Journal articles on the topic 'Physicians (General Practice) China Hong Kong'

ObjectiveTo determine physicians’ knowledge, awareness and preferences regarding the care of familial hypercholesterolaemia (FH) in the Asia-Pacific region.SettingA formal questionnaire was anonymously completed by physicians from different countries/regions in the Asia-Pacific. The survey sought responses relating to general familiarity, awareness of management guidelines, identification (clinical characteristics and lipid profile), prevalence and inheritance, extent of elevation in risk of cardiovascular disease (CVD) and practice on screening and treatment.ParticipantsPractising community physicians from Australia, Japan, Malaysia, South Korea, Philippines, Hong Kong, China, Vietnam and Taiwan were recruited to complete the questionnaire, with the UK as the international benchmark.Primary outcomeAn assessment and comparison of the knowledge, awareness and preferences of FH among physicians in 10 different countries/regions.Results1078 physicians completed the questionnaire from the Asia-Pacific region; only 34% considered themselves to be familiar with FH. 72% correctly described FH and 65% identified the typical lipid profile, with a higher proportion of physicians from Japan and China selecting the correct FH definition and lipid profile compared with those from Vietnam and Philippines. However, less than half of the physician were aware of national or international management guidelines; this was significantly worse than physicians from the UK (35% vs 61%, p<0.001). Knowledge of prevalence (24%), inheritability (41%) and CVD risk (9%) of FH were also suboptimal. The majority of the physicians considered laboratory interpretative commenting as being useful (81%) and statin therapy as an appropriate cholesterol-lowering therapy (89%) for FH management.ConclusionsThe study identified important gaps, which are readily addressable, in the awareness and knowledge of FH among physicians in the region. Implementation of country-specific guidelines and extensive work in FH education and awareness programmes are imperative to improve the care of FH in the region.

Russ Ladwa and Professor Derrick Willmot undertook a joint visit to Hong Kong and mainland China following the invitation of the Academy of General Dental Practice (AGDP) in Hong Kong in June 2010. This groundbreaking visit was the first visit in which the deans of both faculties represented dental surgery on an overseas visit.

As an important issue in the theory and practice of &ldquo;one country, two systems&rdquo;, the national identity in Hong Kong has been given a lot of attention as some deep-seated problems accumulated over a long period of time in Hong Kong have become increasingly acute in recent years. From the perspective of social communication, modern media and public opinion are important factors affecting the strength of national identity in Hong Kong. In view of this, in order to enhance the national identity in Hong Kong, it is necessary to cultivate patriotic and Hong Kong-loving media and improve the social communication platform of national identity, so as to occupy the leading edge of public opinion, cope with the erosion of the wrong trend of thought, spread the national image of China and demonstrate the national confidence of China.

Aim. The aim of the research is to examine how Mainland China and Chinese people are represented in the visual materials of four sets of Liberal Studies (LS) textbooks in Hong Kong. Methods. Fairclough’s Critical Discourse Analysis, viewing language as a social practice and van Dijk’s ideological coding categories are integrated to analyze discursive representations (e.g., the embedded hidden power) in the Hong Kong Today volumes published by four influential commercial publishers: Modern, Ming Pao, Marshall, and Aristo. Results. The analysis reveals that China and mainland Chinese are negatively portrayed in visual images in four commercial LS textbooks, in which, the representations concerning mainland China and mainlanders are all found ideologically biased to highlight their negative characteristics and alienness. Conclusions. Via an overview of Hong Kong’s history, economy, educational policies, and controversial political events, the reasons why China and its people are represented negatively in LS textbooks is explained.

Abstract Since Hong Kong’s handover to China, British newspapers still play an active role in constructing Britain’s connections with its former colony. This study elaborates a schema for protests to help better understand protests in general. Based on this schema, the study examined representations of the 2019–20 protests in British newspapers using the approach of corpus-assisted critical discourse studies. The analysis shows that they mainly used the predicational strategy, and emphasized the Chinese government’s control of Hong Kong – including the inabilities of the Hong Kong government and police violence – in contrast with the protestors’ demands for universal suffrage. They suggested that Britain act as a mediator to shoulder a moral responsibility over Hong Kong. Their attitudes are interpreted with regard to Britain’s foreign policies and the dominant ideology cultivated in its historical, socio-political contexts and suggest that the UK journalistic practice regarding Hong Kong issues is political-driven to a great extent.

The licensing and regulation of physicians is an important topic worldwide and is often tied to discussions in various countries of health care system reform. We conducted a review of current practices for regulating physicians as a key group of health care professionals in eight jurisdictions in Asia and other parts of the world in order to draw implications for the development of future regulatory policies in Hong Kong. Jurisdictions studied included Australia, Canada, China, Malaysia, New Zealand, Singapore, the United Kingdom and the United States. A literature search, supplemented by interviews, was conducted. In analyzing information gathered about global regulatory systems, we used a framework for comparing regulatory typology, developed by the RAND Europe research institute. Our review found that the jurisdictions studied exhibited both similarities and differences in terms of how physicians are regulated and by whom. As a result of our search, we were able to identify 10 key trends in international medical regulation of importance to Hong Kong as it considers reforms to its health care system overall:Changes in medical regulation are seen as a way of improving the quality of patient care.Reform of medical regulation often requires government legislation.The creation of common principles for policies, structures and the organization of regulation between professions is an emerging practice.The involvement of lay people on boards and in inquiries is increasingly common.Medical regulation is moving away from models of self-regulation and toward regulatory models that emphasize partnership between professions and the public, physicians and patients.Health care providers and institutional regulators play complementary roles in medical regulation.Regulation impacts the quality of care — not just the detection and remediation of poor performance.Investigatory and disciplinary functions are increasingly separated and organized independently of each other.Continuous Professional Development (CPD) is compulsory for physicians in many jurisdictions.Overseas medical graduates are admitted into practice in different ways from country to country. These trends are important for regulators in all countries to note as they assess the basic structure and effectiveness of their own medical regulatory systems.

This study is based on the age-friendly community framework advocated by the World Health Organization as the research premise. Through the continuous international academic research cooperation between China and Canada, reference is made to the age-friendly community strategy of Alberta, Canada and the construction practice of the age-friendly city in Calgary, carry out a special investigation on the needs of elderly care services in Guangzhou, apply the international framework of an age-friendly city to the construction of an age-friendly city in Guangzhou, and the construction of specific cities and communities in Guangdong–Hong Kong– Macao Greater Bay Area in China. Based on the demographic development and policy background of China and Guangzhou, this study implements the needs of the national strategy of actively cope with population aging. In preparation for building Guangzhou into an age-friendly city and a city with a livable environment integrated with its own characteristics, providing a theoretical framework, and aimed for building a model city of healthy aging and livable living in the Guangdong–Hong Kong–Macao Greater Bay Area. It could be a sample of healthy aging cities in the Bay Area and models that can be used for reference by other cities.

ArgumentThis article analyzes for the first time the earliest western maps of diseases in China spanning fifty years from the late 1870s to the end of the 1920s. The 24 featured disease maps present a visual history of the major transformations in modern medicine from medical geography to laboratory medicine wrought on Chinese soil. These medical transformations occurred within new political formations from the Qing dynasty (1644–1911) to colonialism in East Asia (Hong Kong, Taiwan, Manchuria, Korea) and hypercolonialism within China (Tianjin, Shanghai, Amoy) as well as the new Republican Chinese nation state (1912–49). As a subgenre of persuasive graphics, physicians marshaled disease maps for various rhetorical functions within these different political contexts. Disease maps in China changed from being mostly analytical tools to functioning as tools of empire, national sovereignty, and public health propaganda legitimating new medical concepts, public health interventions, and political structures governing over human and non-human populations.

PurposeCommercial property market allows for the potential development of a similar real estate investment trust (REIT) structure in China as the commercial REITs (C-REIT) such as those offshore in Hong Kong and Singapore.Design/methodology/approachThe authors examine tax codes of the present real estate investment methods in China in order to understand the interest for a new vehicle that specifically focuses on commercial real estate.FindingsGiven the progress of offshore C-REITS and Chinese government's emphasis on real estate, Chinese shareholders will benefit if onshore C-REITS are issued. Crucial to the success of C-REITS will be how the C-REIT shares will be priced with respect to Net Asset Value of underlying assets.Research limitations/implicationsCOVID-19 pandemic has changed government priorities, and development of C-REITS in real estate for growth may no longer be a priority policy for China.Practical implicationsLiquidity in real estate markets will be enhanced by C-REITS due to participation of private investors.Social implicationsOnshore C-REITS would allow small and individual investors to have a stake in their home country's commercial real estate as an investment security for their own future.Originality/valueThis policy article also includes an interview with real estate professional in China whose opinions are embedded and added to the article.

At this moment, public health authorities, physicians and scientists around the world are struggling to cope with a severe and rapidly spreading new disease in humans called severe acute respiratory syndrome, or SARS. According to World Health Organisation (WHO) this appears to be the first severe and easily transmissible new disease to emerge in the 21st century. Though much about the disease remains poorly understood, including the details of the causative virus, we do know that it has features that allow it to spread rapidly along international air travel routes. As of 10 May 2003, a cumulative 7296 probable SARS cases with 526 deaths have been reported from 30 countries on three continents (WHO, ProMED). In the past week, more than 1000 new probable cases and 96 deaths were reported globally. This represents an increase of 119 new cases and 8 new deaths compared with 9 May 2003 (China (85), Taiwan (23), and Hong Kong (7) represented the overwhelming majority, with one additional case each reported from France, Malaysia, Singapore, and the United States). Only in China, as of 10 May 2003 (WHO) total of 4884 with 235 deaths have been reported. Some outbreaks have reassuring features.

The study examines the underlying curriculum for translation training, pedagogies that integrate translation in the curriculum, teaching practice, and universities' approaches from Saudi Arabia, China and Hong Kong. Consideration of these issues in a curricular framework must also acknowledge the ideological potential of curricula themselves to prioritise individual relationships between the learner and society, relationships which arc investigated from the perspective of a socially situated view of the translator. The purpose of the study is to offer deep scientific apprehension of the explication of translation expertise in terms of learning translation methods, concepts and the intricacy of certain aspects of teaching. The results reveal that traditional language methodology with unprofessional trainers and teachers are the fundamental concerns in this regard, and it requires to rethought translation method and practice in the Chinese affairs and ordinary circumstances. The findings of the manifest study disparities all-around three cases somewhat due to regional circumstances and departmental differences, but are mainly because of discrete notions of the implementation of translation method and practice of theoretical concepts. Translation teaching research informs the training of all-around translators and interpreters and contributes to the growth of translation studies as a discipline.

Purpose The purpose of this paper is to present site planning and design (SPD) relevant variables and items in practice for practitioners to better understand and implement SPD in green building projects. Design/methodology/approach The research methods include questionnaire survey and case studies in the context of China. A questionnaire survey was adopted to identify the importance of 13 variables and the corresponding 38 items in SPD of green residential buildings. Three green residential projects including one in Hong Kong and two in Mainland China were selected to investigate the SPD considerations in practice and to discuss the necessary improvement. Findings The results show that 12 out of the 13 variables of SPD in green buildings are involved in the three case projects to some extent, thereby underscore the importance of these variables. The potential improvement in real-life SPD of green buildings is also discussed such as adopting design-build and integrated project delivery methods and preserving and protecting cultural characteristics on site. Originality/value The research findings may serve as a reference for practitioners to better conduct SPD in green building projects.

Purpose In the context of an economic downturn and three transitions of political power, Taiwan’s Kuomintang (KMT) kick-started the cross-strait mutual trust mechanism, encouraging university graduates to find employment in mainland China’s job market (in both mainland China and Hong Kong). Academia and industry are both paying great attention to this issue. There is still a paucity of discussions about cognitive style with regard to working in mainland China (Macau) Design/methodology/approach This study is based on the Q methodology using a sample of Taiwanese university graduates to explore how behavioral factors relate to cognitive style. Findings This paper defines four cognitive styles based on differences in focus and motivation: lifestyles of health and sustainability (LOHAS), word-of-mouth (WOM), learning/practice match and local market disappointment. Originality/value An association is drawn between cognition theory and psychology’s classification of cognitive style. In the context of the four cognitive styles, this paper explores the practical implications of employment and provides recommendations for those intending to work abroad.

As advertising can be a social factor and cultural artifact, this study analyzes the images of “modern Chinese woman” via an investigation of their role portrayals, appearance/projection, and verbal characteristics represented in a total of 164 award-winning Chinese TV commercials from 2007 to 2009. Results show that a much larger percentage of females in the Chinese TV commercials embody modern rather than traditional representations. The commercials from Mainland China have also manifested modern representations of the women in more dimensions than their counterparts in Hong Kong. Furthermore, hybridization of both the traditional and modern features are most frequently found in the Chinese TV commercials. It is concluded that the modern forms of Chinese femininity is generated from a synthesis of both the traditional and modern values and that the dichotomous approach of globalization vs localization debate in advertising practice has oversimplified the intricate process as well as the product of image representation and transformation of women in Cultural China.

Disaster plans are complex and the role of social workers can become lost amidst plans and processes. Although social workers' skill sets are desperately needed during disasters and recovery, in many disaster management strategies their roles are not acknowledged. In order to maximise their value, specific training for social workers in disaster management needs to be reinvigorated. Associate Professor Timothy Sim, Singapore University of Social Sciences, believes that current social work research in disaster management is underdeveloped, and other professionals are unclear about social workers' roles in it. His project to examine the core competence of social work in various stages of disaster management was funded by the General Research Fund of the Hong Kong SAR Government. He and colleagues from China and around the world devised a new competence framework that is unique from previous attempts. The framework comprises five dimensions: knowledge, values, skills, roles and tasks, in four specific disaster management phases: mitigation, preparedness, response and recovery. The thinking behind this novel structure is that it will help social work professionals clarify related concepts and comprehend competencies, roles and tasks for each phase of the disaster management cycle. The approach is also more comprehensive and precise than has been seen previously and will improve collaboration between social workers, governments and non-government organisations. Furthermore, the team used rigorous research methods when designing the framework, including an integrative review, in-depth interviews and a Delphi study. In addition, the team is confident the framework will have a long-term impact and could be applied to other countries and contexts.

In Michael Jeffery Jordan v Chinese Trademark Review and Adjudication Board, the Supreme People's Court (SPC) set a precedent for foreign companies and celebrities enforcing their rights of publicity against malicious trademark registration in China. This article introduces the legal grounds of the SPC's deliberations on Jordan's claims and responds to the critiques of most Chinese commentators in the field of civil law. Deeply influenced by German law, mainland China's legal system strictly distinguishes between personality rights and property rights. Comparative analysis with the US, Germany, Japan, and Hong Kong indicates that different legal civilizations have developed different approaches to position the right of publicity logically in their legal systems. The Jordan decision indicates that the ‘right of the name’ is a prior right provided in Article 32 of the Trademark Law of the PRC. This article contends that the ‘right of the name’ as provided in the Chinese Anti-Unfair Competition Law differs from the ‘right of the name’ articulated in Article 110 of the General Principles of Civil Law (2017). The former concerns the commercial interest and property aspects of a celebrity's name, which is fairly similar to the right of publicity, while the latter regards the personality right. The further development of the right of publicity protection relies in mainland China on a consistent judicial practice.

