Dinner with Henri Dunant and Gustave Moynier by Kathryn Steger

The Guests

            Since war and its consequences present what is certainly one of the greatest threats to public health, I extended my dinner invitation to two people who were instrumental in establishing, in 1862, the International Committee for Relief to the Wounded, which eventually became the International Committee of the Red Cross (ICRC). The ICRC is perhaps best known for facilitating the Geneva Conventions, which have set international protocols for the care of injured soldiers, the treatment of prisoners of war, neutrality for medical personnel, limitations on the use of torture and biological weapons, and more. The ICRC is also known as the parent organization of the International Red Cross and its many national affiliates. I think these accomplishments are significant contributions to the public health and well-being of humanity, and therefore, I invited Henri Dunant and Gustave Moynier to join me for dinner.

            The original ICRC consisted of five men, but I felt these two played particular and distinct roles in establishing the organization, one as the firebrand visionary, the other, as the dedicated bureaucrat. Their differences, however, eventually led them to become arch rivals and lifelong enemies. For that reason, I wasn’t sure they would agree to come together, so I tricked them by letting them each believe they were the sole guest of honor. As a result, my dinner began a little awkwardly, with a whiff of hostility in the air, but I used my hospitable nature and expert culinary abilities to put these two gentlemen at ease. We began a lengthy, multi-course meal with generous aperitifs followed by:

The First Course—Global Village Salad

            Henri Dunant and Gustave Moynier were both Swiss Calvinists born in Geneva in the 1820s and raised in the comforts of respectable, well-off homes. Moynier was educated in law, and Dunant, somewhat less successfully, in business. I asked them to talk about the transitions in human life they’d witnessed in the 19^th century, and in their enthusiastic responses, they revealed themselves to be men firmly rooted in the optimism of the Enlightenment. There were inventions and scientific discoveries, new forms of transportation and industry, and advancements in communication, information and education. Dunant had had success in banking in Algeria and had started his own enterprise in that French colony. Moynier had embraced the philanthropic tasks of reforming and elevating the poor.

            When I asked what impact all this progress had had on international conflicts, they energetically addressed the horrors of modern warfare. In addition to advancements in technology that made killing more efficient, the adoption of conscription in most western nations meant larger armies and more casualties. But the telegraph had made the battlefield and its nightmares less remote, and there were many citizens like themselves who had become involved in efforts to make war more “humane” or abolish it altogether.

            At this point, I mentioned the book, Memories of Solferino, and was compelled, by the dissent among my guests that it evoked, to move on to:

The Second Course—Peace and Harmony Soup

            Memories of Solferino, which Dunant had written in 1862, had essentially introduced my two guests to each other. Using his own money, Dunant had self-published the book and boldly sent it to many influential Europeans among whom Moynier, as president of the Geneva Society for Public Welfare, was one. Even today, it is a moving and gut-wrenching account of the battle Dunant witnessed in Solferino, Italy in June, 1859 in which French forces and their allies clashed with the Austrian troops of Emperor Francis Joseph. The battle lasted only some fifteen hours, but by the end of it, according to Dunant, roughly 40,000 men were dead. In the hot, summer days and months that followed, another 40,000 soldiers, both Austrian and allied, died of injuries, starvation or thirst in the small, Italian towns and villages surrounding the scene of battle. Dunant describes the “despair unspeakable and misery of every kind” that he saw during the time he spent there. He ends the book with a call for the formation, in peacetime, of societies of non-military volunteers to train and prepare for wartime crises, and for a treaty that would grant these volunteers neutrality on the field of battle.

            In spite of my praise for Dunant who had so compassionately and courageously tended to the wounded and dying at Solferino, as well as for the vision of humanitarian action he had articulated,  Moynier seemed reluctant to acknowledge the profound impact the book had had on European society, and indirectly, on the world. He complained of people who could envision armies of volunteers but couldn’t manage their own finances. He was referring, of course, to Dunant’s scandalous bankruptcy in 1869 which left him shunned and living a life of obscure poverty for the next 20 years. His reputation was eventually rehabilitated towards the end of the century, and in 1901, he was the co-winner of the first Nobel Peace Prize, but he had paid a high price for the honor.

            On the other hand, I understood Moynier’s bitterness. He had spent the better part of fifty years fulfilling his bureaucratic responsibilities as president of the ICRC, but had never received such recognition. Nevertheless, he’d been less than charitable to Dunant when he’d suffered his misfortunes. As gently as I could, I chided him for that, and then to be fair, I scolded Dunant, too, for always letting his emotions get the better of him. He suggested that was a little like the pot calling the kettle black, and I had to agree.

The Third Course—Friendship Fondue

            We all sighed with relief when the next course of Friendship Fondue interrupted our self-reproach and gave us something else to concentrate on. Twirling our skewered crusts in the communal pot of melted cheese required concentration, courtesy and patience. It gave use a chance to ponder the sticky, messiness of life which was the subject we took up next with:

The Fourth Course—Mercy Meat, Shared Potatoes and Mixed Blessing Vegetables

            I began by asking Dunant why he had accepted, at the end of Memories of Solferino, “the prospect of future wars, the avoidance of which, sooner or later seems hardly possible.” And from Moynier I wanted to know why, even today, the ICRC does not put all its efforts into universal disarmament. I also reminded them that the Red Cross has, over the years, come under considerable criticism for aiding and abetting war by making it “more humane,” for militarizing humanitarian aid with a patriotic mission and discipline, and for not doing enough to promote peace among nations.

            As I presume they always had, my two guests fell immediately into their habitual roles, Moynier as the pragmatic pessimist who argued that humanity must be led to improvement in small, manageable steps, and Dunant as the visionary prophet, agreeing with me and clamoring for instant and universal disarmament.

            “All are brothers,” he said to me with tears in his eyes.

            “But Henri,” I said to him (because by now we were on our third bottle of wine and were on a first name basis), “Henri, you are the one who described how Colonel de Maleville seized ‘the regiment flag [and] rushed forward in the face of terrific fire from the enemy, shouting: “Every man who loves his flag, follow me!”’ Don’t you see how heroic this description is, how it might inspire young men to war?”

