Dr. Charles C. Chan

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SARS and Social Cohesion

• Dr. Charles C. Chan
• Convenor, Network for Health Welfare Studies
• Associate Professor
• Department of Applied Social Sciences
• Hong Kong Polytechnic University

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Relationship between SARS, Social Cohesion
Social Capital

• Amplification of Social Cohesion during SARS ?
  potential of cultivating
• Increasing genuine trust, Proliferating
  reciprocity, Facilitating civic participation ?
  aggregated into a construct known as Social
  Capital

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Relationship between SARS, Social Cohesion
Social Capital

• Group membership
• Generalized norms
• Cohesiveness / Solidarity
• Reciprocity
• Network density and strength in neighborhood
• Trust

Empowerment sense of belonging in facing a
common threat
Resource mobilization (Human physical)
Community collaboration in health promotion
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Question 1

• How do we know that what we have done in
  preparation for a public health emergency since
  last SARS outbreak will be sufficient to prevent
  future crisis if not cultivate levels of social
  cohesion further?

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Definition of Social Cohesion

• Social cohesion can be described as the glue
  that bonds society together, promoting harmony, a
  sense of community, and a degree of commitment to
  promoting common good. (The World Bank, 2001)

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Function of Social Cohesion in public health
emergency

• Social cohesion refers to two broader
  intertwined features on society (1) the absence
  of latent conflict whether in the form of
  income/wealth inequality, racial/ethic tensions,
  disparities in political participation, or other
  forms of polarization and (2) the presence of
  strong social bonds measured by levels of trust
  and norms of reciprocity, the abundance of
  associations that bridge social divisions (civic
  society) , and the presence of institutions of
  conflict management, e.g., responsive democracy,
  an independent judiciary, and an independent
  media. (Berkman Kawachi, 2000).

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Importance of Social Cohesion during public
health emergency

• Public health emergencies turns into societal
  crises when there is not the level of trust and
  norms of reciprocity in the society.

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Level of trust in Government abroad

• When asked whether one agreed with the statement
  
• You can trust government in Washington to do
  what is right all or most of the time.
• More than 70 of Americans agreed in the 1960s.
  The number now is close to 30. (a decrease in
  Vertical Trust)
• A Gallup poll in October 2001 found 60 trusting
  Washington all or most of the time, i.e., right
  after September 11, 2001.
• But that figure returned to pre-September 11
  level by June 2002, barely eight months apart.
  Despite renewed sense of urgency that the battle
  against terrorism has evoked by the Bush
  government, there is little prospect that the
  trust number will return to the levels of the
  40s and 60s.

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Level of civic participation abroad

• Engagement in public and civic affairs generally
  has declined by 40 since the mid 60s (a decrease
  of Horizontal Trust)
• Political scientist Putnam (2001)
  A pioneer researcher on social capital

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Aspects of prevention achievement locally

• a. By August 2003, the HA has 580 infection
  control link-nurses supporting 53 infection
  control nurse specialists. They have roles in
• 1. monitoring infection control protocol and
  policy,
• 2. reflecting views from front-line HCWs to the
  management.

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Aspects of prevention achievement locally

• b. The HA opened a 24 hour hotline from end of
  April 2003 as communication channels for its
  53,000 HCWs. About 200 enquiries received in the
  first month focusing on
• 1. personal protection equipments,
• 2. leave arrangement and
• 3. infection control policy and management
  indicating
• potential dilemma they faced between such
  concerns and their duty to care.

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Aspects of prevention achievement locally

• c. A number of community protection measures
  received high profile publicity.
• By Sept 2003, the HA has plans to employ about
  100 private sector doctors to form 12 outreach
  teams to cover about 70 of elderly in elderly
  homes for early diagnostic and assessment of
  infectious diseases, supporting SWD and the
  community geriatric assessment teams work and cut
  down on need and rate of hospitalization of the
  elderly.

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Aspects of prevention achievement locally

• d. Flu vaccinations for hospital patients,
  elderly and health care workers have received
  significant results during the last winter season.

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Aspects of prevention achievement locally

• e. A centrally organized program involving 12
  clinics and a team of designated nurses will
  follow-up on the 1,400 SARS patients
  rehabilitation progress since last November. The
  program intended to be comprehensive and
  long-term.
• There are 16 GOPDs designated as fever clinics
  since last November covering the whole of HK.

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Aspects of prevention achievement locally

• f. The e-SARS information system can be launched
  within two hours of confirmed SARS cases,
  stocking supplies of protective gears sufficient
  for three months usage, drills under
  commander-in-chief, Dr. William Ho himself
  promised to breakdown barriers between four and
  more different government departments and
  individuals responsible for decision making
  during war time.

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So what more do we need to work on?

• The loyalist would say, yes, we now know that
  these are all necessary and we have done most of
  what human intelligence has enabled us to do in
  preparation for another emergency.
• The realist would say, yes, but these may be
  necessary but not sufficient.
• The pessimist would say, no, nothing would ever
  be enough.
• An applied social scientist, would say, instead
  of answering the question directly, we shall ask
  a second question which will help to illuminate
  both questions at the end.

