A note from one of your classmates

For anyone who really liked the subject of last week's class and wants to learn more about Health and Human Rights the Health Law, Bioethics and Human Rights Department has a new 4 credit class this Spring called on "Human Rights and Health". It is on Tuesdays and Thursdays from 5pm-6:30pm on the Charles River Campus.

Sarah Summer

Dinner with Rudolf Virchow by Heron Baumgarten

Across a dimly lit table from renowned innovator and activist, Rudolf Virchow, I am struck by the force of this man’s historical impact on medicine and its politics, and awed by the depth of insight I have been invited to witness. His presence is full of energy and contradiction, the challenging attitude that beckoned his contemporaries toward progression still present in his reincarnate state. We are separated by two plates of food, he has ordered the filet, and I the swordfish, and two half-full glasses of an earthy pinot, which has colored his teeth and lips an ashy purple and brought a rosy glow to his nose and cheeks. Illuminated softly by the amber light from the restaurant’s chandelier and a small candle pushed to the side of the table, I see the eyes of a humanitarian, full of years of struggle against health inequity, asking me to come with him as he guides me through a life dedicated to social medicine.

I am interested in how a man of his impact evolves, and I ask him about his path to medicine and then politics. He begins at the beginning. He was born in what was then Prussia, near the border of Poland, on October 13, 1821. Noticed a rebellious intellectual in high school, he was offered a scholarship to study medicine in 1839 at the Friedrich-Wilhelms Institut in Berlin, Germany. He felt a passion to acquire a universal knowledge of nature, and pursued this goal out of medical school in his studies under the guidance of Robert Froriep, a pathologist at the famous teaching school of Berlin, the Charite. Virchow’s ability to read multiple European languages assisted in his analysis of the current medical wisdom, and he quickly learned his opposition to the constructs of theoretical medicine. He sought a practice of medicine based on observation and experiment and spent a lot of time in the laboratory and the autopsy room.  He tells me, and it is apparent, that it was his attitude toward medicine and his courage to seek answers to his questions in a new way that enabled his early contributions to the medical field. 

While working in Wurzburg in the 1850’s, he professed the concept of cells as the basic elements of the human body, and he blamed disease on the failure of cells to execute their normal and specialized functions. He believed, in a society of opposing thinkers, that advances in patient care would be made through understanding disturbed anatomy, resulting from disease. Through his experimental work, he uncovered understandings of thrombosis, haematosis, and embolism, proved leukemia to be a cancer of white blood cells, and discovered neuroglia, gliomas, giant cells, and the amino acids leucine and tyrosine. He brought to light the process of ischemia and its effect on stroke and heart attack. The Archive of Pathological Anatomy and Physiology and Clinical Medicine, still a highly respected journal 150 years after he started publication, helped to convince germ theorists, Pettenkofer with his “three factors” approach, and Koch the reductionist, cemented to the idea that illness had only one cause which could be pinpointed, to look at medicine with a wider gaze.  As a professor at his alma mater, he wrote his book, Cellular Pathology, hoping “to rid medicine of the mysterious,” and gifting the medical profession with answers to Where? Why? and How? of disease. 

He stops his story here. The subject of discussion up to this point has focused on innovation in pathology and biomedical advancement, cellular medicine. This work taught the medical profession how to successfully provide patient care through continuous progression in the understanding of cells, anatomy, and disease. I tell him, much of the medical profession has left it there. We continue to innovate scientifically, creating new treatments to improve our patient’s health, and yet we are not seeing the improvements we expect. We think that through creating greater access to cellular medicine for the disadvantaged, we will find success in bridging the inequalities we see in health status. There is such an intense reliance on this cellular medicine that Virchow’s work in social medicine has been forgotten or overlooked. I tell him his work is as relevant today as it was 150 years ago, and he knows and says, "we have often referred to 'the scientific method.’ We now find that through applying it, we have moved from medicine into the social field, and in so doing, we have had to consider some of the fundamental issues of our time." 

I ask him to tell me about his work to broaden the role of medicine in society. I want to understand his beliefs and the obstacles he faced in encouraging a cultural change, that I might gain insight into the work I have ahead of me. His eyes brighten and he tells me, "the only goal of our efforts [is] to endeavor to build society on reasonable foundations, or, in other words, to create institutions that guarantee the liquidation of pauperism."  

