How Do We Let Down the Drawbridge?

First published in the NASGP Newsletter in October 2020

A year ago, who could define social distancing? Now, we’re all aware, though even people in authority seem unsure of exactly what the distance is and when it matters.

Last month we took a train to Dorset, our first venture outside London since March. All my life I have marched past the first-class carriages with my nose in the air, but at the time of covid that is where we chose to sit. First class travel, I realise, has always been a form of social distancing.

Separation is built into the fabric of our society, so much so that it takes blatant injustice or a new threat for us to notice it.

Apartheid in South Africa, segregation in the USA, ghettos throughout Europe – they weren’t called social distancing, but that’s what they were: separation imposed by powerful people upon the ‘other’. And locally, there’s always been small-scale partitioning. In 1934 a property developer in Oxford built nine-foot walls and topped them with spikes so that potential purchasers of his smart houses in Cutteslowe would not be deterred by the presence of the nearby council estate. The Cutteslowe Walls were demolished in 1959, but today enclaves for retirement living and luxury gated communities proliferate.

Social distancing doesn’t need a ‘big beautiful wall’. India’s caste system entrenched centuries of social strategies for keeping ‘untouchables’ at a distance, even excluding them from towns in the early morning and evening lest their long shadows fall on someone of caste. Caste discrimination may be illegal in modern India, but as a Dalit with a postgraduate degree from Harvard says, caste follows you like a shadow. An English prejudice I still recall: the mother of a school friend dissuading her from getting to know a particular girl – “Not our class, dear”.

We discovered a historical instance of social distancing on that first first-class train journey. The church in Whitchurch Canonicorum is dedicated to St Wite. Below the coffin containing her relics are three cavities in the wall. Pilgrims inserted their diseased limbs into them in hope of a cure. On the outside wall there once were similar openings so that lepers could seek the saint’s benediction without entering the church.

Lepers used to be required to carry a bell to warn others of their approach. People with leprosy evoked such fear and revulsion that it may well have been a relief for them to be confined to a leprosarium which provided a home and perhaps employment in a community of fellow sufferers. These institutions are now largely redundant, although I still have a rug I bought at a leprosarium in PNG many years ago.

Shaming was a reaction to the fear of contagion by leprosy, and now ‘super-spreader’ suspects are being trolled on social media. In one case the shaming and distancing was so vicious that the victim, a Polish doctor, took his own life. It is uncertain whether he actually even had covid-19.*

Modern medicine has mitigated the social humiliation experienced by people with a disfiguring skin condition, even something as minor as impetigo. Children in hospital are no longer confined to isolation wards with scarlet fever, nor subject to the cruel social isolation I suffered when I underwent minor surgery as a seven-year-old. But ebola, SARS, and now covid remind us that isolation facilities are still necessary. One thing that the pandemic has made plain is the devastating psychological damage that social distancing has inflicted on people in covid wards, in care homes, and in their homes by those without physical company. And what about the families who don’t get to say farewell to their dying loved ones? We know how important skin contact is to our wellbeing – remember ‘Four Hugs a day’? While an elbow touch or an embrace through a wall of plastic is better than nothing, many people don’t even get that.

“Social exclusion is alien to the NHS, one of the few institutions which is open to all.”

As citizens, our social contract obliges us to obey a regulation imposed by an elected government. First class may be more comfortable than steerage, but we are all in the same boat. At the start, most people co-operated with good will. But now the advice is unclear and the private actions of those who break with impunity the rules they make remind us that there are rowboats and there are super-yachts.

Costs are mounting up and there is no apparent exit strategy. Once the Pandora’s Box was opened in a grossly unprepared country, control was never going to be easy and opening up again was going to be risky. Almost every country west of Vietnam is groping for a way of reaching and then maintaining a steady state by embedding behaviours which their citizens can live with. It’s hard. In an emergency people can be persuaded to wash their hands, but it requires a lot of reinforcement to make the habit stick.  Homo sapiens is a social animal and self-regulating our human contacts is a big ask. Social distancing is impossible in primary schools, difficult in secondary schools, and you can’t get university students to stop partying and play Scrabble. But if we don’t mitigate the risks, everyone’s health and economic situation will continue to suffer.

Social exclusion is alien to the NHS, one of the few institutions which is open to all. But when the danger of Covid was first recognised, general practices were instructed to pull up the drawbridge. The public perception is that it is now easier to gain access to a Carthusian monastery than to their general practice. The people who used to be there, for the elderly, the housebound, the chronically sick, the lonely, and for all of us who also may need succour at times, now seem to be out of reach. We become GPs because we enjoy the privilege of accompanying our patients through the adversities of their lives, so those human contacts are important to us, too. We have to find a way to negotiate social distance so that staff and patients are as safe as we can manage, not only from covid but also from the bereavement of social isolation. If we fail, general practice will lose its heart and soul.

* D.T. Max, The Shaming Pandemic New Yorker September 28th 2020

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4 Comments

  1. Thanks Judy. Enjoyed this.
    meant to comment a while ago about the ‘plastination ‘ article. Like you, I was worried about the source of the bodies – had read somewhere about bullet holes. But i found the whole thing disgusting. I think it was because you will reacall that when we did dissection it was drilled into us that the bodies should be treated with respect, and this freak show was a repudiation.

  2. Good article- thought provoking.
    Just one angle from my observations of friends experiences of their relatives in care homes,Now all homes are so scared about getting a covid infection, their residents are being confined to such isolation- lucky id they have one or two visits a week-, even being confined to their rooms. It is an accepted fact, even in prisons, that being kept in isolation is damaging to people and yet in striving to avoid infection in care homes, mental harm is being meted out. There must be a way to secure a better balance.
    Already busy staff now have to combine all the Covid safety measures on top of their normal duties. May be more staff are needed. This costs- who pays? More discussion is needed for pragmatic solutions to ensure residents are not driven into loneliness and even dementia.

  3. Thanks for the article, Judith. While a lot of concern has been expressed about the failure to address the issue of care homes during lockdown, it only seems to have been recently that the problem of GP surgeries has been recognised. For 3 months ours had a huge whiteboard outside with STOP DO NOT ENTER in red. How this was allowed I don’t know and it has now been replaced. However I stood outside in the drizzle this morning for half an hour waiting for my appointment. The fellow in front of me had been there for 40 minutes. Inside the waiting room was completely deserted. We could have waited inside with at least 4 metres between us. No surprise that a lot of people will have been thoroughly deterred. This is social distancing gone mad.

  4. Terrific article! I wholeheartedly endorse your closing thoughts about GPs – even I, happily married – miss the possibility of five minutes of private advice, help or support from mine. Keep telling it how it is, Judith!

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