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Question 2

• Do we have an alternative, hopefully
  complementing conceptual framework to understand
  and address the question?

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Time to move on to a second paradigm

• Input-focus, resource-based model
• aiming at meeting professional and the
  proclaimed needs of the public domain.
• vs.
• Structure-focus, interaction-based model
• aiming at once locating and defining problems,
  needs, as well as solutions and remedies towards
  locally generated action-plans.

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Is this still about listening to people? NO!

• What has changed in Washington is not that
  politicians have closed themselves off from the
  American people and are unwilling to hear their
  pleas. It is that they do scarcely anything but
  listen to the American people.
• Zakaria, F. (2003). The future of freedom
  Illiberal democracy at home and abroad. NY W.W.
  Norton company. P.166.

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A Three-Step Action Plan the CED version

• 1.Capture systematically data on health care
  workers struggle to balance dilemma between duty
  to care and responsibility to self and family.
• 2. Engage regularly a group of public opinion
  leaders in the deliberation, interpretation of
  such data.
• 3. Disseminate the evidence thus generated from
  the HCWs to the public via multiple channels
  including the media.

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A graphical model of Community Health Governance
(CHG) Model
Source Lasker, R. D., Weiss, E. S. (2003).
Broadening Participation in Community Problem
Solving a Multidisciplinary Model to Support
Collaborative Practice and Research. Journal of
Urban Health Bulletin of the New York Academy of
Medicine, 80(1), 14-60.
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Towards a model of Community Health Governance-
Dare to make the FAE difference

• Facilitate a NETWORK of concerned parties /
  organizations as independent but legitimate
  bodies to deliberate emergency measures regularly
  even at non-war times.
• Avoid providing one-sided data and positive
  evidence aim at public assurance in order to
  circumvent reactance from both the opinion
  leaders and then the public even during war
  times.
• Expect non-rational reaction from the public
  after consumption of Government announcement,
  especially in times of public health emergency.

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Theoretical inspirations to the Three-Step Action
Plan

• 1. Justice perception Distributive justice
  procedural (interactional) justice
• Social Psychologist T.R. Tyler
  (1994)
• 2. The highest goal in life individual goals
  may be better achieved when people get to work
  together over individual rationalism
• Welfare Economist A. K. Sen (1987)
• 3. Under conditions of asymmetric information
  tolerance of individual differences in the
  deliberation of the dilemma between duty to care
  and responsibility to self and family
  protection
• Information Economist J.A. Mirrlees (1997)

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A case of asymmetric information and incentive

• We have a variance to Mirrlees classic case in
  taxation. In our case, the agent (HCWs the
  public) is no better informed than the principal
  (government) in certain aspects. This can
  potentially become a case of moral hazard.
• Let us assume that after one whole year of
  efforts by the HA and our government, the
  principal is much more knowledgeable than last
  year in terms of the differential relationship
  between PPE, the care tasks and the likelihood of
  catching the SARS virus.

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A case of asymmetric information and incentive

• The two related questions now face the
  government are
• a. What, how much and in what way should such
  science-based information be disseminated to both
  the HCWs as well as the general public of Hong
  Kong with an explicit goal of making the FAE
  difference in a model of Community Health
  Governance?
• b. What kind of certainty, if any, can one
  predict the attitude and behavior of the HCWs and
  the general public after provision of such
  information?

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ReferenceBarber, B. (1983). The logic and limit
of trust. NJ Rutgers University.Berkman, L.,
Kawachi, I. (2000). Social epidemiology. NY
Oxford University Press.Colletta, N.J., Lim,
T.G., Kelles-Viitanen, A. (2001). Social
cohesion and conflict prevention in Asia
Managing diversity through development.
Washington, D.C. The World Bank.Erdogan, B.
(2002). Antecedents and consequences of justice
perceptions in performance appraisals. Human
Resources management Review. 12, 555-578.Lasker,
R.D., Weiss, E.S. (2003). Broadening
participation in community problem solving A
multidisciplinary model to support collaborative
practice and research. Journal of Urban Health
Bulletin of the New York Academy of Medicine. 80
(1), 14-60.Luhmann, N. (1979). Trust and power
Two works by Niklas Luhmann. NY John Wiley and
sons.Mirrlees, J.A. (1997). Information and
incentives the economic of carrots and sticks.
The Economic Journal, 107 (Sept),
1311-1329.Ostrom, E., Walker, J. (Eds.).
(2003). Trust and reciprocity Interdisciplinary
lessons from experimental research. NY Russell
Sage Foundation.Sen, A. (1987). On ethics and
economics. Oxford Basil Blackwell.Tyler, T.R.
(1994). Psychological models of the justice
motive antecedents of distributive and
procedural justice. Journal of Personality and
Social psychology, 57,830-863. Weber, L.R.,
Carter, A.I. (2003). The social construction of
trust. NY Kluwer Academic/Plenum Publishers.
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End of PresentationThank You!

• Network for Health Welfare Studies
• http//www.acad.polyu.edu.hk/ssnhws/