From David Vincent in Shrewsbury, UK: One’s Jab

February 26.To lifelong republicans, the Queen is a continuing disappointment.

Not only is she still protecting us from the unpalatable prospect of Charles III, she remains capable of embodying essential truths amidst a national crisis.

As the vaccination programme spreads out across the population, voices are being raised about potential discrimination against those who decline the offer. The people in question are not those who for medical reasons should not be vaccinated, such as pregnant women. Nor those who have somehow fallen through the cracks in the official bureaucracy and are not on the radar of the NHS.

We are discussing those who have been invited, could have accepted, and have refused. As I have written in earlier posts, when attitude becomes choice, the numbers of those declining seem to be much smaller than was at first feared. Nonetheless they do exist, and may multiply as the programme reaches younger cohorts who do not feel much threatened by a death on a ventilator.

It is argued that they could suffer discrimination if vaccine passports are issued, denying them access to pubs, restaurants and other organised pleasures, or, in the form of some yet to be agreed documentation, travel to the beaches of Europe. Or they could face actions by employers who will only recruit those who can prove they are unlikely to infect fellow workers or customers of the enterprise. This is seen to be unjust in the case of those who have comprehensible long-term issues with secular authority, including the NHS.

I assume that the Monarch was at the head of the queue when the vaccination programme started, if only because of her age. But today she has made a public statement about her experience:

“Once you’ve had the vaccine, you have a feeling of, you know, you’re protected, which is I think very important. I think the other thing is, that it is obviously difficult for people if they’ve never had a vaccine … but they ought to think about other people rather than themselves.”

The morality is not complex, but it is fundamental to the struggle against Covid-19 since the first lockdown eleven months ago. In all parts of the country, in all walks of life, people have taken actions which cause private harm in the interests of public good. And give or take the odd illegal rave and concealed wedding, mostly they are still doing so.

The current debate about the non-vaccinated threatens to reverse that calculation. The harm that is discussed focusses wholly on the individual, their right to make up their own mind on the risks of illness, their right to oppose any kind of injection, their right to uphold long-held religious objections, their right to dwell in the playground of conspiracy theorists, their right to earn a living irrespective of the health of the larger workforce.

Someone has to point out that they are just making a wrong decision. The Queen has done so. And she has said why.

From David Vincent in Shrewsbury, UK: ‘Sadly’

February 24. We have become accustomed to the ritual announcement of Covid data.

The Government is producing daily figures on the progress of the pandemic. It falls to the newsreaders on the main television channels to deliver these at the head of the bulletin. There are scores for infections, hospital admissions, deaths within 28 days of a Covid diagnosis, and recently, vaccinations.

When it gets to the deaths, always the same feeling is inserted. ‘Sadly’ XXX deaths were reported in the last twenty-four hours.  The point of this extra descriptor is presumably to indicate that the broadcasters comprehend the tragedy that is unfolding day by day. They are not just reading from a teleprompter, but somehow engaging with their own emotions. When they can remember, politicians will also furrow their brows and put the word in front of the deaths they are discussing.

‘Sadly’, when repeated night after night, is an oddly featureless term. I might use it to describe the recent demise of several roses in the arctic winds that blew through my garden last week or the failure of an online order to arrive. I would not think it adequate to encompass the pain I might feel if I were being connected to a ventilator or if a close relative had died.

There is, after all, a thesaurus of terms commentators could use: ‘tragic’, ‘devastating’, ‘infuriating’, ‘unnecessary’. Instead repetition turns ‘sadly’ into a cliché, expressing little more than indifference. This week it means, ‘who cares as long as the figures are coming down.’

Finding a public language to describe the constellation of grief that Covid-19 causes is far from easy. Attention has lately been drawn to an American study which recalculates the bereavement multiplier, the number of individuals left suffering after a death.* The research increases what has been the conventional ratio of five (see my post ‘Computing the Sorrow’, January 22) to just under nine. In the UK context, the current death toll of 121,000 would generate a little over a million bereaved people; globally the figure would be twenty-two million.**

As is often the case, however, sophisticated mathematical tools are being applied to very coarse data. The American study focuses on the nuclear family network of grandparent, parent, sibling, spouse, or child, and asks, given the age-specific Covid mortality and US demographic patterns, how many people would be affected by a death. It is essentially a connections survey. No attention is paid to wider networks of relatives, friends and neighbours, nor are there any questions about the nature of the loss, which presumably can range from shattering grief to passing regret. In the end it is just another version of ‘sadly’, a generalised description of an event which in the States has now accounted for 500,000 lives, or, by this multiplier, 4.5 million bereavements.

More useful research is beginning to appear on the quality of the experience.

