‘So the Plague defied all medicines; the very physicians were seized with it, with their preservatives in their mouths …’
Daniel Defoe
A Journal of the Plague Year
The word ‘prodrome’ refers to that period in the course of a viral illness when the virus first begins its work on the body – the incubation period is passed, the sufferer begins to feel a little unwell but is still able to function. The virus has not begun its multiplication through the tissues of lung, skin, or gut – those parts of the body most exposed to viral attack. The word is Greek: pro means ‘forward’, and dromos can mean running, a sally, an offensive. It’s a term from military history, co-opted to the lexis of medicine to describe that moment in the course of the illness when an infection is preparing its assault. The virus and the immune system are running towards one another across the battlefield of the body.
On 4 February I flew to New York to join a panel at the city’s Academy of Sciences and contribute to a discussion about curiosity and wonder in science and medicine. United Airlines had been sending me a hail of text messages and emails for days, reminding me that if I’d been in China I would be turned back at the US border. Despite sporadic face masks among the travellers, the virus still seemed like a faraway problem; although one that, increasingly, I found myself thinking about with a nagging sense of anxiety.
There’s a masterful history of the 1918 Spanish Flu pandemic called Pale Rider, by Laura Spinney; a couple of years earlier I’d reviewed that book in a long essay for the London Review of Books, and a producer at Radio New Zealand had contacted me to ask if I’d do an interview about the piece, and also offer some perspectives on other pandemics. I thought about the Chinese travel ban and how the fear of the ‘other’ has long influenced how we describe diseases: in Madrid, ‘Spanish’ flu was known as the ‘Naples Soldier’; the Senegalese called it ‘Brazilian flu’; in Brazil it was ‘German flu’ – everyone had someone else to blame. The source of the 1918 pandemic is obscure, but of the three theories Spinney puts forward, the greatest likelihood tips towards an origin in China, it probably having arisen in communities where humans and poultry shared living and sleeping spaces.
The difference in time, logistics and other obligations all meant that this interview, via Skype, was the first thing I did when I reached New York. The absurd levels to which we’re all now interconnected came home to me as I sat down, cross-legged and jet-lagged, in a New York hotel room to talk to a radio presenter seventeen hours into tomorrow. He asked me for predictions on how far the new coronavirus would spread. I remember saying that I had no crystal ball, but what I’d seen of infection control measures in China seemed impressive – I hoped very much it would be contained as SARS-CoV-1 had been contained, and that isolation measures in China would be effective. That day it was reported that 425 Chinese patients had died, and infection rates, for those who’d been tested, stood at just over 20,000.
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The World Health Organization confirmed on 5 February that there was ‘no known effective treatment’ for the new coronavirus; despite the ban, US citizens were still being flown home from Wuhan and allowed in through American airports. I met my editors at the New York Review of Books, where we discussed Donald Trump, American hospital care, mental health, the lack of paid leave for either maternity or sickness in the US, and of course coronavirus. I’d not long written a piece for the magazine about the evolution of diagnostic categories in mental illness. In the field of psychiatry it has often felt as if where America leads, the rest of the world follows; no one I met in New York seemed to think that the same would be true for managing a public health crisis like coronavirus. No one was talking of emulating a ‘US approach’.
The following evening the New York Academy of Sciences held the panel discussion, and on arrival I went to shake hands with the host, who was heavily pregnant. ‘I can’t,’ she said, pulling her hand away, pointing it instead at her swollen belly. ‘I can’t afford to get sick.’ I nodded and apologised, though I shook scores of other hands that night.
Flying out of Newark the next day I found myself in a departure terminal where every table was festooned with tablet computers on stalks. They flashed like gambling machines, entertainment as well as shopping opportunities. To speak to a companion it was necessary to peer over these screens. All food and all payment was to be ordered by touching the tablets. Maybe they wipe them clean regularly, I thought, as I watched a kid pick his nose then start playing with the screen. Waiting for my own flight I picked up the first email from my childrens’ school about coronavirus, bundled in with information about mumps – something my colleagues and I were seeing more and more of in Edinburgh, as vaccination rates among the educated middle classes fell. There was, it insisted, no cause for concern, and anyone with symptoms who’d been in China was asked to stay away from school and contact their GP.
