemic, nearly all hospitals in Hong Kong offered vaccinations, and in 1890, an ordinance was enacted in Hong Kong to ensure that all infants were vaccinated before they reached six months of age.54 Despite these measures, in July 1916, Dr. W. J. Woodman, Acting Medical Officer of Health, was alarmed to find a large number of smallpox patients. Since smallpox had been much more prevalent in the winter than in the summer months, Woodman anticipated a severe epidemic during the coming winter. He asked Tung Wah Hospital and the Chinese Public Dispensaries to mount a vaccination campaign as soon as possible. The 300,000 vaccinations carried out during that dreadful winter were twenty times as many as those of the previous years.55 While there were around 3,000 to 4,000 cases of smallpox, only 1,307 (less than one third) of the infected died in the 1916–1917 epidemic, when the usual case mortality was over 50%. 56 In 1917, among smallpox patients admitted to Tung Wah Hospital, death occurred in 65.6% of the unvaccinated but only in 5.4% of the previously vaccinated, and among those vaccinated who did develop the disease, symptoms were mild.57 All signs pointed to the efficacy of vaccinations. The success of the vaccination campaign during 1916–1917 among the Chinese was largely due to Dr. Tso Seen-wan, who was the chairman of Western District Dispensary and spared no time or effort in organizing and promoting the campaign.58 It is important to revisit Figure 2.5 and consider the drastic spike in vaccinations of the late 1930s. The marked increase in 1938 and 1939 was due to the intensive vaccination campaign in response to the huge influx of some disease-carrying refugees from the mainland during Japanese invasion. Over one million people were vaccinated during those two years.59

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Figure 2.5 Total number of smallpox vaccinations by the CPDs, 1905 to 1938

Source: Registrar General or SCA Reports from 1905 to 1939 in HKSP or HKAR, 1906 to 1939

Public Education on Sanitation and Disease Prevention With the exception of the “anti-dumping” campaign, the response to public education on other matters had been quite positive. In addition to mounting the vaccination campaign during the 1916–1917 smallpox epidemic, Dr. Tso also asked the “Street Committee” and the “lecturers” in his district to persuade people to comply with Woodman’s requests: that all cases of smallpox be reported to the Medical Officer of Health, all occupants of a house where a case had occurred be vaccinated, and a notice be placed on the door when a case of smallpox had occurred in the house. The uncomplaining, cooperative response of the Chinese community to the preventive measures for the smallpox epidemic was radically different from their reaction to the draconian measures imposed for the 1894 plague epidemic. Public health education efforts were becoming more fruitful.60 The compliance with public health measures this time around was enhanced by the support of the well-respected kaifong members, by the efforts of the “Street Committee” of the CPDs to disseminate the government’s sanitary regulations, and by widespread awareness of the ravaging effects of the disease. The colonial administration learned from this experience not to impose public health measures from above without consulting with and seeking help from the local Chinese elite who were highly respected by the community.

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The CPDs also engaged rat catchers in an effort to prevent the spread of plague. By then the relationship between the plague bacilli, the rat fleas (Xenopsylla cheopis), and the rats in the pathogenesis of the disease had been well established. The plague bacilli were found in the intestine of infected rat fleas, and were transmitted to humans by flea bites. For many years, a large number of rats were caught by the rat catchers. For example, in 1911, 65,927 rats were caught in Hong Kong and 21,311 in Kowloon. During the summer of 1911, the CPDs employed men to stop 923 rat runs (routes used by rats) with cement and glass in 232 houses. The whole operation was supervised by Ng Hon-tze and Lau Chu-pak, and other members of the CPDs Committee.61 Because of public health education, the people of Hong Kong became much more aware of infectious diseases and the importance of isolation, contact examination, quarantine, vaccination, and inoculation toward their prevention, and they became much more compliant with sanitary regulations. The compliance persisted after the Second World War, and major epidemics were avoided or controlled rapidly by timely preventive measures. The ritual of “Cleaning the Environment,” during which all households had to clean up the house thoroughly and discard unwanted articles twice a year, initiated during Governor Blake’s administration for the prevention of plague, continued well into the 1950s even though the last two cases of plague in Hong Kong had occurred in 1929.62

The Fate of the CPDs in the Post–World War II Era In 1939, there were discussions of transferring the CPDs to the government Medical Department with the intention to eventually transform them into health centers with better facilities, and steps were to be taken to prepare for the transfer of the major CPDs in 1940.63 Stunting this plan was the international political tumult of the Second World War. The Japanese Imperial Army was already at the Shenzhen border, having marched southward after the fall of Guangzhou in 1938. On 7 December 1941, Japan attacked Hong Kong and Pearl Harbor simultaneously. On Christmas Day of 1941, Hong Kong surrendered to the Japanese Army after seventeen days of vigorous fighting and resistance from the British forces and the voluntary corps. Due to this wartime upheaval, very little

2 . C hinese P ublic D ispensaries   |   3 1

information about CPDs during the Japanese occupation is available. Many Chinese elite left Hong Kong for the Mainland and Macau. Several CPDs were closed. Only Wan Chai, Shau Kei Wan, and Stanley dispensaries continued to operate under trying conditions.64 After the liberation of Hong Kong in 1945, only a few of the CPDs Committee members remained, and they were mostly old and infirm at that point. No one was able to come forth to take up the responsibility of managing the CPDs when such a huge budget was required. In 1946, the government took over all the CPDs and ran them as government outpatient clinics, providing medical care for thousands of patients.65 Because of lack of resources, many CPDs buildings were in a dilapidated state, and renovations and repairs were carried out one by one well into the 1950s. As the 1950s wore on, Hong Kong’s economy gradually improved and really took off in the late 1960s and early 1970s. With increased revenue, the government began ambitious building programs of hospitals and clinics. By the mid-1960s, most of the outpatient clinical activities carried out in previous CPDs facilities were moved to new buildings or health centers of respective districts. Table 2.3 shows the status of the various CPD buildings in 1950 and 1965. In 1964, the Secretary for Chinese Affairs (SCA) was asked to bring an end by an ordinance to unfinished business of the CPDs Committee which had ceased to function since 1941. The SCA was only able to compile a list of nine people who had served as members of the CPDs Committee. The surviving CPDs Committee members all indicated that they had no objection for the SCA to surrender the properties of CPDs to the Crown.66 The SCA, however, found that the dissolution of the CPDs was more complicated than just a matter of surrendering the properties of CPDs to the Crown. Up to 1928, the leaseholds of the properties on which the CPDs were built were registered under different organizations: the CPDs, the District Watchman stations, various temples and temple properties, and miscellaneous trusts, such as schools. In 1928, an ordinance (3/1928) was enacted to incorporate the SCA so that he would be able to deal with the legal estates on which he held the leasehold of properties of CPDs. The vesting was in every case made subject to the trust on which the respective property was held immediately before the commencement of the ordinance.67

IL 1793 IL 1794 IL 2275

IL 1835 IL 790

IL 1747 IL 790

SIL 430

NKIL1126

Western District

Eastern District

Central District

Shau Kei Wan

Kowloon City

Dispensary Lot No.

SCA Inc. for a temporary plague hospital or a dispensary.

A. W. Brewin, RG, for the CPD Committee; E. R. Hallifax, SCA, for the CPDs Committee for ambulance, dead-van and coolies’ residence. E. R. Hallifax, SCA for the community of Shau Kei Wan for the lot to be used as a dispensary.

A. W. Brewin on behalf of CPDs for a permanent plague hospital.

A. W. Brewin, RG, on behalf of Kaifong committee of Second and Third Street.

Title and Trust

Used as CPD, maternity home and quarters for staff.

A connected set of three buildings, the middle one used as a maternity home.

Both lots returned to Central Kaifong committee for a school to be built. Returned to Shau Kei Wan Kaifong Association.

Used as CPD and quarters for staff. Used as CPD and as staff quarters.

Lot surrendered to the Destroyed during the war by government and absorbed into Crown land. the Japanese. Kai Tak Airfield.

Two old buildings on the corner of Kau U Fong and Aberdeen Street, joined by an overhead bridge.

IL 1794 returned to Medical and Health Department IL 1793 to Social Welfare Department.

Ante- and post-natal clinic and staff quarters. The Western District Dispensary was closed in 1949 and used as an extension of Tsan Yuk Hospital connected by a verandah bridge.

Main two-story building and a garage which encroached on the neighboring lot (IL 1794) by 175 1/4 sq ft.

IL 1835, IL 790 to Medical and Health Department.

Status in 1965

Status in 1950

Nature of Building before WWII

Table 2.3 Status of the properties of the Chinese Public Dispensaries, in 1950 and 1965 32  |  A MEDICAL HISTORY OF HONG KONG

Title and Trust

Nature of Building before WWII

NKIL 473, SCA for Kaifong Association 474

Land belongs to the Temple.

HHIL 255 given back to Crown in exchange for a lot to build a school by Hung Hom Kaifong. To Medical and Health Department.

Ground-floor clinic by Medical Department; the staff of clinic occupied another floor in the next building. Ground floor, CPD offices. Firstfloor staff quarters.

Two-story building specifically built for CPD. Three-story building at the All building used as CPD with end of the lot facing Yee Kuk staff quarter on upper floor. Street. Rented building on private land. Two blocks of tenement houses built by Kaifong Association; rent generated to defray the expense of the CPD.

Status in 1965

Status in 1950

Source: Table A and B, prepared by R. R. Todd for the SCA, November 9, 1950, Hong Kong Public Record’s Office Data in 1965 derived from Letter from Paul Tsui for Secretary for Chinese Affairs to Attorney General, Director of Public Works, Director of Medical and Health Services, August 7, 1965, Chinese Public Dispensaries (Winding Up) Bill. Hong Kong Public Records Office, HKRS 1349-1-36, MD 227/50. RG-Registrar General; SCASecretary for Chinese Affairs.

Shek Kip Mei

E. R. Hallifax, SCA, acquired the Yau Ma Tei KIL 1296 lot as a dispensary. and Harbor E. R. Hallifax, SCA, for a temple Sham Shui NKIL 552 for religious purposes and in an Po open space, a CPD. Aberdeen Stanley

SCA Inc. as trustee for Kaifong of Two-story building with Hung Hom HHIL 255 Hung Hom to build dispensary, outhouses and adjoining school, and temple. temple.

Dispensary Lot No.

(Cont’d Table 2.3)

2 . C hinese P ublic D ispensaries   |   3 3

34  |  A MEDICAL HISTORY OF HONG KONG

Because of this, the SCA had several issues with “winding up” or closure of the CPDs by an ordinance. First, even though SCA Incorporated had held, since 1928, the leasehold of all the properties of the CPDs on trusts of various kinds (except Sham Shui Po Dispensary which was built on temple land), the CPDs Committee had ceased to function since 1941, and the circumstances in which the trusts came to be created were no longer valid.68 Second, the SCA was able to locate documentations of the several trusts of the CPDs of which he was the trustee in his capacity as Secretary for Chinese Affairs. He could no longer say that the nature of the trusts was unknown.69 Table 2.3 shows that there was a trust registered on each of the CPDs properties.70 Third, there were requests from some Kaifong Associations to use the CPDs properties as their offices and to provide facilities for welfare and social services badly needed by the community. While legally the government could take over all the properties of CPDs by enacting another ordinance to extinguish all the existing trusts, the SCA felt that this was not advisable. The CPDs were established to fulfill the need for medical services in the Chinese community and the government had encouraged the community to be generous in their donations and contributions to the establishment and operation of these dispensaries. When the government had a need for the premises and took them over, in the eyes of the Chinese, social justice was not done. The SCA believed that CPDs buildings should be put to use in a way that would continue to win the interest and support of the communities who had subscribed to the original CPDs.71 The Chinese Public Dispensary Committee (Winding Up) Ordinance 1967 was finally enacted to extinguish all trusts, enabling the Secretary for Chinese Affairs Inc. to direct the use of these premises free of trusts.72 The disposal and use of the premises in 1965 are also shown in Table 2.3. Many of the buildings continued to provide medical services to the community, while some were returned to the Kaifong Association that had other needs for them, such as using the land to build a school or for social welfare activities. Thus, the story of the CPDs came to an end after serving Chinese communities in Hong Kong and Kowloon for the first half of the twentieth century.

3. The Chinese Elite and the Chinese Public Dispensaries

Contributions of the Chinese Elite Toward the late 1930s, Chinese Public Dispensaries (CPDs) were operating at an annual expenditure of HKD 65,000 to HKD 70,000, while the expenditures of the three Chinese Hospitals (Tung Wah, Kwong Wah, and Tung Wah Eastern Hospitals) were about ten times as much—a huge financial commitment borne by the Chinese elite.1 These institutions received a small grant from the government, amounting to about one-tenth to one-fifth of their total expense, depending on the year. Table 3.1 shows the number of in- and out-patients in government hospitals versus those in the Chinese hospitals (Tung Wah, Kwong Wah, and Tung Wah Eastern Hospital) and CPDs in 1936.2 One can appreciate that the bulk of medical services in Hong Kong, before the Second World War, was provided by the Chinese Hospitals and CPDs. Indeed, it was the Chinese elite, and not the government, who were responsible for the medical care of the vast majority of the Chinese community. Even though the Chinese were responsible for the bulk of taxes received, they certainly did not derive many benefits in return. Why would the Chinese take it upon themselves to establish and finance the CPDs and the three Chinese Hospitals for decades? During the early years of the founding of the colony, most of the Chinese in Hong Kong belonged to the lower socioeconomic class, having arrived in Hong Kong without their families to seek opportunities to make their living. They did not understand English, yet were determined to find success outside of mainland China in order to support their families. They were sojourners motivated by the hope of returning home one day after making a sufficient amount of money. The colonial government, with their conservative financial and economic policies, had neither the desire nor adequate resources to provide medical and social services to Hong Kong’s Chinese population. Any initial medical service development had been catered to the needs of specific, privileged groups of people—the

36  |  A MEDICAL HISTORY OF HONG KONG

Table 3.1 Total in- and out-patient attendances in government hospitals, Chinese hospitals, and Chinese Public Dispensaries in 1936 Hospital/Public Dispensaries Government Hospitals Government Civil Hospital Victoria Hospital for Women and Children Kowloon Hospital Subtotal Chinese Hospitals Tung Wah Hospital Kwong Wah Hospital Tung Wah Eastern Hospital Chinese Public Dispensaries Subtotal Total

Inpatients Western TCM

Outpatients Western TCM

5,875 644 3,367 9,886

0 0 0 0

103,266 0 62,502 165,768

0 0 0

7,157 9,135 4,081 0 20,373 30,259

4,984 4,436 2,650 0 12,070 12,070

34,748 48,106 36,569 474,827 594,250 760,018

170,584 182,813 62,849 0 416,246 416,246

Note: TCM = traditional Chinese Medicine Source: Medical and Sanitary Department Report of 1936, Hong Kong Administrative Reports, 1936, C56. Reproduced from M. Chan-Yeung, A Medical History of Hong Kong 1842–1941 (Hong Kong: The Chinese University of Hong Kong Press, 2018), 241.

colonial administration staff, the civil servants, the police force, and the European businessmen. Gradually over the course of colonial rule, two groups of wealthy Chinese elite emerged in Hong Kong. The first group were the compradors, the natives who were able to communicate in English and were employed by the British ruling class as their agents to act as middlemen in business transactions between the British and the Chinese traders. Inevitably, the compradors became indispensable to the British merchants. After acquiring a certain amount of wealth of their own, the compradors became gentrified. The turbulence of the Taiping Rebellion, which started in 1850 and ended in 1864, brought the second group from China to Hong Kong. They were educated, well-to-do and hard-working refugees, who fled to Hong Kong. These two groups of Chinese emerged as elite in Hong Kong. They offered alms and social services to the poor, which were not provided by the colonial government, in the same way as they were accustomed to in China, where government-funded social welfare was unheard of. The Chinese elite occupied a paradoxical position in the colonial structure of Hong Kong at that time: they were statusseeking, but at the same time, civil-minded individuals.

3 . T he C hinese E lite and the C hinese P ublic D ispensaries   |   3 7

Tung Wah Hospital, founded in 1872 in Hong Kong, provided traditional Chinese medicine to patients free of charge or for a small fee. The operating expense of the hospital mainly came from donations of the Chinese elite and the Chinese community, together with the interest generated from investment of its initial endowment fund.3 Wealthy Chinese merchants vied to become members of the Tung Wah Hospital Committee—a highly sought-after status symbol in the community. The Tung Wah Hospital Committee not only provided medical services but also had immense influence on nonmedical matters in the local Chinese community. It furnished the government with advice and information concerning the governance of the Chinese and helped enforce law and order when needed.4 At the same time, it became the mouthpiece for the Chinese community and exerted enormous power over them. To increase their prestige and perceived authority, some of the Hong Kong Chinese elite purchased “official” titles from the bureaucrats of the Qing Dynasty, who sold the titles for money—a long-time practice. The Qing officials regarded the Hong Kong Chinese elite, who had purchased the titles, as citizens of the Qing Dynasty who should obey the Qing officials and follow the laws of the Qing Dynasty. At times, the Qing officials made unreasonable demands on these Chinese elite—mostly for money, but at times to carry out subversive activities against the colonial government. The colonial administration became suspicious of these Chinese elite. During the Sino-French War in 1884, the colonial officials suspected that some leading Chinese, who were closely connected with the Mandarins in Guangzhou, had been the instigators of unrest. When a riot broke out, Marsh, the colonial administrator, stationed British troops in the Great Hall of Tung Wah Hospital, humiliating the elite by making a show that British authorities would not hesitate to use force to exert control when necessary.5 When bubonic plague erupted in 1894 and twenty undiagnosed cases were discovered in the Tung Wah Hospital (with no isolation precautions in place), the hospital naturally became a target of blame for the deadly epidemic.6 The government held an inquiry in 1896 and used the opportunity to force the Hospital Committee to cease any political activities in Hong Kong and to comply with the following changes: 1) to introduce Western medicine to Tung Wah Hospital, 2) to focus on

38  |  A MEDICAL HISTORY OF HONG KONG

expansion of medical services, and 3) to discontinue political activities undertaken by the Committee.7 The Hospital Committee had since concentrated their efforts on medical services, with formation of a medical advisory committee to guide them. Soon they established several clinics and built two more hospitals: Kwong Wah Hospital in 1911 and Tung Wah Eastern Hospital in 1929. These Chinese hospitals required a huge operating budget and were supported mostly by donations from the Chinese community, especially the Chinese elite, and a small grant from the government. By the late-nineteenth century, another group of Chinese elite emerged—the younger, westernized ones who had been educated abroad. By then, the membership of Tung Wah Hospital Committee was no longer the only route to social recognition. New avenues for social advancement opened up for aspiring individuals. More and more Chinese, who had been naturalized to become British citizens, were appointed by the colonial government to serve on various official boards, such as the Sanitary Board and the Commission of Peace. They were welcomed by the colonial administration as an alternative to the Tung Wah group, which the colonial government distrusted. Dr. Ho Kai was among the first young, westernized Chinese. Like some of his contemporaries, he viewed Tung Wah Hospital’s stubborn resistance to adopting Western science as a symbol of Chinese conservatism and obstruction of progress. He promoted Wester n medicine and was instrumental in building the Alice Memorial Hospital to remember his wife after her untimely death. He conducted fundraising campaigns annually to support the Alice Memorial and Affiliated Hospitals and became the vice-chairman of the CPDs Committee in 1909. Dr. Ho Kai had been such an effective fundraiser that even Governor Lugard relied on him to raise funds from the Chinese community for the University of Hong Kong.8 Another westernized Chinese then was Dr. Tso Seen-wan (Figure 3.1), who was a member of CPDs Committee and also chairman of the Western District Dispensary Committee. The compradors, on the other hand, received their education locally, from government or missionary schools where teaching was conducted in English, such as the Government Central School (now Queen’s College) and the Diocesan Boys’ School. They became compradors after graduation from secondary schools because of their excellent command

Figure 3.1 Dr. Tso Seen-wan

Photograph courtesy of Mr. Lincoln Tso d Educated in England, Dr. Tso Seen-wan (1868–1953) became a barrister and returned to Hong Kong, where he served his people with immense dedication. A close friend and colleague of Ho Kai, Tso was engaged in most of Ho’s projects. Tso supported Western medicine, especially for women, and promoted the founding of the Eastern District Maternity Hospital and Tsan Yuk Hospital. A believer in public health education, he reduced “dumped” bodies in the Western district by ensuring plague patients be admitted to the Western Plague Hospital. Before the 1916–1917 epidemic of smallpox, he encouraged residents in the area to have smallpox vaccinations, thus reducing the morbidity and mortality of the disease. Dr. Tso was one of the founders of St. Stephen’s College, St. Stephen’s Girls’ College, and Munsang College. He served on many medical and educational committees. d

40  |  A MEDICAL HISTORY OF HONG KONG

of both English and Chinese. Figure 3.2 Sir Robert Ho Tung This group included Sir Robert Ho Tung (Figure 3.2) and his two brothers, Ho Fook and Ho Komtong, Lau Chu-pak, and others. Unlike the Chinese living in Hong Kong during the earlier years, this group regarded themselves less as sojourners because they grew up and were educated in Hong Kong. Moreover, after the establishment of the Republic of China in 1912, the country rapidly fell into the hands of the warlords. The social Wikimedia Commons photo unrest and political instability led to another influx of refugees. Sir Robert Ho Tung, the head comprador of Jardine, Matheson & Co., a large British trading firm in the Far East, urged the Chinese in the colony to regard Hong Kong as their new home. He set an example of how to be an upstanding Hong Kong citizen by being civicminded: he served the community by taking on duties and responsibilities in official and unofficial committees, and at the same time, he cared for the Chinese community by generously donating to hospitals, clinics, and schools. After the First World War, Europe was in humanitarian zeitgeist for social reforms. Millions of wounded soldiers and unemployed workers of the war industries invariably led to intense tensions and social unrest. National and international organizations began to spring up to improve social welfare and the health of war veterans, unemployed workers, citizens, and even the indigenous people in the colonies. For example, the International Labor Organization, born out of the League of Nations, introduced eight-hour work days, unemployment insurance, and regulations governing women and children’s working conditions. Governments also began to pay attention to public healthcare, maternal and infant mortality, hygiene issues, housing, and youth education in order to safeguard the primary needs of the populations, impoverished and weakened by the long war. The Chinese elite in Hong Kong were also caught up in the social reform fever. The YMCA movement, led by Chinese Christians, began

3 . T he C hinese E lite and the C hinese P ublic D ispensaries   |   4 1

in the 1910s to improve the minds and the bodies of young people by offering regular lectures and providing facilities for exercise.9 The YWCA was deeply involved with the anti–mui tsai movement in the early 1920s, which endeavored to abolish an old Chinese custom of selling young girls from poverty-stricken families into wealthy families as servants, or mui tsai. 10 On reaching adulthood, a mui tsai might be married off as a second wife or concubine, or she might be sold to a brothel. For a long time, the Hong Kong government had been swayed by the opinions of wealthy Chinese elite who argued against the abolition of the mui tsai system, claiming that the practice was charity that gave food, shelter, and clothing to a child who might otherwise starve.11 The Anti–Mui Tsai Society was formed in 1922 by a group of Chinese Christians in the YMCA. After heated discussion in the community, the Anti-Mui Tsai Bill was finally passed.12 The labor strikes in the early 1920s were all settled generously with a 30% to 40% rise in wages for the workers by owners of companies, European or Chinese. The CPDs movement offered the Chinese elite another avenue to fulfill their desire to serve the community and improve their social status simultaneously. In this endeavor, they were strongly encouraged by the government since government revenue was limited in those days, especially after the 1925 strike-boycott. Because the CPDs were the forerunners of today’s governmental general outpatient clinics, it is of historical interest to go through them individually to find out how each one of them developed and its fate. Some dispensary buildings were returned to Kaifong Associations when the government erected a new building in the vicinity and moved the clinical activities of the dispensary into the new building. In some cases, such as Sham Shui Po Dispensary, the building became a heritage site and continued to function as a clinic.

Individual Chinese Public Dispensaries Before the Second World War, there were ten Chinese Public Dispensaries scattered in different districts of Hong Kong and Kowloon serving the communities in which they were located. Official records of individual dispensaries are difficult to find, as the war had destroyed

42  |  A MEDICAL HISTORY OF HONG KONG

most of them. Table 3.2 shows the dates of first operation and location of each dispensary, subsequent relocation, and construction of some of the dispensaries. They were compiled from various sources as detailed in the table’s caption. Four dispensaries were built together with a small hospital for plague patients. However, even during epidemics of plague, the Chinese infrequently used these local hospitals, with the exception of the Western District Plague Hospital. In plague hospitals, patients were given treatment to relieve symptoms only, as no specific “cure” for plague was available then. Many patients left for hospitals in Guangzhou where traditional Chinese medicine offered a glimmer of hope, albeit a small one, with some herbs. When plague finally disappeared in the late 1920s, one of the four plague hospitals turned into a maternity hospital while another one had a larger maternity hospital built next to it, to provide a much-needed service to the community. Figure 3.3 Location of CPDs in Hong Kong and Kowloon in 1939

Date (d-m-y) 01-04-05 20-09-09 17-10-22 01-04-05 23-04-11 10-12-31 01-02-07 17-01-30 04-10-09 26-07-10 02-09-29 1930 1936 01-07-05 28-06-32 17-06-06 18-07-10 27-05-06 25-01-16 12-04-15 26-10-36

Location 42, First St. HK 63, 65, Third St. HK Junction of Western and Third St. 205, Queen’s Road East, HK Stone Nullah Lane, Wan Chai, HK Extra floor added as maternity ward+ 3, Aberdeen St. Kau U Fong, HK Rebuilt at same site+ Moored in Causeway Bay, HK Rented premises in Shau Kei Wan Main St., Shau Kei Wan West, HK* 45, Aberdeen Main St, HK; later 115, Aberdeen Main St. HK Stanley, HK Sung Wong Toi** Kak Hang Tsun Road, Kowloon City Rented premises Koon Yum St., Kowloon Near Yau Ma Tei Ferry Terminal Kansu St., Yau Ma Tei, Kowloon++ Temple land 137, Yee Kuk St. Kowloon# NKIL552

KIL1296

HHIL255

NKIL1126

SIL430

IL1747, IL1860

IL1835, IL790

IL1793, IL1794 IL2275

Lot No.

Source: Starting dates of operation for each institution from Registrar General Reports of respective years; South China Morning Post of various years; last location of institutions was obtained from Kung Sheung Daily 4 December 1939; Lot number from: Secretary for Chinese Affairs to Hon. Colonial Secretary, 30 September 1964, Chinese Public Dispensaries (Winding Up) Bill and Hong Kong Public Records Office HKRS 1394-1-36 MD 227/59.

*Huazi Ribao 27 August 1929. **Hong Kong Telegraph 29 June 1932. +Kung Sheung Daily 17 January 1930. ++Kung Sheung Evening News 10 December 1931. #Kung Sheung Daily 27 October 1936. The building of the dispensaries or their rebuilding had been confirmed in Hong Kong Public Works Department Annual Reports: Western District: HKAR 1909, PWD Report, P11 Sham Shui Po: HKAR PWD reports, 1913, P21; 1914, P21 1915 Q24 Eastern District: HKAR 1911, PWD Report, P15 Sham Shui Po: HKAR 1935, PWD Report, Q5 Yau Ma Tei: HKAR 1916, PWD Report, Q24 Shau Kei Wan: HKAR 1929, PWD Report, Q21

Sham Shui Po Dispensary

Yau Ma Tei Dispensary Yau Ma Tei/Harbor Dispensary

Hung Hom Dispensary

Kowloon City Dispensary

Aberdeen Dispensary Stanley Dispensary

Shau Kei Wan Dispensary

Harbor Dispensary

Central Dispensary

Dispensary/Plague Hospital Western District Dispensary Western District Dispensary/Plague Hospital Old Tsan Yuk Hospital Eastern District Dispensary Eastern District Dispensary/Plague Hospital Maternity Hospital

Table 3.2 Date of first operation and location of individual dispensaries 3 . T he C hinese E lite and the C hinese P ublic D ispensaries   |   4 3

44  |  A MEDICAL HISTORY OF HONG KONG

The CPDs were staffed by licentiates of the Hong Kong College of Medicine. Their degree was not accepted by the General Medical Council of Britain for medical registration because their curriculum lacked laboratory training.13 As a result, they were not able to practice in Hong Kong. When the CPDs were founded, the licentiates were recruited to work in them. Their services became vital for the Chinese community and were in high demand. The names of some of the licentiates, who had worked in the CPDs and could be traced, were published in the book, Western Medicine for Chinese, by Professor Faith Ho (Table 3.3).14 Table 3.3 Licentiates who worked in CPDs by dispensary and year Licentiate

Chinese Public Dispensary

Year

Au Sze-cham

Western District

1909

Chung Yik-sun

Hung Hom

1936

Ho Ko-tsun

Eastern District

1907–1911, 1916–1949

Kwan King-hung

Eastern District

1908

Lee Yin-sze

Yau Ma Tei

1908, 1915–1935

Ma Luk

Kowloon City

1907

Western District

1908, 1915–1935

To Ying-kwan

Central District

1908

Wong Kwon-kun

Sham Shui Po

unknown

Source: Faith Ho, Western Medicine for Chinese (Hong Kong: Hong Kong University Press, 2018), 75–78.

Western District Dispensary and Plague Hospital The Western District Dispensary was one of the first two dispensaries established in 1905 in Hong Kong as offices of the Tung Wah Hospital by two prominent Chinese members of the Sanitary Board, Fung Wachun, and Lau Chu-pak. It occupied No. 42, First Street in Hong Kong,15 and was supervised by Dr. Ma Luk as the licentiate-in-charge of the dispensary.16 In 1908, the CPDs were officially separated from the Tung Wah Hospital, and the CPDs Committee of nineteen members, mostly Chinese elite, was formed and chaired by the Registrar General, Mr. A. W. Brewin.17 The Committee took over the management of all CPDs (by then there were six CPDs). Because of increasing demand for medical

3 . T he C hinese E lite and the C hinese P ublic D ispensaries   |   4 5

services in the Western District, in 1908, the government presented to the Western District Kaifong Committee a plot of land (IL 1793, 1794–Nos. 64, 65 Third Street, Hong Kong) for building a permanent dispensary and a local plague hospital. The Kaifong Committee was able to raise HKD 5,573 for construction to begin.18 The building was completed a year later at a cost of HKD 10,046, and more funds had to be raised to cover the deficit.19 The following year, living quarters for coolies and accommodation for ambulances and dead-vans were added to the complex. The Western District Dispensary and Plague Hospital was formally opened in September, 1909, with the dispensary on the ground floor and the small plague hospital on the first floor.20 When plague hit Hong Kong in subsequent years, the Western District Plague Hospital was consistently used by plague patients. But by the late 1910s, because of the declining number of plague cases, fewer and fewer patients were admitted to the plague hospital. Figure 3.4 Stone plaque on the wall of Western District Dispensary and Plague Hospital giving a brief history of its founding and the names of the donors

Photograph courtesy of Mr. Lincoln Tso, 2018

46  |  A MEDICAL HISTORY OF HONG KONG

The Western District Dispensary Committee had energetic and enthusiastic leaders such as Ho Kai, Tso Seen-wan, and Ho Kam-tong. They not only raised funds for building and operating the dispensary, but also took active roles in public health education and in encouraging people to take their dead or sick infants to the dispensary. The Western District Dispensary was the only dispensary with unfailing lower numbers of “dumped” bodies than other dispensaries, thanks to the efforts of the street “lecturers” and the leaders of the CPDs Committee.21 Recognizing the success of the conversion of the Eastern District Plague Hospital into a maternity hospital22 and the urgent need for a maternity hospital in the Western District, Tso Seen-wan, Chairman of the Western District Dispensary Committee, had the foresight to apply to the government for a piece of land (IL 2275, No. 36A Western Street, Hong Kong) close by to build a larger maternity hospital instead of converting the small Western District Plague Hospital. The Western District was densely populated, and a larger number of maternity beds was required to meet the demands of the community. Tsan Yuk Hospital (Figure 3.5) was built and opened for service in 1922 with subscriptions from the local community under the leadership of Tso.23 Figure 3.5 Old Tsan Yuk Hospital on Western Street, situated on a lot next to the Western District Dispensary and Plague Hospital

Photograph by Ann Wong

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Figure 3.6 The Western District Dispensary (now a community center) next to the old Tsan Yuk Hospital

Note: The picture shows the Tsan Yuk Building (red bricks) and the old Western District Dispensary (the white building) next to it. The vertical sign on the left of the entrance of the old dispensary shows the name of the current user The Conservancy Association, which is an NGO. There is a bridge between the two buildings on the second floor. Photograph courtesy of Mr. Lincoln Tso, 2019.

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After the Second World War, Tsan Yuk Hospital was one of the first hospitals to reopen in September 1945. The number of admissions rose progressively, but the hospital had a capacity of only 60 beds. In 1950, the number of beds increased to 85 at the expense of the adjacent Western District Dispensary building. Despite this, by the early 1950s, Tsan Yuk Hospital was again experiencing bed shortages because of the postwar baby boom. The Royal Hong Kong Jockey Club generously donated HKD 3,570,000 for a new hospital to be built on a new site on Hospital Road (30 Hospital Road, Hong Kong). On 28 October 1952, the Duchess of Kent laid the foundation of the new hospital, and three years later, on 13 June 1955, Sir Alexander Grantham officially opened the new hospital (Figure 3.7).24 In 1960, the new Sai Ying Pun Polyclinic (32 Hospital Road, Hong Kong) was completed, and all the clinical activities of the Western District Dispensary were moved into it.25 The old dispensary building on IL1793 continued to be occupied by the Medical Department, while the premises on IL1794 was taken over by the Social Welfare Department (see Table 2.1 on Page 26). Figure 3.7 New Tsan Yuk Hospital completed in 1955

Photograph by Ann Wong

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Eastern District (Wan Chai) Dispensary and the Eastern District (Wan Chai) Plague Hospital In 1905, the Eastern District Dispensary, one of the two offices attached to the Tung Wah Hospital, was situated at 205 Queen’s Road East.26 In 1907, the Eastern District Dispensary was very fortunate to have Dr. Ho Kotsun as the licentiate-in-charge of the dispensary.27 Dr. Ho doggedly served the people of Wan Chai throughout the difficult war years using his own resources until his retirement in 1949. In 1910, owing to increasing demand for medical services of the working class residing in Wan Chai, Dr. Ho encouraged the residents to raise funds for a more spacious dispensary and a small plague hospital. A door-to-door collection yielded the required amount for purchasing a lot on Stone Nullah Lane (IL1835) and for construction of the dispensary.28 The government granted an adjacent area of 62 feet by 40 feet (IL790), thus expanding the site.29 When completed and opened on 7 October 1911, the whole complex included a small hospital, a dispensary, waiting rooms, quarters for coolies, ambulances and dead-vans.30 The total cost came to HKD 18,000: the site HKD 6,500 and building HKD 11,500. For operating expense, further subscriptions yielded HKD 4,105 and a fund-raising theatrical performance generated another HKD 3,900. 31 The subsequent outstanding work performed by the dispensary more than compensated for the high cost of the construction. In the late 1910s, there were few plague patients being admitted to the hospital. At the request of the Eastern District Dispensary Committee, the plague hospital began to admit women and children suffering from other diseases on the understanding that the hospital would be staffed by a duly qualified medical practitioner under the supervision of the Principal Civil Medical Officer.32 The plague hospital was eventually converted into a maternity hospital with 22 beds in 1919. At the request of Dr. Tso Seen-wan, Dr. Alice Hickling, who trained the government midwives, agreed to take charge together with Dr. Ho. The number of deliveries increased with time and exceeded 1,000 in the year 1931. At that point, altruistic residents of Wan Chai began to collect subscriptions to expand the hospital. At the end of 1931, rebuilding was completed with a new ward for maternity cases on the second floor.33

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After the war, the Eastern District Dispensary and Maternity Hospital reopened. In 1955, when the New Tsan Yuk Hospital opened, the Eastern District Maternity Hospital closed down. In 1969, when all medical activities were moved to the new Tang Chi Ngong Specialist Clinic next to the Tang Shiu Kin Hospital, the Eastern District Dispensary also closed its doors.34 In 1949, when the government Medical and Health Department took over the management of the Eastern District Dispensary, they unexpectedly found that the second floor of the Wan Chai staff quarters was occupied by the 73-year-old Dr. Ho Ko-tsun, who had just retired after having served at the Wan Chai Dispensary and Maternity Hospital loyally for several decades. His meritorious work at the Dispensary had been recognized by an award of CBE (Commander of the British Empire). He had occupied the flat for 30 years without paying rent to the Dispensary. As he had retired without any pension, the Secretary for Chinese Affairs did not want to evict him. The residents in the neighborhood, who had the greatest admiration and respect for Dr. Ho, also petitioned to the government that he should stay.35 In 1972, the premises on IL1835 and IL790 were leased to three different organizations: the north wing to the St. James Settlement, the central part to the Wan Chai Kaifong Welfare Association, and the south wing to the Lok Heep Club, Caritas.36

Central Dispensary The Central Dispensary (Figure 3.8), located at Kau U Fong, occupied two lots, IL1747 and IL1860, in the Central District.37 Dr. To Ying-kwan was appointed its Chinese licentiate in 1905.38 The dispensary itself was built on IL1747 in 1907 with HKD 3,400 collected from the community, a donation of HKD 2,000 from Ho Kam-tong, HKD 6,825 from the Chinese theaters and HKD 4,000 raised during a special performance of a temporary theater.39 The Central Dispensary was constructed with a credit balance of HKD 8,000 which was used for its operation. Ho Kam-tong also provided coffins to the families who had no means of burying the dead, with the hope of reducing the number of “dumped bodies” in the streets.40 The dispensary did not have enough space for an ambulance or dead box, nor accommodation for the five coolies who were responsible for removal of sick patients to the hospital or transporting corpses to the

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Figure 3.8 Former Central Dispensary Building, later taken over by the Central District Kaifong Association

Reproduced by permission from Cheng Baohong, Chu jing sheng qing: Ji dai Xiang Gang ren de shenghuo jiyi (Hong Kong: Hong Kong Open Page Publishing Company Limited, 2017).

hospital or mortuary. In 1910, A. W. Brewin, Registrar General, acquired a small lot, IL1860, separated from IL1747 by a lane, for building the necessary additions to the Central Dispensary. The two buildings were connected by a bridge with a canopy cover. Ho Kam-tong again paid for its construction.41 In 1930, the Central Dispensary Committee decided to tear down the old dispensary building, which had become too small for the amount of activities going on, and replaced it with a newer, larger building at the same site.42 The premises continued to be used as a dispensary with quarters for its staff until 1958 when the government moved all the clinical activities to a new health center at Kau U Fong. At the closure of the dispensary, the Kaifong Association took over the premises for its social welfare activities.43

Harbor Dispensary and Shau Kei Wan Dispensary The medical services enjoyed by the residents in districts where there were CPDs stimulated residents in other districts to demand for similar

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services. In August 1909, after a meeting of the members of the boat population and the shop owners closely connected with the floating population, a hulk was purchased, fitted as a dispensary, and named the Harbor Dispensary. With the consent of the Harbormaster, the hulk was moored in Causeway Bay.44 Following the example of Harbor Dispensary in Causeway Bay, the large fishing population in Shau Kei Wan also demanded medical services.45 In 1910, Shau Kei Wan Dispensary was established due to the efforts of the Chinese merchants and Mr. A. W. Brevin, the Registrar General. It was housed in the ground floor of a rented Chinese tenement building. The Harbor Dispensary and the Shau Kei Wan Dispensary shared the services of one medical licentiate. To cover the expenditure of Shau Kei Wan Dispensary, the Kaifong Association handed over to the dispensary the management of the Tin Hau Temple and the Tam Kung Temple and the annual rents received from the temples. In 1914, the government granted SIL430 for the building of a proper dispensary.46 Strapped for funds for building a new dispensary, the Shau Kei Wan Dispensary built two small shops on the vacant land in front of the temple to generate more revenue. The dispensary operated under congested conditions for a period of almost 20 years. Finally, in 1929, having saved HKD 8,000, the dispensary committee decided that it was time to have a permanent building as its dispensary. Together with another HKD 8,000 from the temples, and HKD 10,000 raised by the Kaifong Association, the new dispensary was finally constructed on SIL430, the lot granted to it about 20 years ago.47 On the morning of 2 September 1929, the district of Shau Kei Wan was in a festive mood as people set off firecrackers when village elders and Kaifong Association committee members gathered to mark the opening of the new building for the Shau Kei Wan Dispensary. The opening ceremony was performed by Mrs. R. A. C. North, wife of the Secretary for Chinese Affairs.48 The Shau Kei Wan CPD Committee at that time included prominent members such as Leung Pat-yue and its chairman, Li Yau-tsun.49 In the mid-1960s, the premises of Shau Kei Wan Dispensary were turned over to the Shau Kei Wan Kaifong Association when the Medical and Health Department moved the clinical activities out of the dispensary to the Shau Kei Wan Jockey Club Clinic (Figure 3.9) .50

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Figure 3.9 Shau Kei Wan Jockey Club Clinic

Photograph by Rachel Pang

Kowloon City Dispensary The Kowloon City Dispensary was established in 1905 on the ground floor of a rented house near Sung Wong Toi. Some months later, a portion of the building of a Chinese school in Kowloon City was borrowed as the dispensary premises.51 The first district plague hospital in Kowloon City was a matshed that accepted thirty-three plague patients from Yau Ma Tei during the 1906 epidemic. A typhoon in September of that year destroyed the mat-shed completely. The local dispensary committee of Kowloon City found an old building nearby and fitted it as a plague hospital for the following year.52 Because Kowloon City was a well-known district for impoverished residents, it was not a place to raise the great amount of funds needed for a good cause. Subscriptions from local residents and shops in the district and those from inhabitants of the nearby twenty-one villages amounted

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only to a total of HKD 800 (each inhabitant gave 30 cents). In 1915, Mr. Li Yau-Tsun discovered a very clever way to increase the revenue for the dispensary. At that time, the tender for the post of keeper of Hau Wong Temple generated a meager profit of HKD 1,800 per year, hardly adequate for operating the Kowloon City Dispensary. Li reorganized the tender procedure for the position of the temple keeper and strict supervision was exercised over the opening of the tenders. As a result, the proceeds jumped to HKD 3,800 that year and progressively increased in subsequent years.53 The revenue supported all the expenses of the dispensary, and the cost of establishing two free schools with a total of about 275 students. The number of patients treated in the dispensary increased steadily from 3,264 in 1916 to 14,263 in 1931, almost five-fold, surpassing its capacity. In 1931, KIL1126 was granted by the government for a new dispensary.54 The new dispensary, designed by Little, Adams & Wood, was constructed by Wing San Engineering and Construction Co. at a cost of HKD 42,000, a huge sum at that time. On 28 June 1932, Mrs. E. R. Hallifax, wife of the Colonial Secretary, officially opened the brand new dispensary.55 The Kowloon City Dispensary was a small hospital with seventy beds, financed by the CPDs Committee and a grant from the government, and had an operating budget of HKD 20,000. The ground floor had medical and surgical beds; the first floor, an operation theater; the second floor, maternity beds; and staff accommodation on the top floor.56 Sadly, the new Kowloon City Dispensary was damaged severely during the Second World War and had to be demolished. In 1948, KIL1126 was incorporated into the Kai Tak Airfield permanently.57

Hung Hom Dispensary Hung Hom Dispensary started its operation on rented premises in 1906. The following year, the Hung Hom Dispensary Committee found an isolated building next to the dispensary, and repaired and fitted it into a plague hospital.58 The hospital also accommodated patients from Yau Ma Tei during the 1907 and 1908 plague epidemics because Yau Ma Tei did not have a plague hospital. In 1909, the Registrar General acquired a site (HHIL255), adjacent to the Koon Yam Temple, for building a dispensary, a school, and a temple. The lot was granted in trust to the Registrar General for the Kaifong Committee. The new Hung Hom Dispensary was completed in 1910 at

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a cost of HKD 2,935 which was raised by the Kaifong Committee.59 The dispensary was part of a larger unit which catered to various local needs under the leadership of the energetic Hung Hom Kaifong Committee.60 Dr. Lin Yin-sze, a physician trained in Western medicine, moved into the new dispensary building. He had at his disposal about HKD 2,000 per year as an annual budget for the dispensary.61 After the Second World War, the Hung Hom Kaifong Committee made urgent requests to the Medical and Health Department to reopen the dispensary, which had been closed since the outbreak of the war. However, when the Medical Department took over the CPDs facilities in 1947, work could not be carried out for lack of resources, water, and light. To make matters worse, confusion over the building ownership led to the refusal of the Public Works Department to conduct any repair on the building, further delaying the opening of the clinic. The CPDs were built by donations and subscriptions from the Chinese elite and the Chinese community on land granted by the government in most cases, held in trust by the Secretary for Chinese Affairs Inc. and were operated by expenses raised in the community. When the government took over the CPDs to operate them as government outpatient clinics after the war, it was not clear who had the ownership of the buildings. The ambiguous ownership had also caused grief to several other dispensaries. In the end, the Kaifong Committee paid the cost of repair so that the clinic could start functioning.62 In the 1960s, with the closure of the dispensary, the government gave another piece of land to Hung Hom Kaifong Committee to build a school in exchange for HHIL255.63 Hung Hom Kaifong remains an active organization and interested in public affairs to this day. The kaifong members are very proud of their traditional association with the dispensary and with their pioneering social work in providing medical services and education.

