‘I must acknowledge that this time was terrible, that I was sometimes at the end of all my resolutions, and that I had not the courage that I had at the beginning.’
Daniel Defoe
A Journal of the Plague Year
Strictly speaking viruses aren’t ‘alive’ – they’re brainless packets of genetic material wrapped in a fatty envelope, with proteins jutting from their surfaces. Those proteins are the skeleton keys with which viruses enter living cells; once inside, they hijack the cellular apparatus to manufacture copies of themselves. This process can go on until the cells burst, shedding more viruses and irritating the tissue they’ve infected. If that tissue is skin it may cause blistering (as happens with chickenpox or herpes); if the nose, lungs and windpipe, it may cause coughing and sneezing.
Whether they spread through the weeping fluid of blisters or through coughed airborne droplets, as far as viruses can be said to ‘want’ anything, they want the ability to fan out and take up residence in as many individuals as possible without limiting their spread through the death of their host. Effective viruses like influenza are, at any time, immensely broadly distributed among the population – it’s estimated that between 10 and 20 per cent of people in the UK harbour influenza in the course of each year. They’re endemic, meaning that we never truly get rid of them, but at the same time waves of newly evolved influenza strains pass seasonally around the world from year to year, as sections of the population become immune or partially immune to each one.
But viruses that cause illness in humans can also hide inside ‘animal reservoirs’, often without giving symptoms to the host animals, and the ability to do this increases the pool of distribution exponentially. These are called ‘zoonotic’ diseases, from the Greek zōon, meaning ‘animal’, and nosos meaning ‘disease’. We humans share sixty-five infectious diseases with dogs, and comparable numbers of other infections with goats, pigs, horses, poultry, sheep and cows. Measles arrived via dogs or cows; influenza from pigs and ducks; tuberculosis from cows; the ‘rhinovirus’ of the common cold from horses. Most likely, zoonotic epidemics have been with us as a species for at least as long as we’ve kept animals, rather than hunted them.
At the weekend emergency centre in West Lothian, in the first week of March, it was evident just how thick the weekly traffic is between Italy and the UK. The skiing enthusiasts were all returning home, many with coughs and fevers. Cases of the virus were rising as quickly across society: we were now into a period equivalent to the ‘invasive phase’ of an infectious illness, when virus particles begin to proliferate exponentially within the body, producing observable symptoms. One among several calls: a man who’d flown in a day earlier, from the south of France, and who had a headache, exhaustion and a fever. According to the guidance I’d been given, he wasn’t to be considered as a case of coronavirus – I informed him there was no official need for self-isolation. But the advice made me uneasy, and I asked him, if he could, to stay inside and off work for at least a week.
A family fresh from an Alpine holiday, with exhaustion and fevers; according to the location of their resort they were at risk, and they were referred to public health for testing. This was done by sending away an official form to public health – we GPs weren’t told who turned out positive and who didn’t.*
The computer system with which GPs read all medical records, make notes on each consultation and refer patients for specialist care, had new coronavirus codes added in early March. The idea was that anyone with Covid-19 registered in the system would be tagged with a special code that would keep track of the spread of the disease, as well as our Covid-19 workload as GPs. At this point, ‘Advice given about 2019-nCoV’ was the only code that I had plenty of opportunity to use.
Officially, we were still in the ‘containment’ phase of the outbreak, both in terms of the media messaging from government and in the communications GPs were receiving from public health authorities. That meant that we couldn’t swab or check people ourselves for Covid-19, but that the authorities would ‘test and trace’ all suspected cases coming from disease hotspots, isolate them and thereby attempt to stop the spread through the general population. But with cases climbing so fast, in order to carry on with ‘containment’ of the virus it felt like we would need hundreds of call handlers to decide who should stay put, who should self-isolate and who should be tested. And hundreds more workers to trace every contact. Drive-through testing of people who’d been in affected areas was happening in Edinburgh, organised through the Regional Infectious Diseases Unit (RIDU). By now fear was spreading, with some justification, and the situation was beginning to feel extremely serious. One of my patients, a taxi driver called Eddie, worked on a zero hours contract. He paid heavy fees to hire his vehicle, and handled the money of his passengers all day long. ‘I can’t afford to be off for two weeks,’ he said. ‘If I can’t work for two weeks I’m bankrupt. Homeless, too, as I won’t be able to pay my rent.’
As a doctor I’m accustomed to fielding my patients’ concerns, to meeting anxieties with reassurances, but the way this outbreak was evolving, I felt powerless to soothe or placate anyone. One elderly lady requested a letter for her insurance company, to get her out of her package holiday; I explained that until the government changed its advice my letter wouldn’t make any difference and she left, dejected. Another patient, a scientist who works in a lab with coworkers from all over the world, came into the clinic with a headache as if a mallet had dropped on his forehead, a fever of 39 degrees and a cough. He hadn’t been in Italy, though his partner had recently returned from Bologna, and he had colleagues who’d been in China earlier in the year. I had to tell him that under the current rules, he hadn’t been anywhere that meant I could get him tested.
I listened to his chest: it sounded as if he was developing a severe pneumonia, so I sent him to the hospital for a chest X-ray. The local hospital had started asking everyone with cough and fever attending for tests to wear a mask; ‘but the radiographer wasn’t wearing one,’ my patient told me later, and though he isolated for a fortnight with his partner, she never showed any symptoms. In retrospect he almost certainly had Covid-19, but it was my first encounter with what an opaque and capricious virus it is, to affect people so variably, to leave everyone so uncertain as to whether they’ve had it or not.
