Reflections on a pandemic

A version of this article was originally published in the Guardian and can be found here

Had somebody asked me a year or so ago to imagine a pandemic, I would have predicted it to be an anxious time. But as we muddle through relaxing our lockdown, the overwhelming public mood seems to be one of anger.

People seem to be angry for all sorts of reasons. Some are angry there aren’t enough rules, or that the rules aren’t going on for long enough. Others seem angry that there are any rules at all. In an interview with UK’s Channel 4 News, a plumber questioned whether the public expected “a full handbook” on how to act. One social media user replied, “when I want advice during a pandemic, I won’t call a f***ing plumber”. A more sympathetic voice took aim at “a nation of mollycoddled middle class loons”.

Amid this, in hospital beds across the world, lie sleeping patients with plastic tubes in their windpipes, machines breathing their breaths. In normal times, there’s something peaceful about an intensive care unit. The machines’ cacophony is regular, rhythmic, beating. It used to feel peculiar that a hospital’s sickest patients lay in its calmest ward.

Public anger is not regular. It comes in waves and pile-ons, stoked by frustration, resentment and fear. Today, working in an intensive care unit, I feel I live in two worlds. A world inside a respirator mask, where everything is darker, voices are muffled and facial expressions are hidden. Meanwhile, the outside world mimics the old world, only the streets are more anxious and cities play at being closed. A colleague told me her patients had woken from induced comas in blind panic, believing themselves trapped in an organ trafficking scheme, unable to speak for the tracheostomy hole created in the neck, surrounded by masked staff. I’ve seen that panic. I’ve had patients kick and punch, flail to rip out their breathing tubes. I’ve seen patients grasp their nurse’s hand, only to pull it to their mouth in an attempt to bite it.

Amid all the public fury, I’ve surprised myself that I’ve not been angry. I imagined, if ever there was a time to hold an opinion on government policy, it would be during an international health emergency.

Sometimes I wonder if my lack of anger means I don’t care enough; if I’ve been worn down by ventilators being turned off, patients declaring, families asking for a final call. Perhaps emotions overwhelm and suffocate each other in such a situation, leaving no air for something as indulgent as anger. Perhaps my anger couldn’t compete with the humility of knowing that until early March, I and every doctor I knew had predicted that this virus posed little threat beyond a bad seasonal flu. Like my better judgment, perhaps my anger had lost.

Our intensive care unit has been relatively quiet the past few days, which feels slightly fraudulent. When returning home last week, one of my neighbours started applauding. I had seen fewer patients than on an average day before the pandemic, eaten one of the thousands of free meals donated to hospital staff across the UK and even left work early. You try to explain that your day hasn’t been too bad, but they don’t quite believe you. They think you’re protecting them from some dark truth, shielding them from some hidden world. It’s futile. They continue to thank you, they continue to applaud.

The most difficult thing about this pandemic is not that people die. As a doctor you learn that patients die often; in the middle of the night, early in the morning, on bright summer afternoons and dark winter evenings. What I find most difficult is how people die: alone, with their families distanced in some other world. Relatives wait at home, praying for patients to get better, safe from the virus but unprepared for the grief to come. I hear that funerals are similar. There is no social code for a death in a pandemic. No ritualised hope that time will heal, no reassurance that your response is appropriate.

Iona Heath, former President of the Royal College of General Practioners, has spoken about the effect of this. By preventing people from “saying goodbye and holding their [relative’s] hand, we turn it into a traumatic bereavement” she argues. As we obsess about viral transmission, I find myself wondering what risk a final goodbye is worth. Policy-makers have formulas to measure quality of life, to decide which treatments to commission with limited resources. But how to measure the value of a dignified death? I wonder how I would feel if it were my own family, if I would challenge the same rules we tell families now, if I would argue.

The other day, the ICU phone rang. It was the daughter of a patient asking to speak to her mother one last time. I looked across to the bed and saw a woman lying peacefully, a plastic tube sitting in her windpipe, a machine ventilating her lungs. It wasn’t anger I felt, or despair. Medicine teaches you to focus on the practicalities, the things you can do or say, even when you know they will not work.

Perhaps I will be angry one day. When I look back and see the number of deaths, when I read about the questionable behavioural science used to justify policy decisions. When I hear about retired healthcare workers who, were it not for precarious staffing levels, would have been enjoying hard-earned retirements but instead now lie in graves. Perhaps our nation will feel guilty when our minute’s applause each week turns to a minute’s silence in their memory.

The novelist Arundhati Roy has written that this pandemic may be a portal to a better world. I’m not so sure. I don’t feel we are going anywhere. Like so many of the patients stranded on ventilators, I fear we are static, not yet ready to wake into a new world. We talk proudly about producing national vaccines as if viruses respect borders, we rush back to work as economic concerns overshadow lives lost and our governments continue to play games with their press. We are paralysed by old values in a world which does not recognise them.

Maybe I’m just too close to tragedy. Maybe we are all too close to tragedy, living in towns where people are dying, where each family is just one week from losing a loved one. Perhaps times like these are when distanced commentators are needed; to provide confident assertions and pontificate over glib slogans, to maintain some sense of ordinariness in an extraordinary world.

I thought about anger when I watched a patient prepare to be intubated recently. For the previous days, he’d been breathing more than 40 breaths each minute. A breathing mask blew air into his face at a pressure equivalent to travelling at 80mph, through night and day. The respite breaks he’d taken, to sip water and eat small amounts of food, were no longer possible due to his deteriorating lung function. We faded behind the condensation which coated his breathing mask. He couldn’t see anything. We couldn’t see him cry.

He wasn’t angry. He was scared to be put to sleep. He was terrified he might wake into a world where his family, who had also tested positive for the virus, would have met the same fate. When you are intubated, you are given a drug to sedate you, followed by another to relax your muscles, to allow a breathing tube to pass into your windpipe. When he was paralysed, his oxygen levels fell almost immediately. We cautiously watched as numbers dropped on a monitor. As of today, he still hasn’t woken.

Working as a doctor, people treat you differently. Your partner wonders if it’s safe to see you, you wonder when you’ll see your parents again, if you’ll endanger those you meet. Your family and friends question how you are doing. They ask, expectantly, if you’re angry. If you wish the protective equipment had been better, if the preparations should’ve been more robust. They wait for a coherent criticism of the announcement they’ve read on the news.

You struggle. You learn that anger betrays some ignorance about this world. It necessitates a decided world, a clarity about what has happened, what will happen next and what is happening now. Maybe I have lost faith in such a world. Perhaps that faith will return. One day, the decided world may reappear, with its busy streets, open cities and anger bestowed. But maybe not. Maybe it is lost forever.

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