Yau Ma Tei Dispensary Yau Ma Tei Dispensary was founded on 27 May 1906 in rented premises at the request of the inhabitants in the area. There was no hospital for plague patients in Yau Ma Tei Dispensary, and the plague patients were sent to either Kowloon City Plague Hospital or Hung Hom Plague Hospital.64 The dispensary, which was initially sponsored by Tung Wah Hospital, was constantly running at a deficit because insufficient funds were raised.65 In 1911, Kwong Wah Hospital, which opened that year, took over the

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responsibility of operating Yau Ma Tei Dispensary.66 At around the same time, the Harbor Dispensary, the hulk moored at Causeway Bay, had become leaky from old age. When the Kwong Wah Hospital Committee approached the Secretary of Chinese Affairs (SCA, a new name for Registrar General) for a piece of land to build a dispensary to serve both the boat and land population in Yau Ma Tei area, the government granted a site (KIL1296) on Kansu Street, Kowloon. After a prolonged campaign of fundraising, the new Yau Ma Tei Harbor Dispensary came into being.67 The building was erected at a cost of HKD 6,500 with funds donated by Mr. Li Fung-shan and other prominent members of the community, including Ho Fook, Ho Kamtong, Chan Kai-ming, Chan Cheuk-hing, Li Yau-tsun, and Tin Hau Temple. It was opened on January 26, 1916 by Governor Francis May.68 Kwong Wah Hospital, which was responsible for the financing of Yau Ma Tei Dispensary, absorbed its deficits and gains over the years. In 1931, the dispensary was rebuilt to make room for a high volume of patients.69 After the Second World War, Yau Ma Tei Dispensary reopened as a government outpatient clinic as other dispensaries did. In 1967, the clinic’s services were moved to new Yau Ma Tei Jockey Club Polyclinic (Figure 3.10). The lot at Kansu Street was surrendered to the government for extension of Tong Mei Road.70 Figure 3.10 Yau Ma Tei Jockey Club Polyclinic

Reproduced by permission from Hong Kong Medical and Health Department Annual Report, 1966–67, opposite 27.

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Sham Shui Po Dispensary Sham Shui Po Dispensary opened on 1 February 1915, and was the first CPD to be built in New Kowloon and the New Territories.71 The idea to have a dispensary for the poverty-stricken people in the district came from Yau Siu-shi and Li Ping, residents in the area, and received support from the Registrar General. As the majority of people in this district were poor, the Kaifong Association collected only about HKD 700. The dispensary came to fruition in 1915 through the generous donation of Cheung Patshi and other Chinese elite towards the building. Mr. A. Colbourne, the architect, charged only half his usual fees. The physician in-charge of the clinic was Dr. Chiu Hin-yeung, who had many years of experience working in Peking Medical Colleges.72 The dispensary was erected in the open area of Tin Hau Temple (NKIL552). Sham Shui Po Kaifong Association had two other lots, NKIL473, 474, close to it. The Kaifong Association built eight tenement houses on these two lots and used the rents collected to maintain the activities of the dispensary.73 The Sham Shui Po Dispensary standing today is not the same building as the old dispensary on Tin Hau Temple land. The increasing demand for medical services outstripped what the old building could provide. In 1936, the residents raised funds to erect the new dispensary, known as Sham Shui Po Yee Kuk, on Yee Kuk Street (NKIL 552). This reinforced concrete twostory building, designed by Chau & Lee Architects in an Art Deco style, displayed a simple elegance with a perfectly symmetrical façade. The firstfloor balcony, which was built onto the pedestrian walkway, formed an arcade supported by pillars with Western classical motifs, while the balcony railings incorporated local elements of bamboo-shaped Chinese ceramic tiles. Stylized moldings were used as decorations and continued on window heads and sills. Art Deco features can also be found inside the entrance hall, staircase, and some of the rooms on the first floor.74 As there are not many buildings of Art Deco architecture design left in Hong Kong, Sham Shui Po Dispensary became a rare piece of heritage. In 2010, it was categorized as a Grade III historical building (Figure 3.11). The Violet Peel Health Centre, which was opened one year earlier, was designed by the same architect with the same Art Deco architecture as the Sham Shui Po Dispensary. The Violet Peel Health Centre was demolished in 1980s, while the Sham Shui Po Yee Kuk remained and is still in use as a methadone treatment center today.75

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Figure 3.11 Sham Shui Po Dispensary

Photograph by Brian Yu

In “winding up” the CPDs in the 1960s, the SCA decided that the portion of the land occupied by the dispensary (NKIL552 on Yee Kuk Street) should be surrendered unconditionally to the government, but the remainder of the land and the temple on it should remain under the control of the Chinese Temples Committee.76

Aberdeen and Stanley Dispensaries These two dispensaries became part of CPDs in the 1930s. Aberdeen Dispensary began to operate in 1931. Located in rented premises, it did not have a building of its own.77 In 1936, the private dispensary that belonged to St. Stephen’s College at Stanley was used by the CPDs to serve the public.78 The Stanley Dispensary is situated at 14, Wong Ma Kok Road, Stanley. It is built of concrete and has two stories with a simple façade. The oversized flag post and vertical line decoration at the imposing entrance make the building recognizable as an Art Deco building, the only one of its kind in Stanley (Figure 3.12).

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Figure 3.12 Stanley Dispensary

Photograph by Rachel Pang

After the war, the Stanley Dispensary continued its work as a dispensary and a maternity home under the Medical and Health Department to serve the fishing villages nearby. With the rapid growth of population in the early 1970s, the building was used mainly as a maternity center. At present, it is still being used for outpatient and maternity services.79 The Stanley Dispensary plays a very important role in providing medical care in the district. The Chinese Hospitals and the Chinese Public Dispensaries formed the backbone of the healthcare system for the Chinese in Hong Kong during the first half of the twentieth century. The three Chinese hospitals (Tung Wah, Kwong Wah, and Tung Wah Eastern) delivered mainly inpatient services but had inadequate outpatient services. The CPDs offered the much-needed outpatient medical services to the community and promoted Western medicine. Midwife services, maternity hospitals, and infant welfare centers, all associated with CPDs, helped reduce maternal and infant mortality in Hong Kong. However, it was the public health work, which included education on hygiene, disease prevention, and vaccination, that helped the CPDs make their mark on the medical

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history of Hong Kong. The CPDs’ effective educational activities resulted in public acceptance and compliance with sanitary and other preventive measures, thus making the control and prevention of epidemics of infectious diseases much easier. The CPDs also represented a social movement of the westernized Chinese elite in Hong Kong, which started at the turn of the twentieth century even before the First World War. The movement in Hong Kong, sustained by the spirit of social reform after the First World War in Europe, persisted throughout the interwar years despite the enormous cost involved. The late-nineteenth and early-twentieth centuries covered one of the most tumultuous periods in the history of China. The political and social instability in the Mainland gradually changed the sojourner attitude of many Chinese living in Hong Kong to regarding it as their home. In placing their money and efforts into social reform locally, the Chinese elite not only fulfilled their cultural heritage as a gentry in looking after the poor, but at the same time achieved considerable prestige and recognition by the general public as well as the government.

4. Launching of Outpatient Services in Kowloon and the New Territories and the Construction of the Kowloon-Canton Railway and Shing Mun Dam To understand the medical development in the region, a brief timeline of colonial developments in Hong Kong, Kowloon, and the New Territories would be helpful. After it had become a crown colony, Hong Kong failed to meet the expectation of the British to become an “Emporium of the Far East.” The reasons for this failure were multifactorial and included competition from other treaty ports, widespread piracy in nearby waters, and the difficulty of defending the island of Hong Kong in isolation without the Kowloon Peninsula and its nearby islands. The Second Opium War was started mostly to obtain a new and more satisfactory settlement than the Nanking Treaty from China. The signing of the Treaty of Tientsin and the Convention of Peking in 1860 resulted in the cession of the area south of the Boundary Street in the Kowloon Peninsula and nearby Stonecutters Island to the British in perpetuity. Stonecutters Island would later become a “listening” post, monitoring wireless signal traffic throughout the AsiaPacific during the war with Japan in the late 1930s.1 Soon the British found that even with Kowloon included in its territory, the defense of Hong Kong proved problematic because the harbor remained exposed. (Figure 4.1) After losing the Sino-Japanese War in 1894/85, the Qing Empire was under pressure from different countries to open up more ports for foreign trade. Several countries demanded an area of special influence and concessions from China. Britain took the opportunity to extend Hong Kong’s territory for defense purposes, by demanding a ninety-nine-year (1898–1997) lease of the rest of Kowloon Peninsula south of the Shenzhen River and 230 adjacent islands, which became known as the New Territories. The development of Hong Kong’s port facilities began in earnest only after the acquisition of the New Territories on a lease as its harbor then became sheltered. The fine harbor is protected by the mountainous island of Hong Kong in the south, the range of hills of Kowloon, and the New Territories on the north. The harbor offers a safe haven from great storms unleashed by monsoons, and, since the range of tide is small, less than 2.8 meters, berthing

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Figure 4.1 Map of Hong Kong, Kowloon, and the New Territories

Adapted from M. Chan-Yeung, Lam Woo. Master Builder, Revolutionary and Philanthropist, 105.

ships at quays and piers or moorings in the center of the harbor was easy and safe. Shipping companies multiplied and built wharfs along the waterfront. The ship repair and ship building industries grew simultaneously.2 When the British formally took possession of the New Territories on 16 April 1899, it was not without opposition. Fearing for their loss of traditional land rights, a number of villages attempted to resist by mobilizing their militias that were organized to protect shore raids by pirates. They started the Six-Day War of 1899, which began on 14 April when the insurgents burnt down the masthead the British had prepared for a flag-raising ceremony at the Flagstaff Hill in Tai Po. The villagers barricaded the 125 Indian soldiers of the Royal Hong Kong Regiment sent to Tai Po the following day. The soldiers were rescued after the Royal Navy’s HMS Fame shelled the insurgents’ position. The uprising was quashed when the British artillery assaulted the insurgents’ walled villages and killed over 500.3 To prevent future resistance, the British made concessions to the indigenous inhabitants with regards to land use, land inheritance, and marriage laws (for example, the exclusion of women in the New Territories socially and legally from inheritance rights).4 Some of these laws have persisted in Hong Kong; for example, gender equality has yet to be accomplished in the New Territories today.5

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In 1899, Tai Po was chosen as the administrative center for the New Territories, which were divided into districts and subdistricts to adhere as closely as possible to the original divisions recognized by the Chinese inhabitants. The police force, under the superintendentship of Francis Henry May (later governor of Hong Kong), took vigorous action to bring about peace and security in the region.6

Outpatient Services in Kowloon Although Kowloon was ceded to the British in 1860, it was not developed despite Hong Kong’s overcrowding problem. For the rest of the nineteenth century, Kowloon continued to be the tiger hunting ground for the British and a few westernized wealthy Chinese. Eventually over the years, industries gradually developed in Kowloon due to the lack of land on Hong Kong Island. The first ones were the Hong Kong and Whampoa Dock Company, which set up its yard at Hung Hom in the 1860s, and Cosmopolitan Dock at Tai Kok Tsui in 1880. The Green Island Cement Company, which moved its works from Macau to Hung Hom in 1887, became a British company shortly afterwards. By 1897, the population of Kowloon reached 26,402, with Yau Ma Tei having the highest at 8,051, and Hung Hom second at 5,876.7 The construction of Kowloon-Canton Railway (KCR), connecting Kowloon with the mainland and the road to encircle the New Territories during the first half of the twentieth century, was followed by commercialization and the growth of population in Kowloon and the New Territories and demand for medical services in these areas. At the beginning of the twentieth century, the Chinese elite began to establish Chinese Public Dispensaries, where Western medicine was practiced, staffed by the graduates of the Hong Kong College of Medicine. The dispensaries were placed in areas with the highest population density. In Hong Kong, the first two dispensaries to be established were the Western District and the Eastern District Dispensaries. In Kowloon, the Chinese elite established three dispensaries in areas that had already been developed: Kowloon City (1905), Hung Hom (1905), and Yau Ma Tei (1906). Sham Shui Po Dispensary was added later in 1915 (see Table 3.1). The government did not provide any medical services to the residents in Kowloon until 1905, when the construction of the

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Kowloon-Canton Railway began. Anticipating that more workers, and more people would be living in Kowloon, the government set up one medical office on Nathan Road, Kowloon. In 1911, the Nathan Road medical office attended to 1,802 new and 1,601 old patients, with 2,430 prescriptions dispensed.8 With the rising population in Kowloon, the number of patients climbed. In 1914, this medical office became known as the Kowloon Dispensary; during that year there were 5,742 patient visits. In 1926, the Kowloon Dispensary was incorporated into the newly built Kowloon Hospital as its outpatient department, leading to the closure of the Nathan Road office.9 The Kowloon Dispensary was the only government-run outpatient clinic in Kowloon before the Second World War; all other dispensaries in Kowloon were founded and financed by the Chinese elite.

Outpatient Services in the New Territories For administrative purposes, the government divided the New Territories into two districts, north and south, each under a district officer. The dividing line between north and south was a watershed separating the waters flowing south into Hong Kong Harbor from those flowing north into Mirs Bay. Although each district contained mainland and islands, the northern district was mostly mainland at roughly 200 mi2 (518 km2), while the southern district mostly islands, approximately half the size of its northern counterpart at 100 mi2 (259 km2). The population lived in villages situated mostly on or near the coast, and residents were engaged in agriculture, fishing, or commerce. Some of the more privileged villages were easily accessible by road, rail, or water, but others could only be reached after miles of walking. Most villagers lived in small, one-story houses built of bricks or stone, and people abided by more traditional rules and regulations governing village life, which had been handed down from generation to generation. “Village Elders,” who were accepted as arbiters in petty disputes and who had acquired their positions through age, experience, wealth, or family rank, answered to the Hong Kong government regarding conduct of village affairs, however, these elders held no real executive power. When the British took over the administration of the New Territories in 1898, they did not enforce public health laws in the rural areas of the New Territories. The Registration

4. Launching of Outpatient Services in Kowloon and the New Territories | 65

of Births and Deaths Ordinance was made applicable in 1911, but the Vaccination Ordinance had never been made compulsory.10 During the first decade of the twentieth century, most of the medical and sanitary services were concentrated in the northern district where Tai Po, the administrative center, was located and the ongoing construction work of the KCR. After the mid-1910s, the government placed midwives at Tsuen Wan and Cheung Chau stations, situated in the southern district.

Tai Po: A Hotbed for Malaria The establishment of Tai Po as the administrative center for the New Territories brought some British staff, police officers of various races, and staff of various supporting services to the area. A number of police stations (Au Tau, Ping Shan, Sai Kung, San Tin, Sha Tau Kok, Sha Tin, Sheung Shui, Tai O, Tai Po) were also established in the New Territories to maintain law and order. Dr. Ho Nai-hop, a Chinese Medical Officer, who was a licentiate of the Hong Kong College of Medicine, was stationed in Tai Po since 1899. He visited the police stations and the villages in the New Territories regularly. The most common disease the doctor encountered was malaria, resulting from improper drainage of puddles of water in rural areas. In 1901, Dr. Ho treated 812 patients, the majority of whom suffered from malaria. The steps the doctor took to ultimately reduce the incidence of malaria in Tai Po were to give patients daily prophylactic quinine, to eradicate mosquito larvae in the pools around police stations and in the villages by draining away any water, and to put oil or kerosene on top of the water if drainage was not possible. Although these measures successfully lowered Tai Po’s malaria cases, the other common afflictions such as cholera and smallpox nonetheless persisted. To address these problems, Dr. Ho administered free smallpox vaccinations to the police and villagers, but anticholera inoculation was not yet available then.11 Dr. Lau Lai replaced Dr. Ho in 1903. Because of the increasing number of patients seen in the dispensary, a cottage hospital was built to accommodate the sick patients, especially the railway workers. A hut was also constructed for the thirteen lepers in the area who were visited by Dr. Lau regularly.12 In 1907, the total number of cases seen in the dispensary was 1895; malaria was still, by far, the most prevalent disease, followed by injuries (Table 4.1). At that time, Tai Po Dispensary often had patients who were KCR workers.

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Table 4.1 Nature of common illnesses seen in Tai Po Dispensary in 1907 Disease/Illness

No.

Malaria

742

Injuries

162

Rheumatism

64

Febricula (fever of short duration, unknown etiology)

30

Anemia

26

Syphilis

22

Dysentery

17

Beriberi

13

Source: Report of Medical Officer, Tai Po Dispensary for 1907, Hong Kong Sessional Papers 1908, 460.

The various construction projects, including the KCR, Kowloon Wharf, and Shing Mun Dam, catalyzed large-scale development and commercialization of Kowloon in the early twentieth century. Of particular note is the construction of the KCR and the Shing Mun Dam, which were accompanied by a large number of workers in hazardous jobs in Kowloon and the New Territories, necessitating the arrangement of medical services in these two areas in the early part of the twentieth century.

Construction of the KCR: An Impetus for the Development of Medical Services in Kowloon and the New Territories During the nineteenth century, the Western powers competed fiercely with each other for commercial and political influence in China. Hong Kong, being a British crown colony, held an important position in promoting and protecting British trading interests in South China. In order to secure control of the New Territories and enable access to the whole area, the colonial administration planned early to build a road to encircle the entire region. Because of lack of funds, however, it took over two decades to complete the project. To increase Britain’s trade and political influence in China, a railway to connect Hong Kong with China was first proposed as early as 1864. At that time, water transportation between Hong Kong and Canton was inexpensive because of steamships. The idea of building a railway across the New Territories to Canton was predictably killed by vested interest

4. Launching of Outpatient Services in Kowloon and the New Territories | 67

groups, most of which were established shipping companies. It took another thirty years before the plan resurfaced for serious consideration. In 1898, the British Government extracted a number of concessions from the Chinese Government for the British and Chinese Corporation, which was formed as a joint venture between the trading company of Jardine, Matheson & Co. and the Hong Kong and Shanghai Bank. But the Boxer Rebellion (1899–1901) and the Boer War (1899–1902) made fundraising for the project exceedingly tough. By the beginning of the twentieth century, Sir Henry Blake, the governor of Hong Kong, decided that urgent action was required to build the railway for expanding trade in China and developing Kowloon and the New Territories, especially the land along the railway. Discussions between the Colonial Office in London, the Hong Kong Government, and the British and Chinese Corporation led to an agreement in late 1904. The Hong Kong Government would fund, construct, and operate the section of the line within Hong Kong. The section to Guangzhou would be financed through a loan raised by the British and Chinese Corporation on behalf of the Chinese government, which would operate the section after its construction. Even then, it was not easy to obtain agreement from the Chinese government. The value of the KCR depended on whether the railway from Guangzhou to Hankow, and therefore to Beijing, could be constructed or not. Moreover, the Chinese part of the railway was divided into several sections with concessions given to different foreign countries. Protracted negotiations among the Chinese government, individual companies, and countries delayed the construction of the entire railway.13 Two routes were proposed for the British section: a western route of about 55 km from the tip of the Kowloon Peninsula via Tsuen Wan to Castle Peak and then to Yuen Long and finally to the border with China, and a more direct eastern route of about 34 km requiring tunneling through Kowloon’s hills and then to the border via Sha Tin, Tai Po, Fan Ling, and Sheung Shui (Figure 4.2). Following a detailed survey, the more direct and shorter eastern route was chosen, and this route would require drilling a tunnel through Beacon Hill. The Public Works Department began construction on the Tai Po and Fan Ling section in December 1905 even though the Colonial Office in London did not give formal approval until February 1906.14

68  |  A MEDICAL HISTORY OF HONG KONG

Figure 4.2 Route of the Kowloon Canton Railway

Image courtesy of The Industrial History of Hong Kong Group

The British section of the KCR was completed at the end of 1910.15 Godown No. 55 of Hong Kong and Kowloon Wharf and Godown Co. (around where the Hong Kong Cultural Centre is located currently) was leased by the government and converted into a passenger station of the KCR.16 The official opening took place in September 1910.17 Although the railway initially served the local population, when the Chinese section was completed the following year, passengers were able to travel from Kowloon to Guangzhou directly. The terminal station at Kowloon Point on the south side of Salisbury Road at the tip of Kowloon peninsula was finished some years later, with an electric clock of large faces on the tower of the terminal building (Figure 4.4).18 While the terminal building had been demolished, the tower and the electric clock still stand today (Figure 4.6). They remind us of the old KCR Station and mark the beginning of the famous seaside promenade (affectionately referred to as Avenue of Stars, modeled after Hollywood’s Walk of Fame) in Tsim Sha Tsui, facing the magnificent Victoria Harbor. Other stations were built at Sha Tin, Tai Po Kau, Tai Po Market, Fan Ling, and Sheung Shui before Lo Wu Station at Shenzhen, where all passengers had to walk over the bridge on foot and to clear immigration and customs before being picked up by the train on the other side of the border. When the railway on both sides were connected, passengers could ride all the way to Guangzhou without having to leave the train until 1951, when the border was closed.

Figure 4.3 Entrance to the Beacon Hill Tunnel (Lion Rock Tunnel) in 1910 at its completion

Wikimedia Commons photo d The Beacon Hill Tunnel (Lion Rock Tunnel): The Longest Tunnel in China in 1909 The tunnel was one and a half miles long, with a height of 21 ft and a width of 17 ft. At the time, the tunnel was the longest tunnel in China and the fifth longest outside Europe (Figure 4.3). An average of 2,000 men were employed on either ends and they worked day and night, including Sundays. The hardness of the mountain rock surprised the engineers and they decided to use dynamite, which generated thick dense, fumes on explosion. Because many workers suffered from the irritating effects of exposure to the fumes and a few died afterwards, gelatin (gelignite, which is a powerful explosive formed by dissolving gun cotton in nitroglycerine or nitro-glycol and mixing it with wood pulp and saltpetre as an oxidizer), was used instead. The tunneling required a total of 250,000 pounds of explosives. (“Kowloon-Canton Railway: Progress of the British Section,” South China Morning Post, 8 May 1909.) The engineer appointed for the construction of the Beacon Hill Tunnel was Frederick Southey—a brilliant local student of the Diocesan Boys’ School who received his engineering degree in the United Kingdom. (W. T. Featherstone, The Diocesan Boys School and Orphanage, Hong Kong: The History and Records, 1869 to 1929 [Hong Kong: Ye Olde Printerie, 1930], 29.) d

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Figure 4.4 KCR terminal station, Tsim Sha Tsui, 1914

Wikipedia photo

Figure 4.5 Shenzhen Station before the completion of the British section of KCR, 1911

Image from Kowloon-Canton Railway Corporation website

4. Launching of Outpatient Services in Kowloon and the New Territories | 71

Figure 4.6 KCR Clock Tower, 2013

Photograph by Rachel Pang

Class and Racial Entitlement and Malaria in KCR Workers Building the British section of the KCR brought considerable activity to Kowloon and the New Territories. As over 4,000 workers were to be employed, it became apparent in 1905, even before the project started, that a special medical officer for the railway would be needed because of the prevalence of diseases, particularly malaria, in the region. But it was not until October 1906 that a doctor, Dr. J. W. Hartley, could be found for this position. Unfortunately, upon arrival, he was quickly transferred to another service, leading to the immediate appointment of Dr. Chan Hinfan, a licentiate of the Hong Kong College of Medicine, as the Chinese Medical Officer resident at the Tunnel North Face Camp. Dr. Lau Lai,

72  |  A MEDICAL HISTORY OF HONG KONG

medical officer of Tai Po Dispensary, treated the native employees of the railway on the section of the line near Tai Po. A dispensary (KCR Dispensary) was set up at the south end of the tunnel to deliver emergency first aid services and to treat workers with any illness.19 The southern and the northern portals of the tunnel were some distance from existing villages, and sickness among workers was common, particularly malaria. To improve conditions, additional land was acquired and the area drained to prevent the buildup of stagnant water. European workers were given privileges, as expected, that set them apart from Chinese workers. Just as in Hong Kong, where the Europeans lived mostly in the comfort of the Peak district, which was barred from the Chinese, the European workers of the KCR project had their accommodation up in an adjacent hill to enjoy the coolness of the summer, consequently suffering less from attacks by blood-sucking mosquitoes. To minimize traveling time, an 853 m ropeway was especially installed linking their accommodation with the tunneling works. 20 Chinese workers were segregated and lived in coolie lines (row of houses for coolies, pictured in Figure 4.7) below. The mosquitoes had their stomachs filled every day as long as Chinese workers were around. Figure 4.7 North-facing portal of Beacon Hill Tunnel 1907, showing accommodation for European workers halfway up the hill and those for Chinese workers below

Photograph courtesy of The Industrial History of Hong Kong Group

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At that time, segregation of races was encouraged in Hong Kong, even when it came to managing illnesses. European employees were treated by a European medical officer in their own quarters for a brief illness, but, for a more serious one, they were transferred to the Government Civil Hospital. Similar arrangements were made for the Indian population.21 The Europeans despised the Chinese and vice versa. The Chinese often called Europeans “foreign devils” or “barbarians,” resenting the arrogance of the Europeans and their unearned privileges.

Diseases of the KCR Workers The illnesses suffered by the railway workers included malaria, dysentery, beriberi, and work-related injuries. With improved sanitation, cases of dysentery decreased, but unfortunately, the number of injuries rose in 1909. Table 4.2 shows the total number of KCR workers suffering from various illnesses by year from 1907 to 1910.22 The large number of cases of malaria in Tai Po and the two KCR dispensaries boosted the prevalence of malaria for the whole of Hong Kong during those few years.23 Quinine pills were issued daily to coolies whenever practical. All drains were regularly cleansed with disinfectants throughout the year. Pools of water that for one reason or another could not be drained had been regularly treated with kerosene oil. As a result, the number of cases of malaria and hospitalizations for malaria dropped sharply (Table 4.2 and Figure 4.8).24 Table 4.2 Number of cases seen by disease categories in dispensaries at Tai Po, and north and south faces of Beacon Hill Tunnel by year Disease

1907

1908

1909

1910

Malaria

1168

556

450

242

124

53

29

23

Beri-beri

81

58

52

40

Injuries

371

354

608

123

Dysentery

Source: Kowloon-Canton Railway, HKAR, 1909, Annex H, K52.

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Figure 4.8 No. of workers hospitalized for malaria from January 1907 to December 1909

Note: Total labor force (line), number of workers admitted to hospital with malaria (columns). Source: The Industrial History of Hong Kong Group. https://industrialhistoryhk.org/ wp-content/uploads/2015/11/Malaria-Cases.png

Death was not uncommon from work-related injuries (Table 4.3). Severe irritation of the throat and lungs from breathing air heavily charged with dynamite fumes and dust was frequent.25 On June 10, 1909, three workers exposed to dense fumes complained of feeling sick and dizzy and died shortly after.26 Other diseases such as malaria and beriberi also killed a number of workers.27 Malaria and beriberi were two common killers in Hong Kong at that time, and this finding was fully reflected by the death toll of KCR employees. Table 4.3 shows that during the period 1907–1909, out of a total of 96 deaths, 34 (35.4%) were attributed to beriberi, 23 (23.9%) to malaria, and 18 (18.7%) to work-related injuries. Beriberi is not an infectious disease as people thought in the late-nineteenth century, but a disease caused by deficiency of thiamine (vitamin B). The deficiency arose due to poverty among Chinese who could barely afford meat and vegetables and lived mostly on bowls of white polished rice from which all vitamins had been removed. The mortality rate of beriberi among KCR workers was similar to that of the general population in Hong Kong which ranged from 100 to 200 per 100,000 residents during the early half of the twentieth century.28

4. Launching of Outpatient Services in Kowloon and the New Territories | 75

Table 4.3 Deaths (N) from various causes among KCR employees in 1907, 1908, and 1909 Cause Malaria Beriberi Work-related injuries Dysentery Debility Pneumonia Poisoning by gelatine fumes Smallpox Plague Phthisis Total

1907 5 7 6 0 2 2 0 0 0 0 22

1908 14 13 7 3 1 1 0 1 1 3 44

1909 4 14 5 1 2 1 3 0 0 0 30

1907–1909 23 34 18 4 5 4 3 1 1 3 96

Source: The Industrial History of Hong Kong Group, https://industrialhistoryhk.org/ wp-content/ uploads/2015/11/Table-Of-Fatalities.jpg.

At the end of 1909, when the railway line was completed, the Railway Medical Officer was reappointed and renamed Medical Officer of Kowloon and the New Territories (Medical Officer from now on in this chapter).29 The dispensary on either side of the tunnel was disbanded the following year. Instead, three small dispensaries were set up near the railway line for the workers at Kowloon Chai, Sha Tin, and Tai Po Kau. The railway line dispensaries were then visited regularly by the dispensary dresser (male nurse) from Tai Po or the Medical Officer and his assistant to deliver medical care to the remaining workers along the KCR line.30 The duties of Medical Officer included regular visits to all the villages in the northern and southern districts of the New Territories; Sai Kung and Cheung Chau were visited more frequently, once every week.31

Further Development of Outpatient Services in the New Territories In 1928, Dr. A. R. Wellington, a public health expert with previous experience in Asia, was appointed Director of Medical and Sanitary Services and tasked with the reorganization of the medical and sanitary services in Hong Kong, and the eradication of malaria. As the official advisor to the government on all matters of public health, medicine, and sanitation,

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Wellington was appointed to the legislative council. In 1934, having dealt with the reorganization of the medical and sanitary services in Hong Kong, he began to reform the medical and sanitary services in the New Territories. For the purpose of medical administration, he divided the New Territories into western and eastern medical districts with headquarters at Yuen Long and Tai Po, respectively. The western medical district had a population of 49,848 and included four districts on the mainland (Tsuen Wan, Ping Shan, Au Tau, and Lok Ma Chau) and the three nearby islands of Lantau, Tung Chung, and Cheung Chau. The eastern medical district, with a population of 46,864, included five districts on the mainland (Sha Tau Kok, Sheung Shui, Tai Po, Sha Tin, Sai Kung), the Po Toi islands, and Tseung Kwan O Bay.32 The division of the New Territories into two medical districts enabled Wellington to develop a long-term strategy to expand medical services in the New Territories. During 1934, four government dispensaries and a small hospital were established in the New Territories: Lady Ho Tung Welfare Centre, Sham Tseng Dispensary, Tai O Dispensary, Sai Kung Dispensary, and Shing Mun Hospital. Lady Ho Tung Welfare Centre deserves special mention (Figure 4.9). Completed in 1933 and beginning operation in 1934, it had in residence a nurse, a midwife, and ancillary staff of three. It also housed a government traveling dispensary.33 In 1934, there was hardly any medical service in Sheung Shui area, let alone any specialized options, such as healthcare facilities for women and children. The only exception was a small station in nearby Fan Ling set up by St. John Ambulance for the care of infants. The Lady Ho Tung Welfare Centre provided much-needed service to the local community by offering midwife service and education of mothers on simple hygiene and how to care for their babies.34 Built by Mr. Jehangir Ruttonjee and presented to the government, Sham Tseng Dispensary was formally opened on January 30, 1934. It had two nurse-midwives and an amah in residence. The Chinese medical officer visited the dispensary three times weekly on his rounds with the traveling clinic.35 As it was not possible to establish clinics in every village with a sparse population in the region, the traveling clinic enabled the Medical Officer or his assistant to attend the sick in different parts of the northern district on a fixed route and a fixed timetable. On Monday, Wednesday, and Friday, the traveling clinic visited the west side of the northern district. On Tuesday, Thursday, and Saturday, it visited the east side of the northern district. During the latter six months of 1932, 15,709 cases were attended to.

Figure 4.9 Lady Ho Tung Welfare Centre in Sheung Shui area

Photograph by Angelina Wong d Lady Ho Tung, Margaret, Sau-ying Mak Lady Ho Tung should be remembered for her own achievements rather than as the wife of a benevolent business tycoon, Sir Robert, because of her significant contributions to experimental agriculture and to children’s healthcare in the New Territories.    Lady Ho Tung Welfare Centre was situated in Sheung Shui, a portion of the land in the New Territories owned by Sir Robert. On this property, Lady Ho Tung planted lychee and peanuts. She also experimented with growing different types of vegetables, sugar cane, tea, tobacco, and mulberry trees for silk production. During the 1924 British Empire Exhibition, Lady Ho Tung demonstrated the production of silk by a team of nine, performing silk reeling in Hong Kong House, drawing the attention of many, including the Royal Family and the media, and winning an award. She also enthusiastically promoted agriculture locally and organized Hong Kong’s first agricultural exhibition on her property in 1927. In 1931, during the celebration of their golden anniversary, Sir Robert announced that he would donate HKD 200,000 to the construction of a children’s welfare center in the New Territories and a girls’ school in Wan Chai area. Lady Ho Tung also announced that she would donate the land for building a welfare center along with HKD 100,000 for the operation of the center. d

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The dispensary launch was put into practice in 1932 for the boating population in the southern district, where some of the villages could only be reached by water. To avoid competition and overlapping with the work of the voluntary societies, the villages where dressing stations had already been established by the voluntary societies were avoided. The Medical Officer or his assistant paid weekly visits to the village in Tai O, traveling by the Import and Export Department’s launch on Thursdays, attending to about thirty to forty patients during each visit in the village hall. The Medical Officer also paid fortnightly visits to Sai Kung and used the launch as a dispensary.36 By 1934, instead of holding clinics in the motor launch, the Medical Officer or his assistant had the comfort of holding clinics on land. In Tai O, the government dispensary took the form of a small two-story house near the waterfront in the most important part of town, accommodating an examination room, a waiting room, and quarters for the midwife and her amah on the top floor. A similar structure was built in Sai Kung.37 Table 4.4 shows the number of patients attended to by government dispensaries in the New Territories before WWII.38 The number of patients seen in the two major government dispensaries in Tai Po and Yuen Long increased with time, but more dramatically in 1938 and 1939 owing to the massive deluge of refugees from mainland China. The hike in attendance in Sai Kung and Tai O dispensaries, located in more remote areas, was less. Table 4.4 Annual attendance of patients in government dispensaries, 1926 to 1939 Year 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939

Tai Po Market 2,925 2,880 4,373 4,450 5,009 5,114 8,139 11,274 14,917 18,005 17,263 19,819 35,128 48,070

Yuen Long

Traveling Clinic

Sham Tseng

Lady Ho Tung

Tai O

Sai Kung

4,389 4,168 5,860 5,012 4,261 7,103 6,718 8,330 10,083 10,807 10,819 14,967 17,376

15,709 12,607 8,279 8,307 10,328 7,836 13,755 12,970

3,681 4,780 4,190 NA 3,661 3,942

4,387 7,772 6,207 6,410 9,340 11,834

3,354 6,483 6,615 4,452 4,915 6,056

2,398 5,452 4,259 4,546 7,657 6,995

Source: Medical and Sanitary Reports 1926 to 1939, from HKAR of respective years, Hong Kong Government Administrative Reports Online.

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Construction of Shing Mun Dam: A Death Knell for Workers Safe and readily available water is important for public health, whether for domestic use, food production, or recreational purposes. Improved water supply and sanitation can boost countries’ economic growth and contribute greatly to poverty reduction.39 With no natural sources of water in rivers and lakes, Hong Kong had depended on a few reservoirs to store rain water for use during the dry winter months. The demand for water had always surpassed the supply. Osbert Chadwick, who visited Hong Kong on two occasions and gave Hong Kong the blueprint for sanitary reform, also searched extensively for possible sites for storage of water in Hong Kong, Kowloon, and the New Territories.40 After the severe drought of 1929 when water had to be purchased and shipped from China, the government made longterm plans to solve the problem of water shortage. Shing Mun Valley was one of the sites Chadwick suggested. Shing Mun Valley lies at the Figure 4.10 Shing Mun Dam built side of one of the outcrops from across a gorge in the valley of the Shing Mun River in the New Tai Mo Shan, and encompasses Territories some of the grandest landscape scenery in the New Territories. The scheme was to build a dam which would be 285 feet from the riverbed and 15 feet to the foundation below, across the Shing Mun Valley. When the project was completed, it would increase the water storage capacity of Hong Kong by 3 billion gallons.41 According to a report that was written in the 1930s and posted by the Industrial History of Hong Kong Group, “The Shing Mun Dam is one of the most remarkable works of its kind in the Far East. Source: The above article was obtained from It contains 166,000 cubic yards a volume of Wonders of World Engineering edited by Clarence Winchester published (127,000 cubic meters) of concrete, in a 1938 or 39 edition. This was posted on and the rock fill consists of 500,000 3 December 2014 by Hugh Farmer of the cubic yards (382,000 cubic meters) Industrial History of Hong Kong Group o f s t o n ewo r k . Th e d a m wa s at https://industrialhistoryhk.org/shingcompleted in 1937, but the concept mun-dam-reservoir-article-late-1930s/.

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of constructing the Shing Mun Water Supply Scheme was formulated in 1923. It was finally completed in 1939 when the laying of the third crossharbor pipeline from the Kowloon Peninsula to Hong Kong Island was finished. It took 16 years to complete and is the first reservoir to supply water from the Kowloon Peninsula to the Hong Kong Island.”42 The dam was constructed about 500 feet above sea level in a terrain of granite hills separated by steep-sided ravines, in a country with abundant potential breeding places of anopheline mosquitoes, vectors of malaria, many of which were difficult to bring under control. Unless precautionary measures were applied, there would be a high incidence of malaria during the construction of the dam. These narrow ravines had to be drained first and the hillsides were terraced and irrigated for wet cultivation of rice. Because of the broken nature of the country, it was difficult to find appropriate sites for coolie lines (rows of huts for the coolies) and for building accommodation for medical staff, Chinese and European. A small hospital was built in Shing Mun between 1934 and 1935 even before the project of construction of the Shing Mun Dam was underway in anticipation of the medical needs of the construction workers. All these buildings had to be rendered mosquito-proof and the area under sanitary control. The collaboration of the Medical and Engineering Departments finally led to the construction of a small hospital with a ward of fourteen beds.43 Figure 4.11 Hong Kong Shing Mun Reservoir memorial stone

Photograph by Hu Zhaoyang

4. Launching of Outpatient Services in Kowloon and the New Territories | 81

Figure 4.12 Shing Mun Reservoir valve tower

Photograph by Hu Zhaoyang

Despite these precautions, during 1935 when excavation began, there were nine deaths from malaria, 25 deaths from other causes, 758 admissions to Shing Mun Hospital, and 67 admissions to other hospitals from a total of around 1,500 laborers—a very high mortality and morbidity indeed (Table 4.5). While such a high mortality and morbidity would be utterly unacceptable by today’s standards and would undoubtedly cause a public uproar, this high death toll seemed perfectly acceptable in those days.44 Table 4.5 Shing Mun Hospital returns, 1934 to 1936 No. of cases of malaria Deaths from malaria No. of cases of other diseases* Death from other causes Admission to Shing Mun Hospital Admission to other hospitals

1934 68 2 316 3 34 6

1935 985 9 4495 25 758 67

1936 509 3 8620 28 652 45

*Individual causes not given. Source: Medical and Sanitary Reports for the Years 1934, 1935, 1936, HKAR for the corresponding years, Hong Kong Government Administrative Reports Online.

