Pandemic

We all learned about the black plague in the history books. It was one of the most devastating pandemics in human history resulting in the deaths of an estimated 75 to 200 million people in Eurasia, peaking in Europe from 1347 to 1351. 

It is thought to have originated in the dry plains of Central or East Asia where it travelled along the Silk Road reaching Crimea by 1343. From there, it was most likely carried by fleas living on the black rats that traveled on all merchant ships spreading throughout the Mediterranean Basin and Europe. The Black Death is estimated to have killed 30% to 60% of Europe’s population.

The last time there was a virus outbreak in Asia was nearly 2 decades ago, the SARS virus. Then, nearly 800 died died and eight thousands were infected mostly in Asia over a period of 9 months from November 2002 to July 2003. The economic toll was just as fatal especially to open economies relying on trading and travel, like Singapore.  It was estimated that some USD6b of GDP was lost!

This time though it seemed more threatening. Thought not quite of Black Plague proportions, it however is threatening from three aspects. First, the outbreak originated in Wuhan at the start of Chinese New Year when millions are travelling in and out of this major transport node of a city in China. Second, it travels as esaily and as fast and as wide as modern conveyances take it and thirdly, its victims can be infectious without showing any symptoms of illness. So, the guy sitting next to me on a crowded Scoot flight now from Singapore to Kuching .... (argh, too frightening to contemplate.....). 

Which is why, at D’s insistence, I am all masked up. Those who know me know i can be cavalier in matters like this, which is why the blog below (from an anonymous blogger hobbitsma) is a good reminder that we should take nothing for granted, especially someone like me who is often in crowded places in close proximity with strangers!

Make no mistake, the 2019-nCOV virus is not a remake of SARS. It is a blockbuster sequel. Like Empire Strikes Back. And like all well-made sequels. There should be many surprising twists and turns to the plot. I call this a sequel because both SARS and 2019-nCOV belong to the coronavirus family of viruses.

For other old coots like me, we have fought and survived SARS. I wouldn’t call it a victory, but we survived. That’s enough for me because I know people who literally and physically did not survive SARS. The 2019-nCOV is the big test for the current young generation of healthcare workers.

Like most major and surprising developments, there is good news and then there is bad news.

First the good news. From a case-fatality (CF) rate perspective, the 2019-nCOV is less lethal than SARS. The CF rate for SARS was about 10% (10% of those infected died) while the CF rate for 2019-nCOV is hovering around 3%. The other good news is that the international healthcare community has developed very quickly diagnostic tests that can give you a result in about 24 hours, versus SARS when diagnostic tests took about 2 to 3 days to give a result and these tests were only developed late into the outbreak. But even so, we should remain guarded on this point because we are not sure when the tests can pick up the disease because we do not know for sure when the disease turns detectable. The third piece of good news is that this new disease is spread by droplets (and not airborne) like SARS and a good mask and universal precautions should be enough to break the transmission.

So much for the good news. Now for the bad news, of which there are much.

The 2019-nCOV outbreak (I wish someone in WHO or China will give this bug a more catchy name, like R2D2 or BB8 for example) is designed to perfection in several ways. First, it is perfect in timing. It blew up about a week before Chinese New Year in China, the busiest week of the year when hundreds of millions of Chinese are travelling back to their villages or for holidays, both within China or beyond China’s borders. The size of the travelling population in the week preceding Chinese New Year has been likened to the entire populations of France, Britain, Germany, Italy and Spain going on the road at the same time. Or the whole of USA moving. In other words, timing-wise, it is timed to perfection for maximum dissemination/propagation of the virus. And it is not done yet. These people now in their hometowns have to return back to their workplace – so a few hundred million people have to go on the road again soon in the next one or two weeks.

In comparison, SARS occurred post-Chinese New Year in 2003, in mid-spring, when Chinese New Year travelling had already been done and dusted.

