I finally finished a book in 2021! And it’s one with undeniable ongoing relevance. The subtitle is “A GP, a Community & COVID-19.” Francis, a physician who is based at an Edinburgh practice and frequently travels to the Orkney Islands for healthcare work, reflects on what he calls “the most intense months I have known in my twenty-year career.” He draws all of his chapter epigraphs from Daniel Defoe’s A Journal of the Plague Year and journeys back through most of 2020, from the day in January when he and his colleagues received a bulletin about a “novel Wuhan coronavirus” to November, when he was finalizing the book and learned of promising vaccine trials but also a rumored third wave and winter lockdown.
In February, no one knew whether precautions would end up being an overreaction, so Francis continued normal life: attending a conference, traveling to New York City, and going to a concert, pub, and restaurant. By March he was seeing more and more suspected cases, but symptoms were variable and the criteria for getting tested and quarantining changed all the time. The UK at least seemed better off than Italy, where his in-laws were isolating. Initially it was like flu outbreaks he’d dealt with before, with the main differences being a shift to telephone consultations and the “Great Faff” of donning full PPE for home visits and trips to care homes. The new “digital first” model left him feeling detached from his patients. He had his own Covid scare in May, but a test was negative and the 48-hour bug passed.
Through his involvement in the community, Francis saw the many ways in which coronavirus was affecting different groups of people. He laments the return of mental health crises that had been under control until lockdown. Edinburgh’s homeless, many in a perilous immigration situation thanks to Brexit, were housed in vacant luxury hotels. He visited several makeshift hostels, where some residents were going through drug withdrawal, and also met longtime patients whose self-harm and suicidal ideation were worsening.
Children and the elderly were also suffering. In June, he co-authored a letter begging the Scottish education secretary to allow children to return to school. Perhaps the image that will stick with me most, though, is of the confused dementia patients he met at care homes: “there was a crushing atmosphere of sadness among the residents … [they were] not able to understand why their families no longer came to visit. How do you explain social distancing to someone who doesn’t remember where they are, sometimes even who they are?”
Francis incorporates brief histories of vaccination and the discovery of herd immunity, and visits a hospital where a vaccine trial is underway. I learned some things about COVID-19 specifically: it can be called a “viral pneumonia”; it has two phases, virological (the virus makes you unwell) and immunological (the immune system misdirects messages and the lungs get worse); and it affects the blood vessels as well as the lungs, with one in five presenting with a rash and some developing chilblains in the summer. Amazingly, as the year waned, Francis only knew three patients who had died of Covid, with many more recovered. But in August, a city that should have been bustling with festival tourists was nearly empty.
Necessarily, the book ends in the middle of things; Francis has clear eyes but a hopeful heart. While this is not the first COVID-19 book I’ve encountered (that was Duty of Care by Dominic Pimenta) and will be far from the last – next up for me will be Rachel Clarke’s Breathtaking, out at the end of this month – it is an absorbing first-hand account of a medical crisis as well as a valuable memorial of a time like no other in recent history. A favorite line was “One of the few consolations of this pandemic is its grim camaraderie, a new fellowship among the fear.” Another consolation for me is reading books by medical professionals who can compassionately bridge the gap between expert opinion and everyday experience.
Intensive Care was published by the Wellcome Collection/Profile Books on January 7th. My thanks to the publisher for the free copy for review.
Gavin Francis’s other work includes:
Previously reviewed: Shapeshifters
Also owned: Adventures in Human Being
I’m keen to read: Empire Antarctica, about being the medical officer at the British research centre in Antarctica – ironically, this was during the first SARS pandemic. (In July 2020, conducting medical examinations on the next batch of scientists to ship out there, he envied them the chance to escape: “By the time they came home it would be 2022. Surely we’d have the virus under control by then?”)
The Being/Becoming/Asking the Expert week of the month-long Nonfiction November challenge is hosted by Rennie of What’s Nonfiction. This is my second entry for the week after Monday’s post on postpartum depression, as well as the second installment in my new “Three on a Theme” series, where I review three books that have something significant in common and tell you which one to pick up if you want to read into the topic for yourself.
It will be no surprise to regular readers that both of my ‘expert’ posts have been on a health theme: I have an amateur’s love of medical memoirs and works of medical history, and I’ve followed the Wellcome Book Prize closely for a number of years – participating in official blog tours, creating a shadow panel, and running this past year’s Not the Wellcome Prize.