The supected Covid cases began to increase among my patients, all with what we now recognise as classic symptoms, but none meeting the strict national criteria for getting tested. It seemed clear to me that the virus was out there in our communities: a plumber with cough and fever; a woman who had returned from Umrah in Saudia Arabia, vomiting with fever. And still we were being asked to arrange testing on people only if they’d arrived from Italy and east Asia. The media messaging on my daily news bulletins suggested the virus was still fairly contained, but with such poor access to diagnostic tests and so many calls about cough and fever, I had to assume that the situation was much worse than was being admitted.
Watching the news, I thought the measures Italy was taking seemed necessary, if extraordinary: field hospitals springing up, draconian lockdowns, rationing of access to ITU. I once studied with military medics for a Diploma in the Medical Care of Catastrophes, learning about building makeshift hospitals, about dividing clinics into ‘clean’ and ‘dirty’ zones, about planning urgent mass vaccination, about emergency medical supply chains. It felt surreal that those kinds of measures were now being discussed so close to home, in a country with a medical system at least as well equipped as our own – if not better.
On 5 March the UK recorded its first death, an elderly woman who had contracted the virus within the country. There was broadening public awareness of the gravity of the crisis, but at the same time, even as a doctor in receipt of all the public health bulletins, I was having trouble grasping the true scale of what was breaking over the country. On Saturday 7 March, the same day the UK reported more than 200 cases, I was out with friends, many of them doctors, jokes aplenty about nudging elbows instead of shaking hands. I stood in the corner of a pub packed for the rugby: England victorious over Wales. We went together to a sold-out concert in Edinburgh’s Usher Hall – capacity 2,200 – crowds singing, people hugging, everyone pretending to forget about Covid-19 for a night. We knew it was around, we had all seen patients we suspected of the virus, and yet we felt fine – we theorised that perhaps it was less dangerous than the press were reporting, perhaps our medical work, and the routine bombardment by coronaviruses that it occasions, had offered us a measure of protection? I knew the virus was real, that it was spreading, but everyone I’d spoken to with symptoms seemed to be managing at home; a small voice at the back of my mind wondered – perhaps hoped – that some of the sources might be overreacting.
The following day, 8 March, the whole of the north of Italy was in lockdown, but Brits were still being allowed to fly home from there without quarantine. There were frightening stories from hospitals in Lombardy of insufficient ventilators, and operating rooms having to be used as intensive care units – even more frightening given that Lombardy was known to have a sophisticated network of hospitals, and more than double the ITU beds available, per head of population, than are generally maintained in the UK.
My brother-in-law was scheduled to move home to Lombardy from southern Spain that week, and had packed all his possessions into the back of a van, intending to manage the drive over two or three days. But with the worsening spread of the virus he realised he might not be allowed to drive over the border, and would have to go by public transport. He spent 8 March storing his possessions in his landlady’s cellar, to be collected when all this might be over, then took a train across Spain from Córdoba to Barcelona. People there were still thick in the streets, he said, kissing and holding hands as he walked among them in mask and gloves. He took another train from Barcelona to Marseille, where he waited in a corner of the station, keeping himself as far from others as he could. In Nice he met other Italians in masks and gloves, racing to get home, many to look after family members. They were mocked by local kids for their masks and gloves, and name-called ‘Chinoise’.
The Italian border was closed – shocking after all these years of Schengen Area borders in Europe – but he had only to show his Italian ID card, fill in a declaration of why he was travelling into Italy, that he had family there, and that he understood the situation, and he was allowed to continue.
It took him two trains to reach Genova from the border, where the police were uncharacteristically helpful and attentive; the atmosphere was one of gentle camaraderie, he said, and grim obstinacy in the face of the crisis. From Genova he took an (empty) local train home to his village. He’d spend fourteen days in the basement of his parents’ house, avoiding all contact with them until he was sure he didn’t have the virus.
By 9 March swathes of Italy’s north were ‘Category 1’, meaning that anyone who had passed through them was to self-isolate for fourteen days, even if they didn’t have any symptoms. An American journalist reporting from Lombardy flew back into JFK airport in New York, tweeting her surprise at being allowed to walk freely through arrivals with no one querying where she had been, or whether she had a fever. In the UK, newspapers were full of the absurdity of the supposed ‘quarantine’ in Italy, given that people were given free passage out of the country.
The epidemiologist Max Roser began publishing graphs online showing the benefit of doing all that you can to slow the spread of a virus, even if it was inevitable that it would reach everyone eventually. He showed two curves – one with no limits on how the virus might be allowed to spread through a population which looked like a Himalayan arête, and another with extreme ‘social distancing’ measures that looked more like the gentle swell of the South Downs. The same number of people would be affected in both, but the second had a much slower ascent to the peak and a slower come down, meaning the health services wouldn’t be overwhelmed by the peak.
The following day ‘Category 1’ was extended to cover the whole of Italy. There were riots in the prisons, as prisoners protested about visits being stopped, frightened of being left to die, abandoned by a depleted prison staff. Stories emerged of care homes in Italy being deserted by their staff because of the virus, of the military coming in to find residents dead in their beds.
In Edinburgh we GPs had an email from the Regional Infectious Diseases Unit pleading with us not to call them for advice. The volume of calls from anxious GPs passing on the concerns of travellers to and from disease hotspots around the globe was making the on-call system untenable.
There was another message detailing how Scotland would approach the management of people unwell with Covid-19 in the Highlands and Islands; how we might transfer people off islands to the units in Aberdeen or Inverness, in isolation. Reading it felt surreal, and to me it seemed unworkable; I wondered how many involved in creating the protocol had ever been involved with an island transfer: the enforced proximity waiting for ferries or flights for hours on end; the logistical difficulties caused by weather; the speed with which an island’s medical resources are overwhelmed. Six or seven people are required to come together just to make an air strip safe for a helicopter or plane to land. Meanwhile, in Italy they were having to treat the sick in hospital corridors.