Outbreak-wise, the 2019-nCOV is location-perfect. It has chosen Wuhan, the city right in the middle of the world’s most populous country with the most comprehensive network of high-speed trains, otherwise known as the High-Speed Rail (HSR). Wuhan is a bit like the Toa Payoh of Singapore in terms of location- smack in the middle. From Toa Payoh, you can easily travel to Jurong, Yishun, the CBD or Changi by a network of expressways. Similarly, from Wuhan, you can travel to the populous Sichuan province and Chongqing in the west, Beijing in the north, Shanghai in the east or Guangzhou and the Greater Bay area in the south within 4 to 6 hours by HSR.

Wuhan and its surrounding areas are so central that since ancient times, it has been a battlefield for different armies contesting for supremacy of China. This is especially evident in the Three Kingdoms period (at the end of the Han Dynasty in the third century) where the Three Kingdoms of Wei, Wu, and Shu fought around Wuhan and the nearby cities, such as Jingzhou. Wuhan is at the junction or confluent point of these three kingdoms, which underlies the centricity of it’s location. The biggest battle of the Three Kingdom period took place in Chibi or Red Cliff on a tributary of the Yangtze. It’s so famous that director John Woo made a two-part movie about it (Battle of Red Cliff) with a star-studded cast in 2008. Chibi is a stone’s throw from Wuhan and one of the first cities to be locked down together with Wuhan.

You cannot choose a better location than Wuhan in Hubei province to plant a disease outbreak in China. As they say, location, location, location. And Dr Evil couldn’t have chosen a better location even if he wanted to.

Next is the speed of transmission. In the past, a migrant worker may take up to four or five days to return to his kampong from centrally-placed Wuhan – You take a few slow trains, take a bus, hitch a ride and walk etc. Now with the HSR, you are home probably on the same day, within 24 hours, for 90% of China’s migrant working population. China’s HSR and road network is as good as any developed country in the world. That means the spread of 2019-nCOV is several times faster than the 2003 SARS, thanks to great travel infrastructure in 2019. In other words, in terms of coverage, 2019-nCOV beats SARS hands down.

Outside of China, the spread is also of many orders of magnitude faster and bigger than SARS, thanks to the huge number of Chinese travellers going overseas for holidays over the festive period. In 2003, SARS only came to Singapore because the virus travelled to Hong Kong and several Singaporeans caught the infection when they travelled to Hong Kong and stayed at the Metropole Hotel and brought the virus back to Singapore. That took time and quite a few people. Now in 2019, you can see that most countries have the infection introduced to them by people travelling from Wuhan directly to these countries. The number of travellers coming from Wuhan number in the tens of thousands in any given month to major cities in Asia. The number of Chinese travelling abroad in 2003 was a fraction of what we have in 2019. In 2003, we had to “import” SARS from HK, which in turn was imported from Guangdong, China. Now Wuhan has directly “exported” 2019-nCOV to Singapore and several other countries.

SARS lasted quite a few months in 2003. In the end there were about 8000 cases and 800 deaths. Contrast this to 2019-nCOV. Official investigations into this new disease started after the Chinese National Health Commission was alerted to the outbreak on 30 Dec 2019. It took only 4 weeks since then for this new disease to infect about 4000 people, half the total number of SARS patients. It is no surprise that the official (let alone the unofficial) statistics reflect the speed of the spread. This hobbit predicts that many more people will be infected with 2019-nCOV than SARS. Hopefully with a lower CF rate, and better facilities, therapeutic options now than in 2003, not too many people will perish. But I am not betting the farm on this hope…..

These are the hard truths. But there is more. The prospects may be grimmer than the above because of our imperfect understanding of the disease on two fronts:

• We do not know if the infected person is infectious during the incubation period or not
• Simple signs like fever may not be a reliable sign for the disease

These two points dramatically change the game for us battling this new disease. SARS patients were not infectious during the incubation period and when they were infectious, they had fever. That gave us time and ease of detection. Outbreak fighters were given up to one incubation period (a minimum of ~7 days) to locate close contacts of SARS patients so that they could be quarantined and in doing so, break the chain of transmission. Now, if claims that a patient is infectious even during the incubation period are true, that one-week window of safety may no longer be there. There may be no time to find and round up close contacts. The Chinese believe this is so while local (Singapore) experts think this point is still debatable. We don’t have conclusive evidence on this one way or the other.