The three books below are linked by the word “Care” in the title or subtitle; all reflect, in the wake of COVID-19, on the ongoing crisis in UK healthcare and the vital role of nurses.
Labours of Love: The Crisis of Care by Madeleine Bunting
Bunting’s previous nonfiction work could hardly be more different: Love of Country was a travel memoir about the Scottish Hebrides. It was the first book I finished reading in 2017, and there could have been no better start to a year’s reading. With a background in history, journalism and politics, the author is well placed to comment on current events. Labours of Love arose from five years of travel to healthcare settings across the UK: care homes for the elderly and disabled, hospitals, local doctors’ surgeries, and palliative care units. Forget the Thursday-night clapping and rainbows in the windows: the NHS is perennially underfunded and its staff undervalued, by conservative governments as well as by people who rely on it.
We first experience bodily care as infants, Bunting notes, and many of the questions that run through her book originated in her early days of motherhood. Despite all the advances of feminism, parental duties follow the female-dominated pattern evident in the caring careers:
By the age of fifty-nine, women will have a fifty-fifty chance of being, or having been, a carer for a sick or elderly person. At the same time, many are still raising their teenage children and almost half of those over fifty-five are providing regular care for grandchildren.
Women dominate caring professions such as nursing (89 per cent), social work (75 per cent) and childcare (98 per cent). They now form the majority of GPs (54 per cent) and three out of four teachers are female. And they provide the vast bulk of the army of healthcare workers in the NHS (80 per cent) and social-care workers (82 per cent) for the long-term sick, disabled and frail elderly.
These are things we know intuitively, but seeing the numbers laid out so plainly is shocking. I most valued the general information in Bunting’s introduction and in between her interviews, while I found that the bulk of the book alternated between dry statistics and page after page of interview transcripts. However, I did love hearing more from Marion Coutts, the author of the 2015 Wellcome Book Prize winner, The Iceberg, about her husband’s death from brain cancer. (Labours of Love was longlisted for the Baillie Gifford Prize for Non-Fiction 2020.)
My thanks to Granta for the free copy for review.
Duty of Care: One NHS Doctor’s Story of Courage and Compassion on the COVID-19 Frontline by Dr Dominic Pimenta
We’re going to see a flood of such books; I’m most looking forward to Dr Rachel Clarke’s Breathtaking (coming in January). Given how long it takes to get a book from manuscript to published product, I was impressed to find this on my library’s Bestsellers shelf in October. Pimenta’s was an early voice warning of the scale of the crisis and the government’s lack of preparation. He focuses on a narrow window of time, from February – when he encountered his first apparent case of coronavirus – to May, when, in protest at a government official flouting lockdown (readers outside the UK might not be familiar with the Cummings affair), he resigned his cardiology job at a London hospital to focus on his new charity, HEROES, which supports healthcare workers via PPE, childcare grants, mental health help and so on.
It felt uncanny to be watching events from earlier in the year unfold again: so clearly on a trajectory to disaster, but still gripping in the telling. Pimenta’s recreated dialogue and scenes are excellent. He gives a real sense of the challenges in his personal and professional lives. But I think I’d like a little more distance before I read this in entirety. Just from my skim, I know that it’s a very fluid book that reads almost like a thriller, and it ends with a sober but sensible statement of the situation we face. (All royalties from the book go to HEROES.)
The Courage to Care: A Call for Compassion by Christie Watson
I worried this would be a dull work of polemic; perhaps the title, though stirring, is inapt, as the book is actually a straightforward sequel to Watson’s 2018 memoir about being a nurse, The Language of Kindness. Although, like Bunting, Watson traveled widely to research the state of care in the country, she mostly relies on her own experience of various nursing settings over two decades: a pediatric intensive care unit, home healthcare for the elderly, a children’s oncology day center, a residential home for those with severe physical and learning disabilities, a community mental-health visiting team, and the emergency room. She also shadows military nurses and prison doctors.
