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Join Shan Liu, an emergency physician and co-author of Masked Hero: How Wu-Lien Teh Invented the Mask and Ended an Epidemic. Discover the journey of Wu Lien-teh, Shan’s great-grandfather, who played a pivotal role in ending a devastating plague in China in 1911. We’ll explore the challenges he faced as a pioneer in infectious diseases and how his legacy continues to inspire Shan’s work as a medical professional.

Shan Liu is an emergency physician and co-author of Masked Hero: How Wu-Lien Teh Invented the Mask and Ended an Epidemic.

She discusses the KevinMD article, “Dependent on the mask my great-grandfather invented.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Shan Liu. She’s an emergency physician and co-author of Masked Hero. Today’s KevinMD article is “Dependent on the mask my great-grandfather invented.” Shan, welcome to the show.

Shan Liu: Thank you so much, Dr. Pho. It’s such an honor to be here and to speak with you.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Shan Liu: So I’m an emergency medicine physician at Massachusetts General Hospital, and have loved emergency medicine my whole career. And basically during COVID, as you know, we were on the front lines in the emergency department, and I grew up with this story about my great-grandfather being the inventor of the first respirator, or the reason why we wear masks during epidemics and then certainly pandemics.

And so during that time, when America was debating about what kind of masks to wear or who should wear them, I wrote a couple pieces, like for CNN and U.S. News & World Report, about my great-grandfather, because I just felt like everyone should know this story.

And fast forward, during lockdown my first grade daughter didn’t have a lot of structure, because I was her mother teaching her and homeschooling her, and we put her on an online writing class. And one of her assignments just was to write a nonfiction piece about a person. And so at that time I said, you should really know about your great-great-grandfather. And during all of that racial tension and that time, I looked at her and I said, we really should just do this. There’s not a lot of books out there for kids that feature Asians, and much less East Asians, and East Asians as heroes. And I felt like that was my way to address the racial tension that was happening and all the Asian hate crimes that were happening. And so the book formed from that.

Kevin Pho: All right, so we’re going to talk more about your book and your KevinMD article. So tell us the story of your great-grandfather.

Shan Liu: So my great-grandfather, he was born in Penang in Malaysia, and he knew he wanted to be a doctor from a very young age, and went to England to train, and was the first person of Asian and Malaysian descent to graduate from the University of Cambridge with a medical degree. So he stays there, studies infectious disease and tropical diseases, and then goes back to Malaysia and actually had to endure a lot of racism. You could only get a position, even though Malaysia was a colony, unless you were of European descent, even though they were part of the British colony.

So he ends up ultimately doing private practice, and then leaving to go to China to work in medical education at one of the new medical schools there. And eventually, because of his training, was recruited to northern China to deal with this mysterious plague. And he’s 31, he does the first autopsy in China, and basically finds out that it’s a respiratory, it was Yersinia pestis, and it was basically being spread through respiratory droplets rather than from rats, what they had traditionally thought the plague was spreading in terms of its spread.

So he ends up saying, OK, we have to separate people, we have to isolate them, we have to quarantine, we have to wear masks. And originally people wore masks for very different reasons up until that point, but this was the first time somebody implemented wearing a mask to prevent the spread of respiratory diseases. And ultimately has people invent the forerunner of the N95. And within four months, among other measures like isolation and really shutting down the whole city, the plague is ended in four months.

So he goes on to manage the public health system in China and really implement sort of more modern measures to medicine and to public health there. And then ends up being the first to earn a nomination for the Nobel Prize in medicine, first person of Asian descent and first person from Malaysia to win that. And so yeah, that’s the story that I grew up with, and it was really personal during COVID to depend on the mask that he actually invented 100 years prior.

Kevin Pho: So back in the early 20th century, what was public health like then in China, and what was infection control like then, before your great-grandfather arrived there?

Shan Liu: Yeah, so pretty much not much was being done from a public health standpoint, or even, for a lack of a better word, sort of modern or typically thought of as Western medicine, because people hadn’t been trained in it and brought it back to China. So he started all of these measures. He started the public health service. Things like, they actually attribute the lazy Susan to my great-grandfather, not as something you do in a restaurant, but really as a public health measure. So, don’t share your utensils, your chopsticks, with other people, and have basically common-use utensils at the table, and then had this lazy Susan as a means to facilitate that, rather than everyone just sharing each other’s meals and utensils.

So yeah, pretty much there wasn’t this public health system, there wasn’t this germ theory of preventing spread of disease, and he really walked in sort of, and at that time, China had gone through an incredible change politically. It went from being the empire and the emperor to some change in the political scene. So very different sort of world back then.

