pandemic
Love, life, death in a time of pandemic
Rachel Clark was a television journalist before training as a doctor – that probably helps to explain her brilliance with words and her laser focus on exactly what happened, and when, in the early days of the pandemic.
Her latest book, Breathtaking, spans the first four months of the ongoing Covid-19 pandemic, January to April 2020. At its peak, during that first wave, a thousand people were dying each day. And every single day the grit and devotion of colleagues astounded her. She says she has never been prouder of, or more humbled by, the NHS and its people, but that doesn’t stop her probing beyond the heroism, the sacrifices, to the core of what went wrong.
She knew it would be impossible, and probably inappropriate, to try to convey her inside experience to non-medical friends and family, so she used her laptop to vent her feelings. Writing became an anchor, helping to distil her fears, a compulsion that took her through the night and into the early hours of many a morning. Looking back over her insomniac’s diary much later she discovered that what she’d thought of as an unrelenting stream of darkness was actually illuminated by pinpricks of light. Acts of kindness and solidarity, altruism and selflessness, resilience and decency, shone through the storms, and they glimmer throughout the book which evolved from her midnight ‘scribbling’.
Rachel Clark graciously acknowledges the public’s generosity and sacrifice in withdrawing from the public sphere, foregoing so much that makes society and relationship valuable, in order to protect NHS resources.
Invisible threads of everyday sacrifice tie the world outside to the one within the hospital.
But from the outset, she and her colleagues watched with growing horror and incredulity, the UK’s casual approach to the coming tsunami … the effects of deficient supplies of PPE … delayed restrictions … the exposure of the elderly and vulnerable to risk … the appalling gulf between public rhetoric and supplies on the ground … the Prime Minister’s defence of indefensible behaviour when his chief adviser flouted the rules he’d helped to devise … And she’s haunted by the sense that we are all complicit in the betrayal; the alarm should have been raised sooner, been more insistent, more strident.
She is shocked too, by the spin put on the tragedy. When the UK had the third highest death toll from Covid in the world, and was the worst hit in Europe, senior government figure were trumpeting ‘success’!
How very cheap, how spectacularly expendable, one human life must be to them if the avoidance of tragedy is consistent with the deaths of nearly 27,000 people.
(Since then, of course, the death toll has risen vastly – currently in excess of 128,000.)
For this palliative care specialist every person, every loss, every family, matters. And in her view, the only reason the NHS was not officially overwhelmed was because so much of its function was suspended. Real people suffered the consequences. Many felt abandoned.
The professional workforce too paid a heavy price. Entering the personal spaces of strangers steeped in the virus again and again involved massive risk.
The Covid ward is humid and restive. We are on the move, no pausing or lingering, with strained expressions and a twitchy hypervigilance that is as exhausting and stifling as the masks we wear. It is all around us, the virus. It coats our clothes, our hair, the backs of our necks, the keyboards we type on, the surfaces we touch. It hangs in the air, it drops on to our shoes, it floats and waits, ready to be inhaled by anyone too unwell to be masked up in a hot zone.
They endured appalling working conditions, worked ridiculously long hours, put themselves through agonising processes. Their own families suffered. Some professionals lived in hotels rather than put their loved ones at risk. Some gave their very lives.
And on top of that they were unable to relate as normal to those in their care.
Kindness, undeniably, is the glue that ensures patients feel safe and hospitals humane.
But now, everything human was taken away – contact, personal details, names, faces, relatives (the cruellest feature of all).
Covid, in short, necessarily compromises every instinct to deliver humane and compassionate care. It violates something at the heart of good medicine – and the cost to the team is profound.
All they could offer from behind the layers and layers of protection seemed …
grotesque, a parody of communication. It could not be less warm, and more wrong.
And even in extremis, as death approached, they could only clutch at the remnants of human contact, to ensure no one was alone for that final stage.
In the end, as death bears down, there is almost no situation that cannot be made better by someone reaching out, with love and tenderness, towards one of our own. What we have, in our grief, is each other.
Rachel’s own compassion and care and humanity, perfect attributes for someone dealing with people at the end of life in palliative medicine, pervade the book. And for her, words are the most powerful drug used by mankind.
No one knows this better than a palliative care doctor. When drugs run dry, when cure is no longer an option, I deal in words like my patients’ lives depend on it. Words build trust, allay fears, dispel myths, inspire hope. They clarify, challenge, encourage and console. Words leap beyond the constraints of masks and gloves and gowns. Titrated carefully, dosed just right, words can take a dying patient all the way from the depths of despair to a place of hope and even serenity … Above all, our word must be our bond.
