This blog post is based on a conversation between Andrew Papanikitas, Senior Clinical Researcher at the University of Oxford Department of Primary Care Health Sciences and the #MotivationBuddies, a virtual discussion group hosted by Graham Combe and chaired by Professor Tony Sedgwick. Book to join #MotivationBuddies and #CoffeeBuddies on Tuesdays and Thursdays at 2.30 pm BST (GMT+1 hr) at Eventbrite.
In discussions about ethical and moral issues, the world is full of opposing viewpoints, never more so than in the midst of the coronavirus pandemic and the aftermath of the George Floyd killing.
The best and most fruitful discussions are based around respectful disagreement, which seeks to understand why someone thinks how they do and prioritises logic and facts over opinion in the response. Building a consensus framework for medical ethics, particularly in troubled times, needs this kind of reasoned respectful disagreement.
Medical ethics isn't always about consensus though. It can be about a single voice speaking up against the status quo. The issues and skills learned and discussed in medical ethics are not just relevant in healthcare they are widely applicable anywhere.
Ethics: the personal perspective
Our personal ethics can be driven by our goals, beliefs and values, and by the conditions in which we find ourselves, and all of these can influence communication and clinical practice.
Ethics: Coming to consensus
When people understand why they are doing something, and are supplied with principles, structures and processes, they are more likely to comply. Medical ethics frameworks, created through discussion and consensus, should therefore include:
The framework should be applicable to healthcare professionals across the range of professions and agencies, but it should consider different people and perspectives. If guidelines are created for individual groups, care needs to be taken where the sets of people cross over, for example the two sets of guidelines for midwives and obstetricians working with pregnant individuals, or the many different guidelines for the range of healthcare professionals working with older people in care homes.
Ethics, empathy and connection
Feelings of compassion (the desire to alleviate suffering) are important for healthcare professionals. In order to cope, and to be able to make decisions, it is important to mix in logic and reason, but this can result in healthcare professionals taking too big a step back, and healthcare becoming too dehumanised. Empathy (feeling what others feel), can play an important role by allowing healthcare professionals to: develop a two-way relationship with patients; gain insight into their condition and mindset; step into their shoes; respect their dignity; and base their care on the understanding gained.
This is a personal as well as a scientific blog, and as such is being posted on both my websites. My BMI currently puts me into the obese category. I have often said that I don't have an issue with food – I just like it too much. I may be fit and obese, running half marathons, but I can still be damaging my joints and my heart, and risking type 2 diabetes. But now, in the time of Covid-19, obesity puts me at a higher risk than the rest of the population should I become infected.
How big is the risk?
In patients under 60, obesity is a risk factor for hospital admission. In a US study, patients with a BMI of 30-34 were around twice as likely to be admitted to acute or critical care, compared with those with a BMI of less than 30. In patients with a BMI of over 35, the likelihood of being admitted to acute or critical care rose by 2.2-fold and 3.6-fold, respectively. Higher numbers of obese patients require invasive mechanical ventilation.
The OpenSAFELY collaborative carried out a review of electronic medical records of patients in England. According to the results, having a BMI of between 30 and 35 (obese) increases the risk of hospital death by 1.3-fold. This climbs to 1.6-fold for a BMI of 35-40, and a BMI of greater than 40 (morbidly obese) more than doubles the risk of death (2.3-fold). Because the science is moving so quickly, this preprint has not yet been finalised or assessed by experts (peer-reviewed).
The science behind the difference
Being overweight generally makes it harder to breathe, and is known to be a risk factor in respiratory diseases such as asthma, sleep apnoea, acute lung injury and acute respiratory distress syndrome.
There are a number of theories behind the increased risk of more severe illness and death related to Covid-19 in people who are obese:
Looking at the futureMy weight has gone up and down over the years. My biggest gains were in my thirties, and I lost three stone before I got married in 2009, giving me a BMI of 24. During my marriage and following bereavement, the weight went right back on.
But it's not just me. The most recent Health Survey for England (2018) found that 67% of men, 60% of women and 28% of children were overweight or obese. As SARS-CoV-2, the virus that causes Covid-19, is likely to stick around for some time to come, tackling obesity is going to be important.
As part of COUCH Health's mission to improve 1 million lives by 2022, I have pledged to lose weight as part of a challenge alongside my friend and medcomms colleague, Ash Rishi. It has been up and down during the lockdown, but I'm going to try again, driven by the excess risk of Covid-19, using the evidence-based and NHS-backed Low Carb Program.
