McFodzean Ordation
Delivered on 23 October 2004 by Dr. C.H. Leong, President, Hong Kong Academy of Medicine
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by
Dr C H Leong
President, Hong Kong Academy of Medicine

Mr. President, Ladies & Gentlemen

          It is indeed a singular honour to be invited to deliver the McFadzean oration. It is an honour to me in particular as my early medical related days was spent in McFadzean era, both as a student of medicine and as his house staff. In many aspect he was thus my mentor. No, Alexander James Smith McFadzean did not teach me surgery, in fact surgeons were a bred of doctors he dislike, but he taught me much more, as this oration would unveil.

          My very initial impression of Professor McFadzean was a disarray, to say the least. As a student I was asked by him to close the door of the lecture hall, “from the outside”, I was told. As a young doctor burning with desire to be a surgeon, I was baffled by why during every single Christmas, there were bound to be drawings on the wall of Queen Mary Hospital of the Professor of Medicine crossing swords with the then Professor of surgery.

          Yet as I came to understand this fiery Professor from Scotland more, I start to appreciates the way he dwells into details of patients’ illnesses, the environment surrounding the sickness, the societal impact the illness will bring about before exhibiting his evidence based treatment. I started to respect the way that he would stand by the profession, using all his ability to stand up to the integrity of the profession and the institute he serve. Yet he would never give in to any nonsense.

          It is on these two aspirations of Alec McFadzean that I am using tonight’s oration to pay tribute to.

          Professor McFadzean came to benefit HK as a young man at the age of 34. Prior to this he had serve in the Middle East and Africa in an era of infectious disease – malaria, plague, tuberculosis and small pox. Between then and now many of these deadly infections have either been proclaimed to be eradicated or at least very much controlled. Small pox for example was declared eradicated in December 1979. Plague was at least temporary declared controlled when the last officially certified human case appeared in Kanataka state India in 1966. T.B. was considered a treatable condition since Koch discovered the cause, and Malaria should NOT be fatal any more since quinine was discovered. So convinced that infectious disease were on the way out that a Harvard Public Health Group headed by Christopher Murray forecasted in late 1960 that more than 85% of all death in U.S. by the closed of the 20th century would be due to chronic diseases such as cancer and heart problems. Rightly so, in 1900 nearly 800 Americans out of 100,000 every year died of infectious disease and by 1980 only 36.

          Take another issue, of some 1240 new drugs licenced in the 20 years after 1975, only 13 (1%) were for infectious diseases primarily affecting the tropics and poor countries.

          It comes as no surprise that for some 5 decades priorities for infectious diseases, thus public health, was dwindling. In Hong Kong before SARS struck there were only 60 infectious disease beds for a population of some 7 millions. In the record of the HK medical council’s specialist registry there are only 6 registered as an infection disease specialists. Even amongst our community medicine experts, the majority are specialists in administrative medicine, not in public health.

          It therefore came to no surprise too that the world, and for that matter HK, has not been ready to face any public health outbreak with efficiency.

          Yet there had been warning signs. Plague returned to India in August 1994, and resistant T.B. became an epidemic in Russia in 2000. In 1998, W.H.O. launched the Roll Back Malaria campaign to fund incentive for development of the antimalaria drugs while chloroquine began to lose its effectiveness. Of course, there is the Avian Flu of 1997.

          We have not taken the hint, we had lived in the comfortable ignorance oblivious to the fact that new human pathogensis can emerge and old infectious once thought conquered could resurface with a vengeance.

          In short, in the history of mankind, where there are victims, there will be infections diseases. In becomes obvious therefore that we can look at infectious disease from 3 angles :

          Ÿ As a public health issue where properly organized public health means could prevent or control an epidemic, and where its failure could produce a catastrophy.

          Ÿ As a social issue, where the disease is known, the causative agent is identified, its prevention is well mapped, yet difficulties abound in convincing the society to adapt to it – from the Government to the man on the street, and even the world as a community to work together.

          Ÿ As a melodrama where the injection of politics, the struggle for power, could have blurred proper scientific investigations of the disease and hamper the precious lesions learned from any infectious outbreak that is to no ones’ benefit. As Milton in his “Paradise Loss” said “And out of good still to find means of evil”.

          Let me elaborate.

          Whilst it may sound disheartening and perhaps even pitiful, it was decrease in infectious diseases which brought about the increase in life expectancy of the world not the discovery of curative medicine.