In the midst of this revelation of the flaws and deficiencies that have characterised the pandemic, the pain, the frustration, the humility, the dedication, glimpsed in this soul-searching book, are themselves evidence of what is right with the practice of medicine. Beyond price, beyond value.
Decision making on the Covid frontline
Jim Down is an anaesthetist and intensivist in University College London Hospitals. He was working as a consultant there when the Covid pandemic hit this country, and in his book, Life Support, he has captured the slowly emerging horror. We all know so much more about it now, but back in March 2020, not even those at the front line were fully up to speed with what was required. Reports were patchy and conflicting; provision was far from satisfactory; knowledge rudimentary.
By his own admission, Jim Down is a worrier, so what should he do in the face of this emerging crisis? Should he go home to his young family? Should he visit his elderly parents? How close should he get to people? Should he wear a mask? In many ways he felt safest at work protected by layers of suffocating PPE.
I confess, the work of an anaesthetist is much more far-reaching than I was aware of. (Apparently 50% of the country still believe they aren’t doctors!) But in reality, as Dr Down says himself, there are few departments anaesthetists don’t support in one way or another. And throughout the pandemic, it’s been the tribe of c11,000 anaesthetists around the UK who have been vital to the Covid response, converting all available space into fully-functioning Intensive Care Units in record time, delivering care to eye-watering numbers of patients, and designing protocols for some of the most dangerous procedures.
Amongst his other responsibilities Dr Down was given ethics to oversee. Forgive me if I home in on this aspect of his roles – it’s part of my personal raison d’etre, as you know. He set up a ‘three wise people system’ for all major and controversial decisions, and established an Ethics Group for the Trust. But questions and dilemmas presented at every level.
The cost of a day on ICU is approx £1700; what benefit does that need to accrue to be cost-effective? What constitutes a meaningful quality of life? When does a therapy become futile? What risk/chance of disability or suffering makes life not worth living? What constitutes meaningful life? Who decides? When resources are stretched beyond capacity in a pandemic how do we compare relative benefits between patients? All questions that haunt medical practice, but with Covid there were three new crucial differences from the normal balancing acts: the sheer number of patients, the flimsy knowledge of this new disease, and the unusual speed with which decisions might need to be made.
Ethical dilemmas presented too around how far to go, when to stop, when to call family in, in situations where so much was unknown. Then there was the matter of how to effectively deploy limited resources – equipment, drugs, people. The staff themselves were suffering from emotional and physical exhaustion, giving them a diminished capacity to empathise with others, poor concentration, irritability, feelings of helplessness, frustration. Not a good foundation for making sound judgements – thereby increasing stress still further.
Dr Down himself adopted a benchmark: What would I do if it was my brother, sister, mother, father, wife, child? It felt like as good a test of a decision’s rigour as he could muster.
But the personal toll was colossal; the work loads unprecedented. One trained ICU nurse to up to six patients instead of the usual one! One consultant to 42 patients. Teams of medical students and surgeons roaming the units twice a day just to turn people from supine to prone or back again. So much was unknown and unknowable. The patients were extremely sick, for a long time, very fragile and unpredictable, and denied family support. With no simple solutions, very few fixed protocols, the staff constantly questioned themselves, worrying about the repercussions of what they were doing.
We are all acutely aware that something could go wrong for any of us at any time. When it happens to a friend we are reminded of our vulnerability.
They were caring for
the biggest cohort of the sickest patients we’d ever seen, and we were desperately trying to work out how to manage them.
And at times they were treating their own frontline colleagues. Sobering indeed.
This book captures the everyday reality, the swing from the sheer mundanity of meetings and conversations at one end, through the anxieties that proved to be damp squibs, to the overwhelming responsibility of far too many competing demands, the crises at all hours, the inability to support everyone all the time. The frustration of insufficient staff or equipment to carry out the fundamental tasks. The constant questioning.
It underlines the enormous debt the whole country owes to the key workers who bore the heaviest burdens for us all.
Hay Festival: second instalment
They say authors should wait a decent interval before starting to write about pandemics. Well, who exactly are ‘they’, these authorities who know such things, huh?
Even before Covid struck, Val McDermid had already written a radio play about a scenario where a pathogen appeared which no drugs could treat, so she was way ahead of the game. Didn’t stop her publishing it. As she said: There’s nothing more dramatic than the end of the world as we know it.