I woke up on 10 March to a WhatsApp message from a colleague – though we’d seen plenty of suspected cases already at our own practice, the first few Covid-19 cases from our patch of Edinburgh had been officially confirmed with testing, all people returning from Italy. They had a fever, a forehead headache and a dry cough. We were all waiting for the news, but it still came like a cold slap. Everything about the way we worked would have to change. Planes were still flying in from Italy and France. Websites were telling worried people to phone their GP, while each morning we GPs were picking through emails to find out what had changed. Protective suits were to be saved for hospital staff and paramedics at the bedsides of sick people shedding the virus. I began to wake more often at night, anxiously re-running conversations with patients I had had during the day: wondering if I had done the right thing in telling someone to stay at home, or not; wondering how my clinic would manage to go on caring for its patients if the staff began to succumb.
At the surgery, we decided to slash the number of appointments offered by 50 per cent, filled the new space with phone appointments, and used a new code in the medical records: ‘Telephone triage due to Covid-19 restrictions.’ All the same, a colleague and I still made five visits that day to frail, elderly, housebound patients – among the most lonely, isolated people in our community, all of them over eighty-five, and all asking anxiously about the virus, trying with their questions to gauge our own levels of concern.
There were plenty of nervous jokes among my patients that day about the coming Coronageddon, but only one who phoned in with the now familiar dry cough, drenched in sweat and a fever of 39 degrees. He lived alone, hadn’t been abroad for months, and I told him to stay home for a week at least and have friends drop off food at his doorstep – I’d ring in a week to see how he was, and asked him to let me know if his breathlessness worsened. Pubs were still open, and that evening my GP colleagues and I had a meeting in one that felt like a boozy council of war, sharing stories we’d heard of patients in hospital with the virus, and ideas for how to protect the practice, should we each catch it. I remembered planning meetings for the ‘swine flu’ of 2009, but they were nothing like this, and the threat felt nowhere near as real.
Only two and a half weeks after Italy’s first cases were reported, the WHO called Covid-19 a pandemic. The speed at which this virus was moving was unprecedented. The UK Budget was delivered and the NHS was told it would have whatever it needed. I had my doubts. The numbers of deaths in China continued to drop – just 19 new infections. By then they’d reported almost 81,000 cases and just over 3,000 deaths.
At the school gate one of the other parents, a consultant physician, told me that the flimsy masks and aprons we were being advised to use in assessing Covid patients were all we were going to get – not gowns as recommended by the WHO. ‘They’re safe enough if you wash your forearms afterwards,’ she said. A helpful message signed by senior members of all the government health departments, health boards, Royal Colleges and the General Medical Council (GMC) came on 11 March: it said that I’d be expected, in the coming weeks, to go beyond what I’m accustomed to dealing with, but that I can be reassured that the GMC and health board would support me and my decisions through the crisis. ‘Clinicians may need to depart, possibly significantly, from established procedures in order to care for patients in the highly challenging but time-bound circumstances of the peak of an epidemic.’ It felt good to me that the GMC was at my back, rather than on my back, for a change.
Ireland closed its schools and universities on 12 March, and the United States precipitously blocked arrivals from European countries within the Schengen Area – planes, it seems, were still flying, but only US citizens would be allowed into the country on arrival. My patients’ attitudes to the virus that day were an odd mixture of terrified and laissez-faire: a grandmother who had taken on the care of her three grandchildren worried over her ability to go on caring for them should the virus reach her and her husband. A man with advanced cancer, spread to the liver, thought everyone was overreacting. A mother of a 7-year-old girl who was home with fever and cough asked whether that meant she should also be self-isolating.
To those who had mild symptoms – headache, or a dry cough – the official answer was always the same: as long as they hadn’t travelled to a recognised global hotspot of disease, then I couldn’t get them tested for Covid-19, and I didn’t need to inform them to self-isolate. Not yet, not yet, was the refrain – the government and the health board and the Chief Medical Officer were still sending me daily updates and, as far as they were concerned, we were still in the first of the four phases of a pandemic: ‘containment’. But it felt wrong – with the virus now so obviously highly contagious between individuals, and surviving on surfaces for several hours, any one of my patients might have it. It was a relief when that day we switched to the next phase of ‘delay’, where we might accept that anyone with symptoms could have the virus, no matter where they had travelled, and the only thing to do to keep yourself well was to avoid crowded places, wash your hands, don’t touch your face and, if at all possible, stay away from work.
That’s not an option for GPs, of course – that day my practice moved to a system whereby we stopped bringing people into the clinic at all if we could help it, and dealt with as many queries over the phone as possible, shunting those less urgent concerns into some imaginary locus in the future when everything might start to go back to normal. Over morning coffee, a colleague and I joked about getting a HazMat suit each, and moving directly to visiting only the most seriously ill in their homes while hermetically sealed in our own isolation units. We joked, but knew it could be coming.
I spent the afternoon doing a men’s clinic for the city’s rough sleepers and those with no fixed address, some of whom sleep in Bethany Trust dormitories, ‘night shelters’ that ordinarily run through winter and as late into the year as Easter. In my morning surgery in a leafier part of the city every patient had asked me about the virus. My homeless patients had, it seems, more pressing concerns. About half went to shake my hand, and thought me cowardly for bumping elbows instead. For the most part, people without homes or income, who live on the margins of society, whose concerns are so much more immediate, saw this as something for others to worry about – something for the kind of people who go on flights and cruises. Homeless people living in shelters and in temporary accommodation, couch-surfing around the city wherever they could find a place to sleep, were undoubtedly at higher risk than the general population. But it was clear, too, that they faced so many obstacles just to get through each day that the virus was either too intangible to take seriously, or perhaps they simply had less to lose.
