Today’s rhetoric around heroism signifies the failure of prevention and neglect of the public health, argues Guddi Singh, a paediatric doctor and PhD candidate in philosophy at King’s College London.

I. Apocalypse

The ancient Greeks knew a thing or two when it came to human tragedy. Myths and morality tales were spun to help mortals know their place in the web of life and death, strung between cosmos and apocalypse. We use that word – apocalypse – a lot these days, but in the original Greek, it didn’t mean the catastrophe, but the uncovering.

The current catastrophe of the global coronavirus pandemic – monstrous in impact and yet microscopic in shape and size – is uncovering a lot of things. For one, it is uncovering our physical frailty, how precariously we tightrope between health and illness. Blood pressures and heart rates tick in time with the mercurial rise in disease prevalence. It outpaces even our fastest news feeds: as of May 4th, 248,445 people have died so far from the coronavirus COVID-19 outbreak, with 3,579,307 confirmed cases in 210 countries and territories. Even if you can set aside the horror and anguish of each one of those losses, reflect on how the monster has touched so many more by the fear it has struck in our hearts and the shadow it has cast on our lives. With lockdown locked down with no clear end in sight, we live cloistered lives, sirens and birdsong the soundtrack to our days.

As a frontline NHS doctor exploring public health through philosophy, I find myself at odds: mired in the thick of it and yet intellectually intrigued. Coronavirus grants lightning insights about our world, crystalizing in days what might otherwise take months or years to demonstrate. The scientist in me is finding it hard to be dispassionate in the face of this tragedy.

For this monster is unsettling; every new day of the pandemic brings a dizzying amount of change. Remote working, social distancing, economic recession. And in so doing it is also uncovering the flaws in the web of our relationships with each other. The inequality deeply embedded in our landscape guarantees that coronavirus will hit some communities much harder than others; this monster not only exposes, but widens the gulf in brutal fashion. The virus’ mode of infection may not discriminate, but the country’s policies do.  The monster then, like everything else, is deeply political. Prosperous places in the south-east of the country, filled as they are by white-collar workers, contain those whose livelihoods have barely been touched. The most flexible workers tend to be higher earners. Welcome to the new class-divide: the ‘video-conferencers’ and the rest of us. In embracing home-working (often in second homes removed from outbreak hotspots) the affluent are not invincible, but they are insulated from the worst harms of COVID-19 – all while advertising their virtue through social media in combining emails, yoga and home schooling in the Cotswolds.

Even if they can stay at home, lower income families are more likely to be packed together in a small space, helping spread the disease. Ethnic minorities are also more likely to live in crowded houses. “Vulnerable populations,” are much more likely to have chronic conditions like asthma, hypertension and diabetes—all of which place them at higher risk for COVID-19. But they’re also less likely to have access to medical care when they do get sick, take time off or receive paid sick leave. Double-edged, the very measures that are meant to protect, harm some of us in other ways. Lockdown orders crucial for mitigating the spread of the virus can be dangerous for people who have lead in their homes, live in polluted areas or don’t have adequate heating or cooling during extreme weather. And what about the social fallout?  Women enclosed with abusive partners, vulnerable children unseen by social care now that schools are closed.  The hidden casualties of coronavirus are not yet displayed on an infographic, but their distribution will tell a tale that those of us in public health have long known.

The UK is the 5th richest country in the world.  And yet almost 2 million people in the UK were already undernourished before coronavirus hit, with one in five under-15s living with an adult experiencing food insecurity after a decade of austerity. Hunger, much like insecure housing or domestic abuse, is not a new phenomenon. The majority of the detrimental social effects of the virus are distributed along already existing fault lines. The legacy of disinvestment in social services and housing and structural racism – the signs and symptoms of a much deeper disease – have been mapped in bodies for decades.  It’s just that the nature of this crisis has made the ways that certain people fall through the cracks in how we have structured our society – and our complicity with it – unbearable.

II. Heroes

When things become unbearable, we turn to heroes. But heroism implies willing; that the gauntlet thrown down has been met with eyes wide open. But not everyone in the path of the current danger consented to such status.

Battalions of poorly paid and insecure delivery people, who have no choice but to brave their work, service the needs and whims of the video-conferencers. In a fast-moving world where headlines are fugitive in nature, the death of five Transport for London bus drivers in early April barely registered. Inured by talk of peaks and plateaus, and curves that must be flattened, did anyone stop to ask who they were and if they were taken care of? For decades it has been said that those who care for the vulnerable are overlooked and underpaid. Of the one million people working in the care system, a disproportionate number are women and from ethnic minorities. Mirroring society at large, they don’t get security in exchange for low pay; instead they are four times more likely to be on a zero-hours contract than the rest of us. Precarity begets stress, which in turn is strongly correlated with worse health outcomes across the board. Poor people’s bodies encode the evidence of a society structured unfairly.