She then collaborated with a graphic artist, Kathryn Briggs, to produce a graphic novel based on the play: Resistance. Their discussion at the Hay Book Festival with Louise Welsh about how they worked together, was both insightful and humorous. When Professor Welsh said that no person had been left unchanged by the experience of the last fifteen months, she hit on a fascinating fact leading into a fertile line of thought.
Lionel Shriver had just started her latest novel when the pandemic struck, and she’s woven topical lines and references into her story of a couple in their fifties, both medical professionals, contemplating a joint suicide when they reach 80. What would they miss/be spared? What possibilities might present? Dementia? A nightmarish Cuckoo’s Nest retirement home? The end of civilisation? A cure for aging? She has written, and included in the book, twelve alternative scenarios, all with different but parallel endings. As you know, assisted suicide has been an issue very much in my sights for many years, so I’m looking forward to reading Should we Stay or Should we Go. I loved the bit she read aloud, and reviews tell us it’s packed with humour as well as provocative thoughts.
And the pandemic theme even cropped up in a session where comedian/actor Frank Skinner was interviewed by fellow comedian/actor/satirist Marcus Brigstocke about his book, A Comedian’s Prayer Book. Skinner is a devout Roman Catholic and spoke movingly of his commitment, and response to taunts, revealing wide reading and studying alongside much heart-searching. Brigstocke said at one point: ‘I think you are this pandemic’s Galileo!‘ Skinner certainly had clever answers for anything thrown at him, chortling at the excitement of not being quite sure where any sentence would end up, but he came across as respectful of others’ opinions, non judgemental, eloquent and measured, whilst openly sharing his own moral code. The whole event was a magical mix of laugh-out-loud fun with serious and warming reflection. And a fitting ‘last Hay event’ for me this year.
Massive thanks to all who brought this fantastic festival to our homes. I for one, hope it will continue to offer an online version.
Man’s Search for Meaning
HEALTH WARNING: This week’s post may not be easy or desirable reading for those who are finding life tough right now.
In a week where the headlines revolve around the financial implications of a global pandemic, bitter in-fighting in the Scottish government, and the revelations of a woman who found the burden of royal life too much after a couple of years, coming at a time when a proud 99-year-old prince who gave up a successful career and the next 70-odd years of his personal ambitions, to always walk two steps behind his wife, lies ill in hospital … well, I, for one, was looking for perspective.
And I found it in the depths of the Holocaust.
During WWII, psychiatrist Viktor E. Frankl, spent three years in Auschwitz, Dachau and other concentration camps – as an inmate, not as a doctor. But he survived and went on to be professor of neurology and psychiatry at the University of Vienna Medical School until his death in 1997, the author of thirty books. So when he speaks about the importance of finding meaning in life, we ought, at the very least, to sit up and listen.
I certainly did. Man’s Search for Meaning: The Classic Tribute to Hope from the Holocaust – written in 1945 – has been described as ‘profoundly honest’ … ‘inspiring’ … ‘deeply sensitive’ … ‘influential and eloquent’ …’wise, kind, and comforting’. It’s all of those things. And it’s eminently readable to boot.
The bulk of this slim volume is not so much a fascinating account of his own three years of appalling treatment in one concentration camp after another, but his analysis of what suffering of this depth and magnitude reveals about mankind, and what he learned about himself through the experiences. Here he was, ‘stripped to naked existence‘, quite literally. With the exception of his sister, his entire family – father, mother, brother, wife – perished in the camps.
‘How could he – every possession lost, every value destroyed, suffering from hunger, cold and brutality, hourly expecting extermination – how could he find life worth preserving?‘
He dug deep to discover why.
He unpicked, with a kind of detached professional interest, the gradual dulling of emotion, which inured prisoners to horrific sights, sounds, smells and tastes, as well as a brutality and sadism normally unknown to them. He watched the apathy and blunted sensitivities helping his fellow inmates acquire a protective shell – a mechanism of self-defence which eventually detached them from the frequent beatings. He observed the detail of human behaviour in these appalling circumstances, translated it into psychopathological terms, and explained the ‘Why?’- why they followed like sheep; why they sought the centre of the group during marches; why they ripped clothes and food from still warm corpses; why they secreted their meagre ration of bread in their pocket, taking a crumb at a time throughout the day. Throughout his incarceration, he retained this sense of medical curiosity, pitting received wisdom against lived reality in these uniquely horrific conditions, and sometimes he found both medical texts and his own reservoir of knowledge wanting.
