A time to live
“A time to be born, a time to die
A time to plant, a time to reap” – The Byrds (adapted from Ecclesiastes 3:2)
THE RECENT POLITICAL comings and goings are an unfortunate example of poor leadership and judgement, by those who should know better and will only serve to add to the cynicism of politics at a time when we need to be attracting people of ideas, ability and calibre to political life.
That said, the reaction to recent events in Clifden does have another aspect to it. It highlights the need for some open debate about the next steps in our approach to Covid -19.
No one really disagrees about our initial approach to the pandemic, apart from, personally speaking, the ageist lockdown of people on the basis of being 70+ and our lack of preparedness in the nursing home sector.
The next steps, however, are up for debate. Among many of my colleagues on the hospital frontline of this emergency, there is no real belief in the ‘zero’ virus strategy being touted by some, citing a far-off and very unique New Zealand as an example to follow.
Personally, I think New Zealand’s prime minister Jacinda Ardern is a great role model for young aspiring politicians but her government may be tilting at windmills. It’s a virus, it’s in the country and it will break out from time to time and spread unless you can fully isolate away your country and it’s probably too late, in any event, for that.
The emphasis now should, in my opinion, be on control and monitoring while letting society open up to recover and flourish once again.
An Ireland of individuals
There will not be a vaccine for the next year and even then without some individual disclaimer or broad indemnity, given our medicolegal system when it does come, I fear we will probably be near the back of the queue anyway given our propensity to litigate and be handsomely rewarded for every misadventure that befalls us.
In that lies a societal truism at the heart of Irish culture. We are about the individual at every given turn, be it land rights, personal injury or even car parking. It would be common to see a hazard-light pit-stop on the double yellow lines on the basis ‘I was just dropping into the shop for a minute’, agnostic of holding up the flow of traffic and the common good.
We’d probably celebrate and view it as a success if we got planning permission for a ‘one-off’ on the seaward side of a coast road, rather than consider the effect on our common enjoyment of our landscape.
Even in Clifden, it was about our golf society rather than Irish society.
We are all guilty of it, it is part of who we are, an innate antipathy to any form of centralised authority or regulation and enshrined to a degree in a constitutional millstone around our necks.
It is this trait that historically has had clan before nation and in more modern terms, parish before county and county before country in our quaint hierarchy. It is the foundation belief of what emigrating Scots-Irish helped create in the US and is now referred to by some writers as the ‘borderland’ (or Greater Appalachian) culture, the culture of ‘me and my right to do what I want’ without any central control or interference, the predominant culture from which president Trump draws support.
It’s in our culture
We lost the veneer of it for a while when we were ‘culture-colonised’ by the Vatican but not in any lasting or real sense and it permeates our governmental thinking. This individualistic view of life has its merits in our value of the uniqueness and rights of each person and our keen sense of local belonging – but unbalanced, it bedevils the common good.
This view of life has importance now when we consider our approach to Covid-19. To date, our approach has been correctly about reducing the death rate and preventing our acute hospital system from being overwhelmed.
This has been successful but the next phase must also be about the wider good of society and this includes returning to life in as far as possible while carefully monitoring and controlling the effects of this virus.
To lock down society to a degree where what remains in the aftermath of this crisis is a socially phobic, economically depressed and culturally desolate landscape is not a successful result.
Our children are low risk and must return to their education – and the ‘zero-risk’ view of the teachers’ unions in this regard is neither realistic nor a widely held view of teachers in my experience. It’s also certainly not the views of the frontline staff in our public transport, GP and dental surgeries, shops, post offices etc, that have been keeping the show on the road.
Time to boldly move forward
Our businesses and hostelries, the lifeblood of our communities, local employment and social interactions must now be as open as the rates of illness can allow. Our theatres and music venues, the creative spaces of our nation must resume their commentary and give artistic entertainment to our lives in as far as can be acceptable.
Our travel, commercial and diplomatic links with other countries must resume in as normal a manner as possible. In the absence of an imminent vaccine solution, our next steps must factor in what is needed and good for our whole society now as much as our concern for our individual health.
This is a virus that for the majority of people is not causing serious nor indeed any illness. The vast majority of people, including older people, who get sick will survive. It can be serious when it does cause illness and it can kill like any other infective agent of consequence.
