Episode 42 - Siddharth Sridhar

In this episode, we are honoured to be joined by Dr Siddharth Sridhar, whose pioneering work in the field of infectious diseases has pushed him into the public spotlight. In a wide-ranging discussion with our Senior Partner Colin Cohen, Siddharth explains his passion for microbiology and his acclaimed research into viral hepatitis. He also reflects on Hong Kong’s Covid-19 response and the lessons to be learned. Stay tuned. 

• 00:31 Introduction to Dr. Siddharth Sridhar
• 01:31 Early Life and Journey to Hong Kong
• 02:39 Choosing a Career in Medicine
• 03:30 Becoming a Microbiologist
• 05:30 Breakthrough in Hepatitis Research
• 09:57 COVID-19: Early Stages and Response
• 13:33 Challenges and Lessons from the Pandemic
• 21:27 Future Pandemic Preparedness
• 26:15 Personal Interests and Reflections
• 28:36 Conclusion and Final Thoughts

Transcript

[00:31:00] Colin: Today, I am delighted to be chatting with the award winning infectious disease expert, Dr. Siddharth Sridhar, a clinical assistant professor in the Department of Microbiology at the Hong Kong University. He has conducted world leading investigations into transmission and treatment of viral hepatitis and was heavily involved in the pathbreaking research into COVID 19. He has become a familiar figure via mainstream and social media. I'm delighted that his passion for knowledge and sharing and public health education has brought him onto our podcast. Siddharth, thank you so much for joining us. And as I always ask my guests, what's been keeping you busy recently?

[00:31:42] Siddharth: Oh, it's been fun. So at the university, I think the last thing I can say is I'm bored.

So we juggle different things. I see patients. I'm still heavily engaged in research and there's always the teaching of our next generation of doctors to look forward to. So yeah, there's a lot keeping me busy.

[00:32:00] Colin: Let's go back in time, tell us about your early days and how you got to Hong Kong.

[00:32:06] Siddharth: Right, so I actually grew up in India and I spent most of my childhood there. So it was in 2003, right at the end of SARS, that my father, who was a banker, basically got an opportunity to actually spend some time in Hong Kong. So he was supposed to be here for a fixed four year term. And back in the day growing up in India, and all we knew about Hong Kong was pretty much Jackie Chan, Bruce Lee, martial arts, you know. We didn't really know much about it.

So there's a little bit of uncertainty cause I was also coming up to the end of my school life and their university and a lot of things to consider, but we decided to take the plunge. And I finished off my secondary school in Hong Kong.

[00:32:48] Colin: Excellent, so it's the island school, and you went to Hong Kong U?

[00:32:52] Siddharth: That's right. So I wanted to do medicine. So the option was really going back home to India and doing it there or staying back in Hong Kong. And circumstances ended up with me getting an offer at the University of Hong Kong. So I stayed on and did my medicine here. 

[00:33:08] Colin: What made you decide to go to medicine? Your father was a banker, didn't the lure of commerce interest you? 

[00:33:14] Siddharth: That's right. Actually, can't even answer that because, now things are turned on their head and I end up interviewing high school students who want to get into medicine and I realize asking them why they want to do medicine is a difficult question for them to answer because nobody really knows when they are, 16, 17 years old because they don't know what the field is like.

I mean, all I can say is back then is I was always impressed by how Doctors could have a very material impact in terms of somebody's health in a very short period of time. I was always interested in science and stuff, but I don't know, my feeling was that if you get into research, the impact of what you do would only become apparent many, many years down the line.

So I'm one who likes to see quick results, so I decided to get into medicine.

[00:33:59] Colin: And then you did your medicine, you did your normal internships in the hospital, qualified, and then you went to become a microbiologist. How did that come about? Was it just sort of something that's interested you?

[00:34:11] Siddharth: Again, it wasn't something I planned on at all, like most things in my professional life, I must say. I ended up spending some time in Singapore at the end of my medical curriculum, and I was interested in internal medicine and cardiology and things. And I didn't actually get the attachments I wanted, but I ended up getting an infectious diseases attachment at one of the hospitals in Singapore, and I was like, oh, this is interesting stuff. I mean, I'd never thought about this before, and I realized that I was quite attracted to it temperamentally. So I then pursued an attachment here with Professor Yun Kok Yong, who's been very prominent in infection control COVID 19 in Hong Kong generally, and I loved it.