And gradually, over time, he discovered first hand ‘the meaning of the greatest secret that human poetry and human thought and belief have to impart: The salvation of man is through love and in love.’ And that ‘love goes very far beyond the physical person of the beloved. It finds its deepest meaning in his spiritual being, his inner self.’ Even though he had no means of knowing whether she was alive or dead, nothing could touch the strength of his love for his young wife (she had in fact died aged just 23).
But good does not always prevail, and he saw his fair share of evil, before concluding that everyone has a choice as to how they deal with adversity. ‘The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity – even under the most difficult circumstances – to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or, in a bitter fight for self-preservation he may forget his human dignity and become no more than an animal. Here lies the chance for a man either to make use of or to forgo the opportunities of attaining the moral values that a difficult situation may afford him. And this decides whether he is worthy of his sufferings or not.‘ Dr Frankl himself found the courage and resources to make a victory of the experiences, to turn this humiliating life into an inner triumph.
One of the tactics he adopted to gain this inner strength and mastery over his present adversity, was to imagine himself giving a lecture on the psychology of the concentration camp! By this method he somehow rose above the present situation and observed the sufferings as if they were already in the past. Nevertheless, he remained humble and understanding and forgiving of others’ less robust approach. When he saw them steal, or act meanly or brutally, he refused to condemn: ‘No man should judge unless he asks himself in absolute honesty whether in a similar situation he might not have done the same.’ Nor would he judge any group as a whole, not even those who routinely harmed him. None were made up of all angels or all devils; indeed, in his thinking, there are only two races of men in this world – the ‘decent‘ and the ‘indecent‘.
But of course, he saw utter despair and hopelessness elsewhere in Auschwitz and Dachau. And it was through the inmates who were at rock bottom, contemplating suicide, that the psychiatrist in him recognised a fundamental truth. ‘When the impossibility of replacing a person is realized‘ – it could be a father to his child; or an author to his unfinished creative or scientific work – ‘it allows the responsibility which a man has for his existence and its continuance to appear in all its magnitude … He knows the “why” of his existence, and will be able to bear almost any “how”.‘ An understanding shared with Nietzsche.
And it was by this route, that Dr Frankl honed his own version of existential analysis – ‘logotherapy‘. Essentially logotherapy involves searching for the thing that stops a person committing suicide, the one thing that anchors him to life, and using this as the guide-line for psychotherapy, to help him find meaning in life. One is moved to ask, Who better to steer others away from the torments that are devouring them, than this exceptional man?
Part 2 of this little book is a brief capsule version of Viktor Frankl’s therapeutic doctrine: Logotherapy in a Nutshell. As he says himself, it’s a pretty hopeless task to try to collapse twenty volumes in German into thirty small pages in English! Not much hope I can do it in a couple of sentences, then. In essence though, logotherapy focuses on the meaning to be fulfilled by the patient in the future. Man inherently needs ‘something’ for the sake of which to live, and he desires a life that is as meaningful as possible. Using logotherapy, a patient is assisted to identify what this ‘something’ is, and is then reorientated towards the meaning of his life. Dr Frankl himself felt a deep desire to write the manuscript he had started before he was taken to the camps. That helped him survive.
Not your average Holocaust book; but a remarkable tribute to the triumph of hope and endurance against insuperable odds, and a potential doorway towards finding meaning and purpose in our own lives.
The Vanishing Year
Well, I can’t imagine many people will have been sorry to see 2020 vanish into the mists of history; some indeed are willing 2021 away now, given the dire statistics and predictions. A thousand deaths each day in the UK; a total now exceeding 80,000 – the worst statistics in Europe; 2 million lives lost worldwide. Our NHS struggling to cope; long term problems accruing with the overall health of the nation. 
Watching this horror emerging, we’ve all had to find ways of keeping hope alive and maintaining mental well-being. Icy conditions make even outdoor exercise treacherous, another lockdown forces us to stay at home … Eeh dear! Not surprisingly, for me – as well as countless others – books have played a major part in this struggle. It’s well recognised they offer escape and a way of making sense of the world and our place in it. Indeed, several people who took advantage of our pandemic bookcase went so far as to say books had saved their sanity.
Not surprising then, that one novel should pop into my head as we watched 2020 disappear in our rear view mirrors: this thriller, The Vanishing Year by Kate Moretti. Apposite title, but nothing to do with the pandemic, so forgive the tenuous link.
‘Sometimes I feel as if I am made up almost entirely of secrets.‘ That pretty much sums up the main protagonist, Zoe Whittaker.