This is a tough reality and one I have witnessed up close and seen the resultant grief of though, thankfully, have not had to endure personally.
What is reported, however, as ‘cases’ nightly on press briefings are not illnesses in the vast majority but rather positive swab tests. The recent rise in the number of such ‘cases’ has not produced a real rise in hospital cases to any degree that is noticeable thus far.
We are not swamped, overwhelmed or particularly alarmed as of yet on the hospital frontline. We could perhaps push ahead with opening up a bit more. No one wants to return to the levels of Covid-19 we have had but equally, no one wants a longer than necessary legacy on the broader health and life of our society.
A weakened virus?
This is of course but one perspective and may not be the right one but it is one that must be included in discussions. Public health doctors, on the other hand, are justifiably concerned as the rise in positive swabs when mathematically modelled suggests there will be a surge in true illnesses and perhaps an unacceptable level of death.
This assumes the virus is as virulent as it was; we haven’t identified and can’t protect those at greatest risk and we would be unable to identify and control cluster outbreaks in a more opened society, and that is another important perspective. We do need more perspectives in getting the balance right.
For example, if every principle of infection control was rigidly interpreted and followed to the ‘letter of the law’ in our hospitals we might have reduced rates of carriage of resistant bacteria. But equally, it might reduce efficiency, timely treatment and more people might actually be harmed.
Infection control is one of the core considerations in our deliberations in hospital care but it is not the only one when balancing the best outcomes in individual cases and the common good.
There is a real feeling now among the frontline in hospitals and other sectors that NPHET is in danger of ‘losing the dressing room’, that ‘fed-uppism’ is gaining the upper hand and is being fuelled and encouraged by paternalistic and ‘talking down to’ tones.
This is where a danger lies and overly suppressing society runs the risk in my opinion, of losing us the goodwill and co-operation we have enjoyed until now for simple effective measures like handwashing, respiratory etiquette and the wearing of masks in crowded areas.
There needs to be more balance and consideration of what the aftermath looks like if we continue down a more conservative road of societal restrictions. Has Sweden’s more open approach resulted in more deaths? Yes, but not overly so. Will it emerge less damaged as a society from their more open approach? Probably.
There has been sadly and there will be more deaths from this virus. That is hard to accept for a society that has become used to living without the serious threat of infection not to mention pandemic, lost its inherent skillset to cope during such crises and has become resistant to the idea of one’s mortality.
Someone once wrote ‘when I lived in Glasgow death was certain, when I lived in California it became a possibility ‘. I am perhaps more aware than many of our mortality – being a geriatrician – and many of my ‘wise-from-living’ older Covid-19 patients asked of their clinical progress in realistic terms, and with an understanding of the flow of life – as if they wondered would they make it through the rain without getting drenched altogether.
Much of what Atul Gawande led as a discourse with medicine and society at large, in his book “Being Mortal” is what geriatricians practice as core skills, striving to ‘add years to life’ but also to ‘add life to years’.
Over 30% of a person’s lifelong medical care costs in the US may be spent in the last months of life, a shocking statistic of what is in many cases, medical futility.
It is not a tragedy that we die, it is part of life. It is a tragedy if we die unnecessarily or too early of course, but in pandemic situations, there must be that generous understanding of our human state and a level of risk in the greater scheme of society and life and that we protect those most vulnerable but that we also do not destroy our society and cause even greater death and misery by our responses.
Myself and my healthcare colleagues of all suites are not soldiers, we did not sign up to be at imminent risk of death in our hospital jobs. But that is a possibility in a pandemic that we accept now, just as it was with the threatened Ebola pandemic a few years back.
Allied soldiers marching off in the second world war accepted the good of society over their personal safety. A degree of that ‘stiff upper lip’ will also be needed by us all to allow our society to responsibly open more and function.
This is vital for our children’s development and education, the employment of our people, the survival of our businesses and communities, the wellbeing of our mental health and the enjoyment and fulfilment of our lives.
If this doesn’t happen, the equipoise of life is lost to the dark side and what we have worked for and endured thus far will have been in vain.
As an older patient remarked to me ‘I’m not sure this is a life I want to live without family celebrations, community occasions, sporting highs’. There is dangerous truth in this.
Professor Rónán Collins MD FRCP (Lond) FRCPI FESO is a Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital. Follow him @ronancollins7.
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