            Moynier, hearing my criticism, looked a little too smug and righteous so I said to him, “As for you and your methodical and patronizing patience, I’d like to suggest that humanity’s ‘tiny steps to improvement’ have not kept pace with its enormous strides to destruction! Landmines, gas chambers, heat-seeking missiles! You guys are lucky you died at the beginning of the 20^th century! Do you know what Gandhi said when the bombs were dropped on Hiroshima? He said, now we will all learn peace or face certain annihilation!”

The Fifth Course—Compassion Pie Smothered in Love á la Mode

            Clearly I was getting emotional and on my high horse, which I tend to do when I drink too much, so my guests, both kind and good men at heart, abandoned their bickering and plied me with Compassion Pie and fair-trade coffee. “Don’t worry,” Moynier said, “Eventually, everybody gets to rest in peace.”

            Smothering my pie with Love á la Mode, Dunant quoted Thorton Wilder to me. “Speaking as a dead man,” he said, “’My advice to you is not to inquire why or whither, but just enjoy your ice cream while it’s on your plate.”

The Hangover

            The next morning, while nursing my hangover, I thought about what I’d learned from my interesting dinner guests. From Dunant, I learned that even if compassion and respect is all you have to offer a dying person, that is not nothing. I also learned that while working for humanitarian causes, it’s important to tend to one’s personal and financial survival. Otherwise, one ends up on the street, the object of pity and/or scorn.

            From Moynier, I learned the difference between “loving mankind” and “loving thy neighbor.” Sometimes, the latter is the greater challenge. As my brother, the diplomat, has said, “I love humanity; it’s my fellow man I can’t stand.” Maybe if he’d been a little kinder to Dunant, they could have received the Nobel Prize together.

            And finally I learned that furthering the cause of humanitarianism in the world requires both visionaries and pragmatic organizers. These two types of people are interdependent. Both are necessary. But in spite of the best intentions, there is always a shadow side. Even the great humanitarian achievements of the ICRC are a mixture of light and dark. 

Dinner with John Snow by Jennifer Reynoso

Dear Ms. Jennifer Reynoso,

It is with many thanks that I accept your invitation to dine and will arrive tonight at seven o’clock in the evening.  I look forward to discovering the subject of our meeting. 

                                                                                  

                                                                                    Kindest regards,

                                                                                                                     John Snow, M.D.

 

I hadn’t received his reply in time.  Which is why when Dr. John Snow, the Father of Modern Epidemiology, arrived at my house all prim and proper, and exactly on time, I was in my sweatpants, elbow deep in a bag of cheese puffs, surrounded by a pile of books- each one with his picture on the cover.

As I rolled off the couch to answer the door I caught a glimpse of him through the living room window.   Oh no.  There he was mutton chops and all, the man in the pictures standing on my doorstep.  I was immediately in a state of panic.  I surveyed the living room.  What a mess, I thought to myself.  I looked down at my sweatpants and crumb covered shirt—not exactly the meeting I had envisioned.  Perhaps he would chalk my filthiness up to some kind of scholarly eccentricity?  I’d have to take my chances.  I pushed as many books as would fit under the couch- lest he fear me as some kind of stalker- and tossed the bag of cheese puffs into the bedroom and closed the door. 

I paused, wiped my hands on my shirt, and opened the door to greet him.  He was very clearly perplexed by my personal presentation, and I am fairly certain that he shuddered when I outstretched my artificially orange, cheesy hand to welcome him, but he was gracious nonetheless and thanked me for the invitation.  As he stepped past me to come inside, I looked out through the doorway. Had he arrived in a car, a horse and buggy?  And where had he come from really?  He wasn’t particularly dusty or covered in cobwebs.  Where had he been for the last one hundred and fifty years?  Oh well, no clues. 

The next few minutes were somewhat awkward as I clumsily scavenged through the refrigerator searching for anything that could be called “dinner”. Dr. Snow looked through some of his own works scattered across the dining table.  I apologized profusely after preparing him a roast beef sandwich, which he had to turn down on account of being a vegetarian.  Right, should have remembered that.  Finally, I presented him with a salad which, after ascertaining how I had washed the lettuce and from what source the water came, he gladly accepted and sat down.

Naturally, our discussion began with my attempts to explain my invitation.  This was somewhat awkward on my part, as a large piece of lettuce was stuck to my front tooth throughout my monologue, but hopefully he got the point.   I explained my interest in the field of public health and my personal commitment to promoting the health and welfare of people across the globe. Epidemiology, I explained, is the first cornerstone of public health.  “What better way to delve into the roots and methods of epidemiology than to become acquainted with their very father!”, I blurted out with an awkward inflection.  He seemed surprised by the title, and I assured him that I would explain how that had come to be, eventually. 

Drawing on my research, I began to ask him about the early days of his work.  He told me about growing up in York and then joining Mr. Hardcastle, a surgeon, as his apprentice in Newcastle-upon-Tyne.  He said these had been formative years for him.  During that time he had begun to form his beliefs about health, the importance of diet and temperance, and first encountered cholera- the infamous disease he had previously only heard of and which would later monopolize so much of his time. 

I asked him about his years of training and he described the year, 1838, in which he finally became a certified physician and apothecary.  He reminisced about his years in obstetrics and his initial interest in the research side of medicine.  He suddenly grew more animated talking about research and fumbled in his pocket, “Do you have a quill?”  A quill? Ah yes, a pen!  I handed him a pen and he began to feverishly scribble diagram after diagram of his greatest discoveries and inventions on his napkin, explaining each as he went.  When he had used up every bit of space on the napkin he stopped suddenly, embarrassed, and apologized for having destroyed my “linen”.  I responded with something about it being disposable, to which he gave an enthusiastic, “Brilliant!”  

As I got up to begin clearing the table he started to share about his work with anesthetics.  His days were quite busy, he explained, having dominated the market in London for much of his career.   “I anesthetized Queen Victoria you know.  Twice!” he shouted after me as I walked toward the kitchen.   

As I scavenged through the refrigerator in search of “dessert”, I was unaware that Dr. Snow had moved to the living room and had discovered the half-hazardly hidden pile of books below the couch.  As I rounded the corner with two dishes of ice cream, I found him scratching his head, pouring over the unfamiliar books with his name in the title.  I reassured him that he need not be alarmed and began to explain what had come of his career and why he had been declared, by some, The Father of Epidemiology. 

