AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Editorial View
Volume 60, Issue 2, Pages 43-45
Wei-Zen Sun 1,2 , James L. Reynolds 3

A legend has Confucius asking his aged teacher Laozi, “What is the Tao?” In response, Laozi opened his mouth wide but said nothing. Confucius’s eyes lit with insight, but onlooking students were puzzled. “Teacher’s teeth are gone,” Confucius explained, “but his tongue remains. The hard and rigid will break down, but the soft and yielding endures. That is the Tao!”

As we draft this article (first week of May), we in Taiwan are only now being hit with our first “real” wave of the pandemic. While much of the rest of the world has already moved through pandemic burnout and pandemic fatigue, we face it fresh: moving from the position of watching news to being news. On one hand, we know a lot, given that the pandemic emerged more than two years ago. On the other hand, we don’t know how it will hit us here: we’re scared. I (WZS) reflect here on the story of the pandemic as I’ve perceived and constructed it so far. I strive too—with the help of my co-author’s probing questions and patient, forgiving ear—to explore, to construct, and to relate a brief autobiographical sketch: a story of myself, as a human and as a practicing anesthesiologist, struggling to find and hold moments of balance within the storm’s thrall.

My mind cycles first back to the 2003 SARS (SARS-1) outbreak. From the luxurious standpoint of distance, two points flowing therefrom rise into mind: First, we were underprepared. Second, a particular fear-driven overreaction helped make a bad situation worse: An outbreak in a Taipei hospital was met with a draconian lockdown, creating an incubator for infection of many more people than would have otherwise occurred.

These two arms embrace our theme: Laozi’s well-tenured tongue notwithstanding, excessive softness—in the sense of complacency—exacted a tragic toll. And then, as Laozi would have observed, a seemingly steely, resolute decision actually betrayed brittleness: that lockdown came to be widely recognized as a panic-induced error.

When the current pandemic broke out 16 years later, our much enhanced preparation steered us into a safe harbor, then afforded us smooth sailing for more than two years. Though I was never deluded, on a rational level, that we were forever safe, one bumpy patch in this period of calm would whip me against the self-realization that I had become irrationally complacent amidst the tranquility: a May 2021 outbreak here that shook my sensibility.

Prior to that, I was resolved that I would not accept the COVID-19 vaccine, insofar as I supposed I would have a say in the matter. I was never an anti-vaxxer in the sense that we ordinarily use the term, but aside from the basic required childhood immunizations, I have personally refused the typically recommended vaccines for adults (eg, influenza). I generally believe that the best protection against infectious disease is fundamental self-care for body, mind, and spirit. Further, every physician/expert knows that all vaccines carry some level of risk, and that quantifying such is far from settled science. Add to that the facts that, while otherwise healthy, I have a mild autoimmune disorder, an established risk factor for adverse reactions to vaccines in general; the COVID-19 vaccines were developed, trialed, and emergency-licensed at “warp speed”; and that most of those vaccines represented the first widespread use of a novel delivery technology: mRNA. As news of the vaccines’ impending arrival in Taiwan rose to attention, I was fully intent to apply for a waiver. On this matter, and in the context of virtually no community spread here, my position stood hard as a healthy teenager’s dentition. And it was further calcified with reports in the scholarly and popular discourse of possible vaccine-associated thrombosis, myocarditis, etc.

Then howled in a May 2021 Delta outbreak here. Hitting very close to home, it reached a colleague in our own department and hung over several tense hours as we waited together for results from a department-wide test. Who might be next? My colleague in the clinic next to me? Myself? Would I be able to return home to my family that evening? And if I tested negative at that moment, would I be later introducing elevated risk into my home or workplace? Would I be sitting with patients who I feared, and who may have feared me.

One impulse was to harden even more my resolve against getting vaccinated. Had I not made a rational decision, informed by my expertise and scientific training? Finally, I softened my posture. I bent with the wind. Certainly, in good part, because the risk context had changed: community spread of a significantly lethal disease had arrived. I had a duty to protect my loved ones, my colleagues, my patients, and the general public. But I also realized that I had been unconsciously locked in a circumstance of biased thinking and selective attention. Sure, my understanding of vaccine-associated risks was rational and solid—correct, no one can say—but my fundamental orientation was significantly distorted by fear: the proximal threat had previously appeared to be the needle heading toward my arm. But some part of my belief that Taiwan—and somehow perhaps especially I—would remain forever untouched by the virus was an emotionally distorted notion.

