‘I cannot omit taking notice what a desolate place the city was at that time. The great street I lived in … was more like a green field than a paved street’
Daniel Defoe
A Journal of the Plague Year
We spend our lives immersed in an ocean of air, barely aware of the ease with which we draw in portions of sky, hardly thinking of it as something that we could hunger for. Air, the most immaterial of materials, our most obstinate tether to life.
It was April now and, as our experience with Covid-19 accumulated, it was becoming clear that for most people, the virus barely bothers the lungs: sufferers complain of a dry cough as the virus irritates the upper airways; lack of smell as the nose becomes infected; fever as the immune system confronts the infection. A few people have nausea, vomiting, even diarrhoea as the virus upsets the digestive tract. Headache is a prominent symptom, and a bone-weary, sagging exhaustion – sending many to their beds for days.
Some estimates began to put the number who are entirely asymptomatic, but still able to spread the infection, at between 30 and 40 per cent. About a week into the illness, four out of five of those who are symptomatic improve, but in the remainder something more sinister begins to unfold: the tissues of the lung thicken as the immune system, in its attempt to flush out the virus, begins itself to irritate and inflame the lung. This process is poorly understood, but its result is well known: what should be the lightest, airiest part of the body becomes sodden with fluid. We often think of lungs as deep inside the body, but in truth the lungs, together with the gut, are where our body meets the outside world – as far as the body is concerned they’re external, and their flimsy, folded tissues offer a far greater area of contact with air than our skin. Like the leaves of a tree, our lungs have evolved to mingle and exchange the gases we are immersed in; unlike leaves, they’re moist and always warm – an ideal breeding ground for inhaled microorganisms. The immune reaction can make them even more moist, so much so that they can no longer perform their proper task of gas exchange. Covid-19 has been called a ‘biphasic’ illness because it has two phases: first ‘virological’, as the virus sickens the body; and then ‘immunological’, as misdirected messages from the immune system end up hindering rather than helping the lungs.
Heavy, sodden lungs are less efficient, and are difficult to breathe with – people get exhausted, which is why ventilators are needed, to take over the job until the body heals itself. But our lungs didn’t evolve to have air blown into them – they evolved to suck air, thanks to the outward motion of the rib cage and the downward motion of the diaphragm as you breathe in. Specialists in intensive care know that ventilators are a poor substitute for natural breathing. Pushing air at force down into the lungs damages them: it stretches some parts as thin as overblown balloons, while other boggy, swollen parts fail to inflate properly. Uninflated parts of lung are like dead weights: they don’t help with gas exchange and, just as a stagnant pool is a fertile medium for all kinds of life, stagnant portions of lung are at risk of breeding the kind of bacteria that cause pneumonia. Blowing air into the chest also restricts the heart. The inadvertent damage that mechanical ventilation does to lungs is one reason that I was hearing from colleagues in ITU that 6 out of 10 people with Covid-19 needing ventilation, and a third of those admitted to hospital overall, were dying of the disease. But for the moment, that ventilation was the best option we had, and without it the sickest patients would not have had a chance.
On 1 April, a medical school friend, Colin Speight, sent me a link to a project he was involved in. Colin is a GP now, but in former lives has been a tropical medicine physician, an HIV specialist in Malawi and a keen Antipodean surfer – he’s one of life’s enthusiasts. Together with a team of engineers and physicians he was involved in developing a new kind of ventilator, one that worked on the same principle as the old ‘iron lungs’ that helped people survive serious epidemics of polio through the 1950s and 1960s. Polio was known as a ‘silent killer’; the causative virus attacked not the lungs but the nerves that made the muscles move. Victims would suffocate not because the lungs thickened and stiffened with the fluid of an immune reaction, but because the diaphragm and chest muscles that sustain breathing were paralysed, albeit temporarily.
An iron lung is in essence a steel cylinder to lie down in, with a tight rubber seal at the neck. It has an outlet for a urinary catheter, and window hatches in the side for toileting. A machine draws air from the cylinder on a timer, creating a vacuum around the body which pulls the chest wall outwards to produce breaths. Air pulled, rather than forced, into the lungs is less damaging; some patients have remained in iron lungs for decades at a time.
The iron lungs being developed now by the ‘Exovent’ team are shorter, and sit over the trunk only – they have neoprene seals at the neck and around the abdomen. Patients can remain conscious on them, and are able to eat and drink – something that is impossible with traditional tube ventilation, where a wide-bore tube sits in your throat. The clinical staff need less specialist training to manage such patients and, when in motion, the machines create fewer sprayed droplets of virus than other ventilation methods. Breathing through suction rather than blowing helps, rather than hinders, the pumping action of the heart. The project is a not-for-profit humanitarian endeavour, with no financial reward for anyone involved – the team hoped to create a version of the machine for low-to-middle-income countries that would cost only £200 to produce.
Ancient ideas proposed the body as a fusion of water and earth, with air a kind of vital energy needed to ignite the flame of life. In April, as the virus fanned out through the population, hospitals began to fill up with people struggling for breath, their lungs drowning in fluids that threatened to extinguish that flame. It seemed difficult to believe that for all our technomedical sophistication, we were having to repurpose old ways of accomplishing that most primitive and basic of physical functions, the bringing of oxygen to the struggling membranes of the lungs.
