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Journal of a plague year

The New Statesman’s medical columnist describes his experiences as a GP in the face of Covid-19, as a rumour grew to a distant threat and then to the remarkable challenge of a global pandemic

 

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The curtain swept aside and he entered the cubicle. He was well over six feet tall, white-coated, with a notes folder in hand. He took a single glance at Mum – her unnatural pallor, her hands clutching her head as though that would stem the horrendous pain – then set swiftly to work. I was 17 years old, and, not long having passed my driving test, my nerves had been shredded by the late-night dash across south-east London with my acutely ill mother in the back of the car. Now, though, the doctor was here: calm, authoritative, efficient, purposeful. He suggested I return to the waiting room. What the words conveyed to me was: this was his domain; he would take it from here. The relief and the confidence he inspired were powerful.

A couple of hours later, about 3am, I saw him for a second time – briefly, as I drove out of the hospital car park. He was emerging from a doorway at the back of A&E, perhaps heading to his on-call room to grab some sleep while the going was good – this was the era of 100-hour working weeks for junior doctors. As he crossed the grass, he shrugged off his white coat and slung it over his shoulder. His gait was slow, his head slightly bowed. He looked ineffably weary. The sight gave rise to something inside me, something my teenage self couldn’t properly name. It lay in the juxtaposition – the capable, confident healer and the candid glimpse of the human cost behind the professional facade.

It was just a snapshot; I quickly passed him and was gone. I took with me a sense of medicine as not merely a career, but as a way of life. A vocation. A calling. The following year I made up my mind to embark along the same path.

***

Tuesday 10 March 2020. The whole practice team was gathered. There was chat and banter going on – the hastily convened meeting was a change from the norm and had a frisson about it. At that stage the threat still felt distant. There had been no reported cases locally. Now we know that Covid-19 had been circulating for well over a month. It just wasn’t being recognised because, in accordance with official definitions, patients didn’t qualify for testing unless they had travelled to certain countries in East Asia, or had come into contact with a confirmed case.

I looked round the meeting room – our loyal reception and admin staff, my nursing and medical colleagues. In my mind’s eye: a selfie from early February of a 34-year-old ophthalmologist, Dr Li Wenliang, lying in a Wuhan hospital bed, a sheen of sweat on his forehead, a positive-pressure oxygen mask over his face assisting his Covid-ravaged lungs to breathe. Just days after taking the picture, he was dead. Dr Wenliang was already being mythologised as a whistleblower: I read that he had attempted to “tell the world” about Covid-19. It was true that he had been sanctioned and censored by the Chinese authorities, but his supposed transgression had been less dramatic. He had used social media to urge his fellow medics to begin using personal protective equipment (PPE) because of what he had correctly surmised was an outbreak of a novel Sars-like coronavirus in the city.

[See also: The year of the Great Humbling]​

My practice manager called the meeting to order; the way our traditional general practice has always served its patients was about to be turned on its head. Chris Whitty, England’s chief medical officer, had just admitted it was probable that there was now sustained community transmission – over the weekend there had been a sudden uptick in confirmed cases with no relevant travel or contact history. The government continued to insist we were still in the “contain” phase. There was absolutely no guidance from NHS England, so we began thrashing out our own plan to protect ourselves and our patients during the coming first wave. A week later, the same measures we decided to implement in our surgery would be officially mandated countrywide.

That parasite’s back,” Barry told me. I had been his doctor for over a decade. We met several times each year, whenever he suffered an exacerbation of his chronic lung condition. This time was different, though. It was little more than a week after that whole team meeting and we were now dealing with as many patients by phone as possible – minimising the chance of coronavirus getting into the building and spreading to staff or other patients. Geographically separate “hot hubs” to assess possible Covid patients were in the pipeline, but were not yet operational. We had sectioned off an isolation room in the practice in which to see any suspected cases, but our PPE consisted solely of standard gloves and a box of surgical masks left over from swine flu.

I listened carefully while Barry outlined his symptoms on the telephone. He didn’t sound unusually short of breath. “And it feels just like before?” I checked. “Exactly the same.” His wry laugh rattled with phlegm. “I’m coughing up green gunk. And I feel like crap.” Barry placed great store by the drug that had cured him previously. “I just need that antibiotic,” he said, “that’ll sort it.”