This blog post is based on a conversation between Michel de Baar, Executive Director, BD&L - Infectious- and Cardiometabolic Diseases, Vaccines & Immunology at MSD (Merck & Co. Inc) and the #CoffeeBuddies, a virtual discussion group hosted by Graham Combe and chaired by Professor Tony Sedgwick. Book to join #CoffeeBuddies on Tuesdays and Thursdays at 2.30 pm BST (GMT+1 hr) at Eventbrite.
Business development teams looking to fill pharma company pipelines are seeking products that meet unmet medical needs, either filling gaps where there are no existing treatments, or creating a product that is significantly better than something already on the market. These opportunities should come with solid science and at least the beginning of a good data package created using studies with the right models and the right controls.
As discussed in an earlier #CoffeeBuddies session, investments pre-Covid-19 had started to move to earlier stage projects, and this needs companies to reach out actively to universities and biotechs that have assets based on good science that might otherwise slip under the radar. This can be helped by good local, national, and international networks created through links with national and local trade organisations, and local academia. Operating companies in individual territories may be able to provide information on local research via their networks, and even keep an eye open for ideas.
By building relationships with biotechs and academia even before they have something to licence, companies can get an early 'foot in the door'. They can ensure that the science is good as well, by mentoring and supporting the SMEs and institutions as they develop their data packages.
In order to pick the right projects, business development and licensing teams need to remain objective. Working together can help to reduce any natural bias, and can also provide subject matter and technology expertise. Working without a 'shopping list' means that projects can be picked up opportunistically, potentially creating a whole new franchise.
SARS-CoV-2 is a virus that is potentially fatal, and increasing evidence suggests that it could have longer-term effects for some people. This threat is providing a driver for business development teams to find and partner for generic and innovative drugs that could help. The urgency means that some companies are making announcements at the statement of interest stage, even before full agreements are in place. It will be interesting to see if this remains after the crisis is over.
Before the outbreak, MSD's pipeline already included research key to the area of Covid-19 infection – infectious disease, vaccines, immunology and respiratory disease. After the outbreak, the company switched almost all of its efforts to respond to the Covid-19 outbreak The business development teams, the global competitive intelligence group and the discovery teams have worked together to evaluate around 250 different targets and programs with early stage data packages. Assessment of potential assets is ongoing. This includes screening of existing drugs for new activity, which could potentially speed up drug development.
MSD's response to Covid-19 includes a number of vaccine projects. Deciding which will go forward will depend on further understanding of the immunology of the virus, and the manufacturability, safety and immunogenicity of the different candidate vaccines.
The most appropriate type of vaccine for the prevention of Covid-19 isn't yet clear, and companies around the world are taking a number of different tactics, as a previous #CoffeeBuddies session talked about. These include viral vectored and nucleic acid vaccines, which are still new approaches and may prove challenging for approval and scale-up; inactivated and protein subunit vaccines, which are tried and tested but can be complex to manufacture and often need a booster; and live-attenuated vaccines, which produce a strong immune response but may be associated with risks. Controlling the spread of the SARS-CoV-2 virus may require a lower risk vaccine and boosters to develop herd immunity, along with ring vaccination with a shot that produces a faster response but with a slightly higher risk of side effects.
What will the pandemic mean for investors
While the pandemic is ongoing, companies focusing on Covid-19 prevention and treatment are unlikely to make much of a profit; any marketed drugs, especially vaccines will need to be distributed widely and provided cost-effectively to those at highest risk. This means that long term investment will be needed, with an extended period until return on investment – both companies and shareholders will need to be patient.
The future: the 'new normal?
The biopharma industry is currently very much focused on vaccines, virology, immunology, and infectious diseases, which haven't been 'fashionable' areas of research. However, it's likely that there will be a shift back into 'normal' ways of working, with the focus returning to therapeutic areas with a higher potential return on investment, such as oncology and cardiovascular disease.
This blog post is based on a conversation between Musaddiq Khan, Director, Clinical Program Operations at Eli Lilly and the #CoffeeBuddies, a virtual discussion group hosted by Graham Combe and chaired by Professor Tony Sedgwick. Book to join #CoffeeBuddies on Tuesdays and Thursdays at 2.30 pm BST (GMT+1 hr) at Eventbrite.
Clinical programs operations teams focus on the efficient delivery of clinical trials, with time and data quality as the metrics of success.