The same day it was reported that one of the doctors who had alerted the world media to China’s coronavirus crisis, the ophthalmologist Li Wenliang, had died of it. The Guardian newspaper reported that ‘Li was one of eight people authorities targeted for “sharing false information”, in a heavy-handed approach that China’s supreme court later criticised. He agreed not to discuss his concerns in public again. But in early January he treated a woman with glaucoma without realising she was also a coronavirus patient; he appears to have been infected during the operation.’ The paper drew a parallel with Dr Carlo Urbani, an Italian doctor who worked in Vietnam for the WHO, and who in 2003 died of SARS-CoV-1 after recognising the threat the virus posed, and doing everything possible to halt its spread. On its website the WHO wrote of Urbani: ‘because of his early detection of the disease, global surveillance was heightened and many new cases have been identified and isolated before they infected hospital staff’. Li didn’t seem to have been given even that opportunity.
By the time I got home the threat was beginning to feel real: we were into the prodrome of the first wave and it was clear that the infection, having been silently, rapidly spreading across the country, was now ready to make its presence felt. More UK cases had been confirmed: one, a British businessman in Brighton who’d caught the disease in Singapore, was confirmed on 6 February – he was later linked to eleven other cases. That weekend was a grim milestone: the number of deaths in China surpassed those of the SARS-CoV-1 epidemic of 2002–3, at 811. The coronavirus of that particular outbreak was more dangerous by some measures: the ‘case fatality rate’ – the proportion of people who, having contracted the virus, subsequently died of it – was often higher than one in ten. And yet SARS-CoV-1 spread far more slowly than the new coronavirus, taking months instead of days to reach countries outside China. That slowness of spread, and its perilously high fatality rate, all helped to rein in SARS-CoV-1 – outbreaks were spotted quickly because a high proportion of those carrying it became very unwell. This new virus seemed to be transmitted more speedily; many people seemed to be carrying and spreading it without symptoms, making it much more difficult to isolate affected individuals and prevent them from passing it on.
Half term holidays followed: with my wife and three children I drove to Orkney, the archipelago of islands off the northern mainland of Scotland. I once worked as a GP in Stromness, in the west of mainland Orkney, and we have many friends there. After a few days’ holiday my family went home and I took up a locum position as a GP on one of Orkney’s outer islands for a week. There were no hospital facilities on the island and no X-ray machines – just a GP clinic with a wider than average selection of drugs, and the company of one of the island’s nurses.
In the town of Kirkwall, on my way to the ferry, a message pinged from one of the NHS Orkney staff. Did I have time to drop by the hospital and be measured up for a ‘face-fitting mask’? It disturbed me that the request came in such haste. Did they know something I didn’t about the imminence of the outbreak? In Orkney? These masks, which are effective at blocking the droplets of coughs or sneezes that carry viruses, would never normally be needed by a GP, and only rarely by a hospital doctor. I had time if I dropped by the hospital right now, I replied, but had only an hour until my ferry was leaving for the outer isles. ‘It won’t be necessary,’ came the reply, and it wasn’t.
The ferry took a couple of hours; I arrived in darkness, buffeted by gusts of wind, met at the jetty by the outgoing GP who took me to one of the island’s two pubs for some food. He handed me the pager, the keys to the surgery, then with relish ordered his first pint of beer in a while. The following day he left for a skiing holiday in Switzerland.
It was a week of storms – Ciara and Dennis – with the ferries mostly in harbour and the planes grounded. After I’d seen my morning patients there might be a couple of hours of light left to the day, which I’d spend walking on desolate, invigorating beaches, swords of wind chopping at the dunes and raising a miasma of sand that drifted around my ankles. I was free to explore the island, as long as I was never more than twenty minutes from the car in case of a call.
