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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