global health

The warning signs in Hong Kong

In 2017 I traveled to Hong Kong to do research for a paper about the pandemic risks posed by wet markets (marketplaces which sold and slaughtered live animals). I traveled to wet markets large and small, and took notes on their practices and clientele. I also interviewed public health experts and doctors about the territories system to control avian influenza in poultry.

Card in a Shenzhen hotel, which explains China’s internet restrictions to guests. Sorry for the bad lighting. Photo by Shawn Smallman

While in Hong Kong, I also traveled to Macau and Shenzhen. When I crossed into mainland China, I was struck by the extent to which information was restricted. It’s one thing to know that China has a separate digital ecosystem. It’s another to no longer be able to use Google Maps, and to know that there’s no point in even trying to use a VPN to connect with websites at home. When I arrived in Shenzhen, I found this card in my hotel. You couldn’t access your files in Google Drive, check Twitter, watch a YouTube video, or see your kids’ posts on Instagram. The Great Firewall of China is  both pervasive and efficient.

While I was in Hong Kong, I also had an opportunity to talk to someone whom I greatly respected. At one point in our discussion they asked me “Do people see what is happening here in Hong Kong? Are they following what is happening here?” I said that no, in my opinion most Americans did not. In the United States people were focused on the new presidency of Donald Trump. She/he seemed very disappointed by my answer, and asked the same question again with slightly different wording. I gave the same answer. In 2017, I don’t think most Americans -and perhaps most Europeans- were carefully following what was happening in Hong Kong. That would change over the next year and a half. …

Taiwan, Australia, and COVID-19

 

Photo by Tommy on Unsplash

This year I am honored to be a Taiwan Fellow, and am planning to travel to National Taiwan University in Taipei, to work on a research project about how Taiwan used digital tools to control COVID-19. I say “planning” because Taiwan recently closed its borders. For over a year Taiwan had controlled the virus, which was ravaging the United States, Europe and South America. How did Taiwan do so well for so long, only for its public health efforts to unravel in the end?

Taiwan’s intelligence services notified the country’s leadership of an unusual outbreak in China relatively early in the COVID-19 outbreak. Taiwan quickly controlled its borders and notified other countries of the danger. It adopted digital tools to enforce quarantines and permit contact tracing. All travelers entered into quarantine hotels. This response worked, and Taiwan was free of sustained community transition for over a year.

Then -as in Australia- the system around quarantine hotels broke down. A local hotel by the airport wanted to find more customers. So they advertised that people could come to stay at their airport hotel, where people could watch the planes take off and land. They even advertised with financial support from local government. The people came and stayed. And then they left and went to museums, tea houses (brothels for an older clientele) and a masonic lodge meeting. Only later watching the local news did they find out that they had paid to stay at a quarantine hotel. While the people had not been hosted on the same floors as the air crews, they were in the same building. …

COVID-19, the Delta variant and “fleeting contact” in Australia

Few countries have done such a good job controlling COVID-19 as Australia, but now the nation is facing a significant test in Bondi. A driver (sometimes described as a bus driver, and sometimes as a “car-for-hire driver) worked shuttling air crews to quarantine hotels, as well as driving the general public. Even though he was a front-line worker, he was not vaccinated. He also seems to have had poor personal protective equipment (PPE). Unfortunately he was infected with COVID-19. While in the contagious phase he went to see a movie, visited a cafe twice, had lunch at a Japanese restaurant, and drove a large number of passengers.

What was most remarkable, however, was his visit to a mall in Bondi (Westfield Bondi Junction). In that mall, he appears to have infected people despite “fleeting contact” which was recorded on store cameras. There were a number of such cases. One woman was sitting outside at a cafe, where he was sitting indoors. Normally the risk of outdoor transmission is believed to be low. But she was infected. In another case he appears to have passed a shopper, in the briefest of interactions, which was captured on CCT cameras. But that person was infected. The old rules -fifteen minutes of contact is required for transmission; outdoor transmission is rare- don’t seem to apply in this case, which is causing some justified worry in Australia. People are lining up in their cars for testing.

