Ishwinder Thethy
Dr Ishwinder Thethy is a Fellow of the Royal College of Physicians of Edinburgh. She is a Consultant in Acute and General Medicine and works at the Royal Infirmary of Edinburgh.
Due to issues with the recording quality, Ish’s discussion of vaccines (at 10:31) was re-recorded on 21 May 2021.
Details
- Date of interview: 30 April 2021
- Archive reference: RCP/RES/2/12/23
- Interviewer: Daisy Cunynghame
Timestamps
00:00 Introduction
00:43 Changes to work patterns
03:15 Long-term impact of COVID on physical and mental health
10:03 Long term impact on NHS
13:57 Government response to pandemic
18:40 Public response to pandemic
21:12 Vaccines
29:01 Personal experiences of friends and colleagues contracting coronavirus
31:01 Effect of the pandemic and lockdown on home-life routines
Transcription
Interviewer:
If we could just start by you introducing yourself, just saying your name, your college membership status, and where you work.
Ishwinder Thethy:
Okay, my name is Dr. Ishwinder Thethy. I am a fellow of the Royal College of Physicians here in Edinburgh and I work as a consultant in acute and general medicine at the Royal Infirmary in Edinburgh.
Interviewer:
Thank you very much. We could start off by you talking about how the pandemic is affecting your working hours and your practices and thinking about, we talked six months ago, has that changed significantly in the last six months?
Ishwinder Thethy:
Since we last spoke about this, we had managed to establish a COVID admissions unit with clear downstream COVID positive and COVID negative wards, and the guidance and pathways for patient admissions and assessments to try and reduce the risk of nosocomial transmission are somewhat clearer if not perfect. There is still a need to provide extra cover and availability for clinical sections at a consultant level so that we are ensuring that we've got 24/7 COVID admissions unit cover and we've also got weekend cover. So still working weekends at an increased frequency. There's also, of course, to make the rota robust, we have to provide cover for any unexpected sick leave. Only this week, there's been talk of trying to close the COVID admissions unit actually, and I think this is based on the fact that we're now seeing fewer COVID positive patients coming in.
One of the positive things has been the introduction of the lateral flow testing and the rapid [unclear] PCR testing in the emergency department, so that can give us an answer in about half an hour if there's a suspect case. So now the pathway is somewhat changed and evolved so that if someone tests positive in the accident [and] emergency department, then there’s clear signposted side rooms that they can be admitted to and clear guidance for which specialties are going to look after these patients. So that's a new development and it's going to come into force this week, we'll see how that goes. Finally, we're still experiencing a disruption in the provision of non-urgent care, like elective operations and outpatient assessment of patients, despite efforts to try and restructure some of these work streams.
Interviewer:
Thank you very much. Something else that we spoke about six months ago was what you thought the long-term health impact of COVID was going to be. Both on physical health and also on mental health, and I wondered if your perspective had changed at all, or you thought any more about that over the last six months?
Ishwinder Thethy:
I still think that we're seeing an increased and worsening mental health Daisy, and there's also some social ills that are being brought forward. I think this is a combination of some of the detrimental effects that some of our public health measures have had to be honest. It's understandable that these have been enforced in [an] attempt to contain the pandemic, but I think it's important that we quantify the extent of the inadvertent harm that some of these policies may bring about. So, there's still [an] increase in presentations from people who are having worsening anxiety, worsening depression. There's a lot of harm related to worsening alcohol dependence, still seeing people coming in with deliberate self-harm. And I anticipate that we might start to see additional health needs emerging from the long-term economic consequences, because of poverty or worsening employment.
I really think it's important that somewhere along the lines we're quantifying this, so that we can learn from it if we're to have future pandemics, so we can find a balance between the benefits of some of these measures but also trying to minimize the risk and harm that it can cause in the present and also for the future. Of course, we're still seeing a problem with access to face-to-face emergency care and primary care, that still remains challenging and like you said we're still seeing a disruption in our outpatient services. I think we'll still continue to see compounded ramifications of this, where we'll perhaps be seeing late diagnosis and management of serious pathology and/or deterioration of stable chronic health conditions. So, I think my opinions are pretty much the same, we're still seeing worsening mental health issues and we're going to see consequences and impact of some of the measures we put in place.