Kevin Pho: So he invented a precursor to the N95. Tell us more about that. How did he create it? Tell me what kind of materials he thought about in terms of bringing that precursor to the N95.

Shan Liu: Yeah, thank you, great question. So up until that point, the typical masks were worn for either cultural festivals and things like that, so you think of people wearing masks for decorative issues, or they were wearing them sort of to prevent the spread of miasma, in the Middle Ages, like smells, and how they thought that diseases were being spread then. But really he’s the first to recommend people wear this so that germs are not being spread when people cough or when they breathe near each other.

So he invents what’s called the Wu mask, and it’s made of cotton and cloth, and it’s just this huge thing that just covers your entire face. And it’s really the mechanics, like the N95, it prevents germs from being spread through mechanical methods, right? So if it hits one level, then it bounces around, and hopefully you have enough layers that the germs don’t get to the person wearing the mask, or it’s not being spread as well.

So at that time, it’s not like you had factories. They basically had to use what they had on hand and figure out, OK, we have gauze, we have cloth, let’s just figure out a way to prevent this from being spread between people. So it’s really out of duress, right? It’s really out of the need, because it was a nearly 100 percent fatality rate, that you had to come up with these methods to prevent spread.

Kevin Pho: So early on in his career you mentioned that he encountered episodes of racism. That certainly resonates with the racism that Asians faced during the pandemic. Tell us more about the racism that he faced.

Shan Liu: Yeah, so great question. So one was, being of Asian descent or Chinese descent, even though he was trained in England he couldn’t get certain jobs in Malaysia, even though it was Malaya at that time. Even though he had the credentials, he simply couldn’t, because he was of the British Empire but he was of Asian descent. And so literally couldn’t take a post in Malaysia because he wasn’t of European descent in the British colony or in the British Empire. So that was one episode.

He also, when he went to Harbin, or to northern Manchuria, there were a lot of other people from France, Russia, Japan also in the area, because it was a big trading post, and so there was a lot of political interest in that area because it was an epicenter of trade. So a lot of people were interested in controlling that area, so you have a lot of influence from a lot of different powers there. So there were Japanese, Russian, French, European physicians in the area.

And when this plague comes out, everyone comes and, like, what’s going on, and they all have their different theories. And typically up to that point the plague was, as I mentioned, spread through rats, and so that’s how they wanted to control this epidemic, by basically dealing with the rats in the city. And my great-grandfather basically says, no, I did this autopsy, and based on germ theory that’s not going to work. If you try to control the rat population, we really need to control people from spreading it to one another. And the reason why he figured that out is because physicians were going to see patients and then dying right after, and he knew that they weren’t getting exposed to rats and fleas necessarily. And that’s basically why he ended up going down a different pathway and figuring that out.

But there’s this famous sort of story where this Frenchman comes to him and he’s like, you Chinaman. And so my great-grandfather basically says, no, we need to do it a different way, it’s not spread through rats, it’s spread through respiratory droplets. And the Frenchman says, you Chinaman, how dare you defy me, or how dare you question my authority. And then basically this French physician goes on rounds, doesn’t wear a mask, and the story basically ends that a couple days later he dies. So that was sort of the triggering point for people believing that it was being spread in different methods.

Kevin Pho: Now, how did you hear about these stories from your great-grandfather? Did you actually get a chance to meet him? How did these stories get passed down to you?

Shan Liu: Oh, great question. So he fortunately wrote an autobiography about a year and a half before he passed away. He wrote this long autobiography about his whole journey, and so that had been on my parents’ coffee table in the living room just my whole life.

And then it wasn’t until college, which I mentioned in the essay, that I really go to China to just learn about what he had done. He ended up starting what’s the equivalent of the AMA in China, and so it was their 80th anniversary. And as a kid growing up, or in high school and college, it’s like, oh yeah, OK, these are stories, but they’re not really real to me. And it wasn’t until I actually went to China and just saw all of the things that they really were honoring him with, like really revolutionizing modern medicine there, did I really realize what he had done. And I wanted to go to medical school at the time, and so just really learned so much about him from my colleagues that I met at that conference. And then later on we went up to Harbin about five years ago with my children and my parents, and I was able to walk in the footsteps of where he actually did his work during the epidemic.

Kevin Pho: So you’re an emergency physician, and of course a lot of your great-grandfather’s stories resonated with you during the pandemic. So how did he influence your medical career?

