How ill is Boris Johnson?

Johnson has always been ebullient. In between shoulder-charging a Japanese boy during a game of touch rugby and getting stuck halfway along a zipline during the 2012 Olympics, boisterous energy has long been his schtick – whether you found it charming or contrived. But in spring of this year Johnson was flattened by Covid-19.

The prime minister tested positive for the virus on 27 March. Ten days later his breathing deteriorated, and that evening he was taken to St Thomas’s Hospital in London. He was given, by his own account, “litres and litres” of oxygen and the next day wheeled into intensive care.

He lived to tell the tale, but now, six months on, questions about his long-term health are swirling. Boris seems off-colour: distracted, lethargic, and not quite with it, both in his performances, and, at times, his physical appearance.

“Another of his MPs, who wisely wants to remain anonymous, is perhaps in the Chamber today
 He or she said, ‘It’s mess after mess, U-turn after U-turn 
 It’s a fundamental issue of competence, God knows what is going on. There’s no grip.’”

Keir Starmer, leader of the opposition, 2 September 2020

Sources close to him suggest he isn’t alright. On Wednesday, the Times columnist Alice Thomson quoted a family friend of Johnson saying that “even now he still has good and bad days”. On Monday, the TV presenter Piers Morgan, less close to him, was more blunt: “He is lonely, he is ill.”

Could Johnson be one of the growing number of Long Covid sufferers, who experience an array of symptoms months and months later?

C onsidering his public profile we know remarkably little about Johnson’s experience of Covid-19, except from his own account. “I wasn’t struggling to breathe but I just wasn’t in good shape and it wasn’t getting better,” he explained in an interview with the Sun on Sunday in May. “Then the doctors got anxious because they thought that my readings were not where they wanted them to be.” He was moved into intensive care when “the bloody indicators kept going in the wrong direction”. He was given oxygen and it was “50-50” whether or not he was going to be ventilated.

Johnson’s bout of coronavirus was extremely serious; that much is clear. Even in late April, when testing was only just beginning to become available outside hospitals, no more than a quarter of positive cases led to a hospital bed. An even smaller minority were taken into intensive care. At the start of the pandemic 44 per cent of those who did, died.

Taking Johnson’s account on face value, it is plausible that he experienced silent hypoxia – a medical phenomenon that has baffled many doctors fighting Covid in hospitals around the world.

The term “silent hypoxia” (strictly hypoxemia) was popularised by Dr Richard Levitan, a US intubation specialist, who back in April wrote about the number of Covid patients he was seeing who were deprived of oxygen but didn’t feel short of breath.

“I wasn’t struggling to breathe but I wasn’t in good shape 
 then the doctors got anxious because they thought that my readings were not where they wanted them to be.”

Boris Johnson

Normal blood oxygen saturation levels are between 95 and 100 per cent. When they drop below that, breathing usually becomes more difficult. Once they fall below 85 per cent, a patient typically loses consciousness.

But Dr Levitan was seeing Covid patients with oxygen levels as low as 50 per cent, who were not only conscious, but lucid – and even on their phones in some cases. The normal physical signs of low oxygen levels (laboured breathing, discomfort, and others) just weren’t manifesting in these patients. The virus was hijacking the body and starving it of oxygen, but without detection.

It has been fashionable to compare silent hypoxia to the experience of high-altitude climbers. Dr Levitan compared what he was seeing to trying to breathe on top of Everest, where each breath draws in a third as much oxygen as it does at sea level. Another American doctor, Cameron Kyle-Sidell, wrote that it was “as if tens of thousands of my fellow New Yorkers are stuck on a plane at 30,000 feet and the cabin pressure is slowly being let out”. The comparison picked up steam after a study was released in May suggesting that populations living at high altitudes were less vulnerable to Covid-19 because they were acclimatised to low oxygen levels.

It would be an easy headline: Boris Johnson ‘climbed Everest’ in his fight with Covid-19.

But the truth is more complex. Johnson experienced something which was quite possibly worse.

“Covid-19 is not the same physiological challenge as going to altitude,” explains anaesthetic registrar and expedition doctor Matt Wilkes.

Both the prime minister and legendary mountaineer Reinhold Messner, the first person to climb Mount Everest without supplementary oxygen, entered death zones where they faced a hypoxia that could kill.