Background:Fibromyalgia is a chronic disease characterized by the presence of widespread and persistent musculoskeletal pain associated with a variety of symptoms. The concepts and perceptions around diagnosis and treatment of fibromyalgia among physicians are not objectively known. The purpose of this study is to obtain objective data through a survey and describe the concepts and perceptions about the diagnosis, treatment and treatment of fibromyalgia among colombian rheumatologists, physiatrist and pain physiciansObjectives:The main purpose of this study is to obtain objective data on this subject and describe the concepts and perceptions about the diagnosis, treatment and monitoring of FM among colombian rheumatologists, physiatrist and pain physicians.Methods:Cross-sectional study. Through a focus group in which two rheumatologists and one expert in qualitative research methods participated, a survey was designed to evaluated the perceptions and concepts that rheumatologists, physiatrist and pain physicians have on the diagnosis and treatment of fibromyalgia. The survey was self-applied anonymously through the internet.Results:Survey applied to 139 rheumatologists, 99 physiatrist and 81 pain physicians. 35 rheumatologists (25.2 %), 17 physiatrist (17.1 %) and 58 pain physicians (71.6 %) consider that there is not enough evidence to recognize fibromyalgia as a disease. 45 rheumatologists (32.4 %), 86 physiatrist (86 %) and 73 pain physicians (90.1 %) consider that the 1990 ACR (American college of Rheumatology) criteria are not sufficient to diagnose fibromyalgia, despite the fact more than 90% of them use the criteria as a tool to approach the diagnosis when suspecting fibromyalgia. The most formulated medications for managing fibromyalgia are antidepressants and is used by more than 80% of the respondents, followed by antiepileptics in pain physician (88.9%) but less than physiatrists and rheumatologists (66.6 % and 64.7 % respectively), and analgesic much more for pain physician and physiatry and less for rheumatologists (84 %, 75.7 % and 26.6 % respectively). All respondents consider that the patient with fibromyalgia should have a multidisciplinary approach. Most doctors of the three specialties believe that physiatrist should be the leaders of interdisciplinary management in the treatment of fibromyalgia patients.Conclusion:We present objective information on the perceptions of fibromyalgia among a group of Colombian rheumatologists, physiatrist and pain physician, documenting a frequent use of the ACR 1990 classification criteria. As regards treatment, a high percentage use of antidepressants and antiepileptic. Most believe that physiatrist should be the leaders of interdisciplinary management in the treatment of fibromyalgia patients.References:[1]Mu R, Li C, Zhu J-X, Zhang X-Y, Duan T-J, Feng M, et al. National survey of knowledge, attitude and practice of fibromyalgia among rheumatologists in China. Int J Rheum Dis. 2013;16:258–63.[2]Arshad A, Kong KO. Awareness and perceptions of fibromyalgia syndrome: a survey of Malaysian and Singaporean rheumatologists. Singapore Med J. 2007;48:25–30.[3]Arshad A, Kong KO, Ooi KK. Awareness and perceptions of fibromyalgia syndrome: a survey of southeast asian rheumatologists. J Clin Rheumatol. 2007;13:59–62.[4]Bloom S, Ablin JN, Lebel D, Rath E, Faran Y, Daphna-Tekoah S, et al. Awareness of diagnostic and clinical features of fibromyalgia among orthopedic surgeons. Rheumatol Int. 2013;33:927–31.[5]Clark P, Paiva ES, Ginovker A, Salomón PA. A patient and physician survey of fibromyalgia across Latin America and Europe. BMC Musculoskelet Disord. 2013;14:188.Disclosure of Interests: :None declared

AbstractMarilyn Moffat, PT, PhD, FAPTA, CSCSDr Moffat has had a tremendous impact on the physical therapy profession as a visionary leader, a distinguished educator, and an accomplished clinician, administrator, and researcher. She has served as editor of Physical Therapy and, as an elected member of APTA's House of Delegates, has been instrumental in providing direction for the future of the profession. She has served as a member of innumerable committees, task forces, and boards of directors at every level within the Association. In 1991, she was elected President of APTA for the first of 2 consecutive terms.As President, Dr Moffat spearheaded the development of the Association's Guide to Physical Therapist Practice, and she later served as a project editor of the Guide's second edition and was heavily involved in the development of the Interactive Guide on CD-ROM. Dr Moffat has worked tirelessly since 1977, when she first spoke about the professional doctoral degree for physical therapists, to lead the profession through a process of redefining the role of the physical therapist for the future and ensuring that the highest level of practice would be achieved as a requisite for assuming the title “Doctor of Physical Therapy.”As a delegate to the World Confederation for Physical Therapy, Dr Moffat has provided leadership to the international community of physical therapists. She served as APTA's voting delegate to the WCPT General Meeting, on the Executive Committee of the WCPT as the North America/Caribbean Region representative, and as a member of the Task Force on the International Definition of Physical Therapy. Dr Moffat has given more than 800 professional presentations worldwide and has taught and consulted in Taiwan, Thailand, Burma, Puerto Rico, Vietnam, Hong Kong, and Wuhan in China. For her demonstrated worldwide leadership in physical therapy, she was honored with WCPT's Mildred Elson Award for International Leadership in Physical Therapy.Dr Moffat has been the recipient of many APTA honors and awards. She has been recognized with APTA's Lucy Blair Service Award and as a Catherine Worthingham Fellow. She has received 2 diversity awards from the Advisory Panel on Minority Affairs, the R Charles Harker Policy Maker Award from APTA's Health Policy and Administration Section, and the Robert Dicus Outstanding Service Award from APTA's Private Practice Section. The most significant acknowledgments of her lifelong commitment to service are the New York Chapter's Dr Marilyn Moffat Distinguished Service Award and APTA's newly created Marilyn Moffat Leadership Award.

Cold rolled steel structures have been known since the mid-19th century in the United States and Great Britain. Despite the advances in the development of cold-rolled structures, the level of their use was lower than that of hot-rolled structures. A significant factor that influenced this imbalance in application was the fact that there were no regulations. Into different countries of the world have their own national regulations for the calculation of cold-rolled steel structures, which have many controversies. In the European group includes the norms of the countries of the European Union, Great Britain, Hong Kong, Ukraine, Belarus, Kazakhstan; American group - the United States of America, Canada, Mexico, Australia, New Zealand, Brazil, Chile, Egypt. The regulations of such large countries as China, India and Russia have their own characteristics. The article presents the results of a technical survey of the load-bearing structures of the canopy. The survey was carried out to determine the bearing capacity of the roof load-bearing structures in relation to the location of the solar panels on the roof of the building. The construction of buildings and their structural parts from light steel thin-walled structures (profiles) is carried out in the form of light frames, the frames of which are successively connected into spatial systems. A new lightweight roof covering made of profiled sheet and a frame structure made of cold-rolled P-profile and C-profile elements for roofing and installation of solar panels are proposed. Such a coating is the most industrialized, easily and quickly erected. The analysis of constructive options for the effective placement of the profile of cold-rolled elements and joints of the frame and reinforced concrete run of the coating is carried out. The design of the frame was carried out in the software package " Лира САПР 2013" . The results of the work carried out served to draw up recommendations for restoring the properties of the load-bearing structures of the canopy, the development of design estimates and implementations into construction practice during the reconstruction of the canopy.

From the middle of the 1990s, geotourism was introduced through the first geotrails, their evolution, and the first geopark worldwide in Gerolstein/Vulkaneifel, Germany. The latter is one of the founding members of the European Geoparks Network, which was established in 2000 at the International Tourism Bourse (ITB) in Berlin. The main goal of the first geopark was to link geological heritage with tourism in a rural area that was trying to create new perspectives to inspire young people to stay in their home territory. Geotourism was initiated as part of sustainable tourist development and for future sustainable development at that time in the Gerolstein region. The first steps to implement the Gerolstein/Vulkaneifel Geopark, Germany, were taken in 1992. The core aspects included geological heritage, science transfer, and education as tools for developing geotourism in the broad sense and integrating local people and municipalities in the geopark activities of the rural region. Close collaboration with the local and regional tourism organizations highlighted the need to both define tools and demonstrate their success. Up to now, practice has shown that such success can be demonstrated by the infrastructure created, as well as adjacent measures and activities. A network of factors was determined to play a significant role in ensuring the successful sustainable development in a geopark across the field of geotourism. There are many activities and publications on geological heritage, geosite assessment, significance, and use, but there are fewer which reflect on the network of factors highlighted in this contribution which were first presented in 2002. In many publications and investigations, one factor in particular is emphasized, e.g., infrastructure development, such as panels or other items. Not all of the mentioned factors, however, are being addressed. As a result, a selection of good practice examples of UNESCO Global Geoparks (UGGP) working on the network-oriented conceptual basis has been studied here, in line with the conceptual principle set forth about 25 years ago. The geopark examples in this study include Lesvos Island UGGp (Greece), Naturtejo UGGP (Portugal), Vulkaneifel UGGp (Germany), and Hong Kong UGGP (China), as well as the example of the Messel Pit World Heritage Site (WHS) (Germany). The latter was integrated to present an example which is not a geopark, showing that this concept can also be transferred to a WHS as a tool for sustainable development according the UN 2030 Agenda. The information on the development of the selected examples was obtained by visiting the geopark territory and from the geopark’s websites and published material as a combined methodology.

Background Older adults from minority ethnic backgrounds are at increased risk of contracting COVID-19 and developing severe infection and have increased risk of mortality. Whilst an age-based vaccination approach prioritising older groups is being implemented worldwide, vaccine hesitancy is high amongst minority ethnic groups. Methods and findings We conducted a systematic review and convergent synthesis to systematically examine perceptions of vaccinations amongst older adults from minority ethnic backgrounds. We included studies that reported on perceptions, beliefs, and attitudes towards vaccinations in older adults aged ≥65 years from a minority ethnic background. We excluded studies of vaccinations in investigation or development, studies focused on specific medical conditions, studies where ethnic background or age group was unidentifiable, systematic reviews, editorials, and conference abstracts. We searched MEDLINE, Embase, Virtual Health Library, Web of Science, Cochrane Library, medRxiv, and PROSPERO databases from inception to 15 July 2021. Risk of bias for studies was assessed using the Mixed Methods Appraisal Tool. The quality of evidence of collective outcomes was estimated using the Grading of Recommendations Assessment, Development and Evaluation–Confidence in the Evidence from Reviews of Qualitative research (GRADE–CERQual) framework. A total of 28 eligible studies conducted between 1997 and 2020 were included in the final analysis (17 quantitative surveys, 8 focus group or interview studies, 2 mixed methods studies, and 1 case–control study). The majority were US studies in English or Spanish, except for 6 studies set in Hong Kong, 2 studies in Japan, 1 study in Brazil, and 1 multi-centre study (including China, Indonesia, Turkey, South Korea, Greece, UK, Brazil, and Nigeria). In total, 28,262 individuals with an estimated mean age of 69.8 years were included, 63.2% of whom were female. We summarised the common concepts and themes across studies and populations using a convergent synthesis analysis. Thirteen themes categorised as barriers or facilitators were identified and grouped into structural factors—healthcare provider and system related, patient related, and policy and operational—and were analysed by minority ethnic group. The main limitation of the study was the predominance of studies from the US and East Asia. Conclusions In this systematic review, we found that factors influencing vaccination uptake involve healthcare provider and system, patient-related, and governance-level factors that are specific to the older ethnic minority community being served. The evidence included in this review is supported by high or moderate certainty and can be translated to practice and policy. A tailored, multi-level approach combining increased education, access, and culturally competent discussions with trusted healthcare professionals to address health beliefs can maximise the potential impact of widespread vaccination policies.

Play-based learning activities are important programs throughout the world of children's education. Through play, children learn creatively and constructively. This study aims to solve the problem of creativity in early-childhood dance movements with the hope that there will be an increase in aspects of fluency, flexibility and elaboration through play activities related to educational dance. This action research uses an action research method which is carried out in three cycles. The subjects in this study were 19 children aged 5-6 years in Kindergarten in Central Jakarta. Data collection was carried out through observation, interviews, field notes, video documentation and photos. The findings show every child's creativity in dance movements can be improved through playing activities. Increased creativity in dance movements occurs in the aspects of fluency, flexibility, and elaboration. Another important finding, there is an increase in the optimal ability of dance creativity in the third cycle of this action research. The implication from this research is that play activities suitable for learning creative dance in early childhood must be designed as a program that emphasizes aspects of fluency, flexibility, and elaboration. Keywords: Early Childhood, Creativity in dance movements, Play based learning activities References: Bläsing, B., Calvo-Merino, B., Cross, E. S., Jola, C., Honisch, J., & Stevens, C. J. (2012). Neurocognitive control in dance perception and performance. Acta Psychologica, 139(2), 300–308. https://doi.org/10.1016/j.actpsy.2011.12.005 Brehm, M. A., & McNett, L. (2007). Creative dance for learning: The kinesthetic link. McGraw-Hill. Chatoupis, C. (2013). Young children’s divergent movement ability: A study revisited. Early Child Development and Care, 183(1), 92–108. https://doi.org/10.1080/03004430.2012.655728 Cheng, V. M. Y. (2010). 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The basic meaning of "patriots ruling Hong Kong" is that Hong Kong people who love China and love Hong Kong govern Hong Kong society to ensure the smooth implementation of the "One Country, Two Systems" system and the Basic Law of the Hong Kong Special Administrative Region in Hong Kong and maintain the long-term prosperity and stability of Hong Kong society. There is a logical connection between "patriots governing Hong Kong" and Hong Kong's united front work, which has firmly established the consciousness of the Chinese nation's community. "patriots governing Hong Kong" strengthens the awareness of patriotism and love of Hong Kong and helps to forge the consciousness of the Chinese nation's community. The main path for the innovation and development of the Chinese nation’s community consciousness is to promote the generation and development of the national outlook + national outlook + historical outlook + cultural outlook in Hong Kong and Macau, and to promote the industrial chain + supply chain + innovation chain + value in the construction of the Greater Bay Area The “multi-chain integration” of chain + united front chain promotes the exchanges and integration of ethnic groups and ethnic groups in the Guangdong-Hong Kong-Macao Greater Bay Area in the people's livelihood-oriented + science and education-oriented + demonstration leadership.

Dental graduates have a variety of career-path choices. After graduation, they may join private dental practice, government- or hospital-based dental care services, research groups, academia, business or industry. With globalization and frequent international exchange, dental graduates nowadays can explore careers outside their home country. However, dental education systems and job opportunities vary widely across different regions and countries. Diversity of accreditation in dental education, different licensure requirements, and lack of global competencies in dental care often limit the globalization, operation and survival of dental practice and education worldwide. The requirements for professional education and practice can be quite diverse, and these differences will be barriers to dental graduates seeking career development outside their home home country. Fresh dental graduates have minimal experience in job hunting. More specifically, they are unfamiliar with potential career paths. This paper was based on the 4th trilateral symposium 2022 organized by The University of Hong Kong, Tohoku University, and Fujian Medical University, which offered a lecture to discuss career paths for dental graduates in Hong Kong, Japan, and mainland China. The aim of this paper was to provide dentists, particularly fresh graduated dental students, with practical insight into different career paths in Hong Kong (Special Administrative Region of China, SAR), Japan and mainland China, and factors that may influence their career options. It assists dental students in exploring possibilities in dentistry and preparing for their career development after graduation from dental school.

This literature review is a synopsis of what has been written on the currency and monetary policy of Hong Kong since its relinquishment from Great Britain in 1999. In particular, this paper examines the role and policies of the Hong Kong Monetary Authority, the island province’s equivalent to a central bank. Since Hong Kong does not have a central bank per se, it is interesting to note how the money supply is created and maintained, and what its relationship is to mainland China. This institution makes Hong Kong unique among developed economies, which typically have a central bank that oversees monetary creation and policy. The Literature Review is composed of two parts: Part One will cover the revaluation of the Hong Kong Dollar with regard to its value relative to the currencies of China, Japan, Europe, and the United States, particularly during financial crises. This part of the literature review will cover the work of Chan (2002), Schenk (2004), Shah (1996), Cook and Yetman (2004), and Ma and Cheng (2014) as they use different measurement methods to monitor the change in the Hong Kong Dollar’s value over time, especially compared to the period before the creation of the Hong Kong Dollar. Part Two will cover the monetary and macro-economic policies and currency board effectiveness of the Hong Kong Monetary Authority in sustaining the value of the Hong Kong Dollar. This part of the literature review will cover the work of Chen (2001), Siregar and Walker (2000), Chen and Tsang (2020), Funke and Paetz (2000), and Huang and Shen (2017). This paper also includes a section on suggestions for future research, including what effect the shift of pegging the Hong Kong Dollar (HKD) to other currencies, such as the Euro or the Japanese Yen, or when interest rates in other countries are set at zero. The paper wraps up with an overview of the literature discussed and possible paths going forward, including recreating the studies over time to see how effective such a maneuver has been in practice when compared to competing currencies. Followers of the Hong Kong Dollar will especially find these results useful as they seek to exchange currencies for the highest value.

This article seeks to discuss in general the practice of family mediation in some selected Asian countries. For this purpose the practice in Singapore, China, Japan and Hong Kong is described. However the focus of the article is the law and practice of conciliation in Malaysia which are governed by the Law Reform (Marriage and Divorce) Act, 1976. Some issues pertaining to the position of the non-Muslims in Malaysia are also highlighted.

