Monthly Archives: August 2009

Sick But No Fever? It May Be Swine Flu!

Update September 23, 2009, as reported in today’s U.S. News & World Report:

According to Dr Richard Wenzel, a swine flu expert and former president of the Infectious Diseases Society of America, at the beginning of the H1N1 (swine flu) outbreak in Mexico, only 30 percent of patients hospitalized with the infection had fever initially.  Fifteen (15%) percent of patients never developed a fever at all.  What usually sent them to the hospital was shortness of breath or chest pain. In Chile, about half of those with confirmed H1N1 had no fever; many just had a headache and runny nose. 

______________________________________    Original Post  __________________________________
31 August 2009
A few days ago, I wrote a blog entry which was intended to summarize "everything you need to know about Swine Flu (H1N1)," including links to primary sources.  (For link to that blog entry, click HERE). 
There’s good news and bad news.  The good news is that most cases of the H1N1 flu are mild.  The bad news is that, in a small percentage of people, the virus directly attacks the lung tissue. People with this variant of H1N1 will become severely ill and will need hospital based life support to survive. People particularly at risk include asthmatics and others whose respiratory systems are already compromised, minorities, pregnant women, people with high blood pressure, and the morbidly obese.
What I’m most alarmed about — and the reason for this blog entry — is my fear that current criteria for diagnosing H1N1 will miss significant numbers of infected and contagious people, thus contributing to rapid spread of the illness in the population.  Namely, unlike other types of flu, a person can have flu yet be walking around with no fever.  When fever is used as a primary screening measure, therefore, significant numbers of people will not be diagnosed and will therefore continue to spread germs in the general population. 
Public health authorities have known since April that a significant number of people infected with H1N1 have NO FEVER.  Yet, the USA Center for Disease Control has not revised its criteria for clinical evaluation.  My understanding is that it is being left to individual school districts to create their own policies.  At the present time, in my school district, screening for flu still includes fever as a criterion, even though the evidence shows this will result in a false negative assessment somewhere between 12% and 50% of the time!!   If this is correct, it means that significant numbers of H1N1 cases will not be diagnosed quickly.  
School children are one of the groups most at risk for this flu, since older members of the population seem to have some residual resistance due to swine flu epidemics in the 1950’s and 1960’s.  If children are not screened, diagnosed, and contagious students excluded, the virus could spread like wildfire.
Because of the potentially deadly side of H1N1, the consequences of leaving a contagious student in the the general school population can be very serious.
 

I URGE THAT SCHOOLS REVISE CRITERIA FOR SCHOOL EXCLUSION SO THAT

CRITERIA FOR EXCLUSION FIT THE SYMPTOMS OF THIS FLU!

 

references:

 

Many Swine Flu Cases Have No Fever

By LAWRENCE K. ALTMAN

Published: May 13, 2009 NY Times

TO READ ARTICLE, CLICK HERE

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Pandemic Flu Fever Failure Fuels

School Cluster Explosions
Recombinomics Commentary 17:06
August 21, 2009

TO READ ARTICLE, CLICK HERE
____________

Swine Flu: The Next Wave
Wall Street Journal, August 18, 2009

TO READ ARTICLE, CLICK HERE
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Should Fever Be the Main Screening
Tool in School H1N1 Decision Making?


Discussion thread on Flutrackers internet forum

TO READ CLICK HERE

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Swine Flu (H1N1): What You Need to Know

I track flu and other public health threats.  I write this blog entry to help anyone who asks the question, "What do I need to know about swine flu?" or "What can I do to protect myself from pandemic flu?" I rely heavily on the Australian public health information system because it seems to be more proactive about prevention — educating and putting responsibility for preventive measures on the public.  I have mainly cut and pasted information from sources that I deem reliable, with links to each source so that you can read the information for yourself.  I hope you this useful — if you do, please let me know by leaving a comment.   