Deborah Carr and colleagues (good to see the old stars still working) identify two kinds of death: “Good deaths …are distinguished by physical comfort, emotional and spiritual well-being, preparation on the part of patient and family, being surrounded by loved ones in a peaceful environment, being treated with respect and dignity, and receiving treatments concordant with one’s wishes.”

Whereas: “bad deaths … are distinguished by physical discomfort, difficulty breathing, social isolation, psychological distress, and care that may be discordant with the patient’s preferences.” For the bereaved they are characterised by “the erosion of coping resources like social support, contemporaneous stressors including social isolation, financial precarity, uncertainty about the future, lack of routine, and the loss of face-to-face mourning rituals that provide a sense of community and uplift.”**

Yesterday evening’s newsreaders should have said: “in the last twenty-four hours there have been 548 bad deaths.”

*https://www.theguardian.com/world/datablog/2021/feb/22/covid-4-million-family-membersgrieving-us-study-finds

**Ashton M. Verdery, Emily Smith-Greenaway, Rachel Margolis, Jonathan Daw, ‘Tracking the reach of COVID-19 kin loss with a bereavement multiplier applied to the United States’, Proceedings of the National Academy of Sciences of the United States, 117, 30 (July 28, 2020):17695-17701. https://doi.org/10.1073/pnas.2007476117.

** Deborah Carr, Kathrin Boerner, Sara Moorman, ‘Bereavement in the Time of Coronavirus: Unprecedented Challenges Demand Novel Interventions’, Journal of Aging & Social Policy, 32, 4-5 (2020): 425-431. https://doi.org/10.1080/08959420.2020.1764320

From David Vincent in Shrewsbury, UK: Concentrating the Mind

Samuel Johnson: “Depend upon it, sir”

February 15.  When the awards are handed out at the end of this pandemic, a gold medal must surely go to the Office for National Statistics (ONS).

From the beginning it has been the source of sober, relevant and trustworthy data not just on the progress of the disease but on a wide range of associated behaviours and attitudes. It has published reliable answers to the right questions, including attitudes to vaccination now that the programme has gained real momentum.

It has just issued data relating to the end January. With vaccinations being offered to the top four categories it found that 99% of those aged 70 and over had accepted or would accept a vaccine.* Last autumn, when it was being reported that a sixth of the UK population would certainly refuse and offer, and a similar number might do so, I wrote that “the question constitutes an interesting case history for the capacity of digital communication to shape private behaviour.”** Since then the anti-vax campaign has increased its efforts as the vaccines were given approval, and Facebook continued until the last minute to carry its messages.

The ONS survey suggests that orthodox medicine has won a decisive victory. When the invitations were sent out, the conspiracy theories evaporated. Even amongst those still hesitating, the ONS found that most of the doubts had little or nothing to do with stories in the social media. The lead concerns were anxiety about side and long-term effects, then waiting to see if the vaccines actually worked. Only a small proportion of negative respondents declared an outright opposition to vaccines in general.***

The most obvious reason for the outcome, which is critical to the defeat of the coronavirus, is the difference between a hypothetical and a practical choice. The conspiracy theories promoted by the internet should be divided into two categories.

There are those which reflect a state of mind that need never be tested in the real world, and those which sooner or later will have to be. Views about race, sex and religion, about the unreality of climate change and the reality of extraterrestrial beings, may coalesce into active protest, but there is no requirement, no point at which a behaviour has to occur. Like a flu virus they may just mutate over time. Whereas other beliefs, such as the misbehaviour of elected governments, or the evils of vaccination, will at some point become a formal choice, when the polling cards or the medical invitations arrive. In those circumstances, interim polling of attitudes are contributions to a debate, not predictions of an outcome. Also this week it is reported that the Conservatives have opened up a five point gap over Labour. No-one mistakes this for an accurate description of an election that is still four years away. It just has an impact on current political debate. Similarly the anti-vax findings last year stimulated on-line counter-propaganda by orthodox medicine, which may have helped in the final result.

The choice itself foregrounds practical concerns. Since the early weeks of the pandemic we have been told by the ONS and many other authorities, that the elderly and those with pre-existing conditions stand a far greater chance of becoming seriously ill or dying from Covid-19. To paraphrase Samuel Johnson, “Depend upon it, sir, when a man knows he is likely to end up in an intensive care unit, it concentrates his mind wonderfully.”

It is not surprising, therefore, that the ONS returns for those under 70 currently display a greater resistance to vaccination, though the difference is not large. Of the 3% of 50-69 year-olds who currently are not fully committed, two thirds are just saying they are not certain yet. Amongst 30-49 year-olds, where 89% respond positively, the next largest group is 6% don’t know / won’t say. Except for younger medical workers (where there are worrying accounts of BAME resistance) and a few clinically vulnerable, most of these age groups are still discussing only the possibility of vaccination.

