Minna Heeraman had an aggressive cancer. Did the March 2020 treatment shutdown shorten her life?

W hen Minna Heeraman’s friends knew that she was dying, they made a video for her to watch from the hospital bed she had set up in her living room. It was a goodbye video. One after another, her friends spoke to the camera with tears in their eyes. They shared their memories of times spent together. Wine in the garden on sunny afternoons. Hen dos. Weddings. Christmas meet-ups. “I don’t know what more to say, Minna,” says one friend, choking back sobs. “I love you so much. And you’ll always be with us.”

At this point, in September 2020, Minna had been stuck in bed for months. Her one shot at treatment would have been the Whipple procedure. A complex operation to remove the head of Minna’s pancreas – Apple’s founder, Steve Jobs, also underwent the procedure – it can extend the life expectancy of pancreatic cancer patients in about one-fifth of cases. But Minna’s surgery had been cancelled in the first wave of the pandemic. By the time hospitals resumed elective surgeries, it was too late. The tumour had grown to the point where it was inoperable. Whether the Whipple procedure would have saved her life, prolonged it or done nothing at all, is impossible to know. Minna was one of the hidden victims of the Covid-19 pandemic. She didn’t die from the virus, but it affected how she died.

Minna was ready to die. She wasn’t afraid. But cancer is an ugly disease, involving pain and struggle. Her husband, Kavi Heeraman, 38, was by her side. He was devoted to her. When he had to do the laundry or chores in another room, he’d wear a buzzer, in case Minna needed him. Together, they had spent the Covid-19 pandemic indoors, hoping against hope that hospitals would reopen for normal surgeries quickly, they would remove the tumour and she would have just a little more time. They’d only been together for five years.

It wasn’t to be. “I don’t have anything against the hospital,” says Kavi. “It was just the circumstances. But I fail to understand why this procedure that could have saved her life – or extended it – didn’t go through. It could have made a life a bit more pain-free.”

Minna died on 23 February. She suffered a lot at the end. She was 49.

M inna was born in Helsinki, Finland. Her parents separated when she was a child, and Minna lived with her mother and half-sister. “As a child, she was no different from how she was all the way through her life,” remembers her best friend, Marketta Walton, a 42-year-old Finnish-born human resources worker from Twickenham, south-west London. “Incredibly kind. And warm. And so much fun.”

Minna was eight years older than Marketta. Their fathers were best friends; Minna would babysit Marketta when she was little, and they became close. “Despite the age difference, she never made me feel like hanging out with a young girl was a nuisance,” says Marketta. “She genuinely was my friend.”

Minna was fun. It’s the word that everyone uses to describe her. “She was quick to laugh,” says Marketta. “Very witty. Very clever. She found joy in everything. She was easy company.” Throughout her life, Minna loved to socialise. She was a natural extrovert, rarely turning down a social invitation, even if she didn’t know the other people at the party. “Lots of parties, lots of friends,” is how Marketta summarises Minna’s teenage years. “She had some interesting fashion choices,” she laughs. “An 80s style. Really short blond hair. We always joked that she looked like Billy Idol.”

Ambitious and career-focused, Minna worked for Nokia, living in Dallas for a while. She later ran her own marketing business, and went on to get a job with the energy company Monarch Partnership. “She was always really driven,” says Marketta. “She took a lot of pride in her work.” She had a few relationships, but nothing that really worked out. “Minna was quite a strong character,” says Marketta. “It takes a certain person to deal with that.”

Minna was happy in Finland. Her mother and sister lived there, and she had a wide circle of friends, many of whom had children that Minna was also close to. “Children loved her,” says Marketta. When Marketta had children, Minna asked her friend, with characteristic directness, not to make her a godparent, because she had so many godchildren already. It was good that she said something because Marketta had been planning to ask her.

In 2015 Minna, then 44, relocated to the UK. In August, she moved into a house of multiple occupancy in Carshalton, south London, where Kavi already lived. Kavi met her on her first day, as she was moving in late at night. He was on the stairs, about to go to bed. Minna’s long blond hair was wet from the rain. She was wearing a purple raincoat and carrying two suitcases. He was smitten. “She was lovely,” he remembers. “Tall and blond with grey eyes.” He instantly felt drawn to her. “I kind of knew,” says Kavi. “My intuition kicked in, and said: she might be the one.” He corrects himself. “She is the one.”

