Fall of a chief medical officer

I find myself wondering how Catherine Calderwood is feeling this Monday morning. She went to bed on Saturday night a highly regarded chief medical officer of Scotland with a central role in steering Scotland through the Covid-19 pandemic. By Sunday night she had had resigned, was disgraced (not, I fear, too strong a word). I can’t imagine that she slept much last night, and her breakfast will be tasteless even if she can eat it.

Calderwood didn’t kill, lie, plot, or betray. (Well, perhaps she did betray.) She did something that in normal times would be an utterly harmless blessing: she spent two weekends in her second home in Fife. But these are not normal times. We are in the midst of a Covid-19 pandemic, and the advice of Calderwood and the government is to stay home and not make any non-essential journeys. Calderwood has said this repeatedly on television and the radio.

To her credit, when her journey was reported in the Scottish media, she did not attempt to lie or makes excuses. She may well have had strong reasons for making those journeys; perhaps adolescent children were becoming uncontainable, a husband was becoming abusive, or with her head teeming and high anxiety levels she needed the peace of Fife so badly that she took the risk of travelling. I’ve no idea, but no excuse would have been adequate.

The first duty of a leader is to “walk the talk.” There can be no respect for the tycoon who calls for increased cost consciousness and flies his private jet to St Tropez, the preacher who advocates family values and is found in bed with a prostitute, the politician strong on law and order found guilty of embezzlement. The credibility of such leaders is gone in an instant. Why should anybody believe or follow a chief medical offer who goes against her own ardently expressed advice?

Although I have much admired Calderwood’s campaign on “realistic medicine,” the minute I heard the news I knew that she must resign. She must have known that as well, and the story is that she at once offered her resignation to Nicola Sturgeon, the First Minister of Scotland. Sturgeon, who has described her as a “transformational chief medical officer,” urged her to stay. This was surely a misjudgement, and the proposal that she stay but not appear in any media briefings was clearly never going to work. By the evening she had resigned.

We all do silly and stupid things. Usually we don’t pay much of a price or any price at all. Calderwood has paid a heavy price. Although it’s an unsuitable image in that Calderwood was no tyrant, I can’t get out of my head the picture of Sadam Hussein’s statue being torn down. I wish Calderwood well and hope that she will recover, find a route to grace from disgrace, and be able to eat her lunch and soon sleep through the whole night.

Deciding who should live and die and getting it all wrong

The current debate on doctors having to make awful decisions about who will live and who will die brought back a memory from my two years as a junior (and not very competent) doctor.

I was on call one day in a distant time in a distant hospital when we had a man in his 50s admitted in respiratory failure. My memory is that he had Cheyne–Stokes breathing, alternating deep breathing followed by apnoea (no breathing), which I took as a sign that he was close to death. We diagnosed that he had pneumonia. The hospital had no intensive care unit and no ventilators. We gave him oxygen and set up an intravenous line. We wondered if we should treat him with antibiotics or whether it would be “kinder” to let him die?

The man was unconscious, and nobody came with him to the hospital. We knew little or nothing about him, but one thing we did know was that he had congenital hypothyroidism: in the word of the time he was a “cretin.” As Wikipedia describes it, the condition leads to “impairment of both physical and mental development. Symptoms may include goitre, reduced stature, thickened skin, hair loss, enlarged tongue, and a protruding abdomen.” As the patients age they deteriorate mentally and physically. Even in those days an untreated patient was rare, and a patient who had reached 50 was even rarer. (In my memory that patient looked remarkabl like the picture below.)

We began a discussion about whether to treat him with antibiotics.  I think that it may have been the registrar (a slightly older doctor), the ward sister, and me who discussed what to do. I don’t think that we attempted to contact his family or GP or, indeed, to find out anything about him. Nor did we seek any input from a medical ethicist or priest; indeed, I’m not sure that there were such people as medical ethicists at that time. (I had no teaching on medical ethics.) We made our decision based on the little we knew with, I fear, the fact that he was a “cretin” dominating the discussion. We decided against treatment and rang the consultant, who supported our decision.

