Stuck Between A Rock And A Hard Place: Risk Assessment and Ethical Dilemmas in the Time of Covid-19

The View From The Front Line As Osteopath/Medical Anthropologist

MARIA LARRAIN

A week ago, the diary started to look unusually quiet but not surprising giving how the news about coronavirus was unfolding. I had expected that we may have to close if a full lockdown was enforced and started to look into taking video consultations or what is also known as Telehealth.

Now, my practice has, in the span of a week become 100% reliant on technology and an internet connection. The thought of a virus hitting the world wide web and cutting me off from what is a lifeline to my friends, family, patients and colleagues, is a horrifying thought.

I am a PhD student at UCL and also an osteopath running a small practice in Stoke Newington, North London. I work with 4 other osteopaths who share a clinic space and we specialise in women and children, although we treat people of all ages. Most of our patient base is local, consisting of professional couples, young families and a significant proportion of our patients are women and children from the Haredi Jewish community of Stamford Hill. In May I am celebrating my clinic’s 10th anniversary and was planning an event to mark it.

On Facebook my colleagues have been furiously debating our professional and civic responsibilities versus the need to work to pay our rents and support our families. Most osteopaths in the UK are self-employed and work in private practice. We rely mainly on touch as our therapeutic modality.

Osteopathy as a manual therapy, is statutory regulated, and we have been considered Allied Health Professionals since 2014 in the UK. So far, the guidance from our professional and regulatory bodies has been to read between the lines. As a medical anthropologist, I am particularly interested in risk-consciousness, one of the defining features of neoliberal society. The space between the lines is about making risk assessment the choice of the individual. It becomes the role of the individual osteopath to continue working. Just like it becomes the choice of the individual to practice social distancing, which only a few days ago meant that people were still going to the hairdressers and gathering in pubs.  

The Government’s recent blurred lines, making the individual decide and putting the onus on each of us to work out what to do, has led to mass confusion and panic and may have lost us valuable weeks in slowing the risk of infection and spread, hence Boris Johnson using Jeremy Hunt to warn that it may be “too late” to prevent the UK following the same trajectory as Italy. I found making my own risk assessment of a highly virulent infectious disease extremely stressful, to the point where I wondered if my tight chest was the first symptom of the coronavirus.

A week ago, my friends and family in mainland Europe were telling me that they were “shocked” by my choice to continue to see patients. This is when this pandemic became more than about hand sanitiser to me. This is when I felt the moral panic from my loved ones like a stab at my core and an attack on my identity as a moral agent. I was being told that I could be a ‘super-spreader’, a person who does not know they carry the virus but will infect others. I remembered the AIDS moral panic in the 1980s where people thought they could get infected by sharing a towel or from a public toilet. Where AIDS was hitting certain communities that were already stigmatised. Of course, my situation can in no way be compared to the AIDS epidemic, but my ethical dilemmas about continuing to work were made more difficult by people closest to me who do not know me in my professional capacity. I have to make ethical choices all the time as part of my work, but I have never been in a situation where I had to evaluate the care for my individual patients with the potential devastation of whole communities as result of my actions.

My colleagues in France and Germany were told they could carry on working if they wore full Personal Protective Equipment (PPE), but of course there isn’t any and what there is was needed by the frontline healthcare workers in hospital. The choice to stop practising was made for them.

In the middle of last week, one patient told me that she had just come out of quarantine with her family and she reassured me she was fine. I decided to see her as we were already taking all necessary precautions such as removing linen and blankets and disinfecting every surface, wearing gloves and masks. But I felt wary of my newly recovered patient because how could I be sure she was not contagious?. It felt like a distance between us, and I realised how important ‘therapeutic closeness’ was to practice my work effectively, not just physical proximity. Working through PPE would have made it impossible.

I made the decision to only see very acute patients and key workers. I rang up my patient, and booked in with her newborn the following day. She is from the Haredi Jewish community, and I explained to her I was concerned about her and her baby so I preferred she stayed at home. She was so sad, and so was I. We agreed to rebook in a few weeks. At this moment, I am not sure if it will be weeks, months or, when I am feeling particularly catastrophic, ever that I will get to see her again.

I often think how Covid-19 could devastate her community. As I was trying to get the Telehealth interface to work with the online bookings on my patient management system, I started to cry.

Most people in the Haredi community that I see avoid the media. Most do not have the internet.

It is Passover soon and this is when I usually get a surge of women booking in, as they have been busy preparing for the holidays. I see a lot of back pain and shoulder impingements as some have been furiously cleaning and clearing out their homes. This week I was meant to see a grandmother for a follow up appointment. I cancelled her appointment. She left a voicemail telling me how disappointed she was that she could not come for treatment. As a friend said to me “you are stuck between a rock and a hard place”.

I trust that the Jewish community in Stamford Hill will make choices together and take the lead from their religious elders and community leaders. My only thought is – how will big families living in crowded spaces cope with quarantine and self-isolation?

Caring for people as a healthcare professional does not mean that you can just drop them. The choice to close my clinic is not like closing a bar, however devastating it is for the bar-owner and their staff.

As the week progressed, on the day that the Prime Minister enforced a lockdown for all non-essential services, I decided to close my clinic for all face-to-face consultations. At the time of writing we were told that osteopaths are essential in “reducing the burden on the NHS” but that it was up to the individual osteopath to decide to continue. That guideline changed within 24 hours where we have been advised to work remotely and only have face-to-face contact in “exceptional circumstances”.  Many have chosen to close their clinics, some continue working and many have signed up to volunteer for the NHS.

My choice was wrought with ethical dilemmas because I am caring for people. We are not essential in a pandemic but we do provide an essential service to individuals. I had to make the choice between the best interest of individuals versus the best interest of the wider community. It was not an easy one to make when so much is at stake, including my only source of income. “Doing the right thing” became my choice as an individual at a time when we needed to act as a community. The Government’s recent rescue package including for the self-employed to keep people at home demonstrate that you cannot make individuals assess risk in a pandemic. People will take extraordinary risks for their survival.

It took me 10 years to build a practice and it crumbled within a week. It feels like grief, and I am not alone in feeling this way. I know this because on Facebook I have been able to share these feelings with my colleagues. Depending on where we are in the world we have all been on the same emotional rollercoaster, at different stages, trailing behind the trajectory of the spread of Covid-19.

This pandemic has shown some major cracks in our society but also, out of necessity to minimise risk, seen new ways of practicing healthcare. In a post Covid-19 world where touch becomes unacceptable, social distancing the norm, where does it leave us as humans who rely on it, both for our work but also for our healing?  Covid-19 will undoubtedly keep medical anthropologists busy for decades.

ABOUT THE AUTHOR:

Maria Larrain is a practising osteopath and MPhil/ PhD student in medical anthropology. Her areas of interests are contemporary parenting culture, risk, gender and medicalisation. Her research project explores the issue of infant ‘tongue-tie’ and the medicalisation of breastfeeding.

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2 Comments Add yours

  1. Bea JUNG says:

    Dear Maria.What an amazing heartfelt article. I’m an Osteopath too and for the last week I tried to articulate how I felt but I couldn’t really find the right words. You did and I’m really grateful. Thank you.
    Bea

    Like

  2. Kuda Adams says:

    Hi Maria,

    A really deep felt and well written article . I echo your “Doing the right thing” ethos and I do believe that you have done so. Patient welfare is paramount and ultimately shouldn’t make you feel less compromised. Take care , stay well and let’s see what positives can come out of this pandemic. Kuda

    Like

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