“Sunlight is the best disinfectant”
Louis Brandeis - US Lawyer
Disease feeds on ignorance and misinformation. And yet it is often human nature to conceal or silence due to vested self-interest. George Orwell said, “in a time of universal deceit telling the truth is a revolutionary act.” This is the story of a modern medical truth teller Li Wenliang and his predecessor of nearly two centuries: Ignaz Semmelweis.
Li Wenliang, Creative Commons
Li Wenliang was an ophthalmologist working at Wuhan Central Hospital since 2014. Like a lot of doctors (myself included) Li enjoyed using social media, especially the Chinese microblogging site Weibo. Like myself food featured heavily in his posts, in particular Japanese food and fried chicken, as well as his favourite singer and actor Xiao Zhan. He was a husband and father. On his final birthday he posted a resolution to be a simple person, refusing to let the world’s complications bother him. He was an optimistic person and entered various lotteries and competitions especially if the prize involved gadgets.
On 30th December 2019 he saw a patient’s blood result confirming infection by a coronavirus, the same family of virus which had caused the Severe Acute Respiratory Syndrome (SARS) epidemic of 2003. SARS had originated in South China but news of the disease was suppressed by the government. The World Health Organisation was made aware of SARS through internet monitoring and China refused to share information for several months. By the time action was taken 2000 more people had been infected. In total 8098 people were infected with 774 deaths across 17 countries. The possibility of a new disease was politically sensitive. Li knew this.
Li alerted a group of his medical schoolmates on the social media application WeChat about the result. He warned them:
“Don't circulate the information outside of this group. Tell you family and beloved one to take caution.”
Li’s letter of admonishment, Creative Commons
On 31st December 2019 the World Health Organisation was alerted about an outbreak of pneumonia in the city centred around the Huanan Seafood Market. Despite asking for secrecy screenshots of Li’s warning were shared on social media. On 3rd January 2020 Li was interrogated by police staff for rumourmongering. He was warned about his conduct and against making claims on the internet. Li was given an official letter of admonishment which he was forced to sign. He then had to give written answers to two questions: in future, could he stop his illegal activities and did he understand that if he continued he would be punished under the law? “I can” and “I understand” he wrote, placing his thumbprint in red ink by both answer. It wasn’t enough to scare him, this was the kind of punishment given to a schoolboy. His name and the accusations were broadcast by state television. The message from was clear: toe the line.
The People’s Republic of China celebrated its 70th anniversary in October 2019 with a display of military might and what can be achieved through communist rule: mega cities, high speed travel and economic stability. President Xi Jingping became only the second ruler after founding dictator Mao Zedong to have his political philosophy (Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era or simply Xi Jinping Thought) incorporated into the Chinese constitution. In 2018 the Chinese Communist Party voted to remove the two term limit on presidency, in place since Mao, leaving Xi free to indulge in a cult of personality similar to those of Maoism. The unspoken contract between the government and people was simple: in exchange for reduced freedom of speech we will give you efficient and effective government. First came a downturn in economic growth and a trade war with the US. Then the ongoing revolt in Hong Kong. This new disease was a third significant crack in the facade of the Chinese government’s strength.
On 7th January Li returned to work. The next day in clinic he saw a patient with glaucoma who worked at the Huanan market. The patient didn’t have a fever and so Li saw her without a mask. On January 10th he started to cough. He sent his family to his in-laws 200 miles away and checked into a hotel. On February 1st he tested positive for the new coronavirus. “Well that’s it then, confirmed”, he wrote on Weibo from his bed. Li was admitted to intensive care on the 12th January and tested positive for the new coronavirus on the 30th. He died on 7th February 2020 aged 33. There has been an outpouring of support for Li and criticism of the communist government of China with calls for freedom of speech. Despite a ruling from the Chinese Supreme Court on 4th February that Li should not have been punished there has been no apology at the time of writing from the government.
