Kapok: Embrace a Full Ban!

When conflicts of interests are too blatant, public debate can only be farcical, and yet it is revealing of the challenges confronting the new government. The recent exchanges between some legislators and the Secretary for Social Affairs and Culture, Alexis Tam are a remarkable case in point.
Ever since he took office in December 2014, Mr Tam has made no secret that his number one concern would be “public health” and shortly after a comprehensive survey on the “Regime for the prevention and control of smoking” was released at the end of January, he announced, supposedly “on his own” – or so are we led to believe by not so-friendly commentators – that the government would submit a revised piece of legislation within the first half of 2015 that would make way for a full ban on smoking inside casinos, thus implying that VIP rooms would be involved and smoking lounges on mass floors no longer allowed. Mr Tam reiterated that engagement in April during the policy address, and again this week, while reporting to the legislators.
On Mr Tam’s side, there is an ever-growing corpus of medical studies showing that second-hand smoking is in fact as bad as direct inhaling, recommendations made by the World Health Organisation (agreed to by China’s Ministry of Health since 2007) noting that there is no existing technical solution that will equate to non-smoking, and quite a significant number of business-minded pieces of scholarship attesting that smoking bans have not had an adverse impact on revenues in business sectors of direct concern, and essentially the hospitality sector. Clearly, full smoking bans in public places are the trend, so much so that even permissive New Orleans has banned smoking in bars, casinos and other public areas starting on April 22nd.
Mr Tam has also on his side the spirit of the law that was passed in 2011—the first aim of the law being “to protect [the citizens] from exposure to tobacco smoke”—, the fact that the main causes of death in Macao are aggravated by the exposure to tobacco smoke, and the wish expressed by the frontline workers of the industry to see a full ban on smoking being implemented—87.20% of those directly exposed, the croupiers and casino floor staff. Moreover, in the broader context of China—something far more prevalent these days—the National People’s Congress has committed the country to “full implementation of the smoking ban in public places” ever since it voted in the 12th Five-Year Plan in March 2011.
Adversely, Mr Tam is pitted by the gaming industry that has been relentless in trying to lobby every level of government—including Beijing in March during the double congress—in favour of airport-style smoking lounges, with separate ventilation systems and negative pressure in relation to adjacent areas, in accordance with the regulation published by the Chief Executive in June 2014. Several casino operators, including one with a seat in the legislature, have argued that voiding the previous (and rather recent) regulation would make limited (and costly) sense, and moreover that gambling revenues have been in shambles since June last year and thus a full smoking ban could translate into an additional loss estimated at 15%—no methodology given, but the figure is repeated over and over again.
The problem is that it took an extraordinary amount of time to pass the initial law (16 months, to be precise) back in 2011, and this in no small thanks to Mr Chan Chak Mo (a representative for culture!), one of the most vocal voices against Mr Tam today and the number one defender of the food and beverage industry—his group, Future Bright, is everywhere to be seen in all casinos and just lost 95.6% of its profits in the first quarter of 2015. The problem is then that casinos benefited from a three-year reprieve. The problem is that many casinos failed the health bureau tests and everybody was playing cat and mouse with the new regulations.
More compliance with the spirit of the law might have prevented a change in tune. Lobbying failed, now there is only room for embrace.

Published in Macau Daily Times, May 15th 2015

Kapok: In praise of the vouchers

Let me be honest: at first I was more than doubtful about what I was reading, and one could even say that I started looking deeper into the matter with pretty self-assured and somehow offensive ulterior motives. Come on, how could this be? “A study concludes that healthcare vouchers have prevented 123 deaths a year,” read a headline, or in this very newspaper, a milder “Study: Medical Vouchers Prevented Fatalities, Should be Given to TNRs.” For those of you not aware of cross-feeding multilingual acronyms, “TNRs” means non-resident workers, as in the very elegant perfunctory statistical category derived from the Portuguese “trabalhadores não residentes”. So vouchers distributed by the government equal saving lives, and this should be indiscriminate when it comes to human life, hence the noble appeal to extend it to all the contributing participants to and of the community. When absolute efficiency meets generosity…
A scientific mind has a craving for heuristic (meaning that one is always trying to find causality) relations: what are the causes behind a phenomenon, and to what extent these causes alone can explain things. In social sciences, the real “hard sciences” as everything is more complex when one deals with human nature, single factor explanations are pretty rare to come by, and often follow rather cryptic statistical considerations in which the whole exercise consists in isolating factors and relating a dependent variable (in this case mortality because of a disease) with an independent one (the introduction of vouchers).
The press reports based on a Lusa dispatch insist on the main conclusion of Professor Zhang Jinghua’s study, that a 24 percent decrease in cardiovascular diseases recorded as of 2010, compared to the 2001-2009 period, can be directly connected to the introduction of medical vouchers back in 2009, resulting in the prevention of 123 deaths a year over 2010-2012 (the claimed drop in mortality, 0.22%, multiplied by an average of 560,000 residents over the period). And vouchers are here seen as having a direct influence on citizens scheduling health checks or taking medical exams that would have otherwise probably not been undertaken without this exclusive incentive.
My first reaction was not to go to the report but to international studies, especially one by the OECD that indicates that the main reasons behind the sharp decrease in cardiovascular disease mortality rates have to do foremost with the decline of tobacco consumption and also with the improvements in medical care—why would Macao be any different? Then, I went to the official statistics, and if it indeed shows a decline in mortality rates for “cardiovascular diseases” in recent years, it also indicates that the year with the least number of deaths because of cardiovascular issues was in 2007 and the mortality rate because of respiratory diseases has increased rather significantly—the number of deaths because of respiratory diseases used to be 1/3 of the one for cardiovascular diseases, now it is 2/3!
So I finally went directly to the source, and Professor Zhang’s study is indeed pretty comprehensive and compelling, taking into account a multiplicity of factors (medical resources—numbers of physicians, nurses and patient beds per thousand population and public healthcare expenditure, economic development level—GDP per capita, the human development index, population ageing factor, natural seasonal effects and long-term trends), scrutinising the yearly reports of the Macao Health Bureau (incidentally pointing out to the inefficiency of the awareness and educational campaigns) and even admitting to certain shortcomings in the lack of compelling statistics about cerebrovascular diseases or simply the rather limited consideration given to the improvement of medical care because of new technologies, better training and more efficient drug therapies. Ultimately, in its own words, the study merely “suggests a robust connection between the timing of the implementation of the Macao Medical Voucher Program and a significant decrease in the mortality from circulatory system diseases in Macao, but their causal relationship awaits confirmation in further research.” The mere fact that the cancer mortality rate has increased significantly over the same period—as indicated in the study—should have led to more caution in the media reports: I would bet my salary that the vouchers program, conversely, was not responsible for that!


Published in Macau Daily Times, September 19th 2014