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H1N1 IS A PANDEMIC FLU

As school returns to fall session in the USA, a new, pandemic flu is sweeping through campuses across the nation. In the first week of classes, Georgia Tech had 150 suspected cases; the University of Kansas had 200 stricken with it. Source: Associated Press via WDSU News   In Aiken County, South Carolina, 52 students were sent home with flu symptoms during the first week of school. (Eleven of those students were confirmed to have been infected with pandemic flu, though at this time further testing for H1N1 has ceased due to its widespread incidence in the population.) Source:  Aiken Standard Newspaper

ORIGIN AND SPREAD OF THE VIRUS WORLDWIDE

It is speculated that the virus now known colloquially as “Swine Flu” originated about ten years ago in Mexico. It became more widespread in December 2008 and was declared pandemic in the summer of 2009. Source: International SOS Clinics It has now become the dominant influenza strain throughout most of the world. Source: WHO

The term “swine flu” does not mean that humans can catch the flu from eating pork. Rather, this is a virus that has mutations that originated from swine. Source: SC DHEC  Technically speaking, the name of the disease is "Influenza A (H1N1)". With declaration of pandemic status, the proper term for the illness is "Pandemic (H1N1) 2009". (The term "pandemic (H1N1) 2009" refers to the disease, and the term “pandemic H1N1/09 virus" refers to the agent.)

At this time, Pandemic H1N1 flu virus is widespread worldwide, but especially so in the Americas. Indeed, there are so many cases that attempts to keep count of numbers have been discontinued in the USA.  Source: USA CDC

Confounding matters, it is widely reported that somewhere between 30% and 50% of swine flu infections may not induce fever.  Because fever has for so long been a main indicator of flu, many infected students may remain in school, thinking they do not have swine flu.  Further, health departments may refuse to test students for H1N1 because they have no fever. Source: NY TimesRecombinomics, Inc.

For a flu tracker map, click HERE

SEVERITY OF ILLNESS

Most cases of H1N1 are mild. An odd feature of the new virus is the lack of fever in a significant proportion of documented cases, even after some patients become seriously ill. Wall St. Journal  In Chile about half of those affected had no fever. In Mexico City, about a third had no fever, and similar patterns have been reported in other places. Source: NY Times 1 NY Times 2.  In the US, fever is used in the case definition, so patients presenting without fever are not even tested.  Coincidentally, the official USA numbers show that 93% of lab confirmed cases have a fever.  However, this is almost certainly linked to the case definition, because in the USA the standard definition of influenza includes a fever.   Recombinomics, Inc.

The absence of fever in H1N1 can be significant in several respects. Absence of fever among substantial proportions of patients, when fever is specified in the definition, can cause serious underestimation of case totals. For example, the CDC by definition only characterizes symptoms formally as "influenza-like illness" (ILI) if there is a fever of 100 degrees or more, body aches, fatigue and a cough or sore throat for which there is no other known cause. Source: USA CDC Secondly, absence of fever limits the usefulness of thermal scans to identify people who have the virus and thus control the pandemic.  This eliminates a handy means of selecting individuals for segregation or quarantine.  Thirdly, absence of fever removes a traditional identifying symptom for flu and therefore keeps infectious individuals in the public environment (e.g. school or workplace).  Lack of identification and separation from the general population thus leads to increased exposure, school clusters, and faster spread throughout the population. Source:  Recombinomics, Inc.

In contrast to the mild cases, there is also a severe form of H1N1 which directly attack lung tissue.  Clinicians from around the world are also reporting that there is a very severe form of H1N1, also found in young and otherwise healthy people. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays. 

To date, most severe cases and deaths have occurred in adults under the age of 50 years, with deaths in the elderly comparatively rare. This age distribution is in contrast with seasonal influenza, where around 90% of severe and fatal cases occur in people 65 years of age or older.