Virchow became the father of social medicine during the typhus epidemic in Upper Silesia. In 1848, at the age of 27, he was asked by the Ministry of Education to investigate the wretched state of a group of textile workers, “ethnic Poles,” in Upper Silesia under Prussian rule.  He agreed to study the epidemic and concluded that poor sanitation, lack of basic hygiene, poor access to education, and starvation were the origins of the epidemic, a diagnosis he followed with a public demand for democracy. "The answer to the question of how to prevent outbreaks in Upper Silesia is quite simple: education, together with its daughters, freedom and welfare." Through this statement, and the article he wrote analyzing the issue, he illustrated the fact that although "the improvement of medicine would eventually prolong human life, improvement of social conditions could achieve this result now more rapidly and more successfully.” 

Virchow was the first of his time to tie poverty to ill health, and to assess the disease state, encompassing its environmental factors. There were other scholars with similar beliefs in France and England with whom he collaborated, but none addressed the issue completely. Virchow believed that "physicians are the natural attorneys of the poor, and the social problems should largely be solved by them." He himself embodied the role of physician-reformer. “The physician is a citizen uniquely equipped to further the public good, and the practice of medicine cannot be divorced from its social milieu.”

Our world today cannot continue to focus only on scientific medical solutions to poor health. We must broaden our view of medicine to include the environmental factors which so intensely sway our probability of success. This change must include rigorous involvement of physicians who ask questions about education, work status, and social support, enabling research and hence increased knowledge of epidemiology. We know that failure to complete high school is a risk factor for disease as poignant as genetic makeup in our country. In our new approach to healthcare, we may focus on the importance of increased education, equally effective in improving health as the construction of new medical facilities or increased services. It is important that physicians take the lead in illuminating these issues of socioeconomic equity in relation to health in order for politicians and the public to realize the power of their implications. 

It is not without politics that the changes we need will be accomplished. “Every individual has the right of existence and health, and the State is responsible for ensuring this,” argues Virchow, who served as Berlin City Counsillor for 42 years, beginning in 1859. At this post, he worked to improve the sewer and water systems of the city, he organized reform of the public hospitals, and he fought for progression. "The progress of medicine should be as the progress of humanity, the measure of its practical and theoretical utility should serve at the same time as a measure of the correctness of what it accomplishes." During the Franco-Prussian war, he served as medical officer at the front and organized the military hospital system. There, he insisted on providing care to any in need, regardless of nationality. Virchow was also a founder of the German Progressive Party, opposing Bismark. He was elected to the House of Deputies in the Prussian legislature, where he took a liberal stance, advocating the address of social inequity. 

The restaurant is empty, so is the wine, and as his life story concludes, we feel the weight of the reform ahead. As the first to advocate for the social medicine our societies need, he has done his part, and yet I see the disappointment of his face as he realizes society remains stuck so near the place where he gave it its first budge. There is a lot of work to be done. The work is of the hardest kind. We want to change the way people view the world, change cultural expectation, and specifically change the expectations of medical professionals, so disconnected from the pressing responsibilities to be assumed. But, there are people like me, ready and willing to continue Virchow’s work, and supported by the example he set. There are so many people like me.  

Dinner with Mary Mallon by Jiayang Chien

            There’s a saying in our language: “Don’t judge someone until you’ve walked a mile in their shoes.” Generally speaking, it’s a good principle to live by, as it promotes empathy for our fellow humans.  When faced with the ugly reality of death and disease, however, few people can resist the urge to form opinions about those who are less healthy than themselves—especially when these people threaten the well-being of the healthy.  In the history of public health, few people have received as much negative press as Mary Mallon, better known to the general masses as Typhoid Mary.

            Mary Mallon was born in Cookstown, Ireland, in 1869 and immigrated to the US in 1884, at the age of 15.  She found work in domestic service, serving wealthy families in New York as a cook, and probably would’ve lived an unremarkable life had she not been identified as the first healthy carrier of typhoid to be discovered in the US in 1907.  What brings her from fame to infamy is not just her contribution to our knowledge of disease remission and transmission mechanics; rather, it’s the fact that Mary herself lived in vehement denial of her carrier status.  In 1907, she was forcibly captured and made to live in quarantine on North Brother Island in New York.  Feeling as though her rights as a law-abiding citizen had been grossly and unjustly violated, she petitioned for release.  In 1910, a newly-elected health commissioner, taking pity on her case, granted her release on the conditions that she abstain from the cooking profession and report regularly to the health department.  Mallon promptly disappeared upon her release, and was discovered five years later, when a mysterious typhoid outbreak occurred at the Sloan Maternity Hospital in New York, to have been cooking under a pseudonym.  Mallon was recaptured and brought back to North Brother Island, where she lived the remainder of her life until she died of pneumonia, in 1938.  In the newspapers, she was painted—in words and in pictures—as a witch-like harbinger of death.  Though some were initially sympathetic to her protests of unjust imprisonment, arguing that she was an unwitting victim of biological circumstances beyond her control, all support vanished upon her recapture, when she was found out to have deliberately endangered the welfare of others by continuing to cook when she was told not to.

