On 13 January, a bulletin from Health Protection Scotland was sent to all GP practices in the country describing a “novel Wuhan coronavirus”. I work in a small clinic in central Edinburgh with four doctors, two nurses and six admin staff. It was the first time I’d heard of the virus. “Current reports describe no evidence of significant human to human transmission, including no infections of healthcare workers,” it said reassuringly.
I cast my mind back to the Sars coronavirus of almost two decades ago, and briefly wondered how quickly the spread of this coronavirus would be stopped, as Sars was. A seafood market had been closed and sanitised. The bulletin said that although Wuhan was a city of 19 million people, there were only three flights per week from there to the UK, and the likely impact was “very low”. I shrugged, and carried on with my work.
Scientists had already discovered that the new virus was fundamentally different from Sars, though still within the family of coronaviruses. “Corona” refers to the spiky little packets of sugared protein stuck all over the surface of the spherical virus, like fleurs-de-lys sprouting from the band of a crown. Under an electron microscope they look like tiny planets, each one buzzing with angry satellites. They’re a similar size to flu viruses – 0.1 microns – and are widespread among many different mammals. Sars came to humans from the Asian civet; Middle East Respiratory Syndrome (Mers) came via dromedary camels. It seems likely that the new virus has its origin in bats, but whether there was another mammalian intermediary between bats and humans is still uncertain.
That evening I met up with a friend, a consultant physician who had recently come back to work after a period of time doing research. She had been stationed at a general hospital around 30 miles from Edinburgh, and was enjoying being back in the thick of clinical work, though startled at how stretched her medical colleagues were. “It’s the same every year,” she said. “I wonder when health boards will realise how many winter beds we actually need.”
A week later, Chinese infections stood at 550, and the death toll was 17. A new bulletin arrived reassuring me that the risk of infection was still low, but attaching a specific form to be completed should I suspect someone of having the virus – specifically anyone flying in from Wuhan. I was disgruntled but not alarmed when one university asked worried Chinese students to seek GP attention. “By phone!” I wanted them to add, “tell them to seek attention by phone!”
On 30 January, the World Health Organization (WHO) announced a global health emergency. The death toll in China reached 170, and the cases that had tested positive there reached almost 8,000. Further cases were reported in India and the Philippines.
Coronavirus infects and irritates the lungs. Most cases are mild. In severe cases it leads to breathlessness as the lungs struggle to do their job of oxygenating the blood – something that can be relieved with oxygen delivered by mask. A proportion of those patients who require oxygen will go on to need ventilation in intensive treatment units. In these early days of the outbreak, I still thought of the virus as something that, like Mers and Sars, would be contained. As GPs we are accustomed to dealing with an annual spike in flu – the “swine flu” of 2009 turned out to be not much more dangerous than seasonal winter flu – though in its severity and prevalence, this new virus seemed worse.
That same day, another message came in, this time from Lothian health board. It instructed me that masks “and other personal protective equipment” would be sent to the practice shortly, prompting the usual jokes among the staff that we would be sent a paper bag and some of those clingfilm gloves you get at petrol stations. Surgical masks did arrive later that week, along with a roll of tear-off plastic aprons.
During the week, I work at my small Edinburgh practice, but at the weekend I sometimes work evening GP shifts at an “out of hours” (OOH) centre in the city, covering a much larger population, with a team of other doctors and nurses. I had an email from the clinical director of the centre advising me to tell any patients from mainland China that they would only need to self-isolate if they had symptoms, adding that those symptoms did not include a sore throat. Until then, I’d been assuming that a dripping nose and a sore throat would be the herald of coronavirus infection, the way they are for most respiratory viruses. My practice started a WhatsApp group to keep one another updated. It proved as good for sharing joke videos as for the latest governmental advice.
On 4 February, I flew to the US to give a talk at the New York Academy of Sciences about science, medicine and wonder. United Airlines warned me I would be turned back at the US border if I had been through China. There were a few face masks in use at the airport, but I still thought of this as a problem that the Chinese lockdown and the Wuhan flight ban would address.
Radio New Zealand had also been in touch to ask if I would do an interview. The absurd levels to which we are all now interconnected came home to me as I sat down, cross-legged and jet-lagged, in a New York hotel room to talk, via Skype, to a presenter 17 hours into tomorrow. He asked me for predictions on how far this epidemic would spread. I remember saying that I had no crystal ball, but what I’d seen of infection control measures in China seemed impressive – I hoped very much it would be contained as Sars had been contained, and that isolation measures would be effective. That day it was reported that 425 Chinese patients had died, and infection rates, for those who’d been tested, stood at just over 20,000.