On 3 April the UK Prime Minister, Boris Johnson, at home self-isolating with coronavirus, posted a video online. For a doctor it was alarming to watch: he was visibly overbreathing, interrupting his sentences to take brief gasps. Two days later he was admitted to hospital, and on 6 April to Intensive Care. The country itself seemed stunned; no other national leader had yet been affected by the virus so severely. The Foreign Secretary took over press briefings. The BBC published flow charts of how power would transition should the Prime Minister die, which seemed at first premature, but then perhaps there was a need to reassure people that anarchy wouldn’t descend on the country. The weekend came: Scotland’s Chief Medical Officer, Catherine Calderwood, was spotted visiting her holiday house after fronting the media campaign telling everyone else not to. By Sunday night she had resigned, and her deputy, Gregor Smith, had taken over as interim CMO.
Worse stories emerged from Italy. My wife heard of a social club in Lombardy frequented by the father of a childhood friend: not long before Italian lockdown had been implemented an event had brought seventy people together from all corners of the province. One of them must have had the virus, because of the seventy who gathered that day, forty were now dead.
By the end of the first week of April, into the third week of UK lockdown, we were reaching our first peak of patients requiring ITU. Each day I’d watch the figures on my NHS computer screen, my fingers trembling as they clicked between graphs of thin blue lines in steep ascent. London was emerging as the centre of the UK’s epidemic: hospitals were closing there for lack of oxygen, while in Edinburgh each day brought thirty to forty more people into hospital with Covid pneumonia – an admission rate that couldn’t be sustained for long. I wondered whether the hospital, too, would have to close, and we’d be forced to shunt patients to the new one, hastily erected in the SEC Centre in Glasgow, now named the NHS Louisa Jordan, for a Scots-Irish nurse celebrated for her work in the First World War. One of the drivers for the evening and weekend service asked me what I thought of the rumours, circulating on the internet, that the virus was manmade. I told him that as conspiracy theories go it was absurd: why would any government make a virus that is utterly uncontrollable, that has no respect for borders, that could so swiftly debilitate an economy? He didn’t look convinced; perhaps suspicion is hard-wired into us. In the 1600s an English physician, Thomas Browne, wrote of a manmade plague sweeping through Milan, that ‘allegedly was induced by a powder and a pestiferous ointment’.
Reports on the Prime Minister’s progress were anodyne and bloodless, as if the hospital spokespeople had something to hide. At the same time, in my day to day work the pandemic felt like a flu outbreak: I was speaking to three or four patients with Covid symptoms each day, but almost all of them were managing at home – even those with underlying health conditions such as asthma and diabetes. I wasn’t having to admit any to hospital.
The sickest patients were directed to the Covid Assessment Centre for a face to face assessment. The response to the call for volunteers had been good and, despite my offer of working Thursdays and Sundays, there were only a few shifts on the current rota where I’d be needed.
Training as a GP emphasises the importance of building empathy and rapport, but on shift in the Covid hub I stayed as far from the patients as possible until the moment of actually examining them, even taking their medical history from the far side of the room. I remember seeing an overweight middle-aged man there who had flown in from Italy not long before lockdown. Another who had caught it at his mother’s funeral, just as one of my own patients had caught it at a funeral (it seemed the ongoing restriction of numbers at burials and cremations was a cruel necessity). A builder who’d had a sick workmate on the last site he’d worked at before lockdown. A young mother who thought she’d caught it on the train from London. On shift one Thursday evening we all stopped at 8 p.m. to listen for the sound of clapping to celebrate health care workers, but the clinic is surrounded by hospital buildings, and the night was silent. ‘It makes my toes curl anyway,’ said one of my colleagues. ‘I’ll be glad when it stops.’
‘I like it,’ I said. ‘It’s the one time of the week I get to see all my neighbours.’ For me, those Thursday rituals were far more about people cheering one another on than about thanking the NHS.
In my area of Lothian there are usually two cars providing emergency GP home visits over the weekends and in the evenings. A few days after Boris Johnson was admitted to hospital, I was out in ‘Car 2’, driving to the most urgent triage category of visit – which means getting there within an hour. On the phone, the patient had said that after a week of flulike symptoms he was breathless even lying on his sofa, and had a fever – a characteristic story, and I knew that thousands of visits like this one were going on every day, up and down the country. It was early evening, westering sunlight was turning the suburban streets golden, blackbirds were singing in privet hedges. I phoned the patient from the car for directions. His breath came in gasps, his sentences interrupted.
‘Are you alone?’ I asked. ‘Yes.’ ‘Can you sit near the door?’ ‘Yes.’ ‘Just to warn you, I’ll be wearing an apron, mask, visor, gloves. I’ll give you a mask and gloves to wear, too.’ ‘OK.’ ‘If you sit near the door, it’s easier for me – I won’t have to come all through the house to find you.’ ‘OK.’
