Does colonialism still exist in Hong Kong? My 2 recent stories/encounters in Hong Kong.
It has been (at least!) 3 years since I stayed in Hong Kong for more than a month. “What’s changed?” I’m often astounded to realise people are now seeking an outsider’s perspective of home from me… But hay ho I’ve been away for long, long enough to allow me to look at Hong Kong a bit different from how I used to. Today I picked up the post-colonial lens, with my 2 recent encounters/observations in Hong Kong, to make the case of how the western colonial spirit in Hong Kong is far from being a thing of the past.
A view from the Peak in Hong Kong.
Story 1: Short Hike to the Peak
You might have been amazed by unrivalled view from the Peak (a.k.a the Victoria Peak), overlooking the metropolis, all kingdoms of the world under your feet. This is often the first image that pops to my mind when I think about home – I blame the tourism adverts and souvenirs! The hike to the peak is a common route enjoyed by all. European invaders of Hong Kong in the 19th century would concur.
During the long colonial period, the Peak was designated to be an exclusively non-Chinese residential area. However, you could almost convince an unaware tourist that the mandate is still in place in Hong Kong in 2023. There is a very high proportion of non-Chinese people in the Peak area compared with any other areas in Hong Kong (perhaps other than Lan Kwai Fong, where the drinking and clubbing happens). Legal restrictions have transfigured as economical barriers: the most affordable accommodation at the Peak costs in the billions. Apart from luxury flats and houses, you could also find a list of international schools that mostly admit non-Chinese expats kids only. It is like living on stratosphere, no need to learn to read, write or speak Chinese; your social circles never crosses path with the “ordinary” Hong Kong people; you belong to a different class.
I realised this is a source of my unease when someone (in Britain) told me that they have visited Hong Kong. Which side of Hong Kong did they see? Was it the city with the highest number of millionaires by proportion; or the city with the highest level economic inequality in the world? As they enjoyed the horse races at the jockey club, would they recognise gambling was the social device the colonial government introduced to maintain their grips on the people? Were they merely walking in the boots of their fathers, savouring the fruits of their colony; or have they stepped out of the White-only zone, and truly explore this beautiful land? I resort to praise the food every time.
Mark Six, a popular lottery in HK Accessed from Ken Cheung’s blog on Steemit
Story 2: Short Encounter on the Cable Car
It was a clear and a bright December day. No better day for a cable-car-ride at Ocean Park (a theme park in Hong Kong, watch video below for a virtual cable car ride!). As the cable car climbed the hill, we were greeted by a fellow cable-car rider from another cart down the hill. Most of the time, these are handwaves and hellos that adds a pinch of friendliness and sense of community to the fun-packed trip. Coming towards us that day was a family of 3 – a white, 5-year-old-ish boy standing on his seat shouting, and his seemingly oblivious parents. As the 2 cable cars crossed paths, we recognised what the boy was shouting – a bunch of racial slur directed at Chinese/Asian people. My jaws dropped on the spot, for someone to have the audacity to speak ill of Hong Kong people, in Hong Kong! The young boy likely mean no harm, and it is certainly that he was not targeting us. Heck I would even have to applaud his choice of time and place to do this – such that he would hardly be held accountable. At his young age, he had already learned/or have been taught that he is different – different from the “ordinary” Hong Kong people, that he is no member of Hong Kong people, but a successor of the whip, a higher, better class. The boy is not to be blamed, look around: whiteness remains to be the standard for beauty, a synonym for good reputation, the definition for class. Who should be hold accountable for keeping Hong Kong people the remnants of colonialism?
I love to say to people in the UK that Hong Kong is an ethnically homogenous place – the notion of ethnicity and race is just not in people’s minds. But lest we ignore ethnicity as a building block for meaningful conversations across members of the community, and lest we rule out race as a perpetuating cause for social inequality, and racism as a vehicle for colonialism.
See you soon, Hong Kong, with my very best wishes.
A short reflection based on my observations on trends in mental health research. With audio narration.
Listen to the blog here.
Research methodology 101 in psychology typically starts by explaining statistical hypothesis testing, how data can be understood in a certain way (model) to draw inference. A theory-based statistical model is the approach in which researchers make meaning out of the constellation of data-points – in a systemic and falsifiable way that differentiates inferences from astrology.
Research is not easy. There are many decisions and assumptions researchers make in the process, e.g., how are concepts defined, how are these concepts measured, what are the relationship between these variables, do they overlap? Researchers design, clean, collect and frame data in a way such that they can tell a story – Data may speak for itself, but the theatre is built by the researchers. It is more than choosing which variables to put into the model, or discover which variables are statistically associated with the predictors. It is about how the confirmation or rejection of the statistical model should be interpreted, in what context, for which populations – and more.
Psychology research methods 101 – Hypothesis Photo by Tara Winstead on Pexels.com
The industrial revolution automated jobs and led to an expansion of productivity; the “artificial intelligence (AI) revolution” appears to share similar aims. The first questions that pop to people’s minds are – “Can we automate this process? If so, how?” The same ideology has been applied to understanding data – there are AI models spring up like mushrooms after rain, with approaches like “covariate auto-selection” that promises to perform as good as (or outperforms) “traditional analysis” – whatever that means.
I am no fan of such practices. This is because I think data analysis is only a small part of the whole scientific process, there are limited ways you can “let the data speak” if the paradigm of data collection, conceptualisation etc. is never challenged. This AI-do-all approach, if deemed to be the best, or even worse, the default practice, will leave little room for users to challenge the premises and assumptions in which the inference are drawn, hence no true empirical theoretical advancements, but post-hoc theory-making. But can you really blame AI data scientist for this?
There is no point in finger-pointing [maybe 1 >:o)]. The problem of weak theory is prevalent in (mental) health research (More discussion here on formal theory: https://eiko-fried.com/on-theory/ – Eiko’s blogs, with a lot of resource on theory, do check them out!). An example that is highly relevant to my work is the use of ethnicity in health research – is it biology? Is it country of origin? Is it migration status? Is it social support and network? What is it’s relation with the covariates? Papers often describe whether their findings fit with previous research, but most of the time stopped at that level, “More research is needed”, and less discussion on theory. It is this tendency of focusing just on inference and less about theory that precipitates AI-based analytical practice to expand.
