Dr Joanna Herman: They would often say it's visible, you just fade and you stop sort of your talking just gets less and less. And it felt like it was a huge effort for the brain to connect to the mouth and say anything and then it just didn't want to say anything. So it's been really profound like that.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life. Today I chat with Dr Joanna Herman, a consultant in infectious diseases and during the first wave of the pandemic, she contracted COVID. Now despite being defined as a mild case with no risk factors for severe disease, she is still significantly debilitated by symptoms of what we refer to as long COVID and has since been unable to return to work as a hospital physician for the past year. Now as you'll hear on the pod, Dr Joanna is a very well-established physician with years of experience. She's taught at the London School of Hygiene and Tropical Medicine for 14 years. She's been on the council of the British Infection Association since 2015 and she's also worked for Medecins Sans Frontieres. She's a medical writer and a specialist medical advisor for the BBC programme Holby City. You'll also hear about how she is a qualified Ashtanga yoga teacher with years of experience in that practice. Now she wrote an article for the Guardian about her experience with long COVID, which is how I came upon her story and it was particularly touching for me as she also has the perspective of a doctor as a patient. And her experience has highlighted a system that is struggling to help those with a condition not yet understood, not dissimilar from a number of other post-viral syndromes. Last year, she set up a yoga group for people who are experiencing significant lung problems following their COVID infection and combining her medical and yoga knowledge, she's helped them learn how to access their lungs and breathe again and regain their physical pre-viral strength. Now there are some absolute nuggets of inspiration that I personally found useful during our conversation, so I really do hope you enjoy this. It's interesting to see that this whole movement towards studying long COVID and the effects post-viral is almost being patient-led because in a lot of cases, undiagnosed medical or medical diagnosis of uncertain origin are sort of dismissed. And I think this is really bringing it to the light now.
Dr Joanna Herman: And I think it needs to be patient-led because as we've seen, long COVID got dismissed for so long. You know, people, particularly, you know, women would say, oh, you know, you're just a bit down, you know, you're just taking a while to recover. Um, people were described as being histrionic and all sorts of things, which was really awful and anxiety, you know, people were having panic attacks and that's why they were tachycardic. Well, it wasn't, it's because they had myocarditis possibly that hadn't been discovered. Um, and, you know, even for myself, I've been through quite a lot, um, after around the time I got ill and then my mother actually died of COVID. And so people say, oh, you've just been through so much, that's why. And I said, no, no, this is something completely different. This is nothing to do with that. It's and then it just took momentum and took a while for people, I think, it was as you say, it's it was a body of patients coming and saying, this is what's happening, this is real.
Dr Rupy: Yeah, yeah. And the constellation of symptoms is so, it's so wide. I mean, there's some common themes that are coming out like fatigue and headache and and and arthralgia, I think is one of them, but there's so many, so many different symptoms that that could be afflicting people with label with this bucket of long long COVID at the moment.
Dr Joanna Herman: And I think it's very difficult to, you know, people are putting an umbrella, there's a big umbrella of long COVID and then within that you've got some people that seem to just have the fatigue and maybe headaches or, you know, maybe some arthralgia and then you've got others who've got very specific problems that result from myocarditis, from lung involvement with shortness of breath. And so I think, um, and then you've got a myriad of all sorts of weird and wonderfuls that, you know, neurological symptoms and skin issues. Um, and I think it's, like any new and evolving disease, it's going to take a while to tease out what's what and it's only with research and, you know, scanning, um, and, you know, serial investigation of people with this that we're going to really find out more and know how to address it and what we can do to help. So I think at the moment there's a very little understanding of, um, you know, what what is needed. Certainly for some things, you know, if it's if it's a chest issue and they've got respiratory problems and they've got clear problems there that have been demonstrated on scans and lung function, then it's easier to try and manage. But for the other things, we still don't know. I think it's very, um, it's work in progress and it's going to continue to be work in progress for quite a while.
Dr Rupy: Yeah, absolutely. I mean, primarily I want to talk about your your personal experience of this, but um, I think before we go into that, I'd love to know a bit about what led you to your chosen specialty and and what was like life what was um life like before before COVID?
Dr Joanna Herman: Um, well yes, there is life uh before COVID and I I'm sure there will be life again post-COVID. So this year has been like a a sort of suspension, but I know it's been a suspension for everybody. So I um, slightly bizarrely, went to medical school because I wanted to do tropical medicine. It's the only branch of medicine I wanted to do. And I suspect it was possibly the seed was sown when I was a kid and we used to go and visit family in the tropics or the subtropics. And, you know, from an early age I knew about malaria because we were having to pop malaria pills. I knew if I saw a nice lake, I wouldn't be able to swim because there might be some schistosomiasis in there. And um, I knew those blue plastic traps they had everywhere for tsetse fly and that would cause sleeping sickness. So I I don't know if it was sown then, but I think I've I've probably always been fascinated at a sort of the proximity between man and beast, but be it microscopic beast as well. And so throughout my training, I was really, really keen to do tropical medicine. And um, with that went infectious diseases. And everyone used to try and dissuade me from it. I can remember, you know, being newly qualified and my first job saying, oh, what do you want to do? And they said, well, there aren't any jobs in that and why would you want to do that? You know, what about a sort of sensible, you know, specialty, cardiology or gastro or something. And um, I suppose I sort of just continued on that path. So I did, you know, my general training and then um, I went to have a spell abroad and I worked in um, in a remote hospital in South Africa for a while. I just done the um, the postgraduate exam, the membership of the Royal College of Physicians. And when I got there, it was like my textbook had just come to life. And it was it was an amazing experience. I mean, we were, it was quite remote. We were 70Ks down a dirt track to the nearest supermarket through a game reserve. So when you used to go and have and pick up your fruit and veg, if you were lucky, you'd see rhino and if you were really lucky, you'd see lion. That was very lucky. So it was very amazing and I was there, you'd have to sign up for a for a year and I um, ended up staying longer and I stayed for about a year and a half and I I loved it. Um, it was obviously very challenging, but it was it was fantastic in terms of what I saw and obviously saw a huge amount of infectious diseases and tropical medicine, um, as well as a myriad of other things. And then when I came back, um, I thought, well, I need to do, you know, get official training done. So I went to see the head of, um, I think he's the head of infectious disease training and he said to me, no jobs and there are very few, there were very few posts at that stage. And he said, why don't you go off and do a master's or something? So I duly went off and did a master's in infectious disease epidemiology at the London School of Hygiene, which was great and I just met really like-minded people who knew exactly why I wanted to do tropical medicine and infectious diseases. And um, then I went back to the head of training and I said, right, any jobs? And he said, no, why don't you go and do some research for a bit? So I toddled off and went to do some research for a bit. And then finally, um, there were some posts and then I got one and I got into training. It was a long haul. It um, it took a while and I just thought, you know, maybe I should just disappear back off to the tropics because that's I knew that's what I wanted to do, but I kind of hung in there and yeah, so that was the kind of journey of getting in there.
