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Dean's Corner

Academic public health's Forrest Gump by Professor Gabriel M Leung at 2018 Li Shu Fan Oration, Li Shu Fan Medical Foundation

05 May 2018

Secretary (Sophia) Chan, Dr (Walton) Li, Dr Tsao (Yen-chow), Mr (Wyman) Li, honourable directors of the Foundation, colleagues of the Hong Kong Sanatorium and Hospital, distinguished guests, friends, ladies and gentlemen,

           Thank you for your kind welcome but it remains for me to reciprocate by saying how much I appreciate your presence. This must be a most propitious evening since there are many alternatives for you to choose from, including the Hong Kong Medical Forum hosted by my own Department of Medicine, Hong Kong Academy of Medicine's Medical Education Conference, Peking University's 120th anniversary weekend, Peter Woo's birthday dinner, Margaret Leung's farewell dinner from Chong Hing Bank, Lui Siu Fai's family wedding, and of course Maestro Joe Hisaishi composer extraordinaire for Japanese anime films in concert with the HKPhil, amongst numerous others. Yet you chose to be here. So give yourselves a round of applause for being loyal to the Hong Kong Sanatorium and Hospital, and perhaps inadvertently having made the foolish choice!

If the former two-time British Labour Prime Minister Harold Wilson is to be believed, "a week is a long time in politics", then I suppose two years must be an eternity. I was first asked to give the Li Shu Fan Oration in 2016 but gladly bowed out at the eleventh hour to make way for the then "retiring" Chief Secretary for Administration Mrs Carrie Lam to give her medical swansong, of course only to be delighted by her visionary speech as Chief Executive-elect by the time the 2017 Oration rolled about.

There is another saying about politics that goes as follows: "academic politics is the most vicious and bitter form of politics, because the stakes are so low." Since last year's Oration, I have had to live out this dictum alas. Juicy and gossipy the details may well be, as would befit any society dinner such as the present occasion, I shall desist from engaging in the tittle-tattle – 沉默是金 – more on this wise adage in a moment.

Instead I will be spending the next hour reflecting on a moniker I was recently given by the founding dean of public health at the University of Toronto, who perhaps has the distance to give an objective view of my professional life so far. It all came about on the first day of this Year of the Dog, 年初一, when The Lancet published a profile on me , whereupon my Torontonian colleague emailed the following :

"You are truly the Forrest Gump of academic public health, except that you happen to be brilliant."

I was rather suspicious about the "brilliant" part but really liked the Forrest Gump analogy. And here is why.

With Mother's Day coming up next week, surely we must agree with all mothers including Forrest Gump's. For one, my life has indeed been as delightfully unpredictable as a box of DeLafée chocolate truffles. When I think about it, I guess it may have something to do with my personality and heritage.

So first, as this is an august gathering of the best doctors in town, let me show you a simple X-ray of the cervical spine.  The panel on the left is a lateral view of my neck and the most outstanding feature is what we doctors would call the loss of normal cervical lordosis, which simply means the neck is abnormally straight, or in colloquial Cantonese 硬頸! On the right-hand panel, you can see a left oblique view that shows the foramina or openings through which spinal nerves exit. You can see significant narrowing at the C5-6 and C6-7 levels, bone spurs and some loss of disc space between vertebra. My main symptoms of numbness and tingling in the affected dermatomes are textbook classic, and can be relieved with flexing the neck or bending forward. In other words, to minimise suffering, I should keep my head down – in spondylosis as in life generally! However I have been taught from a young age that, as a gentleman,  – "come praise or come blame, we hold our heads high". I suppose I will keep on suffering – 性格註定命運吧!

Continuing on with heritage: I am fortunate to have had many distinguished forebears by way of the various schools and professions with which I have had the privilege of having been associated. Following the excerpt of my old school song drumming into us the virtue of holding our heads up high, let me now play you another song written together by two seniors or 師兄's. Leslie Cheung and I shared the same piano teacher and Sam Hui is a fellow HKU alumnus, in both cases decades apart however. Pay careful attention to the lyrics please.  

A minute ago, Leslie sang:

受了教訓 得了書經的指引

I will therefore now try to share some wisdom from the Chinese classics that have helped me overcome the more challenging moments of my career.

