'No matter how well you've performed, you just have to move on to the next patient. Or the next book.'
VINCENT LAM, DOCTOR AND GILLER WINNER, TALKS TO KATE FILLION ABOUT PANDEMICS,CONTRACEPTIVES, AND HIS SURPRISE VICTORY
Kate Fillion, Maclean's
Monday, November 20, 2006
Q: There were three flu pandemics in the 20th century, the most severe being the one in 1918-19 that killed between 40million and 100 million people. In The Flu Pandemic and You: ACanadian Guide, you and your co-author, Dr. Colin Lee, write thatanother pandemic is inevitable, we just don't know exactly when itwill occur. What's the difference between regular old seasonal fluand a pandemic?
A: Every year, several strains of influenza circulate and cause arelatively low, predictable rate of illness, and they're typicallyrelated to strains that have circulated in human beings in therecent past. Most people have had some previous exposure, if notto those strains, then to similar ones. Pandemics occur when astrain of influenza that previously circulated primarily inanimals, mostly in birds, manages to cross into humans and gainsthe ability to circulate easily. Because most people in the worldhave not had any previous exposure to strains like it, more peopleare more prone to be severely affected.
Q: Last year, everyone was clamouring for Tamiflu, but this yearthe level of hysteria about bird flu has declined. Is that becausethere's less risk?
A: Both the panicked type of furor surrounding the topic lastyear, and the comparative neglect and lack of interest this year,are unjustified. A year ago, people were really going offhalf-cocked, misinterpreting the existence of legitimatescientific and health concerns as a likelihood of that phenomenonactually happening next week. It's true that the issuessurrounding H5N1, the strain of avian influenza people are mostconcerned about, were evolving last year, but it's also true thatthey still exist right now.
Q: Should the average, healthy person get a flu shot?
A: Yes. One, because it reduces their likelihood of missing work;influenza is not like a cold, it involves muscle aches and beingincredibly tired and staying in bed for days. Two, to reduce thechance of transmitting the virus to someone more vulnerable, likeelderly relatives or very young children. People with ongoingillnesses like heart or lung disease, and people who are frail orelderly, suffer more serious consequences from influenza and aremore likely to experience complications and also to die, so it'squite plain to see that for them, getting a flu shot is a goodidea. What's really interesting is that people can be veryfascinated by the prospect of a pandemic, which is serious anddramatic but also unlikely, and yet people cannot appreciate therisk that seasonal influenza causes every year.
Q: Will this year's flu shot provide any protection in the caseof an H5N1 pandemic?
A: It's very unlikely, and the safe assumption is that it wouldnot. But one of the key stumbling blocks once a pandemic comeswill be not only the creation of a vaccine, but the massproduction and distribution of it, which requires a complicatedinfrastructure. Right now, only a tiny fraction of people in theworld get influenza vaccinations -- so the network is vastlyinsufficient to meet the potential demand during a pandemic. Bygetting a vaccination, part of what you're doing is building acommercial incentive that will make it easier for companies tomass produce and distribute a vaccine during a pandemic should theneed arise.
Q: But some Canadians don't even believe in vaccinating theirkids against measles. How do you convince them to get the flushot?
A: One thing SARS taught us, and one thing anyone will realize ifthey visit a country that doesn't have a good comprehensivevaccination program, is that infectious disease is very real. Mostpeople have never been witness to the effects of rubella, forexample, and consequently don't feel it's a real phenomenon. Butit is, and it causes very serious health problems. I do think it'sworth noting that flu shots are universally available, free ofcharge. These are times when costs are constrained. If thegovernment is offering something for free, they must have a goodreason for it.
Q: What can individual families do to prepare for a flu pandemic?
A: They should have some kind of plan for emergencies in general,be they ice storms or hurricanes, and the preparations are reallythe same as those for a pandemic. Canadian families should thinkabout having a stockpile of food -- we suggest a month's worth. Ageneration ago, it wouldn't have been unusual at all to have twomonths of food in the larder, if you could afford it. But now wehave a just-in-time delivery society that counts on being able toget things at the last minute. If there's a disruption in supplychains, and the next pandemic could well cause significant socialand economic disruptions, it would be a good idea to have somefood in the house.
Q: Your plan in the book is so detailed, right down to the levelof suggesting people keep a large supply of contraceptives handy.
A: We're all about detail! Given everything that might be goingon during a pandemic, you might want to think about whether that'sthe ideal time to procreate.
Q: How will medical resources be rationed in a pandemic?