Fortunately, people seem to have been isolating as asked, and wearing masks. As of today, there are still only eleven cases. Hopefully, this outbreak will be controlled. Health authorities are currently dealing with over a hundred exposure sites. One of the places people were exposed was on a bus. This incident raises this question: is the unusual pattern of spread the result of the new, more transmissible Delta variant, or was this something particular to this individual patient. Epidemiologists are discussing this question is multiple venues. Currently 3.2% of Australians are fully vaccinated.

Whatever the answer in this case, we may see more examples. As was the case with Taiwan, the critical failing was around quarantine hotels and air crews. All people who work in any respect with air crews (in nations without community transmission) need to be fully vaccinated. And the system for hotel quarantine needs to be improved. And more broadly, here in the US we are still far off our record for one day COVID-19 vaccinations, despite a slight uptick recently. People need to be vaccinated now, as the Delta variant is growing rapidly. Although it was originally thought that it would be the dominant strain of COVID-19 in the US as early as this August, it’s now looking as though that might happen as early this July. If you’re fully vaccinated, you have a good level of protection and don’t need to worry. If you’re not fully vaccinated, now is the time to do so.

Shawn Smallman, 2021

The strange trip from Chronic Fatigue to long COVID

Every pandemic leaves in its wake people who survived, but were changed by their infection. The most famous example of this is likely encephalitis lethargica, which famously reduced some people to living in a near coma after they survived the 1918 influenza pandemic. For decades some people have been arguing that Chronic Fatigue Syndrome (and perhaps chronic Lyme disease) are also caused by viruses and bacteria, which cause immense but hidden damage in the body. These sequelae endure after the initial infection subsides. Over the last several months many people who were infected by COVID-19 have developed long COVID, a syndrome that remains a medical mystery. One of my favorite new podcasts is Unexplainable, which looks at scientific mysteries. Their recent episode, “The Viral Ghosts of Long COVID” paints an unsettling picture of this disorder. The podcast begins with someone describing the long term effects of their Ebola infection, which closely resemble the symptoms reported by COVID survivors. Many people now wonder whether more research on Chronic Fatigue Syndrome earlier might not have made us better prepared to face this new challenge now.

Shawn Smallman

The odd reasons for Taiwan’s COVID-19 outbreak

I am fortunate to be a Taiwan Fellow this fall. I plan to study Taiwan’s response to the COVID-19 outbreak at National Taiwan University starting this September, where I am being hosted by the global health program. I just received my visa to travel to Taiwan last week. Unfortunately, there is currently a growing outbreak in Taipei. I first heard of it last week, when I was talking with my conversational partner in Taiwan. At that time, she said that the outbreak was still relatively small, as it involved perhaps thirty individuals. But this morning I had an email and a text -the latter of which was sent to everyone who recently received a visa- to say that Taiwan is halting all travel to the island, except for residents. I am hopeful that Taiwan will soon have the situation back under control. But what happened?

Taiwan received human intelligence about the outbreak in China in December 2019. Taiwan acted quickly, in part because it’s political leaders remembered the SARS outbreak in 2003. Since that time, it has used digital apps for contact tracing, mandatory quarantine hotels for travelers, and an effective public health system to contain COVID. Then some odd things happened. Angelica Oung has written a fascinating story (How Taiwan Finally Fell) recounting how a Taiwanese hotel decided to offer a tourism package so that Taiwanese could stay in a hotel near the airport and watch the flights land and depart from their rooms. The local tourism board even advertised this. Although the people were housed on different floors from airplane crews, somehow infected pilots and crews spread the virus to the domestic tourists. After nine pilots tested positive the domestic tourists apparently found out that they had been staying at a quarantine hotel by watching the TV news. But by this point some infected people attended a Lion’s Club meeting, went to karaoke, and then attended “Grandpa shops/tea parlors” in which older women sexually catered to a senior clientele. Genomic testing revealed that everyone with COVID-19 had been infected by the same English variant. …

Singapore’s strange ad to vaccinate

Photo by Pang Yuhao on Unsplash

All around the developed world nations and local governments are trying to persuade people to go have a COVID-19 vaccination. Where I live, I am flooded with ads, which are mostly politicians and public health authorities. These ads mostly have a talking head format, so they don’t have a lot of visual interest. And no catchy songs. Then there is Singapore’s approach.