Interviewer:
Thank you very much. Something else that we talked about six months ago was the challenges around PPE (personal protective equipment) shortages and potentially equipment shortages as well. I wondered what the situation is now with things like PPE and equipment. Has the process of getting this equipment changed over the last six months?
Ishwinder Thethy:
I think, like I said, there were initial teething problems when we first started. Like I mentioned there [were] issues with providing scrubs, and then we went the other way where there was provision of the basic PPE in all clinical areas and there was an agreement about what we were meant to wear in each area. I think actually in Edinburgh we've been lucky with not having too many shortages with PPE. I remember mentioning in the last interview I’d had issues with my skin because I was reacting to some of the face masks and I was lucky enough to have sourced my own face mask which was an ultra-sensitive one which was made by a company, I think, in the [United States of America]. I bought myself one box initially thinking I'll just put this forward to occupational health and my own management so that they can procure the right mask rather than stockpiling these boxes. I wish I had at that point because when it came to me running out of this box of masks by that point the mask wasn't being manufactured anymore, it was out of stock. So, it took a while to restructure how long I was allowed to do a clinical session and for them then to try and find an alternative but that was just a personal experience.
I think on [a] wider scale what we experience, and perhaps some of my colleagues may agree or disagree, wasn't really the PPE the PPE shortages but there's always been an issue with capacity. So, like I mentioned we managed to establish a COVID admissions unit, and the purpose of this unit is essentially to do the first assessment and management of any patient who's coming in with symptoms that are suspect of COVID. But, of course, we know that not everyone who presents with a cough or feels breathless has COVID, so patients would be admitted to our assessment area and the swab would be sent and it would take maybe twenty-four to forty-eight hours for swab results to come back and we do see a lot of admissions with people who have those presenting complaints. So, at times it meant that we were in a position where we had to cohort potentially negative patients with potentially positive patients in a four bedded bay despite our best efforts to minimize transmission of the virus. So that sometimes was challenging.
The other thing is that when people who've had COVID or they've had symptoms suggestive of COVID that may be due to sepsis, they're always at risk of having disturbances in their heart rhythms. Either because of the infection itself or because of development of blood clots which is now emerging as either a consequence of COVID or just people who present with blood clots can have similar symptoms. Often, we take referrals, but we need these patients to have heart rhythm monitoring, and we were unable to do that on the COVID admissions unit. Often that would result in a three-way discussion between ourselves, the accident [and] emergency department, and the high dependency units. And with management as well. So sometimes trying to safely place those patients was challenging. Those are the kind of things that have been challenging in terms of capacity itself rather than PPE.
Interviewer:
Thank you. Something else that we touched on six months ago was the sort of fundamental changes to the NHS which might come out of the pandemic. So how the NHS is funded, organized, and how broadly speaking interaction with patients takes place. Do you have any more thoughts now, six months down the line, on what those changes might be?
Ishwinder Thethy:
I think, like I said to you before, historically we in the NHS, we've always been faced with the challenge of trying to balance the real-time budget restrictions and chronic underfunding with provision of services to meet an ever-increasing demand, right? And although we initially radically mobilized to be able to provide for the acute care needs of people who are infected with coronavirus it has come at the expense of severe disruption to non-acute care, to non-acute surgical treatments, cancer treatments, maternity care, mental health services, and also access to emergency care. So, there's an ever-growing backlog and pressure on these services to catch up. We have to bear in mind that we already had a backlog with some of these services prior to COVID.
And I was reading that in November 2020 the Health Foundation charity had estimated that the extra cost to the healthcare services because of COVID-19 was around 40 billion pounds per year. And we require an increase in funding, approximately 10 billion a year by 2023, 2024 so that we're able to address not only the backlog of care but we're also accounting for an increased demand in mental health care and delivering service improvements that have been set out already in our NHS long-term plan, and we'd be mindful of social care needs as well. I know we were granted an extra 3 billion in the budget, and it might help relieve some of that pressure but it's nowhere near enough.