          To wit, data from England, Wales and Sweden have shown that in 1700, the average male lived just 27 to 30 years. By 1971, male life expectancy was 75 years. More than half of that improvement occurred before 1900. In all 86 percent of the increased life expectancy was due to decrease in infectious diseases that occurred prior to the age of antibiotics. In U.K. T.B. death dropped from nearly 4000 per million people to 500 per million between 1838 and 1949 (The year when antibiotics treatment was introduced). Since then, with the advent of anti T.B. treatment in the next 20 years, the death rate only fell to 460 per million.

          What prompt the decrease in infectious disease is of course a matter of considerable academic debate. Yet one cannot ignore nor neglect that the following could well be key issues :- Nutrition, housing, sewage disposal, safe drinking water, epidemics control, swamp drainage, public education, literacy, access to prenatal and maternity care. All and all public health issues.

          A study of the story of plague will give the whole issue away. As known to us now, plague is caused by Yersinia pestis, a gram negative bacillus that live on fleas that parasite on black rats “Ratus ratus”. Transmission to human is either through flea bite producing bubonic plague or in the case of pneumonic plague, from droplets – bacilli coughing out with blood from those infected. We know now too that the bacilli response favourably to tetracycline.

          Plague in HK began in the early summer of 1894 before the antibiotic era. Many speculations surrounded the cause of the disease – from supernatural believe of offending the ancestors to obnoxious gas from the earth. By July of the same year the causative organism was discovered by Kitasato and Yersin, yet what could be done. Hygiene or better public health was perhaps the only actions which ultimately found to be effective. The infection was highest in areas of HK where sanitation appeared to be the worse. The Sanitation Board ordered cleaning the streets in Taipingshan area, house to house search for sick and suspected patients, isolating these victims in 3 hospitals – Kennedy Town Police Hospital, the Glass Work Hospital controlled by the Tung Wah Board and a naval ship in the harbour – the Hygia. This was not without opposition and antagonism of the local population. People took to the streets – not uncommon by today’s standard – chanting unfounded rumours that house search was an excuse for rape and pillage, and immediate removal of body for burial is for westerner to remove body organs to grind up for medicine. The actions, though unpleasant, look effect and the epidemic was finally controlled by 22 August. All in all, there were 2679 cases notified, 2552 died. Public health took centre page.

          Nor was the story different in recent days – In the summer of 1994 following on earthquake in Maharashastra India, plague broke out in a nearly town of Surat, a place suddenly overpopulated by migrant workers for diamond industry where sanitation was the exception rather then the rules.

          Modern medical treatment did little to help to curb the epidemic. In fact there was a general rush for tetracycline which were soon depleted and the Indian FDA was compelled to warehouse caches of the medicine.

          What brought the containment was the declaration of Surat being “plague list” by the then prime minister - where army was dispatched to maintain order and quarantine, to stop exodus to other parts of the country, to burn up all waste, improve sanitation, kill all the rats. Again a public health triumph.

          Like the public medical service in HK during SARS, the Indian Public Medical Services all kept their ground and work closely with private physicians. But unlike the dedication in HK, 80% of the private physicians in India went into panic and fled the city.

          But public health is not the be all and end all for infectious diseases. In some of the worse infectious disease pandemic, social and societal issue takes the front page. Such is the case with HIV/AIDS.
Since the first case of HIV/AIDS was identified in 1981, and since the discovery of the retrovirus, most countries were aware of the mode of spread – through unprotected sex, sharing needles, mother to foetus transmission, accidental transfusion of infected blood. Similarly, most in the developed world would know the best way to prevent getting infected. The discovery of the “cocktail” treatment using protease inhibitors also brought new hopes to the HIV positive in that the treatment protocol taken life long could delay the onset of eruption of the disease – HIV positive but not AIDS affected.

          Yet up to now some 20 years, the number of HIV/AID round the world was in no way curb. Instead the trend is increasing, in particular in Subsahara Africa, in the Indian subcontinent and in S.E. Asia – In China. Why did all these happen when the message is not about being discrete, but about using condoms and not sharing needles and syringes. Today as the figure looms at 45 million, AIDS becomes not just a public health issue, not just a medical issue but a societal and community issue. There are at least – 5 contribution factors.

          Firstly, there is the issue of denial. In the Mainland, for example, HIV/AIDS was not taken on board as a national problem until as late as the early 1990’s. Hitherto, HIV/AIDS was a foreigners’ disease. Much change in attitude has since taken place for the better, hopefully it is never too late.