The next point is that fever may not be a reliable sign, although according to a study published in The Lancet on 24 Jan 2020 for a cohort of 41 patients, 40 out of 41 or 98% of patients developed a fever, thought it was not stated if they developed the fever early or late into the course of the disease. Other reports cite that up to 30% of patients do not develop fever. The jury is still out for fever as a reliable sign. From a study design point of view, the power of a study based on a cohort size of 41 is debatable. We need bigger studies.

In Singapore, there is no evidence of community spread. Strictly speaking, there is no cause for panic. Or even N95 masks. So surgical masks should suffice for front line staff unless you are dealing with a suspect case, pending serological confirmation, in which case you need to get a N95. But if you are dealing with a suspect case, you are probably working in a restructured hospital, armed to the teeth with PPEs (Personal Protective Equipment) and as a SARS veteran yourself or a younger doctor supervised by a SARS veteran, you should be OK.

The problematic issues for now remain on two fronts

• Where do we get surgical masks (and other PPEs) in the private sector?
• How to risk-stratify and what responses should we make to different risk levels

For folks in the private sector, surgical masks are getting increasingly if not impossible to get. Strangely, you can still get your box of N95s from SMA. But no one can promise you your supply of surgical masks beyond the odd box of 50 masks here or there. That is hardly reassuring to the GPs in the frontlines. This hobbit would like to think or hope that someone is sitting on a war-chest of surgical masks (and gowns) like Joseph hoarding grain in biblical times, now ready to unlock the supply that will be enough to feed Egypt in a famine lasting seven years. Or at least enough masks for seven weeks lah……

As for risk stratification, policy makers have made it clear that travel to China is a major risk factor.

Returning (from China) students and healthcare/eldercare workers are required to be quarantined. The selection of these groups reflects the thinking that these are people with the potential for spreading the disease to many people quickly, should they be infected.

A much more worrisome point is that it has now been reported that 2000 persons who are now in Singapore have been to Hubei recently. How many of these are already carrying the infection? What are the chances that community or local transmission will arise from these 2000 persons?

The next question we must ask is that how do we enforce a proper quarantine for these groups? Should they be monitored closely like in the past during SARS? Does home quarantine suffice, since fever may not be a reliable sign and they may be infectious during incubation and hence may spread the disease to family members? Should we think about hotel quarantine instead? (Since there are going to be quite a few empty hotel rooms soon, I guess)

There are many questions. But as with any novel disease outbreak, the answers are few. We need to buckle down, keep our morale up, and observe strict discipline in our infection control practices. These are obvious.

What is less obvious, and quite worrisome, is that we must avoid the mistake that many generals make – generals often fail or get defeated when they fight the last war.

This is a new enemy. A new war. We have to think new too.

CNY 2020

This blog is now 6 years old and one of the very first entry was around the chinese new year and it featured an ‘everyday’ conversation between my parents. It’s a really ordinary chat on the surface but the discerning listener (esp one who is their offspring) you can hear how totally co-dependent they have become on each other when even the simplest of decisions is a joint one. Around Chinese New Year, there are indeed many things to do: from spring cleaning to banquet meals.

Every culture has its rituals and these rituals are most manifestly expressed in the major festivals. For those of Chinese ancestry, there is no festival bigger than the Chinese New Year, or the Spring Festival. The new year for the Chinese is marked not by a static calendar but rather the celestial calendar. It falls on the day that the Spring Season is deemed to have arrived. Spring itself is a season laden with many good meaning. It is when the first green shoots of growth, the first flowers bloom and the weather turns far more pleasant from a cold dark winter. It is indeed a season worth celebrating.

For the Chinese, the celebration is done loud. Loud noises (from lion dance drums and fire crackers) and loud colours (bright red clothes). It is also done big. Big family gatherings (reunion dinners and visitations) and big business (from all the spring cleaning and new stuff procured). It is also done abundantly. Abundantly long (it last half a month!) and abundantly generous (with food and ang pows galore). 