First up is my favourite scholar-official Su Shi (蘇軾) or more popularly known as Su Dongpo (蘇東坡)

道遠誰雲會,
罪大天能蓋。
君命重,臣節在。
新恩猶可覬,
舊學終難改。
吾已矣,
乘桴且恁浮於海。

Focus your attention on 「臣節在」and「舊學終難改」which express Su's moral rectitude, or "spine" in the vernacular. No wonder I have a stiff neck! When political winds blew against him, which happened all too often, he chose to follow Confucius' advice as recorded in The Analects:

子曰:「道不行,乘桴浮於海…」

My longstanding fascination with Su Shi has recently been reinforced by the chance gift of a book on the protagonist by a government official, trying to pull me out of my emotional nadir. In it was a passage explaining how a fall from grace could be so freely and elegantly captured in calligraphy for all posterity to admire. Specifically this next slide  shows part of the famous scroll 《寒食帖》, popularly acknowledged as the "third best semi-cursive script ever" (「天下第三行書」). It was written after Su Shi was banished from the court in Bianjing (汴京) to Huangzhou (黄州) where he in fact acquired his more popular name Dongpo (東坡) as he farmed on a hillside on the eastern side of town. Notice the verse「臥聞海棠花 泥汙燕支雪」in which the characters 花 and 泥 are written in one continuous stroke, indicating that one day you may be the most stunning flower and the next dirt. It also reflects Su's bitter-sweet reconciliation with his own fate.

My next set of quotes from ancient texts concerns the age-old link between doctoring and politicking.  The top quote comes from The Yellow Emperor's Treatise on Internal Medicine circa the Spring-Autumn Warring States era or some would say West Han period and is very much self-explanatory. It asserts a hierarchy of the increasingly virtuous role of a doctor, from treating disease to looking after individual patients and ultimately the entire nation.

The middle passage describes an episode when 晉平公fell ill and the royal physician 醫和 was called on to attend him. He gave a terminal diagnosis saying:

「不可為也。是謂遠男而近女,惑以生蠱(古);非鬼非食,惑以喪志。良臣不生,天命不祐。若君不死,必失諸侯。」,

whereupon 趙文子, one of the mandarins present promptly questioned 「醫及國家乎?」why as a doctor he would comment on matters of state. 醫和 retorted 「上醫醫國,其次疾人,固醫官也。」 , QED.

To complete the circle, both of the above examples exhorted doctors to take an active interest in governance for a good society. The final quote comes from 范仲淹 who was a high official during the northern Sung period. When foretold by a soothsayer that he would never become prime minister, Fan replied that he would then rather look after the bodies and minds of people –「不為良相,願為良醫」.

In fact one needs not look into the ancient past for examples of politicking doctors. This next slide  showcases more recent personalities since the HKU medical faculty came into being during the past century and a half or so. At the top is a quote from Rudolf Virchow, founding dean of pathology whose eponymous triad of the pathogenesis of thrombosis is still learned by today's medical students. Next comes our first of two graduates, founding father of modern China after his medical career had met with the protectionist medical establishments of Hong Kong, Macau and Guangzhou. Little wonder portability of licensure and mutual professional recognition are knots that will continue to plague future Greater Bay Area talks. Third on the list is Sun Yat-sen's former minister of public health, Dr Li Shu-fan in whose honour we are gathered here this evening. Next we can see Sir Kai Ho Kai, one of the founding triumvirate of our School, followed by Sir Chau Sik-nin whose son the late Chau Kai-bong, or at least his matching outfits with Brenda, would be most familiar to you. Sir Harry Fang hardly requires any introduction, nor of course the evergreen Dr Leong Che-hung who delivered the first Li Shu-fan Oration. The remaining two rows of medical luminaries who have gone into politics one way or another are contemporary colleagues who regularly feature in the daily headlines, albeit some more than others, with the sad exception of the late Dr Lo Wing-lok. So, ladies and gentlemen, you can see that I am in, well, mostly good company.

To recap, I have been blessed by a varied and exciting first half of my professional life. Contrary to what some may suspect, I had not and quite frankly would never plot to advance my career, rather wandered into the various jobs I have held with little planning and certainly no cunning, while holding fast to the principles and values which have been inculcated in me through birth and breeding.