The Shing Mun Reservoir ( Jubilee Reservoir), resulting from the construction of the Shing Mun Dam, was officially opened on 30 January 1937.45

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Voluntary Medical Associations and Their Contributions to Medical Services in Kowloon and the New Territories In the early 1930s, as the post First World War humanitarian spirit from Europe spread to Hong Kong, the local community had a great concern for the poor health of the inhabitants in the New Territories. Two voluntary medical associations, the St. John Ambulance Brigade and the Medical Benevolent Society (MBS), each sent medical practitioners to the New Territories to provide medical services to those in need. St. John Ambulance is the name of a number of affiliated organizations in different countries that teach and provide first-aid and emergency medical services, and are primarily staffed by volunteers. The associations are overseen by the International Order of St. John and its national branches. St. John Ambulance Association was established in Hong Kong in 1884 followed by the Ambulance Brigade in 1916.46 Initially, its main purpose was to provide ambulances to transport the sick to the hospital. Later, it extended its work by establishing a number of dispensaries and health centers in the New Territories, including the Haw Par Hospital in Cheung Chau, and dispensaries in Tai Po, Yuen Long, Kam Tin, San Tin, Fan Ling, and Sai Kung.47 The New Territories Medical Benevolent Society (MBS) had its financial foundation from H. & L. Kadoorie, E. M. Raymond, and J. E. Joseph.48 After a tour of the New Territories, the subscribers were struck by the number of sick people in the area. They donated HKD1,000 for medicine to be distributed free to those in need. The MBS came into being on 25 May 1930. In the beginning, enthusiastic doctors and their nurses spent Sundays treating patients in various centers in the New Territories, such as Tsuen Wan, Tuen Mun, and Ping Shan. They discovered and treated many patients with eye diseases, including trachoma (the most common), and other diseases such as malignant malaria, and typhoid.49 The Society was responsible for the necessary medical supply and medications for the clinics. Later, it employed doctors to work part-time in these clinics three times a week rather than only on Sundays. Later still, permanent clinics were set up in the centers with a resident doctor, a nurse, and a dispenser.50 At the beginning of 1933, there were no fewer than ten medical centers, each with its own resident staff which included nurses and midwives provided by one of the voluntary associations (Table 4.6).

4. Launching of Outpatient Services in Kowloon and the New Territories | 83

Figure 4.13 St. John Ambulance Hong Kong Island Command Headquarters on Tai Hang Road

Photograph by Rachel Pang

Table 4.6 Medical centers established by voluntary associations in 1933 Location

Sponsoring Agency Type of Establishment

Resident Staff

Tai Po

St. John AA

Dispensary

Medical officer and midwife

Yuen Long

St. John AA

Dispensary

Midwife

Kam Tin

St. John AA

Dispensary and hospital for women and children

2 Midwives

San Tin

St. John AA

Dressing Center

Midwife

Fan Ling

St. John AA

Dressing Center

Midwife and dresser Midwife

Sai Kung

St. John AA

Dressing Center

Cheung Chau

St John AA

Dispensary and Maternity 2 midwives

Tsuen Wan

MBS

Dispensary and Maternity 2 midwives

Tuen Mun

MBS

Dispensary

Midwife

Ping Shan

MBS

Dispensary

Midwife

Note: St. John AA = St. John Ambulance Association; MBS = Medical Benevolent Society; Maternity = maternity ward Source: Medical and Sanitary Report for the Year 1933, HKAR, 1933, M112.

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The founding of government dispensaries and the voluntary associations’ medical services in the same location led to wasteful duplication of efforts. In 1933, the two voluntary associations agreed to combine their efforts and amalgamated to form the “St. John Ambulance New Territories Medical Benevolent Branch.” As a result of the amalgamation, two centers (Tai Po and Yuen Long) were closed and new centers opened at Sai Kung (Ha Tsuen, Ting Kok) and Ta Kwu Ling. Another meeting was then carried out between the government Medical Department and the St. John Ambulance New Territories Medical Benevolent Branch to ensure that there would be full cooperation between the Medical Department and the voluntary association. Sensible decisions were made so that the five government centers would be established in Tai Po, Yuen Long, Sheung Shui (Lady Ho Tung), Sham Tseng, and Shing Mun and eight of the ten St. John Ambulance New Territories Medical Benevolent Branch centers would remain: namely those in Kam Tin, Tsuen Wan, Ping Shan, San Tin, Fan Ling, Sha Tau Kok, Sha Tin, and Cheung Chau. The centers established by St. John Ambulance in those locations where government centers already existed would be closed, and the Government Travelling Dispensary would cease calling at the villages where St. John Ambulance already had a center.51 Figure 4.14 Distribution of government clinics and clinics sponsored by St. John Ambulance New Territories Medical Benevolent Branch in the New Territories in 1939

Note: Government clinics (black dots), St. John Ambulance New Territories Medical Benevolent Branch (circles)

4. Launching of Outpatient Services in Kowloon and the New Territories | 85

Japanese invasion of Manchuria began in September 1931 and the Second Sino-Japanese War began in 1937. The Japanese Army marched southwards along the coast, taking over Guangzhou in 1938. When Guangzhou fell, refugees flooded into Hong Kong, believing that Japan would not declare war on Britain. This overwhelmed the facilities in Hong Kong, causing tremendous problems in housing, sanitary and medical services. The government responded by calling on charitable organizations to help out. At the same time, it mounted a smallpox vaccination and cholera inoculation campaign. During 1938 and 1939, over one million people were vaccinated. These campaigns reduced the number of people affected by cholera and smallpox. In addition, the government appointed three Chinese sanitary inspectors and added nineteen scavenging coolies to the existing small cadre of twenty-eight coolies in the New Territories to improve the standard of hygiene. Steps were undertaken to organize collection and disposal of household refuse, especially in the larger townships such as Tai Po, Yuen Long, Cheung Chau, Sai Kung, and Tsuen Wan. Incinerators were constructed in some townships and public latrines were built in crowded areas.52 In December 1941, Hong Kong fell to the Japanese and entered into a long, dark period of Japanese occupation lasting for three years and eight months. Its infrastructure, including the Medical and Health Department that had taken a century to build, lay in shambles. The outpatient clinics in Hong Kong, Kowloon, and the New Territories, irrespective of whether they were sponsored by the government, voluntary organizations, or the Chinese elite, contributed greatly to the medical and healthcare of the community before the Second World War. The construction of two pieces of major infrastructures, the KCR and the Shing Mun Dam in the New Territories, provided the necessary momentum to further the expansion and growth of the area together with the necessary medical services. These two major engineering feats were achieved by the incredible hard work of the impoverished Chinese coolies at a time when protection of workers from physical dangers and chemical exposures were almost nonexistent, resulting in high morbidity and mortality. Industrial health and safety development in Hong Kong only started in the late 1950s as the city evolved into a major manufacturing center.

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5. Post–World War II Government Outpatient Services: The Great Expansion

On 15 August 1945, when the Japanese surrendered, Admiral Harcourt reclaimed Hong Kong for Britain and established a military government. Despite the scarcity of resources, the Hong Kong government worked with remarkable efficiency to maintain stability, and began the slow process of rebuilding all sectors of the government, including restoration of the economy that had crumbled during the war. The population of Hong Kong had dwindled to just around 600,000 shortly after the war, but it rose rapidly to over two million by 1951; thereafter it swelled by one million every decade for the next three decades. In the immediate postwar years, rampant infectious diseases resulted in low life expectancy and high maternal and infant mortality. Still, the health status of Hong Kong’s population rose steadily, from one of a developing region to that of a developed region by the early 1970s. The life expectancy in 1970 was 71.4 years in Hong Kong and 70.8 years in the United States, while the infant mortality rates were around 20 per 1,000 live births in both places. By 2017, Hong Kong had the longest life expectancy in the world.1 How did Hong Kong manage to accomplish such a success? This chapter and the following one concentrate on the government’s focus on development of outpatient services in different parts of Hong Kong, which included providing basic medical care and public health measures to prevent diseases, and examine the impact of these health services which ultimately helped achieve excellent health indices within a short period of time for the people of Hong Kong.

Years of Poverty and Struggle, 1945 to 1954 The immediate postwar decade, for most people in Hong Kong, was a period of poverty and hardship. Further contributing to the population’s

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economic and social struggles was the prevalence of infectious diseases, which accounted for 60% of all deaths in Hong Kong. Additionally, many of the physical structures of the Medical and Health Department were partly destroyed or became dilapidated. Some medical personnel died, and the expatriates, who were interned during the Japanese occupation, returned to their own country. The population was weakened from malnourishment and living in overcrowded conditions where the threat of epidemics lurked. To make matters worse, for a few decades after the Second World War, Hong Kong had to cope with population explosion from streams of refugees from the mainland and the postwar baby boom. In addition, its entrepôt trade and economy were devastated by the United Nations embargo because of the Korean War (1950–1953). The Medical and Health Department, given a meager budget, was forced to decide where to allocate funds: on disease prevention or curative measures. The department wisely opted to spend their limited resources on the former, while also strongly encouraging charitable organizations to provide care for the sick. The Medical and Health Department used its resources mainly on prevention and control of epidemics of infectious diseases, such as cholera, dysentery, typhoid, smallpox, and tuberculosis, and to reestablish maternal and child health services to combat the high maternal and infant mortality rates. The government was also faced with several tough challenges, such as poor environmental sanitation, intense overcrowding, inadequate housing, and exiguous water supply, some of which would require a huge budget that was unfortunately non-existent at the time.

Conversion of CPDs to Government Outpatient Centers Once the Medical and Health Department was reestabished after the Second World War, its director called on the Chinese elite who were responsible for the Chinese Public Dispensaries (CPDs) before the war to reopen the dispensaries, not realizing that the Chinese elite had largely dissipated since the Japanese occupation. Some died during the war, while others were weakened by illness and ageing, and most of their wealth evaporated with, of course, some exceptions. The Secretary for Chinese Affairs was unable to find any member of the previous central or local CPDs Committee who could come up with an adequate amount of funds to run the dispensaries.2 The government had no option but to take over the responsibility of financing and operating the CPDs. Between 1946

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and 1947, eight CPDs were reopened as government outpatient centers (Western, Eastern, Central, Shau Kei Wan, Yau Ma Tei, Sham Shui Po, Hung Hom, and Stanley). The CPDs buildings suffered from the ravages of war, and the lack of resources for repair left them in a state of decay. Renovations were therefore carried out one by one well into the 1950s. Aberdeen dispensary, which operated in a rented building, was reopened later. The remaining dispensary, Kowloon City Dispensary, was destroyed during the war and the land was returned to the government for the expansion of Kai Tak Airfield (see Chapter 2).3 In 1947, outpatient services on Hong Kong Island were provided by six CPDs and the Violet Peel Health Centre while the Kowloon Peninsula had three CPDs and the Kowloon Hospital Outpatient Department. Midwives were attached to six of the CPDs.4 The Police Medical Post and the Families Clinic served the police and their dependents; the Victoria Remand Dispensary delivered care to the prisoners; and the Marine Department Dispensary attended to the members of the Marine Department. The government outpatient clinics charged HKD 1 per visit but, when necessary, this charge was waived.5 These clinics had given care and hope to millions of people in different parts of Hong Kong. In addition, there were three polyclinics, two in Hong Kong and one in Kowloon. First, Sai Ying Pun hospital, the outpatient department of the old Government Civil Hospital, began operating in the early 1950s as the outpatient center of Queen Mary Hospital. Sai Ying Pun Outpatient Center held clinics throughout the day and in the evening often until 10pm. It was the largest and busiest outpatient clinic in Hong Kong and was used for educating medical students of the University of Hong Kong. Being constantly overcrowded and noisy, Sai Ying Pun Outpatient Centre was totally unsuitable as a teaching institution.6 Second, the Violet Peel Health Centre was not any better in terms of congestion, it also ran both day and evening clinics. Due to high demand, the Violet Peel Health Centre erected shelters outside the building to extend the waiting area. Third, the Kowloon Hospital Outpatient Department was the only government major outpatient center in Kowloon. In the New Territories, all the six government dispensaries/clinics before the war (located in Tai Po, Yuen Long, Sham Tseng, Sheung Shui, Tai O, and Sai Kung) and four dispensaries/clinics organized by the St. John Ambulance New Territories Medical Benevolent Branch (San Hui, Sha Tau Kok, Silvermine Bay, and Peng Chau) reopened. All government

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dispensaries/clinics had resident midwives with a small number of maternity beds.7 They also housed services for infant welfare, antenatal care, and venereal diseases. The medical officers from Hong Kong and Kowloon visited Tai Po, Yuen Long, and Cheung Chau to deliver dental and eye care and to attend to tuberculosis clinics.8 In addition, the government utilized two mobile dispensaries operating from Tai Po and Yuen Long, one serving the western part and the other the eastern part of the New Territories respectively. In 1959, two new motor launches, Chee Hong and Chee Wan were added, traveling to areas only accessible by water in the southern district of the New Territories.9 Figure 5.1 (Left) Chee Hong Floating Dispensary to service areas not reached by land in the New Territories, (Right) People trying to get into the boat, 1957

Reproduced by permission from Hong Kong Medical and Health Department Annual Report for the Year 1957–58, opposite 26.

First Period of Growth, 1954 to 1963 Towards the latter part of 1950s, Hong Kong’s economy began to recover from its postwar plunge, with Hong Kong establishing itself as a regional manufacturing center. The government, armed with a bigger but still limited budget for health services, astutely decided to build outpatient centers, which were cheaper and quick to construct, rather than spend all its available resources on erecting expensive hospitals. These centers would deliver basic medical care, provide preventive services, and at the same time, reduce the need for hospitalization. From 1954 to 1963, there

5 . P ost – W orld War I I G overnment O utpatient S ervices   |   9 1

was a modest expansion of outpatient centers, with the appearance of some new clinical buildings and reconstruction or renovation of old ones in different parts of the territory.

Location of the New Outpatient Centers As a result of the postwar population boom, it became clear that Hong Kong’s government needed to respond to the concurrent need for more accessible healthcare facilities. Before the Second World War, most of the people of Hong Kong lived in the urban areas—the narrow strip of land on the northern coast of Hong Kong Island and the whole of Kowloon Peninsula. As the population in Hong Kong climbed steadily after the Second World War, the Hong Kong government made no plans to tackle the huge housing crisis, instead hoping that the refugees would return to Mainland China once the political situation stabilized. When the China–Hong Kong border was finally closed in 1951, the refugees became a settled population in Hong Kong. Squatter huts sprang up in many areas in Hong Kong to accommodate the refugees, often in places without running water, means of disposal of garbage, or electricity. They were a frequent source of fire and outbreaks of infectious diseases. It was the great disaster that occurred on Christmas of 1953 that forced the government to recognize the necessity in accommodating this previously-neglected demographic. The Shek Kip Mei fire turned 55,000 people homeless overnight. So, faced with a huge relief fund of HKD 50,000 a week, the government decided to build public housing to accommodate the victims.10 In addition, the government proposed to construct new towns on undeveloped areas of Kowloon. Tsuen Wan became the first industrial new town while Kwun Tong, located at the undeveloped eastern Kowloon, was the second site chosen.11 The urbanization project in the new satellite towns clearly necessitated the establishment of a new government outpatient center. It was not until the early 1960s that new industrial and residential areas were developed on the flatland of the northern part of Kowloon to accommodate factories and refugees from Mainland China. They were resettlement estates and included Shek Kip Mei, Li Cheng Uk, San Po Kong, Wong Tai Sin, Ngau Tau Kok, Wang Tau Hom, and others.12 In each of the resettlement estates, the government planned to provide education and medical services. An outpatient center was established with a general outpatient clinic and a maternity and child health center. Other special services,

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such as tuberculosis and venereal disease clinics, were organized according to the population density. The outpatient centers and the health services provided in Hong Kong, Kowloon, and the New Territories up to 1963 are shown in Table 5.1 and their location can be found in Figures 5.9a, 5.9b, and 5.9c. Table 5.1 Government outpatient centers, types of services provided, and year of establishment in Hong Kong, Kowloon, and the New Territories up to 1963 Services+

Year

GOPC, MCHC, maternity home GOPC, special and specialist clinics GOPC, MCHC, and some special clinics GOPC, eye center, special clinics GOPC, maternity home

1960/61 1960

Tuberculosis clinic, dental clinic, physiotherapy Harcourt Health Centre School health, MCHC, social hygiene (male) Anne Black Health Centre GOPC, MCHC, maternity home, dental clinic, X-ray survey center Shau Kei Wan Public GOPC, special and specialist Dispensary clinics Shau Kei Wan Polyclinic General, special clinics Chai Wan Clinic and MCHC GOPC, MCHC

1954/55

No. Name of Health Center Hong Kong Island  1 Kennedy Town Jockey Club  2 Sai Ying Pun Polyclinic  3 Central District Health Centre  4 Violet Peel Polyclinic  5 Eastern District Dispensary and Maternal Hospital  6 Wan Chai Clinic  7  8  9    10

 11 Aberdeen Dispensary Aberdeen Jockey Club Clinic  12 Stanley Dispensary Kowloon  13 Li Cheng Uk Clinic  14 Shek Kip Mei Health Centre  15 Tai Hang Tung Clinic  16 Sham Shui Po Dispensary  17 Li Po Chun Health Centre  18 Arran Street Eye Clinic  19 Yau Ma Tei Public Dispensary Yau Ma Tei Polyclinic  20 Ashley Road Social Hygiene Clinic

1907, 1957/58 1935 1911

1946/47 1962/63 1929, 1955/56

GOPC GOPC, MCHC GOPC

1964/65 1958/59, 1968/69 1930 1960/61 1936

GOPC GOPC, special clinics GOPC GOPC, some special clinics GOPC Eye clinic GOPC Polyclinic Venereal disease clinic (male)

1963/64 1957/58 1956/57, 1915, 1955/56 1963/64 1955/58 1906 1966/67 1957/58

5 . P ost – W orld War I I G overnment O utpatient S ervices   |   9 3

(Cont’d Table 5.1) No. Name of Health Center Services+  21 Tsim Sha Tsui Health Centre School Health, MCHC, venereal disease (female)  22 Hung Hom Clinic and GOPC, maternity home, special Maternity Home clinics  23 Kowloon Chest Clinic Tuberculosis  24 Wang Tau Hom Jockey Club GOPC, maternity home, MCHC Clinic  25 Wong Tai Sin Clinic GOPC  26 Robert Black Health Centre GOPC, maternity home  27 Farm Road Dental Clinic  28 Family Clinic Farm Road Family clinic The New Territories  29 Maurine Grantham Health Centre, Tsuen Wan  30 Sha Tau Kok Clinic GOPC, maternity beds  31 Shek Wu Hui Jockey Club GOPC, maternity beds Clinic  32 Ho Tung Dispensary Maternity home with convalescent beds  33 Yuen Long Dispensary GOPC  34 San Hui Dispensary Maternity home, special clinics  35 Tai Po Dispensary GOPC  36 Sai Kung Dispensary GOPC, special clinics, maternity beds  37 North Lamma Clinic GOPC, maternity beds  38 Peng Chau Clinic GOPC, special clinics, maternity meds  39 Silver Mine Bay Dispensary GOPC, maternity beds  40 Tai O Dispensary GOPC, special clinics, maternity beds,  41 Kam Tin Clinic GOPC, maternity beds  42 Fan Ling Dental Clinic

Year 1962/63 1958/59 1951/52 1962/63 1961/62 1963/64 1963/64 1959/60 1954/55 1960/61 1961/62 1934 1932 1957/58 1903 1955/56 1956/57 1958/59 1951/52 1959/60 1963/64 1960/61

Note: +services provided at the time of establishment. GOPC = General Outpatient Clinic. Special clinics = tuberculosis, venereal disease, school health, dental, and ENT clinics. Specialists clinics = clinics attended by specialists from either the university hospitals or the Medical and Health Departments. The numbering of the clinics in Table 5.1 corresponds to those in Figure 5.9a, 5.9b, and 5.9c. The clinics included in the tables are for the general population rather than for a specific group, e.g. government civil servants, police force, and prisoners. The year of establishment of the clinic is the year that the clinic first appeared in the Medical and Health Department Annual Reports. There are likely omissions. Source: Hong Kong Medical and Health Department Annual Report, Building Program, 1954 to 1963; Hong Kong Government Information Service, HKRS545-1-210; HKRS70-3146; South China Morning Post.

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Figure 5.2 Shek Kip Mei Health Centre built in 1957, one of the earlier clinics built after the war

Photograph by Brian Yu

Services Provided by Government Outpatient Centers As mentioned previously, the government took over the CPDs as outpatient centers following the Second World War due to the inability of the Chinese elite, who had initially supported them, to come up with funds. These new dispensaries were simple in structure. They usually had a waiting room, a treatment room, and two to three consultation rooms. There were also extra rooms for the maternal and child health services (MCHC), where mothers brought with them babies to receive education on basic hygiene, childcare, feeding, and vaccination. The early outpatient clinic buildings constructed in the late 1950s followed the design and pattern similar to that of the CPDs. The Anne Black Health Centre in North Point (opened in 1962) is an example with provision for outpatient services and maternal and child health services. 13 Wang Tau Hom Jockey Club Clinic (completed in 1963) had, in addition, a maternity ward of twenty-five beds and quarters for resident staff.14

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There were outpatient centers which provided special services such as school health, dental health, social hygiene, tuberculosis services, and eye, ear, nose, and throat services. In the 1950s, the government built some centers designated for only one or two special services such as the Wan Chai Chest Clinic and Dental Clinic on Kennedy Road (Figure 5.3).15 Tables 5.1, 5.2, and 5.3 also show the types of services in government outpatient centers. While some only had general outpatient clinics (GOPC) and MCHC, others provided several special services. The largest building erected during this period was the nine-story polyclinic at Sai Ying Pun, which consisted of a large general outpatient department, chest and social hygiene services, a radio-diagnostic and superficial radiotherapy department, and outpatient teaching facilities for all clinical units of the University of Hong Kong (specialist clinics). Sai Ying Pun Polyclinic was built with funds donated by the Royal Jockey Club (Figure 5.4),16 which also built a number of other outpatient centers throughout the territory.17 Figure 5.3 Wan Chai Chest Clinic and Wan Chai Dental Clinic on Kennedy Road, 1954

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1953–54, opposite 26.

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Figure 5.4 Sai Ying Pun Jockey Club Polyclinic, built in 1960 (the earliest polyclinic built in Hong Kong)

Photograph by Ann Wong

Attendance The total attendance of these outpatient centers climbed between 1951 and 1963 as Hong Kong’s population mounted (Figure 5.5). Although attendances of the special medical services were less than those of general medical services in the early 1950s, the situation was changed by the mid1950s. Despite an increase in the number of outpatient centers, all services were overcrowded, even in the evening, Sundays, and public holidays. In 1963, the attendances at all government outpatient services came to 5.77 million, of which 2.27 million were new cases.18

5 . P ost – W orld War I I G overnment O utpatient S ervices   |   9 7

Figure 5.5 Total attendance of general and special outpatient services per year, 1951 to 1963

Source: Hong Kong Medical and Health Department Annual Report, 1951 to 1963.

Plan for the Future In 1957, the Medical Department proposed a fifteen-year plan to develop medical and health services. The plan was a statement of what would be required to provide comprehensive service within the limitations of finance, building, and staff training programs. Because of the lack of population census after the war and uncertainty of the economy, the plan was limited to development over five years.19 The government realized that it would not have adequate resources to provide comprehensive medical service to the whole population, nor did it want to do so. As there was a lack of healthcare policy, the need for medical services was estimated in the development plan. In framing the five-year proposal (1960 to 1964), it was calculated that some 50% and 80% of the population would depend on the government for outpatient care and for hospitalization respectively. From the census data of 1961, the average salary of the population, and the cost of various medical procedures, it was possible to determine whether unsubsidized general outpatient care was economically feasible for the above proposal.20 This method for calculating requirement of medical resources continued to be used in the next two decades of planning. In 1964, the White Paper on Development of Medical and Health Services in Hong Kong was tabled in the Legislative Council, and, in

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the face of a rapidly increasing population, suggestions were made to remedy deficiencies in medical services over a period of ten years, from 1964 to 1973. At that time, there were 2.67 hospital beds per 1,000 people, and the plan was to increase hospital beds to 5.75 per 1,000 people, commensurate with those in developed countries. In terms of outpatient facilities requirements, a number of standards were determined: 1) one standard dispensary to 100,000-person urban population and one standard dispensary to 50,000-person rural population; 2) one standard tuberculosis dispensary to a population of 400,000; and 3) one polyclinic for every 500,000 people. A standard dispensary is defined as one with a general outpatient clinic, a maternal and child health center, and a number of maternity beds varying from six in rural health centers to twenty-four in urban health centers.21 This plan determined the pattern of next stage of growth.

Second Period of Growth, 1964 to 1983 The economy of Hong Kong continued to improve, gradually leaving behind the consequences of the aftermath of World War II. By the early 1970s, Hong Kong’s per capita income was among the highest in developing countries in Southeast Asia, ranking second only to Japan in all of Asia. Despite the frequent political upheaval in China and the energy crisis of the early 1970s that ended the long period of prosperity in Western industrialized countries, Hong Kong’s high growth rate, uninterrupted since 1960, was sustained into the 1980s, allowing the government a more generous budget.22 The 1966 Star Ferry riots and 1967 communist-inspired riots pushed the government to change its policies. Despite economic improvements from the late 1950s onwards, the government had remained conservative in its financial and economic policies. It was allocating less than 10% of its budget on combined social services (education, medical and health, social welfare, and housing). This economic and housing laissez-faire policy resulted in tremendous overcrowding and the mushrooming of squatter huts in many parts of Hong Kong and Kowloon.23 Social welfare was left mostly in the hands of local and international voluntary agencies. The following two decades (1970s and 1980s) were characterized by increased spending on social services, including housing, health services,

5 . P ost – W orld War I I G overnment O utpatient S ervices   |   9 9

and higher education, on a scale which would have been unimaginable a decade earlier.24 As a result, there was tremendous expansion on medical services. When the 1964 ten-year plan ended in 1973, the number of hospital beds per 1,000 people was 4.2, and the plan was hailed as a great success. A Medical Development Advisory Committee was formed again in 1973 and a second White Paper on the Further Development of Medical and Health Services in Hong Kong was tabled in the Legislative Council in July 1974 with a goal similar to the previous one: more hospital beds to reach a new target of 5.5 beds per 1,000 people by the end of the next decade and further expansion of outpatient services.25 The two decades from 1964 to 1983 became a golden age for building hospitals and clinics—a period of enormous expansion of medical services. There were two new proposals in the 1974 White Paper. The first was to divide Hong Kong into five regions, Hong Kong Island, East Kowloon, West Kowloon, East New Territories, and West New Territories, in order to facilitate fair delivery of medical services. Each region would have one acute hospital for specialized care, a number of smaller hospitals, and one or more polyclinics with a number of general outpatient centers to provide basic services. Secondly, a decision was made to establish a second medical school to address the persistent and troubling low doctor-residents ratio, which was 0.6/1,000 in 1973.26 The committee also recommended that in addition to the current two nurse-training schools, a third one was required.27 As a result, the second medical school offering programs in medicine, nursing, pharmacy, and public health was established in 1981. The medical school, together with a new teaching hospital in Shatin, part of the New Territories, became an integral part of the Faculty of Medicine of the Chinese University of Hong Kong.

Location of New Outpatient Centers In the late 1960s, when most of the flatlands in Kowloon and Hong Kong had been developed, the government began to create new towns in the New Territories, a largely rural area at that time. The first phase of development of these new satellite towns involved Sha Tin and Tuen Mun, accommodating a few hundred-thousand people. When the first phase was successfully completed, the second phase began with the

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expansion of Tai Po, Yuen Long, Fan Ling and Sheung Shui in 1976, 1977, and 1978 respectively. The extension of Tsuen Wan New Town to Tsing Yi Town also started in the mid-1970s.28 With the construction of new towns, a number of outpatient centers and polyclinics were also built to serve them. The outpatient centers and the health services built in Hong Kong, Kowloon and the New Territories between 1964 and 1983 are shown in Table 5.2. The distribution of the outpatient centers during this period can be found in Figures 5.9a, 5.9b, and 5.9c. By 1983, at the end of the second ten-year plan of medical development, Hong Kong had around seventy-three outpatient centers and a number of polyclinics. Twenty more outpatient centers and polyclinics were planned for the next ten years. Table 5.2 New government outpatient centers established in Hong Kong, Kowloon, and New Territories, 1964 to 1983 No. Name of Outpatient Center Services+ Hong Kong Island  43 David Trench Rehabilitation Centre Rehabilitation  44 Eastern Street Methadone Clinic  45 MacLehose Dental Centre  46 Tang Chi Ngong Specialist Clinic GOPC, family health, eye, ENT, skin, specialist clinics Kowloon  47 Argyle Street School Dental Clinic  48 Cheung Sha Wan Jockey Club GOPC, dental Clinic  49 Lee Kee Memorial Dispensary GOPC, dental clinic, special clinic  50 East Kowloon Polyclinic GOPC, family health, chest  51 Lion’s Club Maternal and Child Family health, maternal home Centre  52 Nam Shan Health Centre GOPC, family health  53 Ngau Tau Kok Jockey Club Clinic GOPC, family health, maternity home  54 Shun Lee Government Clinic GOPC, family health  55 Tin Kwong Road Dental Clinic  56 Wu York Yu Health Centre GOPC, family health, maternity home, methadone clinic  57 Kwun Tong Maternal and Child MCHC Health Centre GOPC, Family health, maternity  58 Kwun Tong Jockey Club Health Centre home, dental clinic  59 Tsz Wan Shan Clinic GOPC, MCHC

Year 1970/71 1972/73 1978/79 1975/76

1981/82 1966/67 1964/65 1976/77 1965/66

1981/82 1982/83 1980/81 1973/74 1964/65 1982/83 1972/73

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(Cont’d Table 5.2) No. Name of Outpatient Center The New Territories  60 Tai Lam Dental Clinic  61 Castle Peak Clinic (Tuen Mun Clinic)  62 Sha Tin Maternity Home  63 Tai Wo Hau  64 Lady Trench Polyclinic (Tsuen Wan)  65 Lek Yuen Health Centre (Sha Tin)  66 Lei Muk Shue Clinic*  67 Mrs. Wu York Yu Health Centre  68  69

 70  71  72  73

Services+

GOPC, MCHC, 24 maternity beds Maternity home MCHC GOPC, skin, methadone, dental GOPC, family health Urban Clinic GOPC, family health, maternity home North Kwai Chung Clinic GOPC, family health maternity home South Kwai Chung Jockey Club GOPC, family health, maternity Polyclinic home, eye, chest, ENT, psychiatry, venereal disease, specialist clinics St. John Hospital outpatient GOPC, special clinics Tsing Yi Town General Outpatient GOPC, family health clinic Tuen Mun Clinic GOPC, maternity, methadone Yan Oi Clinic (Tuen Mun) GOPC, family health, maternity home, eye, chest, skin, venereal disease, dental, methadone

Year 1971/72 1967/68 1964/65 1964/65 1965/66 1980/81 1981/92 1983/84 1971/72 1972/73

1976/77 1982/83 1968/69 1981/82

Note: +services provided by the center when it was first established. GOPC = General Outpatient Clinic. Special clinics = tuberculosis, venereal disease, school health, dental, and ENT clinics. *No longer exists. The numbering of the clinics in Table 5.2 corresponds to those in Figures 5.9a, 5.9b, and 5.9c. The clinics included in the table are for the general population rather than for a specific group, e.g. government civil servants, police force, and prisoners. There are likely omissions. The year of establishment of the clinic is the year that the clinic first appeared in the Medical and Health Department Annual Reports. Some of the clinics that started before WWII may no longer exist. Source: Compiled from Hong Kong Medical and Health Department, Building Program, Year 1972 to 1983; Hong Kong Government Information Service, Hong Kong Public Records Office: HKRS, 545-1-210; HKRS-70-3-146; HKRS 70-8-734.

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Figure 5.6 (Left) Lady Trench Health Centre in Tsuen Wan, a larger building (compared to clinics built in the late 1950s) to accommodate more services, (Right) congestion in the waiting room, 1966

Reproduced by permission from Hong Kong Medical and Health Department Annual Report, 1956–57, opposite 26.

Nature of the Health Centers Although guidelines and standards for building outpatient centers in urban and rural areas had been set, the accelerated development of new towns in rural areas made it difficult to follow such standards. For example, the population of Kwun Tong reached 500,000 rapidly in the 1960s. It would not make economic sense to build five standard outpatient centers in this district to keep up with population expansion. When a district became a satellite town in the New Territories, it no longer remained rural in character, and the standard applied should be that of an urban district. A more flexible approach was necessary. As a result, the standard outpatient centers were enlarged to include a waiting hall large enough to seat 300 patients and a dispensary for medications situated within the waiting area, not outside it. Besides the usual treatment/dressing room, there would be at least six consultation rooms for general outpatient activities, and four rooms for special services. The maternal and child health section was expanded with larger rooms for demonstration and exhibition, plus more consulting rooms so that family planning sessions could be held together with ante- and post-natal clinics. Most of the outpatient centers built since the 1970s were in general larger with more consultation rooms to run special clinics, such as dental clinics, tuberculosis clinics, or venereal disease clinics, with a space for other activities, such as health education.29 The polyclinics provided a range of services. Each polyclinic usually included specialist medical, surgical, and psychiatry clinic. Facilities for rehabilitation, physiotherapy, and occupational therapy units were

5 . P ost – W orld War I I G overnment O utpatient S ervices   |   1 0 3

incorporated to emphasize their importance. Laboratory facilities for clinical pathology, bacteriological examinations, and X-ray examinations were also standard services of a polyclinic to facilitate investigations. Sai Ying Pun Polyclinic was the first polyclinic built in 1960 with these principles in mind. Its success led to the construction of polyclinics in other districts during this period: Shau Kei Wan Polyclinic in 1964, Yau Ma Tei Polyclinic in 1967,30 South Kwai Chung Jockey Club Polyclinic in 1972,31 and Tuen Mun Polyclinic in 1982.32 There were two specialist outpatient centers built close to the two hospitals they supported: Tang Chi Ngong Specialist Clinic opened in 197433 for Tang Shiu Kin Hospital and Li Ka Shing Specialist Clinic in 1998 for Prince of Wales Hospital.34 These specialist outpatient centers accommodate a number of general, special, and specialist outpatient services in the same building, thereby reducing travel time from one clinic to another. A major health center opened in 1983 in Kwun Tong, which included a wide range of facilities: family health, tuberculosis and chest, social hygiene, radiology, and laboratory services as well as day places in geriatrics and psychiatry. There were also physiotherapy and occupational services as well as a health education center.35 Figure 5.7 Shau Kei Wan Polyclinic built in 1964

Reproduced by permission from Medical and Health Department Annual Report 1964–65, between 18 and 19.

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Attendance Between 1977 and 1980, the total attendance of general outpatient services fell, but that of the special clinics/health centers grew; thereafter the total attendance of both general and special clinics/health centers increased at around the same rate, and amounted to about 15.5 million in between 1989 and 1990. (Figure 5.8) Figure 5.8 Total attendances of general and special outpatient clinics, 1964 to 1988

Source: Hong Kong Medical and Health Department Annual Reports 1963/64 to 1983/84.

Evening services continued to be popular and were held in the more densely populated areas such as the Aberdeen Jockey Club Clinic, the Kowloon Hospital Outpatient Department, the Kwun Tong Jockey Club Clinic, the Lady Trench Clinic, the Li Po Chun Health Centre, the Robert Black Health Centre, the Sai Ying Pun Jockey Club Polyclinic, the Shau Kei Wan Polyclinic, the Violet Peel Polyclinic, and the Yau Ma Tei Polyclinic.36

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Period of Consolidation and Change, 1984 to the present After U.S. President Richard Nixon’s 1972 visit to China, amicable relations between the two countries resumed, enabling the development and modernization of China towards the end of the decade. As 1997 drew near, when the lease of the New Territories would expire, Deng Xiaoping, the eminent leader of the People’s Republic of China, who had been advocating “socialism with Chinese characteristics,” devised an ingenious formula—One Country, Two Systems—to preserve the spectacular success of Hong Kong by maintaining the status quo and creating a new set of laws to protect the freedom and rights of the Hong Kong citizens. Even before the signing of the Sino-British Joint Declaration in 1984, ambitious Hong Kong entrepreneurs began to transfer manufacturing production to the Pearl River Delta region in the south China coast, taking advantage of the area’s low labor cost. As Hong Kong continued to upgrade its economy to become a financial center, it relied on the manufacturing hubs of south China. As a result, China’s development in industry and its economy were fast-tracked. During this period, more outpatient/health centers were built in order to accommodate the territory’s ever-expanding population and development in formerly-rural areas, as shown in Table 5.3. Their locations can be found in Figures 5.9a, 5.9b, and 5.9c. Table 5.3 New government outpatient centers in Hong Kong, Kowloon and the New Territories, 1984 to 2015 No. Name of Outpatient Center Hong Kong  74 Wan Tsui Clinic  75 Western Dental Clinic  76 Ap Lei Chau Family Clinic  77 Sai Wan Ho Health Centre Kowloon  78 Shun Tak Fraternal Association Leung Kau Kui Clinic  79 Argyle Street Ophthalmic clinic  80 Lam Tin Polyclinic  81 Yung Fung Shee Memorial Centre  82 Kowloon Bay Health Centre

Services+

Year

GOPC Dental clinic Family clinic GOPC, family health

1987/88 1994/95 1990/91 1995/96

GOPC

1984/85

Eye clinic GOPC, family health, school dental family health, chest, psychiatric, social hygiene, skin, occupational, physiotherapy GOPC, Family health

1991/92 1987/88 1984/85 1999/00

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(Cont’d Table 5.3) No. Name of Outpatient Center  83 West Kowloon Health Centre  84 Central Kowloon Health Centre The New Territories  85 Tuen Mun Polyclinic

Services+ Family health, skin clinic GOPC

Year 1998/99

Eye, ENT, psychiatric, skin, social 1984/85 hygiene, physiotherapy, occupational  86 Tuen Mun School Dental Clinic Dental 1985/86  87 Tuen Mun Wu Hong Clinic Family Health, elderly health center 1993/94  88 Li Ka Shing Specialist Clinic

1989/90

 89

1998/90

 90  91  92  93  94  95  96  97  98  99  100  101  102

Eye, ENT, radiotherapy, skin, physiotherapy, psychiatric, dental Mona Fong Government Clinic GOPC, family health, maternity home, eye, chest, dental Pamela Youde Child Assessment Child Assessment and school dental and School Dental Clinic clinic Tai Po Wong Siu Ching Clinic GOPC, family health, eye, chest, skin, social hygiene, dental Tin Shui Wai Urban Clinic GOPC, Tin Shui Wai Community GOPC family health Health Centre Tseung Kwan O Health Centre GOPC Tseung Kwan O Jockey Club GOPC, Family health Clinic Tsing Yi Urban Clinic GOPC, family health Tung Chung Health Centre Family health, chest clinic, chest x-ray Ma On Shan Health Centre GOPC Ta Kwu Ling General GOPC Outpatient Clinic Fan Ling Family Medicine Family health Centre Yuen Chau Kok General Elderly health, chest clinic, chest x-ray Outpatient Clinic Ha Kwai Chung Polyclinic and Child assessment, dental, elderly Special Education Service health

1990/91 1984/85 1992/93 1994/95 1999/00 1994/95 1990/91 1997/98 1996/97 1994/95 1996/97 1991/92 1997/98

Note: +Services provided at the clinic at the time of establishment. GOPC = General Outpatient Clinic. The numbering of the clinics in Table 5.3 corresponds to those in Figures 5.9a, 5.9b, and 5.9c. The clinics included in the tables are for general population rather than for a specific group, e.g. government civil servants, police force, and prisoners. There are likely omissions. The year of establishment of the clinic is the year that the clinic first appeared in the Medical and Health Department Annual Reports. Source: Compiled from Hong Kong Medical and Health Department, Building Program, Year 1984 to 1990; Department of Health Annual Report 1991 to 2003 HA Report.

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New Administrative Structures: Formation of a New Department of Health and Hospital Authority Despite the marked expansion of medical services with the increasing number of hospitals and clinics, the congestion in the medical facilities remained. Complaints arose not only from the public but also from within the Medical and Health Department itself. It became clear that the problem now was no longer location of clinics or accessibility, but management of hospitals and clinics internally. The Department had grown so huge and so bureaucratic that changes could not be made easily. A review known as the Scott Review was carried out in 1984, recommending the formation of a Hospital Authority to manage all the government hospitals and subvented hospitals in Hong Kong. 37 The Medical and Health Department was dissolved in 1989 to be replaced by a new Department of Health and a Department of Hospital Services,38 which was later renamed the Hospital Authority in 1990.39 The formation of the Hospital Authorty vastly improved the delivery of medical services within the hospitals,40 but the basic weaknesses in administration and management within the Department of Health remained. In 1990, when the Hospital Authority was formed, it had total responsibility of all government and subvented hospitals, including all inpatient services and specialist clinical outpatient services, while the Department of Health had the responsibility of all health services, general and special outpatient services. In 2003, the Department of Health relinquished the administration of all the general outpatient services (N=54) and transferred it to Hospital Authority to integrate primary and secondary clinical services. The list of GOPC in Hong Kong, Kowloon, and the New Territories in 2019 can be found in Appendix 1, Table 1.