AI helps make meaning from a pre-specified framework Photo by Tara Winstead on Pexels.com
This phenomenon begs the question, why is theory playing less of a role in mental health research? What is the driver behind this change in scientific practice? I believe a particular emotion – frustration – plays a role. I see this frustration arise from the huge implementation gap, and the insurmountable unmet needs, which is made worse by the replication crisis.
We are said to be in a mental health crisis. The healthcare system is more sensitive to detect mental health problems: they are recognised earlier and more broadly at primary care, but our ability to treat our patients did not improve to the same extent. It takes 17 years to translate health research into practice. IAPT, new waves of psychotherapy, medications… These attempts to improve service provision (by quantity/access) and quality did not match the increasing demands. With record level of demand for mental health support (even before Covid19), the whole community is pressured to provide solutions. The frustration stems from the compassion to the plight of patients.
The same frustration is felt by the funders too: decades of funding to find a pill to eradicate dementia, pilling resource to prioritise “what works”, stronger than ever appetite for interventions. The positioning of researchers in the field is no longer “neutral observer of (natural) phenomenon”, but “proactive driver of change”. The increasing need to demonstrate “impact” is evident of this change of positioning. Measure of impact depends on ability to demonstrate progress. Theory development is often a twisted journey, it intrinsically fares worse than randomised control trials in that regard in the current paradigm.
In conjunction with the replication crisis, where small sample size and poor methods (but not weak theory) were deemed to be the culprit, strength in numbers feels like a pre-requisite to publish in high-impact journals. This shapes the ecosystem of academia. Bigger institutes are in better position to run larger studies, hence sustenance of the self-prophesised loop of impact as the top research institute. There are less options for smaller institutes to compete – to rely on impact-driven evidence making, rather than theory testing or development. Research became more focused on interventions and local adaptations, rather than trying to come up with a grand theory for a disorder.
Researchers do not have to choose binarily between “theory” and “intervention”, there are plenty of middle-ground between the two. In fact, they go hand in hand to the development of any field. An “intervention”-leaning environment amplifies the need for researchers to understand and clarify “context” – how accumulated evidence can be applied to the situation at hand. I don’t think we are very well trained in this regard (yet), it hasn’t been the focus in the past, nor included in the curriculum. Approaches such as realist evaluation, rapid qualitative reviews etc. arise to address this gap. A “theory”-leaning environment, on the other hand, emphasis on understanding the nature of a phenomenon. For example, the biopsychosocial framework encourages multidisciplinary treatment, which hopefully the restructured integrated care systems are in better position to provide. Another example, where digital based mental health intervention apps taking many different approaches failed to live up to their expectations, perhaps rekindling the positioning and theory of such interventions is the bridge to success. Theory serve as a foundation for knowledge to be generated, decisions justified, and help the field explore alternative explanation of “reality”.
What’s next? It is for us, members of the scientific community to live out the direction of our field. We need to be pragmatic to come up with solutions to address the huge mental health needs, but we need to continue to be observant, patient, and preserve space for new theories and alternative framework of understanding of mental health to be developed and tested.
2 factors that affected my motivation at work: some reflections
Started writing this blog on the 3-month mark of my role. Lack of Motivation has very seldom been a problem for me. Transitioning into my current job, I did struggle with this a bit, especially when I am working from home, with an unstable internet connection and accompanied by a novice flute player downstairs.
I am grateful to be able to be inspired by my mentors and colleagues that has allowed me to reflect on how I work. Here are my 2 barriers to motivation.
1. (In)Ability to Contribute
I’ve received absolutely great support from my supervisors and colleagues. I did not feel like I was dropped into a completely new place with no one to seek help from. People are welcoming, I get to meet new people every now and then. Yet there are still times when I have not felt like a part of the group. The working style in my previous role was quite different from my current one. My previous team is rather spontaneous, we are constantly chasing deadlines, constantly speaking and collaborating with each another. My current role is more structured, things are moving in a slower pace, and it is not very often we get to tackle a problem together. This change of pace and team dynamics mean that sometimes I feel out of place.
In a conversation with my mentor, she noticed that I appear to put a lot of my emphasis on my ability to contribute to the team. Upon further reflection, I think that is very true. I am eager to give, but not just to take. But with my limited expertise and knowledge, I felt like I am in no place to give. And I hope this is not based on mindless patriarchal desire for people to listen to me, but to position myself as a valued member of the group and community, instead of a recipient of charity and welfare. My double-identity as a staff and a student also plays into this. I was heading to a blind alley with this train of thought, and it sometimes then stripped my focus away.
My mentor spotted a gap in my way of thinking. Contribution doesn’t always have to be about knowledge and expertise There are all kinds of contributions. Being kind, active on Teams chats, willingness to listen, responsive to emails, sharing my own perspectives and stories, smile… There are many ways how my presence could help make the team better. That helped me remember that me, as a person, has much more to offer than a domain specific knowledge. I care about equality and inclusion, I care about workers’ rights, I am eager to rise people up. These all shall anchor me as a valued member of the community. Motivation follows.
2. Stress to Represent
We talk about gender/ethnic/any representation a lot in our society. Being the “one” in group appears to be magical – it’s the fundamental step of a building fairer world. That is all good.
But there is a, perhaps, unintended consequence that comes with the above narrative. People from minoritised groups are always under a stress to represent. This stress comes from multiple directions:
a) Am I representing my ethnic group well enough? Will my inadequacy hinder my groups’ already small chances to progress in life? There is this constant worry that it is not enough to be just as good as everyone else. One have to do well in every part of life: always dress smart, be professional, don’t make mistakes and stay on the safe side… And that is not always “me”.
b) Is how I am representing “ME” a product of conformity with social expectations of who I should be? Should a HongKong/Chinese person always be good at Maths, a little bit timid in social interactions, be a diligent worker, bad a driving… It is not about the positive or negative conations of these impressions, but rather questioning, is how I was perceived by others truly comes from me, or is it a implicitly implied characteristics that I should have in order to be socially accepted as a person coming from that particular cultural group.
This thought coincides with point (a), if I am not demonstrating characteristics that would fit a public understanding of how Chinese people should behave – and these characteristics could be positively or negatively judged upon, how would then my fellow people be perceived?