With a novelist’s talent for scene-setting and characterization, Watson weaves each patient and incident into a vibrant story. Another strand is about parenthood: giving birth to her daughter and the process of adopting her son – both are now teenagers she raises as a single mother. She affirms the value of everyday care delivered by parents and nurses alike. I was especially struck by the account of a teenage girl who contracted measles (then pneumonia, meningitis and encephalitis) and was left blind and profoundly disabled, all because her parents were antivaxxers. In general, I’ve wearied of doctors’ memoirs composed of obviously anonymized case studies, but I’ll always make an exception for Clarke and Watson because of their gorgeous writing.
Note: Watson had left nursing to write full-time, but explains in an afterword that she returned to critical care in a London hospital during COVID-19.
What I learned:
Empathy is a key term for all three authors. They emphasize that the skills of compassion and listening are just as important as the ability to perform the required medical procedures.
A chilling specific fact I learned: 43,000 people died in the Blitz* in the UK. Pimenta cited that figure and warned that COVID-19 could be worse. And indeed, as of now, over 63,000 people have died of COVID-19 in the UK. The American death toll is even more alarming.
Here are some passages that stood out for me from each book:
Bunting: “Good care is as much an art as a skill, as much competence as tact. … Care is where we make profound collective decisions about the worth of an individual life. … There is no tradition of ageing wisely in the West, unlike in many Asian and African cultures where age has prestige, status and is associated with wisdom … We need to speak about care in a different language, instead of the relentless macho repetition of words such as ‘efficiency’, ‘quality’, ‘driving’, ‘choice’, ‘delivery’ and productivity.’”
Pimenta: “this will be akin to the Blitz*, and … we need to start thinking of it like that. A marathon, not a sprint. … The challenges to come – a second or even third wave, a global recession, climate change, mass misinformation … and political and societal upheaval … – will all require more from all of us if we hope to meet them. The challenge of our generation is not behind us, it is only just beginning. I plan to continue doing something about it, and perhaps now you do as well. So stay informed, stay safe and be kind.”
Watson: “So much of nursing, I think to myself, seems obvious, and yet seeing that need in the first place is difficult and takes experience, training and something extra. … The mundanity of human existence is where I find the most beauty … It takes my breath away: how fragile, extraordinary and vulnerable, how full of hatred and love and obsession and complexity we all are – every single one of us.”
*I highly recommend all of folk artist Kris Drever’s latest album, Where the World Is Thin, but especially the song “Hunker Down / That Old Blitz Spirit,” which has become my lockdown anthem.
If you read just one, though… Make it The Courage to Care by Christie Watson.
Can you see yourself reading any of these books?
Five of the six shortlisted authors (barring Dublin-based Mark O’Connell) were at the Wellcome Collection in London yesterday to share more about their books in mini-interviews with Lisa O’Kelly, the associate editor of the Observer. She called each author up onto the stage in turn for a five-minute chat about her work, and then brought them all up for a general conversation and audience questions. Clare and I found it a very interesting afternoon. Here’s some context that I gleaned about the five books and their writers.
Ayobami Adebayo says sickle cell anemia is a massive public health problem in Nigeria, as brought home to her when some friends died of complications of sickle cell. She herself was tested for the gene and learned that she is a carrier, so her children would have a 25% chance of having the disease if her partner was also a carrier. Although life expectancy with the disease has improved to 45–50, a cure is still out of reach for most Nigerians because bone marrow/stem cell transplantation and anti-rejection drugs are so expensive. Compared to the 1980s, when her book opens, she believes polygamy is becoming less fashionable in Nigeria and people are becoming more open to other means of becoming parents, whether IVF or adoption. It’s a way of acknowledging, she says, that parenthood is “not just about biology.”
Sigrid Rausing started writing her book soon after her sister-in-law Eva’s body was found: just random paragraphs to make sense of what had happened. From there it became an investigation, a quest to find the nature of addiction. She thinks that as a society we still don’t quite understand what addiction is, and the medical research and public perception are very separate. In addition to nature and nurture, she thinks we should consider the influence of culture – as an anthropologist by training, she’s very interested in drug culture and how that drew in her brother, Hans. Although there have been many memoirs by ex-addicts, she can’t think of another one by a family member. Perhaps, she suggested, this is because the addict is seen as the ultimate victim. She referred to her book as a “collage,” a very apt description.