Shan Liu: Great question. So I don’t remember a time that I didn’t want to be a physician. My father is an engineer, and I think if he could tolerate blood he would have become a physician, but he always shared these stories of epidemics and public health. And so I just don’t remember a time I didn’t want to do that, and I really was interested in public health.

And it wasn’t that he pressured us to do it. My two sisters are not even remotely related in terms of medicine, they don’t do medicine. So it was really just something that I felt like, oh, that is fascinating. It’s such an honor to think about, how do you help people on a public health scale to actually prevent disease?

So I think it had a huge influence, because I always had this idea that, oh yeah, besides just medicine there’s also thinking about the public health as a whole. And so I’ve always struggled with, do you spend your efforts doing things at the bedside in emergency medicine, which is very much one-on-one, affecting their lives, versus do you spend more time in public health and try to prevent disease? And I think the two can marry, but sometimes you have to put your hat on for the bedside clinician hat versus thinking about public health in general.

Kevin Pho: Do you think that there’s anything that we as a society today can learn from your great-grandfather?

Shan Liu: Oh, great, great question. Well, ironically, I think some of the same themes about masks. I mean, we still debate masks today. A 100 years later, a pandemic later, there’s still just a lot of resistance and struggle about, how do you prevent disease? And not that I’m necessarily wearing masks anymore after COVID, but that idea that we still had to reinvent a whole discussion about masks a century later.

I think Asia pivoted so quickly for cultural reasons. There’s an article in the New York Times by Christos Lynteris, who’s an anthropologist in Scotland, and he basically is like, the reason why Asians pivot so quickly to masks is because it’s a sign of, culturally, I believe in germ theory, for one, and two, I care about my neighbor and other people in society, that I don’t want to get them sick. I wear a mask to protect myself, but I also wear a mask to protect others.

And there is still this difficult stigma, I think, in the United States. It’s different, it’s better after COVID, but it’s still controversial. And there was so much controversy over who should wear masks and when in our country, that it was interesting, because I think in Asia it’s just sort of not even a question, right? Like, oh, I just wear this because I don’t want to get sick, I don’t want to get you sick. And it’s really that article that Dr. Lynteris wrote about, it’s basically a nod to, we believe in germ theory, we actually believe that I’m going to prevent the spread of this by wearing something. That’s a small sacrifice, but yes, it’s uncomfortable. We all know that it’s not fun to wear masks, but we do it to protect others. So I think that’s the lesson we can learn.

And then of course I think the general lesson in reading his story, even 100 years later, was that there is still a lot of just stigma and bias in terms of, we can learn from other cultures. Asia had been dealing with this months before things really hit the United States, and so instead of reinventing the wheel, why can’t we think about best practices that people who are experienced can share with us?

And what my great-grandfather did right after the epidemic ended was that he organized the first International Plague Conference, and had people from all over the world come to China and basically say, we need to learn about this, because these will happen again. And they did. They had these little epidemic breakouts of the plague for the next couple years, and instituted these measures to make sure that they got stamped out without it spreading all across the globe.

Kevin Pho: We’re talking to Shan Liu. She’s an emergency physician. She’s the co-author of Masked Hero. Today’s KevinMD article is “Dependent on the mask my great-grandfather invented.” Shan, we can end with maybe a few sentences on how you would like us to remember your great-grandfather, and then end off with your take-home messages.

Shan Liu: Great, thank you. Yes, so I think the take-home message one is that public health measures do make a difference. So I think with some amount of small sacrifices on the part of the individual, we can impact epidemics, and it just takes buying in as a community to care for one another.

Two is, I would like just to have more stories that include representation of Asians, and particularly East Asians, as heroes. I just don’t see a lot of those stories, and I largely wrote this book for my children, to be proud of their heritage and to be proud of who they are in terms of where they come from, and their ancestry and their race.

So I also think that things like silver linings can come out of things like COVID, which was all difficult for everyone, but there was a lot of, I think, finding a passion project, finding a way to deal with all the stress of being in COVID as a physician and being an emergency physician, that this was really a passion project. Which I applaud you, Dr. Pho, for really highlighting how people can thrive in careers in medicine despite really enormously difficult circumstances like epidemics, or just the way that medicine can be really difficult, that you do really need to find these passion projects. And that’s really what this book was about for me, was wanting to spread those ideas and those messages, but also really as a way that I could deal with what was going on in the world in terms of COVID and all of the racial tension.

Kevin Pho: Shan, thank you so much for sharing your story, time, and insight, and thanks again for coming on the show.

Shan Liu: Thank you so much. Quite the honor, and just really so pleased that we could share this story with you.