Represent. Represent. It is counter-intuitive to think that the burden of representation is laid onto 1 person- no single person could fully represent any group, which is intrinsically a combination and emergent identity that no single person can fully grasp. We often set our EDI recruitment goal at a merely the representation level reflected by descriptive demographics. Yet 1 is miles away from demonstrating diversity WITHIN any given group.
Being a One/few-in-many does shape my self-perception. The process and reflection I describe in (2b) above is dynamic. It could well be that over time, that I become more and more similar to the media-portraited image of a Chinese person. It might not be a bad thing either. But perhaps I am not yet ready to represent this label. Perhaps I need to know myself more before I could allow others to learn about my group, and the difference between the two. It would be much appreciated if this process of self-discovering is not needlessly pressured to accelerate, that I won’t have to force to choose the group I am not ready to represent.
I am grateful for my current workspace, that I have the luxury to think about and reflect on these things that interfered with my performance. Some of these, like (1) could be resolved, but other (2) would require a change in societal attitudes towards in-group, towards others, and towards ourselves. I hope this would help motivate you a little bit too 🙂
Reflect on how Hong Kong Chinese names are misrepresented in the UK
“Chi – Chi – is Chi here?”.. “Here.. (unreluctantly)”
I bet the majority of students from Hong Kong have experienced this – Coming to a foreign country, speaking a foreign language, being called a foreign name that took you days to recognise and internalise. Yup, you are here, away from home.
Stripping away the sentiments, I can’t help but be surprised (perhaps I shouldn’t be!) how most of the times (mainly Hong Kong) Chinese names are wrongly represented in English – given the intertwined (colonial) history between Britain and Hong Kong.
These mistakes in naming replicates themselves in educational settings, universities, administrative data and health records. Practically speaking, these mistakes induce higher error rates in records, and hence lower the probability that these information could be used to advise research or public policy – a form of research inequity that perpetuates health inequity in society. If we truly are marching towards an inclusive, more equal society, I do think the first, and the least thing we need to do is to get the names right. Here’s a quick simplified tutorial.
Chinese Name Short Tutorial
In (modern) Chinese, full name (姓名) comprises of a surname (姓) and a forename (名). There is no equivalent of middle name in Chinese.
Surnames typically consist of 1 character, up to 9 characters (only 1 in the Chinese Surname Dictionary)! The 1996 Chinese Surname Dictionary collated 11,936 Surnames, where over 90% of the Chinese population share 120 common surnames (all of them consist of 1 character), and the top 5 surnames (Wang, Li, Zhang, Liu, Chen) take up 30% of the population. As for forenames, they usually consists of 1 or 2 characters, with no upper limits on the number of characters. During the infamous Salmon Chaos discount event in Taiwan, a person has changed their legal name to 50-character-long(49 character forename)!
From the national names report in China 2020, over 90% of Chinese full names consists of 3 characters, as proportion of 2-character names dropped to around 6%, and 4-or-above-character names has a total of around 3%.
Problems with English Representation of Chinese Names
Cantonese and Mandarin pronounces the same character differently – hence their English translation differs. Take my surname as an example, 林, is pronounced more closely to “Lam” in Cantonese than “Lin” in Mandarin (e.g., The NBA player Jeremy Lin). This variation of translation tells us a bit more about where individuals come from – that’s good, as long as people consistently report and record them.
A big issue lies with the forenames. Forename translations in China and Taiwan uses Mandarin Pinyin, which is (sort of) an established method to pronounce Mandarin characters. This is not without it’s limitations, for example, some characters like 呂 (Lǚ) could not be represented using English alphabets. There is no accurate alphabetical representation of Cantonese, mostly due to it’s complexity of having 9 tones and 6 modes/pitches, and that a lot of the words do not share a similar pronunciation mechanism with English. The resemblance between Cantonese-English is much lower than that of Mandarin-English.
Another key difference is that, Mandarin-translated English forenames are usually presented as the same word. For example, 鄧小平 is represented as Deng (Surname) Xiaoping (Forename). Cantonese-translated English on the other hand retains the independence of the forename characters. For example, 鄭月娥 is represented as Cheng (Surname) Yuet-ngor (Forename), where the hyphen is sometimes omitted as space. In the current naming registry in the UK, a lot of the times Cantonese-translated English forenames are truncated and treated as a combination of forenames and middle-names. For example, Yuet-Ngor are truncated as “Yuet”, and “Ngor” recognised as their non-existent middle-name.
How is this still happening in the UK today? Have they not consulted any Hong Kong Chinese? This leads to a key barrier to EDI- power dynamics in Public Patient Involvement. There probably are formal or informal checks with Chinese-speaking people to see whether the existing way of representing names are appropriate, however, these issues might not have been dealt with. We have to be mindful of the power dynamics in which these conversation have happened, in the past and in present. A partial sacrifice of the name and humiliation to the ruling, (White) decision-makers to “earn” a moment of shared laughter might seem to be ridiculous, but it makes a lot of sense amongst the exiled, minoritized communities. Heck, lands were occupied and unequal treaties were signed for the same reasons.
This is not a phenomenon unique to Hong Kong Chinese. It is quite common that people change their naming traditions, willingly or non-willingly, when they enter the country, for example, Vietnamese flip their forename and surnames etc. Speaking from experience, I know there are many occasions that my friends tried to correct their tutors on how their names should be called at Universities. Unless they switch to a “proper” western name, some tutors would insist to use the “name that is recorded on the papers”. The less brave would persevere, like many of our predecessors, to be referred to as a foreign name, even foreign to ourselves.
Glad to see the movement on using the preferred pronouns in communications – I hate to say this but it’s always easier to promote when White people is a beneficiary of any social movement. So my plea is, perhaps it’s also time to pay the long due respect to the un-named, attention to the unseen, and voices to the unheard.
Reflecting on how Ethnicity is researched in academia, challenging “defaults practices”
Listen to the blog here
From the latest release of admin-based ethnicity statistics (ONS), it was shown that, across several administrative data source, there are a significant proportion of people having reported to belong to more than 1 ethnic group.
Similar evidence of changing ethnic identification was demonstrated in Understanding Society @usociety youth survey in young people aged between 10-15.