Abstract Background Patients with sepsis have a high mortality rate, accumulated evidences suggest that an optimal antibiotic administration strategy based on pharmacokinetics/pharmacodynamics (PK/PD) can improve the prognosis of septic patients. Therefore, we assessed Chinese intensive care unit (ICU) physicians’ knowledge about PK/PD. Methods In December 2019, we designed a questionnaire focused on Chinese ICU physicians’ knowledge about PK/PD and collected the questionnaires after 3 months. The questionnaire was distributed via e-mail and WeChat, and was distributed to ICU doctors in 31 administrative regions of China except Hong Kong, Macao and Taiwan. The passing score was corrected by the Angoff method, and the ICU physicians’ knowledge about PK/PD was analysed accordingly. Results We received a total of 1,309 questionnaires and retained 1,240 valid questionnaires. The passing score was 90.8, and the overall pass rate was 56.94%. The pass rate for tertiary and secondary hospitals was 59.07% and 37.19%, respectively. ICU physicians with less than 5 years of work experience and resident physician accounted for the highest pass rate, while those with between 5 to 10 years of work experience and attending accounted for the lowest pass rate. The majority of participants in the Chinese Critical Care Certified Course (5C) were from Jiangsu and Henan provinces, and they had the highest average scores (125.8 and 126.5, respectively). For Beijing and Shanghai, the average score was only 79.4 and 90.9, respectively. Conclusions Chinese ICU physicians’ knowledge about PK/PD is unsatisfactory. Therefore, it is essential to strengthen ICU physicians’ knowledge about PK/PD.

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This paper examines the current situation and the teaching of foreign languages at general school education level in some selected regions, countries and territories in the world: Western Europe, the USA, Singapore, China, Hong Kong, Taiwan, Japan, Malaysia, and Indonesia. The paper brought to light a number of significant features of which five seem to be prominent: teaching foreign languages in the world presents a highly diverse picture; all regions, countries and territories exercise a multi-foreign language policy, but English is the most learned foreign language and takes up a dominant position; there is a tendency to introduce foreign languages (particularly English) at an earlier stage of education; while it cannot be denied that English has become the most learned foreign language, other languages such as Chinese, Russian, Japanese, French, Spanish, German, etc. are also introduced into the general school education in a number of countries; and there are still big gaps and mismatches between policy and practice, between theory and practice, and between practice and practice. These features of foreign language teaching and learning and the problems experienced in these regions, countries and territories in the world can be useful points of reference for Vietnam in the process of renovating foreign language learning and teaching in general school education.

This study validates Shane et al.’s Entrepreneurial Career Motives Scale across nations. A total sample of 948 undergraduate and postgraduate students from five nations (China = 229, Hong Kong = 213, Holland = 136, United States = 155, and Ghana = 215) were recruited to complete a survey designed to measure their entrepreneurial motives and other related constructs. Confirmatory factor analysis supported the hypothesized four-factor structure, namely, perceived recognition, sense of independence, pursuit of learning, and perceived roles. Results of the measurement invariance comparisons satisfactorily established measurement equivalence of the scale across nations, language versions, and genders. Both convergent and discriminant validities were established as the motives were associated with different constructs in an expected manner. Interestingly, different patterns in the entrepreneurial career motives emerged across nations. Overall, our findings provide support for the construct validity of the Entrepreneurial Motives Scale. Implications for practice, limitations, and future research directions are discussed.

The practice of medicine—and especially the patient-doctor relationship—has seen exceptional shifts in ethical standards of care over the past few years, which by and large originate in occidental countries and are then extrapolated worldwide. However, this phenomenon is blind to the fact that an ethical practice of medicine remains hugely dependent on prevailing cultural and societal expectations of the community in which it serves. One model aiming to conceptualise the dichotomous efforts for global standardisation of medical care against differing sociocultural expectations is the individualism-collectivism model, with the ‘West’ being seen as individualistic and the ‘East’ being seen as collectivistic. This has been used by many academics to explain differences in approach towards ethical practice on key concepts such as informed consent and patient autonomy. However, I argue that this characterisation is incomplete and lacks nuance into the complexities surrounding cross-cultural ethics in practice, and I propose an alternative model based on the ethics of clinical care in Hong Kong, China. Core ethical principles need not be culture-bound—indeed, their very existence mandates for them to be universal and non-derogable—but instead cultural alignment occurs in the particular implementation of these principles, insofar as they respect the general spirit of contemporary ethical standards.

Background: Pragmatic trials inform clinical decision with better generalizability and can bridge different streams of medicine. This study collated the expectations regarding pragmatic trial design of integrative medicine (IM) for diabetes and kidney diseases among patients and physicians. Dissonance between users' perspective and existing pragmatic trial design was identified. The association between risk of bias and pragmatism of study design was assessed.Method: A 10-group semi-structured focus group interview series [21 patients, 14 conventional medicine (ConM) and 15 Chinese medicine (CM) physicians] were purposively sampled from private and public clinics in Hong Kong. Perspectives were qualitatively analyzed by constant comparative method. A systematic search of four databases was performed to identify existing IM pragmatic clinical trials in diabetes or kidney disease. Primary outcomes were the pragmatism, risk of bias, and rationale of the study design. Risk of bias and pragmatism were assessed based on Cochrane risk-of-bias tool and PRECIS-2, respectively. The correlation between risk of bias and pragmatism was assessed by regression models with sensitivity analyses.Results: The subtheme on the motivation to seek IM service was analyzed, covering the perceived limitation of ConM effect, perceived benefits of IM service, and assessment of IM effectiveness. Patients expected IM service to retard disease progression, stabilize concomitant drug dosage, and reduce potential side effects associated with ConM. In the systematic review, 25 studies from six countries were included covering CM, Korean medicine, Ayurvedic medicine, and western herbal medicine. Existing study designs did not include a detailed assessment of concomitant drug change and adverse events. Majority of studies either recruited a non-representative proportion of patients as traditional, complementary, and integrative medicine (TCIM) diagnosis was used as inclusion criteria, or not reflecting the real-world practice of TCIM by completely dropping TCIM diagnosis in the trial design. Consultation follow-up frequency is the least pragmatic domain. Increase in pragmatism did not associate with a higher risk of bias.Conclusion: Existing IM pragmatic trial design does not match the patients' expectation in the analysis of incident concomitant drug change and adverse events. A two-layer design incorporating TCIM diagnosis as a stratification factor maximizes the generalizability of evidence and real-world translation of both ConM and TCIM.

ABSTRACT Objective: To evaluate the management mode for the prevention and control of coronavirus 2019 (COVID-19) transmission utilized at a general hospital in Shenzhen, China, with the aim to maintain the normal operation of the hospital. Methods: From January 2, 2020 to April 23, 2020, Hong Kong–Shenzhen Hospital, a tertiary hospital in Shenzhen, has operated a special response protocol named comprehensive pandemic prevention and control model, which mainly includes six aspects: 1) human resource management; 2) equipment management; 3) logistics management; 4) cleaning, disinfection and process reengineering; 5) environment layout; 6) and training and assessment. The detail of every aspect was described and its efficiency was evaluated. Results: A total of 198,802 patients were received. Of those, 10,821 were hospitalized; 26,767 were received by the emergency department and fever clinics; 288 patients were admitted for observation with fever; and 324 were admitted as suspected cases for isolation. Under the protocol of comprehensive pandemic prevention and control model, no case of hospital-acquired infection with COVID-19 occurred among the inpatients or staff. Conclusion: The present comprehensive response model may be useful in large public health emergencies to ensure appropriate management and protect the health and life of individuals.

The aim of this study was to describe the changes in oral health policies and guidelines in response to the Coronavirus disease 2019 (COVID-19) pandemic in different countries and regions around the world. Information on oral health policies and guidelines from 9 countries (Canada, China including Hong Kong, Egypt, India, Japan, New Zealand, Nigeria, Switzerland, and Thailand) were summarized, and sources of the information were mostly the national or regional health authorities and/or dental council/associations. The changes made to the oral health guidelines depended on the severity of the COVID-19 pandemic. This included suspension of non-emergency dental care services at the peak of the COVID-19 outbreak, and easing the restrictions on non-essential and elective dental care when the pandemic became under control. The COVID-19 risk mitigation strategies include strict adherence to infection control practices (use of hand sanitizers, facemask and maintaining social distancing), reducing the amount of aerosol production in the dental setting, and managing the quality of air in the dental treatment rooms by reducing the use of air conditioners and improving air exchange. The COVID-19 pandemic has shown a major impact on dental practice. Dental professionals are trying to adapt to the new norms, while the medium to long-term impact of COVID-19 on dentistry needs further investigation.

Abstract Background The objective of this review was to determine the unmet needs for migraine in East Asian adults and children. Methods We searched MEDLINE and EMBASE (January 1, 1988 to January 14, 2019). Studies reporting the prevalence, humanistic and economic burden, and clinical management of migraine in China (including Hong Kong and Taiwan), Japan, and South Korea were included. Studies conducted before 1988 (before the International Headache Society [IHS] first edition of the International Classification of Headache Disorders) were not included. Results We retrieved 1337 publications and 41 met the inclusion criteria (28 from China, 7 from Japan, and 6 from South Korea). The 1-year prevalence of migraine (IHS criteria) among adults ranged from 6.0% to 14.3%. Peak prevalence ranged from 11% to 20% for women and 3% to 8% for men (30- to 49-year-olds). For children, prevalence of migraine increased with age. Information on the economic burden and clinical management of migraine was limited, particularly for children. When reported, migraine was significantly associated with high levels of disability and negative effects on quality of life. Studies suggested low levels of disease awareness/diagnosis within each country. Of individuals with migraine from China, 52.9% to 68.6% had consulted a physician previously, 37.2% to 52.7% diagnosed with headache had not been diagnosed with migraine previously, and 13.5% to 18% had been diagnosed with migraine previously. Of individuals with migraine from Japan, 59.4% to 71.8% had never consulted a physician previously, 1.3% to 7.3% regularly consulted physicians for their headache, and only 11.6% of individuals with migraine were aware that they had migraine. In addition, studies suggested that over-the-counter medication use was high and prescription medication use was low in each country. Conclusions This review suggests that there are unmet needs for migraine in terms of sufficient and appropriate diagnosis, and better management and therapies for treatment of migraine in East Asia. The findings are limited by a lack of recent information and significant gaps in the literature. More recent, population-based studies assessing disease burden and clinical management of migraine are needed to confirm unmet needs for migraine across East Asia.

Abstract Background Training has been found effective in improving healthcare professionals’ knowledge, confidence, and skills in conducting advance care planning (ACP). However, the association between training and its actual practice in the clinical setting has not been well demonstrated. To fill this gap, this paper examines the association between their readiness for ACP, in terms of perceived relevancy of ACP with their clinical work, attitudes toward and confidence and willingness to perform it, based on the Theory Planned Behavior and relevant training experiences. Methods An online survey about experiences about ACP of healthcare professionals, including physicians, nurses, social workers, and allied healthcare professionals, currently working in hospital and community care in Hong Kong was conducted. Results Of 250 respondents, approximately half (52.0%) had received ACP-related training. Those with relevant training reported significantly more positive in the perceived clinical relevance, willingness, and confidence in conducting ACP and different levels of agreement with 19 out of the 25 statements in a questionnaire about attitudes toward ACP than those without (ps ≤ 0.001–0.05). Respondents who received training only in a didactic format reported a significantly lower level of confidence in conducting ACP than did others who received a blended mode of learning (p = 0.012). Notwithstanding significant differences between respondents with and without relevant training, respondents generally acknowledged their roles in initiating conversations and appreciated ACP in preventing decisional conflict in surrogate decision-making regardless of their training experience. Conclusions This paper revealed the association between training and higher level of readiness toward ACP among healthcare professionals. The findings showed that training is a predictor of their readiness for ACP in terms of perceived relevancy, willingness, and confidence. Those who had received training were less likely to consider commonly reported barriers such as time constraints, cultural taboos, and avoidance among patients and family members as hindrances to ACP implementation.