So I decided to stay on and become a microbiologist. 

[00:34:54] Colin: And explain to our listeners, what is a microbiologist? I know because my brother, he did his PhD in microbiology and I'm interested to hear what you say, what is that exactly? 

[00:35:05] Siddharth: Well essentially, we deal with bacteria, viruses, basically microorganisms that cause human disease. So unlike the rest of medicine where we are basically focusing on the human body, I'd say microbiology is different because we're focusing both on the human body as well as the bugs that basically cause disease. So what we do on a day to day basis is treat individuals who are admitted to hospital with difficult infections. Investigate difficult cases where we don't know why the patient is running a fever, stuff like that. If hospitals have outbreaks of infectious diseases, we are involved as well. So that's approximately what we do.

[00:35:42] Colin: Seems to be quite prevalent here in Hong Kong that we have a lot of infectious diseases. I don't know where it's more than other places, but it seems to be in the newspapers quite a lot. Very recently, I read in the newspapers that we're very worried about a late flu scheme coming at the moment. Which is interesting.

Anyway, so in 2017, you had a very important breakthrough in hepatitis research. Can you tell us a little bit about that?

[00:36:08] Siddharth: Sure, so basically I ended up in the University of Hong Kong in 2017. And I had to pick a research direction. So, I was always interested in people. So this is a particular virus called Hepatitis E virus. So, I mean, for listeners, this is basically one of the many viruses that infect the human liver.

And we'd always known that you catch it usually by consuming undercooked pork products. So it's like local foods like pig liver, congee, stuff like that. It's basically how people catch Hepatitis E. And it had been something that was relatively niche, understudied in Hong Kong, so I decided to get into that.

And I think about one year down the line very quickly after joining the University of Hong Kong my team made the discovery that there was a very unusual species of Hepatitis E that actually infects rats scurrying along the streets in Hong Kong, right? And this rat hepatitis E virus could actually jump to humans and cause human infections.

So that kind of drove what I did at the University of Hong Kong in terms of research, even to this day, actually. I think, one of my first tastes of seeing something completely new that had never been seen before. And that taste of discovery, really, is something that I'll never forget.

[00:37:23] Colin: Is this able to be dealt with? I know we have rats in Hong Kong, but I read about this as well. So what is the position now with...

[00:37:31] Siddharth: Right, we've had cases on and off for the last seven years or so. So it's definitely something that's sporadically being transmitted in Hong Kong. And actually, it's not just Hong Kong. The nice thing about Hong Kong is we seem to, I don't know if it's a nice thing, but we seem to be at the epicenter of a lot of infectious diseases, which makes it really fun for people like me.

At the same time, we have the resources and the will to find new stuff out and it's by no means restricted to rat hepatitis C. I think Hong Kong has a very proud heritage of discovery in the field of infectious diseases and microbiology and rat hepatitis C was one chapter of that.

So we went all guns blazing. We now routinely test for rat hepatitis C in patients admitted to the Queen Mary Hospital, the Department of Health laboratory tests for it as well. So we have a World class, I mean, better than world class, I'd say surveillance and infrastructure for it. And I had the privilege of also working with different departments of Garment and that's a nice thing about being in the University of Hong Kong.

Normally a doctor, you kind of see patients and you go home, but I get to talk to pest control staff from Garment and really liaise with them in terms of how to get this under control in Hong Kong. I'm happy to note that we've had very few cases over the last few years. So I think the rodent disinfestation, control measures, awareness are all coming into place and helping to reduce this disease.

[00:38:54] Colin: Yes, and what's also interesting for the past seven years, in addition to your work as a doctor, you've also been a clinical assistant and professor at the University of Hong Kong. That enables you to pursue your research even more effectively, enjoyable, your teaching and how much of your time is teaching and then how much of your time is doing the work as the doctor.

[00:39:16] Siddharth: Yeah, I'd say it's approximately evenly split, so I'd say a third would be seeing patients in the wards, a third would be teaching, and a third would be, like, research and administration, so it's very evenly split, and I think the nice thing about the setup is that we encountered the first case of rat hepatitis E actually when I was seeing patients at Queen Mary Hospital.