The impact of the Covid-19 outbreak on clinical development
The current pandemic, and the different states of lockdown around the world, have had differing effects on clinical development, dependent on the area of research. Companies working on vaccines and therapeutics for SARS CoV-2 infections have had access to greater funding. They have also seen communications barriers coming down, allowing companies and research organisations to be able to engage more quickly and more directly with regulators. By changing the priorities within pipelines, pausing non-Covid-19 clinical trials, and putting new projects on hold, companies have been able to focus people and resources on pandemic research. Companies working outside the field will also have had to cancel projects and put them on hold. For all of these, as the world moves forward, there will be a need for a second round of pipeline prioritisation, particularly in the light of the warnings of global recession.
During the outbreak, clinical trials may be smaller and quicker, with different stages running in parallel. However, it will be important to maintain the balance of data and speed to keep the confidence of health care professionals and patients. A positive sign of the desire from the general population to do what it can about the virus is the response to the WHO's conditional backing of challenge studies for a Covid-19 vaccine. As of 21 May 2020, more than 24,000 people in the US have signed up to volunteer for challenge studies.
Making the most of the energy in the industry
The urgency to get a treatment or prophylactic for the coronavirus infection has led to heightened energy across the industry, but for individuals, maintaining this level of energy may be hard long term. For some, working from home and meeting via video calling, and so not commuting helps them. For others, however, who have caring responsibilities, are shielding or who find Zoom calling exhausting it can be more challenging. Understanding people's motivations and stress points can help to manage the situation. It is hard to create and maintain the same kind of urgency for chronic disease, perhaps because the coronavirus affects everyone, but chronic diseases, especially the rarer ones, are less in the spotlight.
Getting back to work
Companies looking to get back to work will have to face a number of challenges. Some groups of people, such as lab staff, will find it hard to work from home, and may have to work shifts to get around social distancing. Where the pandemic has forced companies to close clinical sites, management will need to work out how studies can be restarted, for example ensuring the integrity of data.
Into the future
Moving forward, companies will have to reassess how clinical trials are carried out. One approach is to carry out decentralised clinical trials taking the study to the patient, rather than the patient to the site. Virtual clinical trials may use apps, devices, and wearable monitors, have local points where participants can drop off clinical samples, or have nurses doing clinical trial home visits. Hybrid studies include some site visits and some remote monitoring. The pandemic could be the catalyst to normalise decentralised trials, and the pharma industry and CROs need to be ready.
The levels of energy in the industry, and the levels of trust from the public, will depend on the success of any preventive or therapeutic approaches. It will be interesting to see how many of the current changes remain in place once the sense of urgency falls.
Things from this time that it would be good to hold onto include:
This blog post is based on a conversation between Kat Arney, founder of First Create The Media, Peter Penny, life and career mentor, and the #CommunicationBuddies, a virtual discussion group hosted by Graham Combe and chaired by Professor Tony Sedgwick.
Telling stories to each other is a key part of what makes us human. Stories help us make sense of the world, put things in order in our own heads and the heads of our listeners, and aid us in thinking about the form of our lives. Telling stories isn't just personal though – stories play an important role in science and business communication, from explaining concepts to pitching for projects and funding.
The importance of story in comms: Boring comms waste lives
Communicating ideas in story form can stop presentations from being mind-numbing, and become more than just lists of facts or milestones. Boring communications waste lives, by frittering away the listener or reader's precious time. They also allow important ideas that could impact wellbeing, lives and health to slip by unnoticed. The ordered structure of a story not only helps the listener but also works as a cognitive tool to help the teller order their ideas.
Building the story
As in fiction and drama, comms stories have a beginning, a middle and an end. They draw the listeners in and make them want to know what happens next.
Good comms stories use characters – patients, diseases, drugs, researchers – and show what happens to them. They make the listeners feel something and want to do something. Depending on the context, this could be excitement that makes them want to invest, conviction that makes them want to spread the word, or passion that makes them want to campaign and make a difference.
Getting the level of detail right is vital in comms. Too much information swamps the listener and buries the critical bits of information, and too little misses out what is important. The level of detail will vary according to the audience – do they want the Lambs' Tales from Shakespeare, or the story of King Lear? The right number of significant details gives the listeners, be they investors, journalists or healthcare professionals, enough to hold on to, and that might mean cutting favourite facts or slides. The presentation should end leaving people informed and wanting to act.