Photo by Ishan @seefromthesky on Unsplash ABSTRACT A strike to highlight the plight facing contract doctors which has been proposed has received mixed reactions from those within the profession and the public. This unprecedented nationwide proposal has the potential to cause real-world effects, posing an ethical dilemma. Although strikes are common, especially in high-income countries, these industrial actions by doctors in Malaysia are almost unheard of. Reviewing available evidence from various perspectives is therefore imperative to update the profession and the complexity of invoking this important human right. INTRODUCTION Contract doctors in Malaysia held a strike on July 26, 2021. COVID-19 cases are increasing in Malaysia. In June, daily cases ranged between 4,000 to 8,000 despite various public health measures. The R naught, which indicates the infectiousness of COVID-19, remains unchanged. During the pandemic, health care workers (HCWs) have been widely celebrated, resulting in a renewed appreciation of the risks that they face.[1] The pandemic has exposed flawed governance in the public healthcare system, particularly surrounding the employment of contract doctors. Contract doctors in Malaysia are doctors who have completed their medical training, as well as two years of internship, and have subsequently been appointed as medical officers for another two years. Contract doctors are not permanently appointed, and the system did not allow extensions after the two years nor does it offer any opportunity to specialize.[2] Last week, Parliament did decide to offer a two-year extension but that did not hold off the impending strike.[3] In 2016, the Ministry of Health introduced a contract system to place medical graduates in internship positions at government healthcare facilities across the country rather than placing them in permanent posts in the Public Service Department. Social media chronicles the issues that doctors in Malaysia faced. However, tensions culminated when and contract doctors called for a strike which ended up taking place in late July 2021. BACKGROUND Over the past decade, HCW strikes have arisen mostly over wages, work hours, and administrative and financial factors.[4] In 2012, the British Medical Association organized a single “day of action” by boycotting non-urgent care as a response to government pension reforms.[5] In Ireland, doctors went on strike for a day in 2013 to protest the austerity measures implemented by the EU in response to the global economic crisis. It involved a dispute over long working hours (100 hours per week) which violated EU employment laws and more importantly put patients’ lives at risk.[6] The strike resulted in the cancellation of 15,000 hospital appointments, but emergencies services were continued. Other major strikes have been organized in the UK to negotiate better pay for HCWs in general and junior doctors’ contracts specifically.[7] During the COVID-19 pandemic, various strikes have also been organized in Hong Kong, the US, and Bolivia due to various pitfalls in managing the pandemic.[8] A recent strike in August 2020 by South Korean junior doctors and medical students was organized to protest a proposed medical reform plan which did not address wage stagnation and unfair labor practices.[9] These demands are somewhat similar to the proposed strike by contract doctors in Malaysia. As each national health system operates within a different setting, these strikes should be examined in detail to understand the degree of self-interest involved versus concerns for patient’s welfare. l. The Malaysia Strike An anonymous group planned the current strike in Malaysia. The group used social media, garnering the attention of various key stakeholders including doctors, patients, government, and medical councils.[10] The organizers of the strike referred to their planned actions as a hartal. (Although historically a hartal involved a total shutdown of workplaces, offices, shops, and other establishments as a form of civil disobedience, the Malaysian contract doctors pledged no disturbance to healthcare working hours or services and intend a walk-out that is symbolic and reflective of a strike.)[11] The call to action mainly involved showing support for the contract doctors with pictures and placards. The doctors also planned the walk-out.[12] Despite earlier employment, contract medical doctors face many inequalities as opposed to their permanent colleagues. These include differences in basic salary, provisions of leave, and government loans despite doing the same job. The system disadvantages contract doctors offering little to no job security and limited career progression. Furthermore, reports in 2020 showed that close to 4,000 doctors’ contracts were expected to expire by May 2022, leaving their futures uncertain.[13] Some will likely be offered an additional two years as the government faces pressure from the workers. Between December 2016 and May 2021, a total of 23,077 contract doctors were reportedly appointed as medical officers, with only 789 receiving permanent positions.[14] It has been suggested that they are appointed into permanent positions based on merit but the criteria for the appointments remain unclear. Those who fail to acquire a permanent position inevitably seek employment elsewhere. During the COVID-19 pandemic, there have been numerous calls for the government to absorb contract doctors into the public service as permanent staff with normal benefits. This is important considering a Malaysian study that revealed that during the pandemic over 50 percent of medical personnel feel burned out while on duty.[15] This effort might be side-lined as the government prioritizes curbing the pandemic. As these issues remain neglected, the call for a strike should be viewed as a cry for help to reignite the discussions about these issues. ll. Right to strike The right to strike is recognized as a fundamental human right by the UN and the EU.[16] Most European countries also protect the right to strike in their national constitutions.[17] In the US, the Taft-Hartley Act in 1947 prohibited healthcare workers of non-profit hospitals to form unions and engage in collective bargaining. But this exclusion was repealed in 1947 and replaced with the requirement of a 10-day advanced written notice prior to any strike action.[18] Similarly, Malaysia also recognizes the right to dispute over labor matters, either on an individual or collective basis. The Industrial Relations Act (IRA) of 1967[19] describes a strike as: “the cessation of work by a body of workers acting in combination, or a concerted refusal or a refusal under a common understanding of a number of workers to continue to work or to accept employment, and includes any act or omission by a body of workers acting in combination or under a common understanding, which is intended to or does result in any limitation, restriction, reduction or cessation of or dilatoriness in the performance or execution of the whole or any part of the duties connected with their employment” According to the same act, only members of a registered trade union may legally participate in a strike with prior registration from the Director-General of Trade Unions.[20] Under Section 43 of the IRA, any strike by essential services (including healthcare) requires prior notice of 42 days to their employer.[21] Upon receiving the notice, the employer is responsible for reporting the particulars to the Director-General of Industrial Relations to allow a “cooling-off” period and appropriate action. Employees are also protected from termination if permitted by the Director-General and strike is legalized. The Malaysian contract healthcare workers’ strike was announced and transparent. Unfortunately, even after legalization, there is fear that the government may charge those participating in the legalized strike.[22] The police have announced they will pursue participants in the strike.[23] Even the Ministry of Health has issued a warning stating that those participating in the strike may face disciplinary actions from the ministry. However, applying these laws while ignoring the underlying issues may not bode well for the COVID-19 healthcare crisis. lll. Effects of a Strike on Health Care There is often an assumption that doctors’ strikes would unavoidably cause significant harm to patients. However, a systematic review examining several strikes involving physicians reported that patient mortality remained the same or fell during the industrial action.[24] A study after the 2012 British Medical Association strike has even shown that there were fewer in-hospital deaths on the day, both among elective and emergency populations, although neither difference was significant.[25] Similarly, a recent study in Kenya showed declines in facility-based mortality during strike months.[26] Other studies have shown no obvious changes in overall mortality during strikes by HCWs.[27] There is only one report of increased mortality associated with a strike in South Africa[28] in which all the doctors in the Limpopo province stopped providing any treatment to their patients for 20 consecutive days. During this time, only one hospital continued providing services to a population of 5.5 million people. Even though their data is incomplete, authors from this study found that the number of emergency room visits decreased during the strike, but the risks of mortality in the hospital for these patients increased by 67 percent.[29] However, the study compared the strike period to a randomly selected 20-day period in May rather than comparing an average of data taken from similar dates over previous years. This could greatly influence variations between expected annual hospital mortality possibly due to extremes in weather that may exacerbate pre-existing conditions such as heart failure during warmer months or selecting months with a higher incidence of viral illness such as influenza. Importantly, all strikes ensured that emergency services were continued, at least to the degree that is generally offered on weekends. Furthermore, many doctors still provide usual services to patients despite a proclaimed strike. For example, during the 2012 BMA strike, less than one-tenth of doctors were estimated to be participating in the strike.[30] Emergency care may even improve during strikes, especially those involving junior doctors who are replaced by more senior doctors.[31] The cancellation of elective surgeries may also increase the number of doctors available to treat emergency patients. Furthermore, the cancellation of elective surgery is likely to be responsible for transient decreases in mortality. Doctors also may get more rest during strike periods. Although doctor strikes do not seem to increase patient mortality, they can disrupt delivery of healthcare.[32] Disruptions in delivery of service from prolonged strikes can result in decline of in-patient admissions and outpatient service utilization, as suggested during strikes in the UK in 2016.[33] When emergency services were affected during the last strike in April, regular service was also significantly affected. Additionally, people might need to seek alternative sources of care from the private sector and face increased costs of care. HCWs themselves may feel guilty and demotivated because of the strikes. The public health system may also lose trust as a result of service disruption caused by high recurrence of strikes. During the COVID-19 pandemic, as the healthcare system remains stretched, the potential adverse effects resulting from doctor strikes remain uncertain and potentially disruptive. In the UK, it is an offence to “willfully and maliciously…endanger human life or cause serious bodily injury.”[34] Likewise, the General Medical Council (GMC) also requires doctors to ensure that patients are not harmed or put at risk by industrial action. In the US, the American Medical Association code of ethics prohibits strikes by physicians as a bargaining tactic, while allowing some other forms of collective bargaining.[35] However, the American College of Physicians prohibits all forms of work stoppages, even when undertaken for necessary changes to the healthcare system. Similarly, the Delhi Medical Council in India issued a statement that “under no circumstances doctors should resort to strike as the same puts patient care in serious jeopardy.”[36] On the other hand, the positions taken by the Malaysian Medical Council (MMC) and Malaysian Medical Association (MMA) on doctors’ strikes are less clear when compared to their Western counterparts. The MMC, in their recently updated Code of Professional Conduct 2019, states that “the public reputation of the medical profession requires that every member should observe proper standards of personal behavior, not only in his professional activities but at all times.” Strikes may lead to imprisonment and disciplinary actions by MMC for those involved. Similarly, the MMA Code of Medical Ethics published in 2002 states that doctors must “make sure that your personal beliefs do not prejudice your patients' care.”[37] The MMA which is traditionally meant to represent the voices of doctors in Malaysia, may hold a more moderate position on strikes. Although HCW strikes are not explicitly mentioned in either professional body’s code of conduct and ethics, the consensus is that doctors should not do anything that will harm patients and they must maintain the proper standard of behaviors. These statements seem too general and do not represent the complexity of why and how a strike could take place. Therefore, it has been suggested that doctors and medical organizations should develop a new consensus on issues pertaining to medical professional’s social contract with society while considering the need to uphold the integrity of the profession. Experts in law, ethics, and medicine have long debated whether and when HCW strikes can be justified. If a strike is not expected to result in patient harm it is perhaps acceptable.[38] Although these debates have centered on the potential risks that strikes carry for patients, these actions also pose risks for HCWs as they may damage morale and reputation.[39] Most fundamentally, strikes raise questions about what healthcare workers owe society and what society owes them. For strikes to be morally permissible and ethical, it is suggested that they must fulfil these three criteria:[40] a. Strikes should be proportionate, e., they ‘should not inflict disproportionate harm on patients’, and hospitals should as a minimum ‘continue to provide at least such critical services as emergency care.’ b. Strikes should have a reasonable hope of success, at least not totally futile however tough the political rhetoric is. c. Strikes should be treated as a last resort: ‘all less disruptive alternatives to a strike action must have been tried and failed’, including where appropriate ‘advocacy, dissent and even disobedience’. The current strike does not fulfil the criteria mentioned. As Malaysia is still burdened with a high number of COVID-19 cases, a considerable absence of doctors from work will disrupt health services across the country. Second, since the strike organizer is not unionized, it would be difficult to negotiate better terms of contract and career paths. Third, there are ongoing talks with MMA representing the fraternity and the current government, but the time is running out for the government to establish a proper long-term solution for these contract doctors. One may argue that since the doctors’ contracts will end in a few months with no proper pathways for specialization, now is the time to strike. However, the HCW right to strike should be invoked only legally and appropriately after all other options have failed. CONCLUSION The strike in Malaysia has begun since the drafting of this paper. Doctors involved assure that there will not be any risk to patients, arguing that the strike is “symbolic”.[41] Although an organized strike remains a legal form of industrial action, a strike by HCWs in Malaysia poses various unprecedented challenges and ethical dilemmas, especially during the pandemic. The anonymous and uncoordinated strike without support from the appropriate labor unions may only spark futile discussions without affirmative actions. It should not have taken a pandemic or a strike to force the government to confront the issues at hand. It is imperative that active measures be taken to urgently address the underlying issues relating to contract physicians. As COVID-19 continues to affect thousands of people, a prompt reassessment is warranted regarding the treatment of HCWs, and the value placed on health care. [1] Ministry of Health (MOH) Malaysia, “Current situation of COVID-19 in Malaysia.” http://covid-19.moh.gov.my/terkini (accessed Jul. 01, 2021). [2] “Future of 4,000 young doctors who are contract medical officers uncertain,” New Straits Times - November 26, 2020. https://www.nst.com.my/news/nation/2020/11/644563/future-4000-young-doctors-who-are-contract-medical-officers-uncertain [3] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow [4] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327; G. Russo et al., “Health workers’ strikes in low-income countries: the available evidence,” Bull. World Health Organ., vol. 97, no. 7, pp. 460-467H, Jul. 2019, doi: 10.2471/BLT.18.225755. [5] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [6] E. Quinn, “Irish Doctors Strike to Protest Work Hours Amid Austerity,” The Wall Street Journal, 2013. https://www.wsj.com/articles/no-headline-available-1381217911?tesla=y (accessed Jun. 29, 2021). [7] “NHS workers back strike action in pay row by 2-to-1 margin,” The Guardian, 2014. https://www.theguardian.com/society/2014/sep/18/nhs-workers-strike-pay-unison-england (accessed Jun. 29, 2021); M. Limb, “Thousands of junior doctors march against new contract,” BMJ, p. h5572, Oct. 2015, doi: 10.1136/bmj.h5572. [8] J. Parry, “China coronavirus: Hong Kong health staff strike to demand border closure as city records first death,” BMJ, vol. 368, no. February, p. m454, Feb. 2020, doi: 10.1136/bmj.m454; “MultiCare healthcare workers strike, urging need for more PPEs, staff support,” Q13 FOX, 2020. https://www.q13fox.com/news/health-care-workers-strike-urging-need-for-ppes-risks-on-patient-safety (accessed Jun. 29, 2021); “Bolivia healthcare workers launch strike in COVID-hit region,” Al Jazeera, 2021. https://www.aljazeera.com/news/2021/2/9/bolivia-healthcare-workers-strike-covid-hit-region (accessed Jun. 29, 2021). [9] K. Arin, “Why are Korean doctors striking?” The Korea Herald, 2020. http://www.koreaherald.com/view.php?ud=20200811000941 (accessed Jun. 29, 2021). [10] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak. [11] “Hartal,” Oxford Advanced Learner’s Dictionary. https://www.oxfordlearnersdictionaries.com/definition/english/hartal (accessed Jun. 29, 2021). [12] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak. [13] R. Anand, “Underpaid and overworked, Malaysia’s contract doctors’ revolt amid Covid-19 surge,” The Straits Times, 2021. [14] Anand. [15] N. S. Roslan, M. S. B. Yusoff, A. R. Asrenee, and K. Morgan, “Burnout prevalence and its associated factors among Malaysian healthcare workers during covid-19 pandemic: An embedded mixed-method study,” Healthc., vol. 9, no. 1, 2021, doi: 10.3390/healthcare9010090. [16] Maina Kiai, “Report by the Special Rapporteur on the Right to Freedom of Peaceful Assembly and Association,” 2016. [Online]. Available: http://freeassembly.net/wp-content/uploads/2016/10/A.71.385_E.pdf. [17] ETUI contributors, Strike rules in the EU27 and beyond. The European Trade Union Institute. ETUI, 2007. [18] National Labor Relations Board, National Labor Relations Act. 1935, pp. 151–169. [19] Ministry of Human Resources, Industrial Relations Act 1967 (Act 177), no. October. 2015, pp. 1–76. [20] Article 10 of the Federal Constitution states that all citizens have the right to form associations including registered trade or labor unions. A secret ballot with two-third majority will suffice to call for a strike required for submission to the DGTU within 7 days as stated in Section 25(A) of the Trade Union Act 1959. [21] Ministry of Human Resources Malaysia, Guidelines on Strikes, Pickets and Lockouts in Malaysia. Putrajaya, 2011. [22] Ordinance Emergency which was declared in Malaysia since 12 January 2021. Under the Ordinance Emergency, the king or authorized personnel may, as deemed necessary, demand any resources. [23] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow [24] S. A. Cunningham, K. Mitchell, K. M. Venkat Narayan, and S. Yusuf, “Doctors’ strikes and mortality: A review,” Soc. Sci. Med., vol. 67, no. 11, pp. 1784–1788, Dec. 2008, doi: 10.1016/j.socscimed.2008.09.044. [25] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [26] G. K. Kaguthi, V. Nduba, and M. B. Adam, “The impact of the nurses’, doctors’ and clinical officer strikes on mortality in four health facilities in Kenya,” BMC Health Serv. Res., vol. 20, no. 1, p. 469, Dec. 2020, doi: 10.1186/s12913-020-05337-9. [27] G. Ong’ayo et al., “Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis,” Lancet Glob. Heal., vol. 7, no. 7, pp. e961–e967, Jul. 2019, doi: 10.1016/S2214-109X (19)30188-3. [28] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045. [29] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045. [30] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [31] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231. [32] D. Waithaka et al., “Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County,” Int. J. Equity Health, vol. 19, no. 1, pp. 1–15, 2020, doi: 10.1186/s12939-020-1131-y. [33] The study has shown that there were 9.1% reduction in admissions and around 6% fewer emergency cases and outpatient appointments than expected. An additional 52% increase in expected outpatient appointments cancelations were made by hospitals during that period. D. Furnivall, A. Bottle, and P. Aylin, “Retrospective analysis of the national impact of industrial action by English junior doctors in 2016,” BMJ Open, vol. 8, no. 1, p. e019319, Jan. 2018, doi: 10.1136/bmjopen-2017-019319. [34] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231. [35] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327. [36] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010. [37] Malaysian Medical Association, “Malaysian Medical Association Official Website.” https://mma.org.my (accessed Jun. 29, 2021). [38] M. Toynbee, A. A. J. Al-Diwani, J. Clacey, and M. R. Broome, “Should junior doctors strike?” J. Med. Ethics, vol. 42, no. 3, pp. 167–170, Mar. 2016, doi: 10.1136/medethics-2015-103310. [39] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327. [40] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010; A. J. Roberts, “A framework for assessing the ethics of doctors’ strikes,” J. Med. Ethics, vol. 42, no. 11, pp. 698–700, Nov. 2016, doi: 10.1136/medethics-2016-103395. [41] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow

ICSDI 2022 is the most dynamic, informative, inspirational, and innovative event organized by the Engineering College of Prince Sultan University (Riyadh, KSA). The 2022 conference focuses on the State of the Art and Practice in different sustainable development goals (SDGs), as one of the promising and trending Engineering disciplines, this field is still changing rapidly. Along with the diversity of presentations on challenging projects and research, ICSDI 2022 will feature multiple invited speakers on selected topics. The conference will include a wide range of knowledge-enhancing technical and panel sessions, short courses, and workshops. There are around 96 participants attending the conference in the opening ceremony and plenary sessions. They are from the United States, Germany, Canada, India, Brazil, Chile, China, Egypt, Russia, Georgia, Hong Kong and so on. The conference was held in hybrid, both physical and virtual mode due to covid19 restrictions in few countries. Around 18 participants attended in virtual mode. At this conference, we were greatly honored to have outstanding Keynote Speakers and Invited Speakers from different countries. They addressed the audience and shared their knowledge and rich experience in related fields. They are Prof. Dennis D. Truax from Mississippi State University, USA; Mr. Ziyad Alshiha, Group Chief executive of The Saudi Investment Recycling Company (SIRC), Saudi Arabia; Dr. Adam C. BOULOUKOS, The UNDP Resident Representative for the Kingdom of Saudi Arabia; Eng. Turki Bukhari, Vice President, Assets & Facilities Management, Expro, Saudi Arabia; Mr. Raed Albasseet, Chief Environment and Sustainability Officer of the Red Sea Development Company & AMAALA; Eng. Fahad Al Ajlan, President, KAPSARC; Mr. Mark Mirza, Project Leader at Fraunhofer ISC, Germany; Ms. Mayssam Tamim, Assistant Resident Representative; Dr Ahmed Al-Darwish, Deputy Governor for Development, Economic Research & Policy Advocacy; Dr. Ahmad Alwosheel, Assistant Researcher at King Abdulaziz City for Science and Technology (KACST); Eng. Mazin Albahkali, Executive Vice President Strategic Planning and New Business Development, Saudi Electricity Company (SEC), Saudi Arabia; Mr. Bandar Al Blehed Clients Relations Development Head -Saudi Exchange; Dr. Abdullah Alabdulkarem Executive Director of the Enablement Sector at the Government Expenditure and Projects Efficiency Authority (EXPRO); Eng. Waleed AlGhamdi, Associate Director, Smart City & Sustainability; Mr. Turki A. Alrowili, Spokesperson, Public Relations and Communication Director at National Development Fund; Dr. Ameer M. Al-Alwan, Advisory and Training Director, Center for Local Governance. There are 16 sub-sessions during the conference. The tracks of the conference include Manufacturing and Industrial Systems towards Sustainability, Sustainable Construction Technologies and Materials, Energy Sustainability: Challenges and Opportunities, Sustainable Urbanization and Smart Cities, Sustainability and Built Environment, Policies, Regulations and Economic Assessments towards SDGs. Attendees, paper presenters, keynote speakers, scholars and students have benefited in many ways from this conference. We would like to express our great appreciation to the organizers, members of the program committees and reviewers of ICSDI 2022 for their hard work. Without their participation, it would be impossible to hold ICSDI 2022 successfully and ensure the high quality of papers of the conference proceedings. We also would like to express our gratitude to the unbelievable number of authors for contributing their research results to the conference. List of Committees, Statement of Peer Review are available in this pdf.