There is also the effect of the group. In my network, the over 70s and the clinically extremely vulnerable, emails and blog posts have been buzzing since the New Year with descriptions of what it was like, accounts of after-effects (usually very minor), and complaints from those who had to attend inconvenient centres or had yet to receive their invitation. It was a party everyone was joining and from which no-one wanted to be excluded. The minority of the young, invited because of their role in health or social care, had less of a sense of what in a related area is termed a herd behaviour.

Alongside the vaccine data, the ONS has also updated its measure of the mood of the nation: “Following a decline in well-being in early January 2021, this week well-being scores for life satisfaction (6.4), happiness (6.4) and feeling that things done in life are worthwhile (7.1) remained at some of the lowest levels recorded since the survey began in March 2020.”****

This reflects my own view. I have been surprised by how small the lift in spirits has been since I drove down to Ludlow racecourse to get my jab at the beginning of the month. Euphoric is not a term I would use. At best mildly relieved, and aware of the road yet to be followed.

*https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddisea ses/articles/coronaviruscovid19weeklyinsights/latesthealthindicatorsinengland5february2021#vacci ne-attitudes

**November 11, 2020.

***https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddis eases/articles/coronaviruscovid19weeklyinsights/latesthealthindicatorsinengland5february2021#vac cine-attitudes

****Opinions and Lifestyle Survey, Great Britain, 27 to 31 January 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing /bulletins/coronavirusandthesocialimpactsongreatbritain/5february2021

From Bishop Ralph of Shrewsbury: Pray Devoutly and Incessantly

Ralph of Shrewsbury

Almighty God uses thunder, lightning and other blows which issue from his throne to scourge the sons whom he wishes to redeem. Accordingly, since a catastrophic pestilence from the East has arrived in a neighbouring kingdom, it is very much to be feared that, unless we pray devoutly and incessantly, a similar pestilence will stretch its poisonous branches into this realm, and strike down and consume the inhabitants.[1]

Thus Bishop Ralph of Shrewsbury wrote to the archdeacons of his diocese on 17 August, 1348.

Unfortunately, the prayers and the processions that he ordered failed to prevent the Black Death crossing the Channel from France. A year later the Prior of Canterbury asked the bishops in the southern province to take action:

“Terrible is God towards the sons of men, and by his command all things are subdued to the rule of his will. Those whom he loves he censures and chastises; that is, he punishes their shameful deeds in various ways during this mortal life so that they might not be condemned eternally. He often allows plagues, miserable famines, conflicts, wars and other forms of suffering to arise, and uses them to terrify and torment men and so drive out their sins.”[2]

The populations suffering the devastating pandemics of the fourteenth century were at once powerless and active agents in their own destiny. All were exposed to the wrath of a vengeful God, but through prayers, penitential processions and reformed morals it might be possible to hasten the end of a plague and delay its recurrence.

Over the succeeding centuries, the practical task of managing populations and devising cures in a pandemic has gradually transferred to governments and scientists. The moral drama of sin, retribution and repentance, has, however, continued in a new form.

Successive outbreaks of respiratory diseases in this century have been blamed on man’s increasing exposure to infected wildlife. SARS (Severe Acute Respiratory Syndrome) in 2003, MERS (Middle East Respiratory Syndrome) in 2012, and now Covid-19 have crossed the species barrier, probably from bats which carry a wide range of pathogens. An increasing body of literature, together with organizations such as the Coalition for Epidemic Preparedness Innovations, have warned that, like the Black Death in the fourteenth century, one pandemic is almost certain to be followed by another in a matter of years.

Animals may be the proximate cause, but the fundamental problem is the behaviour of people. Land is cleared for population growth, the exploitation of raw materials, and for dairy and meat farming, and as a consequence there are lethal encounters with hitherto isolated reservoirs of viruses. The risks are compounded by the rapid increase in international travel and commerce. The pandemics thus become a metonym for the ecological crisis more generally. As the Professor of the History of Medicine at Oxford writes, “‘emerging diseases’, as they are often termed, have been seen as Nature’s retribution for environmental degradation.” [3]

Mankind has misbehaved, is being punished, and, with increasing urgency, is seeking effective forms of repentance.

The Christian churches, pushed to the side-lines by the secular response to disease, are seeking to reclaim the leadership of what they see as a new moral crusade. “I think the future we are called to build”, writes Pope Francis in response to Covid-19, “has to begin with an integral ecology, an ecology that takes seriously the cultural and ethical deterioration that goes hand in hand with our ecological crisis.”[4]  The Archbishop of Canterbury wrote in 1375 that, “in our modern times, alas, we are mired in monstrous sin and the lack of devotion among the people provokes the anger of the great king to whom we should devote our prayers. As a result we are assailed by plagues or epidemics”.[5] In a pale echo, we have the words of the 105th incumbent: “Around the world, climate change is affecting food security, creating social vulnerability, and disrupting peace and security. There is no doubt we need to act.”[6]

This time, praying will not be enough.