I should now like to highlight a few of the stations in my career so far, just as Forrest Gump stumbled into different phases of his. Both of us delighted in discovering, recovering and rediscovering the marvels that awaited us in our chocolate boxes called "life".

During the last Year of the Dog in 2006, former US Vice President Al Gore produced and starred in a documentary called An inconvenient truth that spoke truth to power. He dissuaded the world from resting in the false comfort of reassuring lies as opposed to struggling with inconvenient truths. Sadly, for his country and the world at large, one Chinese zodiac cycle later, fake news expounded by his President is symptomatic of an age where power trumps truth (with the pun fully intended).

From the day I joined HKU as a clinical lecturer, I have done myself no favours by speaking truth to power. As my first project being the most junior member of staff, I chose to research the vexed issue of breast cancer prevention by mammography screening during a time when it had already become the standard of care in the West and that the Hong Kong Department of Health was about to expand coverage through opening more Women's Health Centres after a couple of pilots, as was the Hospital Authority with its pioneering effort at Kwong Wah Hospital. Two decades later, it still captures headlines and attention at the highest political level.  These latest news reports point out that government remains neutral on the issue and does not recommend for or against mass screening.  The four largest cancer charities take fairly different views. Some experts think it morally indefensible not to offer screening to all while others believe it unethical to do just that. Surely it deserves a fact check!

Going back to the biological basis of screening , a test can only work optimally when there is a detectable pre-disease state. The fact is that pathologists have yet been able to identify such a precursor lesion, quite unlike say colorectal or cervical cancer.  DCIS or ductal carcinoma in situ is not it I am afraid, contrary to popular myth.

That said, I carried out a meta-analysis of the eight randomised controlled trials of screening cumulatively involving half a million Caucasian women and concluded that in those populations there would likely be 20% fewer deaths due to breast cancer. I assumed that the same risk reduction would apply in Hong Kong Chinese, even though our disease rates are less than one-half of those found in western women with a demonstrably different age distribution.

I then asked the next logical question:  if there were new funding to save lives with mass cancer screening generally, what would give the best bang for the buck?  I considered the only three cancers which could apply to the whole population and that there was a validated screening test – namely breast, cervical and colorectal cancers.  Here is a set of efficiency frontiers which basically show that we should invest in ensuring all women receive free Pap smears every three years first and foremost, then cover colonoscopy every ten years for those aged 50 or over, and if we still have extra funds consider mammography for those on the wrong side of 50. This year's government Budget promises mass screening for colorectal cancer but we are still leaving women out of pocket for Pap tests and HPV vaccines which would avert deaths from cervical cancer. Therefore consideration for the less cost-effective publicly-funded mass mammography would be premature.

Next I asked what if we only focused on breast cancer and set out to prevent as many related deaths as possible, disregarding other cancers for the sake of argument. I looked at the entire spectrum of services, from screening to palliation and compared current standard of care offered by the Hospital Authority with best available care that money can buy.  Again, the efficiency curves show that in descending order of value for money, we should reduce waiting time, enhance home-based palliative care for those close to the end of their suffering, provide aromatase inhibitors and endocrine adjunctive treatment where appropriate, and then if there were still additional funds available consider screening well women at average risk of disease by mammography.

Both sets of analyses, carried out independently by different PhD students and post-docs of mine over the span of five years, converge in that screening mammography would yield the least bang for the buck at the societal level, even assuming it works just as well in Chinese women who present differently compared with their western counterparts.

In parallel, internationally, the Nordic countries began to take a closer look at their mass screening programmes that had already been running for 20 years by then. They noticed that breast cancer death rates appeared no different in communities that had a population screening programme compared to those that did not.  A couple of prominent groups in the US and UK also raised similar concerns as well as disproving the putative benefits of screening those in their 40's.

