SARS and Social Cohesion

1. 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

2. 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

3. General health awareness 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

4. 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?

5. 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)

6. 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 bylevels 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).

7. 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.

8. 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.

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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”.

16. 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.”

17. Question 2 Do we have an alternative, hopefully complementing conceptual framework to understand and address the question?

18. 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.”

19. 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.

20. 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.

21. 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.

22. 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.

23. Theoretical inspirations to the Three-Step Action Plan 1. Justice perception = Distributive justice + procedural (interactional) justice Social PsychologistT.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)

24. 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.

25. 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?

26. 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.

27. End of PresentationThank You! • Network for Health & Welfare Studies • http://www.acad.polyu.edu.hk/~ssnhws/