RISK FACTORS FOR SEVERE FORM

Risk factors for the more severe form of the H1N1 infection include obesity, asthma, cardiovascular disease, and diabetes. Pregnant women are also at higher risk.  Source: WHO, NY Times

Minorities and indigenous populations have a particular, increased risk for the severe form. Black and Hispanics are four times more likely than Caucasians to need to be hospitalized for pandemic flu. Source: Associated Press The causes of this difference are not known, though it is suspected there may be a relation to overall health and increased risk factors associated with poverty.  Source: WHO

School Children:  To date, highest attack rates are seen in school children. This is expected for a novel influenza virus, especially considering children’s relatively poor hygiene and lack of social distancing. The virus will likely move upwards into the older siblings and parents and, in later successive waves, to the grandparents. Source: International SOS Clinics

H1N1 and HIV: Early data suggests that people co-infected with H1N1 and HIV are not at increased risk of severe or fatal illness, provided these patients are receiving antiretroviral therapy. In most of these patients, illness caused by H1N1 has been mild, with full recovery. http://www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html

The Aged:  Unlike seasonal flu, older people appear to have less risk. It is theorized that people over the age of 65 may have some natural immunity, perhaps due to circulation of a swine flu virus in the 1950’s. However, due to genetic drift (mutation) of the current virus, the benefit of this immunity is expected to last only one to two years as the virus mutates into new forms. Source: WHO

HOW SWINE FLU IS SPREAD

H1N1 flu is an airborne virus.  It is most likely spreading from person to person in the same way seasonal flu viruses spread: through infectious respiratory droplets. These droplets are expelled when an infected person coughs, sneezes or talks. These droplets can spread about 1 to 2 meters (3-6 feet) before they fall. If they get into a healthy person’s nose or mouth, the person can get infected. (This is called "direct contact".)

Hand hygiene:  Hand hygiene is essential in the reduction of transmission of infectious agents. Hand hygiene includes washing hands with soap and water or cleaning hands with alcohol based products (gels, rinses, foams) that can be used without water.

• If your hands are visibly dirty with respiratory secretions (phlegm, spit), you need to wash them with soap and warm water, scrubbing your wrists, palms, fingers and nails for 15-20 seconds, and then dry with a clean dry towel or paper towel.

• If there is no visible dirt, you could use an alcohol-based hand rub.

• In general, try to keep your hands away from your face.

( source: Australian Dept of Health )

People can also get infected through "indirect contact". The droplets expelled by a sick person can contaminate objects. Flu virus can live on hard surfaces for hours, as long as 2 days. It can get onto people’s hands when they touch something contaminated, such as doorknobs, keyboards, counters, etc. If the person then touches his or her eyes/nose/mouth with their hand, the virus can enter their body.

Influenza may also spread via "aerosol" transmission, where the where the virus floats in the air and infects people. This is particularly possible in crowded places. This is not thought to be a frequent mode of flu transmission, and may only happen in unusual circumstances where ventilation is poor.

Cough and sneeze etiquette:  If you cough or sneeze, you should

• Wear a Facemask if you are coughing and sneezing

• Cover your nose and mouth with a disposable tissue rather than your hands.

If there are no tissues available, cover your nose and mouth with your upper arm rather than your hands. Wash your upper arm (or sleeve) as soon as practical if you have sneezed or coughed into it.

• Dispose of used tissues in the nearest bin.

• Wash your hands afterwards or after touching used tissues.

(source:  Australian Dept of Health)

Any secretions and bodily fluids of someone with H1N1 are considered potentially infectious. This includes vomit, diarrhea and mucus.  (source:  International SOS Medical Clinics)

SYMPTOMS OF SWINE FLU

Initial symptoms of H1N1 are similar to the symptoms of "regular" (seasonal) flu. These are:  fever, body aches, tiredness, headache, runny nose, sore throat and cough. With this virus, people also often have vomiting and diarrhea. Some infected people develop a severe illness, which can include pneumonia and difficulty breathing. Australian CDC

As noted above, however, somewhere between 30% and 50% of cases do not have a fever.  The atypical symptoms with the H1N1 flu, with lack of fever being common, as well as the presence of diarrhea, both of which are unusual in seasonal influenza, are likely to confuse practitioners and lead to delays in diagnosis. Source: Wiki-medpedia (Dr. Richard Wenzel) If you have all the symptoms of flu but no fever, assume that you are contagious and use appropriate precautions to avoid infecting others! 

