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The pandemic letters

The novelist Sarah Perry and the oncologist Sam Guglani discuss the capacity of both medicine and art to respond to the coronavirus crisis.

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From the beginning of the pandemic, unable to write the novel I had been working on, and at a loss to comprehend the scale and speed of the changes brought by coronavirus, I spoke often with my friend Dr Sam Guglani, an NHS consultant oncologist based in Cheltenham – where he manages patients with lung and brain tumours – and a novelist and writer for the Lancet. We talked about the capacity of both medicine and art to respond to the crisis, mortality and the value of the moon.

Sarah Perry Early in March – when I couldn’t countenance the possibility that this virus would make any material difference to daily life – I remember your saying that for you, it had been like waiting for the tide to come in. Do you recall the feeling of those first days?

Dr Sam Guglani We were waiting, certainly, alert to the fact of it coming. There was a sort of electricity to those days, fear and uncertainty and a relentless readying, on the ground anyway, hours and days and evenings and weekends. It was exhausting – oddly because very little had actually happened yet, not to us in any case. But also, I had been waiting for it, or something like it. And exactly like the tide: the material inevitability of that, a shift in the world, and the indifference of that to us.

My father died when I was a teenager, and every day I meet death as an oncologist, so this has always felt nearby to me: a sense of life’s fragility, the world as entirely provisional. Honestly, even walking out in the morning, under a weight of sky, and waving the kids goodbye, I’ll think: will I see them again? Can I trust them to this day? It sounds morbid but it isn’t. Life feels heightened rather than diminished, feels charged, demanding we make sense of it. For what it’s worth, I’m not sure we always do.

SP What seems so striking here is that you were waiting specifically for this particular tide – this pandemic, in the sense of preparing for it professionally. But also that both as an oncologist and someone who faced loss and grief very young, this sudden reminder of mortality – which was such a shock to so many – wasn’t at all shocking to you. The language so often used around the pandemic has been martial – about battles, and winning wars – and we are cautioned against it. But I wonder if when your work moved from oncology to Covid-19, it did feel almost as if you’d been sent to the front.

SG It was shocking, of course it was, and frightening, the sudden enormity. But as I say, also expected. Because we always border loss, don’t we? I’m not sure it’s such a bad thing to feel that readiness for it. The counter-narrative – that we’re solid and indestructible creatures for whom loss and death is met as an affront – strikes me as both false and culpable for so many of the follies of society and medicine.

But, yes: the hospital felt as though it was preparing for battle. And – despite the justified criticism levelled at this sort of metaphor – necessarily so. Almost overnight, the usual walls and structures and processes of a hospital, even in a small English town like Cheltenham, were done away with. We found ourselves in a more heightened and liminal space. The cancer work and the Covid work merged for oncology: a middle line rather than the notional and blurring front line. Conversations about treatments and risk and death were filled with a new immediacy, set against a backdrop of the difficult public debate around who should and shouldn’t receive particular treatments – badly conducted debates, perhaps, where it appeared as though life and death were being metered out, almost, and prejudicially at that.

So yes, a battle, and legitimately. But we ought to ask, surely – at the bedside on a usual Sunday afternoon or in the throes of a pandemic – what are we fighting for? The avoidance of unnecessary death? Yes, of course. But only that? That’s too narrow a conception, to the point of being wrong.

You have questioned the value of writing and art in the throes of all this, both openly and to me – so I’m interested that it remains important to you to describe events and the world well. What, if any, force do you feel that words and literature have in the presence of events like this?

SP You’ve identified a really important element in what I’m thinking of as the mass shock that landed on everyone – I think in particular the day the Prime Minister addressed the nation, and said very specifically “many of your loved ones will die before their time” – and I remember thinking: but if they die, it is their time. Later, of course, people were affronted by this; and the affront was partly because death itself is an affront, and for all sorts of reasons we have got bad at speaking about it. But suddenly we were being asked to simply accept it. Then there’s been the manner of dying under quarantine – so I wonder if at the end of this we will understand better that to die holding a loved hand, or to be kissed goodbye, has a value that was taken for granted.

As to the importance of writing and writers – yes: I felt useless. I’d think of you, and suddenly sitting at my desk writing a novel seemed almost obscene. But I think my usefulness is in this idea of writing the world well, or at least as well as I, specifically, can. I feel as if I am accumulating sensations and observations, so that in due course someone will read what I have written (about, say, the pavements covered in chalk rainbows, or the signs taped to the playgrounds reading COVID EMERGENCY) and they will say: yes, it was exactly like that.