          Secondly, there is the issue of stigmatization and discrimination. For whilst most people are conscious of the fact that HIV/AIDS cannot and will not be caught under the usually social style of contact, many still frowns on having an HIV/AIDS sharing the same building, walking the same road. It is a matter of proper education on a wide ranging base which could be extremely difficult considering the size of some countries and the remoteness of some isolated villages.

          Thirdly, there is the discrimination between the rich and the poor. Yes protease inhibitors are now available to delay the development of full blown AIDS, yet it has a price tag of over HK$1,000 a month. It became obvious that the treatment is for the very rich.

          The state of affairs in the Subsahara African Continent is a shinning example. In South Africa for example where the total infection rate is around 5 million, less than a few percentage can afford the treatment. Data shows that some 290 million Africans have an average income of less than US $1 per day. Whilst it is well known that the “cocktail treatment” if given at early pregnancy could decrease the incident if not eliminate the chance of mother to foetal spread, such treatment was denied in favour of cost. Whilst it may be understandable that many developing or less developed countries could not afford to provide free “cocktail treatment” for all HIV positive victims, pharmaceutical industries are NOT willing to cut the cost, under the disguise of the need to recover the cost of research and development. It comes as no surprise that whilst the whole world in the issue of AIDS is ONE WORLD, with ONE HOPE, in many countries it is obvious that we are all in one world, but many have no hopes. Ironically it is in the poor countries that AIDS are most extensive.

          The fourth issue is lack of trust, lack of trust in the personal who are supposed to look after them, perhaps through lack of communication skills and ultimately reflecting to lack of confidence of the Government.
The tragedy in 河南 is a vivid example of poverty, ignorance, lack of trust and discrimination. 河南上蔡縣is a very poor village. Farmers reap barely enough from their crops for daily living. Extra spending, even schooling for children, requires other ways of acquiring cash. Selling blood became the natural and easy source of income as blood is a 無本生利的工具. Much of the collected blood were pooled together and after the plasma proteins and other necessary blood elements were removed for other purposes, the left behind was transfused back to the donors – sparking a chain of infection transfer. Yes, through international agencies and the Central Government, drugs are available for most inflicted. Regrettably the issuing of these “good wills”, were never properly explained. Like all medications, some may experience certain side effects albeit minor, such as vomiting at the initial phase. Cynicism prevailed, many refuse to take the medication. A philantropic act had thus turned sour. Worse many look to hiding for fear of discrimination.

          The fifth issue is that of societal priorities. As mentioned early, the initial phase of AIDS in the Mainland was that of denial – it is a foreigner disease – it was so sad. The leadership was never seen then to support the necessity to raise concern to AIDS. Yes, in January 1997, the late minister of Health, the 陳敏章 and myself visited the 地壇hospital and shook hands with a HIV/AIDS patient. There were minimal and only local publicity. The visit of Bill Clinton speaking to 清華university on AIDS and afterwards shook the hands of an HIV patient and advocate raised the profile. Premiere Wan saw the need to visit AIDS inmates and place Wu Yee to take charge of AIDS policy and movement in China. For AIDS, both workers and victims, such was a triumph in politics.

          But not all political move, albeit calculated could end up in triumph as the story of SARS and its aftermath unfolds.

          SARS like a whirlwind swept HK off its feet. Everything came almost to a standstill. The health care profession and health care services were hard hit most. Incidentally we were completely ignorant of the cause, the way the illness spread, how we could protect ourselves and our patients, nor did not know the right form of treatment. It was a fear and frustration seeing a continuous stream of patients being admitted, one by one your working partners fall victims of the disease, not knowing when it is your own turn. But our health care workers braved on. Within weeks the causative Corona Virus was discovered and isolated. Every health care personnel stood firm, there was not a single deserter. Instead some even volunteered to serve the infected wards to substitute or replace their colleagues who were either sick or because of higher risk. We lived with our masks, assumed a faceless status, gave up social life but with one aim in mind – get rid of that despicable infectious disease – regrettable, even as of today, there was no vaccine and no recognizable recommended treatment. It was a story of pure and profound bravery.

          As SARS rages on, and as more data and statistics accumulated, HK’s health care workers took the centrefold. Our detailed and transparent records, our rapid breakthrough in discovering the virus and the detail scientific studies on this new atypical pneumonia which could well be another pandemic, became the envy of the world. Our e SAR for contact tracing, our direction to carry on long term studies of the patients for possible complications either of the disease itself or the treatment has put HK on the map to lead studies on infectious diseases. So far over 50 papers have been published on SARS from HK for us to take the grid position.