Outwardly, Zoe has an enviable life – not yet thirty, a fabulous Manhattan home, a rich and charming husband, influence, looks, wealth, connections. But untethered, with too little to do. She feels like a marble in a huge jar, suffocating under the sense that she is accomplishing nothing. Useless, apart from her charity work supporting orphaned and disadvantaged children.
What’s more, in spite of her privileged life, she is haunted by her past, living in fear of being recognised. Because five years ago, Zoe wasn’t Zoe at all. And even her husband Henry doesn’t know her real name. Nor that she was penniless, unable to afford to bury her own mother, until that is, she became a drug dealer, addicted herself to pills and drink, peddling her wares in the presence of children. Until she confessed all to the police, testifying against two human traffickers to a grand jury. Before vanishing.
And now an attempt has been made on the life of the reinvented Zoe. Her home has been ransacked. Her credit card is missing. Someone from her past has come back for her. Threats are being made.
The old classic trademarks are there – control, manipulation, layers of issues, rags-to-riches, fear for life. And the plotting is so devious that, once you know the truth, you want to go back and read it again to see all the clues you missed first time around. An excellent diversion. And a good illustration of how books can give us respite from the stresses of real life, transport us into a different world and time and place – an invaluable bonus during this time of national crisis and mental fragility.
Speaking of a different world and being transported … this opportunity to tramp in a winter wonderland does wonders for my own mental health, too. And yep, it’s well within the current rules of staying local!
Mental health in a time of pandemic
Well, twelve months ago, as we headed towards Christmas, who’d have thought 2020 would be a year like no other? Were you truly savouring each family hug, each shared celebration, each freedom? I certainly wasn’t. We took it all so much for granted, didn’t we?
But plenty of evidence has been emerging that the mental health of the nation has deteriorated during the pandemic, and that’s on top of already soaring mental health issues. One only needs to think isolation, job insecurity/loss, uncertain future, economic hardship, fear of disease and death, bereavement, domestic abuse, cancelled medical appointments/operations, etc etc, to understand why. And official reports bear this out. We heard in September on World Suicide Prevention Day of the serious effect on men’s mental health of lockdown, and now this month, a coroner in Wales has highlighted the tragic suicides precipitated by the profound and detrimental effect of the pandemic.
Recognising the stresses, lots of organisations are offering informative and/or therapeutic sessions online to help people combat the associated effects, some generic, some focused – relaxation techniques, mindfulness, breathing exercises, coping strategies, that kind of thing. I’ve dipped in to some myself, and as well as helping the participants to understand the legitimacy of what’s happening to them, these opportunities enable wider social connections to be made. Just chatting, or simply listening, to those who admit to also feeling beleaguered by developments, can be a comfort in itself.
Then there are the amazing events being streamed online, making uplifting experiences and cultural events accessible to so many more than would normally travel to expensive shows or courses. Ballet, opera, drama, concerts, masterclasses, demonstrations, tutorials … something for pretty much any interest. And again I’ve personally availed myself of these opportunities. It’s so heartening to see and hear artists and experts, actors and athletes, craftsmen and academics, turning their own troubled times to good effect by sharing their expertise with the masses – drawing, running, playing musical instruments, creating beauty, and so on. A bonus for both sides.
The recent doorstep musicals project is a case in point. West End actors have set up Doorstep Productions in a bid to bring theatre to ordinary people in streets across the UK, simultaneously entertaining and lifting their spirits, whilst helping out-of-work actors whose jobs have dried up as theatres are forced to close. Big names like Andrew Lloyd Weber and Cameron Mackintosh are backing this initiative. Heart warming. And the Dundee Rep have just begun to bring their production of A Christmas Carol to the streets of a select nominated few too.
It all says much for the fighting spirit of the nation, doesn’t it? and the resilience of individuals, and the kindness of strangers. I want to add my thanks to everyone anywhere doing their bit to boost morale and unite our nation. In these days of dire health statistics, economic crisis, and uncertainty over Brexit, news of individual or collective positive endeavour or heroism or compassion is a real tonic.
Sobering realities from the Covid-19 frontline
I love the idea of a story about a detective hunting lost triangles! A man whose imagination conjures up that plot for his children has my ear!
A doctor who lets his small daughter paint his toenails lurid colours during a pandemic and leaves it on – It’s a little piece of home to take to work, a talisman to protect me and a token to remind me – gets my attention.
One who’s fearless enough to spell out unpalatable facts about our health service in the face of repeated political assurances of world-beating everything, gets my vote.