In terms of COVID changing the way we practice, of course, as we mentioned in the last interview, the outpatient work stream is being reviewed and we're trying to be a bit more creative with identifying how we can have distant rather than face-to-face consultations with patients. So that's an ever-growing piece of work. When I started my job as a consultant, I had already looked at how we actively triage patients inter-clinic and updated the guidelines. We were lucky that we were already doing this kind of active triaging at consultant level so that we were making sure that those who needed to be seen by us were seen, those who could be seen by another specialty were put forward at an early stage and those who could access healthcare in a different way could do so. I think there's a lot of work in NHS Lothian itself and their regular workshops that are being held with consultants who are involved with outpatient workstreams to further tighten up with the triage to try and think about ‘near me’ consultations. So, we're seeing a bit of a change there. However, I still feel for our general medical outpatients it's important for me to see patients face-to-face for the first time so I can do a proper assessment and examine them, because the history will give me so much and then the examination can help confirm. That's still evolving and I think that's one major change that we'll see.
Interviewer:
Thank you very much. I wondered if you had any comments on the government's response to the pandemic over the last six months, since we last spoke?
Ishwinder Thethy:
Like I said to you the last time I believe that everyone is trying their best and everybody is trying to have measures in place to try and protect their population needs and do the best that they can. However, I still strongly hold the view and I wish that governments, not just in the UK but worldwide would sing from the same hymn sheets when it comes to responding to this pandemic. We've been unable to achieve this even on home ground between England and Scotland itself, let alone achieving a harmonized global response and the pandemic is a global problem and it can only be truly defeated by a harmonized and fair global solution. But instead, what I've observed, not only just in the UK, but like I said to you before I'm from Kenya, their governments have adapted differential territorial approaches. There seems to be a lack of any cross-border cooperation on board of central policies and world over I think that the responses have been disjointed and instead of achieving harmony I'm worried that if anything this is hardening nationalism.
For example, there's been competition for resources especially when it comes to the hoarding of vaccines by high income countries and that leaves the low- and middle-income countries still struggling with supplies, yet they may have [the] equivalent size of population or a bigger population that they need to vaccinate. I just wish that there would be a harmonized approach to all of this. Also, sometimes some of the restrictions that are put into place, whether they're locally or internationally, I wish that there would be a bit more explanation and transparency behind it so the public could understand.
For instance, recently, of course international travel has been very much in the forefront and the UK has introduced these restrictions and certain countries have found themselves being red-listed, and I've been trying to work out the rationale behind why a country would be put on the red list. I was thinking, is it to do with the number of total cases this country has had versus the number of total positive cases per day or deaths? But then if I contrast, say, a country from the EU like France which has had, say, maybe 5 million cases to date and somewhere around 40,000 new cases a day with a country like Kenya, which has had 102,000 cases to date and maybe 366 new cases per day then that doesn't seem to hold. It doesn't seem to be the number of cases and the number of positive cases in the country. So, then that leaves the issue of whether it's because of variants that are being discovered world over. Even with that we have to be mindful that simultaneously various countries may have picked up the same variant or the same mutation at the same time. Even the way we started to name variants, the Brazilian variant, the South African variant, the UK variant, now the India variant, is that variant specific to that country, or was that country the first one through its genomic sequencing and monitoring to discover the variant? We have to be really careful because we risk stigmatizing countries. Myself, I'm in the dark about some of these policies, so my plea or my wish is that there would be more clarity and transparency behind these decisions that are being made.
Interviewer:
Thank you very much. My next question follows on from that one which is: do you have any thoughts on the public response to coronavirus and particularly over the last six months, how that has changed? Do you think people are more aware or less aware, or [are] people's actions or thoughts changing do you think?
Ishwinder Thethy:
Gosh, I think when we last spoke, I remember mentioning to you that I feared the start of COVID burnout, and that was back, say what was it? October or November? And I do believe that to an extent I've observed and experienced some of this COVID burnout. I've observed varying behaviours, there [has] been people who've been very conscientious, very mindful of their community, very mindful of their neighbours and strictly adhering to public health measures. And then I've seen the reverse side of it, where there's people there's no care in the world. That latter has alarmed me, that defiance, and I've observed the lack of repercussions for some of these people.