It was his work with cholera, not anesthetics—I explained as I sat down next to him on the couch—that had in today’s world made him noteworthy.   His growing fascination with the mode of transmission of cholera which had prompted his many writings and inquiries into the matter had been justified with the discovery of the causal organism Vibrio cholerae in 1883.  To this he gave a quick response, “Well of course!” appearing both ecstatically vindicated and offended at the same time.  It was, I explained, his strict commitment to the theory of contagion as the single mode of transmission of disease which made him stand out in his era of history.  Though others had supported similar theories, he had boldly rejected any theory that married contagion with miasmatic theory and beyond that, actually provided epidemiological data to support his theory that cholera was spread person to person by direct contact with a causal organism.  Even further, he suggested the implementation of a practical and successful intervention—in the case of the Broad Street cholera outbreak the removal of the water pump handle to stop the ingestion of contaminated water—which further supported his theory.  The process by which he came to his conclusions- gathering data from the study of a population- is the very essence of modern epidemiology, and for that reason, he played a pivotal role in the development of modern public health.  “That’s brilliant” I declared in my best English accent.   

He sat quietly thinking for a moment and his expression slowly melted from one of satisfaction to that of great disappointment.  Maybe the poorly executed accent was a bad idea?   “But you make it sound so simple, years of observation and study”, he said staring blankly at his own picture.  I was a little taken aback by his sudden sensitivity and wasn’t sure of what to say.  Perhaps some hot fudge? I thought.

I tried, for a moment, to offer something more beneficial than hot fudge and responded that though his story was popularly simplified, I had learned many lessons from studying the finer points of his career.  He looked intrigued.  “Your career was overwhelmingly defined by commitment”, I explained. 

A commitment to the scientific processes of observation and discovery- whether reading the works of scientists that came before him, observing a trend in a human population, or discovering physiology through animal models, his commitment to a lifestyle of learning was evident and undoubtedly led to his great success.

A commitment to practical interventions for practical problems- his unwillingness to settle for the current standards of care and prevention, his true belief that better methods existed, continually pushed him to investigate and create.  His ability to synthesize his learning beyond understanding to the point of innovation and application were pivotal to his success.   

His strong commitment to his theories and the integrity of data- whether defending his theories before his professional organization, Parliament, or in a scholarly journal, Dr. Snow continually risked both his professional and social standing.  I explained to him that though this made him unpopular, particularly within the circles of his profession, it made him a man of scientific integrity.  Ultimately, it was probably this unbending persistence which set him apart from other theorists that supported contagion in his day.  “And that is why”, I explained, “I invited you and not them!”  With that we both laughed, and he finally looked somewhat relieved. 

As he got up to leave I praised him once more for his contributions to my future profession and offered him a few of the books, which he gladly accepted.  I knew that my time with him—awkward as it was—had served its purpose. He thanked me for the meal and made some comment about cholera deaths thankfully being a thing of the past.  I didn’t have the heart to correct him, but hoped that instead, perhaps at our next meeting I might be able to give him the good news that they finally are.  

Food for Thought: A One-Act Play by Diana Petes

 

Cast of Characters

 

Diana Petes:            

First year MPH student at BU.  A twenty four year old American female.

 

Joseph Lister:            

British public health hero from the 19^th century.  Deceased male.

                             

 

 

 

Scene

 

The dinner table in Diana’s dining room in Brighton, Massachusetts.

 

Time

 

September, 2008.

ACT I

 

Scene 1

 

SETTING:    

A smoke-filled kitchen in a

          relatively dilapidated

          apartment building. We

          see a clutter of dirty 

         pots, pans, cookbooks, and

          baking ingredients strewn

          about. The fire detector is

          blaring, and we hear a young

          girl spouting off various 

          expletives in the background.

 

AT RISE:     

DIANA PETES is pacing around

     the kitchen frantically. She

     is in the midst of cooking a 

    British feast for her soon to

    arrive dinner guest, JOSEPH 

    LISTER, a prominent public 

    health figure from the 19^th

 ^{century. Things are not going}

   ^well.

 

DIANA

What did I get myself into? I can barely cook Ramen noodles, and here I am trying to cook a gigantic roast with Yorkshire Pudding. I know nothing about this complicated British food, and I’m going to ruin everything. On top of that, I forgot to wipe down every surface in the dining room with 509, and the “father of modern antiseptic” is going to be arriving at any –-

 

(The doorbell rings.)

 

DIANA

Uh oh...

 

(DIANA answers the door. JOSEPH is at the doorstep. He doesn’t look half bad for someone who has been dead for almost a hundred years.)

 

DIANA

Welcome, Mr. Lister. I can’t tell you how happy I am to see you. I sincerely apologize for the mess, but come in and make yourself at home.

(JOSEPH shakes DIANA’S hand, walks inside apprehensively, and locates the nearest sink to wash his hands before sitting down at the dinner table. DIANA nervously brings out the disheveled beef roast and half-raw popovers.)

 

DIANA

I might as well cut to the chase Mr. Lister. I invited you over because I feel like you’ve had a significant impact on my life. If it weren’t for you and your advocacy for antiseptics in the operating room, I might not be alive right now. I had open-heart surgery when I was a kid, and who knows what kinds of infections I could have gotten? It’s astounding how many lives were saved because of your work. Mortality rates in major surgeries decreased from approximately 45% to 15%. Actually, I might not have even been born since my mother could have died during childbirth if it weren’t for your contributions.

 

(JOSEPH pushes his food around his plate awkwardly.)

 

JOSEPH

Diana, you’re giving me too much credit. I don’t like all this gushing; it makes me uncomfortable. I prefer to be modest about my work. And please, call me Joseph.

 

DIANA

Ok, sorry Joseph. Let’s start over. If you feel I’m giving you too much credit, who else do you think deserves it? Who was your greatest influence?

 

JOSEPH

Without a doubt, Louis Pasteur. He published a paper stating that the rotting and fermentation of wounds could occur without any oxygen if micro-organisms were present. I had a feeling that micro-organisms were causing the gangrenous infections I kept observing in patients. Too many patients were dying from fatal wounds following successful surgeries, and it frustrated me. I wanted to expand on Pasteur’s experiments and do something about it. His work paved the way for all of my studies.

 

DIANA

What kinds of experiments did you conduct?