The incubation period appears to be between one and seven days. People can spread the germs for flu before they begin to feel symptoms and until after symptoms completely disappear.

WHAT TO DO IF YOU GET FLU

Stay at home and keep away from work, school and crowded areas or public gatherings until symptoms have resolved. If medical attention is required, people should consult a medical practitioner by telephone;

Avoid contact with other people where possible;

Cover nose and mouth when coughing and sneezing and, if using tissues, make sure you dispose of them carefully;

Clean hands regularly, and immediately after coughing or sneezing with soap and water or cleanse them with an alcohol-based hand rub;

Alleviate the symptoms: rest, drink plenty of fluids and use a pain reliever for aches. This is adequate for recovery in most cases. A non-aspirin pain reliever should be used by children and young adults because of the risk of Reye’s syndrome

At the present time, the antiviral drugs oseltamivir and zanamivir are effective against the H1N1 virus and reduce the incidence of severe respiratory complications. Source:  WHO. Because these drugs must be administered within 24 to 48 hours of onset of symptoms to be effective, treatment should not be delayed. At present, only a handful of pandemic viruses resistant to oseltamivir have been detected worldwide, despite the administration of many millions of treatment courses of antiviral drugs. Source:  WHO The pandemic flu is resistant to a second class of antivirals, the M2 inhibitors. Source:  Ibid, Australian Dept of Health

Worldwide, most patients infected with the pandemic virus continue to experience typical influenza symptoms and fully recover within a week, even without any form of medical treatment. Healthy patients with uncomplicated illness need not be treated with antivirals.  Source: WHO   Severe cases, however, should be treated immediately with antiviral medications.

DANGER SIGNS

Clinicians, patients, and those providing home-based care need to be alert to danger signs that can signal progression to more severe disease. As progression can be very rapid, medical attention should be sought when any of the following danger signs appear in a person with confirmed or suspected H1N1 infection:

  • shortness of breath, either during physical activity or while resting
  • difficulty in breathing
  • turning blue
  • bloody or coloured sputum
  • chest pain
  • altered mental status
  • high fever that persists beyond 3 days
  • low blood pressure.

In children, danger signs include

  • fast breathing or trouble breathing,
  • bluish or grey skin color,
  • not drinking enough fluids,
  • severe or persistent vomiting,
  • lack of alertness,
  • difficulty in waking up,
  • being so irritable the child does not want to be held,
  • little or no desire to play, and
  • flu symptoms seem to improve but then return. 

Sources: WHOUSA CDC

USE OF FACE MASKS

If you are not sick you do not have to wear a facemask. If you are sick, you should wear a facemask when seeking medical attention or when in close company of vulnerable people.

A household member should wear a facemask if they need to come within one meter (three feet) of an ill person who is not able to wear a mask, particularly if they are in a vulnerable group. 

If you choose to wear a mask you should follow the Facemask procedures below. Wearing a facemask incorrectly or removing or disposing of it improperly can contaminate the wearer’s hands, mouth or eyes with virus, possibly resulting in exposure of the wearer or others to the virus. Sources:  Australian Dept of Health and Aging (Note: The USA CDC seems not to condone use of Facemasks, for reasons unknown to me.   See USA CDC facemask page.  I notice from living in Asia that use of Facemasks as a matter of courtesy to prevent sharing of germs is much more prevalent in Asia.  I speculate this is due to having significantly higher population density, as well as Asian culture in general seems more focused on prevention of illness while American culture seems more focused on intervention after illness.)