I ignored the twitching curtains of the neighbours, the kids out on their bikes. Earlier in the shift, leaving another home visit, a patient had asked me, ‘Can you shout to the neighbours that I don’t have Covid?’ Now I stood at the back of the car, opened the boot, and began the Great Faff, another new protocol to get accustomed to. Thermometer, oxygen sensor, stethoscope, all placed into a clean, clear plastic bag. Apron on, mask on, gloves on, then a second pair of gloves over the first. The apron flapped about in the wind. Some of my colleagues have been Sellotaping the thin flapping plastic to their legs, or using bulldog clips. Visor on last – its frame was 3D-printed in green plastic, with clips for attaching a head strap to the back, and a clear acetate shield to the front. On the inside of the forehead band was written ‘Car 2’ in Magic Marker.
At the patient’s front door, which was ajar, I breathed in the smell of stale cigarette smoke. The man was sitting on a stool just inside the door, elbows on his knees, bracing his chest with his arms to better move air in and out of his lungs. He was wearing grey pyjamas that had lost a couple of buttons.
‘How are you doing?’ He grunted an acknowledgement. ‘Can you manage to put on one of these?’ I handed him the mask, but he couldn’t tie the strings of it. Wishing my forearms weren’t bare, I leaned over him, holding my breath, and knotted the ties at the back of his head and neck.
I counted his breathing – fast, at 28 breaths per minute – and a digital thermometer in his ear flashed red with an impressive fever. I put an oxygen sensor over his finger – by shining light through the skin it gauged the oxygen content of his blood, which was worryingly low. His pulse, as he sat on the stool, was galloping along at more than 2 beats a second.
‘Can you stand up for me?’ I asked. We shuffled awkwardly in the small hall in a doleful dance; he turned around and I lifted his pyjamas to place my stethoscope on his back. The sound of the air passing through his lungs was accompanied by a quiet hissing sound, like sizzling fat. The sound of pneumonia. In his case, pneumonia probably caused by Covid-19.
‘I’m going outside then I’ll phone you about what happens next,’ I told him. I picked up the clear bag with my stethoscope, oxygen sensor and thermometer, and stepped out, trying to hold central to my awareness and every action that there was virus on the walls of the house, on the door handle, on my gloves, and on all my equipment.
On the doorstep I gulped down the fresh air, then it was back to the rigmarole: topmost layer of gloves off and into a waste bag. With my underlayer of gloves I took a chloride wipe and began to clean all the equipment – stethoscope, oxygen sensor, thermometer – and placed them into yet another clear plastic bag, ready for the next patient. The wipe went into the waste, then my apron. Next it was the visor’s turn to get cleaned, and afterwards I placed it on the ground to dry. Then undergloves off, mask off, the clinical waste bag tied off and sealed, and it was back into the car.
With all this donning and doffing of PPE, and cleaning of all the equipment, home visits now took far longer than they used to. I’d have been much happier wearing a gown in addition to the gloves, mask and visor – it would have better protected my arms, trunk and legs from droplets of virus. But, for now, there were no gowns available. A few days earlier I had looked through the supplies of gloves and masks that had been delivered to my practice from central government stores: the masks were stamped with the name of a Canadian company, manufactured in China, and distributed by yet another company from Germany. My gloves had all been manufactured in Malaysia or Vietnam. If we were to get this equipment to the people who needed it in the UK, we needed manufacturers here – and production should have started in January.
From the car I dialed the man’s number again; all those years learning about personal consultation styles, and now I was breaking bad news by telephone from a car parked outside my patient’s house. As I waited for him to pick up I glanced at the car mirror; my forehead was stamped with ‘Car 2’ in reverse, transferred in sweat from the visor headband.
‘I think it’s likely that you have coronavirus,’ I heard myself say, ‘and that it’s affecting your lungs, causing pneumonia. That’s why you feel so breathless.’ Silence. ‘I’ll arrange for an ambulance to come and take you to hospital.’
I waited. His breathing was audible. ‘Is there anything you’d like to ask?’
‘How long for?’ he said.
‘I don’t know.’
Heading on to the next patient I passed the ambulance I’d just called, on its way to collect him. The paramedics both waved and I waved back – one, who wasn’t yet wearing his mask, smiled. One of the few consolations of this pandemic is its grim camaraderie, a new fellowship among the fear.
Later I walked from the GP clinic to the A&E department to see how my patient had fared. One of the emergency nurse practitioners called up his X-ray on the screen: lungs should be light and spongy, the blackness of air clear against the white of ribs, diaphragm and heart. But an ‘infiltrate’ had clouded his lungs; where there should have been a black void there were speckled galaxies of white.
‘How old is he?’ the nurse practitioner asked me.
‘Mid-fifties’ I said. ‘Like the Prime Minister.’
‘Overweight?’ I nodded.
‘They’re all like that, up in ITU,’ she said. ‘Strange days.’ We paused together for a moment in silence in front of the X-ray, before she had to go and attend to another patient, and so did I.*
*
It was striking how many more people were out and about during the day than usual, now that so many were ‘working’ from home, furloughed, or rendered redundant – free to take walks whenever they liked. At the supermarket the evening queue snaked across the car park, everyone two metres apart; on entering we had our hands sprayed with sanitiser before being offered a freshly wiped shopping trolley. Progress through the supermarket was via a one way system, with no one supposed to go near anyone else. We were all potential assassins now.