Singapore’s most recent ad highlights a comic duo, a musical number, uni-color background shots, Singlish and dance. I’m not sure where I first read about this two minute ad, but it shows another approach to public health communication. Here in the United States, I hope that we’ll see ads with football quarterbacks, basketball players, religious leaders, movie stars, musicians and others. People need to see spokespeople supporting the vaccine who aren’t epidemiologists. And maybe somebody else could do a musical about vaccinating. “Steady pom pi pi” everyone.

Shawn Smallman, 2021

Photo by Pang Yuhao on Unsplash

The best source for COVID-19 information?

Photo by Martin Sanchez on Unsplash

Who would have guessed that one of the best sources for regular and reliable COVID-19 information would be a retired nurse teacher in northern England? By this point in the pandemic, one would expect that the last thing that anyone would want to hear would be more news about COVID-19. Yet people turn in daily for Dr. John Campbell’s YouTube update, which usually feature Winston -a stuffed dog- wearing a mask in the background. One of the reasons that the show is so popular is Campbell’s English humor, his guests from different parts of the world, and his concise description of major trends in the pandemic. I don’t know that I always agree with all that Dr. Campbell suggests, such as the strength of the evidence for vitamin D being advantageous. But I enjoyed watching him debate the issue with a vitamin D skeptic, who was also a leading researcher in this field. Such reasoned and respectful academic debate is too rare now.

As I write these words, the situation in India is truly dire. I’ve just been texting with a friend in the country, who said that so many bodies are being burned that their city is covered in smog. The Daily, a news podcast of the Times, has a remarkable episode about what is happening in India now. As an article in Canada’s National Post suggests, India’s experience is a warning to the rest of the world about what can happen if a nation becomes overconfident that they have managed the pandemic. But India is not alone, as COVID-19 cases are also surging in Chile, despite a high level of vaccination with a Chinese vaccine. In the United States numbers are in a steady decline, despite an uptick in both Colorado and Oregon. But we still have a long way to go in this pandemic. In many parts of the world, such as Thailand and Cambodia, the situation is worsening. And Japan is still holding the Olympics, even though most of the country’s citizens do not want to host it. I recommend John Campbell’s YouTube channel for anyone who wants to stay current with COVID-19 news.

Shawn Smallman, 2021

Britain’s vaccine success in the midst of a pandemic

The early story of Britain’s reaction to COVID-19 was an unmitigated disaster, driven in part by uniformed cabinet discussions of herd immunity. Even Prime Minister Boris Johnston himself was infected with COVID-19. As if this story was not difficult enough, a new variant of COVID-19 appeared in Essex towards the end of 2020. We now know that not only is this variant more communicable, but also may be more deadly. In late December this virus came to dominate all the COVID-19 clades in Britain, and caused a remarkable surge in infections.

In spite of this difficult history, Britain has pulled of two remarkable achievements. First, it has conducted outstanding genomic surveillance. While Denmark was also doing so, it was the British tracking which revealed the extent of the threat these new variants posed. Now other nations, such as the United States, are playing catch-up, as they try to create an effective system for genomic surveillance. Even more remarkable, Britain has joined a short list of nations (along with Israel and the United Arab Emirates) leading the global race to vaccinate their populations. How was this success achieved?