I sent a prescription to his pharmacy, and instructed him to contact me again if he wasn’t improving within 48 hours. He never made it that far. He was found dead behind the wheel of his forklift two mornings later, killed by blood clots that had lodged in his lungs. The antibiotic was never going to have helped: this time his exacerbation had been due to Covid-19. It would be another couple of months before the propensity for coronavirus to cause abnormal clotting was recognised.

The pressure for GPs to offer remote consultations – by phone, video and email – has been building ever since self-described “disrupter” Babylon Health launched its primary care service in the UK in 2013. No longer would patients have to take time out of their busy days to attend a doctor’s appointment; they could be connected – any time, any place, anywhere – to a random medic on the other end of a digital device and consult with them from their office, their home, or even while out walking the dog. It was attractively convenient to otherwise fit young patients with simple, transactional problems, but I had long been sceptical of the model. So much subliminal information – physical, psychological, emotional – comes from being in the same room as our patients. Yet coronavirus had, in the space of just a couple of weeks, turned the entirety of UK general practice into Babylon doppelgängers. I have no idea whether I would have sensed that Barry’s case was different this time. But having seen him so regularly with previous presentations, something may well have struck me. Or perhaps I would have found an unusually rapid pulse or a strikingly low oxygen. That thought continues to haunt me.

***

Further into March. Giles, a colleague in the local clinical commissioning group (CCG), was on the phone. Once we’d dealt with the substance of the call, I asked how things were at his end. “Pandemonium,” he told me. They’d had instructions from on high to empty the hospital: “We’ve got to get bed occupancy below 50 per cent.” Assessments and preparations would usually be made prior to a patient leaving hospital. Now they were being sent out as soon as they were deemed medically fit, with care to be arranged post hoc.

“Some of the care homes are throwing a wobbly about taking positive patients,” Giles said. I checked my understanding. Yes, he confirmed: Covid patients, once no longer requiring or being able to benefit from hospital care, were being discharged to nursing homes. Many of those in charge of the homes were up in arms.

“What about some kind of community facility?” I asked. There were Nightingale hospitals being constructed at breakneck speed at various locations round the country. “Couldn’t you get some kind of step-down place commissioned?”

“There’s no time,” Giles said. “They’re just going to have to suck it up.”

I’ve known Giles for eight years. He’s a solid, caring man. I’ve talked to him subsequently, once the discharge of Covid positive patients into nursing homes had turned into a national scandal. He feels personal remorse. But he also feels like a tiny cog in an enormous machine. He was given a task and a deadline to complete it by, and told it was of the utmost importance. At the time he believed that those in authority must have had all this figured out or they wouldn’t have demanded anything so reckless. Yet more than 25,000 patients were discharged to nursing homes in the month after NHS England’s instruction, on 17 March, that hospitals should urgently create bed capacity for the anticipated first wave.

It was not until mid-April that Covid testing was mandated before moving patients into care homes. This seeding of coronavirus among the most vulnerable in our society made a significant contribution to the overall excess deaths in care homes during the first wave – officially stated as being around 20,000, though a recent study by the University of Manchester estimates that the true figure is likely to have been nearer 30,000.

***

The CCG was sending out daily bulletins containing officially sensitive data – case numbers locally, together with predictions based on theoretical modelling of what was going to happen, as March gave way to April. There were different predicted graph lines corresponding to different levels of adherence to the lockdown, recently and reluctantly imposed by the Johnson government: variously coloured curves forecasting intensive care unit (ICU) occupancy for 80 per cent compliance, 60 per cent and so on. Every trajectory saw even the rapidly expanded ICU capacity of our local hospital hugely outstripped. It was simply a question of degree.

An email came round. Additional funding was being made available for GPs to work through the coming weekend, scrutinising the records of all over-seventies and identifying those fit enough to be considered for admission in the event of contracting Covid-19. By implication, anyone not included – knowingly or unknowingly; by design or by accident – would automatically be excluded from the possibility of hospital care. I sent a query by return, setting out the ethical problems of such an approach. I was not alone.

The flurry of objections prompted a rethink. The spectre was Italy, where frail, extremely elderly patients with little prospect of survival had rapidly occupied the available ventilators, meaning those as young as 60 with far better chances were being turned away to die. But these were issues no one wanted to confront. The UK government had refused to sign off on any protocol for the rationing of scarce intensive care resources: no minister would put their name to any such policy. But that left the health service having to decide how to manage.

Our local grass-roots rejection of any such ethically dubious blanket policy was not an isolated case. National bodies such as the British Medical Association swiftly issued statements emphasising that all decisions on so called ceilings of treatment must continue to be made – as they always have been – on an individual basis, in discussion with patients and families. Our CCG convened a working party rapidly to draw up an ethical framework with which to navigate the predicted surge. It was based on the same holistic, person-centred care we have always striven to practise.