Some clip-together disposable goggles arrived at my own clinic in an unmarked bag, but they were fiddly to put together and easily fell off – instead, we ordered wipe-down visors from an online DIY store. There had been media reports of staff being reduced to using kids’ ski goggles and having to wear bin bags – according to the news, many nursing homes were entirely without PPE. An official diktat arrived that any ‘home-made’ PPE should not be used unless it has been subject to safety assessments. The authorities, it seemed, didn’t want people taking their safety into their own hands, but without adequate provision, what choice did carers have?
New guidance was sent out to every medical practitioner in Lothian urging us not to shy away from difficult conversations. For GPs, discussions about ‘rationing’ healthcare are nothing new, but I had the sense that society was only just becoming aware of the gruelling questions that, within medicine, we’re accustomed to asking. Difficult conversations about whether or not to admit frail older people to hospital didn’t begin with Covid – for GPs, they’re a daily reality.
One of the guidance documents described how under ‘surge conditions’ it might become necessary to review all patients in the ITU every twenty-four hours and make a clear decision as to whether they were truly benefitting, and reminded me that the over-seventies have a very low success rate from ventilation and that the use of ITU would need to be ‘optimised’. In other words, I should prepare myself to tell patients, or their families, that there was little point referring the majority of frail older people to hospital even if they wished to be. Cynics pointed out that this seemed more a question of resources than anything else – not enough staff or ventilators to go around. True, but at the same time, overly simplistic: so few people with Covid-19 were surviving ITU that raising hopes of patients and families, only for them to die in a place where visitors weren’t allowed, would also bring cruel and unnecessary suffering. The advice closed with a long and very helpful appendix setting out the kinds of morphine and sedative doses we might need to assist those dying of Covid pneumonia at home.
As hospitals were weighing up the best way to help failing lungs draw breath, GPs like me were contacting everyone on our patient lists who fell into a vulnerable category, asking them to ‘shield’ themselves from the virus until July at least. It was as dismal a task as it was important, and I made the calls with a heaviness of spirit that I tried to disguise. It felt wrong to have such a distressing conversation on the phone, condemning each new patient to a kind of voluntary imprisonment. The categories included organ transplant recipients, those on active treatment for specific cancers, those with severe lung disease, the significantly immunosuppressed, and pregnant women with underlying heart problems. A further catch-all category was added to include anyone else GPs deemed vulnerable. My colleagues and I spent a fortnight going through lists of patients, doubling the number eligible for ‘shielding’ and passing their details to the government: everyone in the category was given a code which offers priority for supermarket food deliveries, benefits and community support.
I spent hours on the phone each day. Many of my patients were deeply frightened, and my line of questioning didn’t help. Did they understand the official advice? Did they need any assistance? Were they happy for the hospital and paramedic staff to have access to a summary of their medical history? Could we update their next of kin details? Grim stories emerged of GPs cold-calling patients to ask whether they wanted resuscitation attempted should they succumb to coronavirus, but I never broached those discussions unless someone raised it themselves. A study was circulated showing that around one in three people appreciate an invitation to have that kind of impromptu life or death conversation, but for the majority it was either unwelcome, insensitive or irrelevant.
In the case of pneumonia from Covid-19, ‘irrelevant’ was almost certainly true. Cardiac resuscitation can be helpful to restart a stopped heart after sudden, temporary interruption in its rhythm, but when the heart stops because of Covid-19 pneumonia it’s practically useless. Mechanical analogies of the body are rarely accurate – who ever heard of a turbine healing itself? – but in this case those analogies hold true: CPR for Covid-19 pneumonia would be like fixing a starter motor when the engine has already broken down.
The number of sick patients was rising in a straight line, with about 1,000 new cases testing positive every day across the UK, despite the lockdown. A huge number of NHS services were on pause, but of course anything related to births or deaths carried on regardless. We had the same number of phone calls from women who were pregnant as we always did, asking advice and for referral on to midwives. The lockdown had been effective in slowing spread and, at the level of our own practice, we had about the same number of people dying as usual, and were making just as many palliative care visits to help those at the end of life stay at home if they possibly could.
One patient in particular I remember from that time, a man in his nineties, Mr Donaldson. He had a chronic distrust of doctors, or rather of medications, and we’d joked often over the years about his reluctance to have his aches and pains, his heart trouble and his blood pressure adequately treated. Often on my visits I’d sit on his sofa as he watched the lunchtime news and we’d exchange opinions about politics. On the NHS, he’d say, ‘I thought it a good idea – I remember voting for it!’ On Brexit, he’d say, ‘That Boris Johnson, he’s a maverick, an entertainer.’ Now he was dying, of some silent cancer that together we’d decided not to identify or pursue, because he didn’t want to go to hospital and didn’t believe knowing the name of his disease would be any comfort to him. Whatever it was that was killing him would be allowed to continue unimpeded; he’d be spared the indignities of tests and clinic rooms for the sake of dying swiftly and, we hoped, in peace. ‘This is no life anyway,’ he’d say.
I thought of how few nonagenarians I knew who still enjoyed a good quality of life, and the bleak sadness of being in the last weeks or months of life but told to isolate from their wider family, and from society. It seemed one of the cruellest corollaries of the measures we had taken as a society, and every day brought new conversations with lonely old people who, week after week, saw no one but paid carers. That the virus spreads through speech and through touch was one of its harshest twists, attacking the most basic elements of our humanity – how we connect, empathise and show love.