Before you conclude that I am a New Age hippie luddite who naturally oppose prevention and wellness, despite my medical credentials, let me stake two disclaimers. I have been talking about public health policy, not informed personal choice by individual women. There is a subtle but crucial difference. And, I am not alone in giving pause to indiscriminately treating screening as a "motherhood and apple pie" issue.  From the first exposition by the polymath and polemicist Ivan Illich in Medical Nemesis during the 1970s to Barbara Ehrenreich's recently published Natural Causes, the medical establishment has been criticised for the over-medicalisation of life. Ehrenreich, who holds a PhD in immunology as well as being an iconoclastic writer and activist, expounds on her belief that much screening is at best invasive and at worst a sham. While I find her thesis excessive and at times inappropriately critical, it should nonetheless provoke our ilk to reflect.

Fully 20 years since I first raised the red flag as a naïve young lecturer fresh off the boat, government recently asked me to lead a massive study aiming to find the best way to reliably detect and provide better care for women who unfortunately suffer from this awful disease. Ava Kwong whom we all adore and admire is of course a major contributor and leader in this exercise. We expect to complete recruitment of 3,000 women with invasive cancer, 500 with DCIS and 3,500 controls without disease by year end. We should have a policy recommendation by the summer of next year.

My next foolhardy prosecution of conventional wisdom and political expediency concerns school closure during influenza outbreaks. Primary school children and those in kindergarten had an extra week off prior to Chinese New Year on account of the influenza B seasonal peak.  The media trumpeted the policy's apparent "success" and uncharacteristically became the loudest cheerleaders for government. But did school closure really cause the outbreak to dissipate or would it have declined anyway? Chicken or egg first?

This year was the third time in the past decade that schools had been closed during an epidemic. My team attempted to answer the chicken vs egg question each time.  The left panel shows that the 2008 seasonal 'flu epidemic had already been on the wane, as the real-time reproductive number of less than 1 indicates. In other words, the intervention was likely unnecessary and merely coincided with a fall in the case count but had little to do with it in fact. The right panel from the 2009 pandemic demonstrates the opposite, that is closing schools early for the summer actually worked – reducing transmissibility by 25% – and probably saved lives by buying time for society to prepare and accommodate.  Regrettably I cannot report the same for this year's exercise. Like the 2008 instance, it only produced a small, or more precisely a 4% reduction in case count, mostly in children as opposed to the elderly who were at highest risk for complications and even death, however much praise has been heaped on it by the lay press. Perception may be everything in politics but counts for nought in science.

Like the rest of Hong Kong, when I opened my box of chocolates in the spring of 2003, my life was changed forever. It was my baptism into the world of infectious disease epidemiology, by fire. The late Tony Hedley, Lam Tai-hing and I wrote to then Director of Health Dr Margaret Chan volunteering our services during those extraordinary days, although none of us had worked in infectious disease control previously. Therefore we roped in the world's leading laboratory led by a former Rector of Imperial College, London Professor Sir Roy Anderson. Together we cracked the epidemiologic riddles of the SARS coronavirus and did our bit to stop the outbreak, alongside the brave clinicians, clever virus hunters and indefatigable public health workers.  But as you can see from the author lists of the two landmark papers that summarised much of that herculean effort, our names were "stuck in the middle" which in the esoteric world of academia means we were not the principal contributors and quite frankly hanging on the coattails of the people who did the heavy lifting.

Ten years later, 十年寒窗, I took another piece of chocolate from the same box labelled infectious disease control. This time the novice has become the master. I was asked by the China CDC to dispatch a team to Beijing to help with the control effort for the newly emerging H7N9 influenza outbreak in the Yangtze River Delta. The bug had evolved an entirely new property never before seen – low pathogenicity avian influenza that could infect humans. Within two weeks, we not only worked out the public health solutions for the national authorities, our efforts were rewarded with three papers published in the Lancet and one in the BMJ – and our names bracketed the author lists, indicating that this time around we did all the heavy lifting.

More recently we wandered even farther afield to provide scientific support to the yellow fever outbreak control in Kinshasa of the Democratic Republic of Congo.  Our findings in part informed the WHO's decision to split the available vaccine stockpile into one-fifth of the original dose so as to stretch the supply to cover five times more people. This is the scientific equivalent of "five loaves and two fishes", 五餅二魚.