So our bedside book kind of directly feeds into a pipeline of new pathogen discovery and research. And I think what we try very hard to do is to make sure that our research actually solves clinical problems. So before the discovery of rat hepatitis E, for example, you had many patients in Hong Kong who had hepatitis and we were never really clear what the source was or the cause was.

And this was the case all over the world, not just in Hong Kong, right? And now we've actually added one more item to the list. So rat hepatitis A explained the cause of hepatitis in quite a substantial number of patients. And right now, Because of our work people, researchers in Spain are finding that there's a lot of rat hepatitis C in for example, in Southern Spain and Cordova.

So what we're doing in Hong Kong is actually solving problems for patients around the world. And I think that's the coolest part of my job, but it is exhausting.

[00:40:25] Colin: It must be. Now, let's start talking about COVID and let's look back at the start of 2020 when Hong Kong began to see the first cases. At those very early stages, what were your thoughts? Of course, you had the history of SARS, but tell us about that. These very early stages.

[00:40:45] Siddharth: The first time I would have heard well, rumours would have been around Christmas time. I was actually in Thailand at the time, happier times, vacationing and stuff. Little did I know that international travel would soon be a distant memory, you know.

So we heard about these cases in certain parts of China. We were hopeful that it was something that was well known and it was just a matter of working up the course of the pneumonia. But then as we went into January, the last time I went to China, to Shenzhen, actually, was in mid January because we were also working at the Hong Kong U Shenzhen Hospital.

Then after I came back soon, it became apparent that things were more serious, and this was not something that was contained to Wuhan, but was definitely spreading around the country. And we also had cases in Shenzhen around about that time. And obviously in and around that time, early January, you had the first announcements that this was a new coronavirus and the first genomes coming out shared by Chinese researchers to the international community as well.

And our department actually was the first to document the well transmission within families in other words, person to person transmission. And that was published at the end of January, I believe, in The Lancet. So we were right at the middle of things. Although we were very distant from Wuhan. Some of the very initial case documentations were actually made in Shenzhen at the University of Hong Kong.

[00:42:12] Colin: It's well documented that Hong Kong followed China in pursuing this zero COVID, whatever zero COVID means, and I think that's quite difficult, i. e. huge, strict travel and isolation regulations here in Hong Kong in the world. With hindsight, initially, was that the right approach?

[00:42:32] Siddharth: Was the right approach at the beginning when we did not have vaccines. So we're talking about early 2021, March, april was when vaccines first started becoming available in Hong Kong. Up until that time, you had a novel infectious diseases that was causing absolute chaos. I think we tend to underestimate or, we kind of look back on it now with more equanimity, but back then terrible outbreaks. Iran, Italy, Spain, the us they were being absolutely engulfed and we managed to avoid all that because of zero covid.

So it was actually very defensible. We started losing the plot a little bit in 2021, early 2022, because the vaccine uptake was very disappointing in Hong Kong. Basically the population group that needed it most, that is the elderly, were the least vaccinated. And that created conditions where we would find it difficult to open up without, creating again the kind of chaos that had been seen in other places.

Unfortunately, Omicron then came along at the end of 2022 and it rendered zero COVID essentially unworkable, especially in Hong Kong, and to be honest, the mainland as well. And we had possibly the worst outbreak of COVID 19 anywhere in the world in that time. Yeah. Early 2022. 

[00:43:57] Colin: And that was because the elderly did not get vaccinated in a nutshell.

[00:44:01] Siddharth: Yes.

[00:44:02] Colin: Would it be fair to say that the Hong Kong authorities. At the early time really didn't do enough to prepare for this inevitable outbreak that we didn't educate the public. Instead what you had was a lot of public fear, stigmatization, scaremongering, and a very poor government public health messaging.

[00:44:24] Siddharth: I think we should have anticipated a certain degree of misinformation and public fears. I think in the initial phases of the vaccine rollout. When you roll out a vaccine to the entire population, by chance, certain people who get vaccinated are going to have unfortunate events happening after vaccination.

Even if they didn't get vaccinated, these happen. But after, if these happen after getting vaccination, often in the public mind, it is due to the vaccine. And there is a certain degree of a rush to judgment in the media as well, in terms of implying causation of these events to vaccination.