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Figure 5.9a Distribution of outpatient centers in Hong Kong established between 1905 and 2015

Note: Clinics from 1905 to 1963 (black dots); clinics from 1964to 1983 (white dots); clinics from 1984 to 2015 (x). 1 2 3 4 5

Kennedy Town Jockey Club Sai Ying Pun Polyclinic Central District Health Centre Violet Peel Polyclinic Eastern District Dispensary and Maternal Hospital 6 Wan Chai Clinic 7 Harcourt Health Centre 8 Anne Black Health Centre 9 Shau Kei Wan Public Dispensary Shau Kei Wan Polyclinic 10 Chai Wan Clinic and MCHC

11 Aberdeen Dispensary Aberdeen Jockey Club Clinic 12 Stanley Dispensary 43 David Trench Rehabilitation Centre 44 Eastern Street Methadone Clinic 45 MacLehose Dental Centre 46 Tang Chi Ngong Specialist Clinic 74 Wan Tsui Clinic 75 Western Dental Clinic 76 Ap Lei Chau Family Clinic 77 Sai Wan Ho Health Centre

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Figure 5.9b Distribution of outpatient centers in Kowloon established between 1905 and 2015

Note: Clinics from 1905 to 1963 (black dots); clinics from 1964 to 1983/84 (white dots); clinics from 1984 to 2015 (x). 13 Li Cheng Uk Clinic 14 Shek Kip Mei Health Centre 15 Tai Hang Tung Clinic 16 Sham Shui Po Dispensary 17 Li Po Chun Health Centre 18 Arran Street Eye Clinic 19 Yau Ma Tei Public Dispensary Yau Ma Tei Polyclinic 20 Ashley Road Social Hygiene Clinic 21 Tsim Sha Tsui Health Centre 22 Hung Hom Clinic and Maternity Home 23 Kowloon Chest Clinic 24 Wang Tau Hom Jockey Club Clinic 25 Wong Tai Sin Clinic 26 Robert Black Health Centre 47 Argyle Street School Dental Clinic 48 Cheung Sha Wan Jockey Club Clinic 49 Lee Kee Memorial Dispensary

50 East Kowloon Polyclinic 51 Lion’s Club Maternal and Child Centre 52 Nam Shan Health Centre 53 Ngau Tau Kok Jockey Club Clinic 54 Shun Lee Government Clinic 55 Tin Kwong Road Dental Clinic 56 Wu York Yu Health Centre 57 Kwun Tong Maternal and Child Health Centre 58 Kwun Tong Jockey Club Health Centre 59 Tse Wan Shan Clinic 78 Leung Kau Kui Clinic 79 Argyle Street Ophthalmic Clinic 80 Lam Tin Polyclinic 81 Yung Fung Shee Memorial Centre 82 Kowloon Bay Health Centre 83 West Kowloon Health Centre 84 Central Kowloon Health Centre

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Figure 5.9c Distribution of outpatient centers in the New Territories established between 1905 and 2015

Note: Clinics from 1905 to 1963 (black dots); clinics from 1964/65 to 1983/84 (white dots); clinics from 1984 to 2015 (x). 29 Maurine Grantham Health 30 Sha Tau Kok Clinic 31 Shek Wu Hui Jockey Club Clinic 32 Ho Tung Dispensary 33 Yuen Long Dispensary 34 San Hui Dispensary 35 Tai Po Dispensary 36 Sai Kung Dispensary 37 North Lamma Clinic 38 Peng Chau Clinic 39 Silver Mine Bay Dispensary 40 Tai O Dispensary 41 Kam Tin Clinic 42 Fan Ling Dental Clinic

69 South Kwai Chung Jockey Club Polyclinic 70 St. John Hospital OPD 71 Tsing Yi Town GOPD 72 Tuen Mun Clinic (former Castle Peak Clinic) 73 Yan Oi Clinic

85 Tuen Mun Polyclinic 86 Tuen Mun School Dental Clinic 87 Tuen Mun Wu Hong Clinic 88 Li Ka Shing Specialist Clinic 89 Mona Fong Government Clinic 90 Pamela Youde Child Assessment and School Dental Clinic 91 Tai Po Wong Siu Ching Clinic 92 Tin Shui Wai Urban Clinic 93 Tin Shui Wai Community Health Centre 60 Tai Lam Dental Clinic 94 Tseung Kwan O Health Centre 62 Sha Tin Maternity Home 95 Tseung Kwan O Jockey Club Clinic 63 Tai Wo Hau Clinic 96 Tsing Yi Clinic Urban Clinic 64 Lady Trench Polyclinic 97 Tung Chung Health Centre 65 Lek Yuen Health Centre 98 Ma On Shan Health Centre 66 *Lei Muk Shue Clinic 99 Ta Kwu Ling General Outpatient Clinic 67 Mrs. Wu York Yu Outpatient Clinic 100 Fan Ling Family Medicine Centre 68 North Kwai Chung Clinic 101 Yuen Chau Kok General Outpatient Clinic 102 Ha Kwai Chung Polyclinic and Special Education

Note: *no longer exists

6. Development of General Outpatient Clinics as Primary Care Providers: Merits and Shortcomings

As soon as the Japanese surrendered in Hong Kong on 15 August 1945, Dr. Selwyn Selwyn-Clarke, who had been imprisoned by the Japanese during the occupation, immediately left the prison at Stanley and returned to work. He resumed the services of the Medical and Health Department by recalling all previous staff to return to work and reopening as many hospitals and clinics as soon as possible. He was assisted by Professor Gordon King, who was the Dean of the Faculty of Medicine before the war, to rebuild the Department, employing as many medical graduates from the University of Hong Kong as possible and those who had completed their medical degrees in Chinese universities on the mainland during the war. As discussed in the previous chapter, the government took over the nine Chinese Public Dispensaries (CPDs) to provide outpatient care. These dispensaries delivered general outpatient services and most of them also had midwives attached to them to provide domiciliary deliveries, while some of the dispensaries had a few maternity beds. The buildings of most of the CPDs were in a dilapidated state and had to be repaired. From the mid-1950s to 1980s, government outpatient services greatly expanded. By 1990, the Department of Health was operating sixty-four general outpatient clinics and a number of special outpatient clinics in the region.1 In addition, mobile dispensaries and floating clinics provided medical services to the outlying islands and remote areas in the New Territories. Other inaccessible areas were visited regularly by the “flying doctor” service2 with assistance from the Royal Hong Kong Auxiliary Air Force. In this chapter the work of the government general outpatient clinics (GOPC) and their role as primary care providers will be discussed.

Figure 6.1 Sir P. Selwyn Selwyn-Clarke

Repinted from Kreol International Magazine, https://kreolmagazine.com/culture/history-and-culture/ sir-selwyn-selwyn-clarke/#.XdzOhtVS82w. d Sir Percy Selwyn Selwyn-Clarke (1893–1976) was appointed the Director of Medical and Sanitary Services in Hong Kong before the War. After the fall of Hong Kong to the Japanese, he felt that he would help the city more by working with the Japanese. He demanded sanitation workers to continue working without pay and to maintain a clean water supply for the population. He provided medications and food for hospitals, prisoner-ofwar camps, and the civilian concentration camp in Stanley through various means. He and his wife Hilda raised funds for supplies. However, these activities finally led to his imprisonment where he suffered grievously. d

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Work of Government General Outpatient Clinics (GOPC) Curative Care General outpatient clinics are the first point of contact for patients when they feel unwell. In general, these clinics, which were free or inexpensive, usually served the poorer Chinese in the community. The bulk of work of a medical officer in a general outpatient clinic was to address the immediate complaint of a patient, give a diagnosis, and provide treatment. Most of the time, the conditions encountered were cough and colds from upper respiratory tract infections, stomach upset or diarrhea from gastrointestinal disturbance, skin problems, and childhood infectious diseases. But at times, the doctor needed to decide whether a sick patient should be sent to hospital for further treatment or be treated as an outpatient. The doctor should know the type of infectious disease (e.g. cholera) currently in the community, send the patient with such a disease to appropriate centers for isolation and treatment, and inform public health authorities for contact tracing. He and his staff also performed vaccinations or inoculations. In fact, doctors in these clinics were primary care doctors and were “gatekeepers” to the hospitals. Unlike their counterparts in CPDs, there was no need for doctors to identify the cause of death for “dumped” bodies (see Chapter 2), which came under the jurisdiction of pathologists in charge of the mortuaries. Doctors were also spared from the duty of performing birth and death registration, because birth and death registries had been set up after World War II. Most of the time, the clinics were so heavily over-booked that the doctors had no time for anything else other than addressing the patients’ immediate problems. The doctors spent very little time with their patients, less than five minutes each, and sent the patient out with a prescription.3 They had little time to investigate the patients’ other health problems, and to practice preventive medicine other than immunization. Patients attending these clinics often had to wait for several hours just to spend three to five minutes with a doctor, and many had to make two trips to the clinic: one in the early morning to obtain a “visit ticket,” and another during consultation hours to receive care. Some enterprising individuals attempted to make money out of selling their “visit tickets” to those who did not have time to stand in line.4 As evidenced by the

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problem of overcrowding of clinics, medical care was “free” only in a technical sense, as patients paid dearly in the less tangible currencies of wasted time, inconvenience, and stress. Evening clinics and clinics during Sundays and public holidays were held regularly, but they nonetheless failed to relieve the congestion in the daytime clinics.5 In 1954, doctors in some of the major clinics worked shifts between 9 am and 12 midnight. In most major clinics, such as Sai Ying Pun Clinic and Violet Peel Health Centre, the volume of patients passing through was incredibly high, about half a million in attendance that year.6 The remarkable expansion of the outpatient services from the 1960s to 1980s only marginally reduced the workload of doctors and the waiting time of the patients because of the concurrent rapid population growth during this period (almost one million per decade in three successive decades from 1950).7

Control and Prevention of Infectious Diseases Other than clinical activities, government general outpatient services performed the work of prevention and control of infectious disease epidemics and conducted health education. Immunization against infectious diseases was and still is one of their vital functions. One of the most pertinent historical examples of CPDs/outpatient services managing an infectious disease is that of the twentieth-century smallpox epidemic. The smallpox vaccination program was part of the duties of the CPDs since their founding in 1905, and was effective in preventing severe epidemices. Around thirty years later, the arrival of refugees from Mainland China in 1937 brought a smallpox epidemic to Hong Kong. Responding to this increase in morbidity and mortality rates, in 1938, CPDs carried out smallpox campaigns in the form of education and vaccination. Altogether, 1.1 million people were vaccinated, resulting in only 198 cases in 1939 in contrast to 2,327 cases in the previous year.8 In 1946, shortly after World War II, almost 2,000 people were infected with smallpox,9 catalyzing a huge anti-smallpox campaign starting in 1947 when about one and a half million people were vaccinated. The vaccination program continued every year until 1979, with over one million people vaccinated annually for several years in the beginning.10 As a result, there were no cases of smallpox reported after 1951 (Figure 6.2). Hong Kong was declared free of smallpox by the WHO in 1979, a testament to the efficacy and importance of vaccinations.11

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Figure 6.2 Number of people vaccinated and number of cases of smallpox, 1946 to 1985

Source: Hong Kong Medical and Health Department Annual Reports for the years 1946 to 1985

An exceptionally vir ulent epidemic of cholera occurred in 1937 that killed 774 of the 1401 affected patients.12 Recognizing the seriousness of the problem, the government was much more alert in 1938 when streams of refugees from China arrived, some carrying the disease. In addition to extensive campaigns on the prevention of the deadly disease, anti-cholera inoculation was carried out by staff in all hospitals, dispensaries, and clinics in Hong Kong. In the end, the total number of deaths was 363 out of the 547 affected, considerably less than the previous year.13 The outbreak of cholera of 1961 also illustrates how the epidemic could be controlled efficiently by

Figure 6.3 Smallpox vaccination certificate issued by the Medical and Health Department Hong Kong in 1947. Note while the vaccination was free, the fee for the certificate was 50 cents (left bottom)

Photograph courtesy of Mr. Keith Poon

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preventive measures. During the first week of August 1961, rumors reached Hong Kong that there had been a recent outbreak of cholera in southern Guangdong. The Medical and Health Department responded to these rumors by immediately increasing the production of the cholera vaccine, mobilizing equipment and staff to open cholera treatment units, and designating a number of inoculation and quarantine centers. The first case occurred in Hong Kong on 15 August and was confirmed by a bacteriological investigation. At the same time, intensive public education in the prevention of the disease was carried out through the media. Anti-cholera inoculation was carried out mostly in these government dispensaries and in a number of other stations that were convenient for people, similar to smallpox campaigns. The response to the campaign was tremendous. People lined up in long queues outside every clinic and inoculation station (Figure 6.4). They all knew about the horrors of cholera and the high mortality from past experience. By 25 August, over 1.5 million persons had been inoculated, approximately half of the population of Hong Kong at that time. With such vigorous measures, the epidemic ended with only 129 cases.14 Figure 6.4 Long queue alongside and in front of the old Wan Chai Post Office for anti-cholera inoculation in a nearby dispensary

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1961–62, opposite 52.

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The government outpatient clinics were vital in the control of any infectious disease epidemic. In those days, enteric fever, typhoid, and paratyphoid, were not uncommon. When T.A.B. vaccines (against typhoid-paratyphoid A and B) became available, inoculation was offered to the public throughout the year,15 but the campaign was intensified during May, June, and July of 1961. Intensive health education was also given at that time on personal hygiene in an effort to decrease the spread of disease through techniques like handwashing and covering the mouth when sneezing or coughing.

Health Education Health education was always an important part of the work of Medical and Health Department, and it was carried out through various channels including talks given by doctors, nurses, and midwives in the outpatient clinics and health visitors going into homes of patients (Figure 6.5). Health education was also delivered through the media, newspapers, radio, and television, and health information, printed on leaflets, pamphlets, or booklets, was given out during health exhibitions. At times, special campaigns were organized for selected experts to give lectures, with teams going to schools and public places to give talks and demonstrations. In government dispensaries and clinics, health education was delivered on a variety of topics. In maternal and child health centers, health education was given on hygiene, how to care for newborn babies, the importance of breast feeding, and immunization. In tuberculosis clinics, the significance of taking all the medications regularly, completing the course of treatment, how to avoid infecting others, and side effects of the medications were taught, while in venereal diseases clinics, patients were given sex education, which included how to avoid getting infected.

Outpatient Work in Remote Areas: Vans, Boats, and Helicopters The early days of development of the New Territories were characterized by a lack of accessibility to medical care, largely due to the absence of public transportation. Therefore, the government sent mobile dispensaries to bring medical officers to the more remote areas where the population was not large enough for a permament, brick-and-mortar clinic to be established. In areas only accessible by water, there were two

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Figure 6.5 Health visitor giving health education to villagers

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1964–65, opposite 18.

Figure 6.6 Flying doctor going into a remote village to visit the sick (helicopter in the background)

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1961–62, opposite 45.

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Figure 6.7 Hailing boat people for immunization

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1961–62 opposite 45.

motor launches to bring services, including medical, dental, and minor surgery, to the community. A helicopter came into service, taking “flying doctors” to remote regions unreachable by car or boat (Figure 6.6). In a medical emergency, when traveling by car or boat would be too slow, the helicopter would also be called in. Mobile traveling clinics and motor launches (Figure 6.7) were recruited for immunization or vaccination campaigns, taking doctors and nurses to these communities, including the boat people. Health visitors often traveled along to give talks to the local community.16

Call for Healthcare Reform Following the 1970s, infectious diseases were no longer the major causes of death in Hong Kong, due to the hard work of the staff of the Medical and Health Department; however, there was still much work to be accomplished in medical services for the people of Hong Kong. The focus of the Medical and Health Department began to shift to personal curative

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care. More hospitals were built to accommodate the ever-changing and improving medical technology of electron microscopes, computerized tomography scanners (CAT), positron emission tomography (PET) scanners, and magnetic resonance imaging (MRI) machines. As these lifesaving technologies evolved, the demand for these high-tech services increased, escalating the cost of hospital care. When the Hospital Authority was founded in 1990, it consumed about 90% of the budget for hospital services, while only 10% was left for the new Department of Health.

Changes in Disease Pattern Despite the virtual eradication, or at least, control of, the infectious diseases that plagued twentieth-century Hong Kong, economic progress and the comparatively higher standard of living resulted in new problems for medical professionals. The positive effects of a more prosperous economy include advancement of medical services, better nutrition, and greater resistance to infection, all amounting to extending human lifeexpectancy and reducing infant, maternal, and overall mortality. At the same time, increased income led to the adoption of the Western style of living with its accompanying consequence—the progressive increase in lifestyle diseases such as cancer, cardiovascular and cerebrovascular diseases, obesity, and diabetes. The pattern of diseases changed. Since the 1970s, instead of seeing patients with infections or infectious diseases in the clinics, the doctors in the general outpatient clinics began attending to patients with chronic noncommunicable diseases. In the 1980s, the demographic pattern in Hong Kong also changed—people were ageing, leading to higher prevalence of chronic noncommunicable diseases. In 1997, the general outpatient clinics had 5.3 million patient-visits. Of these, 32.3% had acute respiratory infection, 24.6% hypertension, 7.6% diabetes, 6.6% skin diseases, and 5.5% musculoskeletal problems. Chronic noncommunicable diseases accounted for about 60% of all deaths in Hong Kong.17 These diseases, while not infectious, are associated with high morbidity, prolonged disability, and a significant burden to society. Studies have shown that the prevalence of these chronic diseases can be reduced by lifestyle changes, and disabilities can be avoided by early detection and early treatment by primary care physicians, who are the first point of contact for most patients. But, in the 1980s, Hong Kong hardly

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had any primary healthcare to speak of, and medical officers, who were overworked in government clinics, had no time to consider prevention of chronic diseases. A stronger primary care system was desperately needed to strengthen prevention and management of chronic diseases, and to care for the elderly.18

Rising Cost of Healthcare Hong Kong continued to prosper until 1997 when it was handed over from Britain to China. Thereafter, it suffered a series of setbacks, including most notably the Asian financial crisis of 1998 and the SARS epidemic in 2003. It was not until 2006 that Hong Kong’s economy recovered fully, and, as its expenditure on healthcare continued to increase during periods of growth, the government began to fear that healthcare costs were no longer sustainable in the future with the rising cost of medical care and the increasing demand for more expensive, advanced services.19

Importance of Primary Care Another driving force for change was the 1978 Declaration of Alma-Ata, when the World Health Organization (WHO) declared that governments should give greater emphasis to primary care services as a method to improve the health of their populations.20 There is vast international data to show that the primary healthcare approach is the most efficient and cost-effective way to implement a healthcare system that produces better outcomes at a lower cost, with improved accessibility and higher user satisfaction.21 The WHO promoted the primary healthcare approach as the key to achieving the goal of “Health for All” by the year 2000.22

Primary Care Reform: Health for All To expedite healthcare reform, the government established the Working Party on Primary Health Care (WPPHC) in 1989. In December 1990, the WPPHC released a report23 which determined that the government had neglected to provide adequate healthcare services in Hong Kong, and that a clear commitment toward primary healthcare was badly needed. At the recommendations of the WPPHC, the Department of Health was

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to implement a number of programs such as a women’s health program (Chapter 7), a new student health service to replace the existing one (Chapter 9), and a senior health program (Chapter 15) focusing on health promotion for the elderly and early detection and prevention of chronic noncommunicable diseases. The WPPHC was critical of the lack of focus of the general outpatient clinics operated by the Department of Health. The staff in these clinics lacked both training in primary care and a career path. The Department of Health made a number of changes to address these deficiencies. However, while the public sector, with forty-two public hospitals, dominated secondary and tertiary care (80% to 90%), the government outpatient clinics were responsible for only 15% of all primary care in Hong Kong. Chinese medicine (CM) practitioners accounted for another 15%, and the general practitioners of Western medicine in the private sector for the remaining 70%.24 Reforms in government services would hardly affect the general practitioners in the private sector and CM practitioners. Therefore, primary care reform to include all private sector general practitioners was necessary. In addition to the WPPHC review, there were a number of reviews of the healthcare system in Hong Kong both by external and internal experts. In 1997, a team from Harvard University was invited by the Secretary for Health and Welfare to conduct a review and advise on healthcare reform. While complimenting Hong Kong’s remarkable health indices and equal access to medical care across demographic strata, the Harvard team identified a number of weaknesses, particularly the deficiency of primary care.25 Public consultations and establishment of advisory boards on healthcare reforms internally resulted in a number of reports with recommendations such as “Towards Better Health”26 in 1993, “Lifelong Investment in Health”27 in 2000, “Your Health, Your Life”28 in 2008, and “My Health, My Choice”29 in 2010. The last four government consultation papers also identified the need to reform primary care along with reform of the healthcare financing structure. The reviews recognized that the current financing system for healthcare in Hong Kong, which had so far been dependent on the taxes collected, was unsustainable and needed to be addressed. Although there were a number of challenges in improving primary care reform, one of the most pressing was the lack of physicians trained in family medicine. In an attempt to resolve this issue, the Chinese University of Hong Kong introduced undergraduate family medicine training in

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1984, and in 1986, the University of Hong Kong followed.30 Then, in 1999, the Hospital Authority (HA) began to provide hospital and communitybased training on family medicine. At the turn of the millenium, the Department of Health began to transfer the fifty-four general outpatient clinics to the HA to integrate primary and secondary healthcare services to provide continuity of care for patients, and the transfer was completed by 2003. 31 Some of these general outpatient clinics would become community-based training centers for family medicine. Another threat to the success of these healthcare reforms was the paucity of qualified family physicians to act as trainers to train family physicians. In 2006, there were only 162 fellows of the Hong Kong Academy of Medicine (Family Medicine) who were recognized as specialists by the Medical Council of Hong Kong and qualified as trainers in family medicine.32 The government and the medical field had initiated a number of changes in response to various criticisms arising from reviews of the healthcare system, taking the Harvard Report’s critique particularly seriously.33 Information on healthcare reform and primary care reform in Hong Kong can be found in more detail in other publications,34 but some of the measures related to outpatient services will be highlighted in the following section.

Disease Prevention: New Focus for GOPC and Private General Practitioners After the deadly attack of the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003, the medical community, especially the Department of Health, realized that despite excellent control of the common infectious diseases, Hong Kong was far from prepared for assaults of emerging infectious diseases of unknown etiology. After several detailed postmortem examinations of the SARS epidemic, a number of proposals were implemented to improve the preparedness for such challenges. As a result, the Centre for Health Protection was created in 2004 with a mandate to prevent and protect Hong Kong citizens not only from emerging infections, but also other medical disasters, such as the medical aftermath arising from a high magnitude earthquake. One of the projects of the Centre for Health Protection was to establish physician sentinel programs (to include both the public and

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the private sector) for surveillance of diseases. The first disease chosen for surveillance was influenza. Although the Viral Laboratory of the University of Hong Kong at the Queen Mary Hospital has been part of the sentinel global network for early detection of influenza and other viral epidemics since 1963,35 Hong Kong has no data systematically collected on the prevalence of influenza locally. There are three main types of influenza virus: A, B, and C. Influenza A viruses are the most widespread and significant, infecting many different avian and mammalian species (including humans). Influenza B and C viruses are chiefly human pathogens that rarely infect other species. In industrialized countries, vaccinations against influenza are most often given to high-risk people and farmed poultry. The vaccine of choice for use is the trivalent vaccine, containing two influenza A virus subtypes and one influenza B virus strain. A vaccine formulated for any one year may become ineffective the following year, as the influenza virions mutate constantly while replicating themselves. Scientists believe that such mutations resulted in the pandemics of 1957 and 1968.36 The surveillance programs are vital for the detection of mutant strains early and may even ward off a pandemic because Hong Kong has become an international city with hundreds of flights to different parts of the world every day. The surveillance program began in 2010 and at present consists of a network of over forty private general practitioners and sixty-four publicsentinel GOPCs. This network reports on the proportion of outpatients with influenza and influenza-like-illness (fever >38°C and cough or sore throat) on a weekly basis. Respiratory specimens, routinely collected from sentinel GOPCs and private general practitioners, are sent to the Public Health Laboratory Centre for sentinel surveillance purposes.37 The purpose of the program is to gather accurate, up-to-date data for the government to combat the influenza disease at its early stage before it turns into an epidemic. A good outcome requires planning and cannot be left to chance. Based on a similar principle, surveillance programs are being carried out on other acute communicable diseases such as acute diarrheal illness, acute conjunctivitis, and hand-foot-and-mouth disease38 on different risk groups, including child care centers/kindergartens, residential senior care homes, and the accidental and emergency departments of public hospitals.39 In this way, possible epidemics could be detected early, and timely preventive measures could be applied to avoid one.

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Efficient delivery of primary care is another important healthcare reform initiative.40 A more detailed discussion of the primary care reform, which began in early 2010s, can be found in other publications and will be only discussed in brief here. The Department of Health set up a primary care office to assume the responsibility of carrying out the following new programs related to primary care delivery: 1. The preparation of a primary care directory of doctors, paramedical personnel, and facilities.41 2. The development of practice protocols for some common chronic diseases, such as diabetes 42 and hypertension, 43 elderly44 and children care,45 and a number of other programs in collaboration with the Hospital Authority and other organizations. These protocols, also known as practice guidelines, aim at elevating the standard of primary care of the targeted population, to identify diseases early, and to treat them more effectively. 3. The development of a computerized clinical management system to coordinate and integrate all the inherent activities involved in the management of a healthcare facility, and implementation of an electronic health-record sharing system to eliminate the communication barrier between the public and private healthcare sectors, in order to more efficiently deliver care. 4. The development of collaborative projects between the Department of Health and the Hospital Authority that encourage private doctors to participate in preventive programs and health promotion in the long-term care of patients with chronic noncommunicable diseases, thereby reducing overcrowding in public outpatient clinics.46 For example, in community health centers, such as Tin Shui Wai, chronic disease patients who were in stable conditions and needed long-term follow-up treatment were allowed to receive therapy from private doctors, with fees partially subsidized by the government.47 This program would hopefully reduce the overcrowding in public GOPCs and in improving the collaboration and the sharing of information between the private and the public sector. In summary, the GOPCs, successors to the Chinese Public Dispensaries, have been providing both basic curative care and preventive healthcare for

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acute infectious diseases. Chronic noncommunicable diseases including cancers and dementia, are the pandemics of the twenty-first century. Up to the turn of the millenium, the prevention of these chronic diseases have rarely been touched on by medical practitioners in the public and the private sector, who had been providing primary care. Preventive measures for chronic noncommunicable diseases include advice on a healthy lifestyle, such as smoking cessation, regular exercises, healthy diet, and weight reduction. A good lifestyle may reduce the risk of development of chronic diseases, including cancer in many individuals. Some well-documented examples are the decrease in the incidence of lung cancer by stopping smoking, reduction of liver cancer incidence by immunization against hepatitis B early in life, and giving up excessive alcohol consumption. Well-planned screening programs are useful tools to detect early cancers before they become clinically apparent. Examples include regular cervical Pap smears for detecting early cervical cancer, mammographic examination for detecting early breast cancer, and colonoscopy for patients who are at high risk for colorectal cancer (see the box below). In Hong Kong’s current era, when chronic noncommunicable diseases are more prevalent than infectious diseases, it is imperative that all primary care doctors, public and private, take an active role in the prevention of these chronic diseases and identify and treat these diseases early before they manifest and cause morbidity. Since primary care doctors in private practice provide the lion’s share (70%) of outpatient services, there is a great deal that they can do to help lower the occurrence of these diseases, thereby easing the high cost of treating the complications and long-term disability from these diseases.

d Cancer Prevention and Screening in Primary Care Setting Another important task for primary care physicians is to initiate education on cancer prevention in high-risk patients: Finding cancer in its early, treatable stages leads to a better outcome. •

Lung cancer: smoke cessation at age 50 leads to 62% reduction in lung-cancer mortality.

•

Uterine cervical cancer: vaccination against HPV leads to 90% reduction in mortality.

•

Liver cancer from hepatitis B: vaccination against hepatitis B virus or treatment with anti-viral drugs of the infected leads to 90% reduction in mortality.

•

Liver cancer from hepatitis C: treatment with antiviral drugs.

•

Colorectal cancer: early diagnosis by screening program for occult blood in stool and colonoscopy for high-risk patients.

•

Breast cancer: regular self-examination and mammography; treatment with selective estrogen-receptor modulators reduces incidence of breast cancer by 50% among high-risk women; and prophylactic salpingo-oophorectomy reduces the risk of breast and ovarian cancer in women with a BRCA1/2 mutation.

•

Skin cancer and melanoma: protect oneself from the midday sun, use of sunscreen, and avoidance of tanning beds and sunlamps.

•

Stomach cancer: eradication of H. pylori infection. d

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7. Midwifery Service: From Antiquity to Modernity

Pre–World War II Maternity Service One fine morning in 1923, Dr. Chau Wai-cheung, the Medical Officer at Tai Po Dispensary, was awoken by a telephone call from the police station asking him to attend an urgent midwifery case. After a quick breakfast, he left home hurrying to the train station hoping to catch the first train to Sheung Shui. Following a two-and-a-half-hour journey, first on foot, then by carriage, and finally on a sedan chair, he arrived at the patient’s home. He was greeted at the door by the midwife who had sent for urgent help after visiting the patient. Dr. Chau wrote of the experience: When I got into the patient’s house, which was merely a small hut and dirty, hardly anything better that [sic, than] a pig-sty, we were invited to go into the house. We had to stoop down before we could step in, and the ground was found to be thickly covered with mud, mixed with excreta of fowls and pigs. I asked to be shown to the patient’s apartment, whereupon I was ushered into a small compact cubicle just big enough to accommodate two persons and not more than two…. It was absolutely pitch dark, and nothing whatever [sic, whatsoever] could be seen…. soon afterwards a joss-stick was lighted and brought into the room. I could see my patient with difficulty lying on a bed made of two wooden planks. The floor had a pool of coagulated blood on it and the beddings were all soiled. … She was about 35 years old, a multipara, this being the sixth labor. Only two out of five children were living.… The patient gave birth three days ago and [the baby] was alive and well, but the placenta refused to come out. The placenta remained in the uterus for three days before they thought of sending for a doctor….1

7. Midwifery Service

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The doctor made a makeshift bed in the main room, which was also small and filthy, and proceded to move the patient out of the dingy cubicle to the makeshift bed where he carried out a vaginal examiation with aseptic technique as much as possible, administering chloroform before dilating her cervix slowly. He then manually separated the placenta from the uterine wall and removed it from the uterus. After she recovered from the anesthesia, he gave her instructions to contact him without delay if she developed a fever. Dr. Chau never saw the patient again because she made a miraculous full recovery. The patient was very fortunate. She could easily die from massive bleeding and/or sepsis, the two most common causes of death for women from giving birth. This case exemplified the situation of some women in labor in the New Territories in those days. The vast majority of Chinese women were uneducated and had their confinement at home attended by wan pos who had no idea what infection was or what caused it. Septicemia was common and a major cause of maternal deaths. Wan pos, the traditional Chinese midwives who had no formal training, learned the tricks of the trade from older wan pos through shadowing and aiding them.2 In the 1920s, the service of a trained midwife was obtainable from most of the Chinese villages around Hong Kong, if the woman’s relative had sufficient faith in modern medicine to send for her. Only when the woman was moribund would she be sent to the hospital as a last resort.

High Maternal Mortality In the old days, having a child was a risky affair for a woman in any part of the world. The estimated maternal mortality in England for 1,000 births was roughly 10.5 from 1700 to 1750, 7.5 from 1750 to 1800, and 5 from 1800 to 1850.3 The mother could die from puerperal fever, severe bleeding, or convulsions due to toxemia.4 Even if she survived the ordeal of childbirth, she could easily lose her baby during its first year of life. Dr. Chau’s patient is representative of the disheartening statistic of two children surviving out of five births during that time. Women’s health in those days received very little attention from the government or the public, as women’s diseases were, to a large extent, synonymous with venereal dseases at that time. Despite high maternal mortality, nothing much was done. Most Chinese doctors were men, and

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Chinese women were shy about their problems that they did not confess all their symptoms, particularly those related to the reproductive cycle. During a consultation with a male doctor, an adult male member of the family had to be present because the woman could not be left alone with the doctor, and she would stay hidden behind curtains and screens. For examination, the doctor was allowed to do only pulse taking. In most cases, the Chinese doctor would give his female patient a small ivory figure and ask her to point to the “seat of pain.” Because the Chinese were highly skeptical of Western medicine then, and Chinese women feared Western doctors, no Chinese complained about the lack of medical services provided by the government. The Chinese Hospital, Tung Wah, founded in 1872, practiced only traditional Chinese medicine, and the hospital did not offer beds for confinement. The Alice Memorial Hospital on Hollywood Road, founded in 1887 by the London Missionary, was marginally better.5 Although it had a ward of nineteen beds for women, few were admitted for confinement. To address the mounting overcrowding following the opening of Alice Memorial, the Nethersole Hospital on Breezy Path was built with funds donated by Mr. Davis, a member of the Medical Missionary Society. Opened in September 1893, Nethersole had thirty-five beds for women and children, and the Alice Memorial Hospital became a men-only facility. The Nethersole Hospital was the only hospital practicing Western medicine for Chinese women and children.6 Additionally, in 1890, Dr. P. B. C. Ayres, the colonial surgeon, introduced confinement beds in the Government Civil Hospital and hired a Chinese nurse trained in the Western method of delivery. He noted that Chinese women were often admitted in dying conditions, reluctant to go to hospital until they were at death’s door.7

High Infant Mortality and Midwifery Service In Hong Kong, infant mortality among Chinese was strikingly high compared with Europeans, as evidenced by the dismal rates of mortality in the late 1800s. In 1885, 31% of all deaths were infants under the age of one.8 Infant mortality in Europe ranged from 100 to 250 per 1,000 live births at that time, while among the Chinese it was incredibly high, varying from 600 to 900 per 1,000 live births.9 Remarking on the frequency of infant deaths and troubled by the strikingly disparate

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rates of mortality between Chinese and Europeans in Hong Kong, Dr. Francis Clark, the hard-working and conscientious first Medical Officer of Health, wanted to improve infant mortality among the Chinese. However, accurate data on births and deaths were not available in Hong Kong at that time because, even though the Colonial Office had pressed for such data, the colonial administration of Hong Kong was reluctant to push for this agenda for fear of arousing suspicions among the Chinese, who had defied any type of registration.10 Many Chinese did not register a birth for fear of taxation, and if they registered at all, it was usually for a male, and not a female birth. Since death must be registered before a death certificate was issued for burial, when a death occurred without a corresponding birth, a falsely higher infant mortality resulted, obscuring the statistics.11 Even though he recognized false statistics were partly responsible for the high infant mortality rate, Clark pointed his finger at the wan pos, who knew nothing about sepsis and were the source of the problem, therefore, responsible for the high infant mortality. In 1895, he recommended the registration of wan pos in Hong Kong, but his recommendation was rejected by the Legislative Council because Chinese legislators thought that it was too premature to regulate Chinese midwives.12 Clark did not give up. In 1900, he noted that the mortality of Chinese infants reached 928 per 1,000 live births. Even though this incredibly high rate was most likely due to unregistered births, Clark blamed Chinese parents for their neglect and raised the horrible specter of possible infanticide, especially for baby girls.13 Once the story was caught by the British press, the colonial government was under pressure to act.14 In 1903, the Secretary of State for the Colonies requested an inquiry into the cause of high infant mortality in Hong Kong, which resulted in a report with a series of recommendations: education of mothers on basic hygiene, registration of births and deaths, and training of Chinese midwives in the Western method of delivery to reduce sepsis and bleeding.15 The training of the first batch of six Chinese midwives was finally launched the following year in the midwives training institute of the Alice Memorial Maternity Hospital. The success of the program can be attributed entirely to Dr. Alice Sibree, who arrived from London to take up the position in the Alice Memorial Maternity Hospital, which was scheduled to open that year.

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The Changing Paradigm of Maternal Care: The Work of a Female Doctor Chinese women had so far refused to go into hospital for their confinement, and they were reluctant to be seen by male doctors when they were sick. It was Dr. Alice Sibree, a female doctor, sent by the London Missionary Society to the Alice Memorial Maternity Hospital, who helped change Chinese women’s attitude toward Western midwifery practice. After spending her first year learning to speak the local language, Sibree mastered the difficult dialect of Cantonese. Being the first missionary doctor to communicate fluently with the Chinese patients, she won the respect of the Chinese community. She was welcomed into the homes of the Chinese, rich and poor alike.16 Dr. Sibree’s success demonstrates the importance of quality doctor-patient rapport, especially when it comes to women’s health issues. Her identity as a woman undoubtedly made her patients feel safer and more at ease when discussing their personal issues, and her dedication to Cantonese language acquisition is a testament to the value of communication in the medical space. Dr. Sibree was the attending staff of the Alice Memorial Maternity Hospital and was responsible for training the midwives in the institute. It was forbidden for women to take up the role of physician at that time. Women had been denied access to clinical training in many universities in England even in the 1870s. Dr. Sibree encountered considerable difficulties with the superintendent of the Alice Memorial Hospital.17 After she completed her five-year contract with the London Missionary Society, Dr. Sibree went back to England. On her return to Hong Kong, contrary to expectation, she started her own private practice instead of joining the staff of Alice Memorial Maternity Hospital. Known as Dr. Hickling after her marriage, she continued her role of training midwives at the institute. In 1919, she was invited to supervise Wan Chai Maternity Hospital, which was converted from the Eastern District Plague Hospital. In 1922, when Tsan Yuk Hospital opened, Dr. Hickling became its consultant.18 Dr. Hickling trained almost all the Chinese midwives during that period. When they graduated, some were employed by the government to work in the Chinese Public Dispensaries and some in the government clinics in the New Territories. Dr. Hickling became their supervisor,19 and introduced a program to teach mothers some basic hygiene and how to care and feed their infants after delivery.20 Her contributions did not

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end here as she later established infant centers within hospitals. Indeed, Dr. Hickling was the founder of modern day maternal and child health service in Hong Kong (see Chapter 8).

Birth of Modern Midwifery Towards the end of the nineteenth century, traditional gender roles began to break down. Women’s issues were becoming increasingly important in the public’s consciousness, even in China, where prior to the twentieth century, Confucian doctrines had relegated women to an inferior role, exiling them to the household. The birth of the Republic of China brought about changing social values. Meanwhile, thousands of missionaries, who had come to China after the First Opium War with the opening of treaty ports, despite having made little progress with their Christian conversion agenda, still greatly influenced Chinese cultural attitudes toward women. They saw education of girls and abolition of foot-binding as the key to emancipation of women in China, forming antifoot-binding societies to eradicate a practice that kept women completely under the control of men,21 and fought alongside Chinese Christians in the anti–mui tsai movement (see Chapter 14). Dr. Alice Sibree provided the vital impetus for modernization of medical services for women in Hong Kong by demonstrating to Chinese women the effectiveness of the Western method of delivery and care for babies. She trained a cadre of midwives to follow her example, thereby reducing infant mortality and female morbidity and mortality arising from child birth. In 1910, Dr. Francis Clark’s recommendation for registration of midwives was finally passed. The Midwives Ordinance was enacted, stipulating, “No one whose name is not on the Midwives Registrar may practice midwifery habitually for gain or describe herself as one specially qualified to carry on the work of a midwife.”22 The Hong Kong Midwives Board was formed, which was the statutory body governing the training and examination of midwives, their registration, and practices. As the demand for Chinese midwives grew, in 1911, a new training institute for nurses and midwives was established in the Alice Memorial Maternity Hospital.23 Initially, only Alice Memorial Maternity Hospital and Government Civil Hospital had training programs for midwives. The opening of Tsan Yuk Hospital in 1922 (Figure 7.1) offered the third training program.

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By 1929, two Chinese hospitals, Tung Wah and Kwong Wah Hospitals, also provided training programs, thereby increasing the number of trained midwives. In 1928, there were 183 registered midwives; by 1937, the number increased to 395. The growing number of formallytrained midwives caused the traditional Chinese midwives, wan pos, to lose their share of the market. They were permitted by the government to practice until 1937, at which time it became illegal for them to continue without registration. By 1938, the total number of registered midwives climbed to 765 when 370 wan pos signed up after training.24 By 1941, traditional freelance midwives could no longer practice in Hong Kong. Figure 7.1 Opening of old Tsan Yuk Hospital on 17 October 1922. Dr. Alice Hickling was standing on the right of Mrs. Hallifax who was seated

Wikimedia Commons photo

Midwifery Service in Government Dispensaries and Clinics Since 1906, the government had been sending trained midwives to work at some of the Chinese Public Dispensaries (CPDs)—Western District, Eastern District, Shau Kei Wan, and Kowloon City dispensaries—where women in the neighborhood could apply through the licentiate doctor incharge of domiciliary delivery (see Chapter 2).

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In 1916, the government began to send one trained Chinese midwife each to Tai Po and Yuen Long clinics to attend home deliveries. In 1917, midwifery service was extended to Tsuen Wan and in 1918, Cheung Chau. By 1939, the midwives program expanded to twelve stations, comprising six Chinese Public Dispensaries (Shau Kei Wan, Yau Ma Tei, Aberdeen, Kowloon City, Stanley, and Sham Shui Po) and six government clinics in the New Territories (Ho Tung Welfare Centre, Sham Tseng, Sai Kung, Tai Po, Yuen Long, and Tai O), and employing a total of sixteen midwives. The total number of confinements attended by these midwives between 1916 and 1939 are shown in Figure 7.2. In addition to attending confinements, the midwives gave advice to mothers on hygiene, baby feeding, and care before and after delivery.25 Figure 7.2 Total no. of deliveries per year attended to by government midwives in Hong Kong, Kowloon, and the New Territories, 1916 to 1939

Source: Hong Kong Medical and Sanitary Report for the years 1916 to 1939

Further Modernization: Hospital Deliveries The story of how CPDs nurtured two maternity hospitals has been told before in other medical histories.26 To summarize, in 1919, the Wan Chai Maternity Hospital, the first maternity hospital in Hong Kong, was converted from the Eastern District Plague Hospital when no plague patients were admitted. Dr. Ho Ko-tsun, the licentiate in charge of the Eastern District Dispensary, was responsible for the Eastern District Maternity Hospital while Dr. Alice Hickling became the supervisor at the request of Dr. Tso Seen-wan, member of the Central CPD Committee. The success

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of the Wan Chai Maternity Hospital led Dr. Tso Seen-wan to plan building a maternity hospital in the Western district, which was densely populated. He raised funds from the local community to help finance building the hospital, Tsan Yuk Hospital. Its location was strategically selected on a lot close to the Western District Dispensary, instead of converting the Western Plague Hospital into a maternity hospital, which was far too small for the amount of work anticipated. In 1922, Tsan Yuk Hospital was opened, and was the first hospital staffed by Chinese doctors and nurses. Dr. Tso invited Dr. Hickling as its consultant. The hospital served all women in the Western District and became an instant success in the community. Dr. Hickling initiated a number of new services in Tsan Yuk Hospital, namely: 1) antenatal clinics, emphasizing the importance for check-ups before delivery to identify abnormalities early; 2) venereal disease clinics, 3) gynecology clinics, and 4) infant welfare centers.27 All these services proved to be invaluable to the welfare of women and children, because now, their health (both mothers’ and babies’) was being tended to by a female doctor. The infant center was the forerunner of future maternal and child health centers. When Tsan Yuk Hospital had grown too large for a voluntary agency to operate, the government realized its importance and agreed to take over the hospital in 1932. The hospital eventually turned into a university teaching center where all future specialists in gynecology and obstetrics in Hong Kong received their training, and where the low maternal and infant mortalities served as benchmarks against which future outcomes of all other hospitals in Hong Kong would be compared. By 1936, there were altogether 337 maternity beds in various hospitals in Hong Kong (government, Chinese charitable, and private hospitals).28 More deliveries took place in hospital settings as Chinese women came to appreciate the value of the Western method of delivery and the safety of deliveries in maternity homes and hospitals. Chinese women were completely converted, totally embracing Western medicine, an important milestone in the acceptance of Western medicine as the mainstream medicine in Hong Kong.