In the end, there were just three emergency calls in the course of my eight days on the island. Islanders’ lives are governed by the weather, and the community appreciates that the price of living in such a beautiful part of the world is that access to hospitals and to specialist services can be fragile, and transfers delayed. A famous description by Jorge Luis Borges of the sea as ‘violent and ancient, who gnaws at the foundations of the earth’ comes to mind, when thinking about the way it can imprison this community, even as it protects it. I had to refer two patients for hospital tests – one for a heart problem, the other to rule out appendicitis. My having dosed them as best I could from the surgery’s extensive pharmacy, they were able to cross to the mainland on the ferries that ran through the brief lulls in the gales.
Several people that week asked me about coronavirus, whether I’d seen any cases yet, whether I thought the news of it was exaggerated, but behind their questions was the unspoken anxiety of what such a virus would do if it got into an island such as theirs. It would very quickly overwhelm the healthcare capacity, the limited oxygen supply, the ability to transfer patients safely to hospital. Each morning I had been conducting a clinic in parallel with the island’s nurses – for the first few days, Helen, and for the last few, Karen, both hugely experienced, extraordinary clinicians, with years of local knowledge of every islander and their difficulties. But with just one doctor and one nurse on the island, there was a brittle vulnerability to the provision of care that could seem unimaginable from the busy hospitals of the mainland. It lay beneath the surface of my everyday exchanges with the patients: usually unspoken, though we were all aware of it. I thought of the way that doctors in China had become seriously ill themselves, and how every year I pick up viruses and colds from patients that I have to shake off. This virus might not prove so obliging.
The Scottish Environment Protection Agency issued a flood alert across the archipelago, because of the height and ferocity of the waves. The wind was gusting over sixty miles per hour. When one of my patients needed to be flown off the island as an emergency that week, the atrocious weather made it a trial to arrange.
When I spoke to the hospital specialist in Aberdeen, she agreed with me that my patient needed to be seen urgently. Because of the storms, the air ambulances weren’t flying. I explained that there were no routine air transfers, and no ferries; if the patient was going to get off the island it would need to be with the help of the Coastguard – the only organisation with boats and helicopters capable of travelling in these conditions. That it might be possible for me to persuade the Coastguard to take the patient by boat to Kirkwall, but the tests available there were limited, and there were no sub-specialists. There was a silence on the line as she took in this information, and then she said: ‘Just do what you need to do to get the patient seen.’
The Coastguard were reluctant to commit the patient to a lifeboat in such storms, but in the end agreed to send a helicopter from Shetland.
I put off thinking about how I’d manage this kind of difficulty should coronavirus take hold in the island. At busy times Scotland’s helicopter air ambulance service flies almost non-stop between urban centres and remote communities, taking patients to urgent medical care. The emerging protocols dictated that, as things stood, the helicopters would not be able to carry coronavirus patients. If someone on the island came down with it we were to order a dedicated ambulance over from Orkney’s mainland, a journey of over two hours, and arrange transfer back again on the next scheduled ferry.*
Each island in Orkney has its own healthcare team: they are remote from one another geographically but their workloads are similar and they face similar challenges. They keep in contact through a weekly videoconference; the doctor or nurse on each island dials in to a central NHS server. That week I sat in the island clinic room with Karen as, one by one, clinicians from each of the other islands of the archipelago popped up on screen, boxed in their own livestream window. Over the videoconference we shared stories of the week’s challenges, and offered one another peer to peer, island to island advice. There was a brooding anxiety over how we’d manage an outbreak; on many islands the clinicians come and go in shifts, and there was real concern that any healthcare worker might introduce the virus to the community they were employed to help. One of the clinicians gave a virtual tutorial on multiple sclerosis – a particular problem of high latitudes – but the real value of the session was to make remote healthcare workers feel less alone.
News reports from Wuhan described a strict lockdown, efficiently policed, and I thought of all those densely packed apartments where people were becoming accustomed to exactly this kind of videoconferencing. We needed it to connect different islands in an archipelago, but there the technology was necessary to connect neighbours across a corridor.
