The MERS outbreak

Life in Korea has taken a dramatic turn in the last few weeks, as there has been a major outbreak of the deadly disease Middle East Respiratory Syndrome (MERS) in the country.

It's major in the sense that it's the largest outbreak that the world has seen outside of the Middle East. And it's of real concern because the disease has a high fatality rate and there is no cure or vaccine. But the absolute numbers are small. As I write, 126 people (in a country of 50 million) have been diagnosed with the disease, and 10 have died. Most (perhaps all) of the fatalities have been elderly people with compromised health; the latest was a 75-year-old man with terminal lung cancer.

My impression is that this has not been major news in the US, but it has generated high levels of panic here in Korea and also, notably, in neighboring China. Objectively it would seem that most of the panic is not justified, but there were some crucial missteps by the government early on that have eroded public trust. That trust wasn't very high to begin with because of the way the Sewol ferry tragedy played out last year.

It looks to me like, with a little luck and no further mistakes on the part of the authorities, the outbreak should come to a natural end pretty soon, but it's hard to say for sure.

The proximate impact has so far been minimal. I've read news stories saying that sales of face masks are up by some incredibly high percentage (was it 700%?) and that people are avoiding public transportation, but here in sleepy Gyeongju I've not noticed any change at all in public life. Restaurants are open and bustling, people walk the streets casually as before.

But there have been many significant ripple effects that are beginning to touch our lives, and are definitely affecting the lives of many Koreans. Large numbers of people (about 3,800) are under quarantine because of the possibility of exposure to the disease.* They remain under quarantine until they test negative for the virus or pass through the two-week incubation period without developing symptoms. Over 1,000 schools in the country are closed (pointlessly, it would seem). Conferences and excursions of all sorts are being canceled.

The sense of alarm in China appears to be especially high. Koreans are being asked not to enter China. Hundreds of thousands of tourists from China have canceled planned visits and tours to Korea. There are many direct flights from China to the tourist mecca Jeju Island, off the southern coast. Although not a single MERS case has been reported there, flights from China are so empty that some are being canceled because they literally have zero passengers.

As you might imagine, all this is not good for the economy.

To a large extent the panic is unwarranted, and is reminiscent of the kind of the irrational fears we saw last year in the US around ebola. MERS is actually extremely difficult to catch. It is not airborne, and is transmitted between humans only through intense, extended contact. Worldwide, it has mostly been contracted between family members or among patients and caregivers in hospitals. It doesn't appear that you can catch the disease in public. The US Centers for Disease Control and Prevention describes it this way:*

Person-to-person spread of MERS-CoV, usually after close contact, such as caring for or living with an infected person, has been well documented. Infected people have spread MERS-CoV to others in healthcare settings, such as hospitals. Researchers studying MERS have not seen any ongoing spreading of MERS-CoV in the community.

In fact, to date all confirmed cases of MERS infections in Korea have happened in hospitals.* It is purely a hospital-transmitted infection. Initially the government refused to say which hospitals were housing MERS patients, probably in order to avoid generating panic. Of course, as is usually the case with this sort of obfuscation, the effect was counter-productive, generating rumors and conspiracy theories. Eventually the government had to give in and make a full declaration of which hospitals have MERS patients. As it turns out, 58—nearly half—of all cases have originated at a single hospital, the prestigious Samsung Medical Center in southern Seoul.*

The outbreak has revealed both strengths and weaknesses of the country's medical system. The weaknesses are both procedural and cultural. In terms of procedure, the hospitals seem to have done a terrible job with basic hygiene and isolation of contagious patients. I don't know enough to say if the problem has to do with practices or technology, or a combination of both. But an equally significant problem is cultural. As The Economist put it:*

One contributing factor is that many South Koreans, like the first MERS patient, visit several hospitals to look for the best care. This can spread disease faster. Hospitals are sociable places where people share rooms with strangers, and where family and friends crowd around to take care of the sick.

There's more than meets the eye in that last sentence. In fact, nursing care of the comprehensive US type is not the norm in Korea, so patients often need family and friends to provide some of that basic care. Those people are not medical professionals and don't always follow best practices (like rigorous hand-washing).

As for strengths, it is presumably the overall quality of care that has created such a low death rate here. Prior to this outbreak, MERS had a shockingly high fatality rate of about 40%. Here it's been about 10%.

As we enter starting to feel affected more and more. Tek's daycare wasn't closed, but a number of his field trips were canceled. Today when I picked him up, the teacher who answered the door literally sprayed my whole body down with disinfectant before I was allowed to enter the building. Parents have been requested to report any visits to hospitals where MERS was contracted to the director of the daycare.

A major international conference that I was supposed to attend next week in Seoul was canceled, not because of any real danger to participants, but because so many attendees from China were pulling out that it was no longer practical to hold the conference.