February 10


[1] Register of Bishop Ralph of Shrewsbury, Somerset Record Society X (1896), 555-6, cited in Rosemary Horrox, trans. and ed., The Black Death (Manchester: Manchester University Press, 1994), p. 112. Despite his title, Ralph, formerly Chancellor of the University of Oxford, was Bishop of Bath and Wells, where he was described by the Dictionary of National Biography as “a wise and industrious bishop, learned and extremely liberal.”

[2] D. Wilkins, Concilia Magnae Britanniae et Hiberniae (1739), vol. II, p. 738, cited in Horrox, Black Death, p. 113.

[3] Mark Harrison, Disease and the Modern World. 1500 to the Present Day (Cambridge: Polity, 2004), p. 189. See also, Mark Honigsbaum, The Pandemic Century. A History of Global Contagion from the Spanish Flu to Covid-19 (Penguin: London, 2020), pp. xiv-xv, 280.

[4] Pope Francis, in conversation with Austen Ivereigh, Let Us Dream. The Path to a Better Future (London: Simon and Schuster, 2020), p. 35.

[5] Wilkins, Concilia, III, pp. 100-1, cited in cited in Horrox, Black Death, p. 120

[6] https://www.churchofengland.org/about/policy-and-thinking/our-views/environment-and-climatechange/why-you-should-act.

From David Vincent in Shrewsbury, UK: Hitler, Shipman, Satan and Mengele

February 9. The sense of optimism as the vaccines are rolled out is colliding with the battle weariness of medical staff.

Rachel Clarke published the first book-length account from inside an intensive care unit.* Its anger with the government and anguish at the bleak and lonely deaths suffered by covid victims was balanced by a joyful account of the sense of community that the pandemic had created. Writing about the first wave last Spring she discovered something new:

“Not once in my lifetime have I seen anything like this grassroots eruption of improvised altruism. Communities coming together, the young and healthy offering to shop for those shielding, restaurants delivering mountains of takeaways to overworked hospital staff, everywhere the desire to be useful, to do something, to make it better, to help out. It startles and thrills me. There is no such thing as society. We do have more in common than divides us.” (159-60)

Nine months later she has written a newspaper article clearly exhausted by her continuing labours on wards that are still operating at peak capacity, and overwhelmed by the hostility of covid deniers and anti-vax campaigners. “I’ve been called Hitler, Shipman, Satan and Mengele for insisting on Twitter that our hospitals aren’t empty,” she writes. Inside the hospital, all is joint endeavour :

“Outside, on the other hand, the virus has once again carved up the country into simmering, resentful, aggrieved little units. It’s too old, too cold to be doing this again. One way or another, lockdown hurts us all. But instead of unity, community and a shared sense of purpose – that extraordinary eruption of philanthropy last springtime – we seethe like rats in a sack, fractious, divided…In short, we have reached the point in the pandemic where what feels like armies of trolls do their snarling, misogynistic utmost to silence NHS staff who try to convey what it’s like on the inside. Worse even than the hatred they whip up against NHS staff, the deniers have started turning up in crowds to chant “Covid is a hoax” outside hospitals full of patients who are sick and dying. Imagine being forced to push your way through that, 13 hours after you began your ICU shift. Some individuals have broken into Covid wards and attempted physically to remove critically ill patients, despite doctors warning that doing so will kill them.”**

So what now of the new sense of togetherness and joint endeavour? There are two destructive factors at work. The first is simply extreme tiredness, both physical and emotional, and explains why the NHS and the Government have been so desperate to bring down the levels of hospitalisation in the second phase. In Clarke’s book, which ended in April last year, the long hours were compensated for by excitement at the drama which she had volunteered to join, and by her justified pride at the way in which the entrenched procedures of hospital medicine had been revolutionized in the face of the crisis. But now it has just gone on too long.

The second is a product of the incivility of contemporary protests, which draw their language from un-moderated social network sites. A community is not a thing, but a set of relationships embodied in discourse. There is a need to interrogate official statistics, up to and including the current debate about vaccine effectiveness. There are quiet reasons for vaccine hesitancy, from inherited folk beliefs to fear of needles. What so demoralizes overstretched medical staff are the ease and frequency with which dissent becomes face-to-face aggression.

Those working in emergency medicine have always had to deal with ungrateful, shouting drunks. I was once in an A and E unit with a slightly injured child late on a Friday evening where there were more police than nurses in the waiting room.