Preparing the pitch
Pitching is a fundamental part of the communications process, and it's important to be as Olympic fit as Princess Anne was in the London 2012 bid. As an Olympian, she was able to talk from a point of knowledge and experience. She presented what the International Olympic Committee needed to hear; that London was able to meet the needs of the games, and could put the logistics and infrastructure in place.
A pitch must meet the client's needs, deal with any pain points, and be in the style that will be most useful. This could mean a traditional presentation, or a Q&A session. Reviewing the presentation from the client's perspective as well as the presenter's perspective can be useful, perhaps by putting a member of another team in the position of the client. This makes sure that it is written in the client's language, and helps to highlight anything that is missing.
During the Covid-19 lockdown, meetings and pitches have quickly become virtual. This will continue as long as social distancing is in place, and may even become part of the post-virus 'new normal'. While virtual meetings allow life to continue, they do bring their own challenges. Virtual meetings do feel more 'real' than voice-only calls, but they can be exhausting. Fewer non-verbal cues and body language come across, and those that do can be harder to process, all of which takes more energy.
If virtual meetings are going to become the way forward, all participants need to become comfortable with taking part. There are a number of ways to get the most out of virtual presentations:
I've been completing the COVID-19 Symptom Study app for some weeks now. This app, developed by King’s College London and health science company ZOE, has been created to combine symptom reports with software algorithms to try to predict who has the virus. This information can then be used to track SARS-CoV-2 infections across the UK and further afield. The study also looks at how symptoms and risks vary between individuals.
I had reported headaches and chills over the weekend, which I think were the result of late nights doing coursework for my MA. The combination triggered an algorithm, inviting me to go for a PCR swab test to help the researchers to understand which symptoms are most related to Covid-19 infection.
"You’ve recently reported feeling unwell with a particular combination of symptoms. We would like to test you to understand if you have the virus right now. This does not necessarily mean you have COVID-19 as we are also inviting some people we believe do not have the virus."
I booked the test through the Department of Health website, which was a bit long-winded but pretty clear, and picked a site for a test, about a 40 minute drive away. I was a bit wary, as I know friends of mine have had bad experiences with the sites, and when I got close to Meadowhall I got a bit anxious, as there were no signs. I followed a stream of traffic, as I figured that SARS-CoV-2 testing was probably the only thing happening at the Meadowhall shopping centre that day, and from that point on it all went really smoothly and efficiently (until I left the site, took the wrong turning and ended up in an industrial estate, but that was my fault, not theirs).
The site was staffed with soldiers in army fatigues and PPE, and as I pulled in, I was shown a sign telling me to keep my window shut unless otherwise told, and to show the QR code I got at registration. I then drove to the next point, where a very pleasant soldier handed me the test using a long-armed grab tool explained the process to me – I was to drive to a parking bay, swab my throat and then my nose, put the swab in the tube, label the tube lengthways with the bar code, and put it in the bag but not seal it. If I needed help, I should put my hazard lights on.
I did the test as per the instructions, swabbing my tonsils (eww) and then pushing the swab up each nostril as far as I could and turning it (ouch). Not something I plan on doing again unless I must. I drove to the exit, where the soldier at the gate checked the bag contents and then told me to seal it, and then grabbed the bag with a long-armed grabber tool. I then drove to the gate, confidently turned right, turned round in the industrial estate and drove back past the testing site with my best 'I meant to do that' expression on my face.
There are a couple of videos on the Department of health website that I found really useful – visiting a regional test site and How to take a coronavirus self-test swab. The results came by text within 48 hours and were negative, thankfully. I have added the result to the app.
The app has led to some breakthroughs in information on Covid-19:
The researchers behind the app are also looking into the influence of hormones such as oestrogen in the responses to infection, and, as well as the effect of ACE inhibitors (angiotensin converting enzyme inhibitors) or ARBs (angiotensin receptor blockers) on the chance of infection.
This blog post is based on a conversation between Michael Watson, CEO of MEVOX and ex-president of Valera, Moderna's infectious disease spin-out, and the #CoffeeBuddies, a virtual discussion group hosted by Graham Combe and chaired by Professor Tony Sedgwick. Book to join #CoffeeBuddies on Tuesdays and Thursdays at 2.30 pm BST (GMT+1 hr) at Eventbrite.
Since the first reported cases of a mysterious outbreak of viral pneumonia in Wuhan, China, in late December, the virus, now called SARS-CoV-2, hasn't been out of the news. Human to human transmission of the infection, known as Covid-19, was confirmed on 20 January 2020.