Dr Rupy: And and when you were in training, did you get the opportunity to to go back and and do a bit of traveling as well?
Dr Joanna Herman: I've always travelled a lot, um, always and um, when everyone, I mean at uni was sort of buying their first sort of stereo or something like that, I would be and me and my friends would be saving up for a long haul trick ticket to the tropics. So, um, I did, I haven't got to travel, I'd say for work, um, apart from, you know, conferences abroad, but um, no, so it's it's been mostly stuck here, I'm saying, but um,
Dr Rupy: Yeah. And and and you and you teach as well at the, uh, the on the tropical medicine.
Dr Joanna Herman: Yeah, so um, I've been teaching at the London school since I guess the the mid-90s or something. Um, and I teach on the diploma of tropical medicine that is is brilliant and it's um, a course that attracts people from around the globe. And you get all levels. So you can be teaching someone who's just qualified, newly qualified from um, you know, the UK or Australia or somewhere to you can have the Minister of Health from Burkina Faso. So and you get everywhere, you know, it's an A to Z of countries from everyone from, you know, I had someone I think from Afghanistan to someone from Zambia and everywhere in between. Wow. So, um, and it it's amazing, um, just working with those people and teaching those people because you learn a lot from them of how they are practicing their medicine there because we've all got different, you know, in low-income countries, obviously life and um, investigations and how you manage things are very different. So, um, and yeah, so you often having to rain people in when, you know, you say, well, how would you investigate this? And, you know, someone from the US will say, oh, we do a CT scan. And I was like, no, you haven't got any electricity and you haven't got a scan. Try again. Um, so it's a great, it's a great thing to teach on and I absolutely, it's I think it's been one of the highlights for me every year is teaching on that course.
Dr Rupy: Yeah, yeah. I remember actually when I was at medical school, I was really drawn to infectious disease and I think because it is, it is in some ways very competitive and you have to be quite committed to to persevere as you've just demonstrated by doing your research and traveling and all the rest of it. And you've really got to love the subject. But I've always looked at infectious diseases, um, the true art of detective work because like you said, you are limited in terms of your resources, particularly if you're not in a Westernized country, industrialized nation. Um, and you have to use almost all your senses, your skin, the, you know, all the different facets of of medicine. Um, I just find it fascinating.
Dr Joanna Herman: Absolutely. And it's often the talking. So the the questions you ask the patient and um, you'll you'll often get the little hints um, will just come up and you've just got to know what to ask. So, you know, how when you're a junior doctor and you've taken this long history and the consultant comes around and just gets it straight away and asks the one thing you haven't. And you can find also with, you know, infectious diseases or tropical that you can come in and you can just because you know and you you kind of seen things before and you know where it might be coming from, you can just ask a sort of minute detail about their dog or, you know, a recent exposure to something or other that might account for where they've been. Yeah. So, yes, a lot of detective work.
Dr Rupy: Definitely, yeah. I whenever I I think of um, you mentioned schistosomiasis, I just remember that typical MCQ on the on the end of year exams of somebody comes back from Lake Malawi and they've been swimming in the water and what and they've got they've got hematuria, what's the diagnosis? I just remember that it's just straight away just pattern recognition. I haven't thought about that for years. Um, but I I wonder if you could give us some insight into what your day-to-day life was like, um, uh, pre uh, 2020 as well. So what what was the day job looking like for you apart from obviously your your um, uh, teaching duties uh, at the London school. Um, what what what would an ID consultant do?
Dr Joanna Herman: Well, I was actually before this, I was actually working in the department of microbiology. So I was working as a sort of um, more as a department of infection. It was slightly different from a usual infectious disease job in that I was working in a microbiology department. So the main difference was that we didn't have patients directly under our care. Essentially, we were more of a consult service advising on all infection-related matters to doctors in other specialties in the hospital. So we'd be taking calls about patient queries, which could be for new admissions or for those on the wards who weren't responding to current treatment or clinic patients, but we'd also see patients that needed review. So each morning we would check what blood cultures results had come up positive overnight and ring those out to the relevant doctors looking after them, getting the story of the patient and checking if they were on the correct treatment. And we had daily meetings with the infection control nurses to see what issues were rearing their head in the hospital. So their work obviously increased exponentially when COVID kicked off. And we'd also do daily antimicrobial stewardship and intensive care ward rounds and attend various other weekly multidisciplinary meetings for some of the other specialties. And then we also had to fit in authorizing results from the lab. So making sure that the results made sense and adding asking the lab to perform any extra tests on the specimens so you could get the best results to guide appropriate treatment for the patients. So, um, we were doing rounds on the wards, we were consulting to, we would do rounds on intensive care, on the general wards, very specifically it was more um, microbiology faced, um, than infectious disease faced, but they came to know um, the hospital, the people in the hospital came to realize I was actually an ID person with particular interest in tropical. So they would often ring me up or particularly ring me from A&E and say, we've got a patient who's just come back from, you know, wherever, what do you suggest? Could you come and have a look? So that's not necessarily, you know, a normal ID consultant post. So I was doing something slightly different. But, you know, it's it's all infection. Um, there was a lot of sort of education also about antibiotics and antibiotic stewardship. So it came more into the general infectious diseases, um, remit of trying to, um, really sort of educate um, the junior doctors particularly about need for antibiotics and, you know, there's that knee-jerk reaction, someone comes into casualty with a fever and you've got to do something and you've got to put them on antibiotics because fever equals infection. And obviously with all the issues with, you know, um, resistance and everything, which is going to take us into a whole another topic. You know, I see it part of my remit as an infectious disease person is to try and educate along the way and try and rain things in when they seem to get, uh, yeah, people are reluctant to do things.