Flying out of Newark, I found myself in a departure terminal where every table was festooned with tablet computers on stalks. They flashed like gambling machines, entertainment as well as shopping opportunities. To speak to a companion it was necessary to peer over these screens. All food and all payment was to be ordered by touching the tablets. Maybe they wipe them clean regularly, I thought, as I watched a kid pick his nose then start playing with the screen.
When I got home from New York, in early February, the threat began to feel real. That weekend the number of deaths in China surpassed those of the Sars epidemic of 2002-2003, at 811. Half-term holidays followed. Along with my wife and kids, I drove north to Orkney to see friends and take up a locum position as a GP on one of the islands for a week. At Kirkwall, on my way to the ferry, a message pinged from one of the NHS Orkney staff. Did I have time to drop by the hospital and be measured up for a “face-fitting mask”? These masks are effective at blocking the droplets of coughs or sneezes that carry viruses. It disturbed me that the request came in such haste – did they know something I didn’t about the imminence of the outbreak? In Orkney? I had time if I dropped by the hospital right now, I replied, but had only an hour until my ferry was leaving. “It won’t be necessary,” came the reply, and it wasn’t.
By the time I got back to Edinburgh eight days later, things were changing fast. The OOH service asked if I could come by and be assessed for a face-fitting mask. But when I tried to set up an appointment, stocks had run out. New guidance appeared that, for the kind of examinations I perform as a GP, it would be enough to wear a “fluid resistant” mask and follow the usual infection control procedures – aprons, gloves, eye protection. The face-fitted masks were to be preserved for those performing the kind of procedures – such as intubations and endoscopies – during which you might be sprayed with saliva, or worse. Some were finding governmental advice infuriatingly inconsistent, but it was clear that tough decisions were having to be made with limited resources, and time was running out. As GPs we were being urged to avoid suspected cases in case we spread it inadvertently to others, though the virus was undoubtedly circulating among our patients at higher levels than were evident in official figures.
On 21 February, Lombardy reported its first cases resulting from spread within Italy, rather than among people who had flown in with the virus. They still had only a handful of confirmed cases. My wife is from Lombardy, not far from Pavia, and her parents went into isolation. Italy reported its first deaths the following day, but several patients of mine were still relaxed enough about the virus to fly there for skiing.
In the next four days, Italy’s number of reported cases leapt from single figures to 229, and China’s approached 80,000. But China’s were slowing while Italy’s appeared to be gathering momentum: on 25 February, a new bulletin from the public health specialists of NHS Lothian asked me to tell anyone who had been in Lombardy or Veneto within the last 14 days, and who had symptoms, to self-isolate. “First of all, for reassurance,” it stated, “with regards to Italy, the area of concern is only for northern Italy – north of Pisa, Florence or Rimini.” I was not reassured.
I spoke that day with a patient who had returned from Milan, but who had no symptoms other than a slight sore throat, common enough for anyone just off a plane. According to the rules I’d been given, he didn’t have to isolate himself. “Have you got a thermometer?” I asked him, and toyed with the idea of dropping round to see if he had a fever, but then more calls and demands came through, and I didn’t. (He subsequently recovered.)
At the OOH centre in West Lothian, in the first week of March, it was evident just how thick the weekly traffic is between Italy and the UK. One among several calls: a man who had flown in a day earlier, from south of Pisa, and who had a cough with a fever. According to the guidance I’d been given, he’d been too far south to be considered as a potential case – I informed him there was no official need for self-isolation. But the advice made me uneasy, and I asked him, if he could, to stay at home and off work for at least a week.
Another call was to a family just back from skiing; according to the location of their resort they were at risk, and they were referred to the public health board for testing. This is done by sending away an official form – we GPs don’t get to hear who turns out positive and who doesn’t.
In early March, the computer system with which GPs read all medical records, make notes on each consultation and refer patients for specialist care, had new coronavirus codes added. The idea is that anyone registered in the system with Covid-19 is tagged with a special code that will keep track of the spread of the disease, as well as our Covid-19 workload as GPs. At this point, “Advice given about 2019-nCoV” was the only code that I had much opportunity to use.
To carry on with “containment” of the virus, it felt like we would need hundreds of call-handlers to decide who should stay put and self-isolate, and who should be tested – and then hundreds more workers to trace every contact. Drive-through testing was happening now in Edinburgh, though there was only one mention of the virus today among the 30 or so patients I saw face to face.
By now, fear was spreading, with some justification, and the situation was beginning to feel extremely serious. One elderly lady requested a letter for her insurance company, to get her out of her package holiday; I explained that until the government changed its advice, my letter wouldn’t make any difference, and she left, dejected.