Ethnicity is a dynamic historic-cultural construct, and for most people from ethnic minorities groups, it changes overtime. In research/policy-based evidence making, ethnic groups are often lumped together (#BAME…), assumed to be constant, and you can only pick 1. It bears the question, how come the default practice in research is to treat ethnicity as time-invariant?
You might notice that – Changing ethnic identity is very uncommon among people reported to belong to White British groups.
And rightfully so! At the time when the population is predominantly white British (or that people from other groups are mostly slaves or seen as objects), research is predominantly initiated by white British, it is reasonable that ways of research are agreed for and within white British.
I am not saying it is a bad thing to have a consistent ethnic identification! But this lived-experience of an invariable ethnicity by white British groups has dominated the knowledge generation process and structure. And this assumption, rightfully based on white British experience was then assumed to be an universal experience.
It became The Default.
I did not recognise the issues with The Default.
I thought it was a consensus, as it was widely replicated and taught to next generations of researchers. I still do the same in my own research: treating ethnicity as lump sum categories, do not change over time.
And perhaps this IS the manifestation of systemic #oppression/#racism. Paraphrasing Dr. Celestin Okoroji: @CellyRanks shared at @kcsamh#PartneringforChange event yesterday (21/6), we need to recognise the hegemonic knowledge and evidence generation mechanisms in this society, and challenge them. (See my thread to capture part of the talk here)
It became The Default. (Photo by Pedro Figueras on Pexels.com)
The next question is: “how” – what can we do, if we think we should challenge the default – or at least suggest an alternative of how “reality” is conceived. I have 2 thoughts – (please share yours with me too!) 1) Community-Centric Research 2) Improving Methods
(1) Community-Centric Research means to put local communities – people – at the heart of research. It is about valuing relationship building, and demonstrate impact valued by local people. It is one form of Public Patient* Involvement I suppose, but more. This should be embedded in how funding is planned and commissioned.
(2) Improving Methods This is one goal of my PhD project (with @Klharron & @rob_aldridge), to improve research equity, to face the biases in “default practices”, more specifically in the practice of data linkage, interpretation and public health policy decision making.
This is new to me – and I am empowered to see so many pioneers on this path. Change can only come from a collective effort. Do share your thoughts and idea with me here or via email!
希望是本無所謂有，無所謂無的。 這正如地上的路；其實地上本沒有路，走的人多了，也便成了路。
魯迅先生 – 故鄉
There is no such thing as Hope, it’s just like the path. There was no path. The path is manifested when thousands of people walk through.
Gender, Race and power in Academia: Complexity of Intersectionality.
Figure 1. Tweet Captured from Prof X’s Twitter feed on 28/4/2022, 10:18 am, UK Time
The tweet above is tweeted by an Asian American women professor in sociology, Prof X, who serves as the director for the Centre for Research on Social Inequality. My understanding of the original post (OP)’s intention is to invite discussion and reflection on the inequity and (micro) aggression directed towards women of racialized communities in academia; in this case, from a student.
However, Twitter reacted slightly different from what the OP expected. At first glance, a lot of people saw this as an act of oppression and public shaming of the student. I thought we Twitter user must have learned by now that 280 characters is just too little to paint the full picture, and to be kind before jumping to conclusions. Prof X very soon found herself at the receiving end of all sorts of criticisms and degrading comments on her character and professionalism. This is an unfortunate case study to look at how intersectionality plays out in real life, how the role of race is dismissed for minority groups in power, and the lack of solidarity within racialised communities.
I am summarising a few common comments (filtering out straight up insulting ones) under the original tweet:
Response 1: “It is a right question to ask!”
This response highlights that it is important to find out about potential supervisors’ skills, styles and whether it matches with them before a student decide to work with them. I think this is indubitably true. However, this comment missed the OP’s point. The problem is two folds. It was never about whether the student should ask the question, but the subjective experience of an Asian American women’s qualifications and capabilities being constantly questioned in academia. It is not about whether the question is appropriate, or even how that question was asked, it is about the cumulative experience of being treated as lesser because of their gender and race. In Ljeoma Oluo’s book, So You Want To Talk About Race (2018), she illustrated clearly the case of how racism cannot be reduced to isolated events. What is experienced and reported in this tweet is merely the tip of the ice-burg, the straw that broke the camel’s back. Many comments along this line went on to discuss “Whether or not” this question should be asked, such as:
“It’s that the student asked a professor if she was qualified (like an interviewer) instead of asking if they were a good fit (like an advisee). The tone and phrasing can feel insulting because it questions competence instead of appealing to the specificity of one’s expertise.”
But the OP is not really talking about the wordings. It is about TO WHOM this question is asked, and what this reflects. In case this was not clear, a fellow Asian American colleague of Prof X shared in the comments, but it did not turn the tides of toxic criticisms towards the OP.
Figure 2. Tweet reply under OP. Captured 28/04/2022, 10:21am, UK time.
Instead of recognizing the racial and gender inequity that lingered for far too long, instead of believing that the OP is, indeed, about race, instead of reading carefully what the OP is trying to get to, Prof X was torn into pieces. This blue bird is definitely a carnivore, beware.
Response 2: “Why would you shame your student in an open platform?”
This points to a different problem. Where is the proper place talk about racism? When is the proper time to talk about racism? Should this be discussed on a public domain where people can share their learnings, or should this be a private conversation between the affiliated parties? We may never have a good-enough answer for everyone for the questions above. However, the problem I see here is the need for people to police on how these issues should or can be discussed. This act of policing itself is part of the attitude that perpetuates structural and casual racism. This suppresses minorities groups to share their lived experiences on a day-to-day basis. Yes, the OP did not spell out word by word that the student is sexist/racist; yes, the OP tried to find excuses for such questions to be asked given it’s unpleasant manner; I see these are the result of similar policing on when can people from racialised or minority groups talk about their lived experience, such that we pitifully comply with conscious choice of self-censoring and humour to cover up our pain. This is not a problem of platform; this is a problem of power.