In 2006, a seminal report from the World Health Organization1 provided an all-encompassing definition of health workers as “all people engaged in actions whose primary intent is to enhance health,” whether involved in direct service provision (e.g., physicians, nurses, midwives) or administrative/support functions (e.g., administrative professional or driver in a healthcare facility), and with or without compensation (e.g., volunteer health workers, family caregivers). Because of limitations on data availability and measurement, however, technical and academic discussions about health workers, or more formally, human resources for health (HRH), focus on those under the formal sector.2 By and large, HRH is considered a vital pillar of a functioning health system3 because the health sector is a labor-intensive industry4 that relies on a substantial number of highly skilled staff to provide services to target populations, and consequently, the attainment of national and global health targets (e.g., Sustainable Development Goals). One challenge confronting HRH management is the issue of geographical imbalance, which means that health workers are attracted to work and settle in urban more than rural areas for a variety of individual, organizational, institutional, economic, political, and cultural factors.5,6 In the Philippine context, the Department of Health (DOH) reported in 2018 that there still exists a maldistribution of HRH in the country, particularly in “hardship” posts where municipalities could not entice, nor retain, HRH.7 For example, a separate analysis of institution-based HRH data in 2017 showed that the National Capital Region had significantly more physicians, nurses, and medical technologists than the Autonomous Region of Muslim Mindanao.8 The paper by Tejero et al.9 in this issue of Acta Medica Philippina adds further evidence to the underlying reasons for the geographical imbalance of HRH in the country. Based on interviews with officials and health workers from 76 rural municipalities across the Philippines, the researchers found that, in general, while local government units attempted to implement strategies to help recruit and retain health workers in their areas, such a response has mainly been inadequate and has failed to bridge the HRH gap confronting their locality. At its core, the financial obligations tied to the recruitment and retention process appear to be a significant driver of this situation since most rural municipalities are dependent on their share of national revenues by way of the Internal Revenue Allotment (IRA), which in turn is based on population (50%), land area (25%), and equal sharing (25%).10 That is to say, rural municipalities can only commit so much financial resources in their annual budget to fund the salary of health workers, given the other equally important social and development programs that need to be implemented. Even the impact of the expected increase in IRA based on the Mandanas Doctrine promulgated by the Supreme Court in 2019 revising the computation of national revenues may be modest at best since some programs, projects, and activities previously supported by the national government will have to be assumed again by local government units.11 The devolution of health services following the promulgation of the Local Government Code of 199112 with its promise of creating a governance structure that is more responsive to the needs of communities has resulted in a paradox whereby local government units are constrained in their strategies and initiatives by, among other things, the financial resources that are available at their disposal. To this end, two important points need to be considered by local government units to address the issue of the geographical imbalance of HRH. First, augmentation of available human resources for health through national-level initiatives (e.g., DOH HRH Deployment Program 8, Medical Scholarship, and Return Service Program 13) as well as private sector support (e.g., project-specific HRH for the tuberculosis control program 14) should be maximized, but with a clear intent that, as we have argued in past publications, these be regarded as temporary measures to rectify the issue in the short- to intermediate-term.14–18 Second, and more importantly, there is a need to explore, mobilize, and maximize non-financial incentives (e.g., housing) and extrabudgetary sources (e.g., share from the feed paid by social health insurance), as more long-term tactics.1,17 Unless and until a viable fiscal environment is put in place, coupled with implementation of a comprehensive policy and framework across the phases of the working lifespan1 , the challenge of HRH maldistribution will continue to persist. Carl Abelardo T. Antonio, MD, MPH Department of Health Policy and Administration College of Public Health University of the Philippines Manila, Manila, Philippines Department of Applied Social Sciences The Hong Kong Polytechnic University, Kowloon Hong Kong SAR, China REFERENCES World Health Organization. The World Health Report 2006: Working together for health [Internet]. Geneva: World Health Organization; 2006 [cited 2022 May 4]. Available from https://apps.who.int/iris/handle/10665/43432 Al-Sawai A, Al-Shishtawy MM. Health workforce planning: an overview and suggested approach in Oman. Sultan Qaboos Univ Med J. 2015 Feb; 15(1):e27-33. World Health Organization. The World Health Report 2000. Health systems: improving performance [Internet]. Geneva: World Health Organization; 2000 [cited 2022 May 4]. Available from https://apps.who.int/iris/handle/10665/42281 Buchan J. What difference does (“good”) HRM make? Hum Resour Health. 2004 Jun 7; 2(1):6. doi: 10.1186/1478-4491-2-6. Zurn P, Dal Poz MR, Stilwell B, Adams O. Imbalance in the health workforce. Hum Resour Health. 2004 Sep 17; 2(1):13. doi: 10.1186/1478-4491-2-13. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 2006 May 27; 4:12. doi: 10.1186/1478-4491-4-12. Department of Health. National objectives for health Philippines 2017-2022 [Internet]. Manila, Philippines: Department of Health; 2018 [cited 2022 May 4]. Available from https://doh.gov.ph/sites/default/files/health_magazine/NOH-2017-2022-030619-1%281%29_0.pdf Dayrit MM, Lagrada LP, Picazo OF, Pons MC & Villaverde MC. The Philippines health system review [Internet]. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018 [cited 2022 May 4]. Available from https://apps.who.int/iris/handle/10665/274579. Tejero LS, Leyva EA, Abad PB, Montorio D, Santos M. Production, recruitment, and retention of health workers in rural areas in the Philippines. Acta Med Philipp. 2022; 56(8):31-42. Congressional Policy and Budget Research Department. Facts in figures, FF2012-03 [Internet]. Quezon City: House of Representatives; 2012 [cited 2022 May 4]. Available from https://cpbrd.congress.gov.ph/images/PDF%20Attachments/Facts%20in%20Figures/03-FnF%20IRA.pdf Manasan RG. Fiscal sustainability, equity, and allocative efficiency in the light of the 2019 Supreme Court ruling on the LGUs’ share in national taxes, DP 2020-18 [Internet]. Quezon City: Philippine Institute for Development Studies; 2020 [cited 2022 May 4]. Available from https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps2018.pdf Congress of the Philippines. Republic Act No. 7160, Local Government Code of 1991 [Internet]. Metro Manila: Congress of the Philippines; 1991 Oct 10 [cited 2022 May 5]. Available from https://www.officialgazette.gov.ph/downloads/1991/10oct/19911010-RA-7160-CCA.pdf Congress of the Philippines. Republic Act No. 11509, Doktor Para sa Bayan Act [Internet]. Metro Manila: Congress of the Philippines; 2020 Dec 23 [cited 2022 May 4]. Available from https://www.officialgazette.gov.ph/downloads/2020/12dec/20201223-RA-11509-RRD.pdf Antonio CT, Guevarra JP, Medina PN, Roxas EA, Cavinta LL, Manalo JA, et al. Facilitators and barriers to the implementation of selected local tuberculosis control programs in the Province of Laguna, Philippines. Philipp J Sci. 2021 Dec; 150(6A):1501-1506. Lawas ND, Faraon EA, Mabunga SY, Antonio CT, Tobias EM, Javier RS. An evaluation of the Medical Pool Placement and Utilization Program (MedPool PUP) of the Philippine Department of Health. Acta Med Philipp. 2016; 50(3):186–193. doi: 10.47895/amp.v50i3.826 Medina PN, Bardelosa DD, Lara AB, Avelino MD, Agbon AG, Cengca RM, et al. A historical perspective of mandatory service policy in the Philippines: a document analysis. Phil J Health Res Dev. 2018; 22(3):1–12. Antonio CT, Guevarra JP, Medina PN, Avelino MD, Agbon AG, Sepe DC, et al. Components of compulsory service program for health professionals in low-and middle-income countries: A scoping review. Perspect Public Health.2020;140(1):54–61. doi: 10.1177/1757913919839432. Guevarra JP, Medina PN, Avelino MD, Cengca MM, Ting ML, Agbon AG, et al. Perception of program administrators and students on the implementation of return service agreement in the Philippines. Acta Med Philipp. 2020;54(3):289–95. doi: 10.47895/amp.v54i3.1666.