By the time I emerged from the clinic the UK Prime Minister Boris Johnson had told everyone with cough and cold symptoms to stay home for a week. At last! I thought. GPs were again told that more protective equipment was coming, but the droplet-resistant masks still wouldn’t be available. Everyone with a beard who worked in a high-risk environment of Covid-19 patients had been asked to shave it off, as the masks don’t work if there’s hair between them and the skin. Anyone with religious or cultural objections was to speak with their line manager.
The relentless news cycle of what was happening in Europe and the rest of the world was strangely enthralling, grimly addictive: it satisfied something of our human fascination with fear, and pandered to our wish to seek examples of what we might one day have to deal with ourselves. A friend told me she watched compulsively in an attempt to foresee what was coming to us, but also because this pandemic was uniting us as human beings across borders and cultures. It didn’t matter whether you’re in Iran, where video footage showed rows of body bags being hurled into mass graves, or Rwanda, where everyone getting on a bus had to publicly wash their hands before embarking, or Bulgaria, where they’d just had their first deaths, we were all at risk, and we’d all get the virus the same way – through an infected human contact. But despite the horror of the images from Iran, the footage coming out of Italy was still more likely what we’d face in the UK – hospital corridors stacked with beds, problems with oxygen supply, lack of sufficient ventilators for our ageing population.
*
Friday the Thirteenth, and there was an atmosphere of dread in our morning meeting at the news from Italy: there weren’t enough ventilators to go round, or nurses; people were being buried without funerals. The practice WhatsApp group was renamed ‘Dream Team CoronaCombat’ in an attempt at levity. There was an air of quiet resignation at what was coming, but an edge of bunker humour, too. One of the clinic thermometers broke, and I went online to buy another – £30 versions were changing hands for £125. But virologists were learning about Covid-19 all the time and, for all their horrors, the Chinese and Italian experiences meant that we were better prepared than we might have been.
One of my patients that day was Mr Mirandola, an Italian gentleman in his late eighties. He told me that the virus was Mother Nature getting back at us. ‘Too many people!’ he said, and chuckled. ‘All us oldies need clearing out!’ I didn’t share his glee. The lab had stopped accepting viral swabs from GPs in order to scale up their testing capacity for the virus for hospital inpatients and, unless someone was admitted to hospital, they didn’t get a test.
It was on 13 March that the first death in Scotland was announced, in Edinburgh. One of my own patients was a close contact of the victim but wasn’t herself swabbed – she was just told to stay home for fourteen days with her husband and children. Another family – husband, wife, two children – phoned me to report a new cough and I told them that they’d need to stay in for a fortnight and arrange deliveries of food. They were incredulous: ‘This isn’t the middle ages,’ the dad said to me. ‘Surely they’ve got ways to treat this.’
The following day, Saturday 14 March, Spain would follow Italy into lockdown, with planes turning back halfway. The UK policy of allowing schools to stay open came under attack. It was obvious we needed new ways to slow the spread, particularly among the over-65s. One of my colleagues purchased us HazMat suits from eBay for home visiting, just in case; in the space of days, what had seemed like a surreal joke became reality.
That weekend I spent some time on the phone to an elderly woman living with her husband who has dementia. They were already barely coping at home despite carers coming in throughout the day and weekly visits from me. But when any GP might be carrying the virus asymptomatically, trying to assess their problems face to face felt like a luxury we couldn’t afford – we had to reduce home visiting to a minimum, almost to life-or-death situations. So the old lady and I had a difficult conversation about limiting those visits, and she had some weighty decisions to make about her own priorities. Both she and her husband were living on a tightrope of frailty, perpetually on the verge of admission to hospital, which no longer seemed like a safe space to be, and now she had to decide how much risk she was prepared to live with at home. It was clear that managing Covid-19 was going to be about so much more than treating surges of people unwell with the virus – it was going to be about transforming the way we could practise medicine.
A young man called me to say that a Belgian tourist had collapsed in his workplace five days ago. He’d spent two hours with the Belgian man and his daughters, while waiting for ambulance paramedics to come. Those daughters came by the workplace to inform them all that it had been confirmed the collapsed man had the virus. No one had contacted the workplace to tell the staff they’d all been exposed, and the victim’s daughters were walking around in Edinburgh not isolated, despite the near certainty of their own infection.
These were the kinds of stories that governments had been hearing but the public had not, forcing the policy to shift from ‘containment’ of the virus to ‘delay’. The public health authorities had a good idea how many people out there were already coughing and spreading it; they knew that the time for containment had long passed.
I phoned the public health authorities and they confirmed the case – no, they hadn’t traced his contacts as far as the workplace of my own patient, but yes, they would now include it in the follow-up. It felt like we had already lost the fight to contain Covid-19, and it was only a matter of time until the practice staff themselves began to get ill.
Of the thirteen coronavirus emails I had to read that morning of Friday 13 March, before starting to manage my own patients, this was the most relevant:
Subject: COVID 19 complete change in UK policy: please read now
Importance: High
Dear Colleagues
The UK coronavirus policy completely changed late last night.
We will not be testing people who have mild symptoms. People with mild symptoms are advised to stay at home for 7 days, that they will not be tested and that they do not need to seek healthcare (even by phone).
Patients with mild symptoms who have been referred to the testing service but have not yet been tested or do not have an appointment already (mainly today) will not be tested. Please advise your patients of this and recommend they stay at home for 7 days from onset of symptoms.
The guidance on specified countries we have been using up til now has been completely rescinded.
We will advise as soon as possible on guidance for the elderly, people with immunocompromise, pregnant and children. We are in a state of flux just now.
Further guidance is to follow re healthcare workers in practices.
NHS inform has not yet been updated. It will no doubt catch up in due course.