At the global level, throughout most of 2015 and 2016, I was closely involved in the post-mortem of the West African Ebola outbreak, as a commissioner of the Global Health Risk Framework convened by the US National Academy of Medicine, a member of the Harvard-London School of Hygiene and Tropical Medicine Independent Panel and a reviewer for the UN Secretary-General's High-Level Panel. Looking back, all this started with that first leap into the unknown back in 2003 – "life was like a box of chocolates, you never know what you're gonna get" indeed.

Helping the world sort out its troubles may be gratifying, although there is no place like home. So coming back to Hong Kong, surely we all remember the watershed events of "Occupy Central", or as some say the "Umbrella Movement".  Even before the civil disobedience campaign officially began on September 28, 2014, I had already been petitioned by students the week prior to give carte blanche to indefinite absence from class without penalty and to provide for online substitute tutorials and makeup sessions. I explained to the students, and to the press corps which they assembled, that it would be a dereliction of my duty as the statutory authority certifying their competence as registrable medical practitioners if I were to grant the requested waiver. The answer was a clear "no". I was promptly labelled as a pro-establishment lackey.  Then the tear gas canisters went off on Harcourt Road on that fateful Sunday evening of September 28 and I found empty classrooms and laboratories the next morning and for most of that first week post hoc.  As any parent would, I went looking for the missing students three times over the course of the 79 days, starting on day 2. All of a sudden some began to see me as being too sympathetic to the young people. So I had the dubious distinction of having been perceived as either too blue, or even red, and too yellow at the same time.

As a scientist, my job is to study and analyse in a dispassionately unbiased way, without fear or favour. As a doctor, I was particularly concerned about the possible impact of Occupy Central on population health – physical, mental and social according to the WHO.  So I set out to assess, amongst other outcomes, depressive symptoms before, during and after those 79 days. The prevalence of probable major depression, which is a serious clinical condition requiring treatment, shot up from a pre-event baseline of about 1.6% to an average of about 7% up to a year after the protests ended. In fact, this four-fold-plus increase persists to today in our continuing longitudinal follow-up, despite the decline in sociopolitical conflict amongst family members in the same household. Remarkably, this melancholic miasma is pervasive and has affected every one, regardless of one's political persuasion or whether one actually took part in the protests.

So we dug deeper to better understand whether there were specific identifiable subgroups who would be more or less susceptible to such a major social movement. Lo and behold, it turned out that 4 in 10 residents became depressed whereas the other 60% were resilient or resistant. Here is where sociology meets biology and we have opened up a novel avenue of research through this process.

The more eagle-eyed amongst you must be wondering how we could have obtained pre-event data. Were we that omniscient to have predicted the protests thus having carried out a baseline survey beforehand? If only. As Louis Pasteur once said, "chance favours the prepared mind".  We were lucky that the Hong Kong Jockey Club Charities Trust invested over 200 million dollars to fund the FAMILY project back in 2007 to better understand family and social harmony and its health impact. The cohort consisting of a 1% random sample of all households in Hong Kong formed a key component of the project.

Ten years later in 2017, in her maiden Policy Address, the Chief Executive and Li Shu Fan Orator last year announced a major push for primary care. She specified four key objectives. The last of these pointed to the need for "big data to plan and devise strategies that best fit the needs of the community". Government looked around for the requisite "big data" and were much relieved when they learned of the FAMILY cohort which in 2013 and 2015 had already delivered tailored reports for each of Hong Kong's 18 District Councils on the health status of their respective communities. Little could we have imagined how our preparatory work in 2007 two Administrations back could help the government of today – surely another instance of "you never know what you're gonna get".

Like Forrest Gump, my career so far has mostly been a series of coincidences by happenstance, where serendipity and God's will and blessing have guided me as a public health itinerant in the medical and political landscape of our time. Fate willing, I will continue to journey through the second half of my professional life with the same passion, principled nature and alas like dear Forrest, dim wit. I will rely on you, my teachers and friends, to cheer me on with cries of,, well, "Run, Gabriel, run", as I continue to sweat it out in the rat race of life. But ultimately,, I agree with Forrest that we should all fulfil our destinies while floating around accidentally like on a breeze wherever life takes us.

One thing I do know for sure though, I will always hold dearest the apricot seeds of the medical forest so that they can bloom and blossom in service of our patients and country. So it would be fitting that my students and trainees have the last word, in song! Ladies and gentlemen, 杏林遍地.