Dr Rupy: Definitely, yeah. I'm I'm really resisting the urge to go down that route actually of talking about antimicrobial resistance, but we we just did a whole podcast series on it with um, Dame Sally Davies and a few other um, microbiologists as well.
Dr Joanna Herman: Oh yes, no, no, that's leave it to them.
Dr Rupy: Yeah. Um, but no, I I find it fascinating and I think it's definitely a hot topic that probably needs uh, again, more attention post-pandemic because we've just been doling out antibiotics, particularly in both primary and um, uh, emergency medicine, um, like like sweeties. So that that's definitely something that that needs attention. Um, let let's turn to to your experience, um, last year in in March, I believe it was. Um, can can you talk us through um, the early stages of of your infection with COVID?
Dr Joanna Herman: Yeah, so, um, the first few days, I just noticed I was slightly bunged up and I had the beginnings of what I thought was going to be a slightly sore throat. And it was only because I'd had contact, um, you know, in the hospital and everything with people that then turned out to have COVID. Um, that, you know, I was then off work for a few days. But then within um, five days of that starting, I went down sort of what I call big time where I felt absolutely flawed. So, um, I developed these absolutely searing headaches, um, to the point I was couldn't wait for the next dose of paracetamol and I'm not someone that takes anything anyway. Um, I had background nausea that was non-stop. Um, I lost my sense of taste. Um, and actually even water tasted disgusting. And I think one of the earliest signs was I I'd made a huge, you know, sort of um, pan of soup that usually tastes delicious. And I thought, why is this disgusting? It tastes perfectly fine last week and now I've made a new one and it tastes awful. And I realized later, I realized it was because of COVID. Um, I was permanently cold, um, and I just felt flawed. I couldn't move. I mean, for the first six days, I just was sort of in bed, um, might make it to the sofa, um, but felt really, really terrible. Um, and so people said, oh, it's just like flu. I said, well, you're as flattened as you are with flu, but the symptoms are nothing like flu. Yeah. Um, yeah, and I had no appetite, so I didn't eat at all. I didn't really want anything to eat. Um, and then so the first, those first six days were really ghastly and then the next six days were slightly less ghastly, but still pretty awful and I probably made it more to sofa than bed. Um, and then I remember thinking sort of day 12 or 13, I thought, oh, I do feel a lot better and it's that sort of sensation where you've had a virus and you think, oh, it's all gone, it's lifting. Um, so I thought, oh, I'll probably be back at work next week. And um, well, I was very wrong. Um, so then I think the subsequent weeks, I um, started to sort of improve slowly. I found I needed to sort of sleep every afternoon for a couple of hours and slowly each week it was a bit less. But that was just like a recovery from any virus, you know, or a prolonged virus really. Um, so there was nothing that I suspected was going to be weird. I just thought it was just a bit long. Um, and also I'd started to sort of do a little bit more in terms of just trying to go for a bit of a walk or a little do a little bit of yoga. Um, and then I also noticed that my hair started to fall out. And it was like post-pregnancy, you know, after delivery, you suddenly lose these huge clumps of hair. And I I my hair just got really thin over the next few months, which I found intensely worrying. Um, and initially there were no reports, but then I think by the summer I started to see reports of other people experiencing that. And then I think something started to change around mid-June. Um, and not there was nothing that I can think precipitated it, but I started to experience this crashing post-exertional fatigue. I forgot to mention I had a bad cough, sorry. That was Oh. I was going to ask, did you have any chest symptoms at all? Yeah, so I had, I had, funnily enough, I had a bad cough, but I did not, it wasn't the worst cough I've ever had. And to me, when I look back on it, the worst symptoms were the headaches and the nausea and feeling terrible. Um, I wasn't breathless. I didn't have chest pains. But then when I started to experience the crashing post-exertional fatigue, I uh, started to develop chest pains as well. That I thought, you know, it felt like they were in the lower third of my lungs and I thought, oh, is this what sort of pleura, infection of the pleura feel like? And it wasn't related to exercise. I wasn't breathless with it. There was there were no other symptoms with it. It was just the fatigue and the chest pains. And if I rested, it all disappeared. Um, and I just want to point out, I never needed to sleep apart from that those early days of getting better. And so people would often say to me and still do say, oh, I suppose you need to sleep a lot. And I go, no, I don't. I just my body needs intense rest and it needs quite a lot of it. Um, but in between, you know, I can function okay. The hair loss probably stopped towards the end of the summer, but I have been left with um, this post-exertional fatigue and the chest pains which still happen. Um, and yeah, I should also forgot the brain, I mean, it's now called brain fog, but my brain felt like it was working at sort of half mast and very slowly.
Dr Rupy: Was that quite early as well?
Dr Joanna Herman: Yeah, so that was um, sorry, yes, that was early. That was in the first um, the first few months. Particularly bad. And it really didn't want to think. And it found it hard to think. And even, you know, sorting out practical things, um, for the house or even, you know, if you needed, you know, for example, the broadband needed renewing or something like that. Yeah. It would take me days to think, I've really got to do that. I don't want to do it. It means thinking, it means, you know, or even looking online to see the best deal. It was just too much. It was really, really hard. Um, and so yes, it was particularly bad those first few months. And I'd say probably even six months was pretty bad. And um, I mean, we wouldn't be having this conversation now. Yeah. And so in the summer, people would come and see me and we'd sit in the garden and, you know, after an hour, that would be it. I would be gone. And they they they would often say it's visible. You just fade and you stop sort of your talking just gets less and less. And it felt like it was a huge effort for the brain to connect to the mouth and say anything and then it just didn't want to say anything. So it's been really profound like that. And um, gradually I've seen, you know, that's increased so I can have a conversation for much longer now. Um, and even, you know, I've written the couple of articles that I've written for the Guardian were fine. They were written on good days. Um, but, you know, an editor got had to speak to an editor about something on one of my bad days and I just said, I just today is not a good day to make changes and need to think straight because it doesn't feel like it wants to think straight, my brain.