To our great relief, the theoretical modelling ultimately proved hugely flawed: we never approached the point of running out of ICU capacity. Yet in some parts of the country, where local resistance to such extreme contingencies was not as robust as in our area, elderly patients and those with learning disabilities not deemed fit enough to be eligible for hospital care were scarred by the experience of receiving, out of the blue, letters informing them that they were not for resuscitation or admission in the event they contracted Covid-19. This issue must be investigated when we eventually have an inquiry into the handling of the pandemic in this country: we cannot let it be lost in the passage of time and welter of events.

***

When I arrived for an early April out-of-hours shift, more than 170 triage calls were listed on a screen that usually contains around 20. Covid, Covid, Covid. I phoned patient after patient, listening to their symptoms, establishing where in the disease process they were, noting their age, clarifying their previous medical history, and trying to ascertain the severity. Every day we were receiving new information. Something called the Roth score had recently been advocated as a way of gauging respiratory compromise remotely: get the patient to count up as far as they could in one breath. Within another week the Roth score was banned, its application having led to some patients with silent hypoxia – dangerously low oxygen yet normal breathing rates – being falsely reassured and told to stay at home.

And chest pain. This is usually a potential red flag. Yet it proved to be common in Covid and usually not indicative of any serious problem. Apart from those patients in whom it signified heart muscle inflammation, or blood clots on the lungs, or an actual heart attack. In call after call, I was trying to work out from the patients’ descriptions which category they belonged to. Who to bring in for further assessment. Who could safely be left at home.

[See also: George Orwell and the road to revolution]

I had no idea at that stage to pay any attention to people’s ethnicity. Picture after picture of deceased healthcare professionals had been appearing on my social media feed, and it had begun to strike me how often BAME colleagues were featuring in Covid’s grim death toll. But it was to be many weeks before its disproportionate effect among certain ethnic groups was to be established.

I do not know whether, among the countless patients I dealt with on the phone, there were some I got wrong. Tragic stories have emerged of people – often relatively young but from vulnerable ethnic groups – advised to isolate who were later found dead at home. I can only hope I managed, with the best of knowledge I had in that fast-evolving landscape, to get my judgements right.

***

Xanthe – amiable, overweight, of Mediterranean heritage – was just one of a cohort of first-wave patients whose Covid symptoms kept recurring. For month after month, from late March through to mid-September. I was trying to figure it out, but test after test came back normal. I was left simply supporting her in this nightmare of debilitating ill health that had no end. Eventually I realised that her relapsing-remitting symptoms represented a distinct form of the disease that had hitherto been unrecognised. The best I could do was to connect her with support groups that were springing up on social media for patients with what has become known as Long Covid. She, and most of this subgroup, eventually recovered, emerging many months later from what had seemed an interminable nightmare. But I still have two patients for whom Long Covid persists. And they will be joined soon by victims of the second wave who are only now falling ill.

We continue to talk about Covid as a binary phenomenon: you live or, particularly if you are in a risk group by virtue of age or co-morbidity, you die. But there are unnumbered thousands – many of whom are young and in previous good health – who have sustained insidious ongoing damage, yet whose experiences never feature in discussions of lockdowns and death rates, or in working out quite what the right way to manage the pandemic actually is.

***

We diagnose about 18 cancers a year in our small practice. Some come to light through screening, but around one a month presents with symptoms. Many of these we would hope to catch early enough to be treatable: extending life, sometimes even a cure.

During the months of the first wave, we had no new malignancies. Then, once the crisis had subsided, four patients, all female, presented in rapid succession. One with lung cancer that would have been amenable to chemotherapy. She died before treatment could get under way. One with disseminated breast cancer who also rapidly succumbed. Another with advanced pancreatic cancer, who was never going to survive. And the last with a rectal tumour for whom we continue to provide palliative care.

It is impossible to know what impact Covid had on their outlook, although Macmillan Cancer Support estimates around 50,000 people experienced delayed cancer diagnosis as a result of the first wave’s impact on usual NHS care. To the best of my knowledge, our practice lost no one through heart disease or stroke, though again the British Heart Foundation estimates that nationally some 3,600 excess deaths occurred during the first wave from circulatory diseases.