Introduction: Artist Villages in Beijing Many of the most renowned sites of Beijing are found in the inner-city districts of Dongcheng and Xicheng: for instance, the Forbidden City, Tiananmen Square, the Lama Temple, the National Theatre, the Central Opera Academy, the Bell Tower, the Drum Tower, the Imperial College, and the Confucius Temple. However, in the past decade a new attraction has been added to the visitor “must-see” list in Beijing. The 798 Art District originated as an artist village within abandoned factory buildings at Dashanzi, right between the city’s Central Business District and the open outer rural space on Beijing’s north-east. It is arguably the most striking symbol of China’s contemporary art scene. The history of the 798 Art District is by now well known (Keane), so this paper will provide a short summary of its evolution. Of more concern is the relationship between the urban fringe and what Howard Becker has called “art worlds.” By art worlds, Becker refers to the multitude of agents that contribute to a final work of art: for instance, people who provide canvasses, frames, and art supplies; critics and intermediaries; and the people who run exhibition services. To the art-world list in Beijing we need to add government officials and developers. To date there are more than 100 artist communities or villages in Beijing; almost all are located in the city’s outskirts. In particular, a high-powered art centre outside the city of Beijing has recently established a global reputation. Songzhuang is situated in outer Tongzhou District, some 30 kilometres east of Tiananmen Square. The Beijing Municipal Government officially classifies Songzhuang as the Capital Art District (CAD) or “the Songzhuang Original Art Cluster.” The important difference between 798 and Songzhuang is that, whereas the former has become a centre for retail and art galleries, Songzhuang operates as an arts production centre for experimental art, with less focus on commercial art. The destiny of the artistic communities is closely related to urban planning policies that either try to shut them down or protect them. In this paper I will take a close look at three artist villages: Yuanmingyuan, 798, and Songzhuang. In tracing the evolution of the three artist villages, I will shed some light on artists’ lives in city fringes. I argue that these outer districts provide creative industries with a new opportunity for development. This is counter to the conventional wisdom that central urban areas are the ideal locality for creative industries. Accordingly, this argument needs to be qualified: some types of creative work are more suitable to rural and undeveloped areas. The visual art “industry” is one of these. Inner and Outer Worlds Urban historians contend that innovation is more likely to happen in inner urban areas because of intensive interactions between people (Jacobs). City life has been associated with the development of creative industries and economic benefits brought about by the interaction of creative classes. In short, the argument is that cities, or, more specifically, urban areas are primary economic entities (Montgomery) whereas outer suburbs are uncreative and dull (Florida, "Cities"). The conventional wisdom is that talented creative people are attracted to the creative milieu in cities: universities, book shops, cafes, museums, theatres etc. These are both the hard and the soft infrastructure of modern cities. They illustrate diversified built forms, lifestyles and experiences (Lorenzen and Frederiksen; Florida, Rise; Landry; Montgomery; Leadbeater and Oakley). The assumption that inner-city density is the cradle of creative industries has encountered critique. Empirical studies in Australia have shown that creative occupations are found in relatively high densities in urban fringes. The point made in several studies is that suburbia has been neglected by scholars and policy makers and may have potential for future development (Gibson and Brennan-Horley; Commission; Collis, Felton, and Graham). Moreover, some have argued that the practice of constructing inner city enclaves may be leading to homogenized and prescriptive geographies (Collis, Felton, and Graham; Kotkin). As Jane Jacobs has indicated, it is not only density of interactions but diversity that attracts and accommodates economic growth in cities. However, the spatiality of creative industries varies across different sectors. For example, media companies and advertising agencies are more likely to be found in the inner city, whereas most visual artists prefer working in the comparatively quiet and loosely-structured outskirts. Nevertheless, the logic embodied in thinking around the distinctions between “urbanism” and “suburbanism” pays little attention to this issue, although both schools acknowledge the causal relationship between locality and creativity. According to Drake, empirical evidence shows that the function of locality is not only about encouraging interactions between SMEs (small to medium enterprises) within clusters which can generate creativity, but also a catalyst for individual creativity (Drake). Therefore for policy makers in China, the question here is how to plan or prepare a better space to accommodate creative professionals’ needs in different sectors while making the master plan. This question is particularly urgent to the Chinese government, which is undertaking a massive urbanization transition throughout the country. In placing a lens on Beijing, it is important to note the distinctive features of its politics, forms of social structure, and climate. As Zhu has described it, Beijing has spread in a symmetrical structure. The reasons have much to do with ancient history. According to Zhu, the city which was planned in the era of Genghis Khan was constituted by four layers or enclosures, with the emperor at the centre, surrounded by the gentry and other populations distributed outwards according to wealth, status, and occupation. The outer layer accommodated many lower social classes, including itinerant artists, musicians, and merchants. This ”outer city” combined with open rural space. The system of enclosures is carried on in today’s city planning of Beijing. Nowadays Beijing is most commonly described by its ring roads (Mars and Hornsby). However, despite the existing structure, new approaches to urban policy have resulted in a great deal of flux. The emergence of new landscapes such as semi-urbanized villages, rural urban syndicates (chengxiang jiehebu), and villages-within-cities (Mars and Hornsby 290) illustrate this flux. These new types of landscapes, which don’t correspond to the suburban concept that we find in the US or Australia, serve to represent and mediate the urban-rural relationship in China. The outer villages also reflect an old tradition of “recluse” (yin shi), which since the Wei and Jin Dynasties allowed intellectuals to withdraw themselves from the temporal world of the city and live freely in the mountains. The Lost Artistic Utopia: Yuanmingyuan Artist Village Yuanmingyuan, also known as the Ming Dynasty summer palace, is located in Haidian District in the north-west of Beijing. Haidian has transformed from an outer district of Beijing into one of its flourishing urban districts since the mid-1980s. Haidian’s success is largely due to the electronics industry which developed from spin-offs from Peking University, Tsinghua University and the Chinese Academy of Sciences in the 1980s. This led to the rapid emergence of Zhongguancun, sometimes referred to as China’s Silicon Valley. However there is another side of Haidian’s transformation. As the first graduates came out of Chinese Academies of the Arts following the Cultural Revolution (1966–1976), creative lifestyles became available. Some people quit jobs at state-owned institutions and chose to go freelance, which was unimaginable in China under the former regime of Mao Zedong. By 1990, the earliest “artist village” emerged around the Yuanmingyuan accommodating artists from around China. The first site was Fuyuanmen village. Artists living and working there proudly called their village “West Village” in China, comparing it to the Greenwich Village in New York. At that time they were labelled as “vagabonds” (mangliu) since they had no family in Beijing, and no stable job or income. Despite financial difficulties, the Yuanmingyuan artist village was a haven for artists. They were able to enjoy a liberating and vigorous environment by being close to the top universities in Beijing[1]. Access to ideas was limited in China at that time so this proximity was a key ingredient. According to an interview by He Lu, the Yuanmingyuan artist village gave artists a sense of belonging which went far beyond geographic identification as a marginal group unwelcomed by conservative urban society. Many issues arose along with the growth of the artist village. The non-traditional lifestyle and look of these artists were deemed abnormal by many of the general public; the way of their expression and behaviour was too extreme to be accepted by the mainstream in what was ultimately a political district; they were a headache for local police who saw them as troublemakers; moreover, their contact with the western world was a sensitive issue for the government at that time. Suddenly, the village was closed by the government in 1993. Although the Yuanmingyuan artist village existed for only a few years, it is of significance in China’s contemporary art history. It is the birth place of the cynical realism movement as well as the genesis of Fang Lijun, Zhang Xiaogang and Yue Mingjun, now among the most successful Chinese contemporary artists in global art market. The Starting Point of Art Industry: 798 and Songzhuang After the Yuanmingyuan artist village was shut down in 1993, artists moved to two locations in the east of Beijing to escape from the government and embrace the free space they longed for. One was 798, an abandoned electronic switching factory in Beijing’s north-east urban fringe area; the other was Songzhuang in Tongzhou District, a further twenty kilometres east. Both of these sites would be included in the first ten official creative clusters by Beijing municipal government in 2006. But instead of simply being substitutes for the Yuanmingyuan artist village, both have developed their own cultures, functioning and influencing artists’ lives in different ways. Songzhuang is located in Tongzhou which is an outer district in Beijing’s east. Songzhuang was initially a rural location; its livelihood was agriculture and industry. Just before the closing down of the Yuanmingyuan village, several artists including Fang Lijun moved to this remote quiet village. Through word of mouth, more artists followed their steps. There are about four thousand registered artists currently living in Songzhuang now; it is already the biggest visual art community in Beijing. An artistic milieu and a local sense of place have grown with the increasing number of artists. The local district government invests in building impressive exhibition spaces and promoting art in order to bring in more tourists, investors and artists. Compared with Songzhuang, 798 enjoys a favourable location along the airport expressway, between the capital airport and the CBD of Beijing. The unused electronics plant was initially rented as classrooms by the China Central Academy of Fine Arts in the 1990s. Then several artists moved their studios and workshops to the area upon eviction from the Yuanmingyuan village. Until 2002 the site was just a space to rent cheap work space, a factor that has stimulated many art districts globally (Zukin). From that time the resident artists began to plan how to establish a contemporary art district in China. Led by Huang Rui, a leading visual artist, the “798 collective” launched arts events and festivals, notably a “rebuilding 798” project of 2003. More galleries, cafés, bars, and restaurants began to set up, culminating in a management takeover by the Chaoyang District government with the Seven Stars Group[2] prior to the Beijing Olympics. The area now provides massive tax revenue to the local and national government. Nonetheless, both 798 and Songzhuang face problems which reflect the conflict between artists’ attachment to fringe areas and the government’s urbanization approach. 798 can hardly be called an artist production village now due to the local government’s determination to exploit cultural tourism. Over 50 percent of enterprises and people working in 798 now identify 798 as a tourism area rather than an art or “creative” cluster (Liu). Heavy commercialization has greatly disappointed many leading artists. The price for renting space has gone beyond the affordability of artists, and many have chosen to leave. In Songzhuang, the story is similar. In addition to rising prices, a legal dispute between artists and local residents regarding land property rights in 2008 drove some artists out of Songzhuang because they didn’t feel it was stable anymore (Smith). The district’s future as a centre of original art runs up against the aspirations of local officials for more tax revenue and tourist dollars. In the Songzhuang Cultural Creative Industries Cluster Design Plan (cited in Yang), which was developed by J.A.O Design International Architects and Planners Limited and sponsored by the Songzhuang local government in 2007, Songzhuang is designed as an “arts capital incorporated with culture, commerce and tourism.” The down side of this aspiration is that more museums, galleries, shopping centres, hotels, and recreation infrastructure will inevitably be developed in order to capitalise on Songzhuang’s global reputation. Concluding Reflections In reflecting on the recent history of artist villages in Beijing, we might conclude that rural locations are not only a cheap place for artists to live but also a space to showcase their works. More importantly, the relation of artists and outlying district has evolved into a symbiotic relationship. They interact and grow together. The existence of artists transforms the locale and the locale in turn reinforces the identity of artists. In Yuanmingyuan the artists appreciated the old “recluse” tradition and therefore sought spiritual liberation after decades of suppression. The outlying location symbolized freedom to them and provided distance from the world of noisy interaction. But isolation of artists from the local community and the associated constant conflict with local villagers deepened estrangement; these events brought about the end of the dream. In contrast, at 798 and Songzhuang, artists not only regarded the place as their worksite but also engaged with the local community. They communicated with local people and co-developed projects to transform the local landscape. Local communities changed; they started to learn about the artistic world while gaining economic benefits in many ways, such as house renting, running small grocery stores, providing art supplies and even modelling. Their participation into the “art worlds” (Becker) contributed to a changing cultural environment, in turn strengthening the brand of these artist villages. In many regards there were positive externalities for both artists and the district, although as I mentioned in relation to Songzhuang, tensions about land use have never completely been resolved. Today, the fine arts in China have gone far beyond the traditional modes of classics, aesthetics, liberation or rebellion. Art is also a business which requires the access to the material world in order to produce incomes and make profits. It appears that many contemporary artists are not part of a movement of rebellion (except several artists, such as Ai Weiwei), adopting the pure spirit of art as their life-time mission, as in the Yuanmingyuan artist village. They still long for recognition, but they are also concerned with success and producing a livelihood. The boundary between inner urban and outer urban areas is not as significant to them as it once was for artists from a former period. While many artists enjoy the quiet and space of the fringe and rural areas to work; they also require urban space to exhibit their works and earn money. This factor explains the recent emergence of Caochangdi and other artist villages in the neighbouring area around the 798. These latest artist villages in the urban fringe still have open and peaceful spaces and can be accessed easily due to convenient transportation. Unfortunately, the coalition of business and government leads to rapid commercialization of place which is not aligned with the basic need of artists, which is not only a free or affordable place but also a space for creativity. As mentioned above, 798 is now so commercialized that it is too crowded and expensive for artists due to the government’s overdevelopment; whereas the government’s original intention was to facilitate the development of 798. Furthermore, although artists are a key stakeholder in the government’s agenda for visual art industry, it is always the government’s call when artists’ attachment to rural space comes into conflict with Beijing government’s urbanization plan. Hence the government decides which artist villages should be sacrificed to give way to urban development and which direction the reserved artist villages or art clusters should be developed. The logic of government policy causes an absolute distinction between cities and outlying districts. And the government’s enthusiasm for “urbanization” leads to urbanized artist villages, such as the 798. A vicious circle is formed: the government continuously attempts to have selected artist villages commercialized and transformed into urbanized or quasi-urbanized area and closes other artist villages. One of the outcomes of this policy is that in the government created creative clusters, many artists do not stay, and move away into rural and outlying areas because they prefer to work in non-urban spaces. To resolve this dilemma, greater attention is required to understand artists needs and ways to combine urban convenience and rural tranquillity into their development plans. This may be a bridge too far, however. Reference Becker, Howard Saul. Art Worlds. 25th anniversary, updated and expanded ed. Berkeley, CA: U of California P, 2008. Collis, Christy, Emma Felton, and Phil Graham. "Beyond the Inner City: Real and Imagined Places in Creative Place Policy and Practice." The Information Society: An International Journal 26.2 (2010): 104–12. Commission, Outer London. The Mayor's Outer London Commission: Report. London: Great London Authority, 2010. Drake, Graham. "'This Place Gives Me Space': Place and Creativity in the Creative Industries." Geoforum 34.4 (2003): 511–24. Florida, Richard. "Cities and the Creative Class." The Urban Sociology Reader. Eds. Jan Lin and Christopher Mele. London: Routledge, 2005. 290–301. ———. The Rise of the Creative Class. New York: Basic Books, 2002. Gibson, Chris, and Chris Brennan-Horley. "Goodbye Pram City: Beyond Inner/Outer Zone Binaries in Creative City Research." Urban Policy and Research 24.4 (2006): 455–71. Jacobs, Jane. The Economy of Cities. New York: Random House, 1969. Keane, Michael. "The Capital Complex: Beijing's New Creative Clusters." Creative Economies, Creative Cities: Asian-European Perspectives. Ed. Lily Kong and Justin O'Connor. London: Springer, 2009. 77–95. Kotkin, Joel. "The Protean Future of American Cities." New Geographer 7 Mar. 2011. 27 Mar. 2011 ‹http://blogs.forbes.com/joelkotkin/2011/03/07/the-protean-future-of-american-cities/›. Landry, Charles. The Creative City: A Toolkit for Urban Innovators. London: Earthscan Publications, 2000. Leadbeater, Charles, and Kate Oakley. The Independents: Britain's New Cultural Entrepreneurs. London: Demos, 1999. Liu, Mingliang. "Beijing 798 Art Zone: Field Study and Follow-Up Study in the Context of Market." Chinese National Academy of Arts, 2010. Lorenzen, Mark, and Lars Frederiksen. "Why Do Cultural Industries Cluster? Localization, Urbanization, Products and Projects." Creative Cities, Cultural Clusters and Local Economic Development. Ed. Philip Cooke and Luciana Lazzeretti. Cheltenham, UK: Edward Elgar, 2008. 155-79. Mars, Neville, and Adrian Hornsby. The Chinese Dream: A Society under Construction. Rotterdam: 010 Publishers, 2008. Montgomery, John. The New Wealth of Cities: City Dynamics and the Fifth Wave. Aldershot: Ashgate, 2007. Smith, Karen. "Heart of the Art." Beijing: Portrait of a City. Ed. Alexandra Pearson and Lucy Cavender. Hong Kong: The Middle Kingdom Bookworm, 2008. 106–19. Yang, Wei, ed. Songzhuang Arts 2006. Beijing: Hunan Fine Arts Press, 2007. Zhu, Jianfei. Chinese Spatial Strategies Imperial Beijing, 1420-1911. Routledge Curzon, 2004. Zukin, Sharon. The Cultures of Cities. Cambridge, MA: Blackwell, 1995. [1] Most prestigious Chinese universities are located in the Haidian District of Beijing, such as Peking University, Tsinghua University, etc. [2] Seven Star Group is the landholder of the area where 798 is based.