Dr Rupy: Yeah, yeah. I remember us having a conversation prior to this, uh, and you you mentioning how, you know, you do have good days and bad days and it just it's really luck of the draw. I don't think there's a a clear sort of trigger that you have for to to sort of pre-warn you. I I'm trying to get into the your mindset quite early on because, you know, you're you're you're a a very well-established doctor, you're a consultant in a busy uh, London hospital, you teach on the um, at the at the London school. Um, you have so many responsibilities, you have a family. How how was it emotionally being not being able to do all those things given that you were fine a couple of months before?
Dr Joanna Herman: It was really difficult. So the first few months, well, the first month, I, you know, actually at the beginning, I thought, oh, great, I've got, I've got COVID, it'll be over and done. I'll be early on in the pandemic and that'll be it for me, done. And I even thought, if the worst came to the worst and I needed a hospital bed, but I have no risk factors for needing it, I knew there would be one. Whereas I figured there wouldn't be a few months later down the line. And so I was fine and then a month went by and I thought, oh, I'm not right still. And my GP just said to me, look, she's seen people who are taking more than a month, some of them taking a couple of months, just hang in there. I'm sure it'll be fine. And a couple of months went by and we had the same discussion and she said, look, just hang in there, maybe three months, maybe four. And then it got to the summer and I thought, crikey, I'm still not better. What's going to happen? And we usually go surfing in the summer. And so I was really looking forward to that and I was thinking, this ain't going to happen. You know, I no way am I going to be able to do anything that active. And I think the first few months were intense frustration that I wasn't getting better. I saw what was happening, I saw what my colleagues were dealing with and I just wanted to be there. I wanted to be in it and um, you know, just just working in a pandemic. A pandemic as an infectious disease consultant comes along very, very rarely. We don't want any more, but it's ironic that as a, if it's your specialty, you end up sitting it out from the sidelines when you should be in the thick of it. Yeah. And so I had a huge amount of frustration and probably disappointment that I couldn't be there and couldn't be doing anything or or contributing. I think that was it that you couldn't contribute when you were actually really needed. And then I think by the time the summer came, I was like, you know, heading towards, well, even later summer, heading towards six months, I just there was a thing of I just had to sort of let go. And I think I just, so there was an acceptance of where it was. Acceptance that I wasn't going to be working and that maybe, you know, by the autumn I would be, but I just had to let go. And I guess, you know, that's probably where yoga helps me and a long practice of that helps with that sort of acceptance and letting go of things. I can't say it helped me get better at all, but um, I think it probably helped mentally.
Dr Rupy: Yeah, yeah. We should say actually that you you've had a a long um, a long practice of yoga prior to to everything happening the last year. Um, what where where did that interest come from?
Dr Joanna Herman: I guess I've been practicing Ashtanga yoga for over since the late 90s, so over 20 years. And I dabbled in odd bits of yoga, different forms, sometime in my 20s. And then I found there was a place, it was actually, I remember it was an ad in the paper I saw, tiny ad, that said, it was called the practice place, come to Crete for, you know, and learn the Ashtanga yoga practice and swim in glorious seas and eat glorious food. And I thought, why not? And I actually couldn't go that year and it it was only when I came back from living in South Africa, I'd kept this little um, ad for it and I went and I was completely hooked. And I'd done odd forms of yoga that were much more static, but this was a very dynamic, flowing practice and I was sort of transfixed by it. It was almost like this dance-like form that flowed around your breath. So breath was crucial. And um, I was basically hooked. Um, and and that was it. And so I've been practicing pretty much ever since. I mean, there've been times when I've been less on my mat and times when I've been more. And as you know, life as a junior doctor doesn't always give you the energy or the time to be on your mat all the time or be doing other things. Um, but it's something, um, I've I've it's just been a part of my life for a long time and I I kind of view it as a, I guess a sort of essential life support, support system.
Dr Rupy: Have your colleagues always known about your sort of um, how you intertwine yoga and and clinical practice?
Dr Joanna Herman: Yes, I think I was just as a sort of people thought I was a bit um, I won't say hippish, but just a bit alternative. And I had one comment once says, I was going off to India to practice with someone and they said, oh, I suppose your yoga goes with your herbal tea drinking. You know, presumptive or pigeon-holing or what, but um, it did make me laugh. And I think every time I went off to India, they imagined me, you know, in an ashram with yellow robes and things, which I wasn't doing at all. But um, yeah, I I mean, I think it's been become more accepting. But people would often and still do say, oh, guess what, I've taken up yoga as if I should be really excited that they've finally taken up yoga. Um, but I guess you know what that's like of, you know, being what we I think we refer to as a slightly hybrid doctor of having a foot in both camps of something that I'm not going to call it alternative, it's complementary.
Dr Rupy: Yeah, definitely. I I think that hybrid model is becoming pretty mainstream, I would say now, um, particularly with the evidence that's mounting around yoga and and and breath work. I I definitely want to touch on the mental health benefits that yoga bestowed on you to sort of help you through this traumatic journey, but um, with the breath um, techniques, were there any uh, breath techniques that you experimented with during that time, particularly when you're having um, chest issues?
Dr Joanna Herman: No, I mean, I've I mean, I should say that the chest issues are the chest pains and I'm not sure that, you know, I still don't know why what what they're caused by exactly. Um, but all I've had is a chest x-ray that was normal. I've not even had, I've not had a scan, so I have no idea. So I just had to, I've been doing the practice I've always been doing, um, although I've had to let go a lot of it. So, um, you know, the breath techniques or the formal word I would use would be pranayama, but easier to call them breath techniques. And prana, you know, as you know, is is is breath, but it actually means life force rather than breath. And there are more uh, slow rhythms and there are more fast, rapid rhythms. And I've given up trying to do the fast, rapid ones because they they they don't work for me right now. So I just do the slow ones, but it's um, I think they all, I think they can all be beneficial and I think it's about, you know, the people I've been teaching haven't done any yoga before and haven't done any breath, but they've and they all had bad effects on their lungs. And they found it, you know, really beneficial to help sort of get into their breath, to extend their breath and actually getting people to learn how to breathe again because people don't often forget, I think, you know, there's a lot of breath holding and anxiety and actually you just need to keep breathing. And you need to focus on areas that you forget where your lungs are. You know, they're not just the front of your chest, they're the back, they're the sides, they're the bottom, there's right up to the top. And just by putting helping people in different positions in different postures and think about focusing their mind on their lungs and different aspects of that, I think has been really helpful to people.