 

JOSEPH

Well, I knew that in the past, carbolic acid had been used for deodorizing raw sewage. I thought I could apply this chemical to human surgeries for antiseptic purposes. I started spraying surgical instruments, incisions on the patients’ bodies, and dressings post-surgery with a carbolic acid solution. Turns out it worked quite well!

 

(Both DIANA and JOSEPH are picking at the unappetizing food. DIANA pours them each a glass of wine to make the situation a little less unnerving.)

 

DIANA

I know you’re humble Joseph, but if you had to pick one contribution you are most proud of, what would it be?

 

JOSEPH

I think it has to be my emphasis on the importance of hand washing. I made surgeons in the operating theatre wash their hands before every procedure with carbolic acid solutions, as well as enforced the spraying of surgical tools and other surfaces in the room with the same substance. I think this minor adjustment in the hospital sanitation protocol may have saved a life or two.

 

DIANA

And what specific population do you think you had the most positive impact on?

 

JOSEPH

Hard to say, but perhaps pregnant women. Too many were dying from post-labor infections, and a great deal of this was due to the lack of antiseptic. After doctors started hand washing and wearing clean gloves, childbirth became a much safer procedure.

 

DIANA

How did you get the staff to listen to you? Previously, Ignaz Semmelweiss and Oliver Wendell Holmes tried explaining the role of cleanliness in preventing infection, but it was not well received by the medical community.

 

JOSEPH

It was all in the way I presented the information. I did not attack or accuse the doctors of being dirty and causing deadly infections in their patients, even though that may have been the case. If you point fingers, your message won’t get through to anyone.

 

(JOSEPH tries a bite of the roast and inconspicuously spits it back into his napkin.)

 

DIANA

Joseph, if you could pass on one piece of advice to a first year public health student like myself, what would it be?

 

JOSEPH

To be deeply passionate about your ideas. Don’t let anyone tell you that you can’t do something. I was known for always standing by my beliefs--they were my religion. It’s the only way I got anything accomplished. Also, I never cared about financial gain or social status. Chances are, you will not make very much money it in this field, but who cares? I was never rich, and I lived happily until I was eighty-four years old with no regrets.

 

DIANA

You’ve made me feel much more confident about going into the public health field. I have received some criticism from my family and friends who think I am going to regret going into a low-paying line of work. You are proof that it is not about the money or status, it’s about the people you help that matters. You’ve also shown me what an enormous influence a small change such as hand washing can have on a population. Most notably, what I’m going to take away from this conversation is your ability to relate to patients and have them listen to you. In public health work, you can tell target populations to do something like wear condoms to prevent HIV infection, but if you don’t convey the message appropriately, they are not going to respond. To make big changes, you can’t bark orders. I can’t thank you enough for chatting with me. It has really been an honor having you over for dinner. Can we do it again sometime?

 

JOSEPH

Sure, but we’re ordering pizza!

 

(DIANA and JOSEPH cheers with their wine glasses, take a final sip, and the curtain closes.)

 

THE END

An Evening with Lady Mary Wortley Montague by Colleen Barrett

Edward Jenner is well renowned for discovering the smallpox vaccine, but there is more to the history of smallpox.  Wanting to understand the fight to protect ourselves from this disease, I called upon (the ghost of the) Lady Mary Wortley Montague, arguably an equally catalytic though lesser known figure in the history of smallpox and its vaccination.  Lady Montague’s ‘contributions to English life’ extend beyond smallpox to include her staunch advocacy of feminism as well as her title as one of the ‘greatest of the English letter-writers of the century.”  I prefer to translate Lady Montague’s legacy as the potential for a public health worker who is not medically licensed but understands the value in the fight against adversity to influence people and implement change.  As we face a new frontier in the 21^st century with the global spread of infectious diseases and potential biological warfare as public health concerns, I knew I could learn valuable lessons from Lady Mary (as she later asked that I call her).  Thus, I was thrilled when she accepted my invitation for dinner and I knew exactly what would be on the menu: meatloaf. 

As I chopped the vegetables, minced the garlic and tenderized the meat, I reflected upon the limited knowledge that I did have about Lady Mary.  During the 18^th century when she was alive, approximately 400,000 people died from smallpox each year.  Lady Mary faced smallpox within her own family – she and her brother both had the disease - but only she lived to tell the tale and to change fate for many to come.  Her story starts while traveling in the Ottoman Empirew when she was exposed to variolation, the process of infecting a person with a small amount of the smallpox virus in an attempt to prevent them from getting the full blown disease.  This form of inoculation was common practice in Turkey at the time; however English physicians did not embrace it.  Upon her return from Turkey, Lady Mary shamelessly promoted the inoculation in Europe, eventually inoculating both her son and daughter.  These successes within the royal family spurred a subsequent wave of inoculations and eventually Europe and the New World would benefit from her work. 

Lady Mary and I had a wonderful evening together and as she is famous for, she kindly wrote me a thank you letter (translated into current vernacular):

Dearest Colleen,

 

Thank you for a splendid evening.  Although I didn’t exactly know what I was getting into when you invited me, I found that it was an emotional trip down memory lane for me and certainly a once in a lifetime glimpse into the future.

I was fascinated by our discussion on what you now call ‘clinical research,’ which we started discussing when I shared the details of the inoculation process I witnessed in Constantinople.  The process of clinical research doesn’t sound as if it differs significantly from my efforts to convince the English to try the barbaric sounding idea of performing those first inoculations on patients.  It was interesting to ponder with you when the true roots of testing medical hypotheses on humans began, but we both agreed it is never easy to involve a human life.  I will never forget when I first had my son inoculated on my own initiative.  I certainly feared the worst after 8 days when he was bedridden, covered in pustules and extremely feverish, but soon enough he was left with nothing but the scar on his arm where the inoculation had taken place.  How would I ever forgive myself if he hadn’t survived that bout?

Consequently, you were right to ask if I considered it an ethical dilemma at the time when prisoners and orphan children were used as ‘guinea pigs’ in the inoculation process.  Perhaps most revealing of my regrets of using those social outliers for the testing was my delight to hear that certain animals such as rats, mice and monkeys have since been discovered to share many of our human properties (did you call them genes?) and are now used in the clinical research process.    