But now the pubs are closed. The verbal violence is coming from those who respect nothing except their own views, and accept no constraints on their expression. It is not to be borne.

*Rachel Clarke, Breath taking. Inside the NHS in a time of pandemic (London: Little, Brown, 2021). **https://www.theguardian.com/books/2021/feb/06/ive-been-called-satan-dr-rachel-clarkeon-facing-abuse-in-the-covid-crisis?CMP=Share_iOSApp_Ot

From David Vincent in Shrewsbury, UK: Going to the races

Ludlow races

February 6. On Tuesday evening we drove down to Ludlow race course for our covid vaccination.  No horses, no riders, no vets, just teams of volunteers in a couple of marquees, remarkably cheerful towards the end of what I was told had been a twelve-hour day checking identities and administering jabs.

We waited in lines of spaced seating.  None of us in our first youth, and all of us, it now strikes me, white. This was rural Shropshire, and should come as no surprise.  A county which voted decisively for Brexit immigration controls has in fact very few migrants.

But with the new finding that white over-eighties are twice as likely to have been vaccinated as black, there is a fresh concern that the BAME community is not participating in the vaccination programme.*  There are similar worries about medical staff who have been offered the vaccine.  The Health Service Journal reports that at the Guy’s and St Thomas’ Foundation Trust in London there has been “substantially lower covid vaccine uptake among its black African, black Caribbean and Filipino staff so far.”** Challenged about these discrepancies, the minister in charge, Nadhim Zahawi, took a glass 85%-full line, stressing the large numbers who had taken the vaccine, and admitting that the Government was not fully recording those who had not done so.

Since the pandemic began there has been opinion-poll evidence from many countries about the scale of what are now politely described as “vaccine hesitants.” The latest survey finds that nearly 40% of the French and 23% of Germans say they will definitely or probably refuse a vaccination***  I have always been cautious about these reports.  No one ever died of giving a negative response to a pollster.  It’s easy enough to unload grievances against politicians, health services, big pharma, when, as is still the case in Germany and France, the issue is largely hypothetical. 

One positive consequence of these widely-reported figures is that they have provoked governments, health providers, community leaders and celebrities into launching educational programmes to counter on-line anti-vax propaganda. The British government has set aside £23m for this purpose. Unfortunately, according the Centre for Countering Digital Hate, anti-vax social media in the UK have also redoubled their efforts now that the choice has become real.****  

It comes down to a question of speed. 

There is a large body of literature on the centuries-old anti-vaccination movements, and on the pervasive presence of malign channels of communication.  But we do not have the time to continue debating the excessive individualism of the modern world.  The current higher BAME mortality rate is going to increase dramatically if we have to wait for generations of folk remedies to be challenged, or for the community’s mistrust of the NHS and agencies of authority such as the police to be overcome.  Equally it is a fantasy to suppose that the main digital platforms are going to deny themselves the advertising revenue generated by alternative covid cures any time soon.

This is why the most effective response to the present dilemma may be that adopted by doctors in Liverpool. They are treating vaccine resistance by BAME groups as an immediate practical matter.  It’s no good, they argue, depending solely on large-scale venues which, like Ludlow race course, can be a long way from where people live (though to be fair the race course had organised a special bus service).  Instead they have started pop-up vaccination centres in local neighbourhoods.  Rather than waging war against social media in general, they have engaged with channels of communication up and down particular streets.  And if particular groups do not trust representatives of white society, alternatives have been sought. 

According to a newspaper report, “Dr Cait Taylor, a GP who is joint clinical director of the Central Liverpool primary care network, decided she and other white medics would not be giving the inoculations. Instead, they put a call out for medical students from BAME backgrounds, offering £10.21 an hour for Urdu and Arabic speakers. ‘We wanted to inspire confidence’ she said. ‘People felt more comfortable there than at a GP surgery where you might be met with a white receptionist, or a white vaccinator, or a doctor who doesn’t explain things to you properly, or doesn’t know your language.’”*****

 Cait Taylor concludes, “the message we’ve got loud and clear from local communities is: come to us and we’d love to take the vaccine, thank you very much.”  As should have been the case from the outset with the test and trace system, as much of the delivery as possible should be left in the hands of health professionals who know and are known by the neighbourhoods they are seeking to assist. 