            Indeed, what kind of person would knowingly pass diseases onto other people?  How can Mallon claim to be a faithful Christian when she deliberately evaded the law in order to engage in behavior that she knew would endanger others?  Why didn’t she believe that she could be a carrier?

            Let us go back to 1936.  Late in her life, Mallon had already been the recipient of a huge amount of negative attention from the press.  As a result, she had been constantly poked, prodded, and interviewed by a variety of professionals, journalists, and medical students.  Unsurprisingly, she was reluctant to consent to my interview, but I insisted that I was genuinely interested in her point of view, and backed up my position with the suggestion of talking over a meal.  I prepared the meal myself, of course, and brought it to her cottage on North Brother Island, along two sets of disposable dishware and utensils.

            “So what is it you want to know that hasn’t already been in the papers?”  She asked.

            Why did you endanger so many people?  I wanted to ask her.  But in an effort to be diplomatic—I had to make sure the interview wouldn’t be prematurely terminated, after all—I asked about her background.  Did she have siblings?  Yes, six brothers, all older than her.  What did her parents do?  Her mother died when she was very young and her father worked in the cotton factories in Cookstown.  Did she attend school?  Until she was twelve.  Why did she come to the US?  Because it was hard to find work that would pay enough to live on, and everyone she knew was leaving.  And they were right—cooking for the upper classes in New York paid good money.  She lived comfortably here.

            This led up to my first real question: “How was your relationship with the families you worked for?”  In other words, did they ever suspect you?

            “I’m a very good cook, and I work hard.”  She replied, hinting that my culinary skills were no match for hers.  In general, she didn’t like what she called “those high and mighty bookish people”—the educated intellectuals that she usually worked for.  “I fed my six brothers and my pa, and it was just us.  These people need six servants for the four of them, and they can barely take care of themselves!”  But she liked the children.  Whenever one of the children in the family got sick, she went to extra lengths to take care of them.  “I’m not any nurse,” she said, “but I know how to care for people.”

            “Did many of the families you worked for get sick from typhoid?” I asked.  About half, she replied.  Did she think that was unusual?  No.  A lot of people were sick in the cities, and it had been in the papers that typhoid was spreading in New York.  But it wasn’t any more common in New York, she thought, than it was in Ireland.  Besides, she’d been with a few families more than two years, and they never had reason to link her to any of the illnesses.  Then why did she change families so frequently?  “Do you think I was the only cook in New York who worked in a different house each season?” She asked me, disbelievingly.  Did she much about typhoid?  Yes, actually.  She knew when someone got sick, they had to be washed carefully, and their bathroom business had to be disposed of properly and quickly.  She also knew that once you survived, you wouldn’t get it again.  Was she ever sick with typhoid?  Never.  She was never a sickly person; that’s why she could get work with wealthy families, because they didn’t want to hire sickly servants.

            I decided to enquire about 1907 and the encounter with Dr. George Soper, a civil engineer with the  who had first linked her to a series of typhoid outbreaks in wealthy families.  “Bah!”  She cried.  The mention of Dr. Soper clearly upset her.  Why?  He said she was the common link in “a plague of typhoid”—an unfortunate choice of words.  He insulted her, then requested samples of her stools.  “It’s not right to ask that of a woman!”  By his own accounts, he was “as diplomatic as possible” and had presented to her the evidence which led him to her.  Was the evidence unconvincing?  “He presented no evidence!” She said, with conviction, “They all think the Irish are dirty, so just because I’m Irish, I must have disease.”  A few of her Irish friends had also been accused by the families they worked for of a number of things, from stealing to poisoning food, and she was convinced that Dr. Soper, who approached her at her place of work, was the same person who’d gotten one of her friends sacked just a few weeks before.  The fact that he then followed her to her home only cemented her belief that he was an indecent man.