The heroes of Greek mythology went on quests to defeat monsters. In the NHS, our heroes are masked warriors battling a monster that is at once everywhere and yet invisible. Social order – replicated in the old hierarchies of medicine – dies hard. Removed as they are from frontline reality, managers and medical leaders rally and redeploy. Those left on the ground – everything from nurses and doctors like me, to the unseen but essential administrators, cleaners and porters – have nowhere to hide. Our work and the danger are one. Our swords and shields are inadequate to the foe – if we have them at all. The pathos of UK health workers begging fellow citizens for masks, gowns and gloves in order to face down the miniscule monster is remarkable in nation boastful of its wealth. What chance do my colleagues in poorer countries have?

I am not immune, of course. Perhaps cowardly to admit, I am terrified. Sick with worry – for myself, loved ones, and all yet to suffer – I enter the hospital head down and stony faced. Yet every Thursday evening my heart and eyes swell as the applause from a new national tradition reaches my ears. To feel the love, gratitude and sympathies of my neighbours – clapping hands and clattering pots, entire council estates near us shouting and waving flags, strangers’ voices mingling in the dusk – I am undone.  They applaud because they can’t keep me safe, and I weep because I am a hero who cannot save them.

Today’s rhetoric around heroism signifies the failure of prevention and neglect of the public health. The Greek legends resonate across millennia because heroes are flawed characters in whom we can see ourselves. Today’s heroes are literally ourselves – NHS and other key workers like me. But we should not have to be heroes.  “In a situation that’s well planned for, you don’t need heroes,” says Dr Chris Subbe, an intensive care consultant in the NHS, “you only need heroes if you haven’t prepared.” By refusing to acknowledge the importance of the social determinants of health and by defunding the institutions that protect and ameliorate them, the real monster has been our nation’s shift from a belief in health in the collective to one where health lies in the individual. In this time of crisis and ‘national unity’, it’s easy to forget that the now much hailed NHS has quietly but savagely been attacked by a turn to neoliberalism over the last three decades. Eviscerated and on its knees, the NHS is a warrior asked to battle on regardless.

The Achilles heel of healthcare in the UK is that we live in an individualistic culture that valorises heroes. Individualism has resulted in a healthcare system that never really addressed the true ‘causes of the causes’ of ill health in the first place. By focusing on acute care and the needs of individual patients, rather than on the health of the whole, the NHS was never going to live up to hopes of being ‘the great equaliser’. Instead, the Anglo-American imaginary peoples its healthcare systems with bold, rugged individuals, preferably maverick doctor-types. Meanwhile the unobtrusive, unassuming, constant efforts of community workers and those working on health promotion have been ignored, underfunded and discarded.

The real monsters in this tale, then, are men and women: the people who are leading us all into the abyss, and us for letting them get away with it. While clapping, discounts and rainbows in windows for NHS staff might be genuine in the hands of the public, they can hardly be deemed an adequate response to political problems in the hands of those in power.  They remain what they are – perfunctory tokens. It suits some to gaslight a nation by conjuring heroes from those who have no choice but to step into the breech. But empty gestures are no substitute for valuing the public’s health and for providing sufficient and justly distributed funding and resources to meaningfully tackle social inequalities. By rescuing us, heroes exonerate the state from their responsibilities to protect and prevent avoidable illness and death in the population, to create the societal conditions in which health can thrive, and to ensure safe working conditions for its workers to operate in.

What we are seeing now writ large through coronavirus is merely a continuation of business as usual. Chronic underfunding and undermining of public health and support systems in the UK has led to some of the widest health inequalities and worst health outcomes in Europe. The narrative of austerity told us that there was not enough to go around, and that we had to tighten our belts: cuts to welfare, housing and health rained down – all while continuing to pay tribute to institutions of privilege such as the monarchy and House of Lords, which cost the tax payer about £82 and £68million a year respectively. Besides, we can always depend on health professionals to pick up the pieces can’t we? And so, year after year, the NHS bears the brunt of our economic and political system’s ills. The NHS has been making up for society’s neglect for decades, with health workers labouring longer, harder and becoming more emotionally burnt out in order for children, families and pensioners in a country steeped in riches not to suffer the full consequences of deepening deprivation.

It’s hard not to typecast our leaders as cold-hearted captains of our fates when their callous disregard for life is rendered so blatant in their utterances. In relation to COVID-19, we’ve been told to “take it on the chin” and that “if that means some pensioners die, too bad”.  Time will reveal the true toll of such attitudes.  Heroes loom large in a society where those who ought to be leading wisely have utterly foundered, and instead of admitting their mistakes and being accountable, hide behind tales of war and glory. Keep calm and Clap on. And hope that heroism on the ground disguises and distracts from cowardice in our generals.

True heroes, as ever, go unsung. Neighbours dropping food packages to those worse off; families converting their homes into miniature factories for personal protective equipment for frontline workers; taxi drivers ferrying patients to hospitals for free – all examples of mutual aid that have sprung from barren soil to fill the gaps of our society.  For every monster there needs to be the men – and women, oh so many women – who can vanquish it. While exposing rents in the fabric of our cosmos, coronavirus is also uncovering kindness and generosity, renewed connection and camaraderie. Evident in the everyday, heroic acts in otherwise ordinary people.