My visits to Mr Donaldson often coincided with those of one of the district nurses, Michaela, whose efforts kept him as comfortable as was humanly possible: like so many of the other medical professionals I work with, a true provider of intensive, compassionate long-term care. On those shared visits Michaela and I would gently roll him to check his back for sores (‘Easy does it there, Mr D!’) and try to position him on the hospital bed that had been drafted in to make nursing him easier through those last days. I felt awkward bending over the bed in apron and gloves and peering at him through an acetate visor, but he didn’t seem to mind. ‘I’m surrounded by kindness,’ he muttered, asking us again and again to keep him comfortable and out of hospital. His voice was a whisper, but his last words to me were: ‘This bloody virus.’
Before the pandemic, whether in ITU or out in the community, every day in medicine was a mixture of triumph and tragedy. In the thick of that first peak through April my days felt much the same, though conducted through a strange, sad and impersonal barrier of PPE and phone calls, and being able to see so few of my patients face to face. With my colleagues in the practice the jokes, puns and anecdotes continued: there can be great fellow feeling between colleagues in such an intense environment. As we peered at one another from behind masks and visors, we found ways of reminding ourselves what we love about the work, reassuring one another that the pandemic would eventually pass and the community would recover.
The mental health consequences of this crisis were deepening: some days every call I took was about loneliness, self-harm, anxiety, panic attacks. France was arranging hotel rooms for victims of domestic abuse forced into staying home with violent partners. New infections in Italy were slowing after four weeks of lockdown in some places, but they were not seeing any slowdown in deaths – still 800–900 per day. Russia’s cases were climbing fast, Spain’s were at 1,000 a day. The UN Secretary General called it the worst crisis since the Second World War, without parallel, while more countries were beginning to report anger against China for not managing to contain the virus. In the US, where the President constantly undermined state-level attempts to enforce any lockdown, case levels were surging past those of China.
More details began to emerge about the stealthy way in which the virus took hold in the body: studies were published that showed that SARS-CoV-2 was four times easier to catch than SARS-CoV-1 had been. The lollipops of sugared protein that jut from the new virus’s surface – the ‘keys’ through which the virus enters human cells – were four times ‘stickier’. SARS-CoV-1 readily infected the lungs, while evidence was beginning to emerge that the new one preferred to begin with the upper airway – nose, throat and windpipe. That affinity for the nose and windpipe made it more dangerous, because it could spread more easily through sneezes and nasal drips.
More detail began to emerge about the disparity in the virus’s effect between the old and the young: immune studies were published showing that the older someone was, the more likely they were to generate a devastating immune response to Covid in the thick of the second, lung-clogging phase of the illness, when the cells that should protect the body from invasion began instead to attack it. The immune system in the elderly is often less efficient at tackling viruses in the first place, and now it looked as if the elderly were doubly disadvantaged: more susceptible to the virus itself, and more likely to be swept away by the storm of the body’s late, damaging response to it. But the pattern was mysteriously uneven – some elderly people showed no response at all, as if they carried in their genetic make-up some as-yet unidentified protection. Every copy of the virus would enter the human body the same way: by applying that lollipop ‘key’ (the ‘spike’ protein) to one of many potential ‘locks’ that cover the cell membranes of human tissue. SARS-CoV-2 binds frighteningly well to one called ACE-2,* which ordinarily helps regulate blood flow through the tissues. Men seemed to be more severely affected by Covid-19 than women, perhaps because they have more ACE-2 coating their body cells; children have much less, offering an explanation for why in general they’re so mildly affected.
In mid-April it was confirmed that the virus came directly from horseshoe bats, not through an intermediate species such as pangolins, as had previously been thought. Other viral mapping studies indicated that the virus prevalent in New York seemed to have come from Europe, not Asia, and was circulating widely when I was there back in February – at a time when a China travel ban was in place, but not a European one. I couldn’t help thinking of all the hands I had shaken at the New York Academy of Sciences, and wondered if I’d put any of my New York friends at risk. The idea of travelling across the Atlantic already seemed like a strange and remote possibility.
We heard of more deaths in the distance, as rumours. As I passed hours of clinic time on the telephone, talking with people at risk and asking them to ‘shield’ themselves from this virus, I listened to their stories. In one local family, a middle-aged woman was in ITU with it, and both her elderly parents had already succumbed – one had died in hospital, the other at home. The daughter had been unconscious for a week, and didn’t yet know that her parents were dead of an illness she had likely transmitted to them both. Another patient told me of her grandfather, who had been in ITU for ten days before it became apparent that he wouldn’t be able to come off the ventilator. Eventually he was allowed to come off the machine and die in a side room.
From rumours, to reality. Miss MacInnes was in her early eighties, a retired schoolteacher, still formidable in her tweed skirts and incongruously dainty hats. For ten years I’d enjoyed her visits: her diatribes about the city council, as much as her lyricism in praise of whatever poetry collection she was currently reading. I’d never had to visit her at home, and so it was a surprise to hear from the receptionist that she’d called for a home visit. Her niece had visited as usual with some shopping and found her muddled: unable to find her way to the bathroom; incapable of preparing a meal.