Kathryn Mannix spoke of how her grandmother, born in 1900, saw so much more death than we do nowadays: siblings, a child, and so on. Today, though, Mannix has encountered people in their sixties who are facing, with their parents, their very first deaths. Death is fairly “gentle” and “dull” if you’re not directly involved, she insists; she blames Hollywood and Eastenders for showing unusually dramatic deaths. She said once you understand what exactly people are afraid of about dying (e.g. hell, oblivion, pain, leaving their families behind) you can address their specific concerns and thereby “beat out the demon of terror and fear.” Mannix never intended to write a book, but someone heard her on the radio and invited her to do so. Luckily, from her medical school days onward, she’d been writing an A4 page about each of her most mind-boggling cases to get them out of her head and move on. That’s why, as O’Kelly put it, the characters in her 30 stories “leap off the page.”
Lindsey Fitzharris called The Butchering Art “a love story between science and medicine” – it was the first time that the former (antisepsis) was applied to the latter. She initially thought Robert Liston was her man – he was so colorful, larger than life – but eventually found that the real story was with Joseph Lister, the quiet, persistent Quaker. (However, the book does open with Liston performing the first surgery under ether.) Fitzharris is also involved in the Order of the Good Death, author Caitlin Doughty’s initiative, and affirmed Mannix’s efforts to remove the taboo from talking about death. I think I heard correctly that she said there is a film of The Butchering Art in the works?! I’ll need to look into that some more.
Meredith Wadman started with a brief explanation of how immunization works and why the 1960s were ripe for vaccine research. This segment went really science-y, which I thought was a little unfortunate as it may have made listeners tune out and be less interested in her work than the others’. It was perhaps inevitable given her subject matter, but also a matter of the questions O’Kelly asked – with the others she focused more on stories and themes than on scientific facts. It was interesting to hear what Wadman has been working on recently: for the past 6–8 months, she’s been reporting for Science on sexual harassment in science. For her next book, though, she’s pondering the conflict between a congressman and a Centers for Disease Control scientist over funding into research that might lead to gun control.
The question time brought up the issues of medical misinformation online, the distrust people with chronic illnesses have of medical professionals, and euthanasia – Mannix rather dodged that one, stating that her book is about the natural dying process so that’s not really her area. (Though it does come up in a chapter of her book.) We also heard a bit about the projects up next for each author. Rausing’s next book will be a travel memoir about the Capetown drought, taking in apartheid and her husband’s family’s immigration. Adebayo is at work on a very nebulous novel “about people,” and possibly how privilege affects access to healthcare.
Addiction, death, infertility, surgery, transhumanism and vaccines: It’s been quite the varied reading list for the five of us this spring! Lots of science, lots of medicine, but also a lot of stories and imagination.
After some conferring and voting, we have arrived at our shadow panel winner for the Wellcome Book Prize 2018: To Be a Machine by Mark O’Connell.
Rarely have I been so surprised to love a book. It’s a delight to read, and no matter what your background or beliefs are, it will give you plenty to think about. It goes deep down, beneath our health and ultimately our mortality, to ask what the essence of being human is.
Here’s what the rest of the shadow panel has to say about our pick:
Annabel: “O’Connell, as a journalist and outsider in the surprisingly diverse field of transhumanism, treats everyone with respect: asking the questions, but not judging, to get to the heart of the transhumanists’ beliefs. For a subject based in technology, To Be a Machine is a profoundly human story.”
Clare: “The concept of transhumanism may not be widely known or understood yet, but O’Connell’s engaging and fascinating book explains the significance of the movement and its possible implications both in the distant future and how we live now.”
Laura: “My brain feels like it’s been wired slightly differently since reading To Be a Machine. It’s not just about weird science and weird scientists, but how we come to terms with the fact that even the luckiest of us live lives that are so brief.”
Paul: “An interesting book that hopefully will provoke further discussion as we embrace technology and it envelops us.”
On Monday we’ll find out which book the official judges have chosen. I could see three or four of these as potential winners, so it’s very hard to say who will take home the £30,000.
Who are you rooting for?
I had hoped this would be a comparable read to Rebecca Skloot’s The Immortal Life of Henrietta Lacks and Siddhartha Mukherjee’s The Emperor of All Maladies, which are two of my absolute favorite books and were also among the first to turn me on to medical-themed literature. Instead, I found myself skimming through the book’s dense scientific and historical information: like Mukherjee’s other book, The Gene, which made last year’s Wellcome shortlist, The Vaccine Race is overstuffed with a mixture of the familiar (for me, at least – genetics), the seemingly irrelevant (cell culture techniques and scientific nomenclature), and the truly interesting (questions of medical ethics).