A: There will be very tough medical decisions as well as ethicaldecisions. Antivirals such as Tamiflu pose a particular problem.Most of the evidence points to the conclusion that if they'reuseful at all, they may be more useful in terms of prevention thantreatment. If you have a limited supply in a public system, doesit make more sense to provide preventative treatment for essentialservices workers -- health care workers, police, electrical andutility system workers -- or to use antivirals to treat illness?
Q: You don't advise laying in a personal stockpile.
A: Absolutely not. For one thing, it's expensive.
Q: And if it turns out to work best as a preventative, you'd needa lot of it, right?
A: You would need enough to last until you can reasonably expecta vaccine to be developed, which is to say, a minimum of eight to10 months.
Q: How would a flu pandemic stack up against SARS?
A: SARS was a logistical nightmare, and threw us for a loop as asystem. But it actually affected relatively few people in terms ofthe final number of illnesses and deaths. An influenza pandemicwould affect a much larger percentage of the population. One ofthe big differences is that with influenza, in the day before aperson has any symptoms at all, they may already be highlyinfectious. With SARS, people were shedding the most virus andwere most infectious about 10 days into the illness, when theywere already quite ill. That's one reason it could be more easilycontained, you could see that they were sick. There are somethings which people expect in a pandemic, and in a scary way,almost fantasize about, like enforced quarantines and signs nailedon the front door telling people not to go in or out. The realityis that we probably won't see those, because the success rate ofenforced, individually directed quarantine and isolation in thepast pandemics simply has not been borne out -- influenza is tooinfectious, and people shed virus before they know they're sick.Once an influenza strain hits the general community, it's almostimpossible to completely stop its progress. What will likely bepossible is to slow down and limit its progression by askingpeople to stay home, voluntarily.
Q: How do you shed the virus, exactly?
A: It comes from your mucous membranes, typically: your nose, ormouth or perhaps from rubbing your eyes. A person coughs orsneezes, and a virus-containing droplet flies out and lands onanother person, or an object like a table or an elevator button.It only travels about a metre, but the droplet, depending ontemperature and humidity, could survive a maximum of about 48hours. A lot of people can touch an elevator button in themeantime, but the thing to understand is that you don't getinfluenza from touching the button -- you get it from touching thebutton, then touching one of your mucous membranes, scratchingyour nose or rubbing your eyes. This is why handwashing is soimportant, you can prevent that indirect transmission.
Q: You published two books this year, including Bloodletting &Miraculous Cures, which won the Giller Prize, and you're currentlyfinishing a novel. You're a practising emergency physician. Andyou have a two-year-old. Do you have any hobbies?
A: The short answer is no.
Q: In your fiction, you're very interested in relationships. Butemergency medicine seems kind of like a one-night stand.
A: Well, literally, because we're there at night. I love beingthrust into a new situation 30 times a day. There's somethingupfront and kind of wild about emergency medicine that makes itboth tiring and, frankly, kind of addictive. I certainly do missthe ongoing sense of follow-up and knowing what happens withpatients. But it's okay. I have a vivid imagination.
Q: Has your medical training helped you as a writer, beyondproviding subject matter?
A: Medicine has taught me that it really doesn't matter how wellyou've performed. Someone will always be dissatisfied or unhappy,either for a reason you couldn't do much about, or for a reasonthat's simply untrue. And you just have to move on to the nextpatient. Or the next book.
Q: What did you think of the other books on the Giller shortlist?
A: I had a moment reading each of the books when I thought eachone should win.
Q: Come on. That's your safe media answer.
A: No, I'm serious. Anyway, I didn't think I would win. Firstcollections of short stories don't win the Giller. I've reallybeen struck by lightning in terms of good fortune.
Q: Did your parents encourage you to write, or did they want youto become a doctor?
A: My parents very strongly encouraged me to be a writer -- afterI became a doctor. I come from an immigrant family but I wasrarely, counter to stereotype, directed this way or that way. Iwas more, nudged. I do remember being advised that first I shouldwork on some way of putting food on the table, then I could dowhat I wanted. Also at 14 or 15, I won a short story competition,and the prize was attending a writing course. The teacher was[fiction writer] Jane Urquhart, and much to my amazement, at theend of the course, she sat me down and said, "You know, you havetalent, and you could probably do this, but I strongly encourageyou to go out and get a job."
Q: Why do you think she said that?
A: I don't know, maybe she was having a tough year. It just mademe think more about writing, though.
Q: Does being a writer help your doctoring?
A: Actually it does, because being a writer makes me listen forstory. And if you can do that, you can get the diagnosis about 95per cent of the time. But I'm probably more gifted as a writer.Being a diagnostician just requires a lot of work.
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