Reflections
I think the presenting case here is a lively example of the complexity of intersectionality, when power and race coincide. A lot of the criticisms following the lines of Response 1 hold the notion that, the professor is in the position of power, it is hence an act of oppression. When the OP talked about her particular interaction with a student, they are automatically assumed to be the oppressor, wherever the platform may be, on whatever topic, in whatever context. The position dictates everything. Perhaps the OP would be much less controversial if the question did not come from a student, but from a colleague, or a member of the public, where public discourse favours OP’s position. Perhaps the OP would be much less controversial if the OP is a white male professor, where public discourse favours the criticisms. This reductionist way of thinking succeeds only in applauding a superficial understanding of “social justice”, but in reality often works against their intention, in worse case, a valorised, covert form of racism.
This is an example in how intersectionality plays out, in situations where systems of powers seem to operate in contradictory manners. When people from minority races are in a position of power, people assumed that their position of power would always overshadow their race, and that racism does not seem to, and should not affect how they interact with the world. The emergence of Critical Race Theory is a response to exactly these situations. Our case here exemplifies that we’ve still got a long way to go.
East Asian are the majority ethnic group in the world, but we are never the majority in these contexts. We are not white, not brown, not black. We are a distant majority group that was left out of the discussion. We are the ones that are stuck in the middle. We do not need to indulge in a competition of whom the most deprived group is, it is meaningless; however, we do need solidarity from other racialised communities to stand with us when we face racism, sexism, as other groups do. Please be kind.
Thinking of you Prof X, hope you are well.
“My dear brothers and sisters, take note of this: Everyone should be quick to listen, slow to speak and slow to become angry,”
Reflection on the Ownership of public space – physical or intangible
A procedural depiction of a futuristic world is characterised by a sophisticated metropolis, with a jungle of high-risers and floating cars. Cities are regarded as the pinnacles of civilisations – from Jericho to Manhattan – displaying the glory of our collective effort and wisdom. For some, however, cities are synonymous for crime and danger, where deceit and lies crouch; for some, cities are apathetic, every one looks after no more than themselves.
Moving from one overpopulated city to another, it wasn’t until awhile ago that I got the chance to visit Brick Lane. With no exception, I too was stunned by the vast display of creativity in the form of street graffiti. This kind of artistic expression is almost never seen in Hong Kong, where the art form is largely associated with outlaws and delinquents. My friendly tour guide explained that the graffiti at Brick Lane is tightly regulated – art pieces are regularly brushed off the walls and replaced by others’ work, popular ones might get a 2-year airtime. Perhaps this is how “Graffiti at Brick Lane” differentiated itself from “malicious defacement of public property” to one of the most popular tourist hotspots in London.
“Regulated graffiti”, I have to applaud the tenacity of the governing party’s attempt to “valorise” the art form. By putting order in disorder, graffiti at Brick Lane became a formal route of artistic expression; one can proudly sign one’s name next to their work, without having to worry about the legal consequences. Having one’s work displayed at Brick Lane became a sought-after honour. Your artwork’s intended audience expands from local bobs to tourists around the world. Comparing to unregulated graffiti, or just “normal graffiti”, rules and regulations freed one’s work from the laws of the jungle: your work won’t be vandalised or painted over just because you’ve painted on the wrong side of the road, or that you’ve taken a “better” spot. Popularity becomes a fair estimation of how long one’s work should stay up, reducing the risk of a horrible work occupying the public space.
However, it wouldn’t take one too long to smell the irony of such practice. One could go as far as saying “regulated graffiti” is an oxymoron. Graffiti emerged as an anti-establishment form of public art. With regulation, with no exception, comes censorship. This compromised version of graffiti sold their soul to buy airtime and public acceptance.
Graffiti at Parkland Walk, North London, photo taken 2020
This short case study of Brick Lane graffiti invites deeper deliberation on the ownership of public spaces. In a framework that relies on rules and regulation, the responsibility of implementing and policing these rules fall onto the governing institute. It became no ones’ but the institute’s responsibility to delegate and manage the public space. With great power comes responsibility (No Way Home!), I’d think the reverse is equally true. The institute, by design, manifest the power of the many, with such power comes freedom to shape the rules in the forms they see fit – no swearing, no nudity, or, no disturbance of public order (…) or national security(…) (almost seems like I’m endorsing anarchy). The institute owns the public space. One might suggest that institute is the least of the evil, assuming the only alternative for an unregulated system leads to barbaric chaos where iron fists and crime rules. I would argue otherwise.
Graffiti is a public art form. The essence of graffiti lies in the public sphere – anyone with a can of paint could chip in. There is a natural selection mechanism – messages that the mass agreed with would be replicated; messages few agreed with would be ignored, and probably soon scratched; only messages most strongly disagreed with would be “cancelled”. There is no singular institute that decides what to censor, it is but a shared power, hence responsibility for all in the community. The public space is then, co-owned by the public. Correspondingly, this system of public space management requires members of the public to take an active role in co-creating, maintaining and cultivating the public ecosystem to ensure people’s artistic expressions could be sufficiently captured.
The elephant on the street, near Brixton, London. Photo taken 2021.
The elephant in the room is, perhaps regardless of how eye-catching the graffiti are, quite a number of us just don’t want paints on our properties. Similarly, not everyone wants to take part in the public sphere. This is a nature of the crowd, and coincidentally the downfall of a completely non-regulated community. The silent majority is how the mafia could take ownership of the streets by brute force. The opportunity to paint on walls would be stifled, when mutual dependency of the public is broken, and that the powerful abuse ones with less power, not respecting their stakes in the community.
Never an easy way to please everyone, ay? There is no one superior way to manage any public spaces, it largely depends on their compositions. I guess a lesson from this is, we should try to be appreciative of opinions shared in the public sphere, be it graffiti, podcasts, or blog posts. They may not occupy the BBC headlines, or shine amongst the Brick Lane graffiti, they nevertheless are part of our voices that deserves to be listened. Pray that the institute have the breadth of mind to reflect on the power imbalance and empower the public; and that the public would feel safe and ready to share and co-create our public space.
— Prof Alison Leary 💙#ProtectNurse (@alisonleary1) July 28, 2021
There are several interesting candidates for “Justifiable Deviances”: “Functional Nonconformity”, “adaptation”, “Workarounds” etc. Of all the suggestions, “Expertise” caught my attention. To compliment his suggestion, Steven Shorrock linked his page with lively examples to illustrate how reality often deviates from prescribed plans (fig 1), and that the specialism of medical staff gives them the authority to make decisions that might deviate from the standard. For example, nurses might change the time of insulin administration to meet the arrival times of meals on ward. Another Twitter user, however, questioned the notion that these medical judgement could at all be impartial, and therefore, leave space for incompetent and immoral practice. This brought my memory back to a conversation I had with my father.