          Like other epidemics SARS have brought HK back to realize that infectious diseases are still very important and that we have been inadequately prepared. It gave us the direction to rebuild the health care service and system, and to define our priorities in service and in training personnel. It also gave HK public medical services a chance to wrangle more money from Government for health care to top up the needs for those priorities, and we have succeeded. A total of HK$1165 million has so far been pumped into or approved for the public medical service to enrich health care in infection control and more could be forthcoming.

          The final chapter of SARS could therefore be that of “they live happily ever after” or like the typical Chinese movie – 大團完大結局.

          But this is not to be the case, instead the closing chapters of the “activities that the whole world praised” were that of Tears, of Frustration, of Rolling of Heads and of Unnecessary Financial Loss.

          Tears, were uncontrollable to mourn the 299 who loss their lives, some 8 of them from the health care team. Frustration, were from health care workers who inspite of selfless devotion fighting the unknown were critically interrogated by the LegCo select Committee and criticized by its reports. At least 3 in the hierarchy of health care resigned and one left HK seeking greener pastures. Millions of dollars were spent, perhaps unnecessary by LegCo to stage the inquisition and by HA to prepare the data and legal grounds for the response. All these as one would realize are money from the public. But this is not all, legal battles are expected from the victims of SARS to the public health care service and possible compensation claims could be magnanimous.

          Why did all this happen? Dare I say it is all backfired from presumably calculated political moves.

          The Government was criticized for initially playing down the severity of the infectious spread suggesting that there might be some “covering up” in favour of possible effects on HK’s economy. But then what could the relevant Bureau do when even on the 22 April 2003 the then China’s Minister of Health at a press briefing in this very building to the HK media said that there were only “a few cases of atypical pneumonia in China”.

          It is obvious that a saga such as SARS where some 299 died and some 1,755 were infected and where HK was almost brought to a stand still deserved some form of a high power independent investigation especially in this political climate of “blame culture” and “accountability and responsibility”. There were calls therefore, from many, that an Independent Judicial Commission be set up by the HK Government to look at the whole picture – from health care to close of schools, quarantine to border control, and to suggest recommendations for the future.

          This was regrettably not to be, in the interim, an expert committee was set up within the Health Welfare and Food Bureau and an independent internal investigatory committee within the Hospital Authority, both to look at lesions to be learnt.

          It is evident from the start that these 2 bodies and their expected reports other than an independent commission will not satisfy our “Peoples’ Representatives” – paving the way for them to set up a Select Committee with “power and privilege” to call and “question witness”. The aim of this Select Committee, since LegCo was not satisfied with the other 2 reports that no blame was apportioned, was to “witchhunt for person or persons responsible”.

          Regrettably this “Select Committee” had areas of fallacies.

          As a start, the efficiency of this body stands to question. It is expected to investigate a complete unknown saga from medical causes and yet it did not have expertise of that specialty within its membership or even as advisors.

          Secondly much questioning were done on the front line health workers with a motivation of criticism when it is obvious that whilst these front lines were sacrificing their lives to fight the war of SARS, many of the members of the Select Committee were in the save environment of their offices, oblivious to the danger that their voters and constituents were facing. It was no surprise that at least one front line executive wrote to the Select Committee.

          “Where were you when we needed you most”.

          Thirdly, perhaps in an attempt to lobby for votes for the then forthcoming LegCo election, conclusions of the Select Committee were leaked well before the investigation was completed, not just once but at least twice. An investigation was staged in LegCo for the so call “McDonald” incidences, but as expected, produced no results. The second leak was from an obvious source but was side stepped by putting the blame on the “efficiency” of the HK Post Office.

          What then was the subsequent score.

          As mentioned earlier, 3 from the health care hierarchy have resigned and one left HK. Of course, they could be replaced.

          Of the 11 members of the Select Committee, only 4 were returned to LegCo, of the remaining 7, 2 elected to step down and 5 were defected. They were all replaced.

          In the whole exercise, nobody won, both the hunters and the hunted succumb. In many cases the hunters becomes the hunted.

          The final closing chapter of SARS was thus a modern day Hamlet. Is it a comedy or a tragedy? Nay, it is neither, it is a pure melodrama of miscalculated politics.

          But is the profession more united? Has the image of the profession improved? Is the integrity of the health care institutions maintained?

Alec McFadzean, I am confident, would NOT have approved.

Thank you!