SG When you say “if they die, it is their time”, the statement presupposes a world where we’re unable to defer death – a world without medicine, or at least modern medicine. But that is not our world. I’m astonished, even in my 25 years as a doctor, how profoundly medicine’s capacity to temper disease and lengthen life has moved on. So it doesn’t follow – at all, I think – that when we die it must be our time to die. The failure to act in healthcare, where there may be the capacity and duty to do so, may be a culpable failure; and doctors and governments should rightly be held to account here.

The difficulty arises because medicine’s technical capacity to intervene in human pathology – slow weathering of or sudden breaks in the flesh, pandemic or not – has evolved steeply; and we struggle to fathom our duties and rights within that capacity.

SP I think one of the most distressing things that unfurled in the early weeks was the news that people felt pressurised into signing “Do Not Resuscitate” orders for themselves, or for vulnerable loved ones. I felt urgently that this could not be quite as malignant or as cold as it seemed, but lacked the medical or ethical understanding to explain or console.

SG The debate around CPR epitomises the tussle. Here is a medical treatment which can prolong life, but in the majority of deaths is both very unlikely to be helpful and can damage the bodies and dignity of the dying. Invasive ventilation in the context of Covid-19 is similar. It is a supportive measure for those in whom the virus has badly damaged the lungs, and is again unlikely to help certain groups of patients, but may carry profound harm as well as the sort of isolation – almost a deprivation of love – that you allude to. It isn’t a question of resource or the value of the individual but a question of what good medicine is.

The repercussions of a world view that insists all human ills are fixable, and our deaths indefinitely deferrable, has even wider impact. It privileges a narrow conception of health and it largely privileges the privileged within that – so it fails to respond to injustices and disparities of suffering and luck, as well as the visible fraying of an entire planet. It damages our shared humanity.

SP This idea that the response to the pandemic has privileged the privileged – and the statistics around the disproportionate deaths of BAME people have made this unignorable – is so vital, and, yes: it damages our shared humanity, absolutely. And though it will take entire departments of academics years to unravel what happened in 2020, I do wonder if the particular vulnerability of BAME people, and the indication that what lies at the heart of this vulnerability is not race but racism, has been fuel to the Black Lives Matter movement and the response to the death of George Floyd.

SG I was thinking more widely, but, yes, differential outcomes in BAME persons asks just this. And honestly: if it remains possible for George Floyd to be killed as he was, almost flippantly, then what do the technological marvels of medicine, our notional reverence for life, and this version of civilisation really amount to? What does it say about how we navigate power and value life, genuinely, all life?

Surely this is why the arts are vital, why literature is vital, why I wholly love your description of “writing the world well”. In writing it well, we stand a chance of making it well. I know you’re wary of any grand claims around the arts, but beyond what you always say about their utility in entertaining us, surely you feel this? Do the arts not interrogate the world for us? To me, anyway, your writing always does this: interrogates the beauty of the world, the sublime and its parallel horror.

SP I have begun to see the virus as a kind of magnifying lens. There is no part of our shared or individual worlds that this event has not examined. So, structural inequalities, the capacity and limits of medicine, the malignity or virtue of our politicians, the function of the press, and the utility of art, have all suddenly come enormously into view. Then there is the amplification of feeling. Every day I am in fear for people I love, and the fear increases the love, and the love increases the fear, so perhaps in the end it is increased capacity for feeling that will help us write the world well.

And, yes, this idea of the sublime – something that is beautiful because it is terrible, or incomprehensible – has always been a preoccupation of mine, and I suppose the task now is to lift out of a sort of mordant contemplation of the terrible, and locate what is perhaps more beautiful because of the pandemic, and write that down. Because they exist together, don’t they, impossibly – which I suppose is why all these weeks I have been sending you photos I have taken of the moon, and thinking of them landing with you somewhere in a hospital ward…

SG Yes, they exist together. I find that all the time, in a hospital, or stepping out of it. And your moon telegrams, which is how I think of them, deliver doses of reverence into the day, of beauty. It’s awe, isn’t it? Brief and overwhelming and intravenous: facing someone from a bedside, some gesture they hold asserting life, or facing our moon in a thin blue sky, the vertigo of it. Moments of grace, I think, which render us simultaneously tiny and enormous.

I felt this as spring opened, almost nonchalantly, synchronous with the pandemic: as though we are incidental to the turning world and its viruses. And I think we really are, honestly. Except for this consciousness, that the world’s matter gestures in us towards consciousness – and that aside from its flourishes of intellect, it holds at least the possibility of love.

Sarah Perry’s novels include “The Essex Serpent” and “Melmoth”. Sam Guglani’s novel “Histories” was published in 2017

This article appears in the 10 July 2020 issue of the New Statesman, State of the nation