My father is a respiratory medicine consultant. He takes pride in providing the best care to his patients, nights in and nights out. He has his fair share of “justifiable deviances”, most of which converted into Thank You Cards on the shelves, but there are occasions when things did not go as planned. There are occasions when the family of the deceased filed complaints to the medical council, and his medical judgements would be put under scrutiny, often against the “standard procedure”. These trials seldom bother him, rightfully so, as he is consistent and transparent in how he communicated and shared decision making with his patients. However, as we share the bottle over Zoom that night, there is this moral dilemma I felt imposed inadvertently by these complaints on my father, in the way he described the case of Pt. X .
A case study: Pt. X
Pt. X was late into their lung cancer when they came to my father. They presented with shortness of breathe and persisting lack of energy, and can barely take any stairs. After several courses of treatment, their lung function returned to pre-cancer level and Pt. X regained independence. After years of cancer management, Pt. X’s condition deteriorated, their lung function compromised, was wheelchair-bounded due to difficulty of breathing, and had to rely on carers for daily activities. There is nothing more to be done according to standard procedure. My father suggested a non-standard treatment that he believe could partially recover Pt. X’s lung function to allow them to regain a certain level of independence. Pt. X acknowledged the risks of the surgery, saying they would rather die then to be left as a burden to their family, and decided to go for it. Surgery was successful, however Pt. X passed away on operation theatre due to other surgical complications. Pt. X’s family filed a complaint to the medical council, which was dismissed after some investigation.
There are occasions when the family of the deceased filed complaints to the medical council, and his judgements would be put under scrutiny, often against the “standard procedure”.
I could imagine the complex feelings my father must have been through: the grief of losing a patient he cared for such a long time, the stress of his professionalism being scrutinised, the sense of betrayal from the patient’s family, and ultimately, the moral dilemma – whether he should have made this option (the surgery) known to his patient in the first place. To answer the question, I would try to draw from different schools of philosophy in dealing with moral uncertainty – being Utilitarian, Deontological and Practical Rationality perspectives. This part is greatly inspired by Professor Trisha Greenhalgh’s article: Moral Uncertainty: A case study of Covid-19. My condolence and respect to Professor Greenhalgh and her family.
A Utilitarian Perspective
A Utilitarian moral theory suggests that whether actions are morally right or wrong depends on their effects (in our context, health). Actions that has the highest degree of moral rightness, or when uncertain, is most probable to maximise moral rightness, are more moral. In our case, we should then ask 2 questions:
Is advising the option of a non-standard surgery morally permissible? I’d say “Yes, but not absolute”.
Permissible since:
If advice taken and successful, Pt. could regain some degree of independence
current condition was “worse than death” for Pt. – Reduces Negative Disability-Adjusted Life Years (DALY)
Not Permissible since:
Pt’s health could deteriorate: Risk of dying when Pt. currently not critically ill
Pt.’s death could have secondary effect on their family etc. emotional
Is NOT advising the option of a non-standard surgery morally permissible? Similarly, “Yes, but not absolute”.
Permissible since:
Out of Standard Procedure means there is Nothing more we should do
Medical resource could be distributed to other patients in need
Not Permissible since:
Pt. would be distressed by the news
Pt.’s health would not improve from their current state
Based on the Utilitarian perspective, whether putting this option of surgery on the table is moral comes down to how likely the desired and undesired outcomes would occur. However, It occurs to me that there is a major conflict in what is deemed to be “good health” – what should be the endpoint of treatment? In the case of Pt. X, proposing the surgery would be deemed more morally permissible if health is evaluated under DALY, to treat such that Pt. could reach their maximum potential of life in their remaining years; whilst the opposite would be true if the endpoint was to manage deterioration of chronic lung cancer. I am in no position to claim to know the risks of the procedures, nor decide if Pt. X’s conditions should be maintained but not treated. Therefore, the Utilitarian approach is of limited use to me on the topic.
Deontological ethics concerns the morality of an action based on whether the action itself is right or wrong (under certain circumstances), rather than based on the consequences of the action. It concerns about the motivation by which action is driven. Let’s put together a list of potential motivations of advising and not advising the surgery to Pt. X.
Advise
From expertise, allow Pt. to regain independence
For Fame and Pleasure from saving a Pt
To push the boundaries of modern medicine
To personal development in surgical skills
To avoid not suggesting an option that could have improved Pt’s quality of life (thus prevent moral injury to self)
Not Advise
From guidelines, nothing more could be done
To avoid risk of receiving complaints by “following the standard procedure”
To avoid “unnecessary” risk of death of Pt, hence emotional burden on family
To vacant resource for other Pt
To avoid suggesting an option that could cost Pt’s life
A deontological moral theory examines the doctor’s motivation in sharing their advice with patients. It depends on whether the decision (of disclosing) is made based on the best interest of the patients.
The deontological model triggers another conflict that medical professionals might diverge on what the roles of “Standard Procedures” in healthcare setting would be. Some regard the “Standard Procedures” as “the gold standard evidence-based” practice, thus following the “Standard Procedure” serves as a safety net as medical professionals would be sufficiently protected from medico-legal responsibilities. Some perceive the “Standard Procedure” as general recommendations and references to guide, but not to dictate medical decision making. Taking necessary deviances from standards based on contextual factors is the value of expertise in a complex, noisy environment.
The former view, embodied as defensive practice, defined as solely following “Standard Procedures”, could be an unwarranted consequence of a medical system where clinicians are punished economically and socially by deviances that did not fare good outcomes; whilst good practice beyond medical standards are seldom rewarded or glorified. It is much easier to find news regarding medical malpractices or negligence than any positive news focusing on individual merits (Could this be partly due to how insurance and legal systems works? We can find numerous catalogues dedicated solely to medical malpractices, and I’d be surprised to find even 1 doing the opposite).
I am not claiming that medical professionals should be let loose to do whatever they see fit, but to state that defensive practice could camouflage itself within “Standard Procedure” and be iatrogenic. This predisposes medical professionals to “stay safe”, take no risk and continue enjoy their social status; while patients, mostly unknowingly, have their opportunities to get better – however we would define it – denied.