In retrospect I find this appalling, but, as I remember it, I slept soundly that night. My conscience was untroubled.

But this story has a happy ending and taught me some important lessons.

When I walked into the ward the following morning the patient was sat up in bed, eating his breakfast, and reading a comic. Soon afterwards his 80-year-old mother arrived and was delighted to see him so well. And as they day progressed more and more people turned up to see him. He was the most popular person in the village where he lived, perhaps a kind of innocent saint. A day or so later he went home.

The first lesson is that the power of medicine is limited. You may arrogantly think that you are deciding who will live and who will die, but nature will trump medicine.

Luckily for me I don’t remember being involved in such a decision again, or if I was I played such a minor role that I’ve forgotten it. Ideally such decisions should be taken by the patients themselves—through advance decisions—if necessary, and they cannot be taken by doctors alone. Next best to patients deciding is family and health professionals deciding together. It’s a failure when the courts have to be involved. And if health professionals find themselves having to take such decisions unaided then it is probably unreasonable to ask them to take the decision on  anything other than clinical grounds—is A more likely to respond to treatment than B, or will the treatment of an individual be likely to cause more or less suffering? Unfortunately, suffering is a function of people not diseases, making the decision in some senses “impossible.”

 

At age 68 I discover a glorious piece of music

I rarely stop to listen to recorded music, a failure on my part. I listen to music constantly while working but am often aware of it only when it stops. But I do sometimes listen to Building a Library, a 45 minute slot on BBC Radio 3, and I listened this morning. Indeed, in these pandemic times I plan to listen every Saturday morning. (And, as far as I know, you can listen to some of them wherever you are in the world.)

This morning they discussed versions of Antonín Dvořák’s Dumky Trio. It’s a glorious piece of music, and, although it was new to me, it’s one of Dvořák’s best known pieces. Dumky is the plural of dumka, which is derived from duma (thought in Ukrainian). Originally a dumka was a form of folk music, “a Slavic (specifically Ukrainian) epic ballad … generally thoughtful or melancholic in character.”  Slavic composers, including Dvořák, Janáček, and Tchaikovsky, developed the folk music into “a type of instrumental music involving sudden changes from melancholy to exuberance.”

This was the last piece that Dvořák composed before he left Europe for America. Playing the piano, he toured Bohemia with the piece. It’s impossible not to hear the music with its alternating slow, melancholic pieces and fast ieces that make you want to dance as both a lament for and a celebration of his home country.

There are six movements, and each movement is a dumka. The first three movements all start with the slow music but then evolve into the fast dance. One of the challenges for the players is for the music to evolve from the slow to the fast rather than the transition be a sudden jarring switch.

The music is a true trio with all three instruments (piano, violin, and cello) having both prominent and supporting parts. One of the debating points in the discussion of the different versions was the relative merits of having either three star soloists or a trio who worked primarily as a trio. I thought that the critics would come down on the side of the regular trios, but the two finalists—and one other they played repeatedly—were all played by three star performers.

The final choice was between YoYo Ma (cello), Lorin Maazel (violin), and Emmanuel Ax (piano) and Isobel Faust (violin), Jean-Guihen Queyras (cello), and Alexander Melnikov (piano). The critics went finally for the version by Faust and others. But listen to any version you can—and ideally sit still and listen carefully while not doing anything else. It’s wonderful music.

 

Death and the climate crisis

The Covid-19 pandemic has revealed our global interdependence and the fragility of our support systems and economy. The archeologist, Ronald Wright, has described how every empire that has ever existed has collapsed, usually for ecological reasons. Now, he points out, we are one global empire. The Covid-19 pandemic will pass like the epidemics before it, stretching back to when humans first began to live in cities, but damage to the climate will be irreparable. The Intergovernmental Panel on Climate Change advises that we have only a dozen years to avoid that damage, but until the pandemic reduced economic activity and travel carbon emissions were increasing not decreasing.