The reasons for these findings include patient reluctance to seek care either through fear of contracting Covid, or through a belief that they shouldn’t burden an NHS they kept being told they had to protect. The emphasis on remote consulting, and the effort to minimise patient attendance at healthcare facilities must have played a role too, though this has not yet been examined, as far as I am aware.

During the chaos of the first wave, calls for an independent inquiry into the government’s handling of the pandemic were a regular occurrence, but it has been months since I last heard it mentioned. The discussions these days are all about tiers and lockdowns, the level of financial support, the effect on the economy. The now realistic prospect of widespread vaccination has also changed the mood. Suddenly an end seems in sight. Exhaustion with Covid is endemic. I can foresee us emerging at some point during 2021 with collective relief and relish at the return of normality. The temptation not to look back will be strong: to excuse the debacles and serial incompetencies that saw our country among the least able to protect its citizens in the developed world. I can hear the arguments: It was all terribly difficult. Unprecedented. Everyone did their best. It’s time for us to move on.

Cathy Gardner, the retired virologist whose father died after a Covid-positive patient was discharged from hospital to his care home, has recently been granted a judicial review of the government’s decision-making. The Good Law Project has recently filed for judicial review of the way the leadership of crucial bodies such as Test and Trace and the Covid vaccine task force were handed, without any competition, to individuals with no relevant experience.

[See also: What science can learn from religion]

Many questions remain. Why were crucial policies so disastrously reliant on inadequate theoretical modelling? The huge overestimate of the April surge led directly to the dumping of tens of thousands of untested hospital patients into nursing homes, many of whom took Covid with them. It also led to the near-total suspension of all normal NHS services. In terms of suppressing virus transmission, why did we spurn our established, though financially decimated, public health services, then throw billions at a dysfunctional privately-run track and trace programme? Why do we continue to regard Covid-19 as though it were a pandemic flu, ignoring its multifaceted, multisystem nature? What effect did the decade of austerity, and a consequent neglect of rigorous planning – as evidenced by the quiet shelving of the 2016 Cygnus report into pandemic preparedness – have on the capacity of our health service to care for all patients, Covid and non-Covid, during the pandemic?

Eighteen years ago, annual appraisals were put in place for all doctors, where we are required to review the preceding 12 months in discussion with an experienced colleague. What professional development and quality improvement activities did we undertake? Have we been the subject of any complaints, or involved in any critical incidents? If so, what have we learned from those experiences?

Appraisals were suspended back in March and reinstated in October, albeit in a different format this time around. The process involves a three-hour conversation with our appraiser, during which we can be debriefed about our experiences, and the effect of the threats, challenges and continual change occasioned by the pandemic can be explored. Not everyone values the appraisal process, but I find it useful. Never more so as this year of Covid draws to a close. How am I different from the doctor I was 12 months ago? And, equally importantly, are there ways in which I am even more resolutely the same?

***

Covid stripped away the soft layers that have accreted around modern general practice – the routine monitoring of chronic conditions, the disease prevention activities, the reassurance of the worried well. During the raw months of the first wave, medicine was pared right back to its essence: unwell, frightened patients seeking succour from those with the knowledge and skills to help.

Covid has been fascinating professionally; gruelling and sometimes distressing personally. On many occasions I have found myself thinking back to that nameless casualty officer who so inspired my teenage self. Within an hour of him attending, my mother’s pain had been controlled, a diagnosis had been made and treatment to effect recovery had been instituted. But what stays with me most powerfully was that moment when the curtain swept aside and he entered the A&E cubicle. As a doctor myself, I now understand intimately what was going on with that first, swift glance. He will have been gauging quite how unwell she was, what immediate actions he might need to take, and what the diagnostic possibilities behind her presentation might be. And his physical presence was as effective as any drug. Calm authority and efficient purpose – these are powerful antidotes to anxiety and fear.

Covid-19 has reinvigorated the sense of vocation that drew me to become a doctor those 35 years ago. I cannot wait to get back to serving my patients properly, as I have always striven to do. To get back to being in the same room. 

The essay is part of the New Statesman Christmas Special, also featuring Helen Mcdonald, Tracey Thorn, Grayson Perry, Helen Lewis, Armando Iannucci, Ian Hislop, Joni Mitchell, Stephen Bush, Jacqueline Wilson, William Boyd and much more of the best new writing.

Phil Whitaker is a GP and the New Statesman’s medical editor. His books include Chicken Unga Fever: Stories from the Medical Frontline (Salt)

This article appears in the 11 December 2020 issue of the New Statesman, Christmas special