‘Has she had a fever?’ I asked. ‘A cough?’ But no. The niece said that she herself had felt tired, queasy and as if she had a headache a week earlier. But the pain and nausea had left her quickly; she was tired, but was otherwise well.
For a few days my colleagues and I returned to Miss MacInnes’s house, trying antibiotics for a presumed urine infection, and seeing if we could get urgent help put in place through social services to assist with her meals. But it was clear that she was becoming more and more unsteady, and would need admission to hospital for round the clock nursing care.
On arrival at hospital, three days after my first visit, she swabbed positive for Covid-19. A week later she died.
The last few hours of life are often peaceful ones, but agitation is not unusual in the days leading up to death. As life begins to unmoor from the body it has often seemed to me as if the body, sensing an ending, begins to lash out, to lay hold of new energy and snatch at what remains of life. This disease is no different – in their agitation some sufferers seem to fight and pull at the very oxygen masks that are keeping them alive.
Miss MacInnes’s niece told me that her brothers and cousins were now ill with the virus; that her own parents, themselves very elderly, were in isolation against it. Focussed on their own struggle with fever, breathlessness, exhaustion, it was difficult for her brothers and cousins to grieve. Five would be allowed at the funeral, she told me, and no one would be able to hug one another.
Within the orbit of my practice are several sheltered housing complexes, where people, mostly in their eighties and some in their nineties, live reassured by the proximity of a warden, cheered and supported by a community of others. They have coffee mornings, knitting circles, exercise classes – but everything was cancelled now. Each was confined to their own small room, each fearful, and at my visits I found every one of my patients despondent, even despairing. ‘When we want to go sit in the garden,’ one told me, shaking her head, ‘we have to go one at a time.’
Towards the second half of April Mr Denholm, who’d once had a heart attack and who came into the surgery every few weeks for blood tests, didn’t show up for his appointment. Pearl, one of our superb receptionists, asked me if I thought we should be worried. ‘He’s not answering his phone,’ she said. ‘That’s not like him’.
‘Have we got a next of kin for him?’ I asked. We didn’t.
After a day of calling Mr Denholm, and getting no response, we alerted the police, who kicked in his door. He’d been dead a couple of days, they guessed. Between 3 April and 10 April there were 8,500 more deaths in England and Wales than in the same period the year before; only 6,000 or so of them were presumed due to Covid-19. Those ‘excess deaths’ were presumably among people for whom the virus had prevented them getting access to healthcare, either through a diminution of services or because they were too frightened of the virus to go to hospital when they should. I kept returning to the thought that Mr Denholm might have had chest pain in the hours before he died, but didn’t call an ambulance for fear of catching the virus.
Much media attention has been paid to doctors, nurses and carers dying of this disease: how inadequate their PPE was; how they were being redeployed in unfamiliar environments; how they were selflessly exposing themselves to the virus in the fulfilment of their vocations. But little has been said about other front-facing, public sector workers such as the police, who were as busy during lockdown as ever, both because of the need to administer it, and because those most likely to break the law were the least likely to observe the restrictions. When I worked regularly in A&E it often felt as if clinical staff and police officers were on the same side, the only sober folk in a city of drunken idiocy. As a GP my encounters with the police are less frequent – I call them if someone in the throes of psychosis is a risk to themself or others, or if, as in the case of Mr Denholm, I can’t get access to the home of someone I’m worried about. But I’ve never forgotten the solidarity of those nightshifts in A&E.
In mid-April I was chatting with a police officer about one of my patients, and heard how difficult the challenges thrown up by the pandemic had been for that service: some stations had been earmarked ‘red’, for potential Covid positive offenders – those with fever or symptoms – while other stations were presumed ‘green’ or ‘clean’. But how this was to be determined, let alone enforced, was an open question: police officers have to arrest people, often wrestle and restrain them, all the while at risk of being coughed at in the face. We’d seen within medicine that those who intubate, examine throats, perform endoscopies were at much higher risk of catching the disease, though I’ve heard little discussion of the risks of wrestling someone to the ground in order to handcuff them. Hot-desking in the back offices of police stations is common, too – another risk factor for transmission. We were all going to need better masks, millions upon millions of masks.
On 15 April the global number of confirmed cases passed 2 million, and would reach 3 million before the end of the month. Forecasts suggested the global economy had already shrunk by 3 per cent, and carbon emissions were set to fall by 8 per cent – for the first time reaching a level that experts estimated is needed year on year to meet international targets. It was being reported that the Himalayas were visible from Delhi, and in Venice the canals were running beautifully clear. But no one was out enjoying the clearing airs and waters. Friends around the country who lived in tourist hotspots told me how wonderful it was to have the place to themselves, though that sensation was bittersweet: their local economies were crumbling, with no prospect of alternatives to be found.
