Hong Kong: long civil unrest with long-term consequences.

Abstract

Hong Kong has experienced a period of civil unrest in the past 6 months, which has affected the everyday lives of citizens. Health-care services have been disrupted, with physical injuries resulting from clashes between protesters and police and the extensive use of chemical weapons at the forefront of medical concerns. The short-term management of these injuries has already strained public health services; however, the long-term consequences could be even more damaging. These effects should be of concern for oncologists, most notably the poorly understood risks of accumulated chemicals and air pollution and the disruption of treatment services and research projects. From both sides of the conflict, the use of chemical weapons is an issue. The Hong Kong police has been criticised for their heavy use of tear gas, with an estimated 16 000 canisters deployed since June, 2019, including near kindergartens, hospitals, and care homes. Indeed, up to 88% of Hong Kong's population is estimated to have been exposed to tear gas in 2019. The police have declined to divulge the chemical composition of the gas, making it difficult to assess the real risks, but nonetheless tear gas is known to be associated with several health hazards, including lung injuries and eye and skin problems. The carcinogenic risk of tear gas, particularly in an urban environment, is unknown. However, its combination with volatile chemicals from firebombs used by protesters, resulting in the emission of copious amounts of carbon monoxide and hydrogen cyanide, and the poor air quality, which was already a problem in Hong Kong, creates the perfect storm for the development or exacerbation of skin, eye, and lung conditions. With protests lasting hours or even days, both protesters and the police are being exposed for substantial amounts of time to toxic agents and many might be unable to use decontamination measures after exposure. For vulnerable populations, such as children, the elderly, and patients with chronic diseases who are at high risk of comorbidities, the effect of accumulated toxic chemicals might be devastating. With the number of new cases of cancers predicted to increase by 30–40% in Hong Kong by 2030 compared with 2016, and with lung cancer expected to represent one of the largest increases, a toxic environment might easily aggravate the cancer epidemic in the region. Disruption of services is a major concern for patients with cancer because their care requires many hospital visits, from diagnosis to treatment and years of follow-up. With hospitals now overburdened with injured people and, understandably, a focus on emergency services and deployment of doctors, nurses, and paramedics in the conflict areas, resources for tertiary care, both in terms of staff and equipment, might be scarce. Transportation has also been affected and with the visible devastation in the streets and citizens concerned for their own safety, patients and hospital personnel might not be willing or able to access treatment or get into work because of disruption of the metro system and other means of public transportation. Whether drug supplies have been disrupted is also unknown. Yet, an uninterrupted provision of all these services is essential for cancer care. Biomedical research has also been affected by the ongoing conflict. With universities occupied by protesters and some under siege by the police, ongoing research projects have been severely compromised. The damage goes beyond infrastructure destruction: several chemicals have been stolen to produce weapons against the police; there is uncertainty regarding the quality of water and air, and the adequacy of electricity supplies; and animals used for research have not been properly supervised and cared for. Therefore, results from in-vitro and in-vivo research are likely to be rendered invalid, with a consequent substantial financial and scientific loss for these universities, in addition to the costs needed to repair structural damage. Funding might also be affected because charities might be unable to proceed with their usual activities. The Hong Kong Cancer Fund, for example, had to cancel its annual fundraising initiative, Stride for a Cure, which should have taken place on Dec 8, 2019, and would have seen the participation of around 2000 people united to raise money to fund cancer research. The management of this conflict must go beyond the actions of protesters and police and the short-term treatment of injuries. The unrest has developed into a protracted struggle that will likely have multifarious long-term consequences, including on health care and research. Health on both sides of the conflict—and even for those not directly involved—is being compromised, which must emphasise the urgency to reach a solution as soon as possible.