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History Lessons
Dr. David Jones published an essay on lessons from historical plagues[1] starting with an essay by Charles Rosenberg about the AIDS epidemic in 1989.[2] Rosenberg pointed out that true epidemics are episodic, “an event, not a trend.” As a result, people know when they are in the midst of an epidemic and, he maintains, it has dramatic elements associated with it. Act I is one of progressive revelation. “…most communities are slow to accept and acknowledge an epidemic. To some extent it is a failure of imagination; perhaps even more it is a threat to interests, to specific economic and institutional interests and, more generally, to the emotional assurance and complacency of ordinary men and women. Merchants always fear the effects of epidemics on trade; municipal authorities fear their effects on budgets, on public order, on accustomed ways of doing things. Only when the presence of an epidemic becomes unavoidable is there public admission of its existence. Bodies must accumulate and the sick must suffer in increasing numbers before officials acknowledge what can no longer be ignored.” Act II involves managing randomness. “Accepting the existence of an epidemic implies—in some sense demands—the creation of a framework in which its dismaying arbitrariness may be managed. Collective agreement on that explanatory framework may be seen as the inevitable second stage in any epidemic. For most previous centuries that framework was moral and transcendent…When threatened with an epidemic, most men and women seek rational understanding of the phenomenon in terms that promise control, often by minimizing their own sense of vulnerability…what might be discussed today under the rubric of risk factors…The managing of response to epidemics could serve as a vehicle for social criticism as well as a rationale for social control.” Act III is negotiating a public response, which is occasioned by recognition of the general threat of the epidemic. “Since the eighteenth century our rituals have been of a diverse sort. We have appealed in an eclectic way to a variety of sources of authority…The adoption and administration of public health measures inevitably reflect cultural attitudes. The poor and socially marginal, for example, have historically been labeled as the disproportionately likely victims of epidemic illness, and they have traditionally been the objects of public health policy… Epidemics ordinarily end with a whimper, not a bang. Susceptible individuals flee, die, or recover, and the incidence of disease gradually declines. It is a flat and ambiguous, yet inevitable sequence for a last act.” Reflecting on the “lessons” created during the AIDS epidemic, Rosenberg noted that the American experience reflected the institutional complexity of modern life. “Institutional complexity implies institutional interest—and thus conflict…Finally, Americans have created a complex and not always consistent health care system, and AIDS has been refracted through the needs, assumptions, and procedures of that system.” Dr. Jones added several observations as to the lessons from history about previous epidemics. “One dramatic aspect of epidemic response is the desire to assign responsibility…Another recurring theme in historical analyses of epidemics is that medial and public health interventions often fail to live up to their promise…Two familiar aspects of the response to epidemics are especially disheartening. First, stigmatization follows closely on the heels of every pathogen…Second, epidemics too often claim the lives of health care providers…Though such mortality reflects the willingness of health professionals to put themselves at risk to care for others, it can also indict governments that ask clinicians to confront outbreaks without the “staff, stuff, space, and systems” they need to be successful and safe.” I think it is safe to say we have experienced this act of the drama beginning in January and ending for some, in March, although it could be argued some have not accepted it yet. There has been criticism of public officials for what they did and did not do. Some of it is a reflection of underlying governing philosophy on the role of government, typically characterized by the media in terms of party labels, but I wonder what the analysis would look like if we examined those who have a business background versus other sorts of backgrounds, as epidemics have negative effects both directly and as a result of the necessary restrictions on social interactions. Individually we are still in Act II. Most physicians are aware of Sir William Osler’s comment that “pneumonia is the old man’s friend.” What he meant was that a quick death from pneumonia was preferable to a slow, lingering death from other ailments. While the clusters of nursing home deaths are sad, particularly because their families could not be in attendance, I am not sure it is the same thing as the deaths of previously healthy young and middle-aged individuals, struck down in the prime of life. But we are not all resigned. Collectively we are in Act III. We are still crafting our collective responses at local, state and national levels. Some rely on “data” to guide action while others question the reliability of the data and yet others take an extreme position such as no deaths from SARS CoV-2 or no restrictions on personal liberty and property. Since we cannot stay in lockdown indefinitely, decision makers must decide, knowing they are going to be wrong no matter what the choose. 29 April 2020 [1] Jones DS. History in a Crisis—Lessons for Covid-19. N Engl J Med 2020;382(18):1681-1683. doi:10.1056/NEJMp2004361. [2] Rosenberg CE. What is an Epidemic? AIDS in Historical Perspective. Daedalus 1989;118(2):1-17. Accessed 29 April 2020 at https://www.jstor.org/stable/20025233. |
Further Reading
Crisis To paraphrase Donald Rumsfeld, you fight coronavirus with the healthcare system you have, not the one you might wish you had. On Dying in America The IOM report "On Dying in America" makes recommendations for change that physicians should embrace. On Resilience Population Health Population health is a phrase that disguises some hard realities as illustrated by two recent reports. Uncertainty Dealing with uncertainty is at the core of practicing medicine. Have we tried to escape this reality? |