Photo by Sangharsh Lohakare on Unsplash ABSTRACT The public should debate the ethical and social challenges arising from heritable human genome editing (HHGE). The notorious case involving He Jiankui may have led to the disfavor of gene editing and a precautionary approach. While the de facto global moratorium on HHGE is clearly justified considering our current inability to implement it safely and effectively, the difficult ethical considerations should be addressed prior to the ability to initiate widespread HHGE. This piece argues that prospective patients and other members of society beyond the scientific community must be included in the conversation. It emphasizes the potential role of those not directly participating in HHGE science, calling the broader academic community not simply to wait for scientists’ results and only afterward react. Pointing to key historical examples, I contend that scientific progress is intrinsically linked with the surrounding societal discussion and that it is not only scientists who can influence where the HHGE story ends. INTRODUCTION l. Rogue Scientists Chinese biophysicist He Jiankui announced the world’s first genetically modified babies in 2018. Naturally, the treatment aroused the attention of the world’s media, which focused on He’s reckless actions. Indeed, in setting up and carrying out the procedure in question, he flouted norms of good scientific practice on a range of levels—errors paid with time in prison. Since the He controversy, few scientists have aggressively approached heritable human genome editing (HHGE) and challenged the current research norms. The most outspoken exception is the Russian molecular biologist Denis Rebrikov of the Pirogov Russian National Research Medical University. He publicly declared his intention to apply clustered regularly interspaced short palindromic repeats (CRISPR) to embryos to help couples avoid passing serious medical conditions to their children. However, Rebrikov met fierce opposition both inside and beyond Russia and, with leading CRISPR scientists and bioethicists abroad describing him as a “cowboy” who had “weak data” and was trying to “grab some attention.”[1] So far, Rebrikov’s plans have failed to come to fruition. Although there are 126 entries listed in a registry of HHGE research recently created by the World Health Organization (WHO),[2],[3] it seems that clinical HHGE has been paused for the time being. ll. Steering the Conversation A section of the scientific community has been trying to steer the ethical debate on HHGE away from the actions of rogue scientists and back to an issue that is central to the matter—the interests of patients. The majority would agree that the most compelling potential application of germline genome editing is for the prevention of devastating genetic conditions, for example, when both parents carry Huntington’s disease, for which “genome editing offers the only prospect of bearing a healthy, genetically related child.”[4] Despite such justification for scientists to continue pursuing research in the area, there has been a notable reticence in the wider academic community regarding making the ethical case for HHGE and clarifying in which medical situations such a technique might be reasonably applied. Even among those who recognize that the HHGE cases' controversies should not be a reason for panic over designer babies, some believe that starting the ethical debate is premature. A key part of the argument is that the current technological and scientific knowledge available is far from ready to deliver on treatments. A similar stance preventing debate in the wider society is that “difficult questions” about cost, accessibility, and social justice remain.[5] Whether intended or not, the implication is that the position of wider society in the HHGE story should be a reactive one, namely waiting to see what the scientists throw at them and then dealing with it. I argue that there is not only an immediate need for broader academic and societal input on the ethical and social aspects of the HHGE debate but that there is a deep symbiosis between scientific progress and its surroundings, whereby science both shapes and is shaped by the societal environment in which it takes place. The WHO published a position paper, recommendations, and a framework for governance. The framework for governance describes global standards for the governance and oversight of HHGE.[6] The position paper emphasized the importance of global and inclusive dialogue,[7] and many other boards have also called for broad public engagement.[8] It is imperative that WHO’s governance framework meets everyone’s needs. After all, as with any medical treatment, it is not the scientist who developed the treatment or the doctor who delivers it that is most important– that honor falls to the patient. In the case of HHGE, the beneficiaries include those members of society who hope to reproduce. Yet HHGE has the potential to impact society. We all should have an opportunity to be a part of world-changing decisions that lead to the creation are made and feel a responsibility to participate. lll. Shutting Down the Academic Debate At the 30th Annual Conference of the Japanese Association for Bioethics, which took place in late 2018 after He’s experiment, the discussion about HHGE was shut down quickly. Notwithstanding the understandable issues raised with He’s case, one participant after another stood up to voice support for an outright and complete ban on the use of CRISPR.[9] The ban was based on the grounds that editing the human genome would result in a cascade of unforeseen and irreversible consequences for future generations. One participant forcefully argued that “the deoxyribose nucleic acid (DNA) rubicon should never be crossed for above all, it was deeply immoral to do so when there was no way of obtaining the consent of those who would actually stand affected—our descendants.”[10] Another saw it as putting humanity on a slippery slope toward enhancements, and some feared the catastrophic mistakes that might result from their use.[11] While the above event provides just one snapshot of the debate that was taking place around the world at the time, it captures the strong reservations in the scientific community. It is a common view, not only in Japan, that the human genome is something sacred, a relic handed down from generations, that we ought to treasure and preserve. In support of such a view, religious and other more pragmatic reasons are offered. For example, some may fear the disasters that might befall us if we choose to intervene in the process through which we pass our genetic code from one generation to another. Such arguments are certainly still at the heart of the ethical debate, but the foundations upon which they are built are by no means universally accepted. Stanford University bioethicist Henry Greely writes, “the human germline genome” does not exist; instead, each of us has a unique genome.[12] Greely argues that HHGE is no different from the changes our genomes have undergone through numerous medical interventions. For example, synthetic insulin has increased the number of people with DNA variations that lead to diabetes. Those with this condition would have died as a child in the past. However, now they live long enough to be able to reproduce. Similarly, the transition from hunting to farming centuries ago resulted in a greater number of copies in our gene pool of starch-digesting genes. Yet Greely suggested that, practically, HHGE is “not very useful in the near- to midterm” (by which he means “the next several decades”)[13] “mainly because other technologies can attain almost all the important hoped-for benefits of [HHGE], often with lower risk,” citing embryo selection and somatic gene editing as two alternative options. Greely argued that applying HHGE for enhancement beyond disease prevention and is currently not a realistic option because we lack the necessary knowledge. In Greely’s opinion, “how worried should we be [about HHGE]…? A bit, but not very and not about much.”[14] Greely’s assertions that other scientific debates should take precedence and that the concerns are not ripe for debate yet are concerning. lV. Why Shutting Down the Debate Might Not be a Good Idea First, the timeframe described by Greely seems somewhat out of line with that described by leading scientists. As far back as 2018, at the same Summit where He made his revelations, George Q. Daley stressed that HHGE is scientifically feasible here and that the ethical considerations can no longer be put off: “…a number of groups have applied gene editing now to human embryos in the context of in vitro fertilization and attempting to determine variations of a protocol that would enhance the fidelity and reduce mosaicism. I think there has been an emerging consensus that the off-target problem is manageable, and in some cases even infinitesimal. There are some interesting proofs of principles, like diseases such as beta-thalassemia that could potentially be approached with this strategy.”[15] It would also be possible to challenge Greely on various other aspects. One of which would be the number of cases to which HHGE would be relevant and the kinds of moral allowances that might be made, and each case concludes that more urgency is required in the ethical debate. Greely suggests that most people can use preimplantation genetic testing (PGD), which is the embryo selection process, and that perhaps HHGE could apply to couples where both have the same autosomal recessive gene.[16] Greely rules out considering HHGE in cases where PGD is applicable. Greely concedes PGD does not already represent the answer on this topic, as it often fails to provide couples with enough healthy embryos to transfer. As a resolution to this issue, he points to the creation of eggs using induced pluripotent stem cell (iPSC) techniques, whereby eggs can potentially be created from other cells.[17] However, given the extremely limited success of iPSCs in the clinical arena to date, in vitro gametogenesis is a highly speculative solution. Certainly, the progress of iPSC research is not such a safe bet that placing all our hopes on it at the expense of HHGE techniques is currently justified. (Also, it should be noted that making eggs using the iPSC technique is hardly an ethical problem-free area itself.) In summary, the cases of couples looking to conceive that Greely rules out by pointing to PGD should be kept on the HHGE table, as various other scholars have suggested.[18] Many of us debating HHGE are not scientists, so the best we can do is draw from the information we glean from those more technically capable. As a society, we are not just passive observers of science; we should have influence over decisions that impact society. Indeed, even if the available science is not yet at a place where we should be worried about large-scale ethical and social concerns, the story will continue to unfold in the future. While Greely is happy to see the human race “muddle through” the ethical challenges of scientific breakthroughs, such a position fails to recognize that society at large is far from powerless. V. Society Influencing Scientific Progress There are some notable examples of society’s impact on scientific progress. For example, political policies led to the development of nuclear technology for war and strategic deterrence, despite societal objections seen through demonstrations of people protesting using the slogan “no nukes.” Furthermore, the Bush administration drastically limited the use of embryonic stem cells in the 2000s due to a strong religious and cultural influence on policy.[19] Societal debate potentially serves as a powerful factor in guiding science. Where societal acceptance is ambiguous, science tends to operate on its own. But where science would impact life’s fundamental issues like war, how embryos should be valued, or the end of life, society should weigh in and influence the role of science. Societal views on the current global moratorium on HHGE could lead to a ban, as has been advocated.[20] On the other hand, societal views that value HHGE as a way to expand reproductive autonomy may justify permitting its use. Opening an ethics debate about it would enable scientists to pursue technologies that society deems justifiable as well as set limits for where they should stop. Making this process more difficult, the He affair has clearly colored public discourse on HHGE in a way that inhibits debate. In Japan, a sequence of questionnaires in 2016, 2018, and 2019 showed that the widely publicized HHGE scandal led to a significant decline in the acceptance of genome editing technology in general, particularly for human reproduction. Specifically, the surveys revealed a stark rise in disapproval of the technology’s use on fertilized human eggs—from 12 percent in 2018 to 29 percent in 2019.[21] The three scientists that conducted these surveys suggested that “the news of the twin babies in China had a substantial influence on the Japanese public,” damaging the reputation of HHGE.[22] It seems likely that the public distaste for HHGE was prompted by He’s research rather than considerations about the scientific potential of HHGE The change in public opinion may also make politicians and scientists more hesitant when it comes to taking the lead in the HHGE debate. Ultimately, this can restrict the public discussion of the central ethical challenges of the technology and hinder efforts to determine whether there is a responsible path forward other than an outright ban. Stressing the importance of the issue again to potential patients and failing to engage further with the HHGE debate is surely not something society should allow. While there are many important ongoing debates about genetics, like biohacking and DIY hobbyists, HHGE deserves attention as well. In fact, attention to the ethics of HHGE should help — more awareness of how these tools can be applied and what germline genome editing is will make people more alert to the existing danger and better understand how to mitigate it. Perhaps more importantly, a clear message from society to researchers about what objectives are reasonable to pursue regarding the HHGE technologies will facilitate good science. Having a publicly determined criterion would allow scientists to not live in fear that they might be blacklisted for seeking progress in grey areas and instead confidently chase progress where it is allowed. Vl. What Now? HHGE is here (or will be soon) and brings many ethical and social challenges. However, the challenges should not be left to individual scientists and couples in desperate situations to manage alone. Moving toward how these challenges can be met practically, it is helpful to draw a parallel with the issue of implementing human rights. In the early 21st century, political philosopher Michael Freeman of the University of Essex lamented that implementing human rights had been left to lawyers. Although legal experts were clearly essential in putting together the global human rights framework, Freeman’s concern was that they were not best placed to understand implementing human rights in various contexts. Setting out a broader, interdisciplinary approach, he called for social scientists to tackle these difficult questions, ultimately moving human rights forward around the world. Similarly, in medical technology like HHGE, scientists are crucial to the story, but at the same time, they are not trained to deal with all the accompanying challenges. Bioethicists are also important, clarifying the arguments that society needs to resolve. There is a need for even wider input from across the scholarly community. For instance, as with human rights, international and domestic regulation is required, and clearly, the legal community has a role here. Moreover, as described by Freeman, since all law is political in its creation and has impacts across society, political scientists and sociologists can provide impactful input. CONCLUSION We are in it together, and we have roles to play in the discussion of HHGE. Societal discourse does not always trail the scientific reality, but rather, it can condition the path that science will follow. Given the importance of what is at stake, not only for the potential patients, but for humanity, we should not leave the HHGE debate only to scientists, and we should not leave it until later. - [1] Cohen J. “Embattled Russian scientist sharpens plans to create gene-edited babies,” Science, 21 Oct. 2019. doi:10.1126/science.aaz9337. [2] World Health Organization. “WHO issues new recommendations on human genome editing for the advancement of public health,” News release, 12 July 2021, www.who.int/news/item/12-07-2021-who-issues-new-recommendations-on-human-genome-editing-for-the-advancement-of-public-health. [3] World Health Organization. “Human Genome Editing Registry,” https://www.who.int/groups/expert-advisory-committee-on-developing-global-standards-for-governance-and-oversight-of-human-genome-editing/registry. [4] Daley GQ, Lovell-Badge R, and Steffann J. “After the Storm–A Responsible Path for Genome Editing,” New England Journal of Medicine 380, no. 10 (2019): 897-9. doi:10.1056/NEJMp1900504. [5] Daley GQ, Lovell-Badge R, and Steffann J. “After the Storm–A Responsible Path for Genome Editing,” New England Journal of Medicine 380, no. 10 (2019): 897-9. doi:10.1056/NEJMp1900504 [6] World Health Organization. “WHO issues new recommendations on human genome editing for the advancement of public health,” News Release, July 12, 2021, www.who.int/news/item/12-07-2021-who-issues-new-recommendations-on-human-genome-editing-for-the-advancement-of-public-health. [7] WHO 2021. Human Genome Editing: Position Paper, WHO Expert Advisory Committee on Developing Global Standards for Governance and Oversight of Human Genome Editing. [8] Daley GQ, Lovell-Badge R, and Steffann J. “After the Storm–A Responsible Path for Genome Editing,” New England Journal of Medicine 380, no. 10 (2019): 897-9. doi:10.1056/NEJMp1900504. [9] 30th Annual Conference of the Japanese Association for Bioethics, 8-9 Dec. 2018, Kyoto Prefectural University, Kyoto. [10] 30th Annual Conference of the Japanese Association for Bioethics, 8-9 Dec. 2018, Kyoto Prefectural University, Kyoto. [11] 30th Annual Conference of the Japanese Association for Bioethics, 8-9 Dec. 2018, Kyoto Prefectural University, Kyoto. [12] Greely HT. “Why the Panic Over ‘Designer Babies’ Is the Wrong Worry,” LeapsMag, 30 Oct. 2017, leapsmag.com/much-ado-about-nothing-much-crispr-for-human-embryo-editing; Greely HT. “CRISPR’d babies: human germline genome editing in the ‘He Jiankui Affair’,” Journal of Law and the Biosciences 2019; 6(1): 111–83. doi: 10.1093/jlb/lsz010; Greely HT. CRISPR People: The Science and Ethics of Editing Humans (Massachusetts: Massachusetts Institute of Technology Press, 2021). [13] Greely HT. “Why the Panic Over ‘Designer Babies’ Is the Wrong Worry,” LeapsMag, 30 Oct. 2017, leapsmag.com/much-ado-about-nothing-much-crispr-for-human-embryo-editing. [14] Greely HT. “Why the Panic Over ‘Designer Babies’ Is the Wrong Worry,” LeapsMag, 30 Oct. 2017, leapsmag.com/much-ado-about-nothing-much-crispr-for-human-embryo-editing. [15] Daley, G. (n.d.). Genome-editing-pathways to Translation. Transcript of the Human-Genome Editing Summit 2018 Hong Kong. Retrieved March 17, 2022, from https://diyhpl.us/wiki/transcripts/human-genome-editing-summit/2018-hong-kong/george-daley-genome-editing-pathways-to-translation/ [16] Greely HT. “CRISPR’d babies: human germline genome editing in the ‘He Jiankui affair’,” Journal of Law and the Biosciences 2019: 6(1): 111–83. doi:10.1093/jlb/lsz010. [17] Greely HT. CRISPR People: The Science and Ethics of Editing Humans (Massachusetts: Massachusetts Institute of Technology Press, 2021). [18] Rasnich R. “Germline genome editing versus preimplantation genetic diagnosis: Is there a case in favour of germline interventions?.” Bioethics 2020; 34(1): 60–9. [19] Murugan, Varnee. “Embryonic stem cell research: a decade of debate from Bush to Obama.” The Yale journal of biology and medicine vol. 82,3 (2009): 101-3. [20] Lander E, Baylis F, Zhang F, et al. “Adopt a moratorium on heritable genome editing,” Nature 2019; 567(7747): 165–8. pmid:30867611. [21] Watanabe D, Sato Y, Tsuda M, and Ohsawa R. Increased awareness and decreased acceptance of genome-editing technology: The impact of the Chinese twin babies. PLoS ONE 2000; 15(1): 1-13. doi:10.1371/journal.pone.0238128. [22] Watanabe D, Sato Y, Tsuda M, and Ohsawa R. Increased awareness and decreased acceptance of genome-editing technology: The impact of the Chinese twin babies. PLoS ONE 2000; 15(1): 1-13. doi:10.1371/journal.pone.0238128.

