Geneva, Saturday 18 April 2020

Let’s start with the lighter stuff before I tackle COVID-19 statistics, lifting lockdown and overloading health services.

Boris the sourdough starter went through a particularly troublesome transition from adolescence to adulthood; I was on the verge e-ordering a cattle prod! But he’s come up trumps and my wife made her first no-yeast whole grain sourdough loaf for our scrambled egg brunch this morning. Truly delicious! Hopefully we can find some white flour in the next days. It’s in short supply.

I’ve edged forward in the putting competition by winning 2 and 1 today; that’s 15 games to 8. I think the golfing goddess was distracted by the prospect of a trip to a nearby garden centre to pick up some sweet peas for potting up on the balcony.

I have noted in this Diary how the lockdown has coincided with an almost spooky spell of fine, dry weather that has lasted five weeks now. Today, we crossed the River Rhône just where it comes out of Geneva’s massive Lac Leman. There was no flow. This is unheard of at this time of year when the lake normally fills with alpine snow-melt. At the end of a hot summer, maybe.

So, COVID-19 statistics, lifting lockdown and overloading health services. I take this on with some hesitation; it is a subject too close to my heart. There are now two very clear schools of thought. One school believes that the number of cases of COVID-19 – with associated mortality – can and should be reduced by some variety of imposed lockdown until the pandemic shows signs of abating. Whether or not this happens and whether or not there is a resurgence of cases after lifting lockdown measures, time has been bought to prepare the health-care services and to protect them from overload as much as possible. We will all just have to shoulder the burden of the economic impact of the lockdown.

The other school of thought believes that the lockdown will not change the number of cases in the long term; it will simply delay their presentation. In other words the epidemic bell-shaped graph will have a lower peak but will simply spread over a longer period of time. The thinking is that whichever way we go, the pandemic will only pass when a sufficient proportion of the population is immune; by having had the disease or by vaccination. This school of thought points to the massive impact on the economy brought about by the lockdown that, ultimately, will outweigh the direct toll of COVID-19. The missing consideration here is that the time bought by lockdown measures serves to prevent overload of the health-care services.

Seeing as I am neither epidemiologist nor economist, I am not qualified to comment on the merits of the two arguments. I accept them both as valid. We won’t know what the right road is until we’ve gone down it. I do know that lifting lockdown before there are zero cases simply means moving policies from the first school of thought to the second.

However, there is one part of this story I am qualified to comment on: the overloading of health-care services. In my work as surgeon with the International Committee of the Red Cross, I have been involved in dozens of situations where there simply weren’t enough people or resources to address the needs of those who reached and needed a hospital. Try this. In this pandemic, policy-makers and commentators need to know what overloading health-care services actually means. It is not just about overworked heroes or scandalous lack of protective equipment or ventilators. To work – or attempt to work – in a barely functioning system at precisely the time when that system is required to function even better than normal can be devastating. 

If ever rational thinking about the capacity of health care is required by policymakers, it is now. A health-care service is an integrated system comprising infrastructure, people, their professional skills and, most importantly, their ethics. Overloading such a system easily finds its weakest links. The worst thing to experience is not the lack of equipment; it is to be rendered useless by one’s own and one’s colleagues physical and mental exhaustion; this precisely when you are needed most. Then the whole thing is worse if you have fears for your own safety. Believe me, it can come to the point that you simply don’t care. In brief, health care is not guaranteed when health-care services are overloaded.

Protecting health-care services in this pandemic means not only injecting resources but also, more importantly, buying time. Time allows systems to be tried, tested and to become resilient. This resilience permits the system to function effectively under overload; the physical and mental well-being of health-care workers can be preserved. Indeed, in my experience, if the system functions in an overload crisis, working within it can be a totally uplifting experience. 