Another question that has stuck with me was about my personal struggle with the English physicians of the time and how I knew to not back down on my personal agenda for change.  You were right that I was bold to counteract the established practice of the time without medical knowledge, but you should not underestimate the power of observational knowledge (as I acquired at the time in Constantinople) and if were able to collect these biostatistics that you referred to, I know that my case would have held all the more weight.  I am encouraged by the fact that you are enabling yourself with such skills for your public health work. 

I have to admit that I was quite surprised (perhaps even embarrassed) by the credit that you gave me for my actions and your claim that my efforts were so instrumental to public health.  I was terrified to learn how widespread smallpox became, and how such a pattern of contagion and disease such is still a part of history, although greatly stunted by the vaccination process that I helped popularize.  More disturbing was what you shared about how avant garde I was in my biological focus on disease.  I cannot imagine how subsequent populations placed such weight on miasmas and vapors as the cause of illness.  I return to my advice on the strength and value of observation as a method of understanding disease.

In closing, I would like to thank you for this opportunity to further validate what I knew was important for English society at the time – and I now know, humankind.

 

Sincerely,

Lady Mary

I eagerly responded:

 

Dearest Lady Mary,

 

Thank you for your kind letter.  I, too, enjoyed your company and assure you that you fully deserve any and all accolades for your accomplishments and for the implications of your actions for the future.  Since you left, my head has been swimming with all of the ways in which I realized that we have learned from your actions – and the ways in which our conversation enlightened how we should learn from you if we haven’t already. 

As you are well aware, royalty set the standard for many fashions and customs during the 18^th century – and inoculation was no exception.  I struggle with the fact that our government doesn’t play the same role and although I don’t believe they should, I worry that we lack the role models and influential figures that are can be crucial in guiding health decisions.  It was interesting to entertain the idea that pop culture has replaced the royal family in their influential role.  Although the public health worker holds great potential, we still strive towards a cohesive effort around preventative measures of health.  Your efforts to inoculate English society were advanced for that time since people mostly responded to health disasters as they ensued instead of preventing them in the first place.  Sadly enough, we still struggle with implementing many simple measures of health prevention and have much to learn about how to influence people.

On a similar note, since our dinner I have realized some of the decisions that we now have to make to protect ourselves are similar to those that you had to make in the 18^th century.  With our increased understanding of biology, negative implications have been introduced alongside the positive advancement.  The Russians introduced a whole new realm of manipulation with their demonstrated ability to create variola virus, the cause of smallpox.  The idea of a disease being used as warfare threat probably sounds entirely foreign to you, but the threat of what we call bioterrorism has become a real worry for our society.  The proposed solution will not sound quite as foreign – increased voluntary smallpox vaccination.  Hence we have come full circle to your efforts to vaccinate the public, and I will be calling upon your methods of influence as a model for us now.

In closing, when you first wrote the following passage to your good friend Sarah Chiswell, I know that you had no idea of the string of events that would ensue in history:

 

“I am patriot enough to take pains to bring this useful invention into fashion in England; and I should not fail to write to some of our doctors very particularly about it, if I knew any one of them that I thought had virtue enough to destroy such a considerable branch of their revenue for the good of mankind…Perhaps, if I live to return, I may, however, have courage to war with them.  Upon this occasion admire the heroism in the heart of your friend.”

 

I can only say that your heroism is still being admired by women, students and public health professionals today.  I hope that I will be able to look back on my public health work with the ‘private satisfaction of having done good to mankind’ as you once declared your intention.

 

Best regards,

 

Colleen

 

In conclusion, my dinner with Lady Mary and what I learned about the history of her actions and the smallpox disease itself proved to be more inspiring than I had hoped for.  I wish I could say the same about the meatloaf…

Dinner with Florence Nightingale by Sarah Summer

When asked to invite a public health figure to dinner I was very excited. I had a few criteria that I wanted to incorporate into my dinner guest selection. First, I wanted to invite a woman. Although many of the “helping professions” such as nursing, public health, and social work, are both currently and historically dominated by women, it is not until recently that women were shown similar levels of respect as men. I am very curious to learn about the experience of a smart, driven female during a time when women were very repressed. My second criterion was to find a woman who has made an impact in the field of human rights as well as public health. This requirement sounds a little but difficult at first blush because the concept of “human rights” was not fully formed until after world war two. However, human rights existed long before then in the idea of natural law. The inequalities and injustice women faced based on their gender has and continues to be a violation of their human rights.

Now that I had my basic criteria I began to brainstorm. Should I invite Jane Adams one of the great leaders in social work? What about Margaret Sanger, the champion of reproductive rights? Or should I invite Marie Curie, one of the first well re-knowned female scientists? What about Eleanor Roosevelt, the voice behind the Universal Declaration of Human Rights? It was then that I remembered the third criteria I had to consider. The public health figure had to be someone from the 19^th century or before. This was much harder. Important female public health figures before the 20^th century were not nearly as well known or easy to find. I finally settled on inviting Florence Nightingale. Now, I know that she did not die until 1910, but she did most of her important work occurred before the 1900’s. Additionally, I wanted to invite someone to dinner who I could relate to, and although Cleopatra, Queen Elizabeth and Abigail Adams were very interesting they were a little too historically distant for me to really relate to. As it turns out Florence became an invalid after her experiences helping wounded soldiers during the Crimean war. She rarely left her home, but fortunately she invited me to come to her place for dinner.

Florence Nightingale was born on May 12, 1820, what is now International Nurses Day.[i] Although Florence had an interest in nursing her parents did not think the occupation was appropriate for a woman of her class and background. They would not fund her education.[ii] Finally, after much effort Florence convinced her parents that nursing was her calling. During dinner I asked Florence if she had ever considered becoming a doctor rather than a nurse. My assumption was that the medical profession for women was strictly limited to nursing during that time. Florence confirmed my response; she said that she had wanted to become a doctor but that the medical profession was closed to her.[iii]  In response she had become a strong advocate for women, and campaigned for woman’s suffrage, and for opening the medical profession to all women.[iv] I found it interesting that although today women are technically allowed (at least in the United States) to become whatever profession they want, in most of the world their role remains as the mother and caretaker of the family. The injustice that Florence fought so hard against still remains. I told her about how in Afghanistan the Taliban forbid women from seeking care from a female doctor. Then the Taliban forbid women from becoming doctors. Florence was shocked and saddened by the revelation that society as a whole has not come very far.