Everything and especially death has to be thought of in the context of the climate crisis. Before the pandemic we were on track for a temperature increase of 8.5 degrees Celsius over preindustrial levels, which, as Nature pointed out, would lead us to conditions like that of the Permian Extinction Event when some 95% of all life forms were made extinct. The climate crisis has the potential to kill most humans, even rendering the species extinct.

Carbon emissions are a function of the number of humans, currently 7.8 billion, and the carbon they consume. The average Briton consumes 5.6 metric tons of carbon each year (Americans 16.1 tons), whereas the average Bangladeshi consumes 0.6 metric tons.  If the world is to reach net-zero carbon emissions by 2050 then people in rich countries will have to consume much less carbon.

(It will be impossible to reach absolute zero, so net-zero implies sequestering carbon by activities like planting trees and enriching soil together with technology to remove carbon from the air. Nature-based sequestering has a limit, and the necessary technology does not exist at the scale necessary. In other words, we cannot rely on technology.)

Health systems account for a substantial proportion of country’s carbon emissions—12% in the US and 5% in Britain. Carbon emissions from health systems are currently increasing, although some, including NHS England, have committed themselves to decreasing their carbon consumption. Indeed, NHS England has established a net-zero committee to advise it on how quickly it can reach net-zero and how it can be done.

The carbon footprint of health systems can be reduced by activities like switching to renewable energy, reducing travel, and redesigning buildings, but it will also mean changing clinical practice. It’s in this context that end of life care must be considered. We are still at the beginning of measuring the carbon footprint of clinical pathways, although methods do exist. Increasingly the carbon consumption of clinical activity will matter more than the financial cost.

Although it feels wrong to many, bodies like the National Institute of Health and Clinical Excellence (NICE) have put a financial price on quality adjusted life years (QALYs). It now becomes necessary to think of the carbon consumption for a QALY, and bodies like NICE have begun to think about this. This Commission has summarised evidence of excessive treatment at the end of life and of high costs. We now need to assemble evidence on the carbon cost: the brutal truth is that the dead consume no carbon, although their bodies must be disposed of.

The carbon footprint of different pathways at the end of life need to be compared. More palliative care in the community, more advanced care planning, greater use of advance decisions, and wider adoption of assisted dying, and broader recognition by individuals and health systems that death may not be the worst option all have the potential to reduce carbon consumption at the end of life.

About three quarters of people in Britain are cremated after death, producing large amounts of carbon into the air. Alkaline hydrolysis in which the body is dissolved has about a tenth of the carbon footprint of cremation, and the resulting fluid makes good fertiliser. https://www.nationalgeographic.co.uk/environment-and-conservation/2019/11/environmental-toll-cremating-dead Composting or natural burial are alternatives.

If we are to survive the climate crisis then almost everything will have to change, including end of life care and funeral customs.

What’s it like to be the Queen?

Everybody in Britain—and many beyond—must wonder at some point what it is like to be the Queen. Ninety-nine out of a hundred must feel grateful they are not her, “a bird in a gilded cage.” She must look behind her and see a line of dead kings and queens extending to invisibility, and she can see in front of her those who may be the next three kings when she is entombed in stone, another dead monarch.

Hilary Mantel in The Mirror and the Light, the third in her Cromwell trilogy, has Henry VIII reflect on what it is to be a king, and then a few pages later Mantel makes more observations. Henry VIII believed that he was appointed directly by God and ruled through a divine right. He was England and completely accountable for everything.

The current Queen doesn’t rule, but the law is not the law until it has her signature. Although she doesn’t have the responsibility of ruling, she does still in a lesser way that Henry embody the country, including now Scotland. And does she think herself appointed by God? Probably she does, and she is the head of the Church of England, which was created to allow Henry to get himself a son.