As of 7 May 2020, there had been 3,843,153 reported cases and 265,657 reported deaths worldwide. The UK's daily confirmed Covid-19 deaths per million (rolling 7-day average) peaked at 13.89 per million on 15 April 2020, and had fallen to 8.37 per million on 7 May 2020.
All about the virus
Coronaviruses (from corona, Latin for crown or wreath) are RNA viruses with spike proteins studded all over their surface. Evolving alongside the amniotes (reptiles, birds and mammals), coronaviruses and have been around for millions of years. Coronaviruses were first identified in the 1960s, and SARS-CoV-2 is the seventh coronavirus known to infect humans. A number of coronaviruses, including B814, 229E and OC43, cause around 15% of common colds. While the new virus' origin is still not clear, it appears to be closely related to bat and pangolin viruses.
There have been a number of coronavirus outbreaks over the last two decades, including the SARS (severe acute respiratory syndrome; SARS-CoV-1) outbreak in China and Hong Kong in 2003, and the MERS (Middle East respiratory syndrome; MERS-CoV) in 2012. The pandemic in 1889-1890, which resulted in one million deaths, may have been caused by HCoV-OC43 jumping from cows to humans.
SARS-CoV-2's spike proteins bind with the human ACE2 receptor, found in lungs, kidney, heart and gut. This ties in with the symptoms of Covid-19, which include fever, cough, shortness of breath, and diarrhoea, and can worsen to cause strokes and kidney failure.
Letting go of the tiger's tail
Modelling from Neil Ferguson and the Imperial College COVID-19 Response Team suggested that, if nothing was done to mitigate the epidemic in the UK, critical care bed capacity would be exceeded in the second week of April, and deaths would peak at around 500,000 in May or June.
Controlling the tiger that is Covid-19 requires primary and secondary prevention, allied with primary and secondary treatment approaches:
The UK went into lockdown on 23 March 2020. The UK government is discussing when and how lockdown will ease, and what social intervention will look like in the future. Between the current peak and a potential secondary peak of infection as lockdown eases is a critical and narrow window for vaccine and therapeutic development. Highly effective contact tracing and case isolation could also be important in controlling new outbreaks.
Antivirals could play a role in treatment
A study of Gilead's remdesivir in 1063 hospitalized adults showed a 31% faster time to recovery in treated patients compared with placebo (p<0.001), reducing the median time for recovery to 11 days compared with 15 days. The mortality rate in treated patients was 8.0% compared with 11.6% in the placebo group (p=0.059). Remdesivir has been studied in Ebola virus disease, MERS and SARS caused by SARS-CoV-1 infection.
Designing a vaccine for primary prevention
A safe and effective vaccine will be the best way out of the current pandemic, as waiting for herd immunity would require between 60% and 80% infection in the population, with a lot of suffering and death over several years. There are over 125 Covid-19 vaccine candidates in the pipeline to date, with eight or nine in the clinic. This is expected to increase to over 25 in the clinic by the end of 2020. Approaches include nucleic acid vaccines (mRNA, DNA),inactivated or live attenuated vaccines, or viral vectored vaccines. Normally vaccine development takes over 10 years, but this outbreak has seen vaccines developed to clinical stage in record time.
Each vaccine approach has its benefits and its challenges:
Another positive for the development of a vaccine – while coronaviruses do continue to mutate, they have an RNA 'proofreading machine' that slows the evolution of the virus. According to data published on 4 May 2020, there have been relatively few mutations spotted to date.
Provided clinical trials can show a 'good enough' protection from an initial dose, or dose + booster, the SARS-CoV-2 vaccine may need to be given annually, much like the influenza vaccine.
iThis blog post is based on a conversation between Lubor Gaal, senior vice president and head of Europe at the global life science transaction firm Locust Walk, and the #CoffeeBuddies, a virtual discussion group hosted by Graham Combe and chaired by Professor Tony Sedgwick. Book to join #CoffeeBuddies on Tuesdays and Thursdays at 2.30pm BST (GMT+1hr) at EventBrite.
Dealmaking in the 21st century is the life blood of the pharma and biotech industries, and it relies on the in-depth knowledge of the business development teams on both sides of the deal. They need a set of skills and knowledge:
The core of dealmaking
Dealmaking is a systematic and strategic process. The business development team from the big pharma needs to know what the scientists are looking for – almost a Christmas present list – and then find out whether these assets exist in the real world. In turn, the strategic approach for biotech BDs is to know who to talk to, and what and how to pitch. It's easy, especially for new BDs, to want to talk to anyone and everyone, but it's important to provide the right people with information on the right asset.