Edinburgh’s Royal College of Physicians was running an online series of seminars, and I logged on to hear a Professor of Emerging Infectious Diseases and Global Health at Oxford, Peter Hornby, updating the College on one of the first research trials to combat Covid-19. It was the RECOVERY Trial, comparing different medications: hydroxychloroquine; an antibiotic called azithromycin; two anti-virals; and steroids – drugs that reduce the intensity of the body’s own immune response. The trial was building on some of the research conducted in China early in the Wuhan outbreak, which suggested antiviral drugs may have some promise. There had been a fanfare of publicity around the use of hydroxychloroquine, but the results so far had been disappointing.
In Lombardy, where the first peak had passed and the grip of the virus on the population was in decline, the provincial government issued my mother- and father-in-law with a surgical mask each, to reduce their risk of inhaling particles of virus. Everyone in Italy was to wear a cloth mask of some kind or another, to minimise spread by those carrying the virus rather than to prevent inhalation of it. By the end of April the same advice was issued in Scotland, and hastily prepared home-made masks began to appear around the city.
One of the acute hospital physicians, Claire Gordon, wrote a document that was circulated to us GPs towards the latter half of April that underlined just how protean and unpredictable the manifestations of the virus could be, which in their diversity, and their severity, seemed so much more extreme than any other viral disease I was accustomed to treating. ‘Fevers I have seen with Covid are pretty mind-blowing in terms of height and duration,’ Gordon wrote, expressing the surprise many of us had felt assessing these coronavirus patients. ‘Paracetamol barely touches them.’ The breathlessness was often subtle, and patients were frequently unaware of just how unwell they were until they tried to move, and found themselves gasping for breath. When considering whether people might be ready to go home, she was monitoring patients’ oxygen levels while walking to and fro in the ward – those in whom oxygen levels dropped on minimal exercise would have to stay in.
As I’d seen for Miss MacInnes, for many elderly people the only sign of infection was feeling muddled, taking to bed, while younger folk complained of muscle pains or a surprisingly deep fatigue. Dr Gordon supposed that the older patients were ‘less surprised to feel like they’ve been run over by a bus’. Headaches could be so severe that she’d had to scan Covid patients’ brains to rule out haemorrhage; on the other hand, she said, a common presentation is solely of nausea and loss of appetite, while 30 per cent of patients have loss of smell and taste. Numbness of skin and weakness of muscles could mimic spinal cord disease, and in a few she’d seen the heart muscle and coronary arteries affected. ‘You may have already picked up that the swab doesn’t seem that reliable yet,’ she concluded. ‘We’re going with gut instinct/clinical probability based on a lot of the above.’ There were hints about the virus’s effect on the body circulation – some patients developed enormous clots, or ‘thromboses’, that seemed to have come out of nowhere, while some patients of mine with Covid-19, who didn’t need to be admitted to hospital for a cough or for breathlessness, developed odd rashes suggesting alteration in blood flow to the skin. I had the fierce awareness that so many of our guesses and assumptions about this disease and how to tackle it would seem laughably inaccurate in the years to come – we were fighting this virus blindfolded by ignorance.
At the same time, it was obvious that in the wider community lockdown was helping slow transmission enormously. The numbers in ITU dropped consistently from a peak in mid-April. We GPs were sent a message of praise from the hospital, thanking us for doing so well at keeping people away. But it was becoming more difficult to field patient frustration at the shutting down of much of what the NHS used to do: no outpatient clinics, no colonoscopies, no IVF, no ultrasound scans. Even cancer services had been stripped back to essentials, and many routine lab tests had been cancelled to create capacity for coronavirus testing.
Though the lockdown had cut transmission it was provoking a silent epidemic of despair: panic and anxiety are the virus’s dark refrains, a second pandemic leaching into everyone’s lives. As the weeks wore on, I was speaking with ever-increasing numbers of people whose mental health, perhaps already fragile before the pandemic, was in freefall. One woman whose mood swings I had supported over the years through face to face conversations, recommendations of long walks, suggestions of group activities and distraction techniques, was now on the phone to me almost daily as we tried new sedative drugs to quiet her seething mind. Another who had only the most tenuous of holds on reality seemed to have drifted off into a world of his own – without the anchors of family, support workers and occupational therapists, his paranoias were deepening and his hallucinations were becoming more frightening. All this while long-stay mental health hospitals – institutions custom-made for viral spread – were still trying to empty their patients into the community ‘for their own safety’.
Alcohol-induced injuries in the over fifties were up, as were injuries from assaults. Within our area of the city we already knew of suicides triggered as a consequence of bankruptcies and business closures, and marriages breaking down. Between 23 March and 12 April there were sixteen deaths from domestic violence in the UK – more than triple the still-shocking average in the same period over the last few years. A police officer friend told me that domestic abuse lines were experiencing a 30–40 per cent increase in traffic. The Samaritans and Childline, too, were receiving high volumes of calls. A domestic abuse hotline for NHS workers had been inaugurated – intended to support both health workers at risk and to offer advice should they suspect patients were being abused. When I checked routine blood tests on my patients I was seeing new flares of liver irritation, suggesting rising alcohol abuse.