I received the vaccine when it became available, and have since had no doubt that it was the right decision—in fact the only decision. Softness there, flexibility, humility, bending with the flow, was the way of strength and vitality. The way.

The May 2021 wave was quickly contained and, in the global scheme of the pandemic, resulted here in little direct morbidity and mortality. It did, however, cast into relief the costs of a relatively hard lockdown: All but the most urgent surgical procedures were denied or postponed. Significant barriers were erected between the public and the healthcare system. At wider levels, businesses and schools were closed, economic activity was dampened, and social connections were curtailed. All of these impacted most adversely those in society who were already most vulnerable.

As we write today, Typhoon Omicron has, at long last, made landfall on Taiwan with full force. We must be grateful that we have enjoyed such a lengthy period of calm. While the rest of the world suffered devastating initial waves before vaccines were developed, we enjoy imperfect but good levels of protection against severe illness and deaths. We are a relatively homogenous and cohesive society. While the relative lack of multiculturalism and pluralism are disadvantageous in many ways, we see this sociocultural attribute serving functionally today: the window of discourse is relatively narrow. It is much less (so far) us against each other; much more us together, facing the storm.

While there is no perfect preparation for large-scale natural disasters, we are so far and on balance, coping well: adjusting sensibly to rapidly changing conditions, and while only fools make confident predictions where myriad unpredictable currents swirl, it appears to us that Taiwan is pretty well poised to turn, to flex, as events unfold, as new and better science emerges, as existing problems may improve, as new levels or kinds of threats may emerge.

In sum, I (WZS) take from this reflection the central realization that my adventures through the outbreak emerging in December 2019 have seen me thrown off-track by a few quite simple mistakes. At one point, I tried to manage anxiety through flight into irrational complacency (I was too soft, minimizing the potential threat of the pandemic). Later, as some of its real impacts hit closer to home, I tried to manage anxiety by digging in to my understanding of the risks of vaccination—quite real and/or plausible risks, but my stance became irrationally rigid as the relevant information grew and became clearer (I was too hard). Finally, I grew stronger by understanding that I needed to take a step back and engage in self-reflection and self-observation. I believe I was able to do this in great part because several important others listened to my thinking processes with sympathetic understanding. Counter-arguments would have likely hardened my stance. Eventually, I understood that my anxieties about vaccination were overcome by appreciating competing risks and the magnitude of my primary responsibilities: to protect the well-being of my family, my colleagues, my friends, my patients, and my country. I came to experience a greater peace by letting go of an increasingly untenable illusion of control, by yielding—though not mindlessly—to forces much greater than me, forces that I have only a limited capacity to comprehend, let alone master.

I end by contemplating another typhoon in my life: My two-year-old grandson, Chi-Yi Sun, rotates wondrously, awesomely, fearsomely, and delightfully around our home. He patters cyclonically about us on excursions into Taipei’s parks and plazas, and blows us out to much-needed excursions into the nature surrounding the city.

Is a child, the manifestation of life itself, blossom of the cosmos, not a ferocious and terrifying force indeed? Do fears not press me to control him? Indisputably, I must assert myself in some circumstances. No one would allow him to run free onto a roadway. Yet, I find the unique advantage of grandfatherhood—compared to being a father a generation ago—a newfound humility, a respect for this force that is, in contradiction to my own eyes, no smaller than me. In fact, he is imbued with a force that is bigger, more powerful, and endowed with more wisdom and intelligence than I will ever comprehend.

Some of my proudest moments occur when, instead of rushing in to “protect,” to “control,” to “teach,” it occurs to me to hold back, to behold, to marvel. To notice the paths he takes, to learn, to wonder what greater, or at least different, things he may be or become that I never was and never will. To check my impulses, that is, to ask myself if I’m inclined to rush in and interfere out of a rational fear for him, or out of some irrational fear that may be my problem, not his.

The answer is not always clear. There are good times to shape and to guide. And even when it may be clear, I often fail to even notice or ask the questions. But the pursuit of perfection is a seductive and illusory hardness of its own kind. I conclude that the most common error is assuming that my place in the storm is bigger and more significant than it really is, that yielding is generally the way when I get lost. Thus, Laozi’s lesson, not merely his tongue, carries cause to endure.

What better thing do I have to offer myself or anyone else than to seek balance, to stand hard or to push when it seems necessary or right, to yield to a greater flow when that is best, to reflect on myself as honestly and as I can, enlisting the help of others, and to make peace with my mistakes?