A PERSON WITH SWINE FLU SHOULD ISOLATE THEMSELVES AS MUCH AS POSSIBLE

A person ill with flu should be isolated in a different area of the house from the rest of the family. One member of the household should be designated to care for the affected individual. The person caring for the affected individual should use fastidious hygiene, including hand washing and proper use of a face mask. If possible, ventilate the ill person’s room with outside air and disinfect surfaces and doorknobs. 

WHAT YOU CAN DO TO PROTECT YOURSELF FROM SWINE FLU

Wash your hands thoroughly and often. Cover your cough with your sleeve, not your hand. Stay home if you’re sick. Stay away from people who are sick. Eat a healthy diet and get plenty of rest

You can prevent getting infected by avoiding close contact with people who show influenza-like symptoms (trying to maintain a distance of about 1 meter (3 feet) or more, if possible) and taking the following measures:

• Avoid touching your mouth and nose;

• Clean hands thoroughly with soap and water, or clean hands with an alcohol based hand rub on a regular basis;

• Do not visit people who have the flu unless it is absolutely necessary; Eat a healthy diet; get plenty of rest;

When someone in the house has flu it is important that:

  • they clean their hands regularly;
  • the household environment is regularly cleaned; surfaces should be cleaned with disinfectant
  • the person with illness stays home and avoids contact with others; and
  • the person with illness wears a surgical mask or other appropriate face coverings, if possible, when others are in the room,
  • and stays at least 1 meter (3 feet) distant from others.

Sources: State of SC DHEC , Australian Dept Health & Aging

VACCINATION

Significant quantities of H1N1 vaccine will not be available until October. Source: Reuters News Service .  In the northern hemisphere, this is well into the expected fall/winter epidemics.  Source: International SOS Medical Clinics

When H1N1 vaccine is available, it will only protect against H1N1; it will not protect against ordinary seasonal flu. Therefore, individuals who seek to be protected against flu will need to be vaccinated separately for seasonal and pandemic flu. It is not yet known whether the pandemic flu vaccine will require one shot or two. Source: Australian Dept Health  Thus, complete flu protection will require either two or three separate shots.

WORKPLACE PRECAUTIONS

Workplaces should focus on:

• Promoting good hand, respiratory hygiene etiquette and other infection control

practices..

• Ensuring that materials needed for hand and respiratory hygiene are readily

available in the workplace (e.g. tissues and receptacles for their disposal, soap and

hand washing facilities and/or alcohol-based hand sanitizers).

• Encouraging and supporting staff members with acute respiratory illnesses to stay

at home until they are well (that is until their symptoms have completely resolved).

• Encouraging visitors/customers with acute respiratory illness to stay away from the

workplace until they are well (that is until their symptoms have completely

resolved).

SWINE FLU IN THE FUTURE

Waves of anxiety and public concern are affecting social patterns in affected countries. High levels of public concern can lead to disproportionate and discriminatory behavior. Source:  International SOS Clinics .  This in itself could be very disruptive to business and trade, travel, and daily pursuits. This type of disruption was evidenced by the reaction to SARS in 2004. It is hoped that disruption will be minimized by a combination of public education and effective control and treatment of the disease.

A serious concern is the possible mixing of genes from H1N1 (Swine Flu) with H5N1 (Bird Flu). Because H5N1 is currently much more deadly to humans than H1N1, any mixing of genes which resulted in increased human to human transmissibility of H5N1 could be hugely threatening. A much less threatening scenario is if the H1N1 outbreak caused suppression of H5N1 virus outbreaks. Source:  International SOS Clinics

In the final analysis, few of the 6 billion people who live on Earth will escape the H1N1 pandemic, but such global spread will take 3-4 years. A combination of sensible behavior, social distancing, hand and surface hygiene and the use of antivirals and vaccines to protect vulnerable groups should suppress mortality to that experienced in the last pandemic of 1968. Source:  International SOS Clinic

REFERENCES

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I Have A Dream

28 August 2009

Today marks the 46th anniversary of Dr. Martin Luther King’s "I Have A Dream" speech, delivered at the end of the March on Washington on 28 August, 1963.  (For text click HERE.)