I think this defensive mentality feeds into the power dynamics between physicians and patients. The physician-patient power imbalance is ever persistent, which could be partly attributed to the 3 gaps (The Knowledge Gap, The Power Gap, The Arousal Gap) as illustrated by Dr Patricia Cantley in her blog. I would add, building upon the Knowledge Gap, optionality, or the choice of disclosure vs concealment is really what gives doctors their power. The choice of concealing a potentially beneficial treatment option is selectively protected by law, and the choice of disclosing a potentially beneficial treatment option punished. In a patient-centred shared decision making rhetoric, physicians’ roles include gatekeeping evidence-based treatment options, communicating risks and benefits of these options, and facilitating patients to navigate within the medical system. If the treatments options are locked within the “Standard Procedures”, there would be no true shared-decision making. The physicians always had the power of optionality. If “Standard Procedures” are the only thing that is of our concern, I’d say the days are numbered before AI completely takes over healthcare.
Enough side-tracking, back to the topic. It is inconvenient that we could not go back in time and read people’s mind to make an objective judgement on whether one’s action was stemmed from a morally-sound motivation, but this could well serve as a alarm bell for us in making future decisions.
If “Standard Procedures” are the only thing that is of our concern, I’d say the days are numbered before AI completely takes over healthcare.
Practical Rationality Perspective
Practice rationality concerns not only empirical facts, but also attempts to capture subjective emotions, narratives and contexts in which an action took place. The decision to provide the option of treatment would be moral in my portrait of Pt. X’s story. Being a strong provider of the family who’s pride and independence stripped away by chronic cancer, Pt. X is desperate to get better, or else they would rather die. It is difficult to argue against this account unless there is more context to Pt. X’s background, relationship with family etc. which we could not illustrate. Contingent on the adverse outcome (of death), we could argue that Pt. X’s family members would have to bear the emotional burden of losing a close relative pre-mature to their original course of life. This could have been what they felt, which drove the action of filing the complaint. Yet this line of reasoning reverts back to the naïve consequentialism, and is unhelpful for us to make future decisions morally.
But, does it really matter?
However, this highlights the crux of our discussion. Discussing what is morally right might be meaningless, when a right and moral decision (of disclosure) does not mean that you would not be punished, in a system where Punishment is solely determined by Consequences. Even all of the complaints were dismissed, the stress you’ve been put under, moral dilemma, reputation tarnished, professionalism questioned… None of these would be reimbursed or valorised. It’s simple operant conditioning, punishment of a moral action discourages future moral actions. It wouldn’t take long until “standard procedures” precedes morality in healthcare. May this be a naïve outcry for change.
You either die a hero, or live long enough to see yourself become the villain.
Harvey Dent, The Dark Knight.
The darkest hour of the night comes just before dawn.
Reflecting on my experience writing this blog, my main motivation is to reassure, comfort and encourage my father – to choose to be stubborn by doing what is morally right. And I hope the same message goes out to every one of you who’s doing the same.
“To be evenminded is the greatest virtue” – Heraclitus
This quote hit particularly strong as it came from Heraclitus, a.k.a “the weeping philosopher”, as later scholars speculate the great mind could be long troubled by depression. To be evenminded, calm, undisturbed is the virtue Heraclitus sought after all his lifetime. People now refer to Heraclitus’ school of thoughts as “early-stoicism”, which some regarded as the philosophical basis for modern cognitive (behavioural) therapy (CBT). CBT is built around the idea of dissecting and challenging the thoughts, belief and behaviours that maintained one’s mental illness. To develop insight (read my MSc Dissertation on the topic), or the awareness of the mental illness, is said to be the first step that is necessary for CBT. Lack of insight – at least the illness recognition components of insight – could not blissful within this framework.
Mood Monitoring is widely used in treatment and self management of mood disorders.
For mood disorders such as bipolar disorders, this idea of mood monitoring is widely used in treatment and self-management. This follows the stream of thought that better awareness of one’s mood changes would prepare one better to account for potential relapses. Jasper Palmier-Claus and colleagues (2021) has recently published an article evaluating whether mood monitoring is Always helpful in people with a diagnosis of bipolar disorder.
The authors cited qualitative evidence that mood monitoring could induce counter-effective pre-occupying thoughts, such that people could not tell whether their day-to-day moods are an early sign of an extreme mood state, or are merely a “normal” fluctuation in mood. Authors also cited the MONARCA single-blind Randomised-control trial that mood-monitoring alone does not on itself reduce depressive or manic symptoms. It seems that mood monitoring alone might not deliver the proposed clinical benefits, and are certainly not without risks. As I quote from Jasper’s twitter thread,
We suggest that an individualised, collaborative and normalising approach to mood monitoring may be optimal and reduce potential limitations.
@JPalmierClaus on Twitter
Authors have identified several knowledge gaps in mood monitoring, I am summarising and adding my 5 cents on the topic.
a) Awareness itself isn’t enough, what we do with the new-found awareness is key.
Authors suggested clinicians to develop pre-agreed coping strategies to increase perceived control over foreseeable problems. This means that mood monitoring shouldn’t be used as a plug-and-play band aid for every one, but a tailored intervention plan that is closely followed-up by trained clinicians.
b) We do not know what is within the normal mood variations We have to understand how mood variation patterns and cycles differ in remission, recurrence and relapse, and how it differs inter and intra-individually.
Both of the trials cited above measured changes in mood once a day. In the same cited qualitative study, a common feedback described the limited flexibility of a daily mood measurement to represent the context and variability of mood within a day. But this could go on further, what really is the meaningful time lapse between each measurement? Or is there a meaningful time lapse for each person? Or, whether it depends on other ancillary factors such as – context?