The term “triage” is often applied to a situation where health-care services are overloaded. It is commonly understood to mean sorting patients by priority so allowing the system “to do the best for the most” or, in other words, to use the available resources in a way that can maximise the outcome for the patients as a group. This is not the whole story. What effective triage really does is protect and maintain the integrity of a heath-care system and the people working in it. Triage becomes easier and more effective if the health-care system concerned has the opportunity to practice it on multiple occasions. In this pandemic, health-care services need to be given the opportunity to try, test and improve their practice of triage. Spreading the burden of this pandemic on health-care services over time could avoid one massive and debilitating overload that could lead to a health-care service with no functioning personnel.

So here I nail my colours to the mast. Applauding our health-care workers is not enough. We have to protect them and buy them time, otherwise we may find ourselves without any effective health-care services.

Geneva, Friday 17 April 2020

It is a summer day in 1999. I am in London only briefly. The one possible place to meet for lunch is his office. I hurry along Whitehall. No need to look for a street sign; the huge iron gates and hi-viz policemen are the giveaway. “Good morning!” I say to an officer. “I have a meeting with Mr Campbell.” He looks at a clipboard, finds my name and waves me through. “Urm… Where do I go?” He smiles politely. “Number ten, sir. Right along there!” I look down a Downing Street devoid of cars and people. “What, I just go and ring the door bell?” That smile again. “I suggest the big brass door-knocker, Sir. There is no bell!”

And so I knock and that door opens. Official efficient security personified shows me to Alastair’s office. It’s been quite some years since I’ve seen my old college buddy. Firm handshake. Warm greeting. Nice sandwiches. Soft drinks. We’ve both gone our separate and very different ways. He’s changed. I’ve changed. We chat about our jobs: me the doctor; he the spin-doctor. We catch up on our families and mutual friends. He’s still Burnley football crazy. “Are you still playing the bagpipes?” He chuckles. My question is the play button for a shared memory. And then we start laughing. 

It was a summer night in 1979. Exams were finished and May Balls done with. I have vague memories of a riotous dress-up party. I was Tartan of the Apes. At about four o’clock in the morning, Alastair said. “You’ve got a kilt! Great! Let’s do a trip!” I was intrigued. “Where?” He took a pull at his beer. “How about Brussels?” We got the first train from Cambridge station to Harwich. Alastair had donned a kilt. I had grabbed a toothbrush. “What’s in the case?” I  asked. He laughed. “The pipes! Thought we could earn a bob or two.” Still hungover, we had a late breakfast on the ferry to Ostende and arrived in the Belgian capital that evening. We had two pounds between us. And I had sobered up.

“So, what happens now?” I asked. All bravado had evaporated with a fast encroaching not-such-a-good-idea feeling. Had Alastair noticed my growing discomfort? I started to worry that my pal was enjoying my worry. This was, quite simply, not the sort of thing that I did. I was a medical student FFS. “Look! A proper pub!” he cried with delight. The Double Diamond! The owner was a scot named Andy. He thought two broke blokes with English accents wearing kilts was a real hoot and merited a couple of free beers. He told us that If we returned later, we could sleep in a box room above the bar. “OK”, said Alastair, “Let’s go to work!” His nostrils flared; he’d caught the scent of Belgian francs.

Walking through the streets of any non-British city looking like a Caledonian tramp is likely to cause a stir. If there’s two of you – and one is carrying the pipes – the air is full of whistles and cheers. New-found friends offered us more beers. Then we spotted a long queue for a cinema. Alastair stopped and fired up the pipes. I realised three things simultaneously. He was very good. The music was hauntingly beautiful. Bagpipes are loud (and therefore, as I was about to find out, ideal for working streets, stations, bars, trains and shopping malls.) I stood by, tapping my feet and swaying my hips feeling a bit of a spare part. I was cheered to see people obviously loving the whole spectacle. Then the music cracked up. Alastair was laughing so much he could no longer blow into the bag. “Wassup?” I asked. “Go on, then! Make some money!” he yelled. I gaped at him. My jaw and the penny dropped together. His job was to play the pipes. My job was to play the hat. I was going to beg on the streets! Feeling slightly ashamed, I set about my task with hesitation but to my utter amazement people gave us money. And how! After twenty minutes said hat was full to overflowing. Coins and notes! So we went for a beer and, predictably, everyone in the bar wanted to hear the pipes. We made more money. We drank more beer. We ate filet steak with Belgian fries. And that was the beginning of a week of non-stop laughter. 