This image is from
http://bit.ly/RdK3z

Dr. King is of course remembered for his role in fighting segregation in the Deep South of the United States.  In that battle against institutionalized injustice, he was one of many voices.  Some of those voices advocated hatred and violence.  A student of Jesus and of Gandhi, King instead chose to lead his people in the way of peace. 

In his Letter from a Birmingham Jail, he wrote: 

In any nonviolent campaign there are four basic steps: collection of the facts to determine whether injustices exist; negotiation; self-purification; and direct action. We have gone through an these steps … .

The March on Washington was a manifestation of his Direct Action campaign.    

[W]e who engage in nonviolent direct action are not the creators of tension. We merely bring to the surface the hidden tension that is already alive. We bring it out in the open, where it can be seen and dealt with. Like a boil that can never be cured so long as it is covered up but must be opened with an its ugliness to the natural medicines of air and light, injustice must be exposed, with all the tension its exposure creates, to the light of human conscience and the air of national opinion before it can be cured.

 
 
 

These two images courtesy of
Wikimedia Commons

Here is a video of the speech: 

(中国人 If YouTube video is blocked, you can see the speech on Tudou, click HERE.)

This blog entry is also cross posted on my Peacemaking blog, Peaceworks

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Lawyer Who Helped Families Still Facing Charges

but China Releases Prominent Human Rights Lawyer on Bail

I am re-printing this for information’s sake.  The original source is HERE

By VOA News
23 August 2009

A leading Chinese human rights lawyer says he was released from detention Sunday, but still might face prosecution on charges of tax evasion.

Legal scholar Xu Zhiyong is seen at a meeting in Beijing, China (File Photo – 17 Jul 2009)

Xu Zhiyong, co-founder of a legal-aid group known as the Open Constitution Initiative or Gongmeng, had been out of contact since security officials seized him from his home on July 29. He was formally arrested last Tuesday on charges of tax evasion.
Xu said Sunday he was released on bail pending trial.
Chinese authorities shut down the legal rights center more than a month ago for alleged nonpayment of taxes. Members of the group reported nearly two weeks later that Xu had been detained by police, and that they could not contact him.
The group has helped victims of China’s tainted-milk scandal and offered assistance in human-rights cases. It also has issued a report criticizing the Chinese government’s policies toward Tibet.
Rights groups say the latest developments are part of a widening crackdown on lawyers, rights activists and non-governmental organizations ahead of the 60th anniversary of the Chinese communist state.
Preparations are under way for a huge official celebration of the anniversary on October 1. Rights activists expect the government will try to prevent any public demonstration of dissent during the festivities.
China recently revoked the licenses of 53 Beijing lawyers, most of them prominent human-rights advocates. Amnesty International has condemned the crackdown on lawyers as a major blow to the human-rights defense movement in China.
In a widely quoted statement earlier this year, Xu said his Gongmeng group aims to help build the rule of law and advance Chinese society by objectively and independently studying human-rights protections, the situation in Tibet and other issues.
One of the government’s main charges against Xu’s group alleges that no taxes were paid on a $100,000 grant the Open Constitution Initiative received from Yale University. Xu has been a visiting scholar at Yale Law School on several occasions.

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The Rule of Law in China? Not looking too hopeful.

9 August 2009

Another prominent lawyer has been detained in China in a movement designed to repress those who fight for rule of law. 

To read the article reporting on  the detention, click HERE

I agree with this quote from the article, by another human rights advocate:  “What the authorities don’t appreciate . . . is that lawyers are leading these people to the courts, where their complaints can be resolved by rule of law. . . . People like Xu Zhiyong can only help the government solve some of the problems it faces.”