Studies of bipolar disorder using Ecological Momentary Assessment (EMA) methods have explored a lot of different time lapses, from daily, twice-daily, to three times a day. Time-gap between each assessment varied across individuals within study, and between studies. It wasn’t always clear in the papers what the rationale, and the theory behind such decisions. A rational approach to the question would be first establishing a representative norm. The ERC-supported WARN-D project (led by Eiko Fried) is set to investigate what a “normal” biopsychosocial mood systems might look like. I am excited to hear more from the project in near future!
c) The fault may lie in the tools of the trades
Set aside the theoretical complexities, another factor that might hamper people from benefiting from the mood monitoring experience could be the poorly designed digital apps. From a recent review of bipolar disorder related apps, of the 98 included apps, 12 were rated as capable of causing harm to a user, by offering potentially triggering information that goes against the treatment guidelines. Only 1 app had supporting feasibility and efficacy studies, but no people with bipolar disorder was involved in those studies. These publicly accessible yet unregulated apps might undermine the efficacy of properly managed and delivered mood monitoring interventions. With the vast boom of self-help and mental health apps on the market in the last couple years, I feel there is an imminent need for relevant regulating bodies to rigorously assess the boundaries of these self-help apps.
“The only thing constant in life is change.” – Heraclitus
Change is only thing that remains to be always, Heraclitus surely helped us avoid all ceiling effects in psychometric surveys! May He enjoy his fair share of even-mindedness in peace.
On the 22nd Nov (2020), as Hong Kong was faced with yet another wave of Covid-19 outbreak with numerous cases with undetermined source, the government announced a $5,000 one-off incentive for all people who tested positive to Covid, aimed at encouraging people to take Covid-19 tests by relieving concerns on loss income in quarantine. The government faced immediate backlash against the proposal, as the public teased the non-means-tested subsidy meaningless. Non-selective, Non-targeted, Non-sufficient. Rather disheartening, but understandably, sarcastic comments about the proposal flooded the internet, with many saying they’re would purposefully get Covid-19 for the 5K “reward”. There is little discussion around whether the amount is sufficient for the unfortunate in desperate needs. Anger and disappointment, instead of empathy and compassion, was elicited by the announcement. However, as always, public discourse has to be viewed in the larger picture, as cross-sectional observations could only depict a snapshot of the undercurrents. The attitudes towards the persons in power in Hong Kong is massively polarised. It is hard to identify the root cause of distrust in the population, to disentangle poor governance, questionable response to Covid-19, and more. It could have been the case that no matter how well-planned the proposal would be, it would not be well-received in the public eye. Sparing myself from the politics (today), this blog will try to shed light on how conceiving the subsidy as a “reward” tells us about how collectivism remains defining a cultural feature of people of Hong Kong.
“Reward” – a potential reason of the disapproval may stem from the sense that the government is using a monetary reward to degrade what is a moral responsibility. That is, one should have the obligation to seek treatment if one might have gotten Covid-19, and that one should be doing so regardless of situation or social economic hardship. This is a defining feature of collectivism, where the cohesion and benefit of the community is placed before the individuals. This was also demonstrated in the 99% populational surgical mask (not whimsy cotton masks) usage in Hong Kong in the first 3 weeks of the pandemic. Whilst it is true mask wearing has been a socially acceptable behaviour, and it is also true that Hong Kong people still aches from the scars SARS left not long ago, both of these reasons are indications of the care for community weigh over individual inconvenience, that collectivism run in our veins.
If this notion of a degrading “reward” stands, we’d expect a similar level of dissatisfaction from the community if we were to say, an incentive was introduced to encourage mask-wearing. Perhaps another way of seeing it, would be the lack of compensation to the public comparing to the extent of economic activity loss in Hong Kong, but dissatisfaction did not reflect through poor adherence to guidelines. This could explain that strict social isolating measures were well-tolerated, such as 14-day mandatory quarantine for inbound overseas travelers, mandatory quarantine camps for people who had close contacts with confirmed cases, school closures etc. Hong Kong is one of the most densely populated city in the world, housing 7.4 million people, thus highly susceptible to mass outbreak. Yet compared to the England capital of 7.5 million people, London has 25 times the number of Covid-19 infections (30th Nov figure), whilst being 30% larger than Hong Kong (in km2), and Hong Kong’s infinite times closer to the first identified cases of Covid-19. Outbreak risks would have been considered negligible in the UK parliament were faced with measures no tier could match, and welcomed by its people. This is a price Hong Kong people willing to pay for the community.
This is a price Hong Kong people willing to pay for the community.
Collectivism is a treasure in a contagious virus outbreak, but it does not come at no cost. The benefit of the community do not always align with the benefit of all individuals. Whilst this do not necessarily always translate into the deprivation of individual freedom, this is the case regarding Hong Kong Mental Health Ordinance (MHO). The MHO is the legislation in Hong Kong that gives medical practitioners power to assess and treat patients with mental incapacity, including intellectual disability (the legal terms were loosely defined). MHO resembles the Mental Health Act (MHA) in the UK. Conditional Discharge (CD) is part of the MHO, it refers to
A legal provision that mandates a person with mental illness who meets certain criteria to follow a course of treatment while living in the community, non-compliance of which may result in a recall to inpatient treatment (Cheung, 2017)
Without going too much in detail, CD is similar to Community Treatment Orders in the UK & Europe. CD could be issued based on a”disposition to commit violence”. In Hong Kong, approximately 2.5% of all patients with severe mental illness are put on CD. There is no limit to the length of CD, and their liberty could be stripped away when the patient was deemed to pose risk of harm to self or others. There is no strong international nor local evidence that CD achieved what it proposed. In a naturalistic cohort of 140 people under CD, only 5% had any forensic contacts after 12 months – meaning the vast majority of them has restricted freedom, and this would continue be so indefinitely. CD could be appealed via Mental Health Review Tribunal, yet there is no available data on the number of people applied or success rate whatsoever. Patients were often left stranded with no money, knowledge and power, when public stigma against mental illness disproportionately weighed in the legal system. I have only scratched the surface on the topic, pleasure to have been inspired by Prof. Daisy Cheung (Hong Kong University) in our chat. Please do follow her series on pragmatic suggestions on mental health law reform. (Twitter @daisytmcheung)
Countless challenges awaits Hong Kong people, as a collective. The search for post-colonial identity, diverse but discriminatory, greedy but generous, together but torn. The love for our community runs in our veins, it is a moral value we proudly upheld in times of crisis. The way forward is not naming, shaming, segregating and excluding, but appreciating unity in diversity, pushing for change without loosing respect for each another. As we share the love for the same community, we shall then share our honor, our pride, our misbehaves, our history, and only then, we can shape our future – collectively.
JosePhD 