But their experiences weren’t the same.

“What’s happening when you go to altitude is that your lungs are reacting to the low levels of oxygen in the atmosphere. And they’re changing the way blood is distributed in the lungs, which causes some back pressure and sometimes causes them to fill with fluid.

“What’s happening in Covid is that you’re getting really vicious inflammation of the lungs, which is then causing them to become sticky, swollen, full of all of these other things. And then it makes people hypoxic. That’s much more damaging and destructive.”

This oxygen depletion is damaging and destructive in the short term, but the jury is still out on the long-term impact, Wilkes continues. “It depends on the degree of hypoxia, but also the toll taken by the other aspects of the critical illness that they experienced.

“We know that if you’re in intensive care for a long period of time, that can lead to long-standing cognitive changes. But how much of that is due to hypoxia and how much of that is due to other challenges, for example delirium, is very hard to parse. I think in Covid, it’s way too early to say.”

Prime ministerial performance is of course a function of many things besides cognitive function, and this government seems to head in whatever direction the wind blows: its U-turns have climbed well into double figures. The process has left erstwhile supporters such as the commentator Toby Young feeling betrayed by a sense that Johnson is no longer the man they voted for. “Britain needs Boris, the extraordinary man I’ve known for 35 years” has gone to “I admit it: I was wrong to back Boris” in just over five months.

This might mean little more than that Johnson is an unreliable and inattentive leader. You would need a lot more evidence to prove he was unwell (Young cautiously introduces the theory that the disease has “actually damaged his brain in some way”). “Except in the grossest sense, it’s very difficult to link physiological challenges to the brain, to cognitive test results, and then finally to complex real-world actions,” Wilkes says. “If you didn’t do so well on a particular puzzle, what would that imply about the decisions you’re going to make as the prime minister? Making those links robustly is really difficult.”

But it is at least worth assessing what people close to him are saying. Last weekend the Times ruminated on the miserable time that the prime minister was having inside Number 10. “He’s pin sharp one day,” a source told the paper, “and then he will say to somebody in his own inimitable way ‘Why have you not briefed me on that?’ and he’ll be told ‘You were told that yesterday.’” The source adds: “Physically I think Covid has had a huge impact, definitely.”

This sense of being fine one day and not so fine the next echoes many reports about the long-tail effects of Covid. David Lat, editor of the Above the Law legal blog, wrote in the Los Angeles Times in July after 17 days in hospital: “Recovering from a severe case of COVID-19 is not like switching a light on or off. It’s more like a dimmer switch, where the light gets brighter, then darker, then brighter again.”

We still don’t know why people experience Covid-19 symptoms months and months after testing negative. Even if we park the potential lasting impact of hypoxia on those who are seriously ill with the virus, several other explanations remain (whether it be a developed immune dysfunction or something else).

What we do know is that a growing number continue to suffer. According to Tim Spector, the professor at King’s College London leading the COVID Symptom Study app, about 600,000 people in the UK have some sort of post-Covid illness. Last week researchers at Trinity College in Dublin found that more than half a sample of 128 people reported tiredness and exhaustion more than 10 weeks after recovering from Covid-19, regardless of the severity of their initial infection. Tinnitus, brain fog, neuralgia, blisters, neck ache: the physical and neurological symptoms which so-called long-haulers have reported are too many to list.

We can’t be certain whether Johnson is in this cohort. But it is clear that he has gone through an experience that can be physically debilitating and emotionally traumatic (one 2018 study of nearly 5,000 intensive care patients found that in the months following their discharge 46 per cent met the threshold for anxiety, 40 per cent for depression and 22 per cent for PTSD). A large part of recovery from any serious illness is making sure that patients pace themselves on a good day, so that the next day is also a good day.

Johnson returned to work as the prime minister, the biggest job in the country, three weeks after being admitted to hospital. His partner, Carrie Symonds, had a baby three days later. He is leading the UK through the biggest international crisis since World War II, and, admittedly by his own choice, through an enormous geopolitical realignment with the EU. It isn’t the ideal recovery schedule for someone who reports having such a close brush with death. It would be understandable if the prime minister was just very, very tired.