Thoughts from a cancer doctor

By George W. Sledge, Jr., MD

We are exhausted, appalled and angry at how our lives have been derailed over the past 2 years. COVID-19 never seems to end, and the new normal is distinctly abnormal. Minor inconveniences aside, the effects on society have been far-reaching. To name a few: economic disruption (job losses due to shutdowns, supply chain issues, stock market flip-flops), social disruption (rising murder rates, rising crimes against women and people of Asian descent), political polarization stacked on top of existing political polarization at the expense of basic public health measures, schools closed and 6-year-olds confined to their homes with working parents whose interaction with their colleagues is done through Zoom conferences. But more than anything else, the nagging feeling that nothing is certain and predictable anymore has led many people to live in a permanent state of unease.

All of us in the health professions know the human toll, the lives lost, the exhausted intensive care nurses and emergency room doctors, the noisy ventilators and the sad family conferences. And all of this followed by the long symptoms of COVID that we are only just beginning to understand and will struggle with for years. We all have stories we could share, but we’re too tired to care.

Already 2019 seems like a different time, a facsimile of an old Jetsons Saturday morning children’s cartoon, when life was dominated by technological advancements and Mother Nature was just a minor interest group. , recognized but generally ignored by a population in love with the latest shiny new gadgets. A time when you could go online and get a ticket to Bangkok or Paris, stand in line at a crowded airport, sit next to someone with a mild cough, fly overseas for 12 hours and don’t think about it.

It was in British Columbia; Before COVID. In the After Covid (AC) universe, a trip to the local grocery store can seem fraught with pitfalls. Flying overseas for a medical conference? Forget it. Get on a cruise ship, those floating coronavirus hot boxes? Are you crazy? We no longer have the freedoms we took for granted, and many of the limitations are self-imposed, derived as much from our own psyches as from public health services or the CDC.

Worse, we no longer trust our fellow citizens. The woman standing behind me at the checkout, her homemade cloth mask covering only her chin, is she vaccinated and boosted? Is her child’s cough a benign rhinovirus or the latest highly transmissible variant? Will I argue about wearing a mask at my child’s school? I never used to worry about someone’s flu shot status – maybe stupidly – but now I ask every patient I see at the clinic what their COVID shots are.

And underlying everything else, this question: when will all this end? A once-a-century pandemic leaves us with few relevant historical comparisons. The last great pandemic was the great flu of 1918-1920, which killed between 50 and 100 million people in a world less populated than today. This pandemic occurred in four waves: a mild one with the characteristics of a regular flu season, followed by the major killing fields of late 1918, followed by another major epidemic that killed tens of thousands of people in the United States in 1919, followed by a 1920 series of localized but smaller epidemics. So about 3 years of fear and death, then back to normal.

Of course, this flu never really went away. It mutated into something less dangerous, with its offspring continuing to the present day. It still kills thousands a year, although less so in the age of COVID: masks work. Perhaps the flu slide from pandemic to endemic is our fate with COVID-19. Or perhaps, and it is fervently hoped, deliverance will come in the form of a universal COVID vaccine, as some have suggested.

Either of these two results would be welcome. But history offers other darker scenarios. Imagine, if you will, being miraculously transported to Stratford-upon-Avon in 1564. If you attend Holy Trinity Church on April 26, you will see the baptism of William Shakespeare. The parish register of this date, probably a few days after his birth, mentions him as Gulielmus filius Johannes Shakspere.”

But don’t dwell on it. On July 11, the same parish register informs us “Here begins the plague”. After that, there is a steady drumbeat of plague-related deaths lasting until the end of the year, including many young children. Shakespeare was lucky.

Follow him as he moves to London in the late 1580s, and the plague awaits him too. In 1592, the plague killed around one in twelve Londoners. City authorities had strict rules shutting down theaters and other public performances once plague deaths reached 30 a week, so the young Shakespeare used his free time to write his poem. Venus and Adonis, which earned him the patronage of an Earl of Southampton. The poem includes these beautiful lines: “May they kiss long, for this remedy/…To drive away the infection of the dangerous year/That stargazers have written of death/May say, the plague is banished by your breath.” Or, as in the case of COVID, “spread by your breath.”