 In 1860, Florence wrote a book titled Nursing: What it is and What it is Not; the book was basically a textbook on how to be a good nurse.[v] What is most interesting to me was that the book was not targeted to nurses but rather as a guide to all women, because as Florence put it, “Every women, has at one time or another in her life, charge of the personal health of somebody…in other words, every woman is a nurse.”[vi] I was impressed with Florence because she was empowering women everywhere to take control over their own education and the health of their own family. She taught women to keep their house clean and sanitary, to separate the sick from the well, and to ensure that food was clean and safe. I was really impressed that Florence decided to empower the average women. However, after speaking to her I realized how frustrated she was because although there were simple things that every woman could do to help ensure the health and well-being of her family, it was hard to communicate those things to them. She told me that many women did not know how to read. Even if they did know how to read, they did not have enough money to purchase her book. Again, I was shocked by how similar the situation in 1860 was to the situation of today. In our world one of the primary indicators of good health is educational status of an individual. If an individual cannot read, then he or she may not know simple ways to protect themselves from disease and risk factors.

In 1863 Florence wrote another book titled Notes on Hospitals.[vii] Florence recognized that more people were dying in hospitals then they were outside of the hospitals. She found this fact fascinating. Florence was one of the first people to understand and recognize the concept of iatrogenic illness. She understood that simple precautionary measures could keep the sick from becoming sicker and may even allow them to get healthier. She spoke to me about how frustrating it was to see so many people die because simple mistakes. She also spoke about how a lack of resources in some countries she worked, such as India, were a real detriment to the quality of health care. I spoke to her about how the same is true today. We both found it frustrating that so much of medicine is concentrated on helping the individual fight whatever ailment he or she might have, but that the underlying root causes of the ailment were never addressed.

Florence and I also discussed biostatistics. I had no idea that she was one of the great statisticians and had used her love of math and statistics to find correlations between health and physical conditions. She even created pie charts to present this knowledge.[viii] We chatted about our shared love of math and science.

Overall dinner was really interesting and informative. What I learned is that since the 1800’s we have not really come so far. Even 100 years after her death women face inequality and the health system in developing countries has yet to learn the valuable lessons she presented in her books. I did not feel completely without hope though. Through her contributions Florence paved the way for the concept and acceptance of public health as a field. She also opened the door for me to be able to attend law school and participate in the political system. On November 4, I will honor her hard work and vote!

A Timeless Debate with an Old-Timer: A Man-date with Johann Peter Frank by John Tucker

From the multitude of personalities who have contributed to the field of public health across roughly five millennia, from the period of ancient Egypt through the Industrial Revolution, I chose to have dinner with Johann Peter Frank.  I think my choice is interesting not because Frank contributed more to the field than any other figure, although some public health historians do refer to him as “the father of public health,” a title I thought was reserved for John Snow.  Nor do I think he’s an interesting choice because his ideas were particularly revolutionary; as Baron points out, the concept of the “medical police” was discussed and implemented in Germany two full centuries before Frank was even born.  The reason why I consider Frank an interesting choice for this topic is because, based on his principles, he seems like the least enjoyable dinner companion in human history.

            Frank’s legacy in public health is his extreme promotion of enlightened despotism, the social philosophy that calls for the state to formulate thorough policies regarding the health of its citizens and to enforce these policies strictly.  In his magnum opus, a six-volume, 6262-page tome entitled A System of Complete Medical Police, Frank attempted to lay out in painstaking detail such policies, regulating nearly every aspect of human health and behavior, including procreation, marriage, food, drink, clothing, entertainment, public safety measures, burial, and education.  A few of the more absurd suggestions outlined in this work include a mandate that citizens at a dance party take a rest before leaving lest they catch a cold in the nighttime air, a ban on corsets as they restrict a woman’s breathing too tightly, and a ban on public performances in which too many characters are murdered, as these works lead to depression in the public.

            His reasoning for such drastic intrusion into the lives of his countrymen was both humanitarian and patriotic.  As a young physician, Frank observed that the diseases affecting people most severely were often preventable as they were rooted in social conditions.  It seemed obvious to him that people could not reasonably protect themselves and needed guidance from the state to stay healthy and happy.  Additionally, Frank reasoned that the best way to strengthen a nation was to strengthen its citizens, a feat best accomplished by regulating their behavior.  Although the rigidity and intrusiveness of his methods seem abhorrent to modern-day democrats, it sounds like his heart was in the right place – he wanted to save lives and strengthen his country.           

Despite his good intentions, I think Frank was terribly naïve and misguided, and were his plan to be fully implemented, I believe mankind would suffer dramatically.  In addition to restricting all the things that might spice up a good dinner party, such as drinking, drug use, gambling, overeating, promiscuous sexual behavior, and entertainment with gratuitous violence, Frank spent his life promoting a theory with which I fundamentally disagree.  If all that weren’t enough, his resemblance to Hannibal Lecter is uncanny.  Why then would I have this guy over to my house for dinner?

 However terrifying and prude he may have been as a person, and however totalitarian his ideology, I am intrigued by the concept he proposed.  Frank resides on the farthest extreme of a topic which to this day remains relevant in public health debate - the question of state control versus individual liberties.  Somewhere at the headquarters of the ACLU, there’s probably a dartboard with a picture of Frank’s head as the bulls-eye.  His ideas represent a libertarian’s nightmare and the antithesis of Enlightenment philosophies on which modern liberal democracies were founded, although most have adopted many regulations similar to those Frank proposed.  The continuation of this debate makes Frank’s principles pertinent, and I think it’s important that people consider the pros and cons of both sides.

 

The message I would like to convey to Frank in the preparation and setting of our dinner is the concept of personal choice, because after all, this is my house.  For this reason, I’ve set up a buffet of American, British, and French cuisine, representing the various hotspots of Enlightenment thinking, and of course a selection of whatever German foods he deemed appropriate for the public in his manifesto.  Wearing a t-shirt and sweatpants, I pile my plate high with steak frites, fish and chips, and a giant piece of apple pie with a piece of American cheese melted over it.  I pour myself a giant beer, and sit down, being sure to leave the seat at the head of the table open for my paternalistic guest.  Once he sits down, I get us rolling on the debate.  “How’s your gruel?” I ask with a mouth full of steak.

“Delicious,” he replies, acknowledging my sarcasm.  “It feels good to eat healthily.”

