Doctors pride themselves on telling hard truths. Before the pandemic, there was a thriving sub-genre of books — like Henry Marsh’s Do No Harm and Adam Kay’s This Is Going to Hurt — where clinicians revealed how much uncertainty and improvisation their work involves. This was the reality to which trusting patients were oblivious (perhaps by choice).
Coronavirus has intensified the disconnect. Doctors and nurses have been applauded as saviours by the grateful public. Yet they have also been flying blind — lacking the knowledge or resources to tackle this new disease.
A year after the enormity of the pandemic after much of Europe entered lockdown for the first time, the stories of hospitals and policymaking are beginning to take shape. Jim Down’s Life Support and Peter Baldwin’s Fighting the First Wave both seek to memorialise the previously unthinkable scenes of the past 12 months, while drawing some lessons for the future.
Down, a critical care consultant at University College London Hospitals, one of the UK’s top healthcare trusts, tells how his intensive care team struggled to fend off the first wave. At the peak in early 2020, 85 patients were in the unit.
A striking theme is how many roles clinicians are expected to play. They don’t just monitor vital signs — they create systems of work, devise kit, draw up timetables, navigate ethics, and console families.
Down is interesting on the subject of Nightingale hospitals, the new Covid wards hastily set up by the UK government to prevent the NHS being overwhelmed, but which end up being barely used.
He explains how the Nightingales were more than a politician’s gimmick — their layout theoretically enabled one consultant to oversee 42 patients, instead of the usual 15 or fewer. But he was sceptical that this promise could be realised, especially as the virus required more diverse and serious treatment than expected.
The intended patients, people “who just needed some time on a simple anaesthetic machine ventilator, didn’t really seem to exist”. To Down’s relief, there is a shift in strategy towards expanding existing hospitals’ capacity.
Clever experts disagreed about the Nightingales; they also disagreed about whether to keep sick patients in deep sedation or to prod them to breathe on their own. Down admits that evidence-based medicine is hard in intensive care, where “there is so little evidence that is overwhelming.” (Treating each patient, incidentally, costs £1,800 a day.)
Life Support is written with a doctor’s methodical manner. Down is straightforward enough to say what he thinks he’s good at (chairing meetings) and a few of his failings (he, like Donald Trump, became briefly excited by hydroxychloroquine). The book comes into its own in the final furlong, when the consultant, not the most emotive of narrators, reckons with the pandemic’s effect on his exhausted team, their patients and the relatives of the deceased. That brought me to tears.
Down knew that his unit’s outcomes would be compared with other English hospitals. In the end, they are roughly the same. But, at a macro scale, outcomes have varied hugely — take, say, Vietnam, Germany, the US, India and Rwanda. Why did the same disease hit countries so differently?
In Fighting the First Wave, Baldwin, a history professor at the University of California, Los Angeles, promises a comparative analysis. He starts by discarding a few possible explanations: for example, that some governments ignored experts (Sweden and Denmark both followed expert advice, and ended up with contrasting policies), or that countries’ political systems determined their responses (democracies and autocracies did both well and badly).
Early analytical books on the pandemic face two bear traps: one is simply to claim that the author’s prior views have been vindicated, and the other is to become overwhelmed with narrative detail, given how much has occurred.
Baldwin falls into the second trap. His breadth is impressive, and his prose often elegant. But his book is dizzying, and not in a good way. It spins from country to country, from anecdote to anecdote, without pausing for breath. I felt like I was jogging through an art gallery.
It would have been more helpful to focus on a few decisions and counterfactuals. What would it have taken for the UK and France to have locked down earlier? Was there ever a prospect of China not containing the virus in its borders? Why were western countries slow to learn from Asia?
Instead, there are endless nuggets: Taiwan traced 630,000 possible contacts of the 3,000 passengers on the Diamond Princess cruise ship; Japan banned screaming on roller coasters; and Germany tried to avoid rationing care, partly in reaction against Nazi euthanasia.
Baldwin majors on Sweden, which he explains was misunderstood by libertarians: its government didn’t want to infringe its citizens’ freedoms, but expected them effectively to lock down anyway (“the quasi-oxymoron of voluntary compliance”).
Mostly, however, Fighting the First Wave can’t answer the question it poses. Baldwin lacks the granular sourcing to explain why policy decisions varied. He admits it’s too early to resolve questions such as whether people in lightly hit areas such as eastern Europe were somehow less vulnerable to the disease.
Perhaps such an ambitious analysis was impossible this soon. Perhaps a doctor would have bluntly admitted as much.
Life Support: Diary of an ICU Doctor on the Frontline of the Covid Crisis, by Jim Down, Viking, RRP£14.99, 216 pages
Fighting the First Wave: Why the Coronavirus Was Tackled So Differently Across the Globe, by Peter Baldwin, Cambridge University Press, RRP£20, 392 pages
Henry Mance’s ‘How to Love Animals in a Human-Shaped World’ is published next month