And when that medic is so incensed by the government’s spineless response to Special Advisor Dominic Cummings’ blatant disregard for instructions to the nation during lockdown, that he tweets a photo of himself in full PPE, stating that if Cummings doesn’t resign, he will, and then does so, has my heartfelt respect.
That man is Dr Dominic Pimenta, Specialist Registrar in cardiology. His story in Duty of Care begins in London in January 2020, when he becomes increasingly aware of a tsunami of disaster heading this way. It’s the stuff of his nightmares.
The book is certainly not comfortable reading. It exposes a stark picture of our country woefully lagging in health care provision:
The simple numbers are so bad they speak for themselves; at present, we have the worst A&E waiting times on record, the worst operating waiting times and the worst record on hitting targets. Even life expectancy is on the decline. We are short-staffed by a figure of around 100,000 staff, including 40,000 nurses. We also have one of the lowest number of critical care beds, general hospital beds and doctors per head of all the 37 countries in the Organisation for Economic Co-operation and Development (OECD). If we were an army, we would be a band of bedraggled, starved and exhausted soldiers. And that was all the case before any sign of coronavirus.
Now, I must confess that I personally have a lot of sympathy for our leaders trying to steer a course between many competing demands, balancing livelihoods against lives, damned if they do, damned if they don’t. It’s all too easy to criticise from the sidelines, or with hindsight. I cringe watching opposition MPs constantly carping about the decisions of government, knowing full well they aren’t going to be held accountable themselves. But this man, Dominic Pimenta, is a medical practitioner, and he had his eyes wide open from the outset. He isn’t scoring political points. So when he catalogues a litany of failings – incompetence, mendacity, lack of transparency, disregard of WHO advice – which have led to thousands of people losing their lives, thousands losing loved ones, thousands developing serious health problems, thousands having vital treatments postponed, thousands suffering serious mental ill health, then we ought to sit up and take note. These are desperately serious consequences indeed.
We could see the pandemic unfold, in high definition, live, 24/7, before our very eyes. And yet, for too long, we did nothing at all.
But in spite of his acute awareness of the true picture, shining through is his pride in the NHS: they responded magnificently to an overwhelming situation. He outlines convincing detail of their titanic struggle, their frustrations, their failures, as well as their triumphs and heroics.
With the right mindset, we are capable of incredible things.
Amen to that.
His own personal energy and determination to make a difference are exhausting to contemplate:
– writing articles spelling out the coming danger
– tweeting analysis and warnings
– publishing in the national press
– appearing on live TV shows
– campaigning for change
– garnering signatories for public appeals
– establishing a charity, HEROES, (now rebranded as Healthcare Workers’ Foundation) for the protection and support of healthcare workers
– attracting celebrity support
– designing prototypes for PPE (personal protection equipment)
– setting up a second organisation, SHIELD, to bring industry leaders and experts together in the creation of innovative solutions to meet the demand for PPE, including cutting edge ‘printing hubs’ …
all while working as a clinician way outside his own comfort zone – at the frontline in ICU – and trying to be a husband, father, brother, son, uncle, friend, in unprecedented times. His manic activity leaves one fearful for both his mental and physical health, but as he says himself, the problem was so vast, it would never feel as if any level of effort was enough.
In Duty of Care he leaves the story at the end of the first lockdown, knowing a second and possible third tsunami are coming. Since he published it, we have all entered that predicted second wave and are dealing with its consequences right now. This week the death toll in the UK passed 62,000. I feel fairly confident we’ve not heard the last from this extraordinary ma, but I leave you with his own parting shot:
So stay informed, stay safe and be kind.
Ethical challenges – did anyone press the pause button?
Well, the world may have been on pause this year, but ethical issues have still raised their heads above the parapet periodically. However, I suspect most of them were lost in the cacophony of sound relating to the pandemic, so to illustrate, I’ll share a selection from the past three months up till yesterday.
December
Sweden’s gymnastic federation has now ruled that young athletes under the age of 18 will be able to train and compete as whichever gender they choose to identify as. They will not need to provide a doctor’s endorsement or any evidence of gender dysphoria.
Following a landmark High Court ruling, in the UK, new guidelines have been introduced by the NHS that make it necessary for children with gender dysphoria to obtain a court order before they are legally allowed to take puberty blockers. It is felt that under 16-year-olds are highly unlikely to fully understand the long-term risks and consequences. However the Tavistock and Portman NHS Trust which runs the UK’s only gender identity development service has said it will appeal against this ruling.