“True, but only if you’ve chosen to eat healthily, rather than being told to do so, right?”

“Wrong, it feels good to be healthy, regardless of how or why you came to be that way.  Trust me.”

“And why should I trust you – what gives you the right to take away my right to choose what to eat and how much?”

“Because your decisions affect me in ways you don’t seem to understand.  The ways you eat, drink, smoke, fornicate, dress, and entertain yourself all contribute to your health, or lack thereof, and as the behaviors in which you choose to engage weaken you, so you weaken my country, and thus weaken me,” he retorts. “I am helping you help yourself and your country.”

“I think you’re ruining my country.  Yes, we’ll all be healthier and we’ll live longer under your system, but we’ll all be miserable wondering what life would be like if we could enjoy the wonderful, dangerous, unhealthy options you’ve taken from us.  And how do you expect the state to progress when you’ve got us stuck in a vacuum?  Personal choice combined with freedom of expression leads to new ideas and progress.  A state that controls its public is stagnant, and that makes it unhealthy,” and as I bring the largest piece of pie I can hold on a fork to my face, Frank slaps it out of my hand. 

“Wrong – you’re unhealthy.”

“Well, that does it.”  I get up out of my chair, lift Frank out of his, and throw him out of my house.  Just as it is society’s duty to revolt against a tyrannical government that breaches its social contract, so it is mine to throw out an aggressive house-guest.

 

Despite this outrageous hypothetical interaction, I actually believe a state should exercise a certain amount of control over its populace when it comes to healthcare decisions.  The enlightened despotism that Frank preached invokes a miserable, Orwellian society, but as awful as that existence would be, there is an equally terrible alternative opposite the spectrum in a pure libertarian state.  Without traffic laws to keep people from running each other over, or the FDA to keep carcinogens out of their breakfast cereals, people would be unsafe, unhealthy, and unhappy, living in fear of all the unregulated, unknown dangers lurking in their environment.  The key is for the state to provide guidance only when absolutely necessary to protect its citizens, without sacrificing personal freedom.  Such balance is obviously difficult to find.

As the causes of mortality rates in industrialized nations have shifted in the last century from communicable to preventable chronic diseases, the debate over state intervention versus individual rights has never been more relevant.  The tricky part about government regulation of the behavioral factors in these diseases (e.g. tobacco, alcohol, unhealthy food) is that their diagnosis doesn’t threaten the public the way that communicable diseases once did.  Therefore, the “well-being of the community” justification doesn’t hold up as much anymore for proponents of coercive public health measures.  This reality forces society today to revisit the question Frank tried to answer two centuries ago – are coercive public health measures necessary to preserve the strength of the state, and if so, is there enough justification to sacrifice some personal freedoms?

When considering the modern debate about state control over public health, it is important to remember Frank’s legacy as a reminder that some government interaction is necessary but too much will crush the individual spirit.  The key to a healthy state lies somewhere in the balance.

Dinner with Ignaz Philipp Semmelweis by Caitlin Patterson

In 1818 in Hungary, a man was born who would influence the development of public health.   Throughout the course of his life, which ended abruptly in 1865, Ignaz Philipp Semmelweis led a dramatic discovery in antisepsis, before full development of the germ theory.  Semmelweis would come to be known as ‘savior of mothers’ when, by mandating hand washing with a chloride of lime solution after performing post-mortem examinations and prior to examining obstetrics patients, he caused significant reductions in maternal mortality rates in Vienna and Budapest in the mid-19^th century.

            Having learned of Semmelweis’ historical significance in my studies of public health, I knew that his discovery of hand antisepsis as a method of reducing disease transmission was not met with widespread acceptance and he was faced by many in the medical community with tremendous adversity.  Although his work had the potential to instantly prevent numerous deaths within hospitals, circumstances and beliefs of the time led to a drawn out period of opposition and therefore unnecessary deaths of mothers and children.  For Semmelweis, the grief of this knowledge was difficult to bear.  Late in his life he was stricken with depression and psychological disease that consequently led to his death. 

            I have invited Ignaz Semmelweis to join me for dinner.  I have selected this man for several reasons.  First, I would like to gain an understanding of his perspective through the course of his discovery, especially as he was met with opposition from the medical community in Vienna.  Second, I would like to give him the opportunity to speak with someone, who, over 150 years later has a basic understanding of germ theory and modern medicine and can validate his concept of puerperal fever.  He is deserving of recognition for his discovery and an understanding of his own credibility.  Finally, I would like to share with Semmelweis modern views on his contributions to medicine and public health and the steps many have taken to recognize him.

            Semmelweis arrived at my home at six o’clock in the evening.  Prior to beginning our meal, Semmelweis inquired as to whether I had washed my hands.  I smiled and nodded, I had.  I informed him of our modern antiseptic methods of antibacterial hand soap, and could see that he was impressed.  As dinner began, I told Semmelweis about myself and my pursuit of a Master of Public Health, a concept that he was intrigued by.  I told him that I was most interested in hearing his story, and he began. 

            My career in medicine began when I moved from Budapest to Vienna to pursue law.  I quickly changed course, as you know, to study medicine.  After one year studying in Vienna and two at the University of Pest, I completed my degrees in Doctor of Medicine and Master of Obstetrics at the University of Vienna.  I became acquainted with three physicians by the names of Joseph Skoda, a teacher of general medicine and statistics, Ferdinand Hebra, a dermatologist, and Carl Rokitansky, a professor of pathologic anatomy. These men would later become close friends and colleagues. 

            I nodded my head, listening closely.  He continued.

            In 1846 at the age of 28 I was appointed assistant to Dr. Johann Klein, professor of obstetrics.  I began assisting with child births in the First Maternity Division of the Vienna General Hospital.  Almost immediately, I noticed a disturbing rate of maternal mortality in the First Division.  It was devastating to watch a healthy new mother transform to a helpless victim of childbed, or puerperal, fever.  It was a terrible sickness: the patient was seized by a shivering fit and a great degree of heat resulting in perspiration, accompanied by severe, consistent pain in the abdomen.  Death usually resulted within a matter of days.  I was told by my predecessor and others that the women were being killed by an invisible miasm, an unknown epidemic influence of an atmospheric-cosmic-teluric nature. 