Dr Rupy: Yeah, absolutely. There's um, so I I did a podcast with a colleague of mine who works at the Wingate Institute in um, in in East London. Um, she's a gastroenterologist and she works with IBS patients all the time and she she often uses that um, that explanation that your lungs aren't just at the front of your chest, which I think is quite, you know, it's a common misunderstanding for people who don't understand anatomy, but they're very very much into the back and into the into the abdomen. So you have to be quite aware of that whenever you're doing breath techniques and uh, um, certainly it has a a calming effect as well that's been, you know, very well researched now. Um, from the mental uh, wellness perspective, how how did yoga sort of help you surrender to your current scenario and and what was that sort of realization like?
Dr Joanna Herman: I think it's um, I think having had a long practice, um, really has helped. And it's I just think that the whole breath-centered approach with Ashtanga yoga and I'm not practicing a dynamic form at the moment because I can't, um, physically, but just that meditative approach to the practice, which essentially it is, I call Ashtanga a dynamic meditation because your postures flow around your breath. So you get on your mat and all you do is breathe and your postures flow around that and if you do that for an hour, your your mind feels quite amazing and very stilled. Um, and you know, if we think of the yoga sutras, the second one is it's uh, so stilling of the fluctuations of the mind. And I think that is really crucial. That's that's how it works. So it it does, you know, I I just think mentally it it does have huge benefits. And I can't pinpoint one part or one area that helps, but I think particularly the breath um, does and when you tie your mind to your breath for however long you are able to practice, it really stills the mind. And you know, even when you're practicing when you're well, you have to you accept where you are on that day on the mat. So you have no idea when you step on your mat how you'll be. You might have been really flexible yesterday and been able to do all sorts of things, but today you might feel stiffer. And it's every day you every time you step on your mat, you face yourself at that point. And you have to, I think it takes a lot to stop striving for, you know, trying to get your foot behind your head or something like that to just accept where you are and to be with that.
Dr Rupy: Yeah, yeah, definitely. I I had a wonderful conversation with a friend of mine who's um, uh, she's now training as a psychiatrist, but she was an F2 when I was training in general practice and was unfortunately diagnosed with um, melanoma. Um, and she spent a lot of time um, going through different diets and trying all these different sort of exercises. And the one thing that really grounded her was yoga. And she's described it very similarly to you. It's just I immediately thought of it just now about how she surrendered to her diagnosis using yoga, how it had so many different benefits to her mental well-being where she just almost flowed with what was going on with the universe. Um, and she's since done very well with her immunotherapy as well. But it just it just really um, yeah, just made me think of that. Um, it's making me want to get on my mat more often. After. After, for sure.
Dr Joanna Herman: Um, I I think it I think it does. I think it it grounds you, I think it, I mean, I often say to people, yoga's not there to add things. It's actually there to remove things. It's there to remove the obstacles that we put in front of ourselves. We're our own worst, we're self-saboteurs, aren't we, at the best of times. My teacher used to say there's no such thing as a stiff body, only a stiff mind. And I think that's really true. Um, so I I think it's probably, you know, just having had that practice for years just helps. Um, but I also think the time when you most need your mat, it's almost the most difficult time to get on it.
Dr Rupy: Yeah, yeah. That's a very good point. I mean, I I draw a parallel with that with meditation as well. When you need meditation the most, you always feel overwhelmed or um, busy or you don't feel like you can fit it in. That's when you know, I always tell myself, you need to meditate because it's telling yourself. Definitely.
Dr Joanna Herman: So you managed to have um, a break, like a like a almost like a holiday at some point um, last year. What what was that? Was that almost like a bit of a breakthrough in terms of, you know, to to how to rest your your body and and and actually improve some of your symptoms or?
Dr Rupy: Yeah, so I think I was stuck for I'd say seven months of managing a 20-minute walk. I'm not even talking fast walking, it was just a 20-minute walk. I mean, there were times where I'd go for a walk and I'd feel better and I'd walk further and I'd end up lying down in the middle of the common because I couldn't walk any further. You know, ended up abandoning the shopping in the supermarket because I just like suddenly, it's like the plug is suddenly pulled out of the socket and that's how you don't always get warning. Um, but yes, so um, I just felt that I needed to get away and I needed someone else to take over the daily chores of the thinking about what to cook, the cooking, the clearing up, the doing the washing, everything. And um, I was very lucky that I could manage to do that. And that really started to help. I mean, I had days when I felt terrible still and days when I crashed and days when I had chest pains, but something started to shift in terms of just being able to do a little bit more. Because, you know, when you're still trying to, you know, you're managing your home, you've got to still think about everything else you've got to do, you don't, you know, you have to prioritize what's essential and you don't have the energy to do it all. Um, so, you know, you know you've got to make dinner, you might not be able to do any yoga or something or you might not be able to go for a walk. But on your good days, you might you'll manage both. Um, so I think it it just gave me and my body some space to allow it to really deeply rest even more. Um, because I know seven months is a long time of not working and being able to rest, but you're not truly able to fully rest because there are still things you have to do, you know, like everybody.
Dr Joanna Herman: Yeah, of course.
Dr Rupy: It's called life. Yeah, yeah, exactly. And and in that respect, what what kind of support were you getting if any from the NHS at that point at that point? I mean, I you you had some appointments with your GP, but uh, I guess.