`November
New euthanasia rules are being introduced in the Netherlands – a country already known for its liberal social attitudes. Doctors will now be permitted to spike patients’ drinks before lethal injections are administered, in cases where it’s impossible to obtain informed consent from a person with an advanced directive who has already expressed a wish for help to die when the time is right, but who might resist the final act. The change comes in the wake of a court case where a doctor in a nursing home secretly slipped sedation into coffee for a lady at an advanced stage of dementia. Opponents of euthanasia are understandably alarmed by this widening of the limits in the medical code.
The English Health and Social Care Secretary, Matt Hancock, spelled out confirmation that travelling abroad for assisted dying constituted a legitimate reason to break lockdown restrictions.
It was an accidental error that led to the Oxford/Astro-Zeneca vaccine against Covid-19 reaching 90% efficacy. About 3000 of the more than 20,000 volunteer trial participants had been given just half the dose they should have received according to the research protocol. The ‘correct’ dose achieved just 62% efficacy. A serendipitous result. And a lucky break for whoever was responsible for the mistake!
October
The Dutch government approved plans to allow euthanasia for terminally ill children under the age of 12 who are suffering hopelessly and unbearably. Objectors see the thin end of the wedge visibly widening.
Legislation to allow medically assisted death was passed by the New Zealand parliament last year, but lawmakers delayed implementing it until the public had had their say in a referendum. Under this law, the End of Life Choice Act, a mentally sound adult who has a terminal illness with a life expectancy of less than six months, and who is experiencing unbearable suffering, can request a fatal dose of medication. New Zealanders have voted overwhelmingly to legalise this, which means the measure will now pass.
An angry backlash developed when the Women’s Prize for Fiction opened up its eligibility criteria to include transgender women.
Six consecutive days of protest followed a near-total ban on abortions in Poland by the constitutional court. A country of 38 million people, Poland already has some of the most restrictive abortion laws in Europe, and an estimated 80,000 – 120,000 Polish women travel abroad for terminations or seek illegal abortions each year.
The English government has been keen to make the process of applying for a Gender Recognition Certificate kinder, cheaper and less complicated. As part of a drive for greater equality, the Women and Equalities committee are in the process of examining whether the currently mandatory diagnosis of gender dysphoria should be dropped from the legal process of transitioning, whether transgender people should be required to live in their preferred gender for at least two years before formally transitioning, and how their rights can be better supported.
As it stands, parents in this country are allowed to terminate a pregnancy where the fetus has Down’s syndrome, at any point up to full term. Three adults with Down’s Syndrome are now launching a landmark legal challenge to the Government’s abortion legislation on the grounds that it makes them feel they shouldn’t exist and would be better off dead.
A former Public Health England medical director, Professor Paul Cosford, had never wanted to be a supporter of assisted dying, but after developing incurable lung cancer himself, changed his view and bravely declared his hand in the BMJ.
A poll of 29,000 BMA members found – for the first time – that a majority were in favour of medical professionals being able to prescribe life-ending drugs. The BMA’s position currently is that they are opposed to assisted dying.
A Dutch fertility doctor has been found to have fathered 17 children during the 1980s and 90s, with women who thought they were receiving sperm from anonymous donors.
September
After President Macron turned down his personal appeal for euthanasia, a Frenchman in his fifties, Alain Cocq, suffering from an incurable condition where the walls of his arteries stick together, announced he would refuse drink, food and medicine, and live stream his death. However Facebook said it would block this being broadcast on its forum. M Cocq subsequently said he had lost capacity for the fight, it was too difficult, and he accepted palliative care.
Last year staff at the Gender Identity Development Service raised serious concerns about safeguarding issues relating to the use of inhibitors and the speed or referral for treatment for young people. It transpired that England’s only NHS gender clinic for children knew about recommendations for puberty blockers from an internal review carried out 15 years previously, but failed to implement them. An independent review into these services is underway now to improve access to and delivery of support for these young people.
Who knew there were so many, huh? I shall never be short of material for my novels!
Stress busting!
I’ve been reminded all over again this week of the importance of books in the nation’s health; never, I suspect, has that need been greater than now when a pandemic is threatening our very foundations and security.
It’s been an uncharacteristically stressful week in my own little world, most of it stemming from the vagaries of technology. Frightening how much we depend on the internet and all things electronic in our everyday lives, isn’t it? Being without connections feels like working with one and a half broken arms.
But I know that my personal stresses are as nothing compared with those of countless others during this time of Covid. The BBC wheeled out some big guns in the world of psychiatry during the past few days, who all tell us about the abnormally high incidence of worrying symptoms for mental illness, symptoms sufficiently serious to warrant medical intervention under normal circumstances.