And in hindsight, we know that I think that vast majority of these cases, vaccines were not implicated at all. So we lost a lot of public confidence and vaccinations, especially for the elderly, because the thinking in Hong Kong was that, Oh, I mean, it's a elderly people. They have multiple medical comorbidities. Let the younger ones get the vaccine, let's do it for the elderly. So that kind of mentality was quite prevalent in Hong Kong. And often in Hong Kong, I've been saying being a very traditional society, the elderly tend to make decisions after discussion with their adult children, and I think that lack of autonomy led to many of them also not receiving the vaccination. So yeah, absolutely. We could have done more to predict the kind of misinformation, but it it's easy to say that in hindsight, because it's the first time you've been rolling a vaccine out to the entire population since I don't know, smallpox, right?

And this is the age of social media. Things very quickly went out of control in terms of the narrative, so to speak. So there's absolutely no doubt that we could have done more to bring the elderly on board.

[00:46:07] Colin: I remember watching, when you were all locked into Hong Kong, watching the Sky News. You saw that in the care homes or the elderly homes, there was massive vaccination. No one ever questioned it. They just went in and just vaccinated saying, if you want to stay here, you have to be vaccinated and they dealt with that very quickly.

That did not seem to be the thing here in Hong Kong. What could they have done to have dealt with that?

[00:46:31] Siddharth: Well, in a way, zero COVID was part of the problem, right? In the rest of the world, I think Everybody knew somebody who had either died of COVID or had severe COVID.

So there was a fear there, but the thing about zero COVID in Hong Kong, they were pursuing zero cases very effectively, I should note, before Omicron came along. So I think that led to a false sense of security and it felt like the threat was not big enough to impel people to get vaccinated.

So I think if we had done something like made it mandatory to a particular segment of the population, that there would have been a tremendous public uproar, which the government is very sensitive. 

[00:47:09] Colin: What is interesting, at the height of the Omicron wave in March 2022, when our city was seeing a massive high number of cases and fatalities and hospitals were overwhelmed, you described it as a predictable tragedy as well. Could something have been done to learn the lessons from this moving forward, in your view?

[00:47:31] Siddharth: The most important thing is public communication. So if in 2021, the middle of 2021, we had said Hong Kong has to open up eventually, and a precondition for this to happen is that people need to get vaccinated, especially this particular segment.

So if we hit this target through whatever means possible, then we get to have a resumption of normality, pre COVID life. But in Hong Kong, we never had that narrative. In Hong Kong, it was all about continue zero COVID, using all means possible. So in the public view, , the threat was never immediate until it was too late.

So I think we should have looked forward a little bit more as to the inevitable end of the state of affairs, but I think we were a little bit too complacent about continuing the status quo.

[00:48:27] Colin: Yes also quite interesting, in the UK and other countries, they have held inquiries, be it formal or informal, into the handling of the pandemic. Do you think it would have been worthwhile for such an inquiry to be held here in Hong Kong? They made it very clear. The government said we're not going to have an inquiry at all, but should have been at least some for moving forward for whether the next disease or infection is going to come here, do you think that would have been helpful to have had an inquiry to decide, look, everyone makes mistakes or judgment calls and all the rest.

Do you feel that perhaps that would have been a better, should that have been done in your view?

[00:49:06] Siddharth: No, I don't think so. And the reason I say that is, it is only useful to hold an inquiry to the extent that the findings of the inquiry are implementable. And I doubt that the findings of the inquiry would be implementable in Hong Kong.

If we have COVID 24 at the end of this year, I feel that the progress of events in Hong Kong would be substantially similar. To what we had in COVID during COVID 19. Insofar what will happen in Hong Kong in terms of infection control policy and all the rest will be very tightly aligned with what is going on across the border.

[00:49:43] Colin: One area which I got involved in is acting for families who, for example, mother pregnant, about to deliver, baby delivered, family then all get hit and get infected, and then the family were absolutely split, one's off to Penny's Bay, others in the hospital, then taking the baby away from the mother as well, and it was very, very difficult.

Indeed, we went to court. to get an injunction for the baby to be, stayed with the mother. The judge said, well, I'm not too sure I'm going to adjourn this. Then, some common sense prevailed, and people were left alone. And that went all over the world. I mean, the Americans, people were saying, staying in Hong Kong, you'll be separated from your children, etc.