At the time, Kavi was on crutches, recovering from a motorbike accident. Minna would knock on his door and ask if he needed anything from the supermarket. On weekends, they would go to the park or to the cinema. Kavi found the courage to tell Minna how he felt about her. “I asked her if she wanted to move this relationship one step further,” he says. “And that was it. The rest is history.” Marketta loved to see her friend settled down and so much in love. “They turned out to be a great love story,” she says. “There was a comfortableness they had together. They were at ease.”

Minna and Kavi moved into their own house, in nearby Wallington, in 2016. Having their own place, with a spare bedroom and a garden, felt like heaven. “We were both over the moon,” says Kavi, who works as a telecoms surveyor. At weekends, they’d stay in with a bottle of red wine and watch films or cook. Kavi would cut up all the vegetables and the meat, and she would cook them. Minna loved to read and speak on the phone to her sister back home in Finland. Sometimes, she’d go and stay at Marketta’s house for a girly sleepover. When she did, Kavi couldn’t sleep in their bed. “If she was away, I would crash on the couch,” he says. “When she wasn’t there, the whole house was empty. And when she was, it felt like a home.”

Minna was the sort of person who couldn’t just do one thing at a time. She’d be working while shopping online and helping tidy up a friend’s CV. If she was watching TV, she’d also be painting her nails. “Sometimes I wished she’d be a bit kinder to herself,” says Marketta. “She would often put herself down or be negative about herself.” But Minna was never like that about other people. Most of the time, she was too busy having a good time. “We would go partying a lot,” says Marketta. “She’d come over to mine, and we’d go out in Richmond. We had this crazy night when I broke my wrist on the dancefloor because we were dancing so much. It was really painful, but we carried on.”

In 2019, Minna saw an advert on Facebook about a street dog in need of a home. She was instantly smitten. Penny came home a few days later. “Penny was very shy,” Kavi remembers. “She just hid in the corner all the time.” Gradually, Minna coaxed the dog out of her shell. Penny would sit between Minna and Kavi when they were watching TV. “It felt like my family was complete,” Kavi says. “Like we’d reached peak happiness.”

When Marketta remembers her best friend, she imagines her with a glass of wine in hand, on her sofa, gossiping and catching up. “She genuinely was a special person,” says Marketta. “Everyone who met her felt her presence. She was loved by everybody, and so kind. She never had a bad word to say about anybody. She was a really decent, fun person. It’s a huge loss. A huge loss.”

M inna started to feel unwell in about February 2018. At first, she thought it was a wheat intolerance. She saw five different GPs over the course of that year, and each time they dismissed her complaints. There would be times when she couldn’t make it out of bed. She would often cry, usually in frustration, after yet another doctor sent her home, telling her that her severe abdominal pain was acid reflux.

In February 2019, she was hospitalised with jaundice. Marketta went to visit her and was horrified. “She was Simpsons-yellow,” she says. Minna told her that the doctors thought they had seen something on a scan. Marketta tried to reassure her. “I said: ‘It doesn’t have to be anything bad.’” But it was bad: pancreatic cancer. When the doctor gave Minna the diagnosis, she didn’t say much, and only asked what stage it was.

The doctor said that it was stage 4. Minna was silent. Her father had died of cancer. She had nursed him through the final stages of his illness. “She knew the stages of cancer, and what she would be going through,” says Kavi. “She knew where it would lead. Deep down in her heart, she knew.” That evening, they came home from the hospital in stunned silence. There were leftovers in the fridge, but neither of them ate. Kavi spent most of the evening Googling cancer clinics to be sure Minna was getting the best care.

Doctors started chemotherapy almost immediately, but Minna couldn’t have the full dose because she had an enzyme deficiency that made the side-effects of her chemotherapy drugs worse than usual. The chemo was awful. “Her veins would turn blue,” remembers Kavi. “She had pain in her arms and her legs. She lost her hair as well.” Watching Minna suffer was unbearable. “You feel helpless,” says Kavi. “It’s like the worst torture in life. Emotionally, it was too much.” Kavi would often have to come home from work because he couldn’t focus.

Minna always accepted that her odds weren’t good, and she was probably going to die. She and Kavi got married in February 2020 during a break in her chemotherapy – they had originally planned to get married in Mauritius in 2018, but they had to cancel after she became ill. Kavi believed he could fight the cancer with positivity – and Google. He is a spiritual person, and looked into ayurvedic medicine and alternative therapies. Minna occasionally found this frustrating; she believed that he was in denial. “I was on the hunt for a person who could give us a solution or a cure,” he says. “But I came to realise that when you’re at that stage, there is no cure.” There is only time. And what little Minna had left of it would be cut short by the Covid-19 pandemic. It was brutal, arbitrary and unfair.