________________

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The Irony of Asking, “Did You Understand Me?”

7 August 2009

Me:  "Is it hot or cold outside?"

Answer:  "Yes"

____________________

I can’t tell you how many times, while living in China, I asked a question, and the person replied with an answer that demonstrated they completely missed the meaning of my question. Of course, that’s to be expected.  Even when two people come from the same culture and speak the same language, communication can be a challenge.  When two people speak different languages, you know there will be additional challenges.  The real problems are those that surface when you don’t even know they exist!   

When you know a person doesn’t understand, it may be a challenge, but at least you know where you stand.  With that knowledge, you can figure out how to deal with the communication issue.  The real problem comes when you think something has been communicated, but you find out too late that the person did not understand. For instance, perhaps you find out the engineer did not understand to make x change in a certain widget, but only after 200,000 of those widgets have been molded.  A simple failure of communication can amount to a costly mistake. 

The most frustrating situation is when the other person thinks they understand, and they lead you to believe they understand, and you rely on that understanding, but at some point (usually at the point when you realize you are headed for total disaster), you realize they had no idea what you were talking about!  The short lesson here is not only to communicate clearly, but also not to leave anything to chance. 

A friend told me a story that illustrates this.  His boss from Europe was coming to see the China operation.  As part of the activities, they planned to host a banquet for the boss.  The boss was Jewish and did not eat pork.  So, the employee gave very careful instructions to the caterer that they were not to serve any pork or shellfish.  On the night of the banquet, they arrived to a fabulous scene.  There were ice sculptures, tiny lights, greenery.  And each table had a suckling pig, complete with red christmas lights for the eyes. 

This image is compliments of webcreationz

 

Another Jewish story.  A friend of mine had just arrived in China.  He was Jewish.  So he asked his translator, "Are there any Jews in this city?"  "Oh, yes," was the reply.  "We have many Jews.  Orange Jews, Apple Jews, Watermelon Jews …." 

Ah, COMMUNICATION!  I have a few suggestions that may help:

_________________ 

1. Make it safe for a person to tell you they don’t understand

To an American, this may sound really dumb, but don’t forget the cultural context.  Americans are trained and ingrained by our culture and by our education to have opinions and express them, to communicate, to clarify, and to disagree.  An American managers expects her employees to question, clarify, and keep asking until they understand.  American managers, therefore, sometimes fail to realize that this is not the norm in some other cultures. 

An employee from an Asian culture may expect to take orders without question.  He may come from an educational system where students were expected to memorize and reiterate, where questions were discouraged.  He may feel that to question a supervisor, even to clarify an instruction, implies disrespect.  I suggest that a manager confronted with language barriers to communication needs to go out of her way not only to communicate to employees that their questions are welcome, but also to display the utmost patience and tolerance when employees ask questions.  Use open and welcoming body language.  Sighs, displays of impatience, or anger in response to questions will shut down communication from an employee who is shy about asking legitimate questions to clarify instructions. 

As a corollary, employees who are eager to please may also stop their questions too quickly.  They want to believe they understand, so they may leave the interaction before they actually have enough information.  Before you allow an employee to leave, make them explain back to you their understanding of what you said.  This allows an opportunity to train them more in what you are expecting. 

2. Make no assumptions about what the person knows

In the USA, children learn certain, standard things.  For instance, they are taught not only multiplication tables, but probably also the "ABC song" and how to brush their teeth.  Thus, when you are speaking to an adult American, you can probably assume that he knows what a toothbrush is or that he knows how to put things in alphabetical order.  Can you assume this about a person from X nationality?  Since you don’t have a common bed of cultural understanding, no you cannot!  How do you know what you can and cannot assume? 

It may seem time consuming in the beginning, but one foundation of good cross cultural communication is to make no assumptions.  You ought to specify what you mean by every aspect of the communication from the most trivial to the most profound.  Even if it is redundant, it will lay a firmer foundation for all future communication.