Now, you work at Queen Mary's Hospital. Well, I mean, there's people, even to this day, people remember what happened about that. Bad handling? Or was it red tape? What caused all of that?

[00:50:41] Siddharth: It was about adapting to an unprecedented situation and a lot of stuff happened, like you mentioned, that shouldn't be the case.

Now, I think going forward, if we get the same kind of situation again, what I said was it's going to go down pretty much substantially the same, but I think at the end of the day, the government has learned a lot of lessons in terms of how to administer an enterprise of this kind, but the fundamental reality is cross border Travel, cross border exchanges are of paramount importance, and that is what the government set as its number one objective.

And if you have a new pandemic coming around and China reacts in a certain way, it's very difficult for Hong Kong to go in its own way. So essentially, you're going to have some degree of harmonization of infection control policies on both sides of border with the kind of hope that at least cross border travel can resume.

That didn't happen during COVID 19. That never happened, but I think that is still going to be the number one priority.

[00:51:42] Colin: I'm always interested in history, spanish flu, huge amount of lives were lost in respect to that. And then lessons were learned. COVID, again, lives were lost. The figures there were as much as the flu after the the first World War.

On the horizon, there must be another pandemic coming. So how do we learn to deal with this to ensure that people that were able to not find ourselves in the situation in those two years where people. I mean, my grandson lost his education. To be very honest, it missed a year of education. It was huge numbers of difficulties with all of that because of not opening the borders and the issues with schools, etc.

So moving forward, how do we deal with the next inevitable infection, which is going to come?

[00:52:28] Siddharth: Yeah, I think we can expect a pandemic every 10 years. You had 2003 SARS, you had MERS coronavirus coming out approximately 10 years later, and then you had COVID again approximately 10 years later. So it seems to be pandemic coronaviruses emerge with disturbing regularity, and you have bird flu, you have all these other threats as well.

There's good news and there's bad news. The good news is, from a scientific point of view, fantastic. This has been such a pleasure, I would say as a young scientist to see what's happening in the field and to see the best minds being applied to COVID research, which has actually inspired me in my hepatitis C research as well.

And I have full confidence that in the next pandemic, we'll be even more ready. You'll have even better vaccines developed with even more rigor. even more quickly. So I'm absolutely confident about that. The massive problem is going to be inspiring public confidence to avail of these vaccines or antivirals that are available in a quick enough manner to make sure that we transition from absolute containment, which is zero COVID, to a mitigation phase.

So I think it's good stuff has happened during COVID. I don't want to be overly pessimistic including in Hong Kong, in terms of the kind of scientific infrastructure we have here. Absolutely world leading. But again, it's essentially the communication, the narratives, building public trust is going to be very important to create the conditions where we can transition out of containment phase.

And I think these challenges apply across the border as well, which is of course, Paramount importance to what happens in Hong Kong, because let's not forget, even well into the fifth wave in 2022, even after we, we still took several months to resume open

[00:54:13] Colin: We were the last, the last frontier to 

[00:54:16] Siddharth: Absolutely. Which is why I say the mainland is of absolutely critical importance in terms of what they do.

[00:54:22] Colin: You also seem to be, suggesting that, taking your vaccine is so important. When I was young, we all had our family doctor. Everyone listened to the family doctor. The elderly Dr. Smith tells you to get vaccinated. Your smallpox, your Chickenpox, all the things, your Measles, your Mumps, whatever it was, you went for your jabs, and the elderly went for their jabs.

And yet, the way the system works in Hong Kong, even getting to see a doctor is not that easy here. How do we get people to understand the importance of being vaccinated?

[00:54:56] Siddharth: We have to engage our burgeoning private sector more effectively, including the doctors down the street that often people visit when they're sick, right? And unfortunately in Hong Kong, a lot of people go to the public sector, A&E departments, especially when they're sick.

And we've got to have a way of using that as a point of linkage to care and getting the importance of shots drilled into people but I would say during COVID, it was, I think, an interesting situation in Hong Kong, right? You had bizarre things like people going for medical checkups before they get their vaccine, which I've never heard anywhere else in the world.

But if you look at other parts of the world for example, israel or Singapore and the elderly vaccination rate was actually much higher in Hong Kong. And I mentioned a few of the factors before, I don't want to repeat myself, but another factor was choice. We gave people a choice between two vaccines and they ended up choosing neither.