Working and making deals pre- and post-Covid-19
Prior to the Covid-19 pandemic, there had been a shift in investments, with VCs leaning towards investments in early stage companies and assets, which is good news for European entrepreneurs. This was a change to previous years when investment had focused on much later stage research. This could be because of a historical lack of funding for preclinical and early clinical research in biotech and small pharma meaning a dearth in the current late stage pipeline. There have also been early signs of a shift towards regional investments, for example Chinese investors looking for local deals after they have been prevented from investing in the US. However, companies making deals need to be aware that local rights could potentially limit future global deals.
During the current lockdown, some companies are continuing dealmaking as normal because of projects set up prior to the outbreak, and some are taking a strategic pause. Gaal said that he is currently transacting and reaching out for assets based on conversations that kicked off during 2019. There is money available now from companies and investors, but access to this may drop long term.
Once lockdown begins to lift, and the world returns to some kind of new normal, it may reveal which were the stronger (or at least better funded) companies, and which haven't survived, much as happened after the financial crisis in 2007-2008. As with the financial crisis, share prices have dropped. This could make negotiation harder on both sides, with smaller companies looking for pre-Covid-19 value in assets to keep them afloat, and bigger companies needing to fill their pipelines but having less money in their pockets. While China is likely to remain a big market and a potential partner, there may be a shift in manufacturing away from China and into Europe.
Working in the Covid-19 space
Companies that were already working in the virology space have shifted investment into developing coronavirus vaccines, with the World Health Organisation (WHO) currently tracking the development of 76 Covid-19 vaccine projects. Of these, five are already in clinical evaluation. It is far too early to see if vaccines, or even the disease itself, provide long-lasting immunity. Success in this space could make the industry stronger, and improve the public's understanding of its importance, but if pharma and biotech are unable to come up with a prophylactic vaccine or a drug or antibody treatment, the impact in the form of falls in funding and in public trust could be seen across the industry.
There hasn't been a noticeable shift towards Covid-19 work for companies outside the field in the short term, but it's hardly surprising that it is being left to the experts in the field. However, the impact of Covid-19 as an emerging disease, and the chance of other emerging diseases in the future as a result of climate change, could mean that there will be a movement into new infections in the longer term.
The impact of success and failure in companies working in the Covid-19 space has already been seen in the value of companies. Gilead's remdesivir, touted as a potential treatment for the infection, has failed in its first randomised clinical trial, according to accidentally-published documents. The company's share value had risen in anticipation but fell when the data from the Chinese trial, revealed in error by the WHO, showed no improvement in patients' condition, and no effect on the levels of the drug in the bloodstream. There is also likely to be a coronavirus-driven effect on the value of companies currently onboarding and running clinical trials, depending on the length of delay.
The role of networking and partnering meetings in the new world
Networking is important in dealmaking, but the Covid-19 outbreak has put a dampener on face-to-face meetings now and potentially for some time to come. Digital networking is continuing, and the importance of this, particularly with people with strong existing networks, is likely to increase as the lockdown continues.
I'm starting to sort out again. The lengthening of the days is bringing back a little of the energy and attention that has been missing for half a year, through a summer of lost purpose and a winter of anniversaries. Memories, dusty as ghosts, come rising out of dented cardboard and crumpled carriers.
My first poems and stories, hand-bound into books with board fronts and backs.
Craft projects kept carefully by my parents over many years, and brought home when I cleared out their house for the last time. My parents' wills.
Love letters from my ex from before we were married. Evidence of his love in my hand where it once was in both of our hearts.
Pictures and paperwork from houses I bought with my ex, including the house in Doncaster that was to be the fresh start for a struggling marriage (I thought) and that turned out to be the step closer to its finish.
Divorce paperwork. Condensing 14 years into just a few pages. Startling in black and white.
The contract for the house in Litton Mill that was a river-lined retreat from the chaos and became the start of my life version 2.
Tim's tenancy agreement from the house in Dadford where things began.
Tim's statements and pay slips. Scraps of paper filled with his spidery writing. Notes left on my desk. Cards from him, loaded with so much love it spilled over the sides.
The estate agent's flier for his beloved shop, now empty, and this beautiful house, now holding only half the love it did. The place where things ended after a decade filled with sweetness.