For example, I was walking home one evening, through Middle Meadow Walk with a friend, and it might have been about 4pm and we were still in winter at that time. And we came across a huge crowd of what to me looked like teenagers, children who might have been roughly between ten and sixteen and they were hanging out in a large crowd. They were screaming, bottles of liquor were being thrown at people, they were also spitting in their face, and there was a policeman parked right in the middle of Middle Meadow Walk, yet they were unable to do anything. They were sat in the van, and of course you're aware that these are teenagers, so they're minors, so the police are unable to intervene to an extent. I remember feeling really scared as I walked through because any passerby could have been at the mercy of these drunken teenagers and I was pretty shaken up and disheartened by it all to be honest. I think as time's gone on, especially for, maybe, I don't know if it's just the younger population, but there's definitely been COVID burnout and there's been bouts where you've seen that kind of behaviour emerging.
Interviewer:
The main thing that has happened since we last spoke is, of course, the availability of vaccines and I wondered if you could talk a little bit about how that's impacted on you and your work, but also your feelings or your perceptions of how the rollout of the vaccine has gone.
Ishwinder Thethy:
I think it's a really big step forward that we were able to come up with vaccinations so quickly and I think that we really need to be grateful and commend the hard work of the scientists who were working on it. I think in the UK, locally, the vaccine rollout we really need to be grateful to our colleagues in primary care and also the nursing staff who mobilized very quickly to try and roll it out. So, I think we've been good in the UK in terms of getting the vaccination program off the ground and really quickly trying to vaccinate as many people as we can.
The only thing that I think, perhaps, that felt a little bit like a grey area to me was when they decided to increase the dosing interval for the first and second doses of the Pfizer vaccine. Scientifically we know that that was not based on the studies of the Pfizer vaccine but the AstraZeneca vaccine, but I understand that perhaps the incentive was to get as many people vaccinated with the first dose. I think there are ongoing trials for treatments but our vaccination is our best hope, so all the different vaccines regardless of whether they give you a hundred percent efficacy or not, what we've been told is that at least it will protect against severe morbidity and mortality by a hundred percent. That's something positive.
The only thing I think with the vaccine on a global level is what sits uncomfortably, because like I've mentioned before this is a global pandemic but instead of uniting everyone I feel like it's separated countries in that every country has had a very territorial approach and we risk nationalistic views becoming stronger. For instance, the UK has purchased, with my understanding, about 400 million doses of vaccines for a population between 60 and 70 million. Then if you contrast that with a country like Kenya that has a population of about 60 million, they've only had access to a million doses of the AstraZeneca vaccine.
Of course, now that we've gone into travel restrictions, I think people need to understand that the countries that are on the red list are middle income and low-income countries. A lot of the high-income countries seem to have bulk purchased all these vaccines and now the other countries are on red lists or amber lists, and these travel restrictions not only apply to movement of people, but it also affects cargo. It affects supplies that are vital in terms of vaccine supplies, as well as medical equipment reaching these countries in a timely fashion. So, we have done well on home ground, but we now really need to focus globally because otherwise we're going to continue to have this cycle of imposing restrictions, locking the world down trying to protect our own borders. I don't think that's a sustainable solution, that's my opinion.
Interviewer:
Thank you. You talked about the travel restrictions; I wondered if you would be able or willing to discuss your own experiences with that at the moment?
Ishwinder Thethy:
As we mentioned, I think in one of the other questions, I was wondering in terms of the systems of restricting travel. I understand that it's to try and stop importation of variants, but then when we think about variants for the virus, each country has its own genomic sequencing and its monitoring what's happening to this virus. Like I said before we risk really stigmatizing [the] country because when this virus first came out everyone said it was the Wuhan Chinese virus and that really brings stigma to people who are of Chinese origin. Then there was the UK variant and then we talked about the Brazilian variant and the Indian variant, but who's to say that simultaneously perhaps the virus genome is changing. Maybe Brazil was the first to detect it or India was the first to detect that particular variant and now it's been put on a red list. With the travel restrictions what I don't understand is what puts somebody on a green list, an amber list, and a red list so they're saying it depends on the number of cases of the R-Rate or positivity rate, and the variants. But I don't think that's necessarily held true when you see how many cases in countries in Europe, contrasted per day and the number of deaths, so it didn't really translate into those countries being blocked.