I rapidly honed my hat technique. I learnt that it came down to, first, giving people a good feeling about putting their hand in their pocket or handbag for change they wouldn’t miss and, second, being right in front of them at the critical moment. If the first person approached put nothing in the hat, working the rest of the crowd was, in financial terms, uphill. The trick was to spot the most willing giver early in the piece. So, the hat would start on the ground near Alastair’s feet. At some point, somebody would make the unmissable move to find some loose change. At this point, I would pick up the hat and be just so positioned to facilitate the nice person’s munificence and congratulate then for it. Everyone else would then be happy to donate to our cause. Even better, when Mummy or Daddy encouraged timid little Marie-Louise to put a coin in the funny man’s hat. An exaggerated thank you. Big smile at parent(s). Gentle ruffle of hair. Guaranteed double takings for the set. As PG Wodehouse would say, it’s all about the psychology of the thing.

We experimented. Once, the two of us collected without playing any music. That worked surprisingly well. In a one-off and beer-fuelled moment we flirted with the idea of street comedy; this involved me trying to play the pipes and Alastair collecting. I could only mange a kind of farting noise. People laughed a lot at my wrestling with a Scottish octopus; it still filled the hat.

Wherever we went, we were the centre of attention. Late one warm evening, we were in a busy street in Dusseldorf. We were doing well with “Amazing Grace” (as usual) until a police car arrived sirens a-blare. The upholders of law and order told us in no uncertain terms to get out of town. The crowd was cheering and jeering when an enormous guy in suit and tie pushed his way through and shouted – in English – “What’s going on here? These are my friends!” Much to our surprise, the police left tail-between-legs. Our new bestie, said “Let’s go to my club!” Bruno (for that was his name,) his entourage, Alastair and I were waved past the queue for, through the doors of and onto a reserved table in a pretty slick nite spot. It was humming. The champagne flowed. We never did discover who Bruno was. He claimed he was the mayor of Dusseldorf; we suspected he was some colourful gangland boss. At some point, he told the DJ to turn the music off so Alastair could play. And Alastair did play. Well… I still had my hat on and felt a responsibility to collect a deutschmark or two. When the management realised what we were up to, we were ejected in short order. Bruno did not come to our rescue.

We’d made enough cash to stay in hotels. That night, we got back to our room and emptied the hat, sporrans, the pockets of our waistcoats and our socks of cash. There was money everywhere. We laughed and we laughed. We laughed until we ached and then some. A man from the neighbouring room knocked on our door and asked us to make less noise. That made it worse. The reception desk phoned threatening to call the police. We were both in serious pain now and the more painful it got, the more we laughed.

Eventually, we arrived in Antwerp. It was a Sunday afternoon. We’d been riding this crazy roller-coaster for six days, were knackered and felt we should head home. All good things have to end and we calculated that we were carrying the equivalent of about two thousand pounds (and this in 1979!!) Antwerp’s centre was quiet but one bar was open… and its terrace was heaving. On top, the clientele were whistling and shouting at us come and join them for a drink. One last gig? Why not? We went in …. only men…. ah! Gay bar! The guy in charge was most welcoming; he went, unsurprisingly, by the name of Willy. He wanted to hear the pipes. Alastair charmed them all with “Atholl Highlanders.” He then announced a jig called “Paddy’s Leather Breeches.” The place went wild. And while they all danced and whooped, I started the rounds with the hat. Now I know what it’s like for a waitress to feel eager hands wander up under her skirt. Having given the terrace a good fleecing, I figured I would head inside where there were clearly more potential donors. I hesitated on the threshold. It was dark. There was a lot of black leather. Willy, much amused by my predicament, took the hat and went in and collected on our behalf. We said goodbye with man-hugs all round. Antwerp kept us in laughter all the way back to Harwich.