Dr Joanna Herman: No, so I'd had nothing. I'd had um, my GP would check in with me sort of every, it was every few weeks initially and then it was every month. Um, and at the end of September, she said, look, there's still no clinics up and running. I'm going to refer you to a respiratory team because of your chest pains, at least you're in the system then and hopefully they will get a COVID clinic up and running at some point. It took another, but apart from that, I'd had nothing. I uh, it then took another few couple of months, I think, end of November, I had a phone consult with the respiratory consultant. Um, who, I mean, it was good to talk to anything, but there was nothing much he could offer me. He said, well, let's get a chest x-ray and I'll refer you to the physio. Like, oh, great. And I'll I'll speak to you again in three months time. And I was like, three months? This is crazy. Eventually got the chest x-ray and, you know, that took me ages to get because it was an effort to go to the hospital and I wasn't convinced it was going to be abnormal anyway, but um, and then I got a call in the new year, um, from the physios at the local hospital said, look, we don't have a COVID clinic, um, and we don't have any specific rehab for COVID, but you're very welcome to join our pulmonary rehab clinic for patients with uh, COPD, chronic obstructive pulmonary disease. So I say, but I don't have any pulmonary disease. And she said, well, that's all we've got. So I said, fine, I'll take that and see how I get on. Um, so I started that a few weeks ago. It's um, two hours a week, um, on two days and by by, you know, on virtually done. And it's pretty hard. I mean, I ended up, the first time I managed 20 minutes and then I crashed for hours. And, you know, I've persevered because it's the only thing. But actually, I don't really necessarily feel it's the right thing. And um, I feel that, you know, we need some sort of more personalized care for people who've got this. And so wouldn't it be great? I got a friend of mine who's similarly affected and she's actually had a one-to-one virtual appointment with a physio who who does assess her. So that's the kind of better way in my mind. But, you know, I I bow out of the class every time within probably 25 minutes, um, because I can't do any more and then I'm usually on the floor for a bit, lying down.
Dr Rupy: This is the thing, we're we're very much um, flying blind with this uh, condition because there are a number of theories that I I spoke about with Prof Altman, um, whether it's uh, a fibrotic issue, whether it's uh, there's an a component of autoimmune conditions, whether it's a lingering virus that hasn't been cleared yet. And physiotherapy is a is a fantastic intervention, but it has to be targeted and what you're having is something specifically for people with pulmonary fibrosis. You know, and so and and it it we don't know whether that's the appropriate treatment. It's like we're just using a medicine because it kind of helps with people who are, you know, all have similar symptoms. So we'll give it a go. Whereas, you know, that that could actually be doing harm.
Dr Joanna Herman: It I mean, it could well be doing harm for some people and it certainly, you know, I I do question when I do it, why am I persisting? And you do, we do some, you know, marching on the spot and then we do some other exercises and we do um, use those therabands, you know, the um, physio sort of latex bands. And I do realize how weak I've become and I was pretty strong before. Um, and so I'm sort of using them and I'll everyone will be standing doing those exercises, I'll be sitting. And I just thought, well, even if I do a little bit, maybe I'll just get stronger. Um, and that will help. Yeah, it it does seem ironic, um, as you say, that to be joining something that's not necessarily the right thing. Um, and I've just the other thing I've noticed with COVID is I lose my train of thought quite easily. So I just had a really good thought to point to make and now I've completely forgotten it, but.
Dr Rupy: It's all right. We'll hope it comes back. But if it doesn't, you can text me afterwards, it's fine. But um, I I was going to ask actually about when um, you sought to reach out to other people that were perhaps having similar symptoms if at all actually. Did you did you go online? Did you look for communities that were suffering with with um, post-viral issues like yourself?
Dr Joanna Herman: Yes. So, um, I think when I I set up this yoga group for COVID people back in the spring. Well, it was I think we started in May when I was just about feeling okay to teach. Um, and to be honest, I haven't reached out to join online communities. We've been a really good group and I think we've been a support system for each other. So every, you know, I teach once a week and every Sunday morning we log on and people would, you know, the early days would recount their symptoms and there were two of us who are medics, so we, you know, would offer some some more knowledge and different knowledge from them. And it was really helpful and um, we uh, yeah, I suppose we we've been on a journey together of COVID together. Some are now much better. Um, one is pretty much completely better, gets the occasional chest pains. Um, and there's some of us that are still quite affected, quite badly still. Um, but I suppose I didn't feel, I was reading a lot, you know, I I knew a lot about what was going on and reading a lot about it, but I suppose I didn't feel I needed to be out there. And I think also with the limited energy reserves I had, I sort of kept it for friends that would drop in and I'd wanted to have those kind of chats rather than be online. And I wasn't spending a lot of time at my computer anyway then. Um, I mean, it took, you know, in terms of brain power, I think it was seven months before I picked up a novel to read it. I just, you know, I'd start an article or I'd read something, but it was short. My brain didn't want to do it.
Dr Rupy: In terms of your your brain power now, would you say you're making incremental improvements that are trending upwards or?
Dr Joanna Herman: Yes, so I think, um, I think, you know, I'm definitely improving. I think it's snail-paced, but it's an upward trajectory. And the way I started to look at it some time ago was you don't look at it daily, you don't look at it even weekly, you look at it month on month. So if I think what I could do a month ago, I can actually do a lot more. And if I look back to, you know, around Christmas, New Year, I can do a lot more. And that's, I think that's been helpful really. Because before I would really beat myself up if I, you know, had a bad week and couldn't do things and I'd think that I, well, I did it two days ago or whatever. Um, and actually it's not, that's not helpful. Um, so it's again, it comes back to that sort of letting go and you just, you know, I can't believe that I'm at a year and that's really hard and on bad days, so on Saturday I had a really bad day and that just felt really hard because it's about my year's anniversary and I'm thinking, I had to cancel my walk with a friend. Um, I just wasn't up to it.