III.    Metamorphosis

Taking stock of all the evidence is overwhelming.  Our world, made up as it is of monsters and men, is shaped and structured to cause pain and suffering to many of us, while a lucky few watch from the shelter of the wings. Coronavirus merely clarifies what we have always known. Injustice is baked into capitalism, and the problems facing historically marginalised and disenfranchised communities are so layered, that the weight of processing it all takes our breath away. At various moments in the unfolding of this pandemic, we have collectively experienced what the protagonist in Kafka’s “Metamorphosis” does on waking. The world is very different to when we went to bed, and what awaits feels simply ghastly. Coronavirus is our Greek tragedy. It has raised questions about human existence. Why must humans suffer? Why is justice so elusive?

As Zeus observes in Homer’s “Odyssey,” “Humans are always blaming the gods for their suffering / but they experience pain beyond their fate because of their own recklessness.” In bringing us apocalypse and heroes, perhaps the virus has been miscast; its role is not villain but rather revealer of the monsters in our midst. Could coronavirus help stimulate a civilizational metamorphosis?

It’s certainly possible. Overnight we grounded planes, limited unnecessary consumption and decided to look at markers other than economic growth as our barometer for societal health. In waiving away debt, housing the homeless and providing what effectively amounts to a universal basic income, we have shown that the old arguments against the status quo were groundless, and that when push comes to shove, we can act quickly and decisively.

This virus has convinced in a way that decades’ worth of rigorous and robust evidence failed to do: health is social and it is interconnected. You can’t have good public health, or even good individual health, without good social health. But global pandemics such as Coronavirus also teach us that health is more than just about humans – it is about the health of our planet itself. The rise and return of birds, animals and plant life are whispered warnings from this cruel and crippling disease: we have neglected to respect our responsibilities and duties to the living world and nature for far too long, and we continue to do so at our peril.

Pre-corona, we spent so much time, money and cleverness on coming up with new ways of making our existing systems – our hospitals, banks and industries – more efficient, streamlined, and cost-effective. Why weren’t we spending the same amounts of time, money and cleverness thinking about why? What is the goal of our economic, political and social systems? And what do we even mean by health? If we don’t collectively establish and agree on the answers to these fundamental questions – on our philosophy – we will never be able to build solutions out of this crisis. How can you build something fit for purpose if you are not clear on what that purpose is?

Most pertinently, the post-pandemic world has opened up a moment in which to rethink health and the role that healthcare systems ought to play in that endeavour. Coronavirus has revealed that tinkering at the edges of the capitalist system will never yield true health, only more medical treatment. There is a great wound at the heart of our healthcare systems. This wound is not only wide, but also deep, for it also lies at the heart of modern society. Our job is to try to heal this wound. However, it is not merely a matter of bringing the edges of the wound together, but also about building health from deep within, from the inside out. This means being willing to engage in a total reimagining of what healthcare systems looks like, what health means and how we live our lives.

Coronavirus has exposed the failures of our social safety net and health care system, our fragility and interdependence, and the worst, most foundational of our problems.  But times of crisis are also opportunities to make big, structural changes. Poverty and inequality are not inevitable or unfortunate – those in power create them. How do we hold onto that sense of the unbearable uncovered by this apocalypse? How do we work with it and factor it in to what we create together coming out of this? How do we transform our failures into a way forward? Can we collectively plot our way to wholesale, global healing born of a belief that we can, and must, do better?

All the greatest heroic struggles required transition and transformation – metamorphosis in order to arrive at epiphany. To return to business as usual now would be to miss our own heroic calling, the ultimate anti-climax. Portentous signs had been missed, and now we are paying the price. Will we learn from our mistakes? Will we, as a civilization, become the true heroes of this saga, and realise that it is not the world that needs to change, but us?

The unknown we are moving into is shared. Our vulnerability and frailty before this transition is also shared. The virus uncovers, but we need to recover. Recover health and a better way of being. Can we together choose what is moral and not profitable, what is just and not expedient? Compassion does not come just from clapping, it comes from caring. Caring for frontline workers – and for each other. Care is what could turn this tragedy into communal, collective, global metamorphosis – and catharsis.

*****

Guddi Singh is a paediatric doctor, public health campaigner and BBC broadcaster in London. Having previously worked on issues related to social justice and health equity with the World Health Organization (WHO) and MedAct, Guddi is the current Advocacy lead for the British Association for Child and Adolescent Health (BACAPH) and helps to manage the independent health think-tank, the Centre for Health and the Public Interest (CHPI).  Keen to ‘humanize’ healthcare and experiment with the arts and humanities in her clinical work, Guddi is currently researching how medical professionalism might advance in the light of the social dimensions of disease and illness for her interdisciplinary PhD at King’s College London. 

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