Later, in Kirkwall, I managed to get my mask fitted. I was met in the hospital forecourt and led through three key-coded doors to reach a side room where a woman in burgundy scrubs and steel-framed glasses awaited me, having laid out some masks on a table. I could see five or six types, and she led me through them. ‘These work better with women,’ she said, ‘and these ones if you’ve got a big jaw. But you’d better start with one of these.’ She handed me a mask and asked me to put it on. It was a white cereal bowl of a thing, with blood-red elasticated straps. I made an idiotic hash of putting it on, at first upside down, and getting only one of the loops over my head. She had seen this many times before, and suppressed a smile. ‘Ah, both straps over my head, then,’ I said, turning it, and she nodded, letting the smile break out.
I suspected that from the moment we met on the hospital forecourt she had been sizing up my jaw and nose like a connoisseur: immediately the mask fitted perfectly, snugly to my cheeks. She gave a nod of satisfaction. ‘I’m just going to put this over your head,’ she said, and shook out a boxy polythene hood, silvered on four sides, with a hole in the one transparent side. I was cast back to primary school, it’s Halloween, and I’ve a painted crate made up to look like a knight’s helmet on my head; wearing a mask beneath the enclosing walls of the hood I began to feel the whispering edge of claustrophobia. The woman picked up a little spray bottle of liquid and poked it into an access hole in the front of the hood. ‘This is Bitrex,’ she said; ‘it tastes really horrible. Just keep breathing through your mouth and tell me if you taste anything funny.’ She began to scoosh and, my head now bathed in a fine mist of foul-tasting droplets, I took a few experimental breaths. ‘It’s the stuff they paint on kids’ nails to stop them biting them,’ she added. ‘I think they used to put it in bleach once, too, so that kids spit it out.’
I remembered that stuff from a nail-biting childhood, but don’t taste anything that brings those years back to me. ‘Right, deeper breaths now, really fill your lungs’; I gulped obligingly. ‘Now call out, loud as you like, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10.’ She led me through a few other hooded aerobics but, despite the extremest of contortions within the mask and hood, I couldn’t taste anything at all, and finally I was authorised to get out of it. A taint of the Bitrex hung in the air, the faintest echo of those nail-biting years suspended in the atmosphere of this modern hospital wing in Orkney. I thought of the virus it was there to simulate: as tasteless and odourless as carbon monoxide and, to some, just as lethal.
Back in Edinburgh on 20 February I dropped into a schedule of work at my own GP practice, with occasional afternoon locums at the Edinburgh Access Practice, a clinic for the city’s homeless population. I’ve worked in various incarnations of the Edinburgh Access Practice over the years, but at the moment it is temporarily housed in the basement of an old church at the west end of the city’s Grassmarket. It’s a church once dedicated to St Cuthbert, a medieval Northumbrian miracle worker who, said the Venerable Bede, ‘saved the needy man from the hand of the stronger, and the poor and destitute from those who would oppress them’. The street it stands on is called Spittal Street, from the old name for ‘hospital’, and it lies along what was once the western boundary of the city. The defensive walls that stood there are long gone, but the traveller approaching from Glasgow would once have had to pass over the site of the clinic and through an arched gateway, its crown spiked with the heads of traitors and malefactors.
There are so many resonances of the word ‘homeless’, and as many ways of being homeless as there are people. There are the couch surfers and rough sleepers, precarious tenants and asylum seekers, the trafficked, rejected and ejected, ex-prisoners turfed out with nowhere to go, and the dreamers who’ve made harsh contact with reality – all of whom have found out to their cost that there is no room at the inn. The homeless have the worst health outcomes in our society – life expectancy for rough-sleeping men is just 46, and for women it’s even worse, at 41. In the UK. By contrast, the lowest national average life expectancy globally is for the Central African Republic, where men average 52 and women 56.