For those whose jobs offered identity and a sense of purpose, being furloughed was experienced as a tragedy exacerbated by forced disconnection from friends and family, even if others were starting to look on the lockdown as a time of recalibration, and reorientation of priorities – no alarm clocks, no social demands and, for those with relative financial security, an odd fusion of heightened and diminished stress. Many children, my own included, were desperately missing the structure and social life offered by school, and every day I heard of more best-laid plans being added to the bonfire of this global crisis. Home-schooling was proving almost impossible for us, as for so many others – the two days per week I was home caring for my own kids I’d sit with them in the mornings, reading through grids of tasks sent in by their teachers: researching polar bear biology, or the social geography of Northern Ireland, or songs to remember the eight times table. But by noon all three children would be jumpy and distracted, and I’d have to get them out to defuse the tension and tear around the garden in what seemed perpetually glorious sunshine. The UK was experiencing its sunniest April on record, with more hours of sunshine than are normally seen in June or July. At least we have a garden, I thought – small mercies.
A morning clinic, only one patient came in to see me – the rest were dealt with on the phone. It was a man complaining of weight loss, and already it felt like a luxury to be able to assess a patient face to face. One woman told me on the phone of her two sons, one in London, the other in Milan, and how both lost their sense of smell and taste at the same time. They flew back home to be with her in Edinburgh as soon as they had recovered, and only now, four weeks on, did she feel as if she was catching the virus. She felt breathless even walking across her kitchen.
Another patient that day, aged 90, had lived through the war; she told me this lockdown felt worse – much worse. ‘I was young then, I know,’ she said, ‘and the war was far away. But we could get out, meet friends, go to theatres, the cinema! But this …’ Words failed her. ‘It’s just so hard for any of us to make one another feel better.’ She told me that every day she climbed up and down the stairs in her home a hundred times, trying to keep fit. ‘The War was six years, the Spanish flu was two years,’ she said to me. ‘How long do you think this will go on for?’
I shrugged. ‘A couple of years?’
‘And I think we need ration books again – that was a fairer way of doing things.’
In an evening Zoom meeting, with 330 Lothian GPs on a single call, I reflected on the birth of a new kind of art form, the simultaneous transmission of so many people’s studies, kitchens and living rooms, so many shelves, maps and art works, so many faces reacting to a speaker’s presentation. We theorised that more people could die of non-Covid disease, through being unable to access healthcare, than could conceivably die of Covid pneumonia. ‘This is the new normal,’ the chair said – the phrase we were hearing so often it had been drained of any power. ‘We need to explore ways of doing work remotely from our patients.’ One of the salient points of the meeting was that, after some fierce lobbying from the medical unions, death in service benefits had been extended to all GPs, in order to persuade us to work in Covid clinics.
The care homes I’d been visiting had all taken extraordinary steps to protect their residents from the virus – the staff within them had changed the way they work, reorientating their domestic geography to keep residents in their rooms as much as was humane. In the three I visit regularly there had been just a handful of cases, and some deaths among residents that had been particularly frail or vulnerable. But we’d been in lockdown now for a month and many GPs were beginning to draw breath, take stock and reach out to one another, and I heard about others who were not so fortunate. In the evening and weekend service, I’d been encouraged to swab any care home residents who seemed symptomatic. Many of my colleagues expressed their unease at being asked to perform such an invasive test, with frightening implications for any home in which a positive case was found, without the PPE recommended by the WHO. On weekend duty I visited homes where exhausted nurse managers spoke of how bewildering their jobs had become – of homes where a worker had swabbed positive, but every resident stayed negative, and others where several residents caught the virus but all stayed well. I listened with horror as a colleague told me of a home neighbouring her own practice where every resident had become infected. In the space of a few short weeks, a third of them had died.
This was the week the US President suggested putting bleach and disinfectant into the blood to combat coronavirus, and trying to get sunlight ‘inside’. It was reported on 25 April that thirty people in New York had been hospitalised after following his advice. ‘Trump’s briefings are actively endangering the public’s health,’ said Robert Reich, a professor of public policy at the University of California, Berkeley. ‘Listen to the experts. And please don’t drink disinfectant.’
By 26 April Wuhan had reported that there were no Covid-19 patients left in any of its hospitals – and China as a whole reported its eleventh consecutive day with no coronavirus deaths. Spain’s deaths dropped to 288 per day, the lowest since 20 March, while globally the death toll passed 200,000. UK deaths had passed 20,000, but it was broadly recognised that this was an underestimate, given that so many in community care homes hadn’t been counted. And in the last days of April the First Minister of Scotland, Nicola Sturgeon, announced a ‘decision framework’ for finding our way out of lockdown, just as Boris Johnson recovered sufficiently to move back into Downing Street and attend the birth of his son; something many parents in other areas of the country had not been allowed to do.
At this point, the end of April, the R0, or ‘reproduction number’, of the virus – how many people each infected person would pass the disease on to – was between 0.6 and 1.0: at this level, cases would continue to drop. But it would only remain so low because of the restrictions; as soon as they eased it was clear that the figure would begin to rise again.
Ramadan began. I took a walk at lunchtime from my clinic to the nearest post box, taking the practice official mail, as well as cards from my kids to their grandparents – they’d leave them untouched for three days after receiving them, to make sure there could be no active virus on their surfaces. And I could feel a change in the air, an impatience – the streets were getting busier, and people more restless.
* He survived, and was discharged five weeks later, having spent just under a week in ITU.
* Angiotensin Converting Enzyme 2