The Era of Midwives, 1946 to 1973 As previously discussed, after WWII, CPDs were reopened as government outpatient clinics. Some with maternity beds were still

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quite dilapidated and unhygienic, and some were without latrines, electricity, and water. The problems were eventually fixed one by one so that the clinics could start functioning. During 1946, both maternal and infant mortality were still high, similar to prewar levels. By the early 1970s, both maternal and infant mortality had dropped markedly due to wide availability of antibiotics, reaching the levels expected of a highincome country. At present, Hong Kong has one of the lowest maternal mortality and infant mortality (Figure 7.3) rates globally. How did Hong Kong achieve this miracle? The postwar baby boom began soon after residents returned from the Mainland after the war. There was a great need for facilities for delivering babies. In those days, babies were delivered in four settings: 1) in a hospital by doctors in the private or public system; 2) in government centers/clinics; 3) in private maternity homes, or 4) in women’s homes by midwives. When encountering any complication, the midwives sent their patients to hospitals. Figure 7.3 Infant mortality and maternal mortality in Hong Kong, 1946 to 2015

Note: Infant mortality—solid line (no./1,000 live birth); maternal mortality—dashed line (no./1,000 births). Source: Hong Kong Medical and Health Department Annual Reports 1946 to 1977; Hong Kong Annual Digest of Statistics 1978 to 2015.

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Tsan Yuk Hospital was the first hospital to reopen after the war. Later, all three Chinese hospitals and the Eastern Maternity Hospital quickly followed suit. The maternity wards of these hospitals flourished with mothers in labor. In time, Queen Mary Hospital, Kowloon Hospital, and other hospitals also reopened their maternity wards one by one. As government outpatient clinics and dispensaries restarted, government midwives also resumed their work attending domiciliary confinements. In 1946, there were fourteen government clinics with maternity services29 and eighty-eight registered private maternity homes (forty-five in Hong Kong, forty in Kowloon, and three in Cheung Chau, but three closed down voluntarily later).30 In 1946, there were 618 registered midwives, but not all of them were actively practicing. To satisfy the demand for midwives, the Hong Kong Midwives Board held certificate examinations in January, April, July, and October of that year to increase the number of eligible midwives in the community. Gradually, more hospitals resumed their training program for midwives. In 1946, the total number of births in Hong Kong were 31,098, which rapidly rose to 42,473 and 47,475 in the following two years. This baby boom persisted during the first two decades postwar. Figure 7.4 shows that the steep rise in the number of births peaked around 1963 and thereafter began its protracted decline. As the city’s manufacturing industry thrived, female labor was very much in demand. From 1961 to 1971, women’s participation in the labor force, particularly those of the reproductive age, climbed from 39% to 46% to supplement the income of the family for a better living.31 Women were marrying later in life and wanted fewer children. Effective birth control measures were also available through the Family Planning Association. Figure 7.4 also shows that in the 1950s and early 1960s, midwives (government and private) together delivered about half of all the babies in Hong Kong. The remaining were delivered in hospitals, and only a very small number of deliveries were carried out at home. It is not difficult to understand why women, who could afford private maternity homes, would choose them for their confinement rather than public hospitals. Maternity beds in public hospitals were usually reserved for those with complications of pregnancy. Some hospitals were so crowded that sometimes two patients shared a bed—a most unhygienic practice.32

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Figure 7.4 Total number of births, and births delivered by private and government midwives, 1949 to 1973

Source: Data obtained from Medical and Health Department Annual Reports 1949 to 1973.

From 1950 to the mid-1960s, deliveries by private midwives in maternity homes or domiciliary settings were highly popular among Chinese women. These maternity homes were small with two to seven beds.33 The supervisor of midwives regularly visited private maternity homes to ensure that the sanitary rules and regulations were followed and the deliveries were carried out properly. Midwives who failed to satisfy the supervisor would be required to take a course of retraining.34 The number of private midwives climbed to over 200 in 1963; thereafter, it drifted downward to below 100 in the 1970s and approached zero in 1988. The caseload for government midwives was high, averaging over 500 deliveries per midwife in 1949, but it dropped rapidly as more midwives entered government service (Figure 7.5). As their caseload lightened, government midwives were assigned extra duties such as conducting antenatal and postnatal examination and supervision of women during pregnancy.

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Figure 7.5 Caseload per year of government and private midwives, 1949 to 1999

Source: Hong Kong Medical and Health Department Annual Reports 1949 to 1980; Hong Kong Annual Digest of Statistics, 1981 to 2000.

The 1950s and 1960s were the heydays for private midwives, and in 1963, they were responsible for 40% of all births in Hong Kong. There were a few well-known midwives at that time: Wong Suet-hing and Mrs. Poon-Wong, who was the grandmother of the first trained cardiologist in Hong Kong, Dr. Joseph Pan Yin-chi. Thereafter, the total number of births declined, as did the number of deliveries by private midwives. Government midwives showed a similar decline in their caseload, and in the end, hospital deliveries became the norm. As hospital services expanded after the 1980s, more women turned to hospitals for their confinement, where immediate help could be obtained in case of emergencies. For the increasing number of mothers-to-be, safety was the main concern for themselves and for their babies. For the poor, free hospital service was attractive.35

Figure 7.6 Wong Suet-hing

Photograph courtesy of Mr. Thomas Wong; picture retaken by the author in 2019 d Wong Suet-hing (1876/1877–1978/1979), also known as Wong Ye-gu, was the most celebrated private midwife before and after the WWII in Hong Kong, having delivered hundreds of babies in her lifetime. She outlived (over 100 years) many individuals whom she delivered. A devoted Christian, she donated most of her estate to St. Paul’s Church. She passed away at the age of 101 and was survived by two adopted daughters, who followed her footsteps to become dedicated midwives. (Personal communication from her great grandson, Mr. Thomas Wong.) d

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Hospital Deliveries and Revival of Midwifery, 1980s to the Present After the 1970s, institutionalized childbirth became the model of maternity care. The growing appreciation for skilled attention readily available in a hospital setting resulted in the closure of maternity beds in clinics and dispensaries. In the private sector, the number of midwives and their workload also fell rapidly so that by 1988, the last private maternity home ceased to operate and there were no more midwives in private practice. The three remaining government maternity homes changed their role to serve multiparous women with normal pregnancy as part of the obstetrical team of a hospital. The maternity homes were also used as postnatal wards for women who were discharged early from the hospital after delivery to relieve the pressure on hospital beds. With rapid advances in medical technologies, such as electronic fetal monitoring, a highly technical system of childbirth was developed in the hospitals. All patients were under the care of obstetricians. The government midwives were transferred from clinics and dispensaries to the hospital and acted more like obstetric nurses, except they personally conducted deliveries of normal cases. Postpartum stay in hospital was limited to one to two days. With the shortened stay in the postpartum ward, it was very difficult for midwives to provide proper health education on baby care and self-care, not to mention the assessment of the mothers’ emotional state. Mothers were encouraged to take their babies to the maternal and child health centers (MCHC) to learn about self-care and baby care and get advice.36 In the last two decades, however, the role of midwives has gradually expanded as a result of the worldwide feminist movement, giving women more options and better control over their bodies. Many women have been critical of hospital obstetric care for its impersonal approach, high fees, and the propensity to use drugs and surgery, in particular the use of Caesarean section in delivery. Nurse-midwifery has been recognized as the best for normal, low-risk pregnancies, a category to which most pregnant women belong. An independent nurse-midwifery practice started in the Prince of Wales Hospital, and soon other hospitals came up with similar programs.37 At present, midwives conduct antenatal classes in obstetric units of hospitals and in MCHCs, and they also give health talks in postnatal wards. Midwives are also on-call through telephone hotlines in maternity units

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to allow mothers to seek advice on health problems and on baby care. Breast-feeding clinics, staffed by midwives who are lactation consultants, have been running since 1996 at Queen Elizabeth Hospital and at other maternal and child health centers to provide support, counseling, and advice for nursing mothers. Midwives have become proficient in a number of technical skills, such as performing cardiotocography, perineal suturing, and ultrasonography. Moreover, they are required to be sensitive and respectful to the emotional state of the women and mothers and be able to provide counseling to them. In Hong Kong, the role of midwives has been transformed from those of wan pos, which did not need formal medical education, to a highly skilled professional of today which requires a basic training of 18 months.

8. Maternal and Child Health and Family Health Service: Healthy Mothers, Healthy Babies Before the twentieth century, although infant mortality was high in most parts of the world, the rate of infant mortality in Hong Kong was among the highest. In Europe, infant mortality ranged from 100 to 250 per 1,000 live births, while in Hong Kong, the rates among the Chinese were strikingly higher compared with the Europeans. As indicated in the last chapter, 31% of all deaths among the Chinese in 1885 were infants under the age of one, while among the Europeans, infants deaths accounted for only 9.9% of the mortality rate.1 These remarkably disparate mortality rates can partially be attributed to Hong Kong’s birth and death registration system, or lack thereof, at the time. Accurate data on births and deaths in Hong Kong simply were not available, and even though the Colonial Office had requested such data as early as 1867, the colonial administration was cautious about pushing for birth and death registration for fear of arousing suspicion among the Chinese, who had defied any type of registration up to then, that the information would be used for taxation purpose.2 At the same time, the government had been reluctant to spend money to set up the infrastructure for registration

Infant Mortality before World War II The Foundling Scandal The high infant and maternal mortality rates would have remained unchanged if not for the foundling scandal that rocked Hong Kong in the late-nineteenth century. In November 1886, J. H. Stewart Lockhart, the acting Registrar General, found that infant deaths from the two local convents in Hong Kong, one French and one Italian, were shockingly high; an average of 92.5% and 79.8% respectively from 1880 to September 1886.3 Dr. W. Hartigan, who investigated the problem for the Sanitary

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Superintendent, found that the majority of deaths were caused by convulsion due to tetanus infection (tetanus neonatorum). Other common causes were fever, “consumption” (tuberculosis), and diarrhea. Hartigan’s account of the conditions of the Tai Ping Shan area where the infants came from describes the horrific and filthy environment in which they were kept: … Anyone who has visited the Chinese dwellings in that locality will know the abominable state of dirt, want of ventilation and overcrowding in which the natives live…. Always filthy, generally puny, their cloths saturated with soil and stinking; their bodies emitting a horribly fetid odor, which is without exaggeration … overpowering; their eyes filled with purulent discharge, their foreheads, cheeks and abdomen seared with the cauterizing rash; the umbilicus, if attached, smelling foully and bathed in fetid pus, or if detached, giving out a dirty graying purulent discharge; the genitals and anus inflamed and most with muco-pus, whilst eczematous eruption spreads over the nates….4 Hartigan continued to report on the cramped quarters of convents. The wards were ill ventilated, too cold in the winter, and suffocating in the summer. An overpowering odor arose from the cots, where several infants would be lumped together. In the orphanage, the children were exposed to unhygienic conditions almost as bad as the ones they had been rescued from, not through any fault of the nuns, but because of lack of resources. Some infants, mostly female, were already dead by the time they were brought in; others, half dead, died shortly afterwards. Two other doctors testified that the infants they examined were malnourished to the brink of death and were virtually hopeless cases. Even though the low survival rate of 10% of infants in orphanages was comparable to those of infants in European orphanages,5 these dismal numbers still were the ultimate wake-up call. In the end, the investigation cleared the convent sisters of all suspicion of wrongdoing, however this incident highlighted the high infant mortality rates due to lack of resources, and also raised the specter of female infanticide—an association that Westerners frequently made with Chinese culture at that time, as the percent of females was always much higher than males among infants sent to the convents.

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Tetanus, the Baby Killer In 1903, a commission was ordered by Governor Henry Blake to determine the cause of high infant mortality among the Chinese. The commission reported that as high as 50% of the infants died of trismus or lockjaw, caused by tetanus infection as a result of the ancient tradition of applying a sealingcord powder to the umbilicus of newborns.6 (In China in the 1920s, 50% to 70% of all infant mortality could be attributed to tetanus.7) Another 40% of infants died of malnutrition, and the rest from infections. Mothers did not understand the importance of breastfeeding or feeding infants in a hygienic way. For example, mothers often chewed their babies’ food themselves and passed the chewed food into their babies mouths. To combat the issue of registration of births and deaths, plus the problem of education of mothers, the committee recommended a proper registry of births and deaths of infants and education of mothers on basic hygiene and infant feeding and to dispel their ignorance and superstition.8 In addition, the Committee proposed training of Chinese midwives in the Western method of delivery to enable the midwives to attend labor in the homes.9 The training of the first batch of six Chinese midwives was finally launched the following year. The registration of midwives began in 1910. 10 As the demand for Chinese midwives grew, in 1911, a training institute for nurses and midwives was established at the Alice Memorial Maternity Hospital.11 The training and registration of midwives improved the standard of deliveries and reduced both maternal and infant mortality.

Dr. Alice Sibree and the Founding of Infant Centers As stated in the preceding chapters, Chinese women remained skeptical of and distrusted Western medicine, with Dr. Chau’s patient in the last chapter being a classic example. Women continued to avoid hospital for their confinement and also refused to be seen by male doctors. It was Dr. Alice Sibree, a lady doctor sent by the London Missionary Society to the Alice Memorial Maternity Hospital in 1904, who changed the attitude of the Chinese women on using the Western method of delivery in Hong Kong. Dr. Sibree, with her ability to speak Cantonese, the dialect of the local people, gained the trust of the local Chinese, rich and poor alike.12 She attended the patients admitted to the Alice Memorial Maternity Hospital and trained the students to become competent midwives.

Figure 8.1 A package of sealing-cord powder

Reproduced with permission from Hong Kong Museum of Medical Sciences Society, donated by Mr. Keith Poon. d The sealing-cord powder was used to “seal” the umbilical cord of a newborn—an ancient Chinese custom. It was made from burnt ash of red cotton cloth, finely ground cow’s dung or human hair, rouge and dragon bones, but more common ingredients were earth or manure—a good culture medium for bacteria, including the tetanus bacteria. The infants developed convulsion from tetanus (tetanus neonatorum) and died from trismus or lockjaw. d

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Furthermore, she supervised all graduated midwives in the dispensaries and clinics in Hong Kong, Kowloon, and the New Territories to ensure their work was up to standard. When the Wan Chai Maternity Hospital and Tsan Yuk Hospital were opened, she responded to Dr. Tso Seenwan’s request to be the consultant of these two maternity hospitals. As her crowning achievement, she initiated a health education program for mothers after delivery, teaching them basic hygiene, nutrition, and general care for babies. She established an infant center in Tsan Yuk Hospital, the forerunner of Maternal and Child Health Centres (MCHCs) to care for babies up to two years of age. Dr. Alice Sibree should be remembered as a pioneer in maternal and infant care in Hong Kong.

Infant Welfare Centers before World War II: Forerunners of Maternal and Child Health Centers Pediatrics was not recognized as a clinical specialty in Hong Kong until after the Second World War, and children and their parents generally received treatment from the same traditional Chinese medicine practitioners even up to the early part of the twentieth century. Not only was infant mortality high, but also few infants who survived their first year of life, reached adulthood due to the high prevalence of infectious diseases such as pneumonia, diarrhea, dysentery, and epidemics of smallpox and cholera. The poor health situation was exacerbated by the lack of knowledge on personal hygiene and miserable environmental sanitation. Even though Tsan Yuk Hospital, Tung Wah Hospital, and the Alice Memorial Hospital maintained antenatal and infant welfare clinics, there was no outpatient program to care for infants, toddlers, and children.13 The government realized the need for such outpatient services. From 1930 to 1940, five such health centers appeared: the “Baby Clinic” at Lockhart Road, Wan Chai; Tsim Sha Tsui Infant Health Centre at Nathan Road, Kowloon; Ho Tung Welfare Centre in Fan Ling/Sheung Shui; Violet Peel Health Centre at Wan Chai; and lastly, Sai Ying Pun Infant Health Centre in the Western District. The “Baby Clinic” located at Lockhart Road, the first infant welfare center, was inaugurated in 1932 by the government.14 The clinic was established to reduce high infant mortality and to improve the health of infants. The waiting room was decorated with posters on the walls giving

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instructions to mothers on the care of their children, the importance of daily baths, giving nourishing food and fresh air and the dangers of kissing children on the lips and chewing their food for them. In the adjoining room, the babies were undressed carefully and washed and prepared for a thorough examination by a medical officer. The doctor’s consultation room and the treatment room occupied the rest of the space. Sick babies were often kept in the clinic for a whole day on the second floor where there were five cots. Changes in clinical condition were carefully noted by the doctor and treated accordingly. The staff consisted of one lady medical officer, one each of Chinese nurse, interpreter, dispenser, and amah. The total number of infants that came under supervision during the first 8 months of the clinic’s existence was 767 with a total attendance of 4,321. Common conditions treated included conjunctivitis, bronchitis, gastroenteritis, multiple boils, impetigo, thrush, congenital syphilis, rickets, and bronchopneumonia. Seriously ill infants were sent to the hospital for treatment.15 The infant health center also offered smallpox vaccination and anti-cholera inoculation. A wellequipped dispensary was attached to the clinic. The instant success of the first infant health center bred a second one in 1934. Situated on the ground floor of 225, Nathan Road, Kowloon, a residential building, the center attended 14,041 infants in 1935, compared with 20,185 in Wan Chai Clinic in the same year.16 Another infant center opened in Sai Ying Pun in 1939. The work of the infant health center in Wan Chai attracted the attention of two influential ladies, Lady Margaret Ho Tung and Lady Violet Peel. Visits of the clinic by these two high-profile women highlighted the importance of the “Baby Clinic” and led to the founding of the Lady Ho Tung Welfare Centre in 1934 and the Violet Peel Infant Health Centre in 1935. The Lady Ho Tung Welfare Centre was already discussed in Chapter 4. The Violet Peel Health Centre (Figure 8.2), opened in May 1935 and designed by Chau Iu-nin, architect, in Art Deco style. The two-storey building was situated at the junction of Johnston Road and O’Brien Road, adjoining the Southorn Children’s Playground. The ground floor contained a waiting room, demonstration room, dispensary, examination room, and office while on the first floor, a dormitory and offices for medical officers.17 The Violet Peel Health Centre continued to serve the people of the Wan Chai community after the Second World War.18

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Figure 8.2 Violet Peel Health Centre in Wan Chai

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1939, M34.

Although the published infant mortality rates between 1935 and 1939 fluctuated between 316 and 376 per 1,000 live births—much lower than 800 to 900 per 1,000 live births reported in the 1900s19––it is difficult to tell whether their decline was the result of greater compliance to birth registration or a true reduction of infant mortality, or both. The eagerness with which Chinese women sought their confinement under the care of government midwives or private midwives trained in Western methods— a departure from the practice before—and the high rate of attendances at the infant welfare centers probably contributed to the reduced maternal and infant mortality during this period before the Second World War.

Maternal and Child Health Centers (MCHC), 1946 to 1973 In 1946, the three infant centers that existed before the Second World War reopened: Tsim Sha Tsui Health Centre, Sai Ying Pun Health Centre, and the Wan Chai Health Centre, the latter having been occupied by the Japanese Maijima Hospital during the war. In June of that year, Wan Chai Health Centre was moved to the Harcourt Health Centre. The infant health centers

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performed antenatal, neonatal, and gynaecological work on mothers, along with teaching mothers on caring for babies up to two years of age. In 1946, the infant centers were renamed Maternal and Child Health Centres (MCHC) to reflect the true nature of their work, looking after both mothers and infants.20 In 1956, five main MCHCs expanded their work and began to offer “Toddlers’ Clinics” for children between two to five years of age.21

Antenatal and Postnatal Care The total attendance for antenatal and postnatal examinations for women were low immediately after the war, with only one to two antenatal visits and one for postnatal visit for each mother, despite the marked increase in attendance of infants at the MCHC (Figure 8.3). For women attending MCHC for antenatal examinations, a sample of blood was taken for Kahn test (to detect syphilis infection). At least 6% of pregnant women were found to be suffering unknowingly from syphilis, which could seriously threatened the life and health of the prospective child if left untreated.22 Gradually, more and more women recognized the importance of attending antenatal clinics for detecting syphilis and for identifying eclampsia (toxemia of pregnancy with high blood pressure), high blood sugar, and abnormal positioning of the fetus. In the 1960s, the number of antenatal clinic visits of each expectant mother increased to about four times.23 The attendance of postnatal care visits, however, remained low.24 Figure 8.3 Number of new antenatal, postnatal, and child attendances in MCHC, 1956 to 1973

Source: Hong Kong Medical and Health Department Report for Years 1956 to 1973

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Mother and Baby Nutrition During 1946, 66,603 babies attended the three MCHCs of which only about one-fifth were considered healthy. Nutritional disorders were by far the most common problem followed by respiratory conditions of which acute bronchitis was the most prevalent, then by diseases of the digestive system such as diarrhea and skin disorders, notably multiple boils. Nutritious meals were offered to mothers in the clinic and a free issue of milk for the babies. The Society for the Protection of Children provided evaporated milk and dried milk powder sold at cost to the needy mothers with babies.25 In 1946/47, the government appointed a committee to investigate into the causes of infant mortality. The committee found that the main killing diseases were, in descending order, bronchopneumonia, gastroenteritis, and prematurity. Other diseases often encountered were tuberculosis, childhood infectious diseases, and congenital syphilis. Overcrowding, harmful superstitious ancient Chinese customs, some Chinese herbs, improper feeding, and malnutrition were important culprits. The committee recommended education of mothers, improvement of feeding, provision of antenatal care, and taking infants to infant welfare centers whenever needed. Another important recommendation was to treat tuberculosis as a notifiable disease seriously; patients suffering from active tuberculosis would require isolation and treatment. Unfortunately effective drugs for treatment of tuberculosis were only widely available in the 1950s. At that time tuberculosis was responsible for 10% to 20% of all deaths; in children, tuberculous meningitis ranked as a major killer.26 Hong Kong’s economic plight and its massive problems arising from deluge of refugees from the Mainland after World War II attracted international attention, most notably, a number of international charitable organizations that sent donations, in cash or in kind such as milk, food, drugs, and technical help. The Maternal and Child Health Team of the World Health Organization (WHO) gave valuable advice and assistance to the Hong Kong programs. For a period of three years, they distributed food supplements, mainly milk and baby food, to nursing mothers and infants. Skimmed milk powder was generously provided by the United Nations International Children’s Emergency Fund (UNICEF) to all MCHCs while half-cream and full-cream milk was supplied by the Hong Kong government.27 Supplementary meals were offered daily for selected undernourished patients, at midday at the main entrance of the clinic.28

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Protection against Diseases: The Benefits of Immunization The immunization program was a crucial part of the MCHCs. In 1950, immunization against diphtheria and smallpox was performed by trained staff in the MCHCs and a combined vaccine against diphtheria, whooping cough, and tetanus was employed in 1953.29 A massive immunization campaign was organized in 1962/63 against poliomyelitis using an oral vaccine. These immunization campaigns against diseases such as smallpox, cholera, and poliomyelitis brought the epidemics rapidly under control. By the 1970s, childhood diseases such as diphtheria, whooping cough, and poliomyelitis virtually disappeared as a result of the extensive, effective immunization program initiated by MCHCs.30 (Figure 8.4) The disappearance of tetanus in infants was likely due to the discontinuation of application of sealing cord powder to the umbilicus. BCG vaccination to prevent tuberculosis was introduced in 1952 to schoolchildren who were tuberculin negative upon skin testing. Those who were tuberculin positive but without active disease were given prophylactic isoniazid for one year. In 1954, the government offered BCG vaccination for all newborns and trained a team of nurses to perform BCG vacciation.31 By the late 1950s, BCG coverage reached 95% of all infants, reducing dramatically tuberculous meningitis, which was a fatal disease if untreated. Figure 8.4 Notifications (no./100,000) of selected infectious diseases in childhood, 1946 to 2015

Source: Medical and Health Department Annual Reports 1946–1980 and Hong Kong Annual Digest of Statistics 1981–2015. Cases of tetanus were not recorded separately (the numbers were small) in Annual Reports or in the Annual Digest of Statistics (from M. Chan-Yeung, A Medical History of Hong Kong: 1942–2015 [Hong Kong: The Chinese University of Hong Kong Prsss, 2019].)

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Figure 8.5 Mothers with their children queuing up for BCG vaccination in the 1950s

Photograph courtesy of Hong Kong Tuberculosis, Chest and Heart Diseases Association

Figure 8.6 A child receiving oral vaccine on a lump of sugar during the massive immunization campaign against poliomyelitis in 1962/1963

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1962–63, opposite 43.

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The mid-twentieth century saw great strides in vaccine research, and as soon as new vaccines were approved by the WHO, the Health Department would introduce them to the immunization program. The immunization program was formulated and periodically reviewed by the Advisory Committee on Immunization, consisting of consultants in pediatrics and microbiology at public hospitals, community physicians, health educators, senior public health administrators, and experts from the universities.

Health Education Health education formed a major part of the work of the maternal and child health centers, and was carried out during home visits of the health visitors, who also visited schools to give health talks. In the MCHC itself, nurses conducted health education vigorously by giving talks and showing films as well as practical demonstrations.

Family Health Service, 1974 to 2015 By 1973, the crude birth rate in Hong Kong declined from 37/1,000, the highest postwar level in 1958, to 19.5 live births/1,000. The downward trend continued until the lowest level of 6.9 live births/1,000 was reached in 2003. Employment of women, higher education, the desire for a smaller family, the increasing knowledge of birth control, and the availability of contraceptive measures provided by the Family Planning Association all contributed to this low birth rate.32 Despite the downward trend in the birth rate since the mid-1960s, the number of MCHCs/Family Health Services continued to increase until the maximum number was reached in 1997 when 50 (some full time, some part time) were recorded. In 1974, the government amalgamated the thirty-two Family Planning Association clinics with the MCHCs and named the newly expanded entity, the Family Health Service. The following programs were expanded or added to each of the family health centers:33 • • • •

Family planning program; Comprehensive observation scheme; Genetic screening, counseling and prophylaxis; Woman health centers.

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Family Planning Program: “Two Is Enough” The Family Planning Association of Hong Kong was first established as the Hong Kong Eugenics League in 1936 by Professor W. C. W. Nixon of the University of Hong Kong. The League began its work in a single clinic at the Violet Peel Maternity and Child Welfare Centre.34 By 1940, the League ran five clinics, staffed by several part-time female doctors and nurses. Its work was discontinued during Japanese occupation.35 After the war, the Eugenics League was revived at the Violet Peel Clinic under a more gracious name—the Family Planning Association of Hong Kong, with its headquarters on Hennessy Road. In the beginning, the Family Planning Association had to fight against the resistance of the Chinese who traditionally preferred a large family. In the recent past, China was predominantly an agricultural society with a large proportion of the population earning their livelihoods in the rural areas—the advantages of having a large family were obvious. The association utilized every conceivable communication channel to promote family planning and to point out the socioeconomic benefits for small families living in a crowded city like Hong Kong, using free pamphlets and advertisements in newspapers, magazines, radio and television. In the 1970s, the motto “Two Is Enough” could be seen everywhere (Figure 8.7). The demand for a larger female workforce and the change in attitude of women desiring a small family led to the acceptance of family planning. Figure 8.7 (Left) “No need for many babies: Two is enough” poster and (Right) mobile van of Family Planning Association

Photographs courtesy of the Family Planning Association of Hong Kong

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The family planning service advised women of childbearing age that they had a right to decide freely and responsibly the number and spacing of children. Appropriate contraceptive methods including condom, contraceptive pills, hormonal injection, and IUD (intrauterine device) are prescribed according to individual needs. The frequency of their use changed with time. Interestingly the use of condoms had replaced the use of the pills between the mid-1970s and the mid-1990s, putting the onus of contraception on men. (Figure 8.8) Postpartum sterilization, which was more commonly adopted by older women, had also been used as one of the accepted methods of contraception. Special clinics, such as a vasectomy clinic and a subfertility clinic, as well as a semen bank were organized and artificial insemination became available for childless couples.36 The fertility rate,37 which had already dropped to 1.63 births per woman in 1971—well below the rate of 2.1 births per woman necessary for population maintenance—fell further. By 2010, it dropped to 1.1 births per woman. Figure 8.8 Percentage of the common types of contraceptive methods used in Hong Kong, 1974 to 2000

Note: IUD = intrauterine device. Source: Hong Kong Annual Digest of Statistics 1974 to 2000.

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The Youth Health Care Center: Abortion Clinic for Young Women The sexual revolution which started in the United States spread to Hong Kong in the 1960s, giving rise to unwanted consequences, the most significant being a rise in venereal diseases and unwanted pregnancies, especially in young people. As a result, there were many illegal abortions performed in Hong Kong in the 1960s and 1970s. The abortion law back then was based on the Offenses against the Person Ordinance of 1861 and modified in 1972 and renewed after two years in 1974. Under this legislation, a woman may have an abortion if “two medical practitioners are of the opinion formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman or injury to the physical and mental health of the pregnant woman, greater than if the pregnancy were terminated.” Those who performed abortions under any other circumstance could be prosecuted under Section 46 of the Offenses against the Persons Ordinance and were “liable to imprisonment for three years.” In contrast, in the United Kingdom, abortions were legalized in 1966.38 Abortion was as controversial then as it is now, with the pro-life fraction against the free-choice fraction. In Hong Kong, the exact number of women who had an abortion each year in the 1960s or 1970s was difficult to estimate because it was such a hush, hush business. The procedure was carried out in some cases by registered doctors and midwives, but most of the time by “unregistered” doctors from mainland China with training in gynecology and obstetrics and others by those without proper training. Women usually paid from HKD100 to HKD600 for the procedure to be done in back street clinics. The unfortunate ones might encounter complications such as infection, hemorrhage, and even death.39 In 1979, the Family Planning Association realized there was a great need to provide such a service for women. An abortion clinic was planned, which received enthusiastic support from the chairperson of the Hong Kong Council of Women, who welcomed it heartily, while some conservative legislative council members lamented “that the move was another step back from civilization into the primitive world” and that it would only encourage people to regard abortion as a means of family planning.40 Nevertheless the first abortion clinic was set up by the Family Planning Association in the Ma Tau Chung Clinic. The abortion law was amended in 1981, legally allowing women to have an abortion if the foetus was diagnosed as abnormal, and if the

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mother was under 16 or became pregnant through rape, incest, and sexual intercourse procured by drugs, false pretense or threat. But they still required agreement by two doctors.41 As abortion figures rose in the 1980s, the need of sexual education for teenagers came into focus. A telephone hotline with personal counseling was offered by the Family Planning Association as part of its education program. Young people phoned in and asked questions. The plight of teenage girls with unwanted pregnancy led Professor Ma Chung Ho-kei, who was then the chairperson of the board of Family Planning Association of Hong Kong, to set up a pilot project—the Youth Health Care Clinic, a name socially acceptable, to help these young women. In 1986, the Youth Health Care Centre was inaugurated in Causeway Bay, with the enthusiastic support from Mrs. Peggy Lam, the executive director of the Association. A team consisting of Dr. Rita Chong, a gynecology and obstetrics specialist, a nurse, and Mrs. Yvonne Cheung, a counselor, was established. Young girls who needed help would come into the center where she was assured of confidentiality, and assessed by the counselor and the doctor. A decision was made regarding the pregnancy, whether to continue with it because the pregnancy was too advanced, or to terminate it and by what means. If the girl was under 16 years old, she would have to be accompanied by one of her parents, usually her mother. The girl and her mother would be given sexual education and relationship counseling.42 In the late 1980s, the situation changed. Young women were heading across the border in increasing numbers to take advantage of cheap noquestion-asked abortion services. Many hospitals in mainland China routinely carried out termination of pregnancy even in the ninth month of pregnancy and on girls as young as 13 or 14.43 At present, schools have sexual education in the curriculum and the number of abortions is on the decline. In 2011, there were 11,864 cases, dropping to 8,518 in 2018.44

Comprehensive Observation Scheme As families become smaller, each child becomes more precious. It is crucial to determine any health problems or congenital anomalies early in life in order to treat or correct them. In 1979, 72,852 children in the 0–5 age group had been screened, and about 1% of the new attendants were found to have some abnormalities, such as congenital defects, or effects caused by prematurity.45 Children with physical diseases and disabilities

Figure 8.9a         Figure 8.9b

Figure 8.9c

Photographs courtesy of the Family Planning Association of Hong Kong d Figure 8.9 The photographs were taken in 1988 during Lady Wilson’s visit to the Youth Health Care Centre at Causeway Bay: 8.9a. (L to R) Mrs. P. Nichols (member of the Education Committee), Ms. Carter (member of the Education Committee), Lady Wilson, Dr. Rita Chong, and Mrs. P. Lam (executive director of FPA); 8.9b. (L to R) Lady Wilson, Mrs. Y. Cheung (counselor), and Dr. Rita Chong; 8.9c. (L to R) Prof. Ma Chung Ho-kei, chairperson of Council of FPA, Mrs. J Tai, Vice-Chair of Council of FPA, and Lady Wilson. d

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were referred to various specialist clinics for in-depth assessments or to a multidisciplinary child assessment center for further evaluation and treatment.46 The Arran Street Multidisciplinary Child Assessment Centre, with a team of pediatricians, clinical psychologists, medical social workers, ophthalmologists, auditory technicians, speech therapists, physiotherapists, occupational therapists, and nurses, offered such a service. The center served children from birth to twelve years old and delivered comprehensive physical, psychological, and social assessment as well as parental counseling and appropriate placement of the child in government institutions and centers or voluntary agencies.47 The location of Child Assessment Centers in Hong Kong can be found in Appendix 1, Table 3.

Genetic Screening and Counseling Program To keep up with new scientific breakthroughs and discoveries, new programs were introduced to further protect children’s health. For example, neonatal screening for G6PD deficiency 48 and congenital hypothyroidism were introduced towards the mid-1980s to detect these diseases early to minimize disabilities. Additionally, the government’s genetic counseling clinic was set up to provide diagnostic services for individuals and families at risk of genetic or chromosomal disorders. It had a cytogenetic laboratory to perform chromosomal analysis on blood samples, tissues, marrows, skin fibroblasts, and solid tumors.49

Woman Health Centers To care for women, the Family Health Service founded three Woman Health Centers between 1994 to 1997 following the recommendations of the Working Party of Primary Health Care Service in 1991 (Chapter 6). In addition, ten family health centers also offered women’s health services. The aim was to provide women with health assessment, health education, and counseling for women at or below 64 years of age, in order to prepare them for changes at different life stages: premarital, pregnancy, puerperium, and menopausal periods.50 Also taking place in these health centers was health education, and safe sex was emphasized to reduce the chance of contracting sexually transmitted diseases and developing cervical cancer. Women were encouraged to get familiar with their breasts so that any changes, such as the appearance of a

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mass, could be identified as soon as possible. Those at high risk for breast cancer would be referred for mammograms. Cervical cytology screening was carried out regularly on women. When abnormalities were found from screening, referral to specialists for further management would be made.51 The women’s health centers also offered advice on menstrual problems and psychosocial problems related to pregnancy. Those with psychosocial problems such as mood disorders related to pregnancy, marital problems, or adjustment disorders at menopause were given individual counseling, education, and referral to social services when necessary.52

New Millenium, New Directions The turn of the millennium brought forth a period of intense selfexamination as to the future direction of the Family Health Service. A number of new projects, such as programs on parenting, breastfeeding, vision screening, oto-acoustic screening, and standardization of physical examination and measurements were implemented after careful assessment of their effectiveness. In 2003, the Family Health Service was reorganized and streamlined, reducing the number of centers from 50 to 31 (Appendix 1, Table 2) and introducing new services. The maternal health program of the Health Department became jointly operated with the maternity units of the Hospital Authority to provide antenatal care (free of charge) and birthing care (at a low cost) to women resident in Hong Kong. This includes a number of screening services to exclude abnormalities at various stages of pregnancy such as gestational diabetes, psychological risk of substance abuse, Down’s syndrome during the first trimester of pregnancy; anomalies of the fetus during the second trimester; and Group B Streptococcal infection, depression, and abnormal cervical cytology in mothers during the third trimester.53 The Family Health Service also has an Integrated Child Health and Development Program for parents to promote holistic health and wellbeing of young children. It has three aims: 1) to equip the parents with the craft of parenting; 2) to protect children with more up-to-date vaccines for immunization. As new and improved vaccines became available, they were introduced to the childhood immunization program, such as the use of new booster DTaP-IPV vaccine to replace DTwP vaccine, the use of oral poliomyelitis vaccine and pneumococcal conjugate vaccine (see Table 8.1);54

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and 3) to provide health and development surveillance which includes a physical examination of the newborn child and periodic examination of the child’s growth parameters: newborn hearing screening, preschool vision test, and developmental surveillance at specific ages. Table 8.1 Hong Kong Childhood Immunization Program in 2019 Age

Immunization Recommended BCG Vaccine Hepatitis B Vaccine—First Dose 1 month Hepatitis B Vaccine—Second Dose DTaP-IPV Vaccine—First Dose 2 months Pneumococcal Vaccine—First Dose# DTaP-IPV Vaccine—Second Dose 4 months Pneumococcal Vaccine—Second Dose# DTaP-IPV Vaccine—Third Dose 6 months Hepatitis B Vaccine—Third Dose MMR Vaccine (Measles, Mumps &Rubella)—First Dose 12 months Pneumococcal Vaccine—Booster Dose# Varicella Vaccine—First Dose* DTaP-IPV Vaccine—Booster Dose 18 months MMRV Vaccine (Measles, Mumps, Rubella & Varicella)—Second Dose* Primary 1 DTaP-IPV Vaccine—Booster Dose Human papillomavirus vaccine—First Dose^ Primary 5 dTap-IPV Vaccine—Booster Dose Primary 6 Human papillomavirus vaccine—Second Dose^ Newborn

Notes: DTaP-IPV Vaccine: Diphtheria, Tetanus, acellular Pertussis & Inactivated Poliovirus Vaccine dTap-IPV Vaccine: Diphtheria (reduced dose), Tetanus, acellular Pertussis (reduced dose) & Inactivated Poliovirus Vaccine #

The vaccination schedule of Pneumococcal Vaccine under the HKCIP has been updated according to the recommendation made by the SCVPD in 2019. Children born on or after 1 Jan 2019 will receive 2 primary doses of pneumococcal vaccine at 2 months and 4 months, followed by a booster dose at 12 months old in MCHCs under the DH. *Varicella vaccine has been incorporated into HKCIP for children born on or after 1 January 2013. Currently, the second dose of MMR vaccine (for children born before 1 January 2013) or MMRV vaccine (for children born on or after 1 January 2013) are given to Primary 1 students by the School Immunization Teams of the Department of Health (DH). DH has been planning to provide the second dose of MMRV vaccine for children at 18 months in Maternal and Child Health Centers. Implementation details will be announced by DH in due course. ^Starting from the 2019/20 school year, eligible female students will receive the first dose of 9-valent HPV vaccine at Primary 5. They will receive the second dose when they reach Primary 6 in the next school year. Source: Department of Health Family Health Website, https://www.f hs.gov.hk/ english/main_ser/child_health/child_health_recommend.html.

8 . M aternal and C hild H ealth and F amily H ealth S ervice   |   1 6 5

The Family Health Service continues to play an important role in safeguarding the physical and psychological health of women throughout their reproductive life along with the health of infants and children. In 2012, the Family Health Service celebrated its eightieth anniversary, dating the establishment of the first infant center in Wan Chai by the government in 1932 as its beginning. However, some may consider the first appointment of government midwives to the Chinese Public Dispensaries in 1906 as the founding of the Maternal and Child Health Service. If so, the Family Health Service would be more than 110 years old.