 *https://www.theguardian.com/world/2021/feb/04/black-over-80s-in-england-half-as-likely-to-have-had-covid-vaccine?CMP=share_btn_link

**https://www.hsj.co.uk/acute-care/exclusive-fewer-black-and-filipino-nhs-staff-vaccinated-amidhesitancy-concern/7029397.article

***https://www.theguardian.com/world/2021/feb/04/covid-vaccine-refuse-france-germany-us-quarter?CMP=share_btn_link

**** https://www.bma.org.uk/news-and-opinion/pushing-back-tackling-the-anti-vax-movement

*****https://www.theguardian.com/world/2021/feb/04/inspiring-confidence-liverpool-gps-tackle-the-vaccine-race-gap

From David Vincent in Shrewsbury UK: Truth-telling

February 4. There is published today a new book by the journalist Peter Oborne: The Assault on Truth: Boris Johnson, Donald Trump and the Emergence of a New Moral Barbarism.*

“I have been a political reporter for almost three decades,” he writes. “I have never encountered a senior British politician who lies and fabricates so regularly, so shamelessly and so systematically as Boris Johnson.”

The standard response to this kind of exposé, however well conducted, is that lying is priced into the Johnson brand, and here he is, world king with an eighty-seat majority and his party still ahead of Labour in the opinion polls.

Covid-19 has, however, created a new and more urgent response to Johnson’s mendacity.

Also just published is a report from the front line, Breath taking. Inside the NHS in a time of pandemic, by Rachel Clarke.** It describes the experiences of a doctor during the early months of the outbreak. Clarke was a television journalist before retraining as a doctor specialising in palliative care. When the crisis broke, like many others from different medical disciplines she volunteered to an intensive care unit in a nearby hospital.

A theme throughout her book is the enhanced importance of truth in communicating with seriously ill patients:

“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, encounter and console. Words leap beyond the constraints of masks and gowns 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 home and even serenity… It follows that doctors have a duty to use our words with exceptional care. We are nothing if our patients cannot trust us. Above all, our words must be our bond.” (p. 212)

Other accounts emerging from intensive care units stress the urgency of what may be final words.

An anaesthetist writes of his experience preparing a patient for a ventilator:

“‘I need to phone my family,’ she gasps. I nod and say OK, almost shouting to be heard over the noise of the alarms. The patient tries to talk to her family on FaceTime. She is extremely breathless and looks like she is dry drowning in thin air. Tears pour down her face. I hear someone on the phone crying and saying ‘I love you’ … While we are pre-oxygenating her, I take off her CPAP hood and lean closer. ‘We’re here to look after you. Everything will be OK.’ I stop talking because I think I might cry. I worry she is dying. I hold her hand. She squeezes it and I squeeze hers back.”***

Every word, however brief and obscured by machinery, masks or bad phone reception, is freighted with a lifetime’s meaning.

An individual or institutional crisis places an additional premium on truth. Stressed and exhausted by her days on the ward, Rachel Clarke was enraged by the casual, self-regarding misrepresentations in Boris Johnson’s daily press conferences. She knew just what was happening in the hospitals, how much worse matters really were for both patients and staff.

“I never wanted Red Arrows, medals or minutes of silence” she writes at the end of her book: “Like my colleagues, my needs were more prosaic. Really I just wanted honesty from those who rule us.” (p. 216)

*(London: Simon and Schuster, 2021)

**Rachel Clarke, Breath taking. Inside the NHS in a time of pandemic (London: Little, Brown, 2021).

***https://www.theguardian.com/world/2021/jan/31/im-an-nhs-consultant-anaesthetist-i-see-theterror-in-my-covid-patients-eyes?CMP=Share_iOSApp_Other

From DavidVincent in Shrewsbury, UK: Monuments

Monument to the Great Fire of London

February 2. “History”, writes the Guardian columnist Jonathan Freedman, “suggests we may forget the pandemic sooner than we think.”*

He is commenting on the milestone of 100,000 covid deaths in the UK.

Freedman begins with the point I made in my Computing the Sorrow post last week: “So far, the act of remembering has been deferred or even forbidden. Second only to the deaths themselves, perhaps the greatest pain the coronavirus has inflicted has been its denial of the right to say goodbye.” But his subsequent argument that thereafter there may be no collective memory seems at best premature and in most respects open to question.

He repeats Laura Spinney’s observation that there are no public memorials to the 1918-19 Spanish flu epidemic which killed probably between fifty and a hundred million people, in contrast to the current covid global death toll of 2.2 million in a much larger population.** This is to confuse monuments with memory. London erected a column in honour of the Great Fire, not the Plague a year earlier, but two generations later Defoe wrote his Journal of the Plague Year for a readership still traumatised by the epidemic.

He states that the “facts” of pandemics can “take years to emerge”, noting that initial estimates of the 1918-19 outbreak were decades later revised sharply upwards. But thanks in particular to the Center for Systems Science and Engineering at Johns Hopkins University, this has been a minutely calibrated disaster. There remain some variations in how covid deaths are measured in different countries, but there is not going to be some subsequent recount which adds tens of millions to the death toll.