W hen the nations of the UK went into lockdown in March 2020, hospitals closed for non-essential procedures. GP clinics switched to online-only consultations, which can be inadequate; as a result, some people would go on to have cancers misdiagnosed by GPs on video calls. Ambulance services were swamped with Covid cases, so much so that bosses had to beg the public to dial 999 only in an emergency.

The reasons for the shutdown were straightforward. If Covid got out of control, it would overwhelm the NHS. All patients, not just those infected with Covid, would suffer. “It was clear at the beginning of the pandemic that we didn’t know what we were dealing with,” says Dr Jodie Moffat of Cancer Research UK, “and there were going to be huge demands placed on the NHS. The focus had to be on reducing infections and taking the burden off the NHS. But, of course, cancer continued throughout the pandemic, as did other serious diseases.”

In a letter to hospital trusts sent on 17 March 2020, just days before the UK’s nations went into their first lockdowns, NHS bosses required that all non-urgent elective operations be postponed until 15 April. Cancer treatment and other clinically urgent care was supposed to continue unaffected. In practice, this did not happen. Minna’s surgery was cancelled because doctors judged she was at high risk of contracting Covid while in hospital. (About one in four patients being treated in English hospitals during the second wave of the pandemic caught Covid while hospitalised for an unrelated condition.)

The consequences of this first-wave shutdown were devastating. “Urgent cancer referral rates fell off a cliff,” says Moffat. “Screening programmes were paused. Diagnostic interventions were halted. Surgeries were delayed.” GP surgeries moved to virtual-only services, or in some cases, temporarily closed to patients. Any delay can prove catastrophic for cancer patients, but particularly so for people like Minna, with fast-growing, aggressive cancer. Just four weeks can have a disastrous impact on a person’s chances of survival. A meta-analysis of cancer patients, published in the British Medical Journal in October 2020, found that a four-week treatment delay was associated with increased mortality rates for seven different cancer types. “Overall, we found that a four-week delay to treatment increased a person’s mortality rate by 10%,” says Dr Timothy Hanna of the Kingston General Health Research Institute, which led the meta-analysis. In other words, Hanna goes on, “cancer surgery can’t wait. Time is of the essence.” More than 650,000 people with cancer in the UK have experienced disruption to their cancer treatment because of the pandemic.

It was on 27 March 2020 that Minna received the phone call. Her surgery, which had been scheduled for 30 March at the Royal Marsden hospital in London, had been cancelled. The doctor told her that it would be too risky because Minna could catch Covid-19 while recuperating. (Due to her cancer diagnosis, Minna was classified as clinically extremely vulnerable.) Her doctor also told Minna that there were no alternative treatments they could offer her. She would just have to wait. Minna didn’t quibble or argue. She thanked the doctor for her call.

Over the next month, Minna grew more isolated and dispirited. The pandemic was eroding what fragile independence she had left. When she took Penny for walks in the park, joggers ran too near to her. She stopped going out, and mostly stayed at home. “Covid couldn’t have come at a worse time for Minna,” says Marketta. “She was so close to being able to have that procedure, and then it was taken away. It was never guaranteed to work for her, but it was her one lifeline. That was pretty cruel.”

On 20 April 2020, Minna was concerned enough to contact her doctors. She felt that her disease was possibly progressing. The pain in her abdomen was more severe. The hospital booked her in for a scan, but there was nothing more they could do until surgery resumed. Kavi would lift her mood by putting on comedy films. They watched Dumb and Dumber, and standup comedians such as Omid Djalili. Minna tried to feel grateful for the fact that she had a garden to enjoy and Penny to play with, unlike other people who were trapped indoors in poky flats with no outside space.

On 29 April 2020, NHS England wrote to the chief executives of all English hospital trusts telling them to resume non-Covid urgent services within the next six weeks. In late April, Minna had her scan. It was bad news. The tumour was by then too big for them to operate. There was nothing else that they could do but try more chemo in the hope that it would shrink the tumour.