In the hours after Dr Li’s death nearly two million Chinese netizens had shared the hashtag “I want freedom of speech” on social media before it was taken down by authorities. Petitions have been signed and sent calling for greater freedom of expression to be guaranteed in China. Party chiefs are now using Dr Li as a hero, blaming his mistreatment as mistakes being made by individuals. Global Times, a nationalist tabloid, has stressed that Dr Li was a loyal Communist party member and the pro-democracy forces whipped up by his death are the work of enemies abroad and dissidents in Hong Kong.
The new coronavirus has been named COVID-19 by the World Health Organisation who then declared a Public Health Emergency of International Concern. On 12th February 2020 the Chinese authorities announced a previous unrecorded extra 13,332 cases and 254 deaths. The official explanation is that this is due to recording patients with lung changes on CT scan suggestive of infection rather than just those with confirmed positive blood tests. The memory of SARS casts a long shadow, however, and suspicion remains that China are not being truthful about the extent of the epidemic. President Xi Jingping, despite being invisible for much of the early outbreak, is now the “commander of the people’s war against the epidemic” according to the state news agency, Xinhua. Stirring stuff, but as scientists point out, the language of war doesn’t leave room for debate and discussion. The international medical community is pushing against the censorship of a governnment. In the past, however, doctors have been behind the suppression of knowledge.
Ignaz Semmelweis, Creative Commons
Ignaz Semmelweis was born on July 1, 1818 in the Tabán, an area of Buda which is part of present day Budapest, Hungary which was then part of the Austrian Empire. He was the fifth child of ten of the family of grocer Josef and Teresia Müller Semmelweis. In 1837 he began studying Law at the University of Vienna but a year later switched to Medicine and graduated in 1844. After failing to secure a position in Internal Medicine Semmelweis was appointed assistant to Professor Johann Klein in the First Obstetrical Clinic of the Vienna General Hospital on July 1, 1846.
At the time free maternity care was available to women as long as they agreed to let medical and midwifery students to learn from them. Semmelweis was in charge of logging all patients as well as preparing for teaching and ward rounds. There were actually two clinics: the First Clinic was led by doctors and medical students, the Second was midlife which alternated daily. Semmelweis caught wind of the terrible reputation the First Clinic had. Indeed, destitute women would rather give birth in the street and wait a day than be admitted to the First Clinic. The difference was due to mortality. 10% of women admitted to the First Clinic died of fever compared to less than 4% of those in the Second Clinic. What was the difference? Meticulous to the extreme, Semmelweis began investigating and eliminating differences. The climate was the same, there was no difference in religious practice, it couldn’t be overcrowding as the Second Clinic was actually the busier. He was haunted by the question.
Jakob Kolletschka, Creative Commons
Tragedy would give him his answer. In 1847 his good friend Jakob Kolletschka, a Professor of Forensic Medicine at the University of Vienna, accidentally cut himself with a scalpel during a post mortem examination. He developed fever and multi-organ failure. Semmelweis had actually left Vienna to give himself a break from the question of the First Clinic. He returned on 20th March 1847 to discover that Kolletschka had died a week earlier. Semmelweis wrote:
“Day and night I was haunted by the image of Kolletschka's disease and was forced to recognize, ever more decisively, that the disease from which Kolletschka died was identical to that from which so many maternity patients died”
Rather than looking at just the clinic Semmelweis looked at what was taking place elsewhere. The medical students who ran the First Clinic started their day in the mortuary performing dissections before coming to see patients. The midwives of the Second Clinic spent all their time on the ward. Semmelweis surmised that there was a link between dead bodies and the fever which had killed his friend and was killing his patients. This was decades before the work of Koch and Pasteur and ‘germ theory’. All Semmelweis could postulate was that some ‘cadaverous particles’ were on the scalpel which cut his friend and caused his death and these particles were being spread to his patients by the medical students.
Semmelweis instituted a policy of using a solution of chlorinated lime (modern calcium hypochlorite, the compound used in today’s common household bleach) for washing hands between autopsy work and the examination of patients. He felt a strong smelling solution would eradicate the smell of rotting flesh and so eliminate whatever infectious agent was causing disease. Mortality in the First Clinic plummeted from 18.3% in April 1847 to 1.95% by the August.