Watching the news, the measures Italy was taking seemed extraordinary, though necessary. Once, when I worked as an Antarctic expedition doctor, I studied with military medics for a diploma in the medical care of catastrophes. We learned about building makeshift hospitals, about dividing clinics into “clean” and “dirty” zones, about planning urgent mass vaccination, about emergency medical supply chains. It felt surreal that those kinds of measures were now being discussed so close to home.
The gravity of the crisis was only just starting to be felt. It seems incredible now that I was so blase, but on Saturday 6 March, I was out with friends, jokes aplenty about nudging elbows instead of shaking hands. I stood in the corner of a pub packed with people watching the rugby. (England were victorious over Wales.) A GP friend in Fife told me that she was convinced the disease was already widespread among her own patients – she was seeing more viral breathlessness than usual, but none from people who had travelled to the “at risk” areas, and none who fulfilled the criteria for testing. We went together to a sold-out concert at Edinburgh’s Usher Hall – capacity 2,200 – crowds singing, people hugging, everyone pretending to forget about Covid-19 for a night.
Another friend, a hospital specialist, told me in a crowded pub that night that what we needed urgently was to slow its spread – allow the government to buy time, get in more ventilators and prepare the hospitals. But he wondered if we were doing too little too late. “We could run out of ventilators by May,” he said. Evidence from China was showing that if you buy ventilators early and deploy them in new and cleared-out hospitals, you save lives.
The following day, Italy went into lockdown, but Britons were still being allowed to fly home. The supermarkets there started offering free delivery to the over-65s. My parents-in-law at least have a garden; a neighbour is passing fresh bread over the fence. They have their chickens, their vegetable patch and a well-stocked garage. There are frightening stories from Lombardy hospitals of insufficient ventilators, and operating rooms used as intensive-care units.
I woke up on 10 March to a WhatsApp message from a colleague – the first few Covid-19 cases from our patch of Edinburgh had been confirmed, all in people returning from Italy. They had a fever, a frontal headache and a dry cough. We were all expecting the news, but it still came like a cold slap. Everything about the way we work would have to change. Planes were still flying in from Italy and France. Websites were telling worried people to phone their GP, while each morning we GPs were picking through emails from local and national health boards for the latest advice. Protective suits were to be saved for hospital staff and paramedics at the bedsides of sick people shedding the virus.
We decided to slash the number of appointments offered by 50%, filled the new space with phone appointments, and used a new code in the medical records: “Telephone triage due to Covid-19 restrictions”. All the same, a colleague and I still made five visits that day to frail, elderly, housebound patients – all of them over 85 (two over 90), and all asking anxiously about the virus, trying with their questions to gauge our own levels of concern. These are among the most lonely, isolated people in our communities. But when any GP might be asymptomatically carrying the virus, trying to assess their problems face-to-face feels like a luxury – we have to reduce home visiting to a minimum.
There were plenty of nervous jokes among my patients that day about the coming “coronageddon”, but only one who phoned in, drenched in sweat, with a dry cough and a fever of 39C. He hadn’t been abroad for months, and I told him to stay home for at least a week. That evening, my GP colleagues and I had a meeting in the pub that felt like a boozy council of war. We shared stories we’d heard of patients in hospital with the virus, and ideas for how to protect the practice, should we, one-by-one, end up catching it. I remembered planning meetings for the swine flu of 2009, but they were nothing like this, and the threat had felt nowhere near as real.
On 11 March, the WHO declared Covid-19 to be a pandemic. Events were moving at unprecedented speed. The UK budget was delivered and the NHS was told it would have whatever it needed. We’ll see. Deaths in China continued to drop – just 19 new infections.
A helpful message signed by all the government health departments, health boards, royal colleges and the General Medical Council also arrived on 11 March. It said that I’ll be expected, in the coming weeks, to go beyond what I’m accustomed to dealing with, but that I can be reassured that the GMC and health board will support me and my decisions through the crisis. “Clinicians may need to depart, possibly significantly, from established procedures in order to care for patients in the highly challenging but time-bound circumstances of the peak of an epidemic.” It’s good to feel the GMC is at my back, rather than on my back, for a change.
Among my worried patients were a grandmother with full parental responsibility for all her grandchildren. A mother of a seven-year-old daughter who has a fever and cough asked whether that means she should also be self-isolating. According to official guidance, the answer was still a disquieting “no” – we were still in the “containment” phase – but I asked people to be pragmatic. If they felt at all unwell, stay in and minimise contact with others. The only unconcerned patient was a man with advanced cancer, spread to the liver, who thought we were all overreacting.