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9. School Health Service: Healthy Children, Better Learners

It is a well-known fact that a healthy child is a better learner, while poverty and its offshoot, lack of access to medical care, impede a child’s development and ability to learn. Just imagine a child going to school hungry, or with a toothache, or a child with myopia trying hard to see the blackboard in school without glasses. These problems are frequently encountered in school-age children, and hinder students’ ability to concentrate and learn at higher levels. In this chapter, we will explore how the colonial government of Hong Kong solved these problems and gave schoolchildren the best chance to excel by protecting their health and wellbeing. In 2019 Hong Kong’s population topped the world in life expectancy, 82.2 years in men and 88.1 in women. Few people would know that in 1880, the mean age at death for Chinese over the age of 20 years was 43 (compared with 55 in England), and when those who died before the age of 20 years were included in the calculation, the mean age of death for the whole population was only 18.3 years (29 in England). In 1881, the published crude death rates for Chinese were 26 to 30 per 1,000 compared with 20 per 1,000 reported in London, England.1 Poor nutrition, meager water supply, unsanitary surroundings, lack of education on personal hygiene, and unlivable housing all contributed to the swift spread of infectious diseases, which were rampant in those days, irrespective of the routes of transmission (water-, food-, or air-borne), to become an epidemic. Plague struck Hong Kong in 1894 and recurred regularly for almost thirty years. For the first time, the government realized the importance of public health in disease prevention and began to implement several measures to improve hygiene, such as increasing water supply, improving environmental sanitation, educating the public on hyg iene, and compliance to sanitary regulations and public health measures. The government encouraged schools to teach hygiene, and to stimulate interest in this topic. It organized inter-school competitions on hygiene to emphasize its importance and at the same time encouraged

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physical exercise in strengthening the general well-being of the students.2 The Medical Department went a step further and organized the school health program (called school hygiene program then) for the first time in 1921, following the policy of the mother country, where the school health program was already well established. In England and Wales, the Education (administrative provisions) Act of 1907 permitted local authorities to undertake medical examinations and provide treatment to schoolchildren.3 The comprehensive examinations took place at three points, five, eight, and twelve years of age during their schooling, covering physical, mental, and dental wellbeing as well as cleanliness.4 Research shows that peer influence has its strongest impact on the growing brain; each young person has a remarkable propensity to adapt their behavior to fit group norms, a phenomenon known as peer pressure. Hence, educating students in school about proper hygiene would have a high success rate in the community, especially in poor working-class neighborhoods, where knowledge of hygiene and public health was minimal, hindered by a centuries-old system of non-scientific customs and superstition. The success in hygiene education eventually led to a changing attitude in the community with much better compliance to sanitary regulations.5

School Health/Hygiene Program before World War II The school hygiene program consisted of two parts: medical examination of schoolchildren and inspection of the educational environment. There were four types of schools in Hong Kong: 1) government schools, which were run and staffed by the Education Department of the Hong Kong government; 2) grant schools, which were institutions owned and administered by missionary organizations and received grants from the government; 3) “subsidized” (the proper subsidy code began only in 1937) schools were private institutions which received a subsidy from the government when conditions warranted it; and 4) unaided schools, which received no support from the government. Government schools and grant schools were modeled after more advanced schools in Europe and America. Teachers at these schools possessed a knowledge of modern hygiene and were responsible for teaching it. These schools were also

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recipients of the school health program, which started with a small number of schools, and in time more schools were included.6 In 1925, medical examinations (excluding of the heart and lungs) of students were carried out on all 4,063 children in eighteen government schools and thirteen grant schools. In later years, only new entrants to these two categories of schools received medical examinations. The most common health problem among schoolchildren was dental caries; 90% of them had caries in their teeth, affecting deciduous more than permanent teeth.7 There was no school dental service before the Second World War, although, there was a plan to establish one.8 About 10% of students were found to have visual defect, myopia being the most common. Those with visual defects were referred to have testing for refraction error, and spectacles were provided when necessary at government expense. Other common abnormalities included problems with tonsils and adenoids, nasal catarrh, heart disease, spinal deformities, skin diseases, and suspected tuberculosis. Minor ailments were treated at the Government Civil Hospital or the Chinese Public Dispensaries.9 In 1931, a small room was set aside at the Ellis Kadoorie School for treatment of minor medical problems by a school medical officer and in the following year, Yau Ma Tei School also set aside such a room.10 By 1937, 2,780 students, mostly from government schools, had been treated in five such small clinics. There were also two special clinics: an eye clinic and an ear-nose-throat (ENT) clinic.11 Students were not free from epidemic infections. In fact, every year, about thirty to fifty pupils developed one of the communicable diseases. In order to combat the spread of disease, the Medical Officer of Health notified the School Medical Officer of any school cases reported to him, and the school nurse would visit the homes of the affected and give health education. The schools themselves were also inspected for lighting, ventilation, space, sanitation, seats and desks, blackboards, water supply, general cleanliness, state of repair, and the number of students allowed. The schools that were not up to standard were informed and expected to have the defects corrected on reinspection.12 The school hygiene program before World War II was well received. Unfortunately, because of inadequate resources, medical examination was carried out on all students only once, rather than on three different occasions in the course of the school life of a student as in England and

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Wales.13 Many students benefited from the service of having their medical conditions diagnosed and treated. During the Japanese occupation, all schools, with rare exceptions, were closed, and the school hygiene program suspended until the conclusion of World War II.

School Health Program after World War II After the Second World War, the school hygiene program resumed its service. The nature of the school health program did not stay the same, and evolved over the years according to the changing socioeconomic conditions. The school health program can be chronologically divided into three stages known by different names: School Health Program from 1946 to 1963; School Medical Service from 1964 to 1995; and Student Health Service from 1995 to the present.

School Health Program, 1946 to 1963: Beginning of a Welfare State? Many schools reopened soon after the war in order for children not to miss too many years of schooling. In 1946, the School Health Program also resumed. During the year 1946, the School Health Officer and his team examined 10,686 students in fifty-five schools. Those with abnormalities were sent to Ellis Kadoorie School, Harcourt Health Centre, Kowloon Hospital Outpatient Department, and the Nethersole Hospital for further evaluation and treatment.14 The school-age population (primary and secondary) swelled with emigrants returning to Hong Kong and the continual arrival of refugees from the mainland coupled with the postwar baby boom. Owing to the shortage of accommodation, a two-session and sometimes three-session system were adopted in many school premises. The government and grant schools were usually accommodated in buildings specially constructed for school purposes, and the premises were generally satisfactory. However, the majority of “subsidized” and private schools were conducted in tenement flats or in buildings that were never intended to be used as schools. The regulations in the Education Ordinance had safeguarded the hygiene aspects of these types of schools, but they were mostly situated in congested urban settings with no facilities for physical exercise and sports.15

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In 1953, the school population increased to around 200,000, and the number of participants in the School Health Program increased to 46,051. The program now broadened to cover medical examinations on entry to school and repeated at the ages of five, seven, ten, twelve, fifteen, and eighteen—more frequent than the program offered in England. Those found to have abnormalities would be referred to general or special outpatient services such as dental, eye, and ENT. The staff of the program was increased to include a medical officer in charge of the program, eleven doctors, one nursing sister, eleven nurses, and nine clerks. The dental and ophthalmology programs consisted of two ophthalmologists, three ophthalmic technicians, five dentists, five dental assistants, and two health inspectors—a huge financial commitment for the government.16 Participants in the scheme only made an annual payment of HKD 15 and enjoyed free medical, dental, and ophthalmologic attention. Children requiring hospitalization were admitted to government hospitals and only paid a nominal fee of HKD 5. Teachers of participating schools could also join the program.17 Between 1948 and 1963, a high proportion of schoolchildren were found to have some health problems and were referred to general or special government outpatient clinics (Table 9.1). In the 1950s, only about 20%–30% of student participants were completely healthy. Another 20%–30% had poor or slightly below average nutrition; between 5% and 10% had visual defects, which could be corrected by eyeglasses in the majority of cases. About 70%–80% of children examined were referred to the School Dental Service for necessary dental work (see below).18 Others included tonsils and adenoid problems, nasal catarrh, heart trouble, and skin diseases. Tuberculosis was not uncommon among students and teachers. In 1956, 49 (1.3%) of the 4,000 prospective teachers were found to have active tuberculosis and were sent for treatment.19 Other benefits of the School Health Program included free immunization against smallpox, cholera, diphtheria, and enteric fever. Students received tuberculin testing, followed by BCG vaccination if the test was negative. UNICEF sent dietary supplements, such as milk powder and vitamin capsules, which were distributed to mothers and children, and CARE (Cooperative for Assistance and Relief Everywhere) gave protein canned foods. At midday in the main clinic center, a special meal was prepared for selected undernourished patients. Health education, particularly by health visitors to the homes of patients, formed a major part of the work of this service.20

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Table 9.1 Number of participants of the School Health Program, visits to the general clinic, dental clinic, eye clinic, ENT clinic, and schools inspected, 1948 to 1963 Year Participants 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963

16,325 28,536 25,994 56,186 56,285 56,982 63,060 67,535 56,399 50,602 45,395

39,327 38,619 37,265

General Clinic 11,785 14,600 17,549 17,772

Dental Clinic 5,728 7,304 8,761 19,788

Schools Eye Clinic ENT Clinic Inspected 1,481 311 2,092 2,034 463 2,031 1,908 386 2,582 5,781 983 533

55,187

32,356

8,451

99,493 78,359 71,038 65,690

37,974 32,360 26,284 35,522

6,855 3,483 4,076 3,901

3,751 2,499 2,323 2,184

2,648 1,672 1,569

47,605 41,947 32,673

34,086 30,060 27,873

1,715 3,696 3,641

3,806 1,796 1,189

1,646 2,866 2,330

2,292 2,589

Note: blank = information not available. Source: Hong Kong Medical and Health Department Annual Reports 1948 to 1963.

It is hard for children to concentrate in school with an empty stomach. As early as the 1900s, studies showed that giving children one nutritious meal a day made them more robust, and would allow them to read, write, and calculate and even sing better in schools. Well-fed children were less prone to skin and respiratory infections and tuberculosis. Even though there was no malnutrition among schoolchildren in Hong Kong in the 1960s, many suffered from undernutrition as evidenced by the amount of illnesses they suffered from. In 1961, Bishop R. O. Hall (Figure 9.1) of Hong Kong Sheng Kung Hui (Anglican Church of Hong Kong) established a Children’s Meals Society in primary schools in industrial areas, such as Li Cheng Uk, Wong Tai Sin, Sham Shui Po, Kwun Tong, and others, serving one lowcost nutritious meal to undernourished school children each school day. In a previous pilot project, the visionary Bishop Hall had noted that children improved both physically and mentally after six months of receiving one nutritious meal per day. The program ended in 1974 when, as a result of rising economy, Hong Kong’s standard of living improved even for the lower social class, and children were no longer hungry from lack of food.21

Figure 9.1 Bishop R. O. Hall of Hong Kong Sheng Kung Hui (Anglican Church of Hong Kong)

Photograph courtesy of Canon Christopher Hall d Ronald O. Hall, Bishop of Hong Kong (1932 to 1966), was the longestserving and most influential bishop of the Anglican Church of Hong Kong. In addition to rebuilding the Church after WWII, he dedicated his life to the postwar reconstruction of Hong Kong.    A social activist, he created a number of ingenious social welfare agencies that looked after the needs of underprivileged people, especially orphans, juvenile delinquents, and children of workers. His influence led to the establishment of the Social Welfare Department in Hong Kong. He advocated for low-cost public housing to accommodate the massive number of refugees in postwar Hong Kong and founded the Hong Kong Housing Society. A visionary educator, he helped expand the numbers of schools by establishing a number of primary and secondary schools. He pioneered a form of modern secondary education that emphasized training young people in trades rather than in academic pursuits. He founded Chung Chi College and played an important role in the establishment of the Chinese University of Hong Kong. The Children’s Meals Society was but one of his many projects.    Many believed that his work in housing, education, and social welfare contributed to social stability and indirectly to the eventual economic takeoff in Hong Kong in the late 1960s. (M. Chan-Yeung, The Practical Prophet, Bishop Ronald O. Hall of Hong Kong and His Legacies [Hong Kong: Hong Kong University Press, 2015], xvi.) d

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Even though there was a dramatic increase in schoolchildren in the postwar years, only a limited number of students were accepted to the school health program due to inadequate funding (Figure 9.2). The program required that schoolchildren be examined every two to three years, and those with abnormalities were investigated and treated. Schoolchildren with intercurrent illnesses were also treated. Despite a huge budget for the program, because of lack of space and facilities, it was impossible to provide adequate medical services to the 37,000 to 67,000 students enrolled in the program repeatedly according to the above schedule. The staff of the School Health Program was often criticized. At that time, there were 250,000 schoolchildren, and only around one fifth of them participated in the School Health Program (Figure 9.2). While many people believed that the School Health Program should be made available to all schoolchildren,22 others to whom “socialism” in any form is anathema baulked at the budget required to provide medical service to the whole population of schoolchildren, regarding it as the beginning of a “welfare state.” In the opinion of these taxpayers, the total cost of social services in Hong Kong was high enough already, which, of course, was far from the truth.23 Figure 9.2 Total student population and the number of students in the School Health Program, 1948 to 1963

Source: From Hong Kong Medical and Health Department Annual Reports of respective years.

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In the end, the laissez-faire policy won. After 1955, the School Health Service was frozen due to lack of funds, inadequate staff, and lack of clinical premises. Hence, no new entrants were admitted. By 1960, the government realized that it was not possible to provide curative care to all 600,000 schoolchildren in Hong Kong and determined that a new system was necessary. So, a new scheme, which involved financial contribution partly from participants and partly from government subsidy, was proposed and submitted to the Hong Kong Branch of the British Medical Association and to the Chinese Medical Association for discussion. As is the case with many government endeavors, the scheme took a few years to materialize.24

School Medical Service, 1964 to 1995: Private Practitioners’ Contribution During this period, the medical examination and the curative service components of the School Health Program were transferred to a newly established School Medical Service (see below), while the School Health Program continued to assume responsibility for environmental sanitation, control of communicable diseases, immunizations, and health education for all registered schools in Hong Kong The newly established School Medical Service was operated by private practitioners under the auspices of the Chinese Medical Association on a per capita contributory basis. It was suggested that a fee of HKD 14 a year be charged for each student (HKD 10 for consultations and HKD 4 for medicines), with the government subsidizing each student to the extent of HKD 5 a year. The government also donated HKD 1 per participant for the administration of the School Medical Service Board.25 During 1964, 250 private doctors participated in the program providing outpatient medical care for nearly 82,000 students from 485 schools.26 Over the years, more students joined the program and more private general practitioners took part in it (Figure 9.3). In 1966, further changes occurred in the School Health Program. While the inspection of school premises continued to be carried out by School Health Inspectors, the work of immunization against various infectious diseases was assumed by the Area Health Officers. Tuberculin testing and BCG vaccination were maintained by the Government Tuberculosis Service. The work of the School Health Program became fragmented.27 Little information is available on the health of the students during this period. One

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Figure 9.3 Total number of students in Hong Kong and the number participating in the School Medical Service, 1964 to 1994

Source: Data of total student population from Hong Kong Annual Digest of Statistics 1963 to 1994; data of participation in the School Medical Service from Hong Kong Medical and Health Department Report for 1964 to 1994.

would assume that the general health of the students must have improved because of better nutrition, better standard of living, improved sanitation, and preventive measures against infectious diseases. Student participation in the School Medical Service was entirely voluntary. In 1980, for a token fee of HKD 5 a year, the participant could receive free medical attention from any one of the practitioners, who participated in the program, of their choice. The government contributed HKD 50 a year for each student enrolled in the system.28 In 1985, the fee of each participant doubled to HKD 10 per year, and the government contributed HKD 65 a year.29 In 1989, the School Medical Service almost collapsed because the government changed the rules and allowed students unlimited free consultations and free medicine for just HKD 75 per student per year (HKD 65 from the government and HKD 10 from the student). This new scheme led to an average of 9.7 visits for each student per year, when in the past it was only three visits. Fifty doctors left the School Medical Service.30 Even though the fees increased to HKD 15 for enrollment and HKD 10 per visit for the students, with the government contributing HKD 105 in annual

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subsidy per student per year, the unlimited visits and treatment occupied a great deal of the participating private doctors’ time. The doctors felt that they were subsidizing the School Medical Service. In 1990, the School Medical Service Board recommended its own death knell by proposing eliminating curative service from the School Health Program while keeping preventive services.31 Before the School Medical Service was dismantled, it was covering 44% of the total eligible student population (compared to only 6% in 1965), indicating the popularity of the program.

Student Health Service, 1995 to Present: Prevention Over Cure In 1989, in response to the call of the World Health Organization to focus on primary healthcare, the government formed a Working Party on Primary Health Care, which subsequently released a detailed report on its findings and recommendations in December 1990. One of the recommendations was to replace the School Medical Service with a new one that would emphasize health promotion and disease prevention, rather than curative care of the students.32 Together with the recommendations of the School Medical Service Board, the government decided to establish a new entity named Student Health Service, with emphasis on the wellbeing of students, to replace the School Medical Service. In 1995, the new Student Health Service was established to be implemented in two phases. Phase 1 was launched in September 1995 for primary schoolchildren when seven student health service centers and one special assessment center were set up. Phase 2 began the following year with the addition of five student health centers and another special assessment center for secondary school students. Enrolled students were given an annual appointment to attend a student health center and were screened for problems related to nutrition, blood pressure, vision, hearing, spinal curvature, psychosocial health, and sexual development. Students found to have health problems were referred to a special assessment center for further evaluation and management. Individual health education and counseling were also provided.33 Common health problems detected at student health service centers were related to vision (myopia and astigmatism), growth and nutrition (obesity), and psychosocial difficulties. A number of programs was launched: 1) an adolescent health program to promote the mental health of adolescents with an information technology

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management team in 2004 to manage the health-related data processing and smooth the process of serivce; 2) a joint service in 2004/2005 with the Hospital Authority to enhance the screening service for diabetes in obese students with early referral of suspected cases for further management; 3) a basic life skill training program with social workers as facilitators in classrooms; and 4) a program to enhance the use of hearing screening service, visual screening test, and referral to Student Dental Service.34 The doctors in the Student Health Service worked closely with allied health professionals such as radiologists, radiographers, audiologist, optometrists, clinical psychologists, dietitians, and social workers for assessment of health conditions and to provide quality health promotion services to the schools; however, curative care was not provided to students. Even though some parents had mixed feelings about the new service because they had to seek and pay for curative care for their children, enrollment was encouraging, and participation increased with time. In 2015, participation was 75%, the highest since the establishment of the School Health Service in 1921 (Figure 9.4). At present, there are twelve Student Health Service Centers in Hong Kong, Kowloon, and the New Territories (Appendix 1, Table 4). There is no charge for eligible students (those born in Hong Kong or holders of a Hong Kong Identity Card) joining the Student Health Service, while the fee payable for each of the noneligible persons (visiting students or holders of travel documents) is HKD 535.35 Figure 9.4 Total student population and the number of participants in the Student Health Service, 1995 to 2015

Source: Data for student population from Hong Kong Annual Digest of Statistics 1995 to 2016; and participants from Department of Health, HKSAR, 1995 to 2016.

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Over the years, the School Health Program had provided curative primary care at a token fee. The huge population of schoolchildren made the program a heavy financial burden for the government, which passed some of this burden onto the medical profession. In the end, the government changed the focus of the School Health Program to disease prevention and health promotion, leaving the curative medical aspect to the primary care doctors in the public and private systems. In giving up curative service, the School Health Program was able to expand its preventive service to promote and maintain the physical and psychological health of schoolchildren, thus maximizing their learning potential.

School Dental Service After the war, the government Figure 9.5 A volunteer dentist in dental service established a special Hong Kong, in 1969, note the types g rog r am, the Student Dental of instruments used Service, with referrals from the School Health Program. The staff of the Student Dental Service consisted of five assistant dental surgeons. In the 1950s, as high as 70%–80% of schoolchildren in the School Health Program had abnormal dental findings and were sent to the government School Dental Service, where most of the time, extraction was carried out rather than filling or conservation work. Because of the demand, even though the number of clinics increased from three to eight over the years, the wait time was still Photograph from The National Archives long (two to six months). The of the UK, ref. CO1069/462 students in government and grant schools paid HKD 5 per year to benefit from all the dental work; students in private schools paid HKD 15 per year.36 Preschool children were not eligible for the School Dental Health service.

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In 1957, 90% of the six-year-old schoolchildren in Hong Kong were found to have dental caries.37 Because of this finding, the government realized that prevention of dental caries was necessary. The Hong Kong Dental Society proposed fluoridation of water supply in the colony by bringing up the concentration of fluoride in the water. The benefit of fluoridation of water had been dramatic. Within 25 years, this single project accounted for an eleven-fold increase in the percentage of children without dental decay in their primary dentition (3% without dental decay in 1960 versus 33% in 1987).38 Over the years, the level of fluoride in water was changed because while caries was prevented, dental fluorosis occurred. Dental fluorosis is an unaesthetic tooth defect caused by excessive intake of fluoride during enamel formation, which can result in the hypomineralization of tooth enamel (Figure 9.6). The initial fluoride level in water was at 0.8 parts per million (ppm), increasing the following year to 1.0 ppm—a level found to be excessive because it led to a high prevalence of dental fluorosis among seven- to twelve-year-old children.39 In 1978, the fluoride concentration was reduced to 0.7 ppm, and in 1988, it was further adjusted to 0.5 ppm. Dental fluorosis decreased accordingly.40 There had been a change in the treatment practice since 1960. In the Student Dental Service, the proportion of fillings to extractions of permanent teeth rose from 7.9 to 1 in 1961 to 10.4 to 1 in 1962. More efforts were spent on tooth preservation rather than extraction.41 The demand for dentists in Hong Kong had always outstripped the supply. The same goes for dental hygienists, dental therapists, and dental technicians. In 1980, a new School Dental Care Service was introduced, aiming at promoting dental health Figure 9.6 Mild dental fluorosis— and hygiene as well as providing opaque white patches on enamel; dental care to primary schoolchildren. more severe dental fluorosis will The government also decided to lead to discoloration of the teeth and damage establish a dental school at the University of Hong Kong and at the same time to build a hospital for students of dentistry and affiliated personnel.42 Prince Philip, the Duke of Edinburgh, officially opened the new hospital bearing his name. The Matthew Ferguson 57@Wik imedia Faculty of Dentistry at the University Commons

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of Hong Kong has been ranked as the top dental school in the world among 364 institutions from different countries in the QS University Rankings by subject in 2016 and has retained this position up to 2018.43 Training of dental therapists and hygienists was based at the MacLehose Dental Centre that incorporated a school dental clinic. With more qualified personnel, six more dental clinics were set up, and they received enthusiastic support from parents.44 The participation rate of students increased from 29% in 1980 to 64% in 1985.45 In 1991, on the twelfth year of operation, the participation rate increased to 78% and in 2000/01 school year, it was 87.4%.46 Figure 9.7 Prince Philip Dental Hospital, opened in 1980

Photograph by Ann Wong

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As of 2018, for eligible students, the cost of joining the School Dental Care Service is a nominal fee of HKD 30. The charge for noneligible is HKD 725.47 The eleven dental clinics in Hong Kong can be found in Appendix 1 Table 5. Two dental surveys were carried out in 2001 and 2011 by the government. In 2001, more than one-third (37.8%) of the schoolchildren (six to eleven years old) had a caries experience in their permanent dentition;48 in 2011, only 22.6% had such an experience.49 A large number of participants claimed that they had regular checkups. This improvement was associated with better oral health knowledge and oral care habits in both parents and children. The School Dental Care Service provides basic and preventive dental care to primary schoolchildren through school dental clinics in the different districts. Despite great improvements in the oral health of Hong Kong’s children over the past fifty years, dental caries remains an oral health burden in the community, in particular among preschool children where the prevalence of caries stays high (35% to 51%). Despite this, the dental condition of Hong Kong’s schoolchildren is considered relatively good by international standards, as worldwide, dental caries affected 60% to 90% of schoolchildren.50

Ophthalmology Service for Students The two most common visual problems of students in Hong Kong are myopia and astigmatism, and often both occur together. Of all the primary school students who took part in the visual acuity test at the Student Health Service Centers from the 2005/06 school year to the 2014/15 school year, about 31% to 35% were wearing glasses to correct myopia, astigmatism, or both. The percentage that failed the visual test even when wearing glasses varied from 19% to 24% during those ten school years. On further evaluation of this group, the percentage with myopia varied between 75% to 84%, while astigmatism varied from 55% to 61%.51 Schoolchildren before the war also suffered from the same eye problems. Students with abnormal eyesight were referred to an eye clinic. Those with myopia were given a pair of free spectacles,52 a necessity not only for learning but also for everyday living. After the war, until 1974, free or inexpensive glasses were also provided to schoolchildren who

9 . S chool H ealth S ervice   |   1 8 3

needed them.53 About 2,900 pairs were given out each year.54 Since the formation of the Family Health Service in 1974, children aged four to five were given preschool vision screenings aiming at detecting any early visual abnormalities such as amblyopia, squint, and significant refractive errors, so that they could be referred to ophthalmologists for further visual assessment and treatment. In the Student Health Service established in 1995, a visual acuity test was offered for all primary school and secondary school students during their annual health check, but free corrective glasses were not provided. For those with problems, parents could choose to consult private optometrists for assessment and follow-up. The staff of the Student Health Service screened the students for other visual problems and made appropriate referrals accordingly. They also provided advice and education to promote eye health, such as healthy reading habits, including proper use of electronic screen products, and the importance of regular checkup for those with a high degree of myopia and astigmatism.55

Ear, Nose, and Throat (ENT) Service for Students ENT or otorhinolaryngology is a special branch of surgery, and remains as a division of the Surgery Department today. Since the establishment of the School Health Service, students with tonsils, adenoid, and nasal catarrh problems were sent to ENT clinics for assessment and treatment. In addition, the ENT service ran two clinics: an audiometric unit and a speech therapy clinic. The former handled diagnostic hearing tests and the latter treated all those with defects and disorders of voice, articulation, and fluency. Severe cases of deafness in children were taken care of by the hearing and speech center of the Education Department.56 Except for the numbers of students being seen each year from 1948 to 1963 as shown in Table 9.1, there was little published information on other ENT services offered to students. The Student Health Service identified children with abnormalities early in life, such as dental, eye, hearing, and spinal problems, so that timely treatment could be given. Dental caries, myopia, and astigmatism were the most common afflictions of schoolchildren in Hong Kong. Visual and hearing problems of schoolchildren not only affect their

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learning ability negatively, but also often affect their cognitive and social interactions with others. Independent of the above government services, Bishop R. O. Hall’s introduction of one nutritious meal a day in the 1960s and early 1970s for the undernourished children undoubtedly resulted in the improvement of the general well-being of schoolchildren. All these measures helped reduce the risk of childhood diseases and infections and increase students’ ability to learn and achieve their academic goals. The metamorphosis of Hong Kong from an unsophisticated provincial town to a world-class city and a financial center has been greatly assisted by a healthy well-educated population, an outcome of this far-sighted investment in student health services by the government, with the support of the industrious Hong Kong taxpayers.

10. Ambulatory Treatment and Control of Tuberculosis

Tuberculosis, also known as the white plague because of the skin pallor it causes, is an ancient disease that can be dated back to the discovery of the mummified skeleton of a priest of Ammon around 1000 B.C.E., which showed typical features of Pott’s disease (tuberculosis of the spine). Other archaeological and historical evidence indicates that tuberculosis had been widespread in early Hindu, Greek, and Roman societies. By the early-nineteenth century, tuberculosis had become the major cause of death in Europe and North America.1 The cause of the disease remained unknown for centuries until 1882, when German microbiologist, Robert Koch, clearly established the mycobacterium tuberculosis, a pathogenic bacterium, as its cause. Even though it was widely known that the germs were spread by droplets from sneezing and coughing, an effective treatment was not yet available until much later.

Tuberculosis before World War II Tuberculosis was diagnosed as early as 1849 in Hong Kong, when three cases were found in the Government Civil Hospital.2 Tuberculosis thrived in Hong Kong since the latter part of the nineteenth century as the overcrowded, unsanitary conditions of the tenement houses in Tai Ping Shan, where the Chinese population densely aggregated, were highly conducive to its propagation. In the cubicles where a whole family lived, family members huddled together and literally coughed on each other, thereby infecting each other. Dr. Henry Harold Scott, the government bacteriologist in Hong Kong in the 1920s, studied a series of patients who died from tuberculosis. He marveled at the “large percentage of children of tender age who died from tuberculosis.” He found three infants who died from tuberculosis before one month of age: at twenty-two days, twenty-four days, and

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twenty-nine days old respectively, while two died at several months of age. Even though he did not specify how many were in his series, and whether there were any other comorbidities, it is quite amazing that the children developed the disease so early and died from it so soon. He postulated that this could be due to mother-to-child intrauterine spread of the disease during pregnancy or in the intrapartum period.3 Successive colonial surgeons recorded at least 10% of all deaths each year among the Chinese were due to tuberculosis. Dr. A. R. Wellington, the Director of Medical and Sanitary Service (1928 to 1937), who documented the causes of death carefully in the death clock in his annual report, confirmed the above findings. In 1933, tuberculosis caused 12.3% of all deaths.4 The first tuberculosis wards in Hong Kong were established at the Kwong Wah Hospital, which was inaugurated in 1931 by Sir William Peel, Governor of Hong Kong. The hospital was part of the Tung Wah Group of Hospitals and was financed by the Chinese elite. Governor Peel made highly relevant remarks about the prevention of tuberculosis. In his speech, he said that the most effective way to stop the spread of tuberculosis in Hong Kong was to reconstruct the whole town of Victoria and to make people live according to sanitary principles created to prevent disease. He also suggested an anti-spitting campaign, believing that spitting is “a most serious contributory cause.”5 Dr. Wellington made great efforts to provide accommodation for cases of infectious pulmonary tuberculosis in special wards at the government and Chinese hospitals. He would have liked to build a special hospital for these patients, but there was no funding to do so. He proposed legislation to pasteurize milk in 1937, but opposition delayed the passage of the bill until 1938.6 The new Queen Mary Hospital, which opened in 1938, had two wards of twenty beds for patients with tuberculosis who developed complications or needed surgical treatment. This was hardly sufficient for the large number of patients with the disease then. Because of the lack of specific drugs for treatment of tuberculosis, the government did not see the purpose for providing outpatient facilities. Patients diagnosed with tuberculosis were told to go home and rest, but they had to make a living. Those with a cough were told to isolate themselves from family members, but the whole family likely lived in one cubicle. They were told to improve their nutrition, but they could not comply due to lack of means.

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Nevertheless, just before the Second World War, several nongovernmental organizations (NGO) saw the need to provide care for tuberculosis patients, establishing outpatient clinics reserved for their care. The first clinic was established in collaboration with the Secretary for Chinese Affairs in one of the poorest districts, Kowloon City. Maryknoll Convent staffed the clinic with female doctors and nurses knowledgeable of the disease, and patients were examined and given advice on personal and domestic hygiene. As no specific drugs had been discovered for the treatment of tuberculosis as yet, the clinic dispensed cod liver oil donated by the drug companies,7 and distributed soya bean milk to the patients’ homes to improve their nutrition.8 The need for more accessible care was so great that the AntiTuberculosis Association opened a tuberculosis clinic in Stanley and at the Violet Peel Health Centre, which was attended by volunteer doctors.9

Tuberculosis after World War II After the war, the housing situation in Hong Kong, which was already problematic, devolved into a crisis. Severe shortages of construction materials hindered the repair and rebuilding of damaged houses, and the influx of refugees from communist China in late 1949 and 1950, and the severe overcrowding in unsanitary tenement houses, along with general poverty and malnutrition, led to major setbacks in disease control and prevention in Hong Kong. In 1948, tuberculosis accounted for 14.6% of all deaths in Hong Kong, rising to 17.7% in 1950, while tuberculous meningitis was responsible for 22% of all tuberculosis deaths. In 1951, the notification rate (number of cases of tuberculosis reported to the Medical and Health Department per year) reached 700 per 100,000 residents, the highest recorded in the history of Hong Kong.10

Treatment of Tuberculosis Han Suyin, a celebrated novelist and a medical officer working at the Queen Mary Hospital in the late 1940s described in her book, A Many-Splendored Thing, the tragic situation of patients diagnosed with tuberculosis, the plague of Hong Kong: “There were not enough hospital beds for the patients, and no treatment for them. They continued to work to support their families until they could no longer do so and went on to die …”11

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The high death rate and high incidence rate of tuberculosis finally prompted the government to action. The Medical and Health Department tried to admit patients with tuberculosis to the hospital for isolation and for surgical treatment, which offered some hope. In 1947, all patients admitted to government hospitals were seen first at the Harcourt Clinic where a proper diagnosis was made by a chest X-ray and sputum examination. Of the 4,855 patients with the diagnosis of tuberculosis in 1947, only 515 patients were admitted.12 The pathetic situation led several NGOs to build sanatoria for tuberculosis patients. In 1949, the Hong Kong Anti-Tuberculosis Association (Figure 10.1), with support and a generous donation from Mr. Jehangir Ruttonjee, a successful Hong Kong businessman and philanthropist, opened and operated the Ruttonjee Sanatorium, which had 140 beds solely devoted to treatment of tuberculosis, under the administration and care of the Columban Sisters who devoted thirty-nine years to the care of tuberculosis patients in Hong Kong. In 1956, the AntiTuberculosis Asssociation, again with the support of the Ruttonjee family, built the Freni Memorial Convalescent Home, and in 1957 the Grantham Hospital. In 1959, almost a quarter of the 7,500 hospital beds in Hong Kong were occupied by tuberculosis patients.13 Figure 10.1 The Hong Kong Tuberculosis, Chest and Heart Diseases Association (Hong Kong Anti-Tuberculosis Association)

Photograph by Rachel Pang

d The Columban Sisters The Missionary Sisters of Saint Columban was founded in Ireland in 1922 for missionary work in China, where they opened and staffed hospitals and clinics in Hanyang, Wuhan. In 1949, they responded to Mr. Ruttonjee’s request to take over the administration of the Ruttonjee Sanatorium in Hong Kong. For 39 years, they devotedly cared for tuberculosis patients until 1988 when sanatoria around the world closed down because effective drug treatment could be carried out on an ambulatory basis. The Columban Sisters also founded palliative care in Hong Kong. Medical students from the University of Hong Kong during that period learned about tuberculosis from Sister Aquinas and Sister Gabriel, both physicians. The Columban Sisters were innovative and were deeply spiritual. In a highly secular society, they showed the love of Christ not by displaying crucifixes, but by their love and dedication to tuberculosis patients. Lovein-action was their mode of evangelization. d

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Surgery Before WWII, there was no anti-TB drug available for the treatment of tuberculosis. Instead, the prescribed treatment consisted of rest, sunshine, and nutritious food. Wealthy patients in Hong Kong could be admitted to private hospitals to receive “collapse therapy” that would immobilize and collapse the lung, allowing the infected lung to rest and have a better chance to heal. “Collapse therapy” could be accomplished by one of the following techniques: 1) artificial pneumothorax (Figure 10.2), a procedure that collapses a lung by injecting air or nitrogen into the pleural cavity, allowing an infected lung to rest and heal; 2) artificial pneumoperitoneum, a procedure to introduce gas into the peritoneal cavity to collapse the lung; 3) plombage, sometimes referred to as pneumonolysis, which is a surgical technique that involved creating a space underneath the rib cage and filling this space with some inert material (such as lucite [acrylic] balls, ping-pong balls, or mineral oil) that would force the lung to collapse; and 4) thoracoplasty, a more drastic procedure to collapse the lung. Often deforming and crippling surgery was performed, like the Figure 10.2 Apparatus for induction of pneumothorax to collapse the lungs

Photograph courtesy of Hong Kong Museum of Medical Sciences Society

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removal of multiple ribs from the chest wall to permanently collapse the diseased lung. On the other hand, artificial pneumothorax and artificial pneumoperitoneum were considered relatively minor procedures and were performed on outpatients as early as 1931 in the Government Civil Hospital.14 These procedures led to improvement or remission in some patients, but the tubercle bacilli were not completely eradicated by such procedures; relapse of disease was common. After the war, even when anti-tuberculosis drug therapy became available, these “collapse” procedures continued for several years as an adjunct therapy before they were abandoned completely.

Era of Chemotherapy: From Single to Multiple Drugs Although streptomycin, an antibiotic, was discovered in 1944, it was not available in Hong Kong until late 1949. At first, treatment of tuberculosis with a single drug (streptomycin) was prolonged, lasting twelve to twentyfour months, and development of drug resistence was common. When more effective drugs, such as isoniazid and rifampin, were discovered, combinations were used to prevent the development of resistance. To find out which combination was the best, i.e., shorter duration and less recurrence, Hong Kong’s medical and health professionals participated in many drug trials that were conducted by the British Medical Research Council. The regimen of two months of isoniazid, rifampin, and pyrazinamide, followed by four months of isoniazid and rifampicin (a total of six months), was found to give a disease relapse rate of less than 3% in two years. From 1984 to 1995, this short-course regimen became the recommended treatment of tuberculosis. In 1995, because of increasing resistance to isoniazid, ethambutal or streptomycin was added to the initial treatment segment, increasing the cocktail to four drugs. This regimen of four drugs for the initial two months followed by isoniazid and rifampin for four months continues today to be the standard protocol for uncomplicated cases of tuberculosis with no drug resistance.15 With this powerful drug combination, patients with smear-positive tuberculosis (tubercle bacilli found in sputum smear in the most infectious period) became smear-negative usually within two to three weeks of treatment. Outpatient treatment with anti-tuberculosis drugs became the mainstay of treatment for the disease. There was no longer the urgent need for these patients to be admitted to the hospital for a prolonged period of isolation and treatment. Most patients could be discharged within

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two to three weeks when their sputum smear turned negative (no longer infectious) and would continue treatment as outpatients. For those whose sputum was only culture positive in the beginning, treatment could be taken entirely as an outpatient. Monitoring of liver function tests was necessary at least in the beginning because some of the drugs may cause liver damage. The beginning of 1980s marked the end of tuberculosis sanatoria worldwide, and Hong Kong was no exception. Tuberculosis clinics for outpatients became the important foci where diagnosis, treatment, and public health measures to control the disease were carried out.

Ambulatory Treatment of TB and TB/Chest Clinics The development of effective drugs changed the paradigm of treatment of tuberculosis from inpatient to outpatient therapy. These drugs led to a cure of the disease, reduced the cost of treatment, and allowed patients to return to work early and live a productive life. The first tuberculosis clinic in Hong Kong was opened in 1947 at the Harcourt Health Centre. The Harcourt Chest Clinic was small but had a high volume of attendance. The building was unsuitable and there were no X-ray facilities. X-rays were carried out at the Queen Mary Hospital, quite a distance from the clinic. The first X-ray examinations were done on 35-mm film and positive cases were confirmed in full-size pictures on paper. Clear films were used most sparingly because of costs. Sputum examinations were carried out by the Government Pathology Institute.16 Despite being overcrowded, lung collapse therapy (artificial pneumothorax and artificial pneumoperitoneum) was carried out in the Harcourt Clinic.17 Soon after the opening of the Harcourt Chest Clinic, a few subsidiary clinics were initiated in Aberdeen, Stanley, Tai Po, and Yuen Long Dispensaries.18 The second main tuberculosis clinic was launched in 1951 in Kowloon.19 In 1954, the new Wan Chai Chest Clinic replaced the Harcourt Chest Clinic. Equipped with a chest X-ray machine onsite, the Wan Chai Chest Clinic hastened the process of diagnosis. The clinic handled about 400 to 500 patients each day and over 1,000 patients collected drugs from the clinic every month.20 In 1950, when single-drug treatment was the common approach, only about a quarter of tuberculosis patients completed the full course of treatment. The twelve to twenty-four month-long regimen was too arduous, and the side effects too frequent and unpleasant. This had

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unfortunate consequences, as recurrence of the disease was common and the tubercle bacilli grew resistant to the single drug.21 In 1951, patients were given a combination of streptomycin and para-aminosalicylic acid for the first time. Although the compliance to treatment was much improved with the shortened course of six months starting in 1984, some still defaulted treatment. To solve this problem of treatment default, Dr. A. S. Moodie, the first Director of the Government Tuberculosis Service, introduced supervised treatment in the early 1950s, whereby patients would come to the clinic five days or three times weekly for their medications and the clinic staff would ensure that they took the drugs in the clinic for the whole duration of treatment. This tactic would later be adopted by the WHO and became known as Directly Observed Therapy (DOT). It was so successful in ensuring completion of treatment that it has become the cornerstone for tuberculosis treatment in Hong Kong.22 The implementation of DOT increased the work of the clinics considerably, with the hours of the clinics extended, starting early in the morning before the patients went to work and ending late in the evening to enable the patients to attend after work. The clinics were also opened on Saturdays to accommodate those who were too busy during the work week. The government provided adequate funding to ensure the success of the project, and in 1993, when tuberculosis was declared a global emergency, the WHO recommended DOT as the gold standard for treatment, validating Dr. Moodie’s visionary four-decade-old approach.23

Prevention of Tuberculosis Treating all patients with active tuberculosis to reduce the spread of infection obviously is the first priority, but this strategy alone would not decrease the incidence of disease quickly enough. Other preventive measures are necessary. The key methods to prevent and control tuberculosis include finding active cases using contact tracing and chest X-ray surveys, treating active cases in a timely manner, BCG vaccination of newborns and young children to prevent tuberculous meningitis, and extensive health education.

Contact Tracing Case finding of tuberculosis for treatment is essential to prevent spread of the disease. To achieve the most cost-effective result, one would

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concentrate on case finding among high-risk groups, such as contacts of active cases, immunocompromised patients, patients with cancer, silicosis, and diabetes. Contact tracing was so successful that it is still used as a method of discovering active cases. Contact examination in adults consists of a chest X-ray and obtaining sputum samples for examination and in children, with a tuberculin skin test and a chest X-ray if the skin test was positive. In the 1950s and 1960s, as high as 5% to 7% of close contacts were found to have active disease;24 but since the 1970s, with better control of tuberculosis, the yield of active disease among contacts dropped to only about 1% (Figure 10.3).25 Figure 10.3 Number of contacts examined and the percentage with active disease, 1951 to 2000

Source: Hong Kong Medical and Health Department Annual Reports 1951 to 2000.

Mobile Chest X-Ray Surveys Tuberculosis was so ubiquitous in Hong Kong that in the 1950s and 1960s, mobile vans with X-ray machines (Figure 10.4) were often sent out into the community to screen individuals. Prisoners, government employees, schoolteachers, and schoolchildren were interviewed and given chest X-ray examinations, and even though around 4% of those screened were suspected to be infected, only roughly 1% of those examined were proven to have active tuberculosis.26 In the late 1970s, when tuberculosis was increasingly brought under control, these surveys became less fruitful, and they were discontinued.27

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Figure 10.4 Mobile chest X-ray unit donated by the Hong Kong AntiTuberculosis Association

Photograph courtesy of Hong Kong Tuberculosis, Chest and Heart Diseases Association

BCG (Bacille Calmette-Guérin) Vaccination The BCG vaccination campaign began on 1 April 1952 with assistance of staff from UNICEF and the WHO. Three teams, each consisting of three vaccinators and one clerk, were provided by the Department of Health and trained by WHO personnel to perform tuberculin testing and vaccination. The Hong Kong Anti-Tuberculosis Association, an NGO, recruited the fourth team at the Ruttonjee Sanatorium to perform vaccination for the general public. The government planned to vaccinate all schoolchildren and the general public. When it was found that nearly 95% of the population of fifteen years old and over were tuberculin-test positive, mass vaccination of the general public was not carried out as these individuals had already been infected. One of the vaccination teams was integrated into the School Health Service, and vaccination was offered to all schoolchildren on a voluntary basis if they were negative on tuberculin testing. Schools were visited systematically and by the end of 1952, the school population had been mostly vaccinated. Thereafter, only the new entrants to the schools needed to be vaccinated. The preschool children were vaccinated in maternal and child health centers, and also during domiciliary visits. Vaccination of newborns was carried out in hospitals and larger maternity centers by government midwives, and in private maternity homes by private midwives trained to perform the procedure.28 The proportion of newborns vaccinated gradually increased, and by the 1960s, coverage reached over 95%.