            What struck me most about all of this was the fact that in my first year, 459 women died in the First Maternity Division.  Next door, however, in the Second Maternity Division, only 105 deaths occurred: nearly five times fewer.  I found other trends in mortality.  The women who delivered outside of the hospital, on the street, were not dying of childbed fever.  Alternatively, the women who experienced longer period of labor were nearly always victimized by the disease.  These inconsistencies consumed me, and I investigated every possible explanation that I could conceive.  I spent a great deal of time in the deadhouse performing post-mortem examinations; back and forth between autopsies and deliveries.  It was not until the day when I learned of the death of my friend from a knife cut during an autopsy that I realized the cause: physicians, myself included, were carrying decomposed animal organic matter from the corpses to the mothers.  This explained the difference in number of deaths between divisions: in the First Division, patients were examined by physicians who also performed autopsies, in the Second Division, patients were examined by mid-wives and nurses who did not.  It also explained why the women who did not deliver in hospital did not contract the disease: they were never examined by a physician.  The women who experienced longer laboring were examined many times by physicians, hence their higher mortality rates. This was a difficult reality to learn, that I, the doctor who should be providing care for my patients, was actually carrying to them the disease that was killing them.

            He went on.

            Immediately, I mandated hand washing by every medical student and physician with a chloride of lime solution.  Within months, the number of puerperal fever deaths in the First Maternity Division fell to the levels of the Second Maternity Division.  From what I understood about childbed fever, and as I described in my publication later on, there were three sources.  The first, from a dead body.  The second, from a sick person who is afflicted by puerperal fever.  The third, any decomposing matter.  This was identified when the sheets of an afflicted patient were transferred to a healthy patient who subsequently acquired puerperal fever.  The blood that had contaminated the sheets carried the disease.  I found that the disease was transmitted by the hands of the examiners, the hands of the operators, surgical instruments, bed clothes, atmospheric air, sponges, and the hands of midwives and nurses who came in contact with the excrement of afflicted patients.  Subsequently, we began washing medical instruments in the solution between patients as well.

            At this juncture I was compelled to interject.  I explained to him that his discovery was quite remarkable considering the fact that germ theory was yet to be fully uncovered, and also that he was almost completely accurate.  Today, we know puerperal fever to be caused by bacteria called Group A streptococcus.  We also discussed that fact that hand washing was not a completely new concept at the time of his discovery. The unique aspect of his discovery was that he recognized the cause of puerperal fever was being directly transmitted from one individual to another on the hands, and he understood the concept that there was one cause for the disease.  He was ahead of his time.  I told him that today his innovations represent the basis of infection control practice.  In hospitals, where we still face the danger of bacterial infection transmission from patient to patient by way of health care providers, physicians are required to wash there hands frequently, and always before contact with a new patient.  Hospital acquired infections continue to be one of the major preventable, iatrogenic complications of hospitalization.  What I find so fascinating about his compulsory hand washing is that appropriate action was taken to avoid infection based on inadequate information about the infection. 

            Semmelweis stated that he is pleased to hear what I have told him, but that it was an extremely difficult time in the mid-1800s when he was attempted to change the ways of physicians.  Dr. Klein was the first to denounce Semmelweis’ findings.  Others stated that ‘the mere suggestion the puerperal fever might be transmitted by medical attendants was abhorrent, would damage the trusting physician-patient relationship, and that fear engendered in the laboring woman by such a suggestion might in itself cause her to be afflicted by the disease’.  He described the frustration and anger he felt with the medical community.  Differing opinions with Klein led to his dismissal, and he left Vienna for Budapest.  When invited to speak on his findings in Vienna, he initially refused.  His methods of communication seemed, to me, inadequate to accomplish the change in physician behavior he was seeking.

            Listening to Semmelweis, I could sense the frustration and turmoil that he felt during this time in his career.  He went on to explain that when he did publish his work, which he had put off for several years, he could not help the angry tone that came across.  As the end of his life neared, he was not the same doctor he had once been.  He alluded to the final days when he was admitted to the asylum, where he died from an infection that entered through a cut on his hand.

            It was late then, and I thanked Semmelweis for spending this time with me, that it was an honor.  I also told him of the recognition he has been given.  Within 40 years of his discovery, his hand washing technique was adopted by most in the medical community.  I told him that Budapest Medical School is now named Semmelweis University of Medicine.  I told him that although the type of innovation he was attempting was initially accompanied by resistance and hostility, ultimately he is known for making a landmark contribution in the prevention of puerperal fever.  He smiled and thanked me, and I hoped that our conversation had given him a small glimpse into his success as a physician.  We then said good bye.

After Semmelweis left, I had time to process all that we discussed and all that I have learned from my research on his work and life.  His experience offers many lessons in public health: around discovery and innovation, communicating information, and implementing changes necessary for improvement. Semmelweis made a significant discovery at a time when he lacked complete information about the disease he was studying.  The set up of the First and Second Maternity Divisions played an extremely important role in his discovery, as he was able to use them as a case-control study.  Epidemiology played a role through his comparisons of the two divisions and the resulting tables he created.  Semmelweis faced unique challenges in his time.  A majority of the medical community was resistant to his discovery.  They felt that hand washing before each patient would be time consuming.  In some journals, the profession was referred to as believing it was divinely blessed, and therefore it would be unreasonable to think the physicians themselves could be causing the disease. The germ theory was not clearly developed at this time.  These circumstances presented challenges for the acceptance of Semmelweis’ discovery.

Semmelweis lacked important skills to implement change.  He presented his work but did not publicize his discoveries for several years.  When he did communicate his work, he did so in what is described as an angry, resentful, and, at times, threatening tone.  He refused offers to address medical colleagues. Some viewed him as ‘tactless, volatile, single-minded, with a pompous’ personality.  His responses to requests for proof were often rude.  He clearly lacked patience and tolerance that is required when presenting a new concept to a group with established beliefs.  Often success relies on one’s personal attributes and ability to communicate a new idea.  Semmelweis had one half of the requirements needed to improve public health but lacked the other half – the ‘change agent’ skills.  Spending time with Semmelweis helped me to realize some of the challenges I will face in the field of public health and some of the methods that can be utilized to overcome these challenges.  It is apparent that historical figures in public health, like Ignaz Philipp Semmelweis, continue to make contributions to our learning years after they are gone.