In 1603, the plague raged again, killing 30,000 people in a city of 200,000, and playhouses were closed to prevent the spread of infection. And in 1606 the plague returned, and again Shakespeare and company faced government-mandated closure and loss of income.

Shakespeare’s company, originally the Lord Chamberlain’s Men in Queen Elizabeth’s time, then the King’s Men (as they were favorites of King James) left London and toured the provinces when the theaters were closed. But if one stayed in London and the Black Death was known to have afflicted a family member, their house would be locked for a month and the occupants of the house prohibited from leaving. In James Shapiro’s wonderful book Lear’s yearsubtitle Shakespeare in 1606the author argues that the playwright’s landlady may have died of the plague at the age of 40. If so, as in 1564, Shepherdess pestis may have come too close for comfort.

Shakespeare mentions the words “plague” and “pestilence” in his plays, but usually not as the centerpiece of the works. Perhaps the memories are too painful for the citizens of London. But the plague is often there in the background, just like in real life. Take Romeo and Juliet, for example. When Romeo’s friend Mercutio is stabbed and dies, he says “a plague in both your houses”. To modern ears, that’s just a witty metaphor, but if you were attending the Globe Theatre, how would that sound? You “I’ve seen friends die in days, sore festering buboes turning lymph nodes into torture chambers. You’re scared for your life just thinking about it. Maybe the phrase would be equivalent to saying something something like, “I hope you both die of cancer. “If you lived until 1603, where 15% of the population perished within a few months, that was not an innocent metaphor. It was a curse.

Later in the play, in what will have tragic consequences for the young lovers, a letter is not delivered in time to Romeo. The reason is the plague: “the searches of the city, /Suspecting that we were both in a house/Where the contagious plague reigned, /Sealed the doors, and did not let us out.” Quarantine is a very old idea, and for Shakespeare’s audience a living presence.

The plague would not disappear from London until after 1666, when the Great Fire of London and the subsequent rebuilding of much of the city in brick rather than thatched roofs, made it less friendly to the fleas and rats that transmitted the plague.

Here’s the thing that amazes me: the Black Death first came to England in 1348. 1603 was 255 years after that, and the bubonic plague still has half a century or more to plague English citizens. Two hundred and fifty-five years ago, it was 1767; imagine that COVID then comes and goes every few years, killing only a few in “good” years and 15% in bad years. And still having half a century to go before it disappears for good. What an intensely depressing thought. But that was the world in which Will Shakespeare lived.

If there is anything to be learned from the history of infectious diseases of Shakespeare’s time, those plague years long ago, let it be this: In 1606, when the Globe Theater closed during the most of the year, Will Shakespeare hasn’t blundered off. Shakespeare scholars believe he wrote macbeth, Antony and Cleopatraand King Lear, all within 12 months. Has a writer ever had a better year?

Or, perhaps, consider the end of 1665. That was the last time the plague would visit England, but its spread temporarily shut down the University of Cambridge. Students were sent home until things calmed down in 1666 and classes resumed. One of the students, young Isaac Newton, returns home to Woolsthorpe Manor. In 1726, towards the end of a not too shabby scientific career, he shared this anecdote with his biographer: “After dinner, the weather being hot, we went into the garden and drank tea in the shade of a few apple trees…he told me he was just in the same situation as when he once thought of gravitation…caused by the fall of an apple, while he was sitting in a contemplative mood.”

Somewhere in a lab, or perhaps a crowded apartment, a graduate or postdoctoral student, whose life has been put on hold by the pandemic, sits in a contemplative mood. Newton’s apple I want to believe fell from the sky and hit this smart kid on the head and we haven’t heard of it yet. Maybe finding the cure for cancer or crafting the development of the universal vaccine that will end COVID-19 once and for all, but either way create something that will transform the world. There is, after all, a precedent; the greatest playwright in human history and the greatest physicist of the human race both give us hope that something good will come out of all this pain and suffering.

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