Introduction In December 2010, Nespresso, the world’s leading brand of premium-portioned coffee, opened a flagship “boutique” in Sydney’s Pitt Street Mall. This was Nespresso’s fifth boutique opening of 2010, after Brussels, Miami, Soho, and Munich. The Sydney debut coincided with the mall’s upmarket redevelopment, which explains Nespresso’s arrival in the city: strategic geographic expansion is key to the brand’s growth. Rather than panoramic ubiquity, a retail option favoured by brands like McDonalds, KFC and Starbucks, Nespresso opts for iconic, prestigious locations. This strategy has been highly successful: since 2000 Nespresso has recorded year-on-year per annum growth of 30 per cent. This has been achieved, moreover, despite a global financial downturn and an international coffee market replete with brand variety. In turn, Nespresso marks an evolution in the coffee market over the last decade. The Nespresso Story Founded in 1986, Nespresso is the fasting growing brand in the Nestlé Group. Its headquarters are in Lausanne, Switzerland, with over 7,000 employees worldwide. In 2012, Nespresso had 270 boutiques in 50 countries. The brand’s growth strategy involves three main components: premium coffee capsules, “mated” with specially designed machines, and accompanied by exceptional customer service through the Nespresso Club. Each component requires some explanation. Nespresso offers 16 varieties of Grand Crus coffee: 7 espresso blends, 3 pure origin espressos, 3 lungos (for larger cups), and 3 decaffeinated coffees. Each 5.5 grams of portioned coffee is cased in a hermetically sealed aluminium capsule, or pod, designed to preserve the complex, volatile aromas (between 800 and 900 per pod), and prevent oxidation. These capsules are designed to be used exclusively with Nespresso-branded machines, which are equipped with a patented high-pressure extraction system designed for optimum release of the coffee. These machines, of which there are 28 models, are developed with 6 machine partners, and Antoine Cahen, from Ateliers du Nord in Lausanne, designs most of them. For its consumers, members of the Nespresso Club, the capsules and machines guarantee perfect espresso coffee every time, within seconds and with minimum effort—what Nespresso calls the “ultimate coffee experience.” The Nespresso Club promotes this experience as an everyday luxury, whereby café-quality coffee can be enjoyed in the privacy and comfort of Club members’ homes. This domestic focus is a relatively recent turn in its history. Nestlé patented some of its pod technology in 1976; the compatible machines, initially made in Switzerland by Turmix, were developed a decade later. Nespresso S. A. was set up as a subsidiary unit within the Nestlé Group with a view to target the office and fine restaurant sector. It was first test-marketed in Japan in 1986, and rolled out the same year in Switzerland, France and Italy. However, by 1988, low sales prompted Nespresso’s newly appointed CEO, Jean-Paul Gillard, to rethink the brand’s focus. Gillard subsequently repositioned Nespresso’s target market away from the commercial sector towards high-income households and individuals, and introduced a mail-order distribution system; these elements became the hallmarks of the Nespresso Club (Markides 55). The Nespresso Club was designed to give members who had purchased Nespresso machines 24-hour customer service, by mail, phone, fax, and email. By the end of 1997 there were some 250,000 Club members worldwide. The boom in domestic, user-friendly espresso machines from the early 1990s helped Nespresso’s growth in this period. The cumulative efforts by the main manufacturers—Krups, Bosch, Braun, Saeco and DeLonghi—lowered the machines’ average price to around US $100 (Purpura, “Espresso” 88; Purpura, “New” 116). This paralleled consumers’ growing sophistication, as they became increasingly familiar with café-quality espresso, cappuccino and latté—for reasons to be detailed below. Nespresso was primed to exploit this cultural shift in the market and forge a charismatic point of difference: an aspirational, luxury option within an increasingly accessible and familiar field. Between 2006 and 2008, Nespresso sales more than doubled, prompting a second production factory to supplement the original plant in Avenches (Simonian). In 2008, Nespresso grew 20 times faster than the global coffee market (Reguly B1). As Nespresso sales exceeded $1.3 billion AU in 2009, with 4.8 billion capsules shipped out annually and 5 million Club members worldwide, it became Nestlé’s fastest growing division (Canning 28). According to Nespresso’s Oceania market director, Renaud Tinel, the brand now represents 8 per cent of the total coffee market; of Nespresso specifically, he reports that 10,000 cups (using one capsule per cup) were consumed worldwide each minute in 2009, and that increased to 12,300 cups per minute in 2010 (O’Brien 16). Given such growth in such a brief period, the atypical dynamic between the boutique, the Club and the Nespresso brand warrants closer consideration. Nespresso opened its first boutique in Paris in 2000, on the Avenue des Champs-Élysées. It was a symbolic choice and signalled the brand’s preference for glamorous precincts in cosmopolitan cities. This has become the design template for all Nespresso boutiques, what the company calls “brand embassies” in its press releases. More like art gallery-style emporiums than retail spaces, these boutiques perform three main functions: they showcase Nespresso coffees, machines and accessories (all elegantly displayed); they enable Club members to stock up on capsules; and they offer excellent customer service, which invariably equates to detailed production information. The brand’s revenue model reflects the boutique’s role in the broader business strategy: 50 per cent of Nespresso’s business is generated online, 30 per cent through the boutiques, and 20 per cent through call centres. Whatever floor space these boutiques dedicate to coffee consumption is—compared to the emphasis on exhibition and ambience—minimal and marginal. In turn, this tightly monitored, self-focused model inverts the conventional function of most commercial coffee sites. For several hundred years, the café has fostered a convivial atmosphere, served consumers’ social inclinations, and overwhelmingly encouraged diverse, eclectic clientele. The Nespresso boutique is the antithesis to this, and instead actively limits interaction: the Club “community” does not meet as a community, and is united only in atomised allegiance to the Nespresso brand. In this regard, Nespresso stands in stark contrast to another coffee brand that has been highly successful in recent years—Starbucks. Starbucks famously recreates the aesthetics, rhetoric and atmosphere of the café as a “third place”—a term popularised by urban sociologist Ray Oldenburg to describe non-work, non-domestic spaces where patrons converge for respite or recreation. These liminal spaces (cafés, parks, hair salons, book stores and such locations) might be private, commercial sites, yet they provide opportunities for chance encounters, even therapeutic interactions. In this way, they aid sociability and civic life (Kleinman 193). Long before the term “third place” was coined, coffee houses were deemed exemplars of egalitarian social space. As Rudolf P. Gaudio notes, the early coffee houses of Western Europe, in Oxford and London in the mid-1600s, “were characterized as places where commoners and aristocrats could meet and socialize without regard to rank” (670). From this sanguine perspective, they both informed and animated the modern public sphere. That is, and following Habermas, as a place where a mixed cohort of individuals could meet and discuss matters of public importance, and where politics intersected society, the eighteenth-century British coffee house both typified and strengthened the public sphere (Karababa and Ger 746). Moreover, and even from their early Ottoman origins (Karababa and Ger), there has been an historical correlation between the coffee house and the cosmopolitan, with the latter at least partly defined in terms of demographic breadth (Luckins). Ironically, and insofar as Nespresso appeals to coffee-literate consumers, the brand owes much to Starbucks. In the two decades preceding Nespresso’s arrival, Starbucks played a significant role in refining coffee literacy around the world, gauging mass-market trends, and stirring consumer consciousness. For Nespresso, this constituted major preparatory phenomena, as its strategy (and success) since the early 2000s presupposed the coffee market that Starbucks had helped to create. According to Nespresso’s chief executive Richard Giradot, central to Nespresso’s expansion is a focus on particular cities and their coffee culture (Canning 28). In turn, it pays to take stock of how such cities developed a coffee culture amenable to Nespresso—and therein lays the brand’s debt to Starbucks. Until the last few years, and before celebrity ambassador George Clooney was enlisted in 2005, Nespresso’s marketing was driven primarily by Club members’ recommendations. At the same time, though, Nespresso insisted that Club members were coffee connoisseurs, whose knowledge and enjoyment of coffee exceeded conventional coffee offerings. In 2000, Henk Kwakman, one of Nestlé’s Coffee Specialists, explained the need for portioned coffee in terms of guaranteed perfection, one that demanding consumers would expect. “In general”, he reasoned, “people who really like espresso coffee are very much more quality driven. When you consider such an intense taste experience, the quality is very important. If the espresso is slightly off quality, the connoisseur notices this immediately” (quoted in Butler 50). What matters here is how this corps of connoisseurs grew to a scale big enough to sustain and strengthen the Nespresso system, in the absence of a robust marketing or educative drive by Nespresso (until very recently). Put simply, the brand’s ascent was aided by Starbucks, specifically by the latter’s success in changing the mainstream coffee market during the 1990s. In establishing such a strong transnational presence, Starbucks challenged smaller, competing brands to define themselves with more clarity and conviction. Indeed, working with data that identified just 200 freestanding coffee houses in the US prior to 1990 compared to 14,000 in 2003, Kjeldgaard and Ostberg go so far as to state that: “Put bluntly, in the US there was no local coffee consumptionscape prior to Starbucks” (Kjeldgaard and Ostberg 176). Starbucks effectively redefined the coffee world for mainstream consumers in ways that were directly beneficial for Nespresso. Starbucks: Coffee as Ambience, Experience, and Cultural Capital While visitors to Nespresso boutiques can sample the coffee, with highly trained baristas and staff on site to explain the Nespresso system, in the main there are few concessions to the conventional café experience. Primarily, these boutiques function as material spaces for existing Club members to stock up on capsules, and therefore they complement the Nespresso system with a suitably streamlined space: efficient, stylish and conspicuously upmarket. Outside at least one Sydney boutique for instance (Bondi Junction, in the fashionable eastern suburbs), visitors enter through a club-style cordon, something usually associated with exclusive bars or hotels. This demarcates the boutique from neighbouring coffee chains, and signals Nespresso’s claim to more privileged patrons. This strategy though, the cultivation of a particular customer through aesthetic design and subtle flattery, is not unique. For decades, Starbucks also contrived a “special” coffee experience. Moreover, while the Starbucks model strikes a very different sensorial chord to that of Nespresso (in terms of décor, target consumer and so on) it effectively groomed and prepped everyday coffee drinkers to a level of relative self-sufficiency and expertise—and therein is the link between Starbucks’s mass-marketed approach and Nespresso’s timely arrival. Starbucks opened its first store in 1971, in Seattle. Three partners founded it: Jerry Baldwin and Zev Siegl, both teachers, and Gordon Bowker, a writer. In 1982, as they opened their sixth Seattle store, they were joined by Howard Schultz. Schultz’s trip to Italy the following year led to an entrepreneurial epiphany to which he now attributes Starbucks’s success. Inspired by how cafés in Italy, particularly the espresso bars in Milan, were vibrant social hubs, Schultz returned to the US with a newfound sensitivity to ambience and attitude. In 1987, Schultz bought Starbucks outright and stated his business philosophy thus: “We aren’t in the coffee business, serving people. We are in the people business, serving coffee” (quoted in Ruzich 432). This was articulated most clearly in how Schultz structured Starbucks as the ultimate “third place”, a welcoming amalgam of aromas, music, furniture, textures, literature and free WiFi. This transformed the café experience twofold. First, sensory overload masked the dull homogeny of a global chain with an air of warm, comforting domesticity—an inviting, everyday “home away from home.” To this end, in 1994, Schultz enlisted interior design “mastermind” Wright Massey; with his team of 45 designers, Massey created the chain’s decor blueprint, an “oasis for contemplation” (quoted in Scerri 60). At the same time though, and second, Starbucks promoted a revisionist, airbrushed version of how the coffee was produced. Patrons could see and smell the freshly roasted beans, and read about their places of origin in the free pamphlets. In this way, Starbucks merged the exotic and the cosmopolitan. The global supply chain underwent an image makeover, helped by a “new” vocabulary that familiarised its coffee drinkers with the diversity and complexity of coffee, and such terms as aroma, acidity, body and flavour. This strategy had a decisive impact on the coffee market, first in the US and then elsewhere: Starbucks oversaw a significant expansion in coffee consumption, both quantitatively and qualitatively. In the decades following the Second World War, coffee consumption in the US reached a plateau. Moreover, as Steven Topik points out, the rise of this type of coffee connoisseurship actually coincided with declining per capita consumption of coffee in the US—so the social status attributed to specialised knowledge of coffee “saved” the market: “Coffee’s rise as a sign of distinction and connoisseurship meant its appeal was no longer just its photoactive role as a stimulant nor the democratic sociability of the coffee shop” (Topik 100). Starbucks’s singular triumph was to not only convert non-coffee drinkers, but also train them to a level of relative sophistication. The average “cup o’ Joe” thus gave way to the latte, cappuccino, macchiato and more, and a world of coffee hitherto beyond (perhaps above) the average American consumer became both regular and routine. By 2003, Starbucks’s revenue was US $4.1 billion, and by 2012 there were almost 20,000 stores in 58 countries. As an idealised “third place,” Starbucks functioned as a welcoming haven that flattened out and muted the realities of global trade. The variety of beans on offer (Arabica, Latin American, speciality single origin and so on) bespoke a generous and bountiful modernity; while brochures schooled patrons in the nuances of terroir, an appreciation for origin and distinctiveness that encoded cultural capital. This positioned Starbucks within a happy narrative of the coffee economy, and drew patrons into this story by flattering their consumer choices. Against the generic sameness of supermarket options, Starbucks promised distinction, in Pierre Bourdieu’s sense of the term, and diversity in its coffee offerings. For Greg Dickinson, the Starbucks experience—the scent of the beans, the sound of the grinders, the taste of the coffees—negated the abstractions of postmodern, global trade: by sensory seduction, patrons connected with something real, authentic and material. At the same time, Starbucks professed commitment to the “triple bottom line” (Savitz), the corporate mantra that has morphed into virtual orthodoxy over the last fifteen years. This was hardly surprising; companies that trade in food staples typically grown in developing regions (coffee, tea, sugar, and coffee) felt the “political-aesthetic problematization of food” (Sassatelli and Davolio). This saw increasingly cognisant consumers trying to reconcile the pleasures of consumption with environmental and human responsibilities. The “triple bottom line” approach, which ostensibly promotes best business practice for people, profits and the planet, was folded into Starbucks’s marketing. The company heavily promoted its range of civic engagement, such as donations to nurses’ associations, literacy programs, clean water programs, and fair dealings with its coffee growers in developing societies (Simon). This bode well for its target market. As Constance M. Ruch has argued, Starbucks sought the burgeoning and lucrative “bobo” class, a term Ruch borrows from David Brooks. A portmanteau of “bourgeois bohemians,” “bobo” describes the educated elite that seeks the ambience and experience of a counter-cultural aesthetic, but without the political commitment. Until the last few years, it seemed Starbucks had successfully grafted this cultural zeitgeist onto its “third place.” Ironically, the scale and scope of the brand’s success has meant that Starbucks’s claim to an ethical agenda draws frequent and often fierce attack. As a global behemoth, Starbucks evolved into an iconic symbol of advanced consumer culture. For those critical of how such brands overwhelm smaller, more local competition, the brand is now synonymous for insidious, unstoppable retail spread. This in turn renders Starbucks vulnerable to protests that, despite its gestures towards sustainability (human and environmental), and by virtue of its size, ubiquity and ultimately conservative philosophy, it has lost whatever cachet or charm it supposedly once had. As Bryant Simon argues, in co-opting the language of ethical practice within an ultimately corporatist context, Starbucks only ever appealed to a modest form of altruism; not just in terms of the funds committed to worthy causes, but also to move thorny issues to “the most non-contentious middle-ground,” lest conservative customers felt alienated (Simon 162). Yet, having flagged itself as an ethical brand, Starbucks became an even bigger target for anti-corporatist sentiment, and the charge that, as a multinational giant, it remained complicit in (and one of the biggest benefactors of) a starkly inequitable and asymmetric global trade. It remains a major presence in the world coffee market, and arguably the most famous of the coffee chains. Over the last decade though, the speed and intensity with which Nespresso has grown, coupled with its atypical approach to consumer engagement, suggests that, in terms of brand equity, it now offers a more compelling point of difference than Starbucks. Brand “Me” Insofar as the Nespresso system depends on a consumer market versed in the intricacies of quality coffee, Starbucks can be at least partly credited for nurturing a more refined palate amongst everyday coffee drinkers. Yet while Starbucks courted the “average” consumer in its quest for market control, saturating the suburban landscape with thousands of virtually indistinguishable stores, Nespresso marks a very different sensibility. Put simply, Nespresso inverts the logic of a coffee house as a “third place,” and patrons are drawn not to socialise and relax but to pursue their own highly individualised interests. The difference with Starbucks could not be starker. One visitor to the Bloomingdale boutique (in New York’s fashionable Soho district) described it as having “the feel of Switzerland rather than Seattle. Instead of velvet sofas and comfy music, it has hard surfaces, bright colours and European hostesses” (Gapper 9). By creating a system that narrows the gap between production and consumption, to the point where Nespresso boutiques advertise the coffee brand but do not promote on-site coffee drinking, the boutiques are blithely indifferent to the historical, romanticised image of the coffee house as a meeting place. The result is a coffee experience that exploits the sophistication and vanity of aspirational consumers, but ignores the socialising scaffold by which coffee houses historically and perhaps naively made some claim to community building. If anything, Nespresso restricts patrons’ contemplative field: they consider only their relationships to the brand. In turn, Nespresso offers the ultimate expression of contemporary consumer capitalism, a hyper-individual experience for a hyper-modern age. By developing a global brand that is both luxurious and niche, Nespresso became “the Louis Vuitton of coffee” (Betts 14). Where Starbucks pursued retail ubiquity, Nespresso targets affluent, upmarket cities. As chief executive Richard Giradot put it, with no hint of embarrassment or apology: “If you take China, for example, we are not speaking about China, we are speaking about Shanghai, Hong Kong, Beijing because you will not sell our concept in the middle of nowhere in China” (quoted in Canning 28). For this reason, while Europe accounts for 90 per cent of Nespresso sales (Betts 15), its forays into the Americas, Asia and Australasia invariably spotlights cities that are already iconic or emerging economic hubs. The first boutique in Latin America, for instance, was opened in Jardins, a wealthy suburb in Sao Paulo, Brazil. In Nespresso, Nestlé has popularised a coffee experience neatly suited to contemporary consumer trends: Club members inhabit a branded world as hermetically sealed as the aluminium pods they purchase and consume. Besides the Club’s phone, fax and online distribution channels, pods can only be bought at the boutiques, which minimise even the potential for serendipitous mingling. The baristas are there primarily for product demonstrations, whilst highly trained staff recite the machines’ strengths (be they in design or utility), or information about the actual coffees. For Club members, the boutique service is merely the human extension of Nespresso’s online presence, whereby product information becomes increasingly tailored to increasingly individualised tastes. In the boutique, this emphasis on the individual is sold in terms of elegance, expedience and privilege. Nespresso boasts that over 70 per cent of its workforce is “customer facing,” sharing their passion and knowledge with Club members. Having already received and processed the product information (through the website, boutique staff, and promotional brochures), Club members need not do anything more than purchase their pods. In some of the more recently opened boutiques, such as in Paris-Madeleine, there is even an Exclusive Room where only Club members may enter—curious tourists (or potential members) are kept out. Club members though can select their preferred Grands Crus and checkout automatically, thanks to RFID (radio frequency identification) technology inserted in the capsule sleeves. So, where Starbucks exudes an inclusive, hearth-like hospitality, the Nespresso Club appears more like a pampered clique, albeit a growing one. As described in the Financial Times, “combine the reception desk of a designer hotel with an expensive fashion display and you get some idea what a Nespresso ‘coffee boutique’ is like” (Wiggins and Simonian 10). Conclusion Instead of sociability, Nespresso puts a premium on exclusivity and the knowledge gained through that exclusive experience. The more Club members know about the coffee, the faster and more individualised (and “therefore” better) the transaction they have with the Nespresso brand. This in turn confirms Zygmunt Bauman’s contention that, in a consumer society, being free to choose requires competence: “Freedom to choose does not mean that all choices are right—there are good and bad choices, better and worse choices. The kind of choice eventually made is the evidence of competence or its lack” (Bauman 43-44). Consumption here becomes an endless process of self-fashioning through commodities; a process Eva Illouz considers “all the more strenuous when the market recruits the consumer through the sysiphian exercise of his/her freedom to choose who he/she is” (Illouz 392). In a status-based setting, the more finely graded the differences between commodities (various places of origin, blends, intensities, and so on), the harder the consumer works to stay ahead—which means to be sufficiently informed. Consumers are locked in a game of constant reassurance, to show upward mobility to both themselves and society. For all that, and like Starbucks, Nespresso shows some signs of corporate social responsibility. In 2009, the company announced its “Ecolaboration” initiative, a series of eco-friendly targets for 2013. By then, Nespresso aims to: source 80 per cent of its coffee through Sustainable Quality Programs and Rainforest Alliance Certified farms; triple its capacity to recycle used capsules to 75 per cent; and reduce the overall carbon footprint required to produce each cup of Nespresso by 20 per cent (Nespresso). This information is conveyed through the brand’s website, press releases and brochures. However, since such endeavours are now de rigueur for many brands, it does not register as particularly innovative, progressive or challenging: it is an unexceptional (even expected) part of contemporary mainstream marketing. Indeed, the use of actor George Clooney as Nespresso’s brand ambassador since 2005 shows shrewd appraisal of consumers’ political and cultural sensibilities. As a celebrity who splits his time between Hollywood and Lake Como in Italy, Clooney embodies the glamorous, cosmopolitan lifestyle that Nespresso signifies. 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