The unlikely protagonist of this story is Leonard Hayflick, a single-minded and resourceful researcher who is still alive in his late eighties and assented to dozens of interviews and many more e-mails as Wadman put this book together. While in high school Hayflick made a chemistry lab in his basement, and in college he built his father a dental lab: that tells you how driven he was. After graduating from the University of Pennsylvania, he worked at the Wistar Institute on its campus. He chiefly investigated whether viruses cause cancer and whether a cell line will be immortal or subject to the normal rules of aging – the Hayflick limit, named after him, is the number of cell divisions possible before a cell line dies out.
Hayflick experimented on his third child’s placenta, but also on aborted fetuses from the university hospital. Replacement fetal cell lines sourced from the Karolinska Institute in Stockholm, Sweden were used to produce the polio, rubella and rabies vaccines. In particular, he relied on the WI-38 line he developed from fetal cells taken from the Swedish “Mrs. X,” who – like Henrietta Lacks’s family – was never compensated; she did not want to be interviewed for or mentioned by name in this book. In the 1970s, with Roe v. Wade in the pipeline, the controversy over using aborted fetal tissue in research heated up*, and Hayflick was somewhat disgraced in the course of a 1976 lawsuit about his right to profit from WI-38.
But that’s not the only dubious ethical situation associated with the development of the twentieth century’s major vaccines: Hayflick’s bosses and associates had also tested early vaccines on intellectually disabled child “volunteers,” while a celebrated cancer researcher had injected cells into dying hospital patients and healthy prisoners in the name of science. Wadman writes, “by the mid-1960s, ordinary people were becoming less willing to give scientists carte blanche to tinker with human beings on a ‘Trust me, I know what’s best for you’ basis.” The question is whether these morally suspect strategies were worth it, given the alternative: rubella in pregnancy causes severe birth defects including blindness, while polio can be crippling and untreated rabies can lead to a slow and painful death.
These ethical questions are certainly worth thinking about, though the abortion history in particular is probably of much more interest to American readers. Here in Europe, abortion is a non-issue, so I don’t expect anyone to get fired up about the history of fetal tissue research. Wadman is certainly a thorough researcher and capable storyteller who doesn’t talk down when explaining science. That said, she might have scaled back on the science a bit to ensure that her work holds broader appeal for lay readers of popular science and medical history.
*More recently, Debi Vinnedge’s Children of God for Life nonprofit has opposed stem cell research despite a Vatican ruling that vaccines developed from fetal tissue are acceptable to use as long as there is no alternative.
See what the rest of the shadow panel has to say about this book:
Annabel’s blog tour review: “The thrillerish feel to big pharma’s politics, and Hayflick’s continual battles for recognition and against anyone who wanted to take his cells away from him made for fascinating reading and added the much-needed human aspect.”
Clare’s review: “The Vaccine Race is a very dense read and some of the lengthier descriptions of things like the finer points of the biotechnology industry went a bit over my head in places. … However, the ethical debates are fascinating and clearly presented.”
Laura’s review: “Wadman writes clearly and compellingly, and given how much material she’s handling, managing to structure the book sensibly is a feat in itself. But I felt that The Vaccine Race was often not one thing or the other.”
Paul’s review: “It is a very important story that Wadman is telling … especially given that we may well be on the dawn of a new era in medicine with the rise of immunity against antibiotics.”
(Also, be sure to stop by Paul’s site today for an exclusive extract from The Vaccine Race as part of the ongoing blog tour.)
My gut feeling: This is the most science-y of the six books on the shortlist. For me that actually works against the broadness and public-facing nature of the prize, as expressed in its brief: “At some point, medicine touches all our lives. Books that find stories in those brushes with medicine are ones that add new meaning to what it means to be human. The subjects these books grapple with might include birth and beginnings, illness and loss, pain, memory, and identity. In keeping with its vision and goals, the Wellcome Book Prize aims to excite public interest and encourage debate around these topics.”
- Tomorrow I’ll quickly recap my thoughts about the two shortlisted books I read before the shortlist announcement, With the End in Mind and The Butchering Art.