For patients with symptoms requiring admission to hospital please organise admission in the usual way, noting the presenting symptoms.
Thank you
If testing of suspected cases was being abandoned, I realised with a strange mixture of terror and relief that the government must be moving towards a ‘herd immunity’ strategy. Relief because it made the difficult work of contact tracing redundant, but terror because slowing the virus, but continuing to allow it to spread through the community, could lead to horrifying numbers of deaths. The city’s universities were closing down, and that afternoon our Personal Protective Equipment (PPE) allocations arrived at a depot. Each bundle was supposed to be delivered to the appropriate GP practice after the weekend, but there was a scramble for it, and a rumour was already spreading that there was none left – that practices who didn’t send a representative to the depot that afternoon would be left with none.
My parents, both in their seventies, called and asked me whether this was all as serious as it sounded. ‘Yes,’ I told them, ‘stay home. I’ll get your shopping.’
I started reading Boccaccio’s Decameron, the Italian classic narrated from a fourteenth-century Florentine villa by ten aristocrats, all in lockdown from the plague. Over ten days, each of the ten tells a story to help pass the time – making a hundred tales. Boccaccio borrowed most of his stories from other sources – many were old classic tales in their own right before he stole or borrowed them for his book, and I flicked through them restlessly. Stories of lewd nuns, double-crossed simpletons and duplicitous priests weren’t going to be helpful in getting me through the next few weeks. I was still thinking in terms of weeks for how long it would take to bring this virus under control, rather than months or years. I had more luck with Daniel Defoe’s A Journal of the Plague Year, a semi-fictional account of life in London through the plague of 1665, that Defoe is thought to have based on the diaries of his uncle, Henry Foe (Defoe was only five years old in 1665). Passage after passage could have been written about our own modern-day ‘plague’, and I underlined many of them, as if they had something to teach me not just about surviving epidemics, but about the timelessness of human experience in the face of infection.
Four days later, on Tuesday 17 March, the practice felt oddly quiet – people were stunned by the implications of the guidance delivered by the Prime Minister the night before, to avoid going out, to avoid restaurants and theatres, to self-isolate for fourteen days if anyone in the household has symptoms. Exceptional, necessary, belated advice. Of the twenty people I spoke to on the phone, a couple certainly had the virus – a new headache, fever, cough, malaise and exhaustion. I coded them ‘suspected coronavirus infection’ and gave them advice to stay in with their whole families, and call us if they got worsening breathlessness, before adding them to a lengthening ‘to do’ list to remind me to check in on them. As healthcare workers we’d been told to follow the same advice as everyone else – stay off work for fourteen days if anyone at home had a cough or fever; adjacent practices to my own were already losing staff, and we were clamouring for testing. Hospital clinics were being cancelled wherever possible, all elective surgery postponed. It felt as if we were clearing the decks for an onslaught the likes of which hadn’t been seen in over a century. The government’s brief flirtation with a policy of herd immunity appeared to be over, and a net was closing in on the whole of society – I could feel a UK-wide lockdown coming, and soon. Every day I was speaking with families stressed at being ordered to confine themselves together in their homes because of the symptoms of one family member; I wondered if they’d feel more able to cope once everyone in the community was ordered to stay home.
On Wednesday 18 March we heard that UK schools would be closing, too, and my wife and I – like millions of parents – would be contending with the competing needs of our three kids, the virus, her work and the NHS. We took the children to the local library the day before it closed, and stamped out stacks of books and story CDs – I realised it could be months before it opened again.
My wife contacted her GP in Lombardy; the situation is, he said, very grave, and he wished us luck with what is to come. Several of his colleagues in neighbouring villages had died through seeing infected patients. Many priests had died, too – shocking but not surprising, given how many of them shake rows of hands outside churches, and offer communion into the open mouths of their congregations. I messaged a medical contact in Beijing, the Chinese translator of my books, the surgeon Dr Xiangtao Ma, who said things were improving there, with few new cases. ‘As you know, isolation is the only effective method to stop the virus,’ he added, and asked that I give thought to the mental health of my patients as much as to their physical needs. He ended on a sanguine note: ‘People will have to change their habits for a while. The spring is coming.’
The masks we’d had delivered from NHS central stores were originally stamped with an expiry date of July 2016, perhaps warehoused for the swine flu epidemic of 2009, but someone had affixed new stickers stamped August 2021. It didn’t bother me – what can expire about a mask? – but some people must have written to the government in horror. An email came from Gregor Smith, then the Deputy Chief Medical Officer for Scotland: ‘I would like to clarify that this stock has been subject to rigorous assessment and shelf-life extension by the manufacturer and is therefore safe to use. I hope this allays any concerns you may have.’ It was obvious that what pandemic preparations had been in place had slipped.
My ‘clinic’ was almost all on the phone, and I had finished by 5 p.m. I had an hour to spare before an evening shift performing ‘telephone triage’ for the evening and weekend service – ringing anyone concerned about their symptoms and gauging who needed to be seen in hospital. I walked slowly through the city towards the clinic base, past all the closed bars and cafés, wondering if I’d have to turn up to work hungry. The first restaurant I passed, Encounter China, was closed but an Italian place, Cafe Artista, was still open for a plate of spaghetti – although the owner told me he’d close the following day.
A colleague sent me a copy of the research study from Imperial College that had changed government policy into one of lockdown, or ‘suppression’ of the virus, rather than a ‘mitigation’ policy whereby it’s assumed that the bulk of the population would have to catch and develop herd immunity to the virus. The latter strategy would need vulnerable, elderly or particularly susceptible people to hide or ‘shield’ from the virus while it’s in general circulation, which might take months or even years. It was the first time I had heard the term.