So I think in the future, especially once there's more confidence in the whole mRNA vaccine technology as well, I don't think we need to spoil people for choice because you can't expect a person who's not trained in these matters to make a reasonable choice between two vaccines and to just show up at a vaccine center and say, I want to get vaccine A, not vaccine B.

Most people are going to say, I'm just going to wait and watch to see what happens to the people around me who get either of these, so I think that was probably another factor. But that was done for a reason, I must say I agreed with it at the time, but in retrospect, it's another factor that let us down.

[00:56:21] Colin: Yes, I mean, I find it quite interesting. I mean, for the elderly, I think I'm young, but I'm not. I go and see my good doctor, David Owens, and the most important thing he checks on my annual checkup are all my vaccination records. And then he says, you must have this shingles jab. You must have that.

And I just say, yes, I do it. I don't even think about it. And I think it's education more than anything else at the moment. 

 So I understand in your spare time you do a lot of traveling and you do a little bit of writing. Can you tell us a little bit about that? 

[00:56:50] Siddharth: Well quite a bit, my parents moved around quite a bit, so I was still kind of steady one in the family. You know, I haven't moved out of Hong Kong for going on 20 years now. My parents moved around quite a bit. They were in Indonesia for a bit. Obviously, India. And then they're now in East Africa and Kenya.

So I think going home for me has meant going to different places and we traveled around quite a bit in Java and Sumatra and in East Africa. I've had the privilege of, being in Uganda and Ethiopia. Absolutely fantastic destinations. And yeah, it's been great.

So I got to sow my wild oats, do stuff like. Hike up Mount Kenya and I think I'm happy that very lucky to have had the opportunity to, go to places a little bit off the beaten track. And I got in trouble in Mount Kenya. My guide actually got mountain sickness.

[00:57:44] Colin: And you have to look after him.

[00:57:45] Siddharth: Well, I couldn't really because I was feeling it very badly as well. So he just said the route is that way. You just go and find help. And this was that, 4,000 meters or and I was feeling absolutely sick and screaming for help in the wilderness and there's nobody around.

And eventually, I always remember there's this footprint on the ground, and I just happened to look down at the right moment and there's a single mud, kind of boot print, and it told me that there's humanity in that direction and you go forward and I managed to find people and just collapse there. We never made it to the summit of Mount Kenya. 

[00:58:18] Colin: That's interesting. And also, you write some short stories.

[00:58:21] Siddharth: I did from time to time when I was in the early stages, I think it's very harrowing experience sometimes to go through internship and your early medical career in a place like Hong Kong public hospitals, which can be very busy, almost war zones, you know?

So I think a way of sublimating all that into something positive was through Literature and a little bit of poetry. I read back at it and I think some of the stuff can potentially be reworked into something good and I think I look forward to doing that at a less busy phase of my life if that ever happens.

Then I can get these desk drawer works and revert them into something else. I got a couple of pieces published but I think this is something I look forward to working in my later life. 

[00:59:05] Colin: Hong kong's your home, right now?

[00:59:06] Siddharth: Hong Kong is my home, definitely. I would also call India home. I've spent half my life in both these places.

So I guess I'm lucky to have two homes and with very, very different value systems. And there's wonderful stuff to be gotten from both places. 

[00:59:24] Colin: And you're going to continue here at Hong Kong? You continue teaching and curing and educating?

[00:59:30] Siddharth: Yeah, that's the plan. I think for what I am interested in, Hong Kong is definitely the place to be. As I said, we are at the epicenter of a lot of interesting stuff and we also have the resources and the will to pursue these things. And I think that's a very rare combination.

[00:59:46] Colin: It's great to hear that you do take the view that our public health education, our system here, is one of the best in the world.

[00:59:54] Siddharth: That's what I tell a lot of secondary school students, come up to me and say do I do medicine here? Do I do medicine overseas now that we're allowing some people back from selected universities? I mean, I always say I've pursued my medical career at Hong Kong. Medical education at Hong Kong. And I mean, one word, it's been absolutely world class and it's always getting better.

[01:00:14] Colin: Siddharth, it's been a pleasure, a privilege, talking to you. Thank you so much for joining us on Law & More.

[01:00:21] Siddharth: My pleasure. Thank you.