I think I broke my toe last week. As the swelling has finally started to go down, I'm noticing the toe is misshapen. I should probably go to a hospital to get it splinted. But a hospital is the one place in this country that I'm afraid to go right now. (A lot of people are feeling the same, of course. Lucky for me I hardly have a life-threatening emergency. I would guess that the broader effect on public health of so many people avoiding hospitals is going to be significant.)

And then there are these two signs that just got posted on the door of the studio apartment building where Erma and I rent a room to serve as our office, next to the sign that went up in the winter requesting that residents keep the door closed so that stray cats don't go in.

Some information about MERS and a public service announcement about hand washing

And here's the sign that was posted by the front entrance of our apartment complex.

Dos and Don'ts for MERS. Two of the Don'ts aren't likely to come into play here, since they involve camels.

"Avoid intimate contact with camels." Check.
"Avoid drinking unpasteurized camel milk and uncooked camel meat." Check.

We are now 3 weeks into the outbreak. It's possible it will peak soon, but it's hard to say. In the meantime, things sure are weird around here.

P.S. Just to reiterate, we feel completely safe here.


*Sources and additional references:

CDC on MERS transmission: here
News article from Nature on why MERS doesn't spread easily: here
Recent statistics: here
The Economist on missteps in dealing with MERS in Korea: here
Problems at Samsung Medical Center: here

Mom Zone

Let't talk Korean-English bilingual punning.

This is a photo of the hospital that we took Tek to back in January, when he had a really bad illness and we were worried it might be flu. (Because we didn't have any Korean medical insurance at that time, we had to pay the full cost of the doctor's visit: about $15.)

There is a pediatric clinic on the first floor, but the hospital primarily specializes in ob/gyn. The English name of the hospital appears in the koala bear logo at the top, as transcribed in the photo caption:

It says: MOM ZONE WOMEN'S HOSPITAL

The Korean name of the hospital is: Mam Jon Yeoseong Byeongwon. The first two syllables (pronounced "Mahm Jone") sound very close to English "Mom Zone".* The rest of it is "Women's Hospital" (여성병원 女性病院). So the Korean name would seem to be just a borrowing from English: Mom Zone Women's Hospital.

But wait! I am told that Mam Jon 맘존 is also a common, playful contraction of Ma-eum Jo-eun 마음 좋은, which means "kind-hearted".** So setting aside the similarity to English "Mom Zone", in Korean the hospital name means something like "Kind-Hearted Women's Hospital".

That's a pretty sophisticated bilingual pun.


* Korean has no "z" sound. The closest sound is "j". Koreans do not perceive a difference.
** Corrected from earlier.

Mopoyeom

The Korean word for 'folliculitis' was not one I anticipated learning during this trip, or indeed ever. But there it is, titling this blog entry.

I had my follow-up visit with the dermatologist today. The antibiotics have done wonders. I'm pleased to be able to show you a normal-looking (more or less) picture of my face.


My nose is no longer swollen and is pain-free. There are no more sores or pustules. As you can see, there is still some discoloration -- darker spots -- at the sites of the infection, but the doctor said these will fade to normal color and there will be no scarring.

This is after seven days of oral antibiotics and application of a topical antibiotic. The doctor prescribed another five days of antibiotics to be on the safe side. Apparently minor outbreaks of folliculitis are common -- a pimple-like swelling around an irritated follicle -- especially among men who shave, it's just that they don't usually spread aggressively like mine did. He suggested that if I use a fresh towel each time I bathe, and aggressively treat any new sores that might appear with topical antibiotics, I should be fine.

Like you, I'm looking forward to getting back to blogging about things other than my skin.

Oh, I took some pictures of the parking guys at St. Mary's Hospital. As you would have predicted if you'd seen this and this earlier entry, they were wearing cowboy hats.

Gamyeom

Many of you expressed concern about my face after seeing the pictures I posted earlier. Since the sores didn't seem to be responding to treatment with a topical antibiotic, I went to see a doctor. Erma's mother helped set up an appointment with a good dermatologist who has treated members of the family, at St. Mary's (성모) Hospital, and went with me there yesterday.

Although my face had mostly seemed to be healing, a day before the appointment something frightening happened: my nose became very red and painfully swollen.

The doctor diagnosed folliculitis, which is usually a kind of staph infection. This is in fact what I had been diagnosed with, and treated for, last month in America when I had a large swollen infected area under my left eyebrow. Although I'd taken a full course of antibiotics and had been without symptoms for several weeks, the doctor thought it likely that what I have now is caused by the same bacteria.

So, I've been prescribed another round of oral antibiotics and a topical antibiotic. Hopefully my symptoms will start to abate in a few days. I have a follow-up appointment with the dermatologist next Wednesday.