Well, I’ve always been acutely aware of the fine dividing line between normal and abnormal when it comes to mental health. I rapidly but determinedly side-stepped psychiatry in my training, even though the way the mind works and its link with physical health fascinate me. And I’ve never forgotten the patient who first alerted his family to pathological disease when he started cutting his sausages lengthwise … but that’s another story. This week, when things started unravelling for me, it was time to segue into active stress-management mode.
Aromatherapy, mental puzzles and games, exercise, relaxation techniques, helping others less fortunate … the whole gamut came into play. And breathe … And relax …
But of course, books remain one of my main go-to resources. There’s nothing to beat losing yourself in another world. And in this context all I need is something unexacting but gripping. Time to turn to a tried and tested author: Harlan Coben.
I have a stack of his books on my shelves for exactly this kind of situation; these are just a selection, collected over many years. First off the shelf was Run Away.
First page, opening paragraph …
Simon sat on a bench in Central Park – in Strawberry Fields to be more precise – and felt his heart shatter … he stared straight ahead, blinking, devastated …
and I’m already asking who, what, why, when?
His once lovely daughter Paige – who ran away from her comfortable, professional, stable, ordered family life, to shack up with a criminal and wallow in addiction, has been seen busking in that very park where Simon sits with his heart splintering into fragments. Watching her. He’s appalled by what he sees: a malodorous, strung out bag of bones with matted hair and yellow teeth and a cracked voice. Trickster, manipulator, thief. And that encounter leads him deep into the dark and dangerous underworld that swallowed her up – guns, violence, murder, drugs …
because if someone hurts your daughter, a father has an obligation to stop him, no matter what.
But when the man who took her to this hellish place is murdered, Paige vanishes. He’s lost her again.
A second plot line shows a series of young men being targeted and killed. Why? What’s the connection? I twigged the ‘what’ by P167, and the ‘who’ by P194, but not the ultimate ‘why’… P319. Kept me turning the pages. Better still, it crept close to my own field of interest – genetic inheritance, infertility, adoption, ethics … now you’re talking my language!
And all the threads don’t fully come together until the epilogue. The work of a devilishly clever mind. And balm to my troubled one.
Sweets or brussels sprouts?
We … read fiction to learn about what we don’t know and to recognise what we do.
To feel less alone. And we share fiction, in online and physical book clubs, sometimes to find a way to discuss those issues we are struggling with in our everyday lives – and at other times to get as far away from them as possible.
Discuss!
No, this wasn’t really on an exam paper, but in the official journal of the Society of Authors: The Author.
It’s a complete joy to read these productions, every article beautifully written and relevant and helpful, but this particular quote made me pause and reflect on the hundreds and hundreds of books on my shelves and why I a) chose them and b) read/will read them. I’ve given away more of my personal library this year than ever before, partly because the pandemic has meant more time for folk to read books so I’ve shared mine, and partly because many found their way onto the bookcase we put out during lockdown.
It’s terrific news that the nation has turned so wholeheartedly to reading. Apparently online sales of books surged fourfold with an estimated 41% of the population in the UK – both more in number and almost doubling time spent devouring them. Wahey!! And the notes we received from users of our bookcase showed how vitally important books are to mental health.
I loved the observation made by Waterstone’s Children’s Laureate Cressida Cowell: every single primary school needs a well-stocked library, where the stories are ‘modern and exciting and relevant to children’s lives, like sweets, not brussels sprouts‘!
For adults, of course, we need a very mixed diet. Sometimes it does us good to have a sour taste left in our mouths; sometimes our teeth need to be set on edge; sometimes we need to persevere to educate our palate. Writing about difficult issues – mental illness or suicide or sexual abuse or body dysphoria or death or whatever – can hardly be described as sugar candy, and I’m all too conscious that many of my own novels are not mugs of decadent hot chocolate for bedtime. Indeed, I select with great care when I send any of them to people with vulnerabilities. But opening up healthy dialogue about subjects currently shrouded in myth and taboo and isolation and misunderstanding, is wholly desirable. And sometimes fiction can reach the parts and the consumers better than more formal texts … provided care is taken. I was much impressed to hear that the Society of Authors has been working in close collaboration with the Samaritans and recently issued a set of guidelines for authors writing about suicide or self harm. Brilliant. It would be so so easy to get it wrong.
So, let’s hope the habit of reading acquired in this difficult year of Covid-19, becomes a bonus that continues way beyond the pandemic.