I think with the travel restrictions, like I've said, we have to be very mindful. If we look at the UK and we look at the percentage of [healthcare workers] that are not UK born and bred so they probably have come from countries in Asia or Africa [or] South America. So a significant proportion of healthcare workers and they've been working relentlessly and they sit with when they'll be able to see their families and in my situation essential travel is required and I'm in a situation where I can't return that easily and I want to get back to my job, but my job is not on the exemption list. As a frontline key healthcare worker who's been fully vaccinated, the government does not consider that as important as if I was working in the oil industry or if I was picking vegetables seasonally or if I was an elite sports person or if I was running a large clinical trial. I don't understand why someone in the healthcare profession [whose] role isn't considered key enough to be exempt from some of the restrictions. That's what I think and it's really baffling and it's a really unprecedented and unsettling time to be honest.
Interviewer:
Without naming individuals, since our last meeting has anyone you know contracted coronavirus and if you're comfortable talking about it would you mind talking a little bit about that?
Ishwinder Thethy:
Like I mentioned before, since the start of this pandemic it would be very unusual if anyone said that they didn't know anybody who had contracted the virus. Through the course of the entire pandemic, I've either had family or friends or work colleagues who’ve contracted COVID, and every single time even as a clinician when I hear that someone's tested positive there's an immediate concern and an immediate fear of the trajectory that the person's health will take. That's because we still don't have definitive treatments.
One thing that's been very apparent, and it's not just something unique to me as a diaspora doctor who has family that is not in the UK. Every time you hear about a worsening caseload, or you hear about a family relative who is not in front of you, who is in a different country, who is in a different healthcare system, contracting coronavirus, that anxiety is crippling. I can't mention specific examples, but I think there's a theme here, every time someone gets it there's an immediate concern.
Interviewer:
Thank you. Something else that we talked about before was the impact of seeing that the pandemic had on your home life routines. Obviously, the world has changed a little bit since then in terms of lockdowns and things, so I was wondering what is your home life routine like now and is it different from how it would normally be under non-pandemic conditions?
Ishwinder Thethy:
Like I mentioned before, I think what the pandemic has really brought to the forefront for me is that it's difficult when you are living on your own and you have to be in lockdown. This is because even before the pandemic I would spend a lot of time at work and I found my office hours increasing just because it meant that I was around people. And then when I went home, I would do what most other people do, you'd think about what you were going to prepare as a meal, you'd think about what you were going to watch on Netflix. You think about your walk, which became routine but also boring because you were only going within a certain mile radius and there's just so much of the same walk that you can do daily to try and refresh yourself. Then over winter it's been difficult in terms of not being able to see people indoors, you can't really see people outdoors either because by the time you leave work it's dark.
I decided to form an extended bubble with a couple of friends who are a couple and they said, “you're on your own, would you like to form an extended household?" I'm glad I did that because that meant that I could at least have some sort of interaction outside of work indoors after work. I think it's really making me consider the long-term, because again I keep coming back to this element where my family [lives] in a different country and these travel restrictions and the uncertainty makes it a million times harder in the long run. Considering if something happens to a close family member, if you have to travel, when you'll see them next. And although this was already difficult for me before the pandemic, every time I'd visit for say a couple of weeks and as I'm leaving the airport, I would actually have a physical searing pain in my chest as I was sobbing. I normally would offset that by saying “It's okay, anytime I want to see them, or I have to see them, I can jump on a flight and be there in under a day”. And that doesn't really hold true anymore. So, then you start to think about what's important and if some of this doesn't ease, then is it wise in the long-term, to keep doing this? So that seems out of balance as well. I don't know if that makes sense.