I see on-line that my friend Alastair is still piping. He does so outside his front door as his part of the Thursday evening clapping for carers. He even serenades his neighbour, a nurse, when she returns from her gruelling hospital shift. Predictably, his political colours still fly; he hounds the government to recognise and right any short falls in the COVID-19 response. I wish him well. Perhaps one day I’ll persuade him to meet up in Brussels. We’ll see if two guys in their sixties can, in the post-COVID-19 era, graft and laugh as much as those two post-pimple young men straight from college without a care in the world. 

Day 31 (15 April) found us unable to put out a post. Apologies! A brief followup to Day 30: Not only did Donald Trump ignore WHO’s advice, he’s withdrawing all US funding for the organisation. Deflection on the grandest of scales! However, the Commander in Cheat has back-tracked on who makes the decisions. State’s governors do still have authority, it seems. My wife beat me in our daily putting competition on the fifth play-off hole!! That’s 14 games to 8.

So… Geneva, Thursday 16 April 2020

This morning, through the glorious dawn chorus of birdsong, we heard a plane taking off from Geneva’s airport. We rushed out with binoculars to see which airline was flying. Swiss International. We tried to imagine where it was going and how many people were on board. 

The number of countries are actively lifting lockdown measures or planning to do so in the very near future is growing. I estimate crunch time is three weeks away. We’ll know then whether the different versions of lockdown have served to prevent cases or simply delayed their inevitable occurrence.

Neighbouring France seems to be taking the most cautious approach by extending the lockdown to early May at least. The start of the Tour de France has been postponed to 29 August.

Most surprising is that Médecins Sans Frontières has started a programme for homeless people in Canada. Please tell me this is not a publicity stunt! 

Piling up her popularity points, New Zealand’s Prime Minister, Jacinda Ardern has imposed on herself and other ministers a pay-cut. The All Blacks rugby team have followed suit. 

I recognise graffiti and street art can be controversial. However, I admit to being a huge fan of Banksy. I have a book of the unidentified artist’s iconic work. In true Bansky style, the book’s cover cites a Metropolitan Police Spokesperson: “Thers’s no way you’re going to get a quote from us to use on your book cover!” Of course, the man who pointed out that “art” is an anagram of “rat” has made his own tribute to lockdown. I love the rat in the mirror counting the days!!

On Day 16 of this Diary, I observed that “the COVID-19 pandemic has rightly elevated health-care workers to a position in public perception of being necessary for national integrity. This position, up to now, has been the near-exclusive domain of the armed forces.” The last two weeks appear to validate this observation. Let’s stay with this theme of the burgeoning importance of health care.

In the 1950s when my father was practicing general practice in rural Norfolk, most of the population were vaccinated against small pox, diphtheria and tetanus. Because of improved living conditions, diseases such as tuberculosis and rheumatic fever were on the decline. The therapeutic drugs available to him were limited pretty much to digitalis, aspirin and morphine. Antibiotics were just arriving. The cost of administering the vaccines, the medicines and any hospital stay were covered by the young and revolutionary National Health Service. It was all free. In most other countries, still today, the patient pays (and is often ripped off.) The wealthier are healthier despite the 1946 WHO constitution promoting “the highest attainable standard of health as a fundamental right of every human being.” Every gain for this right has been hard won; COVID-19 might give it a major bump up the charts. From now on, health care will not just be an assured service for the citizens of wealthier countries; it will be widely acknowledged as a pillar of national integrity going hand-in-hand with national security. This broader view of the importance of health care is generating two welcome developments. First, care homes are coming to be seen as part of the overall health-care system and not just as long-term, entry-only storage facilities for old people. This had to happen at some point because of the increasing proportion of elderly people in every country’s population. Second, and at long last, there is mainstream and urgent reporting of the miserable state of health care in poor countries. COVID-19 has forced recognition that poor people’s lack of access to health care puts us all at risk and, as we are seeing, can precipitate a national economy’s flip into a catastrophic tail-spin.

Please find enclosed a picture of my childhood home. My father’s consulting room and dispensary were on the other side of the house.

PS…. I never could paint trees!