More broadly he draws a contrast between military and medical narratives. “Wars offer a compelling, linear story”, he argues. “There are causes and consequences, battles, surrenders and treaties, all taking place in a defined space and time. Pandemics are not like that.” As I argued in an earlier post,** set against the other great misfortunes of our time, particularly inequality and climate change, the pandemic does have a plot, with a beginning, middle, and a now somewhat delayed ending. This is why the most influential accounts of such events, those of Defoe and Camus, have taken the form of conventional novels. The dynamics of inequality, as Thomas Piketty has shown, can be traced at least as far back as the late eighteenth century and have no resolution in sight. Equally the destruction of nature commences with the industrial revolution and to take the most optimistic view, will not be overcome for decades.

Freedland’s final point is more fundamental. A viral infection is unlike a world war. “Crucially,” he writes “a pandemic lacks the essential ingredients of a story: clear heroes and villains with intent and motive.” There is an obvious truth in this. The ultimate cause is bats, not people. Covid infections occur by chance, carelessness or neglect, and for all the errors of a Trump or a Johnson, the event as a whole cannot be blamed, except by conspiracy theorists, on individual or collective malevolence.

And yet, as in the stories of Defoe and Camus, the accounts emerging from the pandemic are full of personal courage and achievement as well as individual and institutional shortcomings. In the midst of the struggle it is fruitless to determine how countries will revise their national narratives in the aftermath of so seismic an interruption to their affairs. It will in the end be a matter of choice rather than historical inevitability.

We can remember and then act, or we can forget and then repeat the failings of human agency in this pandemic. We can keep in front of our minds the lessons learned about collective endeavour in the national health service, in science laboratories, and in communities up and down the country. Or we can allow the incompetence and self-interest of politicians and the private sector to be buried with the victims.

*https://www.theguardian.com/commentisfree/2021/jan/29/history-forget-pandemic-spanish-flucovid?CMP=Share_iOSApp_Other

Laura Spinney, Pale Rider (London: Penguin, 2017), p. 291.

**’Pandemics and Plots’, October 19, 2020

From David Vincent in Shrewsbury: The doctor will not see you now

January 29. I cannot remember the last time I had a face-to-face conversation with my doctor. Probably in 2019, perhaps earlier.  To know how he and his profession are managing in the pandemic I turn to the new account by an Edinburgh GP, Gavin Francis.*

Francis and his publisher, together with the Wellcome Collection, deserve praise for getting the book out while the crisis is still in full flood.  Inevitably there is a cost in coverage.  The narrative ends in the autumn of 2020, before the third surge in infections and deaths.

Throughout Intensive Care, Francis is concerned with the consequence of talking with patients only by phone or through masked faces:

“As GPs we’re taught to value the subtleties of human communication – to glean as much from what the patient doesn’t say as from what they do say. As trainees we have to submit videos of our consultations to demonstrate how carefully we attend to body language, to silences, to the way patients hold or evade eye contact.” (p. 56)

My surgery is located in a nearby large village. In common presumably with all practices, its switchboard has been greeting callers with a recorded message explaining that only telephone appointments can be made; the doctor will then decide whether it is necessary to see a patient in the surgery or at home. If you stay online, you then get a recorded message purchased from some third-rate utility:  “Your call is very important to us. Please wait for the next available agent.” This week, however, there is an additional message which I encounter when I ring to renew a prescription:

“Our phone lines are very busy due to the volume of calls we are receiving about the covid19 vaccine. The NHS is prioritising vaccinating those people who experts have agreed would benefit from it the most. We will let you know when it is your turn to book you a vaccination. If would like more information about the vaccine, please visit http://www.nhs.uk/covid/vaccination. If your query was about the covid vaccine, please hang up now.”

So not even a someone to talk to on the other end of the phone. Rather implied censure for making the call in the first place. Clearly this is a surgery under stress. But it is possible to suggest another response which acknowledges that:

• receiving the vaccine is for vulnerable groups by a distance the single most important event, medical or otherwise, that they are facing;

• at this moment, potential recipients are being treated differently in different regions and you well may know of people in similar circumstances who have already been vaccinated;

• in so large a project there must always be an apprehension that as an individual you may fall through some bureaucratic crack;

• over your lifetime you have been used to treating your GP surgery as your portal for all health enquiries, and that being re-directed to an impersonal website offers little comfort.

In the concluding discussion to his book, Gavin Francis is preoccupied with the defects of non-face-to-face medicine, necessary though it may be in the crisis:

“As time goes on, and if telemedicine prevails, those relationships forged in person will become more remote, and the medicine GPs practise will become more perfunctory, based on the avoidance of being sued rather than on what’s best for the patient. Those conversations would be not ‘consultations,’ but triage, fire-fighting, damage limitation. It’s difficult enough to engage with the unique complexity of another human being’s suffering in ten or twelve minutes when sharing the same space, but on the telephone it’s near impossible.” (p. 191)

With doctors, as with so much else, the meaning of this pandemic will not just depend on the temporary expedients that are adopted. Rather the question is which emergency devices are rescinded the moment the crisis is over, and which are allowed to persist, whether out of inertia or institutional self-interest.