This year it is celebrated on the 25th of January. So, we are celebrating two new years in a month. Its the year 2020 and the year of the mouse which starts a 12 year cycle. The Chinese New Year is also anchored by a zodiac animal. There are 12 altogether. Legend has it that the celestial supreme being had summoned the world’s creatures for an audience and the first 12 were honoured with years named after them. The first of these animals is a mouse. The legend continues that the mouse, though small is really crafty. It had sought out the hardest working animal, the ox, whom it knew would set out first to the heavens and hitched a ride on its back. Upon reaching the gates, the mouse leapt off the ox’s back and dashed to be in first place.

So this new year is a particularly apt moment to start afresh. I am reminded of this quote from Walt Disney.

Never doubt a small creature. Especially one with imagination and courage. Just like Walt’s Mickey.

May the year of the mouse bring all of us abundant peace and happiness.

Like Lewis and Tolkien

These are two giants of English literature, esp that of magical creatures in mystical lands. M and I spent a day wandering through the streets and parks of Oxford just like these two friends. We talked like friends, too, on subjects ranging from mythology and religion to sociology and knowledge. We even managed to squeeze in a low-brow activity, watching a live televised match between Manchester United and Liverpool in an Irish pub (well, I watched while M attended to some club activity and expectedly my team lost :-().

M guided us expertly to all the places.  And without any digital navigation aid. In fact, she also got us in time to the church, to the match and to our dinner reservation. I remember it was J who often did the map reading so I am so glad to see her progress in this department. Clearly, D’s spatial intelligence gene has been passed down to our second child too. It surely couldn’t have come from me for I was born with none whatsoever! Speaking of intelligence, everyone here oozes it, from a learned chaplain at SBH to the diner next to us who has written books on the Middle East. I must say I got a real buzz from just being here in the midst of all these.

So, even as I was flying off to Davos, an advertising poster in Heathrow Airport caught my eye, “not all intelligence is artificial”. I was drawn to this because just earlier this morning, Sundar Pichai, the Google CEO, published an Op Ed on FT arguing for the regulation of AI. I do agree. Market forces will not be able to control what it should or should not do. But until governments, get their act together, us humans must recognise one thing: the intelligence that will matter now is that of imagination. Of God’s creatures on Earth, and of the human creations too, only humans have the imagination and ability to create and innovate. M and I were chatting over dinner and I had argued that the act of originating a new creation is often prized over that of innovating on something already created. M pointed out that innovating, however, is often the more practical and ultimately more accepted and hence rewarded form. She is right.

At the root of it, maintain our spirit of curiosity: to always wonder and search for new and better ways to do things. That is the fuel which Messrs Lewis and Tolkien thrived on to create their respective monumental works. Truth is they drew inspiration from the city they lived in: the river that flow through it, the college grounds and especially the sinewy trees that grow there and of course, while they are close friends, they are also rivals and hence they are constantly and simultaneously inspiring and challenging each other to do better. Indeed, better they became. The lands of Narnia and Middle Earth are now part of our mental landscape as much as the world’s geography is.

As creatures of God, we are all made to have a day’s of rest. Just like the one M and I had. In fact, we yearn for it and that’s why we have holidays and vacations and governments have regulations against over-working and some are even legislating ever shorter work weeks. Therefore, it is completely logical that to get us to our greater heights, we need the challenge of a rival. Whether it was Lewis vs Tolkien, or Edison vs Tesla vs Westinghouse or Mozart vs Saltieri or Senna vs Proust and of course Manchester United vs Liverpool, rivals can and do make us better. So those endowed with that gift of curiosity should also embrace the threat of a challenge. These two combine to hone our creative powers.

There is however one more element we need. If our creations are to become world changing, like electricity, joyful music and thrilling drives, we need courage. There is no denying that any worthy endeavour is a hard endeavour. And I don’t mean intellectual difficulties which we overcome by working harder. I mean societal resistance. To break through, courage is about being prepared to be unpopular, and in some cases even being prepared to lose it all. M pointed out to me that education advocate, Malala Yousafzai is in LMH, which is a stone’s throw away from her hall of residence. There were countless detractors who were not just resistant to change but are opposed to change and therefore opposed to her and indeed one of them shot her. She soldiered on and her courage got her here to the university to help change the world for educating women in less developed countries.