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The efficacy of the BCG vaccination had been controversial. In many parts of the world, it was not found to be effective, but in Hong Kong, the BCG vaccination program was an unqualified success in preventing tuberculosis in infants and young children, and in reducing mortality from tuberculosis, mostly from tuberculosis meningitis (Figure 10.5).29 Figure 10.5 BCG vaccination coverage and tuberculous meningitis in children < 2 years 1958 to 1972

Source: Modified from Tuberculosis Manual, 2006, figure 15.1. Tuberculosis and Chest Service, Centre for Health Protection, Department of Health.

Social Assistance and Health Education All patients on first diagnosis were interviewed by the Almoner Department (now Social Service). For those requiring hospitalization, any financial stress would be alleviated as much as possible to relieve the patient’s anxiety for his family. Since social security did not exist as we know it today, few tuberculosis patients could afford to give up work for the length of time necessary for treatment. The Almoner’s office had to work hard to secure a promise from the patient’s employer to keep the job for his worker until he was fit to work, but most of the time it was an unrealized dream. The government was able to assist such cases by provision of funds and helping a patient’s job search should he or she be fired. The Almoner’s office distributed milk powder to some needy patients and their children.30 In terms of prevention, pamphlets and posters with information on the disease, emphasizing completion of the full course of treatment, were widely distributed. Messages on prevention and treatment prepared by the

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Department of Health were delivered through the radio and television regularly in order for patients to seek diagnosis and treatment early.

Contributions of Tuberculosis Clinics Throughout the 1950s to 1980s, tuberculosis clinics were some of the busiest in Hong Kong. The number of chest clinics mounted to cover as many districts as possible to allow patients ready access to DOT. In 1973, there were seven main chest clinics, ten part-time clinics, and ten other clinics where patients could receive injections (of streptomycin) or participate in DOT (Table 10.1). The general medical outpatient clinics provided the space and personnel for the part-time chest clinics as well as those giving injections to the tuberculosis patients. Table 10.1 Government chest clinics in 1973 Full-time

Hong Kong

Kowloon

Wan Chai Chest Clinic Sai Ying Pun Chest Clinic Shau Kei Wan Chest Clinic

Kowloon Chest Clinic Kwai Chung Chest Shek Kip Mei Chest Clinic Clinic Yau Ma Tei Chest Clinic

The New Territories

Part-time Aberdeen Jockey Club Clinic

Robert Black Health Centre Kwun Tong Jockey Club Health Centre

Sai Kung Dispensary Sha Tin Clinic Shek Wu Hui Jockey Club Clinic St. John Hospital Tai Po Jockey Club Clinics Tuen Mun Clinic Yuen Long Jockey Club Clinic

Injection

Hung Hom Dispensary Ho Tung Welfare Centre Peng Chau Clinic North Lamma Clinic Sha Tau Kok Clinic Silvermine Bay Dispensary Tai O Dispensary South Lantau Hospital Chee Wan Floating Dispensary Chee Hong Floating Dispensary

Source: Hong Kong Medical and Health Department Annual Report, 1973/74, Table 26.

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Table 10.2 shows the work of the chest clinics in 1956 and 1960, the number of new patients, total attendance, the patients who were diagnosed and began treatment, and those who completed treatment. Of all the new patients referred to the chest clinics, about one-third were diagnosed to be suffering from active tuberculosis. Those started on treatment would require sputum examinations and chest X-rays on follow-up examinations to assess their progress. On completion of treatment, they would be followed up annually for at least three years for possible recurrence. Table 10.2 Work of government chest clinics in 1956 and 1960 First attendance Cases of tuberculosis discovered Total attendance for treatment Under treatment from previous year Started treatment during the year Completed treatment Failed to attend Admitted to hospital Still on treatment at the end of the year Contact examination Contact chest X-ray Contact tuberculin testing No. of X-ray done for surveillance

1956 34,607 10,733 401,568 1,703 7,861 1,037 2,022 1,029 5,887 10,857 7,699 3,158 27,842

1960 35,991 12,937 2,001,960 16,062 12,617 3,724 4,975 1,592 16,433 18,411 10,514 3,299 69,274

Source: Hong Kong Medical and Health Department Annual Report, 1956/57, 24 and 1962/63, 30.

After an active case of tuberculosis was diagnosed, contact tracing had to be carried out. Contacts would require investigations, including chest X-rays, sputum examinations, and in children, tuberculin testing to find out whether they have been infected or have the active disease. Contacts diagnosed with active tuberculosis would be processed in the same way as new patients. Each patient with active tuberculosis would be interviewed by the Almoner Department to see what assistance would be required. Health visitors would make visits to track down the defaulters and persuade them to continue their treatment. Chest X-ray surveys were carried in a number of workplaces, especially if one or multiple workers in the same organization contracted the disease. Thus one diagnosed case

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of active tuberculosis would generate a large amount of work for the chest clinic. For three decades, the chest clinics maintained a very high level of activities. Their persistent efforts bore fruit. The death rate from tuberculosis dropped rapidly when drug treatment became available in the early 1950s and continued to do so at a gradual pace until the late 1970s when the death rates decreased to below 10 per 100,000 and in 2019, it reached 2.7 per 100,000. The fall in notification rate followed two to three years after the death rate of tuberculosis began to decline and dropped rapidly from the mid-1950s to the late-1970s. The decline of tuberculosis notification rate slowed down thereafter and remained above 100/100,000 until 2002, when it dipped for the first time to two digits. In 2019, it reached 53.3/100,000 (Figure 10.6). At present, there are still eleven fulltime and six part-time chest clinics (Appendix 1, Table 6). Figure 10.6 Notification and death rates of tuberculosis in Hong Kong, 1950 to 2020

Source: Centre for Health Protection, HKSAR, https://www.chp.gov.hk/en/statistics/ data/10/26/43/88.html.

In countries with advanced economies, the notification rate of tuberculosis had fallen to below 10 per 100,000 as early as the 1980s. It is unclear why in Hong Kong the rate declined so slowly after 1980, despite

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the vigilance and the hard work of the chest clinics. About 60% of all active cases of tuberculosis in Hong Kong in the recent two decades occurred in those over the age of sixty, and in these patients, the disease was mainly due to reactivation rather than new infections.31 In other countries of advanced economy, all individuals with positive tuberculin and negative sputum examinations would be given twelve months of isoniazid prophylaxis. In Hong Kong, prophylactic treatment is not given to these individuals because of the high incidence of hepatitis B infection and the high incidence of liver toxicity to isoniazid and rifampin among Chinese with chronic hepatitis.32 Globally, tuberculosis remained one of the top ten causes of death worldwide, and a leading killer in HIV-positive people.33 It was estimated that in 2019, an projected 10 million people fell ill with tuberculosis of which 1.2 million were children. Tuberculosis incidence is falling at about 2% per year globally, but the decline is slower than anticipated. In Hong Kong, the decline in the notification rate of tuberculosis has been slow since the 1980s. There is still a long way for the tuberculosis rate to fall below 10/100,000, as found in other countries with advanced economies. While Hong Kong is fortunate in that HIV infection and multidrug-resistant tuberculosis are not major issues for keeping the rate of tuberculosis high, it does need to find a strategy to hasten the decline of tuberculosis and to bring the notification rate to a level commensurate with its claim as a world city.

11. Sexually Transmitted Diseases (STDs): Ancient and Emerging Diseases

Venereal Diseases (Syphilis and Gonorrhea) before World War II Venereal diseases, which refer mainly to syphilis and gonorrhea, are an ancient group of diseases that have in fact ravaged Hong Kong for centuries. They did not discriminate against men or women, Europeans or Chinese, rich or poor, and were ultimately brought under control with the use of antibiotics together with public health measures. The government attempted to control the spread of these diseases by passing a number of ordinances to legalize prostitution in the nineteenth and early twentieth century. To ensure the inmates of brothels that served the foreigners were free from these diseases, the government provided regular medical examinations, but the brothels for the Chinese were exempted. Despite the infectious nature of the disease, the high prevalence and morbidity among the Chinese, nothing was done by the government to relieve the suffering. It was not until 1921 that the first venereal diseases clinic was created at the recommendation of the National Council for Combating Venereal Diseases, after its chairmen’s visit to Hong Kong. Over the years, more venereal diseases clinics were established, and the staff of these clinics were responsible for treating and preventing this group of diseases. In its early days, Hong Kong was a city filled with many more men than women. In this city where men arrived to make a living without their families, prostitution flourished. Due to the prohibitive cost of accommodation, Chinese men were reluctant to bring their wives and children with them, and preferred to leave them in the care of relatives in their native villages. Also, Chinese immigrants failed to see prostitution as negative. It was just a necessary service for a place with a high male to female ratio, an imbalance that persisted until the Second World War.1 Hong Kong was also frequented by the British army, the Royal Navy, and

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many foreign merchant ships. As the business of prostitution boomed in those days, its unwanted side-effects—venereal diseases—increased. The rule of segregation of the Chinese from the Europeans also applied to the brothels, with some brothels servicing only Chinese and others only foreigners. The brothels for foreigners were usually patronized by foreigners of lower social class, mostly soldiers and seafaring merchants; consequently, they employed women of similar social standing. Higher class foreigners did not frequent brothels as they tended to keep “protected women.”2

The Epidemic, and the Government’s Attempts at Control The venereal diseases epidemic began in the mid-1850s, when the rearadmiral noted a large number of his crew came down with venereal diseases after visiting Hong Kong.3 In 1857, Dr. J. C. Dempster, Colonial Surgeon,4 noted in his annual report that every sailor admitted into the Seamen’s Hospital with fever or bowel problems also had a venereal disease, as did almost all prisoners in the jail, whether they were Chinese or European. He had never witnessed such an appallingly high prevalence of venereal diseases in other cities where he had served.5 Dr. P. B. C. Ayres, Colonial Surgeon from 1872 to 1896, noted the scourge of these diseases among the local population: “It was a daily occurrence to see Chinese in the streets of Hong Kong horribly scarred with syphilitic disease, with nose and eyes completely gone. Prisoners come into the Gaol who, when stripped, reveal most horrible scars and deformities, the result of syphilis in its worst form….”6 At that time, there was no specific treatment for venereal diseases. The Hong Kong government attempted to control the epidemic by passing a number of ordinances. The first ordinance, the Venereal Diseases Ordinance, was enacted in 1857 for “checking the spread of venereal diseases,” and mandated the registration and inspection of brothels, compulsory medical examination of the prison inmates, and punishment of prostitutes who infected their clients. It also required the segregation of diseased prostitutes in the aptly named Lock Hospital until they were cured.7 The ordinance required prostitutes to undertake mandatory periodic medical examinations. Chinese prostitutes, particularly those belonging to brothels that served Chinese clients, objected vehemently to this ordinance. As a result, they were exempted from examination, even though venereal diseases thrived among the Chinese population.8

Figure 11.1 Painting by Rembrandt

Portrait of Gerard de Lairesse, 1665–1667, Rembrandt, Robert Lehman Collection, 1975, The Metropolitan Museum of Art. d Congenital Syphilis In 1665, Rembrandt painted a portrait of his younger colleague, Gerard de Lairesse, leaving the latter’s unique physical appearance for contemporary speculation. de Lairesse was also a celebrated Dutch artist who was widely influential in his time for his French-style paintings. Today, many believe that he shows the late facial manifestations of congenital syphilis: frontal bossing, saddle nose, short maxilla, and protuberant mandible. (https://canadiem.org/spot-diagnosis-case-dutchpainter/) d

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Ten years later, a more draconian ordinance, the Contagious Diseases Ordinance of 1867, was enacted to empower the Registrar General and the Superintendent of Police to break in and enter, without a warrant, any house suspected of being an unlicensed brothel, and to arrest the keeper. In unlicensed brothels, both the brothel keeper and the prostitutes were targeted for punishment.9 Following the implementation of the 1867 Contagious Diseases Ordinance, even though the incidence of venereal diseases was reduced in the army, the conduct of the police in handling prostitutes generated many scandals, abuse, and corruption.10 The inspectors of brothels zealously suppressed unlicensed brothels and tracked down hundreds of women to prosecute. Many women were terrified at the prospect of a degrading punishment and risked their lives in efforts to escape by running into another house or trying to flee onto adjacent rooftops. Some fractured their arms or legs, or suffered worse consequences. On the night of October 17, 1877, two women who were trying to escape fell from a roof and died.11 These scandals triggered Sir John Pope Hennessy, Governor of Hong Kong (1877–1882), to form a commission to enquire into the workings of the 1867 Contagious Diseases Ordinance. The inquiry was carried out over a period of months by three people: Thos. C. Hayllar, one of Her Majesty’s Counsels for the Colonies, who chaired the Commission; Reverend E. J. Eitel, a sinologist; and W. Keswick, an unofficial member of the Legislative Council, who was the taipan of the British “hong,” Jardine Matheson & Co. They produced a highly critical report of the workings of the 1867 Ordinance.12 In the meantime, moral reformers in England objected to the implicit double standard in the ordinance, as only women were compelled to submit to demeaning medical examinations. They fought hard to have the Contagious Diseases Ordinance revoked. Finally in 1886, the British parliament repealed the ordinance and abolished licensed prostitution. Bouyed by this success, moral reformers directed their fight to end legalized prostitution in the British colonies. The Colonial Office had no option but to instruct the Governor of Hong Kong to follow the parliament’s decision. In 1894, the bill to abolish legalized prostitution was passed in Hong Kong, carried through only by the official members of the legislature, with unanimous opposition from the unofficial ones. The results were predictable—the incidence of venereal diseases in the garrison climbed because of the higher rate of disease among the prostitutes

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who serviced the foreigners when periodic medical examination was discontinued. In 1897, over 50% of the troops in Hong Kong underwent treatment for venereal diseases. In Singapore it was not different.13

Extralegal System of Registration of Brothels The next Secretary of State for the Colonies, Sir Joseph Chamberlain, was sympathetic to the plight of the Governor of Hong Kong, Sir Henry Blake, and understood the problem of venereal diseases among British soldiers and navy sailors. Despite legal prostitution having been abolished years earlier, in 1899, Blake, in collusion with Sir Joseph Chamberlain, instituted an extralegal system of regulations, approving registration and medical examination of prostitutes in the same way as before.14 This state of affairs persisted for over twenty years until 1921, when a commission from the National Council for Combating Venereal Diseases, consisting of Mrs. C. Neville-Rolfe and Dr. R. Hallam, arrived in Hong Kong. The commission discovered this extralegal system of licensing of prostitution and the almost complete lack of facilities for treatment of venereal diseases. In their report to the Parliament, the commission described fully not only the situation regarding prostitution in Hong Kong, but also other abominable conditions that they discovered in the colony: high infant mortality and the virtual lack of public health measures.15

Social Hygiene Clinics The report by Mrs. Neville-Rolfe and Dr. R. Hallam caused quite a stir in the British Parliament when they exposed the secrets of the Hong Kong government, and one of their recommendations led to the formation of venereal disease clinics in Hong Kong. The first clinic for treating venereal diseases began at the Government Civil Hospital in February 1928 headed by the Medical Officer of Health. In the beginning, the clinic was open only on Wednesdays and Fridays from 5 pm to 7 pm. During the first six months, only 126 patients were treated, of which 61% suffered from syphilis, 28.6% from gonorrhea, and 10.3% from chancroid. At the end of March of the same year, Tsan Yuk Hospital started a social hygiene clinic for women. Venereal diseases were also treated at the outpatient departments of various government hospitals as well as government dispensaries (Table 11.1), however, the nature of treatment was not described.16

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Table 11.1 Number of clinics and new cases seen in government social hygiene clinics, 1929 to 1939 Year 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939

Clinics 1 1 2 2 3 4 4 6 6 6 6

Male (N) 439 1,047 1,619 2,488 3,296 3,804 3,685 4,462 5,213 5,379 5,894

Female (N) 0 0 347 443 1,035 1,305 1,482 2,307 2,549 2,542 2,679

Total (N) 439 1,047 1,966 2,881 4,331 5,109 5,167 6,767 7,762 7,921 8,573

Note: N = number; 1 = Government Civil Hospital (GCH); 2 = GCH, Kowloon Hospital (KH); 3 = GCH, KH, South Kowloon Hospital (SKH); 4 = GCH, KH, SKH, Violet Peel Welfare Centre; 6 = GCH, KH, SKH, Violet Peel, Tai Po, and Yuen Long dispensaries. Source: Medical and Sanitary Reports for years 1929 to 1939, HKAR 1929 to 1939.

In those days, heavy metals were used for the treatment of syphilis and gonorrhea. These poisons were ineffective and highly toxic. For syphilis, mercury was administered in various ways: orally, topically, and by injection. A more drastic method was to enclose the patient in a box with the patient’s head sticking out. Mercury was then placed inside the box and a fire started under the box, causing the mercury to vaporize,17 hence the expression “a night in the arms of Venus leads to a lifetime on Mercury.” Those who endured this twenty- to thirty-day treatment developed sweating, salivation, and sore gums—signs of mercury poisoning. In 1910, a more effective drug, Salvarsan, containing arsenic, was developed for the treatment of syphilis. In the 1920s and 1930s, arsphenamine, another arsenic compound, was recommended. The arsenicals could not be used alone, and they had to be reinforced with bismuth, which also had to be given in long courses, often extending for over one year even when treatment began in the primary stage of the infection. The prolonged treatment was the greatest obstacle to compliance. The most serious complications of arsphenamine were agranulocytosis and hemorrhagic encephalitis; treatment therefore required monitoring of urine and white blood cell count. These treatment modalities were used until after World War II, when penicillin became readily available.18

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Syphilis was a scourge that accounted for many premature deaths before the discovery of penicillin. Many famous classical composers are known or strongly believed to have contracted it, including Mozart, Beethoven, Schubert, Hoffmann, Smetana, Wolf, Delius, and Scriabin. Their symptoms ranged from fevers to blindness, deafness, dementia, and death. Yet because syphilis often masquerades as other diseases such as mental illness, there might be more composers affected without knowing. For example, Scriabin presented with symptoms of mental illness late in his life, including messianic megalomania brought on by the late stage of syphilis. What the world of classical music would be like if penicillin were discovered two centuries earlier.19

Venereal Diseases after World War II After World War II, the governor made a proclamation mandating treatment of venereal diseases (renamed sexually transmitted diseases [STDs] because of their method of transmission) in certain classes of patients, namely the sex workers, because of the high incidence among the British army, navy, and air force personnel.20 The intention of this legislation was to provide a means of examining and treating persons believed to have caused the spread of this disease to others. Health visitors, on receiving the names of sex workers usually from the various sources, such as the patients or the clinics, visited them and persuaded them to receive treatment. Government STD clinics reopened in 1945.21 During the first year, 12,767 new patients attended. More STD clinics opened. In 1947, there were five government clinics: one in Sai Ying Pun, which served both men and women; one each in Wan Chai and in South Kowloon for women; and one each in Harcourt Clinic and in Kowloon Clinic on Ashley Road for men. In addition to these main clinics, small clinics were held in dispensaries in Kowloon City and the New Territories.22 Because of the high incidence of STDs after the war, the subject of social disease was no longer a taboo but emerged out of prudery to occupy a prominent place in society. Even maps of Hong Kong and Kowloon had addresses of various STDs clinics (Figure 11.2). Throughout the health week in April 1947 organized by the government, the public was advised on checking personal health and receiving treatments for medical conditions.23

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Figure 11.2 Names and addresses of social hygiene clinics in a 1950s’ directory of street names of Hong Kong & Kowloon published by a local bookshop

Photograph courtesy of Mr. Keith Poon

The STD service was under the supervision of the Senior STD Officer, a specialist, who had five medical and twenty-five technical staff to assist him in the 1950s. In addition to the five clinics, there was a small hospital with twenty-eight beds in Wan Chai for female patients and six beds at the Queen Mary Hospital for male patients with venereal diseases.24 The STD specialist also provided services for leprosy and dermatology (skin) diseases.25 In 1961, because of the large number of patients with skin diseases, the STD service was rearranged to provide nine clinics for purely dermatology diseases and thirteen clinics for STDs and leprosy. The Wan Chai Hospital continued to serve female patients and the Lai Chi Kok Hospital male patients.26 In 1984, the Yung Fung Shee Social Hygiene Clinic opened, making a total of seven full-time and six part-time clinics throughout the region. In 1984, the clinics served a total of 35,288 new patients with a total attendance of 176,024.27 Since then, with good treatment and better control of the disease, the number of new cases and total attendance declined. At present, there are six STD clinics serving female patients and the same number serving male patients.28

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Penicillin: The Miracle Drug The wide availability of penicillin, the so-called miracle drug, after the Second World War led to effective treatment of syphilis and gonorrhea. Current treatment of syphilis is fairly straightforward, consisting of one intramuscular injection of long-acting benzathine penicillin G 2.4 million units which will cure primary, secondary, and early latent syphilis.29 At variance with tuberculosis treatment, which requires multiple drugs for a minimum of six months in uncomplicated cases, treatment of syphilis and gonorrhea was uncomplicated until the development and spread of antibiotic-resistant gonorrhea. At present, for genital and anorectal gonorrhea, the WHO recommended dual therapy: one ceftriaxone 250 mg intramuscular injection as a single dose plus azithromycin 1 gm orally as a single dose because of high prevalence of resistance to penicillin and to azithromycin.30

STDs and the Sexual Revolution The sexual revolution or liberation, which posed a challenge to the traditional social values, began in the United States, and between 1960s and 1980s, gradually spread to other parts of the world, with accompanying STDs. It was estimated that during that period, 200 million people were infected with gonorrhea and 50 million with syphilis every year globally. Another worrying feature is the high percentage of cases among the fifteen to twenty-five year olds.31 Figure 11.3 shows the incidence of all STDs, compared to syphilis and gonorrhea specifically, in Hong Kong after the Second World War. The incidence of all STDs increased very briefly in the 1950s and rapidly declined until 1980, when it took an upward swing at the same time as STDs were declared a “worldwide epidemic” by the World Health Organization.32 Fortunately, in Hong Kong, STDs took a downward course again after 2000. Of note is that the incidence of gonorrhea and syphilis did not increase after 1980 even though the total number of STDs increased, indicating the increase in STDs between 1980 and 2000 was mainly due to the modern variants of STDs (see the following paragraph).

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Figure 11.3 Incidence (no./1,000) of gonorrhea, syphilis, and total STDs, 1950 to 2015

Note: Data for individual STDs not available in Medical and Health Department Annual Reports after 2001. Source: Hong Kong Medical and Health Department Annual Report 1951 to 1989 and Department of Health 1990 to 2017.

Changing Pattern of Diseases: New Variants of STDs The downward trend of STDs in Hong Kong after WWII was associated with a changing pattern. Diseases such as syphilis and gonorrhea decreased with time (Figure 11.4) and were replaced by other STDs, such as nonspecific genital infections, nongonorrheal urethritis, genital herpes, and genital warts (Table 11.2). The latter conditions are caused by organisms not sensitive to penicillin. For example, genital herpes, manifested as ulcers in the genial region, is due to a virus related to the virus causing cold sores in the mouth and is moderately contagious. Nonspecific genital infection and nongonococcal urethritis are commonly caused by chlamydia infection, but can also be due to other bacterial or viral infections. Interestingly, conditions such as chancroid (Haemophilus ducreyi) and lymphogranuloma venereum (Chlamydia trachomatis) diseases produced by organisms not responsive to penicillin also gradually diminished. By 2000, nonspecific genital infections and nongonococcal urethritis accounted for over 50% of all STDs, overtaking gonorrhea as the most common STD.33

25.4 19.1 14.5 17.3 3.8 4

1950 1960 1970 1980 1990 2000

54.5 59.4 67.6 43.8 23.7 11.9

Gonorrhea 18.5 8 4 2.6 0.3 0

Chancroid

Lymphogranuloma+ 1.6 0.14 0.65 0.57 0.07 0

Genital Infection* 0 0 0 8.7 13.9 25.4

Source: Hong Kong Medical and Health Department Annual Reports of respective years. Data on the types of STDs were not available in the above reports after 2001.

Note: +Lymphogranuloma Venereum; *Nonspecific genital infection; **Non-gonorrheal urethritis

Syphilis

Year

Table 11.2 STDs (% of total) seen in the government STD clinics, 1950 to 2000 0 5.4 6.4 15.5 18.9 24.1

Urethritis**

Genital Herpes 0 0 0 4.2 7.3 5.4

0 0 0 10.7 16.5 12.1

Genital Warts

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Like syphilis and gonorrhea, these newer STDs invariably have an adverse impact on sexual and reproductive health. Mother-to-child transmission results in stillbirth, neonatal death, low-birth-weight, prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital abnormalities. HPV (human papillomavirus) infection, which induces genital warts, also predisposes one to cervical cancer. Infections such as gonorrhea and chlamydia are major reasons for pelvic inflammatory disease and infertility.34 Diseases such as herpes and syphilis increase the risk of HIV infection threefold or more. The urgent need to prevent STDs cannot be overestimated.

Control and Prevention To encourage patients to come forward for treatment, the STD Service offered consultation and treatment free of charge to any member of the public: sailors of all nationalities, women referred from maternal and child health centers, prison inmates, psychiatric patients from Castle Peak Hospital, persons referred from the Medical Examination Board, and applicants for emigration to the United States and Canada.35 Starting in November 1950, free Kahn tests for detecting T. pallidum infection were provided to all pregnant women attending either antenatal clinics or midwives in private practices. In general, approximately 7% of antenatal blood samples and 1.5% of cord blood samples were Kahn test positive. The patients and their babies were treated accordingly.36 Figure 11.4 shows the declining rate of positive Kahn or VDRL tests (to detect syphilis infection) in the blood of pregnant women between 1950 and 2000. The incidence of congenital syphilis also decreased accordingly from 200 cases per year in the 1950s to one or two cases per year after 1980s.37 Blood samples taken from patients attending hospitals and clinics for treatment of other conditions showed a VDRL positive rate of 8.5% in 1954, which dropped to 3.3% by 1958.38 In the late 1950s and early 1960s, a group of around 1,000 prostitutes attended the STD clinics voluntarily for periodic examination every year. For the first year, 64.8% had no STDs, and the percentage increased to 76.1% on the fourth year.39 In addition to treatment of those with a disease, the STD Service employed a number of health visitors to carry out contact tracing, finding those who defaulted treatment, and performing periodic examination for volunteers who were at high-risk of developing these diseases, such as sex workers.40

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Figure 11.4 Incidence of positive VDRL in the blood of pregnant women, 1950 to 2000

Source: Hong Kong Medical and Health Department Annual Reports 1950 to 1989 and Department of Health from 1990 to 2000.

Health education materials in the form of pamphlets, posters, and cards were distributed and, lectures were given monthly to patients and nurses in training in various hospitals and clinics.41 Counseling on behavioral approaches, including safe sex, risk reduction, and condom promotion, was directed at key populations, such as sex workers and adolescents. The aim was to improve people’s ability to recognize the symptoms of venereal diseases and to understand the importance of seeking early medical care in order to avoid lifelong complications—all were key measures to prevent the dissemination of STDs. Outpatient services play an effective role in the treatment, prevention, and control of STDs.

HIV/AIDS: The Emerging STD Just as STDs were under control, a new disease appeared in the horizon first, in the United States and then spreading to Hong Kong. In 1984, Hong Kong reported the first HIV (Human Immunodeficiency Virus) infection,

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and one year later, the first case of AIDS (Acquired Immunodeficiency Syndrome). HIV is caused by a retrovirus which produces two enzymes, reverse transcriptase and integrase, to enable the virus to enter the human cell called the CD4 lymphocyte. The virus proliferates within the lymphocytes, eventually resulting in the death of the infected cells. CD4 lymphocytes are crucial for the body’s immune defense system. If the CD4 lymphocytes drop to below 200 per cu mm, the patient will become susceptible to opportunistic viral, fungal, or bacterial infection, alone or in any combination such as PCP, cryptococcosis, mycobacterium avium intracellulare, and reactivation of toxoplasmosis or cytomegalovirus infections.42 The horrors of this disease generated alarm and fear around the world. In 2019, close to 38 million people globally were living with HIV (of these only two-thirds were receiving treatment), 1.7 million became newly infected, and almost 690,000 people died from AIDS-related illnesses every year. Since the onset of the epidemic, 32.7 million people have died from AIDS-related illnesses.43

Prevention Program for HIV/AIDS Because of the high morbidity and mortality of AIDS, even before its arrival, the Medical and Health Department organized several education programs concerning the disease. As soon as the first case of HIV was reported in 1985, the Department started a surveillance program on HIV/ AIDS to provide updated information on the prevalence of HIV infection among various risk groups, such as homosexuals, multi-transfused patients, and intravenous drug abusers. The Hong Kong Red Cross Blood Transfusion Service also began mass screenings of blood donors for antibodies to HIV.44 The government appointed the Advisory Council on AIDS to take the lead to fight against the disease, and a number of nongovernmental organizations (NGO) also engaged actively in health education and in supporting those with disease. The Council operated through two committees: 1) the Committee on Education and Publicity on AIDS and 2) the Scientific Committee on AIDS. The Committee on Education and Publicity on AIDS promotes community involvement in AIDS education, sustains public awareness, coordinates the training of intermediaries to provide education and

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counseling, fosters support of HIV-infected individuals, and coordinates activities for target groups such as students, youths, drug abusers, and others engaging in high-risk behavior. Various channels are employed, including mass media, health talks, and special programs for specific groups.45 The Scientific Committee on AIDS, which focuses on the production of comprehensive guidelines for the prevention of HIV transmission in healthcare settings, oversees the HIV surveillance program, undertakes quality assurance programs on HIV-antibody testing, and carries out studies and scientif ic research projects on HIV.46 In 1994, the Advisory Council published its policy document: Strategies for AIDS Prevention, Care and Control in Hong Kong. Working groups were formed targeting students, youth, drug users, and workers.47 A Special Prevention Program for AIDS was launched which included maintaining the voluntary HIV/AIDS reporting system, coordinating the HIV seroprevalence system, operating a behavioral surveillance system, supporting an STD surveillance program, and running a series of registries.48 Despite these efforts, cases of HIV and AIDS continue to increase in Hong Kong (Figure 11.5).49 Figure 11.5 Cumulative number of HIV and AIDS cases, 1985–2020

Source: Modified from Annual and Cumulative HIV/AIDS Statistics in Hong Kong Centre for Health Protection, Department of Health, HSAR, 2020, accessed on 23 March 2021, https://www.chp.gov.hk/en/statistics/data/10/26/130/122.html.

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At present, HIV prevention and health promotion programs are carried out in the community and delivered mainly under the operation of the Red Ribbon Centre (RRC), a special government unit of the Public Health Services Branch. The mission of RRC is to facilitate and enhance the community response to HIV/AIDS. It collaborates with community agencies in a number of projects such as the Youth Funding Scheme on AIDS and organizes condom promotion activities and outreach programs to drug users.50

Clinical Program for HIV/AIDS The delivery of clinical services to people living with HIV/AIDS ranges from hotlines, HIV counseling and testing, clinical consultations and treatment, nursing care, and psychological support. Other clinical activities include management of needle injuries and dermatological/genitourinary consultations.51 There are at present three special clinics offering treatment and other services to those with AIDS: the Hong Kong AIDS Foundation Ltd., the Kowloon Bay Integrated Treatment Centre, and the AIDS Concern Health Service Center. The Queen Elizabeth Hospital is the designated hospital for AIDS patients who need hospital care. A doctor and a health nurse are responsible for the monitoring of those tested HIV positive for treatment and counseling. The AIDS program is not under the administration of the Hospital Authority but remains a centralized government operation under the Department of Health.52 The prevalence of HIV among gay men in Hong Kong was around 6.54% in 2017,53 up from the previous years (around 4%)54 and higher than other at-risk populations such as female sex-workers and drug users. Heterosexual transmission has remained relatively stable, with around 130 cases per year, as have the number of cases in drug users. Condom use among gay men with different partners has increased, as have the rates of HIV testing. The increase in HIV testing may partly explain why the number of new infections detected in the community remains high and is indeed climbing, despite the use of condoms. However, among certain subgroups such as young gay males who find sexual partners through the internet, and people who travel overseas for sex, risky behavior remains high and level of condom use low.55 Worldwide, in 2019, more than one million sexually transmitted infections are reported every day and more than 290 million women have

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human papillomavirus (HPV) infection, which may cause cancer of the cervix. Almost one million pregnant women were infected with syphilis in 2016, resulting in adverse birth outcomes including 200,000 stillbirths and newborn deaths.56 In Hong Kong, sexually transmitted diseases remain endemic and occurred at a rate of 175/100,000 in 2018,57 compared to the highest level of 1,100/100,000 in 1952. In recent years, the two seemingly unrelated diseases, tuberculosis and STDs, are linked together by an emerging infection, HIV, which is sexually transmitted. HIV patients are predisposed to tuberculosis and tuberculosis is a major killer of HIV-infected patients. The diseases that have haunted us since ancient times are still very much with us today, despite all the efforts to eliminate them. Though not appearing in the same epidemic proportions as they used to, they are made much more difficult to treat and more deadly because of the development of drug resistance.

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12. Mental Health Service: From Asylum to Outpatient Care

Patients suffering from severe mental illness require prolonged periods of rehabilitation before they can be reintegrated into the community. They are often stigmatized, making it very difficult for them to reestablish themselves in society. To make matters worse, mental illness tends to relapse and requires constant supervision and aftercare to detect early relapse, without which reintegration is unlikely to be successful. Although the process of patient rehabilitation is usually a long and arduous one, rehabilitation is important not only from a humanistic point of view, but also in alleviating societal burden by returning some of the patients to the work force. In the seventeenth century, asylums were built to house those with mental disorders, to protect them from doing harm to themselves and others, and at the same time to remove them from the view of their families and communities. These institutions were usually overcrowded and unhygienic. The medical community treated these patients with brutal methods such as physical restraint, ice water baths (hydrotherapy), and later with convulsive therapy using insulin or metrazol and electroconvulsive therapy. These treatments were inhumane and lacked scientific basis. During the second half of the nineteenth century, with the introduction of drugs such as morphia, chloral hydrate, paraldehyde, and hyoscine, pharmacological agents were gradually replacing physical methods for behavior control. Asylums gave way to mental hospitals, but many patients still required institutionalization. By the twentieth century, the discovery that certain psychoses, such as cerebral pellagra and neurosyphilis, could be treated by appropriate drug therapy, reduced the number of patients in mental hospitals. In the mid-twentieth century, effective and safe treatments for mental illness, such as schizophrenia, depression, and anxiety disorders, finally arrived. Management of these patients changed from hospital-based service to community-based service as outpatient treatment with modern pharmacotherapy became possible. At present, the use of pharmacological agents seems to be the exclusive

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approach to treatment of most mental illnesses. The psychological approaches to management, which are far too time consuming, are often forgotten, and not many psychiatrists have been adequately trained to do so. The evolution of management of mental illness in Hong Kong followed a similar pattern as in Western countries: institutionalization, rehabilitation, and community-based services. The last phase which includes outpatient services, lagged behind the West for decades because of social and environmental situations in Hong Kong, where the population density was high. It was difficult for any family to be able to care for a sick family member at home, especially one with mental illness, partly because of stigmatization and partly lack of physical space.1

Era of Lunatic Asylums Before 1875, there were government institutions for lunatics—an antiquated term referring to patients with mental illnesses then. Due to the British presence in Hong Kong at the time, lunatic patients were segregated racially, just as the ordinary people. The European lunatics were sent to Victoria Gaol on Old Bailey Street while the Chinese lunatics to Tung Wah Hospital when it opened in 1872. Inside Tung Wah Hospital was a special insanity ward, where patients wore restraints. To add to the stereotypical, but very real, imagery of this type of institutionalization, these patients were looked after by a Chinese doctor, but confined in dark dreary cells. Patients who displayed violent tendencies were chained like wild beasts.2 In 1875, a temporary lunatic asylum was founded on Hollywood Road for European patients with mental disease and relocated in 1880 to a deserted old Chinese school house on Hospital Road. When a typhoon struck Hong Kong, all the European patients had to be transported to the Victoria Gaol for safety.3 The number of admissions was small, about six to eight each year, mostly destitute seamen from various ports in different parts of the world. The government, saddled with the cost of keeping them, tried hard to have them repatriated and to have their consulates pay for their journey home.4 In 1885, the European asylum with eight beds was finally moved into a new, fine, airy building not far away from the Government Civil Hospital.5 In 1890, the first Chinese Lunatic Asylum was built just below the asylum for Europeans. It had eight beds, and the patients from Tung Wah Hospital were transferred there.6

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As the population in Hong Kong climbed, the number of patients with mental illness grew. The Chinese Lunatic Asylum became consistently overcrowded. To resolve the problem of overcrowding, the Hong Kong Government in 1894 arranged with the authorities in Canton to accept transfers of Chinese patients from Hong Kong to the John Kerr Refuge for the Insane in Fangcun, about 0.5 km away on the southwest bank of the Pearl River (Zhujiang) in Canton. The Hong Kong Government remitted funds to the refuge to cover the expenses of the patients each year.7 Dr. John Kerr, an American medical missionary, after retiring from the Ophthalmic Hospital in 1899, devoted all his time to caring for the mentally ill. Between 1876 and 1880, Kerr campaigned for the necessary and just treatment of patients in mental hospitals, but the city government did not want to build a mental hospital. Kerr used his own money to purchase seventeen acres of land in Fangcun, as a building site for the hospital. With donors’ assistance, two buildings were erected in 1898.8 The medical missionaries brought Western medicine into Hong Kong and China using it as a means of spreading the gospel. “Healing bodies and saving souls” was their motto. Their dedication and affection for the Chinese people resulted in saving the lives of many and left behind a legacy in the medical and healthcare development of Hong Kong and China. The number of Hong Kong patients sent to the John Kerr’s Refuge in Canton from 1923 to 1932 is shown in Figure 12.1. During the Second World War, there was no repatriation. After the war when the mental hospital reopened, the process of repatriation resumed until 1949, when the bamboo curtain came down between Mainland China and Hong Kong. In 1925, the Chinese and the European asylums in Hong Kong merged to form the Victoria Mental Hospital (Figure 12.2). It had only twenty-three beds, but sometimes housed up to 100 patients. In 1938, the government renovated the medical staff quarters of the former Government Civil Hospital at the corner of High Street and Eastern Street to accommodate the quieter type of patients, and the total number of beds increased to eighty-four.9 Clearly though, the number of available beds in the asylum did not reflect the number of patients in need of care, and this lack of proper accommodation undoubtedly led to overcrowding in mental hospital facilities, which likely could have exacerbated patients’ already-fragile mental states. Mental illnesses at that time were classified on the basis of symptoms, with little attention paid to disease causation. Dementia, delusion, melancholia, and mania were the most common

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diagnoses; among Europeans, symptoms from alcoholism were also common. Proper diagnoses according to present-day criteria were not usually made because of limited knowledge of mental illness then. Figure 12.1 Yearly admissions to European and Chinese Lunatic Asylum (1900 to 1932) and number of patients sent to Canton (1923 to 1932)

Note: The numbers sent to Canton from 1900 to 1923 and after 1934 were not available. The number of patients sent to Canton decreased between 1926 to 1927 probably because of the strike-boycott which almost destroyed Hong Kong’s economy. Source: Medical and Sanitary Reports, HKARs, of respective years.

Figure 12.2 Victoria Mental Hospital, 2 High Street, Sai Ying Pun, Hong Kong

Photograph by author, 1987

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Institution and Rehabilitation: Psychiatric Hospitals and Halfway Houses, 1945 to 1966 The next phase of development of mental health services in Hong Kong almost coincided with the founding of the People’s Republic of China. In 1948, Dr. P. M. Yap, (Figure 12.3) Hong Kong’s first properly trained psychiatrist, was appointed to head psychiatric services, establishing the Hong Kong psychiatric and mental health service.10 The development of mental health treatments after that can be divided into two phases: 1) institutionalization and rehabilitation services to enable patients to return to the community, and 2) community care service. In recent years, different types of psychiatric facilities are available to serve mentally ill patients in Hong Kong.11 With the establishment of the People’s Republic of China, the route of relieving congestion in Victoria Mental Hospital by transferring patients to the John Kerr’s Refuge in Canton was closed. The government decided to build a new mental hospital with 1,000 beds in Castle Peak. The first ward for 120 patients was completed in 1957 (Figure 12.4),12 and all the patients from the Victoria Mental Hospital were relocated to the new site. The rest of the Castle Peak Hospital was officially opened in March 1961.13 Common mental illnesses in this era include schizophrenia, major depression, personality disorders, anxiety disorders, suicidal behavior, and eating disorders. Castle Peak Hospital was equipped with a multidisciplinary team of doctors, nurses, medical social workers, occupational therapists, as well as two psychologists and a pharmacist.14 The advent of psychotropic drugs for treatment of mental illness permitted some patients to leave the hospital. While taking long-term medications, some patients were able to carry on a productive life outside. However, they needed to be rehabilitated and closely monitored in outpatient clinics. Increasing efforts were made to rehabilitate the long-stay and grossly mentally handicapped patients, aiming to make them fit to earn a living. Two open wards in Castle Peak Hospital were specifically set up for this purpose. Non-pharmacological treatment included group therapy, occupational therapy, and re-education with training that had a direct bearing on their work after leaving hospital. By these means, a number of patients with poor prognoses were discharged to earn their living in the community.15 Some patients traveled daily to Tsuen Wan, San Hui, or other places to work in factories for a short period of time prior to final discharge from the hospital.16

Figure 12.3 Dr. P. M. Yap

Photography courtesy of the Mental Health Association of Hong Kong d As the first professor of Psychiatry at the University of Hong Kong, Dr. P. M. Yap (Professor 1948–1972) trained a generation of psychiatrists and psychiatric nurses. He introduced new modalities of treatment, physical and pharmacological, and organized the first volunteer mental health service—the Hong Kong Mental Health Association. He encouraged other nongovernmental organizations (NGOs) including New Life Psychiatric Rehabilitation Association and others to develop rehabilitation services in Hong Kong, such as halfway houses and rehabilitation farms. He was, indeed, the founding father of mental health services in Hong Kong. d

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Figure 12.4 Castle Peak Hospital in 1957

Reproduced by permission from Hong Kong Medical and Health Department Annual Report, 1957–1958, opposite 60.