Dr Rupy: I honestly, I think that's such a fantastic perspective for people to hear about not getting caught up in the day-to-day or even the week-to-week. It's those month-to-month reviews or maybe even quarterly reviews for some people where you can actually take a step back and look at the change overall because if you're constantly looking at it on a day-to-day basis, and this doesn't need to just apply to people with a post-viral syndrome, it can be people who are trying to achieve whatever goal it might be, you know, whether it's a a habit change, lifestyle, weight loss, whatever it is, you really have to take a step back and look at the overall picture. And I think that's just such a a brilliant way of looking at it because otherwise you can spiral into that um, negative self-perception, that that that shame spiral. Um, and I think the the way you've described it there is is is really helpful for people.
Dr Joanna Herman: Yeah, and I think there's, there's a shame, there's almost an embarrassment and you know, you get people saying, oh, are you back at work yet? No. Oh, well, do you know when you're going to go back or whatever? And I was like, no way, I'm nowhere near well enough. I mean, when the vaccination came out and the roll out, I thought, great, I could, you know, I think I was on a good day, I thought, oh, maybe I could go and help vaccinate people. And then the next day I had a rubbish day and I thought, you can't even be, it's so unpredictable. Um, you can't really be reliable. And you know, if you're going to do something like that, you need to know that you can show up.
Dr Rupy: Yeah, absolutely. And and considering the potential numbers of people who are going to be afflicted with prolonged recovery from COVID, I think it's it's, you know, particularly pressing that we do need to have that A research and B the funds to to actually tackle the problem and and lend support. And on the subject of of support and and I know this is your anecdotal experience, but perhaps combining your your knowledge of post-viral syndromes, your own sort of um, uh, interest in in yoga and and and exercise modalities. Are there any things that you feel that could be beneficial to people who are having a a prolonged recovery?
Dr Joanna Herman: I think it very much depends on what issues they've got. So for me, it's just post, it's the post-exertional fatigue and the occasional chest pains. But for people that have got, you know, they might have fibrotic changes in their lungs or they've got issues with their heart and arrhythmias or tachycardia or or gut issues, it's very different. So I don't think there's one thing that fits all. Um, so I haven't, I've had no light bulb moment where I thought, aha, that's what I need to start doing and that's going to improve matters. There hasn't been anything like that. For me, it's been, you know, a lot of patience, um, a lot of just going with it. Um, I try to, you know, interestingly, no one's talked about nutrition particularly in COVID and I think, you know, we that's another discussion. Um, but, you know, when I I think there was something I read about, oh, improving your diet during if you're getting better from COVID and it looked at sort of whole grains and lentils and dried fruits and pulses and nuts and I was like, well, I do that anyway. What else can I do? So there was nothing really to offer me. Um, so I'm I'm not sure that I've got a, there is no magic. You know, at a year on, there's nothing quick. Um, and I have to say, I've found the last few weeks really hard mentally because I was coming up to my year's anniversary. And, you know, I don't want to call it an anniversary, that's usually something to celebrate, but it's been a really hard few weeks thinking, gosh, when is this going to go? When am I going to feel better? Um, and actually, I mean, I was thinking the other day that actually if there's a time to be really unwell and a whole year to lose of your life, it's during the pandemic because no one else is doing anything. So I was trying to look on the bright side. I can tell you've definitely got like a positive disposition to things, you know. It's really nice to see and to hear. But um, but yeah, no, it is tough. It's it's I I can't uh, begin to imagine how tough it it must be for you considering, you know, your previous position and everything um, that you're going through at the moment. So, you know, I think the one of the biggest takeaways I've got from this is the fact that you have to give yourself time and you can't rush these things. And I think everyone's experiencing that in in various ways that, you know, we used to live quite fast-paced lives and we're being forced to slow down now. You more than most people. Um, but but overall, hopefully that will lead to um, a better mental state rather than a negative mental state in a weird way.
Dr Rupy: I think the most crucial thing for COVID is to pace yourself. So you just have to watch what you do. And if you do more of one thing, then you do less of the other. Um, so I remember a few weeks ago feeling really good on a Saturday morning, so I thought, right, I'm going to do some yoga with a friend. This is all virtually. Because I felt up to it and I'd also arranged to walk with a friend later afternoon. And I thought, that's fine, I've got quite a few hours. So the yoga was fine, didn't do too much, quite gentle on myself. And I felt great going for a walk and it was a sunny day. And then by the evening, I was a disaster. And I should have known, I'm not up to doing two things like that. Um, and the next morning, I think I had to cancel my teaching because I was still bad. Um, but it's that classic boom and bust cycle that you've probably heard of. So with uh, post-viral fatigue, there is a tendency, you know, you boom, when you're when you're booming, when you're feeling good, you do everything you can or do more than you should and that only leads to a bust when you crash and sort of collapse in a heap. And so it's breaking that cycle. Um, and I think the crucial thing is is really pacing. But it's really tempting, you know, the sun's out and you want to walk.
Dr Joanna Herman: Absolutely. Yeah, I can imagine, especially if you feel like energetic in that moment, you're just like, and you've been, you know, holding back or you've been physically held back for such a long period of time.
Dr Rupy: Yeah. My immediate thought would be to like jump out and, you know, really go and enjoy it, especially, you know, on a day like today with the sun's out.
Dr Joanna Herman: Well, I had to I had to do it this morning. So I looked out and thought, really sunny, I really fancy a walk having done nothing at the weekend. And I thought, no, I've got a long conversation. You cannot go for a nice walk in the sun. So you have to choose. It's all about, you know, it's every day you sort of you prioritize what you really need to do.
Dr Rupy: Okay. Well, I hope this talk was worth it because I feel bad now that I've kept you from a nice sunny walk.
Dr Joanna Herman: No, I didn't mean to. No, not at all. Not at all. Laughter is the best medicine anyway, so that's good.
Dr Rupy: Definitely, definitely. I I I will have to let you know about um, Professor uh, Robert Thomas's um, research. I'm I'm interviewing him tomorrow and he's he's conducting the only nutritional intervention trial for post-COVID patients at the moment. So he was, he uh, is well known for the Pomi-T trial, um, which which is a a high nutrient dense supplement for prostate cancer. So he's an oncologist at Addenbrooke's. And um, they've done something with um, COVID patients just post-COVID patients that I think they've had about 150 people and they've put together um, an intervention arm, which is a probiotic plus some some high nutrient dense ingredients like some green tea and a few other things in a capsule. And that's the intervention and the the control arm is just the probiotic because they couldn't recruit people without the probiotic. So there's all right, we'll give you guys the we'll give them both the probiotic and we'll blind the um, uh, the intervention which would be the nutritional. So I'll let you know if there's anything there if you're if you're up for experimenting with anything.