So, there you have it, curiosity, challenge and courage. Add it altogether, you can change the world. And my weekend here with M really brought to life how she is indeed living this life. A curriculum and tutors that endow her with new curiosity. Fellow students and friends who challenge her to perform even better. The courage though she needs to find that herself. We spoke about all of these as we wandered the streets and parks like Lewis and Tolkien. From all that I can see and hear, she certainly is.

Hilary Term

This is a rather quixotic world, with a vocabulary all of its own. Most universities would refer to their terms or semesters numerically or maybe according to the season. But not here in O. The terms are named after angels or some significant religious event. That is what happens when the university is over nine hundred and twenty years old. Time, or rather meaningful time, a millennium ago was marked more by religious events. In this case, M’s 2nd term is called Hilary, after the feast day of St Hilary which falls on 14th January which was when term started. The first term is Michaelmas after the feast of St Michael and all angels and the third and final term of the year is Trinity, which starts after Trinity Sunday.

I am on my way to Davos and thought I drop by and see her. She has already moved into a a new room at NG, sat for her first collections (another curious word to describe exams) which test a student’s grasp (or recollection?) of what was thought the term before. M sat for this in a chapel, wearing a black and white gown (sub fusc). I think I have confused you, dear reader, enough. And it is indeed into this disorienting world that M stepped into all by herself, having lived in the relative comfort and safety of home for over 19 years.

She is assigned a new room for Hilary Term and it is larger and faces the Gardens of the Nunnery. Previously, she was also facing the “Gardens”: the road called N Gardens :-). So progress!

 The real progress is that she packed up her previous room and unpacked fully into her new room. It’s often said that household skills skip a generation because an unusually able parent (in, say, packing) would do all of that to the extent that the child need never do it. D is that unusually skilled packer, so M had to learn really fast, and learned she did. Although she had only moved in less than a week ago, when I stepped into her room this morning, it felt really settled in already.

She has indeed had to navigate through many new situations. Some are trivial: do I join my friends to the club or not? Some are simple: where do I lunch today? Some are important: which course do I take/drop next term/year? Whatever she chose, she also learnt that there are no wrong decisions. Life is wonderful that way. It is a journey that allows for course correction... so there are no failures, just learnings. Don’t enjoy clubbing after deciding to go, then leave early. The lunch place was not up to expectations, avoid it the next time. Even with courses, there are always new knowledge to be gained. M is obviously putting her thinking and analytical skills to bear as she makes these decisions: big and small and in time she would know which are the big stuff to think more deeply about and which small stuff not worth sweating gray matter over.

Right now, she is getting ready for her third and final collections for the start of this term. It so happens to be about evolution. We have all evolved over millennia and in M’s case, in just a few short months, she has already evolved into a more independent person and more ready to take on the world.

Doors

It was Alexander Graham Bell who famously said, "When one door closes, another one opens. ..."

It is human nature to rue our mistakes, and the more perfectionist the human, the deeper the regret; for after all over-achievers don't fail .... or do they?

The truth is the biggest names in history, be it in science, literature, sports, politics had all been forged through the fires of failure. From missed opportunities to silly mistakes to poor miscalculations, Edison, Shakespeare, Ali and way too many politicians to name, they all have two things in common: they had doors closed, even slammed shut in front of their faces. And secondly, they never lingered too long in regret in front of that shut door but went on to find the doors that open instead.

At a much smaller scale, but big in the context for a student returning to university, M was very much confronted with a shut door arising from her own illness-induced forgetfulness. But rather playing the blame game with herself, she surprised both her mum and me and indeed the airlines counter staff with a decision. She had accidentally checked in her carry on bag which was unlocked and contain valuables needed for school. The big question was whether we could get the bags offloaded and re-checked in time. In an absolute moment of clarity, in front of anxious parents, she decided to let the bags go ahead.

