Wednesday, October 21, 2009

SARS, Freedom & Knowledge

Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
 Adapted from Ching-yuan (1067-1120)

In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.
         For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease.  The alarm was first raised by its first victim, Carlo Urbani.  He was an Italian physician employed by the World Health Organisation (WHO) and based in Hanoi, Vietnam and he gave the disease its current name. It was as if this newly mutated virus knew what it was on about. Get the doctors as they would be the first who could deal with you. Urbani died. So did some of the medical staff that attended the first few patients.
         Doctors often thought that they would be immune, a God given right I suppose.  Not so this time! The virus obviously knew what it was doing.
         Our knowledge base was in total chaos. What we knew was obviously not good enough. Nor were the most up to date antiviral drugs. Even then in some places they were sold out as rumours spread. There were rumours too of vinegar and certain dietary items giving protection to certain ethnic groups, notably Koreans. The lack of knowledge about this new infective agent led to the great proliferation of myths that were soon spreading like wild fire on the Internet. Anyone with cold symptoms was treated as if he was carrying the plague. It was the plague, the new plague.
         Without any sound knowledge authorities took draconian measures – any measure anyone could dream up.  Some worked well if only to raise public awareness. One actually caused more harm and unfortunately deaths. That was the restriction of movement in one of the tower blocks in Hong Kong – a true quarantine. In the absence of insight into how the infection was spread, more people were infected. Some broke the law and fled the buildings before the quarantine. Unfortunately 321 people were infected and 42 died. Eventually someone was sensible enough to move them to another quarantine site.  Otherwise there would have been more deaths.
         Canada's hasty decision to declare its virus free status when so little was known about the virus proved costly and further eroded the public's trust in governments and people in positions of influence. Clinicians’ view no longer seemed to hold any sway where commercial interest was more important.
         Except in Canada, one advice was almost universally adopted – the wearing of a mask.  During this time, I was in correspondence with many of my medical colleagues and relatives in Hong Kong and Canada. One thing was clear: even the most difficult child complied and wore a mask. To this day one still needs to wear the appropriate mask to visit someone in hospital in Hong Kong, on top of having a dollop of alcohol gel to sterilize one’s hands. Many clinics require patients and staff to do the same.
         Now this must be the clearest lesson to every parent in every land. Where life and death is concerned, there can be no compromise.
         So it started me thinking about my practice, specifically Anorexia Nervosa and other difficult cases that I have encountered.  Take Anorexia, it may have been unnecessarily classified as a mental illness, given that it is the result of the parents giving the individuals concerned too much right and freedom for self determination.  If a child can be made to wear an uncomfortable mask, why can parents not make a child eat?
         The answer may lie with our view of freedom. Many parents of Anorexia Nervosa sufferers are highly educated, and some hold high positions in big corporations and even in Health Authorities. Many are professionals. Many have a great respect for individual freedom and self-determination and unfortunately they get caught in a bind of not being able to be authoritarian as far as their own children are concerned. It is not difficult to see why many parents of Anorexia Nervosa sufferers are not prepared to give up being a modern parent, and until they do, we psychiatrists will have to soldier on with the difficult task of treating what need not necessarily be an illness, let alone a mental one. 
         My second thought is that when something as familiar as chest infection can turn out to be a deadly new plague called SARS, we need to examine again the relationship between our existing knowledge and medical practice. We have to keep an open mind. What we know from the past should be an aid, not a hindrance.

Otherwise we shall never see the mountains and waters for what they really are.                                               

                                                                                                           From The Cockroach Catcher

Recent political decisions on Swine flu would seem to indicate that not much has been learned from the SARS experience in Canada and Hong Kong.

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