 * Gavin Francis, Intensive Care. A GP, A Community & Covid-19 (London: Profile Books and Wellcome Collection 2021).

From David Vincent in Shrewsbury, UK: Computing the Sorrow

Computing the Sorrow

January 27.  Boris Johnson says it is ‘hard to compute the sorrow’ after the official covid-19 death rate passes 100,000 in the UK.

In fact there is a perfectly simple calculation that can be made. Grief professionals work on the basis of at least five bereaved people for every death.*  On current figures that gives us a population of half a million in the UK facing a lonely future.  If we take the more accurate figure of those dying with covid-19 on their death certificates, the number is already 600,000.  Globally there are now 2.21 million deaths, generating a population of over 11 million coming to terms with traumatic loss.

Estimating the length of the sorrow is a more difficult task.  There seems to be an inverse ratio at work: the more rapid the event of dying, the more extended the process of grieving. 

The struggle to come to terms with a loss begins more uncertainly and is likely to proceed more slowly than is the case for non-pandemic bereavements.  In this sense Johnson was for once correct in his account.  It will be a long time before we can take a measure of the suffering generated by a death rate that is the fifth highest in the world, and the second highest as a proportion of the population.

A recent review of the first tranche of academic papers on covid-19 bereavement summarises the difficulties facing the relatives of victims:

“There is sometimes little chance to say farewell in accustomed ways, or to observe cultural or religious mourning practices; there may be regrets or anger about the possible preventability of the death. A persisting difficulty has been noted: social isolation has brought with it the lack of physical support from family and friends or physically-present spiritual support, reflecting sometimes severe societal disruptions in general. Such distancing can intensify feelings of loneliness that is part of any bereavement experience, even without isolation orders in place.”

“In the face of such difficulties,” the paper concludes, “one might speculate that letting go, finding a place for the deceased in ongoing life, relinquishing the old ties/bonds and moving on may not be tasks that can yet be dealt with.”**

The established rituals of bereavement, whatever they may be, work on the basis of manageable numbers.  Defoe’s account of the 1665 plague stands for every pandemic:  “It is here, however, to be observ’d, that after the Funerals became so many, that People could not Toll the Bell, Mourn, or Weep, or wear Black for one another, as they did before, no, nor so much as make Coffins for those that died.”***  In our own event the pressures are compounded by regulations designed to prevent the spread of infection.  No more than 30 socially distanced mourners can attend an English funeral, and only six can gather at the wake (but none in Wales and Scotland).   

Every manual on bereavement stresses the importance of listening to those who are left alone, which becomes more difficult as physical encounters are limited.  The comfort of touch is frequently out of reach.  The small pleasures that can provide escape from the intensity of grief become unobtainable.  Those whose lives have been shattered have difficulty occupying the centre of their own dramas when all around them are competing narratives of loss.  The novelist and counsellor Rebecca Abrams, in a training seminar for Cruse, the leading bereavement charity, stresses how the young in particular, accustomed to talking through their crises with networks of friends, find it difficult to commence their mourning.****

There are compensating resources.  There were already in existence a of range of organisations, including Marie Curie, Cruse, Sudden, The Loss Foundation, The Good Grief Trust, the Samaritans, Supportive Friends, with established bereavement methodologies and networks of volunteers, although most of their work has had to become virtual.  Social networking more generally has never been as important, especially amongst the young who are already accustomed to working through their problems online.

Medical researchers are drawing attention to a bodily ‘long covid’, where a range of often serious conditions persist after the initial symptoms have been overcome.  Amongst those who have lost people close to them, as well as health workers exposed to post-traumatic stress disorders, there is also going to be a long covid of the mind, which may in turn have further physical outcomes.

The army of the bereaved will be living amongst us for years to come, patching together their recovery as best they can.

*Julia Samuel, Grief Works.  Stories of Life, Death and Surviving (London: Penguin Life, 2017), p. xii

**Margaret Stroebe and Henk Schut, ‘Bereavement in Times of COVID-19: A Review and Theoretical Framework’, OMEGA—Journal of Death and Dying 82, 3 (2021): 500–522, 501.

*** Daniel Defoe, A Journal of the Plague Year (1722; London: Penguin, 2003), p. 164

****Rebecca Abrams and Cruse Clinical Director, Andy Langford, recorded as a webinar on 5 May 2020.https://www.cruse.org.uk/training/covid-19-different-kind-grief.