The weather was still cold. I saw a woman who’d been trafficked from east Asia, who didn’t speak any English and who was pregnant. For an hour I was passed between telephone interpreters, trying to find one that spoke a dialect close enough to her own. Eventually I was able to establish that the police were already involved, and was able to pass on information about how she might get more support. Two men just released from prison, needing prescriptions for the drugs to ease their anxiety – both housed in B&B accommodation. Written across the notes of one of them was the message ‘DO NOT SEE THIS MAN ALONE’. Towards the end of the afternoon John, one of the practice nurses, called me through to take a look at someone’s feet. He lay on the examination couch, his rolled-up trousers filthy, and on his sockless feet I could see the purple stains of frostbite flourishing across his toes. Many years ago I worked as an expedition doctor in polar regions, but I had never seen a case of frostbite as severe as his. It was shameful that it was contracted not in Siberia, or in arctic Canada, but right here, in my home city, on my own doorstep.
In Edinburgh things were changing fast; the weekend service asked if I could come by and be assessed there for a ‘face-fitting mask’, just as I’d been asked in Orkney, but I knew the size I’d need now anyway. Then the offer was rescinded: new guidance had appeared that said that for the kind of examinations I perform as a GP it would be enough to wear a less protective ‘fluid-resistant’ mask and follow the usual infection control procedures – aprons, gloves, eye protection. The ‘face-fitting masks’ were to be preserved for those performing the kind of procedures where you might be sprayed with saliva, or worse, such as intubations and endoscopies. The blizzard of correspondence through our email inboxes about issues of personal protective equipment felt surreal – in the course of my work as a GP people are always coughing in my face, and every winter I get ill with one virus or another. I always take the flu vaccine and, year on year, I muddle through without having to take a day off. The kind of protection being proposed was frighteningly robust, and made me conscious that this virus was something entirely new, posing a level of danger that I’d never in my career previously encountered.
Some GPs were finding the governmental advice infuriatingly inconsistent, but it was clear that tough decisions were having to be made with limited resources. As the virus ran towards us from all corners of the planet, time was running out. As GPs we were being urged to avoid suspected cases in case we spread it inadvertently to others. But for every confirmed case who’d been unwell enough to need testing or who had been tentatively diagnosed, there would perhaps have been many asymptomatic people who were spreading it around, and who’d never fit any of the criteria for being tested.* If testing was supposed to throw a cordon around affected individuals, it was a patchy and ineffective one at best.
By the third week of February Italy, Spain and France had all reported coronavirus cases, and on 21 February Lombardy reported its first cases resulting from spread within Italy, rather than among people who’d flown in with the virus – they still had only six confirmed cases. My wife’s family is from Lombardy, not far from Pavia, and my mother-and father-in-law went into isolation. Italy reported its first deaths the following day, but several patients of mine were still relaxed enough about the virus to fly to Milan and travel from there to the Alps for skiing holidays.
Within four days Italy’s reported cases went from 6 to 229 and China’s approached 80,000. In the UK the total stood at 13, although amongst the other GPs I spoke to it seemed we had to assume that the virus was circulating at higher levels than were evident in the official figures. But China’s were slowing while Italy’s appeared to be gathering momentum: a new bulletin from the public health specialists at NHS Lothian asked me to tell anyone who’d been in Lombardy or Veneto within the last fourteen days, and who had symptoms, to self-isolate. ‘First of all, for reassurance,’ it added, ‘with regards Italy the area of concern is only for northern Italy – north of Pisa, Florence or Rimini.’ I was not reassured.
I spoke that day with someone who was, in retrospect, my first Covid-19 patient: a man who’d just returned from Rome, but who had no symptoms other than feeling feverish with a very slight sore throat, and an irritating dryness in his chest – common enough symptoms for anyone just off a plane. According to the rules I’d been given he didn’t have to isolate himself, and didn’t justify getting tested because he hadn’t been in northern Italy or in China. ‘Have you got a thermometer?’ I asked him, and toyed with the idea of dropping round to see if he had a fever. But then more calls and demands came through, and I didn’t. The first case of Covid-19 caught within the UK rather than imported was confirmed three days later, on 28 February. That same day, the first death of a British citizen occurred, not caught within the UK, or in China, but aboard the Diamond Princess cruise ship moored off the coast of Japan.
* These protocols have evolved since February 2020.
* It was later confirmed that the virus was circulating in Paris in December 2019.