Paul Waldie has a remarkable article in Canada’s Globe and Mail, titled “How Britain became a world leader in COVID-19 vaccine distribution – despite other pandemic problems.” In Waldie’s narrative one remarkable woman, Kate Bingham, and the task force that she led, managed to identify the likely winners in the vaccine race, negotiate contracts, and bring vaccine production home to Britain. What is most impressive is how proactive the task force was. Britain has had many missteps and still faces many challenges. Yet when the history of this pandemic is written, I think that -based on Waldie’s description- this task forces’ actions will be held up as a case-study of effective leadership during a crisis.

Shawn Smallman

Two pandemics: Ghosts of the 1918 outbreak

Recently I’ve been reading a book (published in 2004) by Betty O’Keefe and Ian McDonald titled, Dr Fred and the Spanish Lady. The work examines the experience of Dr. Fred Underhill, who was the senior public health officer in Vancouver during the 1918 pandemic. While there had been a host of influenza pandemics through history, the 1918 pandemic killed perhaps 100 million people globally.

What struck me while reading the work was the manifold similarities between our experience of COVID-19 and that of almost exactly a century before. During our current pandemic some countries, such as Australia, New Zealand and Taiwan, acted quickly to enact travel restrictions. But that was the exception rather than the norm. Similarly, in 1918 troop ships brought influenza to Canada, even though during the crossings the ships would have to repeatedly stop for the burial of sea for returning soldiers (O-Keefe and MacDonald, 30-31). In 1918, travel restrictions were not implemented because everyone in Canada wanted to bring the troops home. While understandable, this was also tragic. During COVID-19 there were no effective limits on returning citizens in the United States, likely because there just was not enough public support for this measure. Of course, there were limits on non-citizens’ travel. But since the SARS-Cov2 virus does not discriminate based on citizenship, those countries that did not limit their citizen’s movement, and quarantine them on arrival, have paid a heavy price. …

How quickly can you catch COVID-19?

Throughout the last several months, the US Center for Disease Control has messaged that in order to catch COVID-19 you had to be within six feet of an infected person for fifteen minutes. This was reassuring information. But sadly the US was also perhaps in a difficult place to answer detailed questions about COVID cases, because the contact tracing system has been overwhelmed. The US has also lacked a national COVID tracking app, as many other nations (Australia) have had. Realistically, this would have been a political impossibility to implement in the US, given that even masks have been highly politicized here. So, how realistic was the CDC’s guidance?

The CDC itself pointed to a case in Vermont in which a masked corrections officer was infected with COVID even though he never spent more than a single minute with infected prisoners. Instead, he spent perhaps a total of 17 minutes in a day with them over the course of multiple brief visits, all of which were captured on video. He also wore a mask, gown, and goggles. The prisoners sometimes wore their masks, and sometimes not. After this case, the CDC changed its rules to reflect cumulative exposure. Still, the fifteen minute rule still held. But would new information change these guidelines?

In Korea, contact tracing has been highly effective. It turns out that the combination of a digital tracking app with highly skilled contact tracers has been more successful than either purely digital or human tracing would be. And what Korea has learned -in a remarkable piece of scientific work- is that in one case a high school senior was infected after five minutes of exposure and from twenty feet away. The infection took place in a restaurant (which had video recording) and it turns out that an air conditioning unit was wafting air from an infected person towards the student. The quality of the data that the contact tracers obtained -and the history of how they learned it- is remarkable, and well worth reading.

There is nothing magic that happens at the six feet mark from another person. And being exposed to an infected person indoors can be risky even when the CDC’s old guidelines might make us feel safe. In this case, Korea has given us not only important information, but also let us see the quality of information contact tracing can provide. The key message is that neither six feet of distance, or avoiding more than fifteen minutes of exposure to another person, may be enough to keep you safe from infection, particularly indoors. So indoor dining is probably always unsafe.

Shawn Smallman

Privacy & Cookies: This site uses cookies. See our Privacy Policy for details. By continuing to use this website, you agree to their use. If you do not consent, click here to opt out of Google Analytics.