            None of her subsequent dealings with any heath department official or hospital doctor would allay her mistrust of the government.  She was passed from lab to lab and doctor to doctor, none of whom would believe her claim that she had never been sick with typhoid in her life.  When she was finally taken to North Brother Island, she was “so prostrated with grief” that she developed a problem in her eye.  Repeated requests for medication went ignored.  Nurses would talk about her, doctors treated her like an exhibit (“I was a peep show for these doctors!”), and she was put on several medications were not right for her condition.  “They gave me a pill for kidney trouble!  Me, a healthy woman!”  Not all of her stool tests were positive for the typhoid bacteria, and as a result, the doctors, who did not know all of the mechanisms associated with typhoid transmission, kept changing their minds about where it was coming from.  She was asked to undergo a gall bladder removal.  “No knife would be put in me.”  She declared firmly.  She did not trust them.

            I turned our conversation to her release and subsequent recapture.  “What I and everyone else want to know is, why didn’t you keep your promise that you made in court, not to cook for others again?”  “I tried not to,” she said.  “I got a job washing clothes, but it hurt my back and my hands, and I wasn’t paid enough to buy my sweat.”  In the hierarchy of domestic service, in-house positions offered much better pay and amenities.  But Mallon, who had been cooking since the age of 16, did not have any other skills.  “What was I to do?  With no husband and everyone calling me Typhoid Mary when they found out who I was?”

            I finally asked her if she regrets anything she did.  She did not.  She felt, even after having lived on North Brother Island for thirteen years, that she acted in the way she could have, under the circumstances.  I decided to try something; I began to explain to her, in simplified terms, some of the mechanisms of disease transmission via a carrier, and how it’s known that people can carry a disease but not manifest the symptoms.  “You’re a strong woman,” I said, “That’s why it wouldn’t hurt you.”  I don’t think she was convinced, but she at least appeared to think it over.  I asked her to indulge me and pretend that she did for the last couple of questions.  “Knowing that now, and thinking back, what do you think Dr. Soper should have done differently?”  She thought for a moment.  “He shouldn’t have said anything about a plague.  And me being Irish—what did that have to do with any of this?”  What about the other doctors and the officials at the health department?  “I’m not a crazy woman.  If they’d treated me like a person and listened to me, I would’ve listened to them.  I’m a good Christian and I’d done no wrong.  They had no cause to treat me like a peep show.”  And with that, dinner concluded.

            In the field of public health, it’s probably easy to make the mistake that Dr. Soper and the New York Department of Health did.  As officials, it is easy to assume that we know better than the general populace, and that we who think in terms of the well-being of the masses must take precedence over the individual’s concerns over their own liberty.  But it must be remembered that, in order for public health policies to be effective, they must obtain the cooperation of the people.  The officials who dealt with Mary Mallon contributed to the subsequent conflict with her in several ways.  First, they assumed that she would view things from the same perspective that they did.  The fact is, they were a part of a group of well-educated intellectuals who believed in germ theory, while she was a part of the less-educated masses who based their beliefs on tradition and observations made from experience.  And Mallon had observed that not everyone she came into contact with had fallen ill. The health community had utterly failed to convince her of the validity of their arguments, in part because they used arguments well above her level of comprehension, and in part because what they did say often conflicted with each other.  And this is the second point, that the doctors themselves were, at the time, engaged in a kind of debate over what exactly the mechanisms of typhoid transmission were.  Thus, Mallon received conflicting bits of information from different sources, that all that the common effect of convincing her not to believe any of it. Finally, the officials failed to consider the social and economic circumstances that heavily influenced Mallon’s decisions.  An immigrant woman with no family and no support network can rely only on her skills to sustain a living. Mallon’s skills were limited to cooking.  Once barred from that, she would not have been able to sustain herself for very long.  In such desperate circumstances, it’s no surprise that she put her own survival and well-being over that of the people she came into contact with.  Furthermore, the anti-Irish sentiments of the community at the time made themselves felt quite acutely.  Irish, Italian, and Jewish immigrants were often blamed for outbreaks of disease in major cities, and the negative attention of the press would have only exacerbated Mallon’s feelings of hostility.

            In other words, this case of Mary Mallon is a classic study in “What not to do when confronted with a possible human source of an epidemic.”

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…