Semmelweis had discovered that rates of infection could be cut dramatically by the simple act of handwashing. This went against established medical theory at the time which had concluded that miasmas or ‘bad air’ was behind infection and that balancing the humours through procedures such as blood letting were the basis of treatment.
In a precedent to modern China this was also a time of political upheaval. 1848 saw revolutions across Europe and in Hungary saw an independence movement rise up against Austria. Although ultimately quashed the rebellion would have consequences for Semmelweis’s research. His brothers were involved in the movement and his superior Professor Johann Klein was a conservative Austrian who probably didn’t approve of their actions. Semmelweis had other struggles. With no scientific explanation as to why hand washing worked he was faced with scepticism. The medical community was not prepared to accept that they were somehow unclean and responsible for the deaths of patients. There was also a problem with Semmelweis’s poor presentation of his project and high handed manner which some of his colleagues found off putting.
In 1851 Semmelweis took a new post on the obstetric ward at St. Rochus Hospital in Pest (now part of Budapest), Hungary. Again through handwashing he virtually eliminated post-partum fever amongst his patients. Between 1851 and 1855 only 8 patients out of 933 births died due to fever. However, even within the same city his ideas failed to spread. Ede Flórián Birly, the Professor of Obstetrics at the University of Pest, continued to believe that puerperal fever was due to uncleanliness of the mother’s bowel and so continued to practice extensive purging.
In 1858, Semmelweis finally published his own account of his work in an essay entitled, “The Etiology of Childbed Fever”. Two years later he published a second essay, “The Difference in Opinion between Myself and the English Physicians regarding Childbed Fever”. In 1861, Semmelweis published his main work Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers (The Etiology, Concept and Prophylaxis of Childbed Fever). In his 1861 book he lamented:
“Most medical lecture halls continue to resound with lectures on epidemic childbed fever and with discourses against my theories. The medical literature for the last twelve years continues to swell with reports of puerperal epidemics, and in 1854 in Vienna, the birthplace of my theory, 400 maternity patients died from childbed fever. In published medical works, my teachings are either ignored or attacked. The medical faculty at Würzburg awarded a prize to a monograph written in 1859 in which my teachings were rejected”
His health was in decline. He was obsessed with his work and the wronging he had suffered. He aged physically and became increasingly absent minded in his work and distant at home, slipping into depression. By 1865 he was drinking and visiting prostitutes. It’s been suggested that this was due to mental illness, the beginnings of dementia or even third-stage syphilis; a disease that obstetricians sometimes picked up from their patients. In 1865 a board made up of University of Pest professors referred Semmelweis to a mental institution where ‘treatment’ including being placed into a straitjacket, doused in water and beaten up. During one beating by the institution’s guards Semmelweis received a cut to his right hand which became gangrenous. Two weeks after his institutionalisation Semmelweis died of septicaemia; the condition he had spent his career fighting. His funeral was a quiet, poorly attended affair.
Two decades later Louis Pasteur confirmed the germ theory of infectious disease. Joseph Lister would pioneer aseptic surgery. Ignaz Semmelweis’s reputation was revised by a humbled profession. Now he was “the saviour of mothers”. There is a university named after him in Budapest and his home is now a museum. It is too soon to be able to fully evaluate Li’s legacy but in the immediate aftermath of his death he is being held up as a martyr to the nascent Chinese pro-democracy movement.
COVID-19 has been described as potentially China’s ‘Chernobyl moment’. As as with the USSR China’s monolithic one party state is struggling to contain and respond to a human disaster. The government is attempting to make the fight against the disease as a test of Chinese pride, a populist struggle to rise to. However, as history tells us disease is no respecter of borders, regimes or reputations. I’ll leave the last words to Dr Li given to Chinese media from his hospital bed shortly before he died:
“I think there should be more than one voice in a healthy society”
Thanks for reading.
- Jamie