I've spent a lot more time in Korean hospitals than I ever imagined would be the case. I now have two Korean student ID cards and two Korean hospital ID cards.

(As it turns out, my tuition at the language school provides insurance and entitles me to use the university health clinic, but it seems better for now to see a doctor who has been personally recommended. Because I am not a Korean citizen and have no general health insurance, I had to pay about US $35 for my visit. Expensive by local standards, this seems pretty cheap from an American point of view. The cost of my prescriptions medications was about $13.)

Byeongwon 2

I finally saw an orthopedic hand specialist at Severance Hospital. The doctor I'd been seeing before, a pain and rehabilitation specialist, decided I should see him because of some abnormalities with my finger's recovery. This new doctor thought that the paraffin wax treatments and physical therapy exercises wouldn't be useful anymore. He said it might still be helpful to put some metal rods inside the fingers to act as internal splints for a few months, but he couldn't guarantee improvement. I opted not to do that. He also suggested going back to wearing splints at night might help, although my physical therapist in the States thought that there was no point in further wearing the splints. So who knows?

The interesting thing about my visit to the orthopedic hand specialist was the high-tech screen in the hallway outside his office. It looked like this:


Patient names are listed on the left, in the order they will be seen. Next to the first name it says "When the current patient exits, you may go in." Next to the second name it says "Next in order." Next to the third name, which is mine, it says "Please wait just a short time."

How is patient privacy protected? Most Korean names consist of a one-syllable surname and a two-syllable given name. On the screen, the second syllable of the given name is replaced with "*". This is sufficient to disguise the identity of someone. Most Koreans share one of a few common surnames, so eliminating the second syllable of the given name is the equivalent of identifying someone as "J. Smith". The last four digits of the patient's hospital ID number are also listed.

This system completely breaks down with my Western name, though! It appeared on the screen as "SLEUTHE LANC*".

Byeongwon

I've been going to Severance Hospital twice a week. It's the hospital attached to Yonsei University, and it is less than a ten-minute walk from our place.

The reason I've been going is because of the mallet finger injury I suffered back in July in America. (In mallet finger, the tendon that attaches to the last finger joint separates from the bone; as a result, the joint flops over and can't be straightened. The treatment is to splint the finger straight for at least six weeks and let the tendon re-attach to the bone.)

The first picture was taken the morning after the injury, before the fingers were splinted. The second was taken the day the splints were removed. The third was taken today. The fingers look pretty straight in the middle picture, but that's largely because they were frozen into that position by the splints and stiff as boards. As they loosened up, they also started to flop over more. I left for Korea right about when I should have been starting a program of physical therapy to restore strength, range of motion, and a normal appearance to the fingers.

So, after I was here a couple of weeks, I decided to see if I could find a therapist at Severance. The hospital completed a brand-new, state-of-the-art building in 2005 that is clean, modern, and very high-tech. There is an International Health Care Center in it that caters to foreigners and has staff speaking English and other foreign languages. For simple treatment the Center doctors can take care of you themselves; for more specialized treatment, the Center acts as a liaison to the rest of the hospital helping you schedule appointments and communicate with doctors and staff.

Through the Center we set up an appointment with a doctor, and he recommended that I get paraffin wax baths for the hand and see a physical therapist. Before each appointment I'd go to the International Health Care Center, they'd charge my credit card, and walk me over to the right place for my appointment.

After a while I realized that they were charging me $30 a visit for this service. So, with Erma's help, I started using the hospital's services directly. Since the appointments were all already set up, it turned out to be pretty simple. I even have my own Severance Hospital patient card now!

Each paraffin wax treatment costs about $15. It involves sticking my hand in and out of a hot vat of molten wax, letting the layers congeal around the hand. This seems pretty low-tech, but it's a great way of permeating the fingers with long-lasting, even warmth to loosen up the tissues and make them flexible. (If I remembered more from high school chemistry and physics I could perhaps claim that it has something to do with the specific heat, but I don't.)


My hand gets bigger and bigger, and smoother and more doughy-looking, with each immersion. It's actually quite comfortable, even soothing.


No matter how many layers of wax go on, though, my monkey-knuckle-hair shows throw black as ink.

The therapist uses a spoon to scrape off the wax, and then we repeat the whole process two more times.


Seeing the physical therapist costs about another $15. She taught me how to do little strength-and-flexibility exercises that I can practice at home and at school multiple times a day. Here I'm extending one of the injured fingers back against pressure from her fingertip.


The fingers are definitely getting stronger, but I'm not sure they'll ever fully straighten out.

From what I've seen of this hospital and the staff, I'd feel pretty comfortable getting treated here for a major trauma or injury.