Here are Mantel’s words:

‘The burden of kingship,’ he [Henry VIII] says, ‘no man can imagine it. All my life, to be a prince: to be observed to be a prince; all eyes to be set on me; to be an exemplar of virtue, of discretion, of excellence in learning; to have a mind young and vigorous yet as wise as Solomon; to take pleasure in what others have designed for my pleasure, or be thought ungrateful; to discipline all my appetites, to unmake myself as a man in order to make myself as a king; to waste not a minute lest I be seen to waste it; for idleness, no excuses; always alert to prove, always to show, that I am worthy of the place God appointed me.

Is a prince even human? If you add him up, does the total make a man? He is made of shards and broken fragments of the past, of prophecies and of the dreams of his ancestral line. The tides of history break inside him, their current threatens to carry him away. His blood is not his own, but ancient blood. His dreams are not his own, but the dreams of all England: the dark forest, deserted heath; the stir in the leaves, the dragon’s footprint; the hand breaking the waters of a lake. His forefathers interrupt his sleep to castigate, to warn, to shake their heads in mute disappointment. At a prince’s coronation, God transfigures him, his human faults falling away, his human capacities increased; but that burst of light has to last him. That instant’s transfusion of grace must sustain him for thirty years, forty years, for the rest of his mortal life.

 

 

What I learnt from a book on the Spanish Flu epidemic

I recommend reading Laura Spinney’s Pale Rider, a book on the Spanish Flu epidemic. It’s readable, romps along, roams widely geographically, scientifically, socially, and artistically, and inevitably gives you thoughts about our present pandemic.

(The title—not a good one, in my opinion—is taken from Pale Horse, Pale Rider, an autobiographical short story by a survivor Katherine Anne Porter. “Flu can cause inflammation of the optic nerve, and one well-documented effect of that is impaired colour vision. Many patients remarked, on regaining consciousness, how washed out and dull the world appeared to them.)

Here are some of things I learnt:

1. There have been pandemics ever since humans moved into cities some 10 000 years ago.
2. The main way to respond them, quarantining, is the same now as 10 000 years ago.
3. “Flu pandemics don’t really start or stop. They invade the seasonal flu cycle, grotesquely distorting its morbidity (sickness) and mortality (death) curves, then recede until those curves reveal themselves again. Even now that the tools exist to differentiate seasonal and pandemic strains, defining a pandemic’s limits is an essentially arbitrary task.”
4. They take two to three years to pass through.
5. They have profound, lasting effects.
6. The Spanish Flu pandemic came in three waves: a relatively mild wave in the spring of 1918; the lethal wave in the autumn of 1918; and a milder wave in the Spring of 1919.
7. Nobody knows how many people died. It was long thought to be 20 million, but it could have been 100 million.
8. Mortality was W-shaped with not only the very young and very old dying but also those between 20 and 40. (We are “lucky” that deaths in the current pandemic follow “normal mortality,” so concentrated among the elderly and increasing with age.)
9. Nowhere escaped, but the impact varied greatly among and within countries.
10. Poor people and people in poor countries suffered most.
11. “Doctors tell us to keep away from infected individuals during an outbreak, yet we do the opposite…. Psychologists suggest an… intriguing explanation…. They think that collective resilience springs from the way people perceive themselves in life-threatening situations: they no longer identify as individuals, but as members of a group – a group that is defined by being victims of the disaster…. At some point, according to the theory of collective resilience, the group identity splinters, and people revert to identifying as individuals. It may be at this point – once the worst is over, and life is returning to normal – that truly ‘bad’ behaviour is most likely to emerge.”
12. The economic consequences can be more severe than the health consequences: “One Swedish study found that for each flu death, four people moved into the poorhouse. A person who was accepted into a public poorhouse in Sweden at that time received food, clothing, medical care and their funeral costs, but was declared legally incompetent.”
13. Pandemics bring out both those who falsly reassure and alarmists: “[Estimates of the number of deaths of a future (now present) pandemic] range from fewer than a million, to upwards of 100 million dead. Reflecting that huge span, there are those who say there is nothing to fear from a future pandemic, and others who lament how woefully underprepared we are. The former accuse the latter of being alarmist, the latter accuse the former of burying their heads in the sand. The chasm between them illustrates how much we still have to learn about pandemics in general, and about flu pandemics in particular.”
14. ‘Painful readjustment, demoralization, lawlessness: such are the familiar symptoms of a society recovering from the shock of the plague.’ Philip Ziegler