In the end, the bags arrived safely, she had less to carry on to handle and most importantly learnt the lesson that Mr Bell had so succinctly put across. When bad things happen, we need to move forward. Thinking through new options (but don't get analysis paralysis) and most importantly, decide and act. The rest will take care of itself.

Careers

Its 9pm here in Vijayawada airport. I landed here at 8am this morning from a 6am Delhi flight. And had landed in Delhi at 8pm the night before from Singapore. My first flights as I start work this new year.

I met the Chief Minister of Andhra Pradesh and his team to discuss a balanced, inclusive growth plan for the state; as well as to help with a PR crisis he is now facing. PR risks are now part and parcel of advising governments. In this age of social media, everything a public figure say or do (in private and in public) can and will be captured and published and often out of context, esp. now as we live in a world of polarising politics.

Tough job indeed! But then again here at the airport I got to witness poor ground staff being harassed and verbally abused by passengers of a delayed flight. It reminded me of my own experiences (some quarter of a century ago now) of having to handle very much these situations. There are others too like lost bags, wrong seats, and worse of all overbooking!

I had sought to get out of such frontline jobs only to land myself in another frontline job, this time with more high powered customers! Talk about leaping from the frying pan into the fire. I am not sure though if I would do it any other way, or rather if I would do it again, i think i would still take a front office job over a back office one. There is something to be said about human interaction and solving these problems dynamically.

At some level, all jobs are the same. Its about delivering a good/service to a customer who has paid for it. The key difference is at what stage of the value chain one plays. Some are upstream, designing the product. Some play midstream, making the product. Others downstream, fulfilling the order. Still others orchestrate the whole chain. And then the managers who see to everyone doing their jobs.

At the end of the day, the most fulfilling job is the one you like, because it makes you feel you have been purposeful.

2020

This marks the start of a new decade. A century ago the 20s was a roaring decade only to end in a great depression globally. Lets hope this 2020s will be lived more sensibly, esp. as a bunch of folks born near the beginning of the new millennium comes of age, for they are our future. In fact, they are very soon going to become the present, in terms of being part of the humanity that has learnt enough to now contribute to society.

For my part, I have worked for nearly 3 decades and while I would like to think I have done my part, and even made a difference, esp in the last 3 years leading the practice to help governments globally, I am not sure that as a generation, we have covered ourselves in glory. Yes, there wasn’t a global military war in that period, so peace reigned but other wars were waged: on the working class, on the environment and even on race and religion that the world we are now bringing into 2020 is one that is more divided than in the past half century.

Who is responsible for this? Well, no one specifically. We all worked within the system that prevailed and in our case a free market capitalist system, largely led by the democratically elected national/global leaders. And in the words of Pope Francis, “if no one is responsible, then we are all resposible”.

J asked the family as we chatted the night before he returned to the US, for our new year resolutions. I thought about it for a moment and realised that I have not made up any for awhile now. The way it happened is simple: my life, unlike one of a student's, is no longer regulated by the year but rather by a tenure, a tenure of appointment to be precise. I am midway through my 6 year term and hence see this period as one contiguous block of time with a clear expression of what success looks like in 6 years time' but not less, because near term milestones are less meaningful when one can course correct until the eventual goal.

Speaking of goal, we had a family new year's dinner and as often happens, we would land on an interesting (often big) topic of conversation for the table. Yesterday was no different. I had put forth the proposition that people with small issues should set out to solve bigger problems. That way, their issues would become smaller (and hence less important and more surmountable) in context and they may even deliver great value when solving the larger problems. Then again, even this bigger problems do not need to be fully resolved. We just need to have a purpose and yes, it'd be good to have made some progress along the way.

The greater problems for me now are two-fold. At the world scale, it is to move us all positively forward on issues of inequality. At the homefront, it is about being there to support my family as they forge their way ahead in this world.

Photo Credit: D who snapped this 

during our 2-hr patience testing

 stand-still jam at the 2nd Link

That, and yes: to lose my belly fat and manage my stress.

Resolutions.