Dr Joanna Herman: I I to be honest, I'm up with anything. Uh, you know, I I'm happy to try things. I have, I have to say on the on the back of I think my first article, I got offered all sorts of strange things including, I'm trying to remember what they were now, but propolis, so bee pollen. Um, I got offered, someone suggested a a load of anti-retrovirals for me, but I didn't didn't really think they were what I wanted. Um, and some sort of other sort of slightly alternative things um, that I can't say I've gone with. Um,
Dr Rupy: Well, you know, it it conjures up a lot of um, because the the symptoms are very similar, people think, oh, the mechanism might be the same. And I think that's where, you know, these social groups online as supportive and as, you know, uh, incredible as they can be, they can actually perpetuate a lot of um, issues because people are, oh, I tried the keto diet and I had Lyme disease and I feel much better now and I used to have the same symptoms as you. So, you know, maybe you should try the keto diet and that might be wholly the wrong thing to do. So, um, yeah, I think like to your point, it really needs to be personalized to people's symptoms and and have a targeted approach. And I do think we need to do more investigations. Like you said, you know, your interleukin uh, and and CRP and a whole bunch of other parameters would be really useful.
Dr Joanna Herman: And I think what I'd really like and what I've been wanting for ages is an exercise physiologist. So someone who tells me what's happening, you know, electrolyte wise at my muscle levels, oxygen levels, whatever, when I crash. There must be something going on. And so, you know, that that's been something I've been wanting for probably over six months, I think.
Dr Rupy: Is there like um, a reproducible crash as you've described it that um, you can do in an experimental environment? So let's say you were put on the treadmill for 30 minutes at a at a walking pace or a high walking pace, whatever. Is there a point where you can say, okay, this is probably about the time where I'm going to have that that crash or is it really dependent on the day?
Dr Joanna Herman: It can be variable. So the other day, um, I walked for half an hour and I needed to sit down on a bench. And then the other week I'd walked for 50 minutes and I felt great. So, you know, I felt great at the time, but hours later I felt, oh, you know, not great. But yeah, be willing to try anything if someone wants to put me on a treadmill. It won't last very long, be very quick.
Dr Rupy: Yeah, yeah, exactly, which which is why it's it's quite, I can imagine it would be an easy controlled experimental environment where you can, you know, do bloods pre and post, you can look at glucose levels, you could even do things like muscle biopsies. I know they're painful, but you know.
Dr Joanna Herman: No, you see that's what I'd really like or or just oxygen, you know, what's going on at my my muscles, you know, what's going on with my mitochondria, you know, even down to that level is what I've been thinking. Um, and yeah, that's not going to happen in your average NHS clinic, that's for sure. But it's in a research environment.
Dr Rupy: Exactly. Um, but I think those are the way we're probably going to get the answers. Um, you know, whether you can then change things, but the first thing is to understand what's going on. And I think that brings me back to the frustration of the whole thing is that, you know, no one's, no one's examined me. I've been in a year and I've not had a single examination. Not saying that I need one, but I've not had one. Um, so yes, it's kind of um, weird, but it it would be, you know, it'd be very interesting what um, Danny Altman comes up with.
Dr Joanna Herman: I'll be sending him a message.
Dr Rupy: You need to get on with it.
Dr Joanna Herman: Yes. PDQ. Um, and uh, yeah.
Dr Rupy: Well, this has been fantastic talking. Honestly, thank you so much for sharing your story. Um, and uh, and and I would love you to keep in touch as well and and and let us know how you're you're progressing as well. I think it'd be and if there's anything else as well that you'd you'd want people to know about or, you know, that that to just do let us know because um, it's uh, it it it's great to to, you know, have some insight into this because I think it's going to be a bigger issue than we are currently being led to believe and I think we're reacting to a problem right now, which is obviously what we need to be doing, but we also need to be prepared for the eventual issues of um, prolonged recovery.
Dr Joanna Herman: Yeah, no, I completely think so and I I also think that having doctors on board and trials that, you know, who've been experiencing it themselves, um, is is really important. Um, it's very different when you're the patient as the doctor. Um, so completely different perspective. Um, but yes, no, it's been been lovely to speak to you and um, I seem to remember saying very happy to do the podcast, but I'd like a few meals in return. I will definitely sort that out for you, don't worry. That's the thing I that's the thing I struggle the most with is like cooking. That's just a huge energy, but you know, it's an essential thing.
Dr Rupy: Definitely. Well, I you know, it's funny, I was doing a program um, on ITV the other night with uh, Martin Kemp from Spandau Ballet. Yeah, I'm a big fan ever since he was in EastEnders and I think he was in the um, uh, the Kray twins uh, movie as well, um, years ago. And and I do like Spandau Ballet. And so it was a it was a program all about aging and aging well. And they wanted me to do some recipes with aging mind and I said, look, we could do recipes, you know, whole grains and largely plants and colorful diet, etc. But the the there are other things you need to be aware of. So people who are not motivated to cook themselves, perhaps because their partner who was the the main cook has has passed away. Um, lack of energy, um, as well as, you know, lack of wanting to go out and stuff. And there was actually a few parallels because I've been asked on social media by a few people who say, look, I love your recipes, but they're a bit involved and they involve a lot of chopping, etc, etc. So I came up with a concept of no chop one pots. Oh, great. Where there's no chopping involved. It only requires one pot, so there's minimal washing up and you'll you'll get in at least three portions of fruit and vegetables and they'll be flavorful and they could be things like um, stir fries or sautes or even curries where you're using things like pastes or just ripping up some coriander leaves or herbs or even mushrooms and stuff stuff like that rather than going through peeling and chopping and the things that people find as barriers. So if I do come up with a few recipes, I'll definitely send them over to you to test, but I I promise I will cook for you at one point as well. Don't worry. I'm not getting out of it. That sounds great.