The paper estimated just how dangerous this disease would be without active suppression and distancing. Just ‘mitigation’, with minor changes to how society functions, would, the paper’s authors thought, lead to hundreds of thousands of deaths. With full societal lockdown they hoped to limit the deaths to the tens of thousands.
Edinburgh’s medical centre for telephone triage is on the south side of the city, in an old convalescent hospital built after the First World War. For my shift that evening there were ten or twelve of us – GPs, district nurses and telephonists – all in an open plan office on the ground floor of the old building. We passed around a single packet of antiseptic wipes with which to clean each workspace before starting. The wipes might have been in short supply, but there was a cupboard stuffed with chocolate bars and packets of crisps. ‘This is the best base,’ said one of my colleagues, holding out a tin for my 25 p donation, ‘it has a tuckshop with 1980s prices.’ I spent the evening with a recently glued and Sello-taped headset, one finger in my uncovered ear, phoning patient after patient with the same symptoms – dry irritating cough, headache, chest feeling tight, some rib pain – giving advice and arranging for the sickest, who might need oxygen, to be seen at one of the hospital bases.
One of the district nurses on duty was Christine, a Highlander who on day duty works my patch of the city. Her quiet competence, and accent down the phone line of English lilted with Gaelic, always comes as a relief to the ear. We joked about the tuck shop, swapped stories of shared patients, but when a call came in for a visit the atmosphere shifted. With a colleague she suited up in mask, visor and overalls, and gave a grim smile and a wave. ‘Wish us luck!’ she said. None of us were accustomed, yet, to having these barriers of plastic between us and our patients.
As GPs we’re taught to value the subtleties of human communication – to glean as much from what the patient doesn’t say as from what they do say. As trainees we have to submit videos of our consultations to demonstrate how carefully we attend to body language, to silences, to the way patients hold or evade eye contact. At this stage of the pandemic we were consulting for the most part on the phone, and for me those encounters felt alien, and profoundly unsatisfying. In happier days there was a sense of fellowship to my meetings with patients; on a crackling phone line, I could barely make myself understood to the anxious, ill person on the other end. Carrying out home visits in a mask, I feel like a surgeon looming over someone on the brink of anaesthetic oblivion.
‘Social distancing’ measures should of course have come in earlier, to buy us time – we all saw that then. We’d been like toddlers on the beach, fascinated by the waves edging ever closer up the sand, but who still squeal with shock when the water rolls over our toes. None of us could be persuaded to jump back until the disease was already on us.
That weekend supermarkets and Amazon dropped selling books, as they were considered dispensable items; warehouse workers needed to be shifting food and toilet rolls instead. I stopped off at the local bakery on the way to work to buy cake for all the practice staff, correctly guessing that by the following day it would be closed. So many more cases of cough and fever on the phone, but more than that, we were now struggling to address a mental health crisis with the feeble but essential minimum of telephone calls. I spoke to several people facing bankruptcy, many with panic attacks, who couldn’t sleep.
Our practice building has only one entrance, and there was no way to make a ‘green’ or a ‘red’ area for separating Covid patients from others. To make the best of it we opted to use our now-empty waiting room as a Covid clinic, laid out a mop and a bucket of disinfectant, and bought a folding clinic screen on the internet to offer a minimum of privacy. The virus could hang in droplets in the air, we were told, so a larger space would make the air less dangerous to breathe, and we opened the window. Patients would wear masks, and anyone with throat problems I’d see outside, where I hoped the perpetual Edinburgh breeze might carry viral particles away from their gaping mouths before they could settle on me. New IT services in the NHS usually take months, but a system for video calls with patients was implemented in the space of a few days. From my computer I could send a link to a patient’s smartphone which would patch them through to the computer in my office. I used it to diagnose a child’s rash on a screen, and with a woman in lockdown suffering chest pains, not from the virus but from rising panic.
One of the patients I spoke with asked, ‘Isn’t this all a bit much, Dr Francis? I mean, it’s hardly bubonic plague!’ I agreed to a point, but asked if she’d watched the news from abroad. The plague may have killed around a quarter of the population with each epidemic, while Covid-19 seemed to be killing ‘only’ around 2 per cent. But at the same time, outbreaks of plague are easier to spot, and consequently control. With the power of this coronavirus to be transmitted without symptoms, kill 10–15 per cent of the most fragile people in our communities, make a much larger proportion very ill, and with its long-term effects still unknown, I asked her if she might prefer we do nothing.
In a bid to contain the spread of infection through GP clinics, ‘Covid clinics’ or ‘Hot Hubs’ were planned to go live the following week: it made sense to concentrate all the suspected cases in one place rather than have patients coughing the virus over the surfaces of every GP surgery in the country. At first it was presumed these hubs would have access to better PPE than us out in the community, but no – they were to have the same disposable aprons and surgeons’ masks as the rest of us.
Outside, there were still too many people on the streets, and one of the London hospitals had called a critical incident. On the news there was talk of Italy needing a European Central Bank bailout, and of Spain urgently seeking to ‘flatten its curve’ within a fortnight. By 21 March, the spring equinox, thirteen doctors in Italy were dead of the virus. Three months earlier my wife and I had thrown a party to celebrate the winter solstice, with friends and neighbours crushing into our house and garden. We’d planned to hold another party at the spring equinox, but the people squeezed together in the rooms of our house, the hugs and chinking glasses, already seemed to belong to another age.
Barra in Scotland’s Outer Hebrides closed, the island literally self-isolating to keep its community safe. Kate Forbes, the Scottish finance secretary and Member of the Scottish Parliament for Skye & Lochaber, asked people not to take to the Highlands and Islands in their campervans. As I had seen in Orkney, the isolation of remote communities both protected them and threatened them: remoteness from urban centres meant remoteness from medical infrastructure and resources. Any small jump in Covid cases could swamp a small community. During the Spanish flu pandemic, remote communities endured some of the highest mortality rates: in Tonga, the mortality rate was 10 per cent, in Samoa, 20 per cent. There were some Inuit communities of Alaska where 50 per cent of the people died.
