EDINBURGH, SCOTLAND—In Scotland, the spread of the virus was two or three weeks behind London as lockdown came in, and we’ve seen the benefit of that delay. Bed occupancy in Edinburgh’s ICUs peaked around April 9, is dropping now, and only briefly breached the pre-Covid-19 capacity. But the delivery of medical care is utterly transformed.
I work in primary care. As the hospitals were cleared out for Covid-19, specialist outpatient clinics for practically everything but cancer were cancelled. Many routine hospital tests are now unavailable. The labs are frantically expanding their viral testing capability and have little capacity for anything else. The private hospitals are closed to procedures and clinics: there’s no IVF, no outpatient physiotherapy, no drop-in sexual health services. The psychiatrists are as busy as ever, but on their phones. Surgeons can’t operate on anything but cancer and emergency cases because anethesiologists are all redeployed to the newly expanded critical-care facilities—previously, forty beds for a population of 850,000, now one hundred and thirteen.
The government has issued letters to everyone in the country who falls into one of six categories asking them to “shield” themselves from the virus—i.e., stay at home with extra precautions—for at least the next twelve weeks: organ transplant recipients, those on active chemotherapy, those with severe lung disease, those with certain metabolic diseases, the significantly immunosuppressed, and pregnant women with underlying heart problems. A seventh category is anyone whom we primary care physicians deem vulnerable—which has effectively doubled the length of the government list. Every individual considered high-risk is sent a code that gives priority for supermarket food deliveries, benefits, and community support.
In my own clinic, during routine office hours, I spend much of the day on the phone or with hastily rolled-out video-conferencing technology, addressing and assessing every medical problem I can without face-to-face contact. Before Covid-19, I’d manage thirty to forty patients a day; now, it’s about half that number. I bring in or visit at home just two or three patients per day, when I absolutely have to perform a physical examination to rule out something sinister.
I’ve spent twenty years working toward a model of health care in which optimizing the medical encounter was all about body language and non-verbal communication. I loved the subtlety, variety, and intensity of practicing medicine that way; the depressing new normal means that I have to minimize exactly the kind of contact that, for me, used to give it value. People now email me photos of their rashes.
For the few in-person appointments, I put a mask over the face of anyone who might conceivably have Covid-19, and consult with them from behind a visor, apron, and wearing two pairs of gloves. Last week, I was obliged to use video-conferencing to talk someone down from a panic attack. Many of my colleagues feel the same, tired out already, though we’ve got months, and likely years, of this pandemic to run.
Panic and anxiety are the virus’s dark corollaries, a second pandemic leaching into everyone’s lives. As the weeks wear on, I speak with increasing numbers who can’t sleep, who are facing bankruptcy, who are turning to drink, whose mental health, already fragile before the pandemic, is now in freefall.
One woman whose mood swings I’ve helped manage over the years through face-to-face conversations, recommendations of long walks, suggestions of group activities, and distraction techniques, is now on the phone to me almost daily as we try new sedative drugs to quiet her seething mind. Another patient, who had only the most tenuous of holds on reality, seems to have drifted off into a world of his own: without the anchors of family, support workers, and occupational therapy, his paranoias are deepening and his hallucinations are more frightening. All this while long-stay mental health hospitals—institutions custom-made for viral spread—are trying to empty their patients into the community “for their own safety.” We’ve spent many years fighting for mental health to be prioritized and granted resources on a par with physical health, but this lockdown has shown how much mental health is left behind whenever death rates soar.
Like everyone else, we’re figuring out how to ease restrictions safely. The death figures for England and Wales between April 3 and 10 showed 8,500 more deaths than the same period last year. Only about 6,000 of those were formally ascribed to Covid-19, the rest presumably among people for whom the virus has damaged their access to health care, either through a diminution of services or because they were too frightened of the virus to go to the hospital when they should have. The disease poses a double tragedy: unchecked, it would overwhelm our health system. But suppressing it will have grim and enduring consequences.
Gavin Francis is a physician and writer in Edinburgh. He has won several awards for his books, which include Empire Antarctica, Adventures in Human Being, and, most recently, Shapeshifters: A Journey Through the Changing Human Body. (May 2019)