By this point, we GPs were doing almost everything over the phone, even if it meant prescribing antibiotics without seeing patients, and making guesses about non-urgent diagnoses – shunting anything that wasn’t an emergency into an imagined future of normality. Over morning coffee, my colleague joked about getting us beekeeper outfits, visiting only the most seriously ill in their homes while hermetically sealed in our own isolation suits. As jokes go, it wasn’t very funny.
I spent the afternoon doing a men’s clinic for the city’s rough sleepers and those with no fixed address, some of whom sleep in Bethany Trust dormitories. In my morning surgery, everyone had asked me about the virus; my homeless patients had, it seems, more pressing concerns. About half went to shake my hand, and thought me cowardly for bumping elbows instead.
By the time I emerged from the clinic, Boris Johnson had told everyone with cough and cold symptoms to stay home for a week. “At last!” I thought. Maybe people will take it seriously. We were again informed that more protective equipment was coming, but the droplet-resistant masks still won’t be available. Everyone with a beard who works with Covid-19 patients has been asked to shave it off, as the masks don’t work if there’s hair between them and the skin. Anyone with religious or cultural objections was told to speak with their line manager.
Friday the 13th, and an atmosphere of dread in morning meeting at the news from Italy. There aren’t enough ventilators to go round, or nurses, and people are being buried without funerals. The practice WhatsApp group has been renamed “Dream Team CoronaCombat” in an attempt at levity. There was an air of quiet resignation at what’s coming, but an edge of bunker humour, too. One of the clinic thermometers broke, and I went online to buy another – £30 versions are changing hands for £125. But virologists are learning about Covid-19 all the time, and for all their horrors, the Chinese and Italian experiences mean that we’re better prepared in the UK than we might have been.
One of my patients that day, a man in his late 80s, told me that the virus is mother nature getting back at us. “Too many people!” he said, and chuckled. “All us oldies need clearing out!” I didn’t share his glee. Some who have had coughs for weeks, but that have worsened, asked me if they’d got it – but there’s no way of knowing, and I told them all to stay home for a further week. The lab had stopped accepting viral swabs from GPs, so unless someone is admitted to hospital, they aren’t tested. And also on the 13th, the first death in Scotland, in Ediburgh, was announced.
Spain followed Italy into lockdown, planes turning back halfway. The UK attitude of allowing schools to stay open came under attack. It was obvious we needed new ways to slow the spread, particularly among the over-65s – they’re the ones most at risk from this disease. One of my colleagues has purchased us hazmat suits from eBay for home visiting, just in case. The medical students of Edinburgh University have set up a pet-and-babysitting service for NHS staff.
On Tuesday 17 March, the practice was oddly quiet – there was a hush on the streets, a sense of anxious anticipation, and my days now feel like a prelude to what is to come. People were stunned by the implications of the guidance delivered by the prime minister on Monday night – to avoid going out, to avoid restaurants and theatres, to self-isolate for 14 days if anyone in the family has symptoms. Unprecedented, necessary, belated advice. Of the 20 people I spoke to on the phone, a couple almost certainly had the virus – a new headache, fever, cough, malaise and exhaustion. I coded them “suspected coronavirus infection” and gave advice to stay in with their whole families, and call us if they get worsening breathlessness.
As healthcare workers, we’ve been told to follow the same advice as everyone else: stay off for 14 days if anyone in our homes has a cough or fever. Practices adjacent to my own are already losing staff, and we’re clamouring for testing. If I develop a cough but test negative, I can go on working. Even better will be some future test that can show if I’ve had the virus, and developed immunity – then I’ll be able to work overtime through the coming weeks without fear. Hospital clinics are being cancelled wherever possible, all elective surgery postponed. We’re clearing the decks for an onslaught. Yes, it would have been nice to have been better prepared for this pandemic, but though it’s frightening, it could also be worse, and I don’t feel the same anger as some of my colleagues towards the government for its prevarication over such immense and unprecedented decisions.
On Wednesday I heard that schools are closing, and so my wife and I will be contending with the competing necessities of the kids, the virus and the NHS. My wife contacted her GP in Lombardy. The situation is, he said, very grave, and he wished us luck with what is to come. I messaged a medical contact in Beijing, the Chinese translator of my books, who said things are improving, with few new cases. “As you know, isolation is the only effective method to stop the virus,” he added, and asked that I give thought to the mental health of my patients as much as to their physical needs. He ended on a sanguine note: “People will have to change their habits for a while. The spring is coming.”