Over that summer, the usually sociable and gregarious Minna felt isolated and bored. “I tried to see her [in person] as much as I could,” says Marketta. “But whenever I did, I was always worried: what if I’ve brought something?” Minna reached out to Macmillan Cancer Support, and through their Telephone Buddies scheme she was paired with Julie Shawcross, a 51-year-old volunteer with the charity, who lives in Greater Manchester. They spoke once a week, on Fridays, for an hour. In these calls, Minna confided to Shawcross that she was thinking about stopping the chemotherapy. Cancer patients are often told they have to be brave and fight, but sometimes they don’t want to. “I allowed her to have that conversation with me,” says Shawcross. “She didn’t feel able to have it with her friends and family because she knew they’d say, no, you have to fight and carry on.” Minna debated quitting the chemotherapy, but she stuck with it.

In her final calls with Shawcross, Minna was morose. “There were things she had wanted to do, such as going home to Finland, that she knew she wasn’t going to be able to do,” says Shawcross. Minna worried that, due to the travel restrictions, her mother would not be able to enter the UK. “She was really stressed about her mother being able to come and visit,” says Shawcross. “That was the only time she got frustrated.” In the end, Minna’s mother was able to come, in August 2020.

In September 2020, Minna was discharged from the Royal Marsden. Doctors had stopped the chemotherapy because it wasn’t working and was making her sick. Minna was expected to die within a fortnight; a month at most. She spent almost all her time on a hospital bed in the living room, with Kavi sleeping on the sofa. Because of Minna’s height, the ever-devoted Kavi had customised her hospital bed, extending it to make it more comfortable. By then, Kavi had quit work to care for his wife full-time. “I would change her clothes, wash her hair, do her commode,” he says. “I don’t know where I got the strength.”

Perhaps worst of all, Kavi and Minna had to give away Penny. “It was the hardest decision we both had to make,” says Kavi. They knew it was the right thing to do; Minna was too weak to walk the dog and Kavi was too busy looking after his wife. “Penny was lying under Minna’s bed all the time,” says Kavi. “When I’d try to take her out, I’d walk a few houses with her, and she wouldn’t move. She’d start walking back to the house. She wanted to be with mummy.”

All through the autumn of 2020, Minna busied herself with the practicalities of dying. She gave away half her wardrobe, to her friends. “She was very concerned that all the practicalities were sorted,” says Shawcross. “We had a conversation about it, and then she spent hours making lists of passwords and things like that she needed to close down.” She gave Kavi the password to her laptop, with all the arrangements for the funeral. “Minna was mentally strong,” he says. “She always said that, after she was gone, I needed to get back on my feet and find somebody and get my life back on track. But I feel like that’s just not me. She is my wife. She will always be my wife.”

Around Minna, Kavi tried to hold things together and appear strong. “I never broke down in front of her,” he says. “I knew that my wife needed my support 100%.” Sometimes, when it was too overwhelming, he’d tell Minna he was going for a cigarette outside, so he could have a cry. “She would know that I was out there crying,” he says.

Minna was prepared to die. There was nothing left to do now but wait.

T hroughout the pandemic, the plight of those living with cancer has been used by those who oppose lockdown measures or even believe that Covid-19 isn’t real. Newspaper columnists fulminate against the injustice of prioritising Covid patients above cancer patients, as if the measures put in place to mitigate the worst public health crisis in a century were an arbitrary coin toss by uncaring bureaucrats who cared more about Covid patients than young mothers dying of cancer. The conspiracy theorist Piers Corbyn has frequently, and inaccurately, stated that lockdown measures cost more lives than they save. Signs about cancer treatment are ubiquitous at anti-lockdown protests.

It is not that the lives of those infected with Covid-19 are more valuable than those of people living with cancer or depression, or any other serious disease. It was simply that a system overrun by a deadly pandemic would be unable to treat anyone at all. But this is not to minimise the plight of those living with a long-term or serious health condition during the pandemic. For people with chronic illnesses, disabled people and those shielding, the Covid-19 pandemic has been a particular nightmare.

“We have been hearing from people throughout the pandemic that they feel forgotten,” says Steven McIntosh of Macmillan Cancer Support. “Either because of a change to their treatment or because they’ve been stuck at home, shielding for a year, because their immune systems are compromised, making them extremely vulnerable to Covid. All of these factors mean that being diagnosed with cancer, or going through treatment in the last year, has been the most isolating experience possible. People’s support networks have been stripped away from them.”

