February 2020 Bulletin

During the terrible influenza epidemic of 1918, my grandmother was a young girl in India. But not too young to remember the piles of bodies of victims; there were so many daily influenza deaths that it was impossible for city workers, funerary workers and relatives to keep up with cremations. Her father was the Health Officer for the town of Poona under British rule, and while it was his responsibility to stay in town and oversee response to the epidemic, he sent his family away to safety on the high ground of Poona where the epidemic had not yet reached.

My great-grandfather’s brother decided to keep him company, and together the two men occupied a deserted ancient “vada” – a combination of a fort and villa and palace – in town. They were of adventurous and romantic spirit, and had years earlier sought their fortunes in Burma together as young men. So, it was natural for the two brothers to keep watch together and keep each other company in this desolate situation. The vada had a rich and storied history, and was reputed to be haunted. My great-grandfather was troubled nightly by the same vivid dream – a Brahmin priest who exhorted him to dig in a specific place in the courtyard of the vada and claim the treasure he would find there. The priest’s instructions were specific, and included a stern warning that he must dig alone under cover of darkness as he alone had been chosen to receive the treasure. As the city Health Officer, a physician and a man of science, he dismissed the dream, but night after night, the priest returned, ever more insistent. Finally, he confessed the dream to his brother, who encouraged him to dig.

There was a significant problem, however. The courtyard floor was made of stone, and digging by hand was no easy task. Ignoring the priest’s warning, my great-grandfather charged the few men under his command to help him with the arduous work of digging through feet of stone and mud. After half a night’s work, the exhausted workers hit something solid and stopped to rest. They slept in the courtyard, and each awoke at dawn utterly terrified. Each man had had the same dream in the night. A ferocious tiger was standing guard over the area of the dig, barring the workers from finishing their task and threatening them with certain death if they dared to proceed. Each of the workers was terrified enough to leave their tools and flee in the morning. Meanwhile, the man of science had had his own dream that night: The Brahmin priest was furious at him for having disobeyed instructions and again told him to dig quickly and alone.

The next night, legend has it that my great-grandfather completed the dig himself by lamplight with his brother’s help and found a giant earthen vessel several feet deep and several feet across in width. Incredibly, it was filled to the brim with ancient gold coins. Before he could evacuate it, the British authorities – alerted by the terrified workers – stepped in and claimed the treasure for the Crown.

Somewhere, I imagine there was a ghostly Brahmin priest rolling his eyes and swearing.

What lessons can we learn from this? First, if you are contacted in your dreams by a ghost and are bequeathed a treasure, have the good sense to obey instructions to the letter. Second, plagues and pandemics have been with us since the dawn of time, and typically have similar social and political effects.

The coronavirus epidemic sweeping through China is rumored to be having a death toll much higher than the Chinese government is willing to admit. Like the influenza epidemic of the last century, deaths are outpacing civil authorities’ ability to deal with them. We have not advanced that much in the last centuries in terms of stopping the spread of viral epidemics; we still rely on quarantine and travel restrictions as the most effective way of stopping infection. While the virus may be isolated, a vaccine is still months or years away. Our greatest advance is the discovery of antiviral medicines, some of which may be effective in combination, according to recent reports from Thailand stating that high dose Tamiflu (oseltamivir) along with two anti-HIV drugs have been used successfully in coronavirus patients.

The Bubonic Plague, which decimated Europe in centuries past, also had significant sociopolitical effects which may be mirrored today in China. In medieval Europe, previously respected sources of authority (government, royalty and religion) themselves fell victim to the plague, undermining their credibility to the common man. How could leaders styling themselves as infallible and under divine protection fall victim to the Plague, if the Plague was being presented to the public as punishment for individual sins? The public began to wonder, and question, and challenge authority.

The Chinese government is worried that its inadequate and ineffective response to the epidemic will undermine public perception of the government, thereby fomenting civil unrest and possible revolution. The Chinese government already keeps its people in line by policing all communications and encouraging people to report against each other for credit. Only something as dire as an uncontrollable and deadly epidemic could disrupt such a draconian authority as desperation leads the people to speak out.

According to a recent CNN report, Wuhan ophthalmologist Li Wenliang had alerted his medical school alumni WeChat group in December that patients from a local seafood market had been quarantined in his hospital with coronavirus illness. He urged them to privately warn their families and be on the alert for additional patients. Hours later, screenshots of his post had gone viral, but without his name redacted. As he predicted, he was quickly punished, along with several other doctors who had done the same thing. But this was not like shouting fire in a crowded theater. The community had lived through SARS, and the government should have had a disaster plan and stores of equipment for emergency workers. Quarantine plans should have been in place. The municipal government health commission released a statement in response to Li’s post, acknowledging that patients from the seafood market had fallen ill with an unknown pneumonia, but that “any organizations or individuals are not allowed to release treatment information to the public without authorization.” The next day, the Wuhan authorities finally were forced to announce the outbreak and alerted the World Health Organization (WHO). Li was punished and forced to apologize Jan. 3 for “spreading rumors online and severely disrupting social order” and was afraid he might be detained. He was allowed to return to work, was exposed to coronavirus and died Feb. 7.

Widespread reports indicate that China is hiding the death toll to save face and avoid social and governmental collapse. Anger is building among the public that swifter public safety measures were not instituted and that government secrecy and desire for control may be harming the public interest.
Currently, Chinese social media is awash in images of government officials taking face masks intended for healthcare workers for their own use. Medical staff appear to be using makeshift masks and gowns out of garbage bags, and appear exhausted and overwhelmed. Donations pouring into hospitals from Chinese citizens are being confiscated by the government. Photos also show government officials wearing N95 respirator masks while doctors are only wearing standard surgical masks. There is a mask shortage of all kinds in China.

What can we learn from all this? Our government is thankfully different from that of China, but the same problems can occur anywhere. Desperation and the natural will to protect life and loved ones leads to competition over scarce resources, and the result can be rioting, violence and deaths.

1. Physicians need to speak up and lead, no matter what the cost. Our oath comes first.
2. Silencing physicians is never a good idea, as seen in China.
3. Involving physicians to help lead a government response may be key to good outcomes.
4. We are never safe. There always will be a new virus and a new threat. But for quarantine and surveillance, the same epidemic could be raging in our country.
5. We all need a disaster plan, and a stockpile of protective equipment and resources especially for medical personnel dealing with victims.
6. We all need a personal disaster plan as citizens – including a pledge not to put others at risk needlessly, i.e., “Stay home if you have the flu. Get a flu shot. Participate in herd immunity if it is reasonable to do so.” And perhaps keep a respirator mask aside for each family member, the same way we might have a life jacket on a boat, or a fire extinguisher or escape ladder in the house.
7. Transparency will not cause panic when you have a swiftly executed disaster plan; secrecy in the name of saving face will result in great losses and ultimately great disgrace.
8. The tiniest microbe can topple empires. We all must stay vigilant.

 

Author profile
Deval (Reshma) Paranjpe, MD, FACS

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin.