“This disease is unlike anything I have seen before. If you end up on ICU, you are potentially in real trouble. I have never seen anything like it before.” These words were written by one intensive care physician working at a London teaching hospital. As deaths accumulate, the early message that severe acute respiratory syndrome coronavirus 2 causes mostly a mild illness has been shown to be dangerously false. One in five patients develop complications and are at grave risk. A further misunderstanding concerns age. An impression was given that only older people are at risk of serious illness. But the average age of non-survivors is under 70 years. Two-thirds of those admitted to hospital in China were younger than 60 years. The complexity of illness in these often quite young patients is challenging to comprehend. Patients are not commonly dying, for example, from hypoxaemia. The cause of death is often cardiovascular, with high-sensitivity cardiac troponin I being a more reliable marker for mortality. Thromboembolic disease, hypercytokinaemia, secondary sepsis, hypovolaemia, and renal complications are a toxic combination of problems for intensivists to manage. The number of patients admitted to intensive care units has been doubling every 2 days. Deaths are so frequent that hospitals have created emergency mortuary space, often in car parks, moving bodies at night to avoid media scrutiny. Intensive care teams are doing truly remarkable work. But it is a huge physical and mental struggle. Here is one physician, writing from the front line. You can feel the anguish in her words. “We are therapeutically bereft (phrase borrowed from a colleague), and I am concerned that the push to do something, anything—which I fully share as I am on the wards with these patients too and it feels desperate—is resulting in suggestions of repurposed drugs too rapidly and without a cool look at plausibility or risks.” The focus of the political debate about coronavirus disease 2019 (COVID-19) has so far been almost exclusively about the public health dimensions of this pandemic. But at the bedside there is another story, one that has so far been largely hidden—a story of terrible suffering, distress, and utter bewilderment.
© 2020 Maurizio De Angelis
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Stephen Dorrell, a past Conservative Secretary of State for Health, argued last week that the UK “government has overpromised and underdelivered” in its response to COVID-19. Matt Hancock, the present Secretary of State for Health and Social Care, has now described at least one strategic failure in the UK Government's response—“we did not have the scale”, he has admitted, for virus testing. A previous science adviser to the government, Ian Boyd, has also agreed that “we were poorly prepared”, blaming inaction on the conclusion that “nobody likes living under a fortress mentality.” But forget the idea of a fortress. The response is now framed as a full-blown war: “we are at war against an invisible killer”, Hancock has said. War metaphors are powerful political and emotional instruments that grip public attention and are widely understood. They create a sense of fear, threat, and urgency: we are engaged in a fight against an evil enemy. A war means that sacrifices have to be made—in the case of COVID-19, restrictions to our freedoms. And, in a war, there is a sense that we have to unite, to forge an unprecedented alliance, to look forward not back, to create one national effort. Paul Nurse, Director of the Francis Crick Institute, endorsed this invocation of war when he talked about “a Dunkirk spirit”. But war metaphors also have dangers. They suggest there will be a simple victory or defeat. They emphasise treatment over prevention. And they encourage the view that criticising government strategy is somehow unpatriotic. The Lancet is receiving many messages from front-line health workers reporting “bullying”—bullying National Health Service (NHS) staff by threatening disciplinary action for raising concerns about workplace safety, testing, and access to personal protective equipment. “I never thought I lived in a country where freedom of speech is discouraged”, wrote one doctor. The NHS is fortunate to have a Duty of Candour, endorsed by professional regulators: “As a doctor, nurse, or midwife, you must be open and honest with patients, colleagues, and your employers.” For those who believe now is not the moment for criticism of government policies and promises, remember the words of Li Wenliang, who died in February, aged 33 years, fighting COVID-19 in China—“I think a healthy society should not have just one voice.”
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