For reintegration into the community, halfway houses, supervised workshops, support and understanding from family, relatives, friends and community at large are necessary. The Mental Health Association of Hong Kong was formed in 1954, the first NGO in Hong Kong to promote mental health education and mental healthcare.17 Irene House (named after Dr. Irene Cheng, daughter of Sir Robert Ho Tung), a twenty-bed unit, was established by the Mental Health Association in 1967 for discharged male patients from the Castle Peak Hospital.18 Another NGO, the New Life Psychiatric Rehabilitation Association, was formed to share the responsibility of providing services to mental patients after discharge from hospital. It founded the first halfway house, which was an industrial rehabilitation farm called New Life Farm, in 1964.19 In 1968, the association set up another halfway house in Hung Hom.20 As the population in Hong Kong expanded, more hospitals were required to care for the mentally disturbed. In 1972, Siu Lam Psychiatric Centre and Siu Lam Subnormal Hospital opened each with 200 beds for criminal offenders who were mentally ill and severely subnormal individuals respectively. Lai Chi Kok Hospital (324 beds), which had been an infectious disease hospital, was converted into a psychiatric

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hospital in 1974 to accommodate the overflow of patients from Castle Peak Hospital. The long-stay psychiatric patients who required minimal nursing care were transferred there. Kwai Chung Hospital, which began operating in 1981, has 1,326 psychiatric beds and is situated next to Princess Margaret Hospital. It consists of seven blocks of buildings connected by subways. To avoid the adverse effects of a large hospital, a few subspecialties were created such as wards for children, adolescents, geriatrics, neurotics, and psycho-surgical patients. There are also spacious areas for social and recreational activities such as a playground, sports fields, and roof gardens.21

Towards Community-Based Services, 1966 to Present Medical services expanded intensively between the 1960s and 1980s. Instead of building another mental hospital, the government decided to move psychiatric services to the community by establishing a number of psychiatric or mental health centers and units. This took the form of day hospitals and outpatient services for follow-up of cases from psychiatric hospitals.

Psychiatric or Mental Health Centers The new Yau Ma Tei Psychiatric Centre with different types of psychiatric services was inaugurated in 1966 to replace Tsim Sha Tsui Psychiatric Centre.22 It is the reference center for patients in Kowloon. The Yau Ma Tei Psychiatric Centre includes a part-time child psychiatric clinic, the first of its kind in Hong Kong. The Hong Kong Psychiatric Centre, created in 1968/69, was and still is the reference center on Hong Kong Island for the majority of patients for admission.23 The South Kwai Chung Psychiatric Centre was opened in 1977, providing a full-time clinic for people living in western New Territories. The Kwai Chung Hospital, with 1,326 psychiatric beds, was opened in 1981 with wards for children, adolescents, and elderly.24 The hospital provides a comprehensive psychiatric service from psychiatric inpatient service, psychiatric rehabilitation service, and community psychiatric service. The Chai Wan Psychiatric Centre was

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launched in 1977 to provide outpatient facilities for people living in Chai Wan and Shau Kei Wan. It has a day-hospital.25

Psychiatric Units in General Hospitals The Kowloon Hospital Psychiatric Unit, opened in 1971, aimed at providing comprehensive psychiatric services in a general hospital setting. Because of shortage of staff, only the outpatient section, the day hospital, and half of the inpatient sections were operational in the beginning. By the following year, all inpatient sections became fully functional. The Kowloon Hospital Psychiatric Unit provided the only EEG investigation service for Kowloon.26 After the opening of Kowloon Hospital Psychiatric Unit, a number of general hospitals including the Prince of Wales Hospital, Tuen Mun Hospital, Shau Kei Wan Hospital (now Pamela Youde Nethersole Eastern Hospital), and the United Christian Hospital began to have psychiatric units.27 These psychiatric units provided comprehensive psychiatric services which included halfway houses, daycare centers, community psychiatric services, and outpatient services. Without these services, outpatient treatment of most patients with mental illnesses would have been exceedingly difficult, if not impossible. Attendances of psychiatric outpatient clinics only increased after 1965 when such services were available (Figure 12.5). Figure 12.5 Total attendance of the psychiatric outpatient clinics, 1952 to 1988

Source: Compiled from Hong Kong Medical and Health Department Annual Reports 1952 to 1988.

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Psychiatric Outpatient Clinics The first full-time psychiatric outpatient clinic for adults was opened in 1962 in Queen Elizabeth Hospital,28 while the second one in the Tsim Sha Tsui Health Centre in Kowloon. For disturbed children and adolescents, Yau Ma Tei Psychiatric Centre operated child psychiatric outpatient clinics on the Kowloon side, and the University Child Guidance Centre in the Hong Kong Psychiatric Centre provided the same services on the Island.29 Outpatient psychiatric clinics are now held in the mental health centers and psychiatric units in different parts of Hong Kong.

Community-Based Rehabilitative Services Up to the 1970s, community-based rehabilitative services were provided by NGOs, such as sheltered workshops, halfway houses, rehabilitation farms, and social clubs, while the government provided medical treatment in hospitals, day hospitals, and outpatient services. Two major policy papers were published by the government. The first one was the White Paper on “Further Development of Medical and Health Services in Hong Kong” in 1974, which suggested psychiatric wards and supporting services be established within general hospitals. The second was the Green Paper on “The Further Development of Rehabilitative Service in Hong Kong in 1976.”30 In this paper, mental patients were formally recognized by the Hong Kong government as one of the territory’s disabled groups. From that time onwards, mental patients were fully eligible for rehabilitation services, and the concept of rehabilitation was integrated in planning and formulating mental health services in Hong Kong. Social rehabilitation was regarded as equally important as medical rehabilitation to enable psychiatric patients to return to employment after a prolonged period of hospitalization. Various forms of community care services were implemented by the government, but psychiatric patients were not actually integrated into the community yet. The psychiatric rehabilitation organizations kept a low profile to lessen the public awareness of the presence of mental patients within the community care service units.31 Psychiatric terms, like “halfway house” and “sheltered workshop,” were not used, and patients were generally kept from contact with community members. At that time, stigmatization of the mentally ill remained common, and the general

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public was so afraid of these patients that they tended to avoid them altogether, which only perpetuated the unfair stigma.

Rejection by Local Community In 1982, a most unfortunate incident occurred in Un Chau Estate, which impeded the development of community-based service in psychiatric care for more than a decade. A psychiatric patient killed his mother and sister at home and over thirty other victims in the staircase of the apartment block and in a nearby kindergarten and created an uproar in the community. After this episode, any application for establishing a psychiatric unit in the community was met with strong opposition for fear of occurrence of a similar incident.32 To counter this, the government attempted to strengthen the standards of halfway houses and established a working group to advise on preventive measures on ex-mental patients with a history of criminal violence or assessed disposition to violence. One of the recommendations was to change the law so that people suffering from mental illness could be admitted to a mental hospital without the consent of their relatives. To ensure that the patients were not incarcerated for periods longer than necessary, it also proposed a new tribunal to be established, chaired by a member of the judiciary, or an unofficial Justice of Peace with relevant legal experience to have the power to discharge patients unconditionally or conditionally. The members would include a psychiatrist, a social worker in the mental health field, and a representative from the legal department. The Medical and Health Department established a Central Registry of ex-mental patients with a record of criminal violence or a disposition to violence and access to such information would be limited to three senior officers of the Department and available to professional staff involved in the rehabilitation and aftercare of patients on a need-to-know basis.33 Despite these measures, a review of two halfway houses in 1987 showed that in the first year after admission, only 17.1% of the residents were discharged to the community, 15.7% were readmitted to a psychiatric unit, and the rest remained in the house, indicating that the halfway houses were not really halfway. There was just not adequate facilities nor staff for aftercare to make follow-up checks on the patients after discharge from the halfway houses.34 The shortage of medical staff in psychiatric services was well known. The problems were: 1) society’s ostrich attitude to mental illness; 2) the

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poor image of the medical specialty, which drew little esteem from the medical community; and 3) the future for this specialty was not bright or lucrative. It was a question of too few professionals trying to provide too big a service. The specialty was just as unpopular among nurses who worked under extremely difficult situations and even ran the risk of assault.35 In 1989, the revised edition of the Mental Health Ordinance was finally enacted, and several new legal mechanisms were introduced, such as appointment of approved social workers, the establishment of the Guardianship Board and the Mental Health Review Tribunal, and the implementation of the search and detention warrant for conditionally discharged psychiatric outpatients.36 Despite these measures, strong objections to having any psychiatric facilities within the community continued, frustrating any push for community-based psychiatric services. The 1982 massacre prevented the integration and rehabilitation of mental patients within the community; instead, most of the efforts and resources of mental health services shifted from psychiatric rehabilitation to prevention of the unpredictable violence of mental patients.37 As a result, the deinstitutionalization movement occurred late in Hong Kong.

The Final Breakthrough The situation brightened after 1990 when the Hospital Authority was founded to manage all public and subvented hospitals, dividing the hospitals into regions for better management. A region-based, consultantled multidisciplinary team was created to support various mental health services including hospital beds in psychiatric hospitals, district-based psychiatric outpatient clinics and day hospitals, as well as a team of occupational therapists, and community psychiatric nurses. It also set up more psychiatric outreach teams to visit halfway houses, sheltered workshops, and group homes to better support the needs of the exmental patients, and to detect early relapses while instituting timely and appropriate treatment and intervention. The process was further advanced with the help of two policy papers published by the government: the Green and the White Paper on Rehabilitation Services (1992 and 1995 respectively). In these two papers, the government acknowledged the need to improve the standards of community care and psychiatric rehabilitation services.38

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In 1994, despite the strong opposition of the residents of Laguna City private estate, a psychiatric daycare center was opened after social workers worked hard in the community to pacify the residents. 39 This episode stressed the need and the value of a major public education campaign.40 Since 2000, there was a rapid transition from hospital-based to community-based psychiatric services in Hong Kong. The number of psychiatric beds peaked in 2000 when there were 5,395 beds distributed across two psychiatric hospitals and ten general hospitals. The general public’s gradual acceptance of patients with psychiatric illness in society and the absence of any major problems was associated with a progressive reduction of psychiatric inpatient beds and an increase in outpatient services. By 2012, there were 3,607 psychiatric beds, representing a reduction of 33% in twelve years. In the meantime, psychiatric outpatients and psychiatric day hospital attendance climbed, rising by 75% and 50% respectively.41

Challenges Ahead The major obstacles to deinstitutionalization are the prevailing social stigmas attached to mental illness, the lack of dedicated mental health funds, and the overcrowded living conditions in Hong Kong that made family members unwilling or unable to support patients with mental illness in the community, especially during periods when they need more intensive care. Sadly, with the rising demand for mental health service, there is conversely a marked shortage of professionals. There were only 4.5 psychiatrists per 100,000 in 2015 in Hong Kong compared with 14.63/100,000 in the United Kingdom. The size of the mental health nursing workforce in Hong Kong is also small, 29.15/100,000 versus 83.23/100,000 in the United Kingdom. The number of new psychiatric cases registered in the specialist outpatient clinics in public hospitals had grown from 39,770 in 2009/10 to 47,958 in 2014/15.42 The shortage of personnel is not confined only to doctors but also members of the frontline caregivers: case managers, nurses, and occupational therapists with knowledge in mental health services. In 2019, the waiting time for a psychiatric patient to see a doctor in a public hospital in the seven hospital districts varies from 55 to 105 weeks in Hong Kong.43 In addition to the shortage of psychiatric

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personnel, there is a lack of involvement of primary care in mental health service. At present, it is solely the public specialist psychiatrists who provide mental healthcare, and primary care doctors are not involved because of lack of training in psychiatric care. All these factors render deinstitutionalization and provision of community-based outpatient care difficult to accomplish. Following a review committee formed in 2013, the government has started to increase the manpower of the public psychiatric healthcare team.44 People in Hong Kong face many personal and social challenges, such as long working hours, insomnia, overcrowding, noise, and environmental pollution—stressors that contribute to mental health problems. It has been estimated that one in seven people in Hong Kong suffer from a common mood disorder but three-quarters do not seek professional help. Moreover, an increasing number of children and adolescents are diagnosed with mental health problems. A joint survey of Caritas and City University of Hong Kong in 2016 found that an alarmingly high proportion, 40%, of students in Form 1 (equivalent to Grade 7) had suicidal thoughts.45 Apart from the increasing prevalence of mental illness, an increasing number of the elderly are facing problems of dementia as the population ages in Hong Kong. It has been reported that about 10% of the elderly population in Hong Kong are suffering from dementia. 46 The rise in chronic diseases, such as diabetes, hypertension, heart disease and stroke, due to adverse effects of today’s modern lifestyle in an affluent society is another risk factor for dementia.  Attention to early diagnosis and treatment of these diseases are other important avenues to reduce dementia risk.47

The Mental Health “Tsunami” In addition to a family history and personal trauma, social unrest can trigger depression, anxiety disorder, and Post Traumatic Stress Disorder (PTSD). Patients with PTSD experience involuntary vivid flashbacks of memories of traumatic events and can have nightmares, and even physical symptoms such as heart pounding and chest tightness as if they were actually reliving the trauma. They are also hypervigilant, easily startled, and have difficulty sleeping. Without proper help, serious consequences such as addiction to drugs, alcohol, and other dangerous behaviors may develop. As PTSD may not present until sometime after the trauma, a

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mental health “tsunami” brought on by a political or economic crisis may not hit until weeks, months, or even years in the future. Because of the long latent period, it is often difficult to establish the causal relationship between the psychiatric problem (such as PTSD, drug abuse, alcoholism) of the individual and the traumatic event. Unfortunately, Hong Kong is experiencing unparalleled political and social turmoil, which will undoubtedly affect the mental health status of those involved. Toward the latter half of 2019, Hong Kong turned from one of the most advanced, expensive, and safest cities in the world into a battle zone with mass anti-government protests. Hong Kong’s police force, once known as “Asia’s finest” was seen in riot gear. Running battles have raged through the streets, shopping malls, and metro stations. The South China Morning Post and Ming Pao on 8 and 9 December, respectively, summarized that the police fired 16,000 rounds of tear gas, 10,000 rubber bullets, 2,000 bean-bag rounds, 1,900 sponge grenades, and nineteen rounds of live fire with 5,980 arrested (the youngest eleven and the oldest eighty-one). Of the arrested, 2,300 were students, of which 740 were from various universities in Hong Kong. Public hospitals treated 2,600 patients with injures related to the protests. Complaints of police brutality and overuse of their powers reached 2,100 while at the same time, over 1,600 sets of traffic lights and eighty-five metro stations were vandalized by the protesters. What caused this sudden change? In February 2019, the Extradition Bill was proposed by the Hong Kong government to establish a mechanism for transfers of fugitives not only for Taiwan, but also for Mainland China and Macau, which are currently excluded in the existing laws. The introduction of the bill caused widespread criticism domestically and abroad from the legal profession, journalist organizations, business groups, and foreign governments fearing the erosion of Hong Kong’s legal system and its built-in safeguards, as well as damage to Hong Kong’s business climate. Many in Hong Kong fear for the loss freedom of speech and communication and the loss of the “high degree of autonomy” as promised in the 1984 Sino-British Agreement.48 Other inciting factors include the rising Gini coefficient, an index to measure the wealth gap, and the expanding fraction of the population below the poverty line, especially among the elderly. In June, 2017 the Gini coefficient for Hong Kong was 0.539—the highest in forty-five years.49 At the same time, despite a consistent surplus each year since 2006

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(revenue-expenditure), the percentage of social spending (on education, medical and health, and social welfare) had actually decreased. Since the handover in 1997, the government had not addressed these fundamental issues to improve the lives of its citizens. These issues, together with unaffordable housing, led to acceleration of social discontent among the young people who saw no hope for their future. The introduction of the 2019 Extradition Bill was the last straw, and young people began to feel that there was no future for them. In the meantime, society became increasingly polarized, with a prodemocracy group versus a pro-government group, with each side staging demonstrations. The social dispute led to fist fights, knife attacks, but more often fallout of friends, breaking up of families and marriages, and arguments between family members. Some young people were forced to leave home as they were no longer welcomed by their parents due to differing views. Over one thousand applications of students seeking help from the Red Cross, Hong Kong.50 The schism in the society widened, and emotions ran high, with the two groups becoming increasingly intolerant of each other.

The Impact of the Social Unrests Many young protesters suffered severe physical injuries and some would be left with permanent disabilities. The financial loss from the protests far exceeded those due to the outbreak of Severe Acute Respiratory Syndrome (SARS) that hit Hong Kong in 2003. Many countries had advised against travel to Hong Kong for safety reasons, causing a collapse in tourism. Retail, restaurants, and hotel businesses ground to a halt. While all these impact negatively on the politico-economic future of Hong Kong, the city has yet to deal with another grave sequelae—the effects on mental health.51 Hong Kong citizen’s mental health status has been on a slow decline in the last eight years, and lowered further in 2019. In 2018, around 18% of respondents to a survey in Hong Kong claimed that social disputes affected their mental health; but in 2019, the figure more than doubled at 41%. The average score for the 2019 mental health index is 46.4, below the passing mark of 52. This finding was substantiated by a ten-year cohort study carried out by the University of Hong Kong in eighteen districts. The participants were assessed at nine timepoints from 2009. After the two

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baseline surveys, random subsets were followed up. Probable depression (measured using the Patient Health Questionnaire-9) was reported by 11.2% (95% CI 9.8–12.7) of the participants in 2019, compared with 1.9% (5.3–7.6) during 2009–2014, and 6.5% (5.3–7.6) during 2014–2017, after the Occupy Central Movement (which took place in 2014). Suspected PTSD (by PTSD checklist and direct exposure to traumatic events) was estimated to be 12.8% (11.2–14.4) in 2019. The estimated mental health burden identified in this study would add an excess of 12% of service to the public sector.52 This excess did not include those with PTSD, who would require more intensive treatment. The mental health community in Hong Kong is working hard to provide psychological support or treatment to those in need. The Hong Kong College of Psychiatrists has released a set of mental well-being public health education materials to schools, news agencies, social welfare agencies, community centers, health clinics, and hospitals, giving advice on restricting the use of social media, sleep hygiene, balancing different life roles and commitments, and sustaining social network. Eighty psychiatrists offered treatment at a low rate for the needy. Volunteer social workers, counselors, psychologists, and doctors are providing acute psychological support to those who feel traumatized by the street confrontations or disillusioned by the lack of foreseeable solutions. The Hong Kong Council of Social Service has also launched a referral program for people with mental health problems. There are open lectures to educate teachers, social workers, counselors, journalists, and police officers on stress management and early recognition of symptoms.53 Given that mental health has been recommended as one of the new indicators of state-wide health,54 the government should address mental health problems seriously. Mental health problems cannot be treated in isolation from the sociopolitical context, and without addressing underling social and political issues, public anxiety and concomitant mental health problems will continue to climb. The sad fact is that even when social unrest finally ceases, its legacy remains in the form of persistence of mental health problems, and may affect the second and third generations. Hong Kong has to be prepared for a wave of mental health problems in the years to come.

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13. Substance Abuse and Drug Addiction

The Opium Epidemic before World War II Since Hong Kong’s colonization by the British, opium was the most commonly abused drug. Opium addiction in China can be dated back to the seventeenth and eighteenth centuries, when the European demand for Chinese goods like tea, silk, and porcelain was high, while conversely, the Chinese demand for European goods was nonexistent. This relationship created a huge trade imbalance between the Qing Dynasty and Great Britain, and the British became deeply concerned that more and more silver was flowing into the Chinese Treasury year after year. Finally, the British discovered a commodity that the Chinese wanted: opium from India. Soon the Chinese, rich and poor alike, gathered in opium dens to smoke the imported drug. Wealthy parents even encouraged their sons, except the eldest one, to take up opium smoking so that they would become too lethargic to gamble—a vice that might pile debt onto their families. Millions of Chinese became addicted and subdued, including government officials, merchants, coolies, and servants. As a result, the British not only balanced their trade but also reversed the flow of silver, strategically subordinating the Chinese state into an inferior, and dependent, economic position. In 1799, the Qing Emperor became alarmed by the prevalence of opium addiction in his country. He banned opium trade, but this was easily circumvented by greedy and corrupted Chinese officials themselves who were involved in a smuggling network. The First Opium War started in 1841 after Viceroy Lin Zexu confiscated 20,283 chests of opium from British merchants, mixed with salt and lime and threw them into the sea. Britain responded by sending a military force to China and defeated the Chinese. Hong Kong was ceded to the British as a result. For decades after Hong Kong became a British colony, the opium trade flourished when other business failed to prosper. All major foreign

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firms participated in the opium trade, which became the primary source of revenue for these firms as well as for the Hong Kong government. The revenue generated from farming out the opium monopoly constituted about 30% of the government’s revenue for many years.1 At that time, possession of opium and smoking opium were not considered illegal. Opium was readily available in hotels (Figure 13.1) and public dwellings. Opium has to be heated to temperatures that cause the active alkaloids to vaporize. Smoking opium requires a pipe with a glass porcelain bowl and a long stem usually made of bamboo, although ivory, silver, or even jade, are sometimes used. Smokers usually lie on their sides to prevent falling as they relax and doze after inhaling the heated vapor of opium (Figure 13.2). The Colonial Surgeon considered smoking opium to be harmless and that its users would not experience any symptoms of withdrawal without it, except for those who used large amounts of opium.2 This was, of course, not true. Addicts usually turn into lethargic persons with no initiative and enterprise, living only for the next puff without which they would suffer acutely from withdrawal symptoms which include aching all over, cramps, running eyes and nose, abdominal pain, and diarrhea.3 Nevertheless, successive governors, in order to keep the revenue coming, used their Colonial Surgeon’s opinion to uphold their opium policy. As a result, opium divans flourished in Hong Kong. In 1908, under international pressure, British India agreed to reduce its export of raw opium to China over a period of ten years. The Colonial Office issued an order to close all opium divans in Hong Kong.4 In 1910, Governor Lugard reluctantly instructed all 192 divans in Hong Kong to be closed, but he managed to negotiate a substantial amount of compensation from the British government for the loss of revenue from the opium farm.5 In 1912, as a result of the work of the Anti-Opium League, the International Opium Convention was held in The Hague, and an agreement was reached to control the production and distribution of opium. Because Britain was a signatory of the agreement, the Hong Kong government was threatened with impending insolvency since 30% of its revenue was generated from the opium trade. The government cleverly solved the immediate problem by taking over opium farming and to distribute the opium, ostensibly to exert a stricter supervision over excess abuse, but in reality to enjoy its financial spoils.6 In this way, between 1915

Figure 13.1 Receipt for tea and other items from Ching Tin Hotel Co. Ltd. in Hong Kong in 1930s. The last item in the bill, daigongyan (purchasing opium on behalf of ), which this customer did not order.

Photograph courtesy of Mr. Keith Poon

Figure 13.2 Opium smoker using a special pipe in a lying down position to avoid falling

Photograph courtesy of Wellcome Collection

Figure 13.3 Opium paraphernalia

Photo courtesy of Mr. Keith Poon Note: On the top left is the ceramic pipe-bowl painted with a lion. It is hollow inside with a funnel-like end piece for connection to the body of the opium pipe, usually made of wood for the average smoker. The pipe-bowl is inserted into the top hole of the wooden “connector,” which in turn is joined horizontally with the pipe to complete the smoking instrument. The three containers on bottom right of the picture are for storage of raw opium. The first one is silver, with a dragon design, presumably for use by the rich. Next to its top left is an ivory container to hold the raw opium and on its right is a small spoon to transfer the raw opium. The container next to it is made of white copper and engraved with elegant calligraphy, presumably used by a scholar. The one in the right lower corner is also made of white copper and takes the shape of a pile of 20 cent silver coins. The lid is made up of a real coin. Such a container would be used by a businessman.

d The Opium Trade: Hong Kong’s Treasure Chest A significant portion of the Hong Kong’s revenue depended on the opium trade since it became a British crown colony until as late as WWII. All major foreign companies such as Jardine, Matheson & Co., Dent & Co., and Russell & Co. dealt in opium trade, which was not illegal then. Governor John Davis reported to the Secretary of State for the Colonies on 13 May 1844 that he was unable to recommend any local resident to be an unofficial member of the Legislative Council because “almost every person possessed of capital who is not connected with government employment is employed in opium trade” (G. B. Endacott, An Eastern Entrepot [London: Her Majesty’s Stationery Office, 1964], 77). Many Chinese were also involved in the opium trade. Lee Hysan, nicknamed the Opium King of Hong Kong and Macau, was a Hong Kong businessman who inherited his father’s great wealth and the opium trade. Later Hysan turned to the land development business when opium trade became illegal. d

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and the end of WWII, the government obtained a percentage of revenue from the opium farm by reducing the amount of opium produced each year right up to the time of the outbreak of WWII.7 In 1943, under pressure from the United States, Britain decided to adopt the policy of total prohibition in the Eastern Territories, and the opium monopolies ran by the colonial governments could no longer be reestablished under British rule after the war.

The Era of “Chasing the Dragon”: Heroin and Other Narcotics after World War II After World War II, Hong Kong’s entrepot status, designed to encourage free flow of regional trade with minimal government control, was exploited by international traffickers of narcotic drugs. The government’s suppression of opium unsurprisingly resulted in an increase of narcotic trafficking, with addicts turning from opium to heroin, which is much easier to smuggle, conceal, and produces a stronger high in addicts. The effects of heroin are far more pernicious, as the drug is extracted from opium and about thirty to eighty times more potent than opium by weight.8 Heroin typically induces a surge of pleasurable sensations—a “rush,” which is usually accompanied by a warm flushing of the skin and mouth, and a heavy feeling in the extremities. After the initial effects, the users are usually drowsy for several hours, with mental function clouded and breathing slowed, sometimes leading to a life-threatening coma when overdosed.9 Smoking heroin is much easier and simpler compared with opium. Heroin can be consumed in many different ways. The local addicts smoke heroin by a method called “chasing the dragon,” which is done by putting the granules of heroin with a base powder in a heated folded piece of tinfoil or a metal spoon, and the resulting fumes inhaled through a small tube of bamboo or rolled paper. Other methods include intravenous, intramuscular, or subcutaneous injection, and it can even be taken orally with other ingredients. The dirty, unsterilized needles used by addicts increase the risk for tetanus, hepatitis B, and HIV infection. Some addicts may use barbiturates as a base powder during smoking of heroin, and this produces a more severe form of addiction. Because of the ease of use, paraphernalia being less bulky, and no suspicious smell, heroin became the preferred drug among addicts.

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Opium, heroin, and morphine are not the only form of narcotics used by addicts. Other pharmaceutical drugs such as pethidine are also used but they are difficult to obtain and addiction to them uncommon. Drug users obtained their supplies of opium and heroin from peddlers or by frequenting divans. The divan keepers and peddlers were often drug addicts themselves so they could obtain their own supply of drugs to use. They were the ones to get caught, not the higher-ups who controlled the market. To avoid discovery, the divans were moved from one place to another in squatter areas where thugs and members of triad societies were employed to intimidate potential informers.10 The extent of drug abuse before and during the immediate postwar period was unknown. In 1958, out of a total of 18,410 persons sent to prison, 11,863 (60%) were found to be narcotic addicts (from confession of his/her vice prompted by withdrawal symptoms when the drug supply was stopped on imprisonment for an offense unrelated to drugs). Of these, just over 60% took heroin, 36% opium, and the rest other drugs such as morphine. It was estimated that the total number of addicts in Hong Kong could be as high as 150,000 to 180,000.11 The majority (98%) of addicts who went to jail were men, and most of them were either unemployed, casual laborers, or hawkers, while female addicts were mostly sex workers. These people turned to drugs for physical or psychological relief when they found themselves in squalor and misery. Once the habit had been formed, it was impossible to break, and they spent almost every cent on acquiring the drug, even at the expense of food and clothing. In the end, some would turn to crime to support their dependency.

Sources of Supply and International Control in the 1950s In the mid-twentieth century, the principal method of controlling narcotic addiction was suppression of narcotic supply, which invariably resulted in a proliferation of organized criminal networks. The Dangerous Drugs Ordinance (Cap. 134 of Laws of Hong Kong, 1950 edition), enacted in 1936 and amended several times, gave the government authority to deal with the drug problems in Hong Kong, and municipal law enforcement agencies to administer the international conventions and agreements. As opium and heroin were smuggled in from Yunnan, Thailand, and north-east Burma, Hong Kong was dependent on an international

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system to disrupt the drug trade. The League of Nations, through a Permanent Central Opium Board and a Drugs Supervisory Body, was the watchdog before the Second World War. After 1946, the Commission on Narcotic Drugs, which was set up by the United Nations (of which the United Kingdom was a member), supervised the implementation of the international agreements and advised United Nations Economic and Social Council (ECOSOC) on developments in the international drug situation and on changes needed to meet the stipulations of international agreements. Police forces of different countries cooperated in order to intercept illegal consignment of drugs. Their exchange of information was assisted by the International Criminal Police Organization in Paris (Interpol). The World Health Organization contributed to the control system through an Expert Committee on Addiction-Producing Drugs and organized studies on the medical aspects of drug addiction.12 In 1949, the Hong Kong government produced a White Paper on narcotic drug addiction and proclaimed, “As drug addiction is one of Hong Kong’s greatest social and economic problems, government’s policy is to neglect no measure that has a reasonable chance of contributing to its suppression.” In 1950, the Dangerous Drug Ordinance (Cap. 134 of the Laws of Hong Kong, 1950 edition) lists the drugs declared to be dangerous and the regulations concerning their manufacture and movement within Hong Kong. The cultivation, import, and export of these drugs were prohibited, and the maximum penalty was ten years imprisonment or a fine of fifty thousand dollars.13 But nothing more was done on the problem of narcotic drugs by the government until 1959, despite its 1949 claim.14 It was estimated in the 1950s that one in nineteen of Hong Kong’s population was a drug addict. At least HKD 170 million a year was spent on opium and heroin.15 Faced with such an alarmingly high frequency of drug addiction, in 1958, the Reform Club of Hong Kong called for the establishment of a special institution for addicts, to treat and rehabilitate them rather than to regard them as criminals.16 The Reform Club’s recommendation of treatment and not prosecution for addicts received broad support in Hong Kong. Even the Kaifong Association of Hong Kong and Kowloon pledged support of the Working Committee for the Aid, Treatment, and Rehabilitation of Drug Addicts.17 Treatment of addiction at that time was to treat the symptoms of withdrawal and to improve users’ nutrition afterwards. A period of psychological readjustment and rehabilitation was then required.

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There were no designated facilities in Hong Kong to offer the necessary treatment for the drug addicts. The government, after a prolonged period of inaction toward the problem of drug addiction after the war, was under pressure to act. In 1959, the government issued another White Paper entitled “The Problem of Narcotic Drugs in Hong Kong,” outlining a few anti-drug measures: 1) strengthening preventive services; 2) conducting an all-out anti-drug publicity campaign; 3) establishing a voluntary narcotic treatment center in Castle Peak Hospital; 4) passing new laws to block loopholes in existing ordinances; 5) forming a narcotic advisory committee; and 6) enacting tighter laws to combat drug trafficking.18

Treatment and Rehabilitation Centers Following the 1959 White Paper, a series of initiatives were carried out in Hong Kong aiming at rehabilitating drug addicts. First, a special recovery institution was established. The Tai Lam Gap Correctional Institution was opened as a treatment and rehabilitation center accommodating 700 drug addicts. Prisoners, who were sentenced to periods between six to twelve months, were selected to go through successive stages of treatment and rehabilitation under the direction of a medical officer, followed by a period of aftercare.19 Second, when the Castle Peak Hospital was opened in 1960, 120 beds were set aside for a trial of two to three years for drug-addicts who were willing to submit voluntarily to a course of treatment for six months. Treatment designed to build up the individual physically and psychologically was given during the period of rehabilitation before reabsorption into the community. For the program to be successful, a vigorous effort against trafficking was maintained by the police and preventive forces. The regimen of treatment and rehabilitation was guided by a psychiatric specialist. Based on this experience, the government was able to evaluate the need for a separate voluntary treatment center for drug addicts.20 An addiction clinic was established in the Hong Kong Psychiatric Centre for addicts seeking treatment to register. As the accommodation in the two wards were limited, some criteria for admission became necessary. In consultation with the Narcotics Advisory Committee, the following criteria were laid down for suitability for treatment: 1) a genuine desire to be rid of the habit; 2) good prospects for re-employment on discharge;

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and 3) absence of a record of serious crime and freedom from severe mental or physical illness. In the addiction clinic, the selected subjects underwent a thorough physical examination and a chest X-ray, followed by a psychiatric assessment for suitability for admission to the Treatment Center at Castle Peak Hospital.21 The essential therapeutic aim was to prevent relapse, and a great deal of attention was given to follow-up in the community. The Pui Sun Fraternal Association, an organization similar to Alcoholics Anonymous, was formed in mid-1962 under the Categorical Aid Department of the Lutheran World Federation to follow up these individuals. The Association attempted to substitute their old habits and interests with healthier ones such as football, badminton, swimming, table tennis, and mahjong.22 Of the 604 patients who were admitted to the Treatment Center at Castle Peak Hospital between March 1961 and March 1964 and treated for six months, 52% were followed up by almoners; of these 60% remained clean at the end of this period of observation (see Figure 13.4). As the study was carried out on selected subjects and there were a large number of drop-outs from follow-up, the results were likely biased. The reported rate of success was likely to be higher among those who were selected for treatment and were follow-up compared with those who were not treated and those who were treated but not followed up. Figure 13.4 Number of patients treated in the drug addiction center, March 1961 to March 1964 Drug Addiction Treatment Centre March 1961–March 1964 Registered    1,567 Submitted to Selection Procedure Approved for Admission Admitted for Treatment Followed-up by Almoners Currently Abstinent

No 192

Yes 1,375 No 585 

Yes 790 No 186

Yes 604 No 290

Yes 314 No 124

Yes 190

Reproduced by permission from Hong Kong Medical and Health Department Annual Report 1963–1964, 71.

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Shek Kwu Chau (Coffin Island) Treatment Centre The Shek Kwu Chau Treatment Centre (Figure 13.5) for addicts was founded in 1963 by the Society for the Aid and Rehabilitation of Drug Abusers (SARDA), which is a voluntary organization. It is situated on a remote island with a tiny transient population, about 4 km west of Hong Kong, once known as the Coffin Island. In 1965, it took charge of all the patients from Castle Peak Hospital Treatment Centre. The island is, at present, still the home to 200 recovering drug addicts. The center is adorned with mock Roman baths and faux marble sculptures—some standing in fountains and lily ponds, a legacy of the stonemasonry projects to keep the drug addicts busy. The island has its own electricity and running water from a reservoir. A ferry, which brings in food and supplies three times daily from the nearby Cheung Chau Island, is the only connection with the rest of humanity. All residents are admitted voluntarily, live in one of the nine residential buildings, and are given responsibilities for maintenance and domestic duties around the island. There is zero tolerance for drug possession and random urine tests are carried out. If a resident fails one, he or she will be expelled from the island immediately.23 Shek Kwu Chau Centre can accommodate 500 males, but there are no facilities for females. The average length of stay at Shek Kwu Chau is around 50 days. Figure 13.5 Shek Kwu Chau Treatment and Rehabilitation Centre

Photograph courtesy of Nora Tam/South China Morning Post

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Since 1969, under an ordinance the Correctional Services Department operated a compulsory treatment program for drug-dependent individuals, who had been found guilty of an offense punishable by imprisonment to a term of treatment for a minimum of two months to a maximum of twelve months. There were two other drug addiction treatment centers for this type of offender in Hong Kong: one at Hei Ling Chau and another one at Tai Lam, with a capacity for 938 males and 136 females offenders respectively.24

Anti-drug Campaigns and Public Health Education Several anti-drug campaigns with intensive public education programs were carried out by SARDA. The first one was launched in November 1967 and lasted for a month. Widest publicity was given through the press, radio, and television interviews and showing of the film, Suicide on Hire Purchase, in schools. Posters were put up at public buildings, in resettlement housing estates, public transport stations, and other public places. Leaflets were also distributed through public and voluntary agencies. The emphasis was on the preventive aspect of drug addiction, and publicity was directed toward education of the young.25 The public campaigns did a great deal to increase public knowledge on drugs, drug addiction, the importance of rehabilitation, and prevention. More importantly, these campaigns changed society’s attitude toward drug addiction and drug addicts and to regard them as patients with a mental health problem.26

Tightening Anti-narcotics, Trafficking Laws and Other Antinarcotics Efforts The Dangerous Drug Bill was enacted in 1968 to draw a distinction between drug traffickers and drug addicts (the former charge being much more serious than the latter), to strengthen the laws of evidence in criminal proceedings, and to widen the powers of police and preventive service officers to enable them to conduct routine searches and to detain personal vehicles, even ships and aircrafts under certain circumstances, in order to carry out their duties effectively.27 In 1965, an Action Committee Against Narcotics (ACAN), chaired by Sir Albert Rodrigues, was constituted to advise the government on overall policy and strategy to deal with the problem of drug abuse in

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Hong Kong. ACAN became the anti-narcotics organization to advise the government and to coordinate several government departments, such as Health, Police, Customs and Excise, Correctional Services, Social Welfare, Educational and Information Services, and various voluntary organizations such as SARDA, Society for the Aid and Rehabilitation for Drug Addicts, and the Hong Kong Council of Social Service.28 In the 1970s, various government agencies and NGOs worked together to set up a central registry of drug addicts in the Narcotics Division of the Secretary for Home Affairs with the following objectives: 1) to obtain information on the average success rate of institutionalized treatment; 2) to estimate the total number of drug addicts in Hong Kong; and 3) to compare the success rate of organized treatment with other forms of treatment. Various agencies and private practitioners were requested to forward information confidentially.29 The central registry has proven to be useful in providing information on the status of drug addiction in Hong Kong.

Methadone Detox and Maintenance Since 1962, Britain allowed doctors to treat narcotic drug abusers with drugs. The British government had been providing addicts with free heroin in order to reduce the crime rate and the number of addicts dying from overdoses. The number of drug addicts in the maintenance program escalated in the 1960s. In 1972, because of growing social pressure against free heroin, the British government changed the program in favor of methadone. Methadone allows the addict to discontinue heroin use without symptoms of withdrawal or discomfort associated with detox. Oral methadone had a longer-lasting effect and enabled an addict to take a job without worrying about the need for frequent heroin fixes.30 Dr. Gerald Choa, the Director of Medical and Health Department from 1970 to 1976, was a great proponent of the methadone maintenance program, which began on 2 December 1972 at the Pilot Maintenance Study Center in Eastern Street, Sai Ying Pun (Figure 13.6). Treatment was given in two stages. For the first two to three weeks, patients lived in the clinic, during which they were subjected to simple laboratory tests. Once they were successfully placed on methadone, they were discharged and became outpatients, calling at the center once a day for treatment. Methadone was given orally mixed with fruit juice.

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Figure 13.6 Methadone Pilot Program in Eastern Street, Sai Ying Pun, Hong Kong, 2021

Photograph by Ann Wong

Depending on the progress made and the degree of confidence established, patients on the program were allowed to take home a small supply of methadone for daily use. This experiment lasted for three years. About 550 patients took part in the study. The maximum dosage used in the center was 40 grams by mouth daily in one dose. This low dosage blocked heroin cravings but did not produce euphoria. At the same time, social rehabilitation and education were carried out.31 In July 1974, Dr. Gerald Choa presented the results of the trial. At the end of three years, only 25% of the 550 patients remained completely free of heroin and methadone. Yet this number was considered quite high compared with other centers in the world. Dr. Choa concluded that the treatment plan for the estimated 100,000 addicts in Hong Kong should aim at both physical rehabilitation and methadone maintenance simultaneously—the most humane treatment for drug addiction.32 A Narcotics Advisory Committee, which consisted of unofficial Chinese members of the Executive and Legislative Councils and two of their European colleagues, was set up in the early 1970s to oversee various

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activities in the treatment and rehabilitation of drug addicts and the education program on drug addiction.33 By 1976, a total of 7,100 addicts had been registered at the four methadone maintenance centers with an average daily attendance of 2,352. In addition, there were twelve new evening clinics, two on the island, nine in Kowloon, and one in the New Territories. They opened from 6 pm to 10 pm daily. Each of these clinics was staffed by a doctor and three members of the Auxiliary Medical Services comprising one assistant nurse and two assistant dressers. Each clinic was able to cope with fifteen patients each evening.34 The methadone program, praised by experts from other parts of the world,35 expanded. In 1991, the total number of methadone clinics further increased to twenty-five, operating daily, including Sundays and public holidays.36 The total attendance of all the methadone centers in Hong Kong peaked in 1986 and showed a downward trend since (Figure 13.7). The total number of registrants per year in methadone clinics also declined from 12,000 in 1986 to around 9,000 in 2000,37 partly due to the shift in drugs of choice of users, from narcotics to psychotropics as discussed in the section below, rather than due to the success of the antidrug campaign. Figure 13.7 Total attendance at the methadone centers, 1978 to 2015 and registrants/year, 1985 to 2000

Source: Hong Kong Medical and Health Department Annual Reports, 1978 to 2015.

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Era of Psychotropic Drugs, 1991 to present The total number of drug addicts reported to the Central Registry of Drug Abuse had been slowly on the decline in the 1990s. In general, the percent of young addicts (21 years and