- On Saturday morning I’ll announce our shadow panel winner. That day Clare and I are attending an event featuring five of the shortlisted authors in conversation at the Wellcome Collection in London. I’ll report back about it on Sunday.
- Monday is the awards ceremony, which I’ll be attending for the second year in a row. Expect my write-up of the experience on Tuesday. (In between you get a break from Wellcome Prize stuff with Library Checkout plus some recommendations for May!)
Tomorrow the six titles on the Wellcome Book Prize shortlist will be revealed. I’ve managed to read one more from the longlist since my last batch.
The Butchering Art: Joseph Lister’s Quest to Transform the Grisly World of Victorian Medicine by Lindsey Fitzharris
Surgery was a gory business with a notably high fatality rate well into the nineteenth century. Surgeons had the fastest hands in the West, but their victims were still guaranteed at least a few minutes of utter agony as they had a limb amputated or a tumor removed, and the danger wasn’t over after they were sewn up either: most patients soon died from hospital infections. The development of anesthetics and antiseptic techniques helped to change all that.
Fitzharris opens with the vivid and rather gruesome scene of a mid-thigh amputation performed by Robert Liston at University College Hospital in London in 1846. This surgery was different, though: it only took 28 seconds, but the patient felt nothing thanks to the ether he had been administered. He woke up a few minutes later asking when the procedure would begin. In the audience that day was Joseph Lister, who would become one of Britain’s most admired surgeons.
Lister came from a Quaker family and, after being educated at University College London, started his career in Edinburgh. Different to many medical professionals of the time, he was fascinated by microscopy and determined to find out what caused deadly infections. Carbolic acid and catgut ligatures were two of Lister’s main innovations that helped to fight infection. In fact, whether we realize it or not, his legacy is forever associated with antiseptics: Listerine mouthwash (invented in 1879) is named after him, and the Johnson brothers of Johnson & Johnson fame started their business mass-producing sterile surgical dressings after attending one of Lister’s lectures.
My interest tailed off a bit after the first third, as the book starts going into more depth about Lister’s work and personal life: he married his boss’s daughter and moved from Edinburgh to Glasgow and then back to London. However, the best is yet to come: the accounts of the surgeries he performed on his sister (a mastectomy that bought her three more years of life) and Queen Victoria (removing an orange-sized abscess from under her arm) are terrific. The chapter on treating the queen in secret at Balmoral Castle in 1871 was my overall favorite.
I was that kid who loved going to Civil War battlefields and medical museums and looking at all the different surgical saws and bullet fragments in museum cases, so I reveled in the gory details here but was not as interested in the biographical material. Do be sure you have a strong stomach before you try reading the prologue over a meal. This is a comparable read to The Remedy, about the search for a cure to tuberculosis.
Now, I’ve still only read half of the longlisted titles so far, so it’s hard to make any solid guesses. However, the below fall somewhere between wishes and informed predictions:
- In Pursuit of Memory by Joseph Jebelli: A definitive treatment of an epidemic of our time, Alzheimer’s disease. The neuroscientist author achieves the right balance between history and research on the one hand and personal stories readers can relate to on the other.
- The White Book by Han Kang: The only fiction title from the longlist that I haven’t read at least part of. This is also on this year’s Man Booker International Prize longlist and has been well received. From what I can tell, the health theme seems stronger than that of Stay with Me or Midwinter Break, and it would also be nice for one title in translation to make the shortlist.
- With the End in Mind by Kathryn Mannix: As I said in my review last week, this is an excellent all-round guide to preparation for death, based around touching patient stories plus the author’s experience in palliative care and CBT. Practical, compassionate and helpful.
- I Am, I Am, I Am by Maggie O’Farrell: For me, this book stands out as the one that most clearly illuminates the effects of illness, medical treatment, and other threats to life and limb in the course of an ordinary existence. I’d be very happy to see it win the whole thing.
- EITHER The Butchering Art by Lindsey Fitzharris OR The Vaccine Race by Meredith Wadman: I reckon one history of science title deserves to be on there; I think Wadman might have the slight edge.
- EITHER To Be a Machine by Mark O’Connell OR Behave by Robert Sapolsky: The Wellcome Prize loves big books investigating human tendencies and possibilities. I find the thought of either of these daunting, but I know they would also be illuminating. I’d prefer to read the O’Connell, but I’d give the edge to Sapolsky.