 

And some quotes:

‘The minds of different generations are as impenetrable one by the other as are the monads of Leibniz,’ wrote Frenchman André Maurois,

This, then, was the world into which the Spanish flu erupted: a world that knew the motor car but was more comfortable with the mule; that believed in both quantum theory and witches; that straddled the modern and premodern eras, so that some people lived in skyscrapers and used telephones, while others lived much as their ancestors had in the Middle Ages. There was nothing modern about the plague that was about to be unleashed on them, however; it was thoroughly ancient. From the first fatality, it was as if the entire population of the globe, some 1.8 billion people, had been transported back several millennia, to a city like Uruk.

Delirium was common. ‘They became very excited and agitated,’ wrote a doctor in Berlin. ‘It was necessary to tie them to their beds to prevent them hurting themselves as they threw themselves about.’ Another doctor in Paris observed that the delirium seemed to manifest itself, counter-intuitively, once the fever had broken. He described his patients’ anxiety-provoking sensation that the end of the world was nigh, and their episodes of violent weeping. There were reports of suicides – of patients leaping from hospital windows.

 

Why do we remember the two World Wars but not the Spanish Flu pandemic?

The Spanish Flu pandemic of 1918/19 is often described as “forgotten,” whereas the First World War is constantly remembered. Some 80 000 books in 40 languages have been published on the First World War, whereas there have been only 400 books in five languages on Spanish Flu. Every village in Europe has a memorial to the war, while there are few if any memorials to those killed by the Spanish Flu. Yet the Spanish Flu killed two and possibly five times as many people as the war. Why the difference in how wars and the flu are remembered? Laura Spinney tries to explain in her book on Spanish Flu, Pale Rider.

She also explains that interest in the Spanish Flu is increasing, with most of the books on the pandemic published in the past two decades and increasing rapidly, more and more academics in many disciplines studying it, and the pandemic appearing in popular programmes, including even Downton Abbey, where three of the main characters developed the flu and one died of it.

One reason for the difference in memory is that the dead are very visible and easily counted in wars, while flu victims are distributed and often not very visible. For most of the 20^th century people thought that 20 million rather than 50 million (or even 100 million) died in the pandemic. And for most people the flu is a mild infection, influencing the way that people think about the disease. This confusion continues now: we hear about tens of thousands of deaths, but most of us if we have the flu at all have it mildly.

Then, Spinney points out, memory is an active process. Wars have victors, whereas flu has only the vanquished. We have armistice day every year, and there is a Holocaust day. The explosion of the first atomic bomb is remembered every year. There is no day to remember those who died of the flu, partly because there is no day of special significance.

Research into collective memory finds that things are best remembered when the story is rather simple and “comprises only a small number of salient events referring to beginning, turning, and end points helps”; and a mythical component helps. “Wars,” writes Spinney, “slot easily into that structure, with their declarations and truces, their acts of outstanding bravery. A flu pandemic, on the other hand, has no clear beginning or end, and no obvious heroes.” I think too of Alfred burning the cakes, Robert the Bruce and his spider, Joan of Arc and her vision, and Fleming discovering penicillin when a fungus floated through the air. These stories, which are almost entirely myth, are engaging and memorable, and we have no equivalent with the flu.

But Spinney thinks that we are beginning to develop a collective memory of the Spanish Flu pandemic, as witnessed by the increase in books, academic studies, and references in stories; and the present pandemic can surely only add to the memorising. It led me to read Spinney’s book, and like many others, it seems, I may reread Camus’s The Plague.