An example from my own life is that in college, one of my math professors began the semester with the proofs that "a = a", and then "if a = b then b = a, and then "if a = b, and b = c, then a = c".  And so on.  Laying down of these proofs may have taken only the first fifteen minutes of class, but review of these simple postulates provided a firm foundation for all else that happened that semester. 

A personal example of disaster from making assumptions was that I accompanied a friend one time to pick up an evening gown she was having tailored for a gala.  A master tailor in an off-site location had sewn her gown from expensive silk and then delivered it back to the storefront shop for the customer to pick up.  All that remained to be done was for the girl running the shop to measure and hem the gown.  My friend was impatient, and new to China.  She spoke no Chinese, and the girl in the shop spoke virtually no English.  The girl asked for clarification of how long my friend wanted the gown.  My friend held the hem a few different places.  Here, or here.  The girl seemed confused and asked some more questions.  We were, indeed, both tired.  My friend grew impatient.  "Just get it right!’ she exclaimed.  Well, what do you mean by that?  She made an assumption that the girl knew what to do and how to do it.  But when we returned to pick up the finished product, the dress was several inches too short, and it could not be repaired because the hem had been cut off.  In other words, simple clarification of every instruction, leaving nothing to chance, is very important. 

3. Don’t skimp on the translator

The communication really is only so good as the language skill of both parties.  A translator is limited by his or her previous life experience.  If the translator has never seen a phreonopoly and has no idea what that is, he is going to have difficulty translating that term into his native language.  You may choose to hire a translator who already knows what a phreonopoly is, or you may choose to train your translator.  Either way, you must have a translator who is educated about the topic you are discussing. 

The translator must also be dedicated to providing honest facts in a culturally sensitive way.  In other words, she must bring a degree of diplomacy in how she phrases things, but a commitment to faithful rendering of your message.  Given the significance of the role of translator, the person needs to be someone you can trust to act and speak in your best interest, to tell you not only what is said but also the sometimes hidden meanings in the communications.  The translator thus has a pretty high level function which many people underestimate.  Let’s put it bluntly: this person needs to be someone who can keep things in confidence and who will be loyal to the company and to the manager in the information they convey and the manner in which they communicate it. 

4. Use every tool in your toolbox by supplementing with nonverbal communication

Words are just one tool.  Make use as well of diagrams, pictures, pantomimes, dictionaries, and books.  There are many people who get along just fine in other cultures, never learn to speak the language, merely by being resilient and by using nonverbal communication for many needs.  For example, I was telling an expat friend one time about my frustration about not being able to pronounce the Chinese word for "restroom" properly, so that no one could understand what I meant.  She replied, "I always find that jumping up and down works really well."  She did a little demonstration, and I saw that it was a very effective way to communicate the idea.  Be creative! 

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More about The Social Status of Women in China)

 3 August 2009

Here’s an article written a few days ago in Newsweek about that issue of women’s social equality in China:

 A Great Leap Backward

This article focuses more on women in business, but the underlying issue is how women are perceived, and the role they play, in society overall.  It’s not considered demeaning for women to be referred to as "flowers"
or for a job description to state beauty and age features of the
proposed receptionist or waitress. The motto may be that women may hold up half the sky, but like many ideals of the Communist revolution that one has also largely been swept away by time. 

If anything, in my view, the article doesn’t go far enough in describing the extent of discrimination in China.  For instance, it describes the gender imbalance in allowing families to have a second child if the first child is a girl, on the supposed assumption that boys are more useful to poor, rural farmers.  It may be true that boys are more useful to poor rural farmers, but there is a larger and more significant purpose to the "girl" exception to the one child policy.  It reduces infanticide of female infants.  That one comment is like the canary in the coal mine:  it says a lot about the relative value of males versus females, opportunities available to them, and in my view that’s a sad statement about society. 

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My last blog entry on this topic was More on 三八女 (the social status of women in China) 11 March 2009 (click link to view)

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