Even before the pandemic, the NHS was in terrible shape when it came to cancer care. According to research published in 2017 by the Association of the British Pharmaceutical Industry, UK patients had worse survival rates in nine out of 10 cancers after five years compared with the European average. “Covid has exacerbated and shone a light on the weaknesses in cancer treatment in this country,” says Macintosh. “We were consistently missing NHS cancer waiting-time targets. We lacked thousands of essential cancer nurses and clinicians to deliver the standards of cancer care we would expect. In cancer terms, that means that people wait a long time for treatment, and the services that look after your needs will be affected. The Covid pandemic has dramatically worsened that.”

Macintosh hopes that, as we come out of the Covid pandemic, there will be the political goodwill for real investment in cancer treatment and care, as well as a general staffing up of the NHS. As a result of our ageing population, the number of people living with cancer in the UK is projected to double from over two million in 2020, to four million by 2030. “One in two of us will have cancer in our lives,” says McIntosh. “This isn’t just facing a minority of us.”

E ven though doctors had told Minna that she had weeks to live in September 2020, she survived until February 2021. Her last few days were not peaceful. “She was constantly in pain or uncomfortable,” says Marketta. When she slept, Minna had terrible nightmares, and would wake up screaming. Kavi would come and comfort her. She would often tell Marketta that she wanted to die. “Watching those last few months, I was sorry for her,” says Marketta, sighing. “She said: ‘My body won’t let me go. I am ready. I don’t want this any more.’”

On 14 February 2021, Marketta FaceTimed Minna. In Finland, Valentine’s Day isn’t a romantic holiday, but rather a day to celebrate friendships. During the call, Minna asked Kavi to bring her a glass of Coca-Cola. Kavi didn’t want to because Coca-Cola was bad for her; he wanted her to drink water. They both started laughing. “She was literally dying,” Marketta says. “It didn’t matter what was good for her, or not.” Even in death, Minna was able to see the absurd side of life.

She died on 23 February. In her last moments, “she was really fighting for breath”, says Kavi. “She had tears in her eyes constantly. We both had tears in our eyes. I knew she was in pain.” A nurse from south London’s St Raphael’s hospice was there. The nurse told Kavi: sometimes, they need permission. Kavi gave Minna permission to die. He sat next to her and held her hand. She died at about 2.30pm. “I was numb,” he remembers. “My mind was totally blank.” After a few days, the grief hit him. Kavi would shout in the shower, or fall on his knees and cry. Two months on, Kavi still can’t sleep in their bed. He falls asleep on the sofa watching TV. Sometimes, he sleeps in Minna’s old hospital bed. “I don’t know if it makes sense, but I feel connected to her when I sleep in her bed,” he says.

There will be many more people like Minna, in the coming months and years. Macmillan estimates that there are 50,000 missing cancer diagnoses in the UK, meaning that their cancer has not yet been caught by doctors. In England, urgent referrals for cancer care are 11% behind 2019 levels. It will take nearly two years to work through the cancer-diagnostic backlog. Performance against the NHS’s 62-day target to begin treatment after an urgent cancer diagnosis fell to its worst level on record in February 2021. Just 70% of patients started treatment within the 62 days. Across all conditions, more than 4.5 million people missed out on hospital treatment in England last year due to disruption occasioned by the pandemic. For some of these people, the delays will be catastrophic. As we come out of the pandemic, Moffat urges healthcare authorities to redouble their efforts to identify those people who may have no idea that they have cancer. “It is imperative we find those patients and get as many through to treatment as possible,” she says.

“We don’t yet know what the impact will be on cancer survival rates, and the long-term impact for people going through cancer treatment when their cancer is diagnosed later, and requires more aggressive treatment,” says McIntosh. “People will end up having their cancer diagnosed in the emergency departments of A&E because they’ll go there with symptoms. This effect will play out in the coming years. And we’ll have to make sure we’re supporting people through that experience.”

There are so many more victims of Covid-19 than the people who had it on their death certificates. There are people like Minna, the ones robbed of precious extra months – or even years – with their families. There are the people denied mental health support; who killed themselves in those lonely and isolating months of lockdown. There are people who died of heart attacks, too frightened to call an ambulance in a deadly pandemic, and people misdiagnosed over the telephone because GP surgeries were closed. None of them have been counted in the official death tolls read out by grave-faced ministers. But perhaps they should have been.

We have been tested as a country. The loss is unfathomable. The impulse is to forget. But we should remember them.