Driving down the motorway to a shift in the out of hours centre that weekend, I saw that the traffic signs ordinarily dedicated to accidents, deviations and seat-belt admonitions had all switched to public health: ‘COVID-19 – ESSENTIAL TRAVEL ONLY.’ They were a forewarning of the Prime Minister’s announcement, on Monday 23 March, that everyone must now stay home, and that there were just four permitted reasons for leaving the house: essential work; to buy food; to exercise once daily; or to care for someone. Everyone was in lockdown whether they were ill or not. It seemed incredible that we’d come to such measures in such a short space of time, but I was grateful that I no longer had to make the nerve-wracking decisions about whether to advise people to stay in or allow them to go out. In just three days a further three Italian doctors had been reported dead of Covid.
The day after lockdown was announced I pedalled to my clinic, exchanging guilty looks with everyone else who was out, as if we were all preparing our ‘essential worker’ alibis. Roadworks were still going on, and builders were labouring at a couple of house extensions I passed. I thought how much the crisis had triggered the wholesale recalibration of the prestige of different jobs: shelf-stacker, refuse-collector, care-provider, all seen for their value and essential utility.
Doctors and nurses, too, of course, but we already enjoyed a measure of prestige (though surveys consistently show that doctors aren’t the most trusted professionals – nurses are). On my return journey the roadworkers and builders had disappeared.
The ITU of the city’s Royal Infirmary was operating at 20 per cent capacity; a friend who worked there said it was as if they were waiting for a deluge. GPs were sent guidelines about how to assess levels of ‘respiratory distress’ without coming close to a patient, just by watching breathing movements and measuring oxygen levels of the blood. A method of gauging oxygen content of the blood over the telephone just by asking the patient to count as long as they could in one breath, the Roth method, was widely disseminated to GPs, then rapidly discredited after it was shown to be tragically inaccurate in cases of Covid-19 pneumonia.
The Covid patients I spoke with that day included an agoraphobic woman who picked up the virus at her aunt’s funeral. She had the headache that’s so characteristic of the infection, the dry cough that she couldn’t suppress for more than a few words, and was feeling acutely breathless in the mornings – though her sense of gasping for oxygen seemed to fade over the course of the day and she felt well overnight. We discussed how, after years of agoraphobia and anxiety, paradoxically she was feeling better now that no one else was allowed out. She had taken herself off all her anxiety medication for the first time in years. Other anxious patients of mine, habitual worriers, reported a similar sense of relief: the worst actually had happened, and that realisation brought an unexpected sense of liberation.
That week the Italian cases began to drop for the first time, while in the US cases were burgeoning. The WHO chief described how the first 100,000 cases took a month to be confirmed, the next 100,000 cases just eleven days, and the third 100,000 cases took only four days. Very soon we’d be talking in terms of millions of cases.
The Health Secretary wrote to tell me that Covid hubs would mean I’d shortly be able to get back to my usual workload. That email was quickly followed by another from NHS Lothian telling me of the ‘desperate’ need for more volunteers – could I put more of my usual work aside? The hub had just opened and I’d signed up for Thursdays and Sundays, but there was little slack available now that the schools were all closed, and when not in my own clinic I’d be at home with my children. Many of my colleagues were reluctant to sign up because work in the hubs was considered ‘ad hoc’, and offered no sickness pay if you caught Covid while working at them; there were similarly no ‘in harness’ benefits for the families of anyone who died of it. At the same time, we GPs were trying to support our own patients: if the network of general practice collapsed, it was obvious that hospitals would struggle to cope.
It was a weary week, the first week of UK lockdown, oppressive with the weight of all the misery this pandemic had unleashed. We’d been told so often in the last few years that mental health is the equal of physical health in terms of the respect and attention it should be accorded. But suddenly mental health was being obliged to take second place in order to protect the physical health of the community’s most vulnerable members. One day, 25 March, almost everything I dealt with related to mental health – all those people cooped up at home, watching their debts accumulate while their prospects dwindled, as vast swathes of the economy devoted to leisure, travel and tourism collapsed. There was so much regret out there, stewing in isolation – people wishing they’d seen this coming and changed their work or their finances to prepare.
One of the many problems general practice was facing was a surge in patients with chronic mental health problems such as schizophrenia being discharged from long-term hospital stay. It was assumed they would be safer outside an institution, and from the point of view of Covid risk that was true – but these were all people whose mental health was so precarious and volatile that they were thought to need hospital care to be safe. I was asked if I’d take over the care of one long-term patient with schizophrenia, including her regular injections of antipsychotics, and was told she would turn up for her injections, because if not she’d be breaking her ‘community treatment order’.
There was the misery, too, of people for whom home was no refuge, obliged to shut themselves in with aggressive or violent partners. The foster carers of troubled kids. The couples in immiserating marriages. The single parents barely coping. Every week I spoke with people in all those categories and more, while fielding a huge number of calls about who could be considered resilient enough against the virus to continue attending their ‘essential’ work, and which essential workers now had to stay at home. And all the while, the economy was buckling, shrieking, twisting into a wall of coronavirus.
In London the ExCeL Centre was being turned into a 4,000-bed hospital, and New York’s governor was screaming for 30,000 ventilators. India was attempting a lockdown of 1.3 billion people.
My friend Polly teaches in China, but had been sent back early in the Wuhan outbreak to the UK. Now she flew back to take up her job again in Shanghai – China had done so well in bringing its epidemic under control. The flight was almost full, but all the other passengers with her were in suits and masks. A day later, all visas and flights were cancelled. Every worker at the airport in Shanghai had full PPE with suits and masks, she told me – better than the PPE issued to doctors and carers in the UK. She went directly from the airport to a testing centre in a sports hall, where everyone on the plane was tested. They waited together there for the result – six hours, as compared to the three or four days it was taking for us in Scotland to get results – and because she tested negative she was allowed home (anyone testing positive was transferred to a government quarantine facility, along with all those passengers who had been seated nearby). Nevertheless, a device was fitted to her door to enforce a fourteen-day quarantine, and she was visited twice daily by a doctor to check her temperature. ‘My compound was very supportive,’ she told me. ‘They allowed me to have deliveries which they brought themselves via the security guards in suits, and they took my rubbish out for me every day.’ It felt as if China would solve the problem of the virus long before Europe would, but at the cost of a degree of state intrusion into the private lives of citizens that few Europeans would wish to contemplate.
Every NHS service was being stopped or scaled back. Cancer screening, new stroke clinics, IVF, sexual health (though with social distancing, STI transmission was plummeting). ECGs and X-rays were to be reserved only for the critically ill, or those in whom cancer was suspected.
Prince Charles tested positive, with ‘mild symptoms’, and was recuperating at Balmoral, though the nation had just been told not to stress the fragile resources of rural communities by travelling to the Highlands. There was mention of taking over the Scottish Exhibition Centre in Glasgow to make a giant Covid hospital, but I wondered if Balmoral might not be a better choice. Good views, fresh Highland air, plenty of bedrooms, relative isolation.
By the final weekend of March the virus wasn’t slowing in Italy, which was recording over 900 deaths a day, or in Spain, and was accelerating in New York. A German finance minister committed suicide. I watched maps online showing the number of cases as red dots blooming into wide circles, like spores in a petri dish. In just a week the number of deaths doubled, from 13,000 globally to 27,000 – the swine flu of 2009 saw about 20,000 confirmed deaths worldwide. Epidemiological studies were published showing the virus has the potential to cause 30 million deaths worldwide, comparable to the Spanish flu.
There was still no PPE as recommended by the WHO, so I spent a Sunday morning on eBay trying to find protective disposable suits. They were mostly sold out – though you could still order them from China. And the news from Wuhan was that life in the city was starting up again – its train station opened that weekend, against a background of only 47 new cases, all in people flying in from abroad.
As I drove down empty motorways that weekend on the way to my shift, I saw the notice boards saying simply ‘STAY HOME, PROTECT THE NHS, SAVE LIVES’.
As the month drew to a close, the thought of what the virus could do if it got into care homes was terrifying. There was a new drill for visiting Covid-suspected patients in those homes, and we GPs were told at first we could either adopt the protocol for every patient we saw within a care home or just for those with cough and cold symptoms, or fever.
First, we were to phone the care home staff from the car park before entering, to make sure the issue couldn’t be dealt with from outside, and warn them we’d be wearing PPE. I was to ask the staff to bring the patient as near to the door as possible, so that I wouldn’t have to walk through the home. I was to stay two metres from the patient until the moment of examination. If possible I was to ask the patient to take their own temperature, and measure their own oxygen levels, by handing over the equipment. I was to keep my examination as minimal as possible, then decide on a patient care plan from outside, after cleaning all the equipment and taking off my mask and apron. All wipes and PPE were to be double-bagged and incinerated, and all medications for the patient left at the front door.
One of my first visits was to a man in his eighties with Parkinson’s disease; he had fallen out of bed and wasn’t using his arm. I stood in my shirt sleeves, mask and apron on the doorstep of his nursing home, shivering and looking for the buzzer, until I realised that the door was open.
All visiting had been suspended, and the atmosphere inside was sombre: there was a crushing atmosphere of sadness among the residents, many of whom had dementia, not able to understand why their families no longer came to visit. How do you explain social distancing to someone who doesn’t remember where they are, sometimes even who they are? The staff, though, were magnificent – through their own masks and aprons they were doing their best to keep to usual routines. But the care home sector has spent decades trying to emphasise the ‘home’ in ‘care home’: they are not clinical spaces, they have carpets and soft furnishings, bingo nights and group excursions, dancing and card games. The expectation that a care home could limit the spread of a virus in the same way as a hospital could seemed absurd. Making residents feel at home, looking after them, often with inadequate resources, is an enormous accomplishment, and as ever I stood in awe of the work that carers do. And not for the first time, I thought how much the phrase ‘intensive care’ might reflect more than the specialist, techno-medical specialism of keeping people alive, but also the kind of attitude that works tirelessly to keep them happy, safe and living with dignity. This care home at least seemed to have plentiful supplies of masks and gloves.
So many door handles to negotiate! So many points of contact: my hand on my patient’s shoulder as I steadied him, my bag placed by the bedside table, the thermometer at his ear, the oxygen probe on his finger, my hands on his shoulder as I tested his deltoid muscle, my hands on his elbow as I gently rotated the joint. He hadn’t broken anything, and it didn’t appear as if his fall was precipitated by an infection or a stroke.
‘Any Covid cases?’ I asked the shift manager as I gathered my things. She shook her head.
‘Not so far,’ she said, ‘but I’ve heard some haven’t been so lucky.’ I’d began to hear the rumours, too – of patients being discharged from hospital to care homes, bringing the virus with them.
‘Tragic, isn’t it,’ she said as we walked past the day room towards the exit, all the residents spaced out in chairs two metres apart, the staff moving between them under their layers of clinical plastic.
That day it was announced that a UK doctor had died of the virus – Amged El-Hawrani, an ENT specialist.
* That didn’t change until August, when a new system linked to national clinical records began to inform GPs of every coronavirus swab result.