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A matter of opportunity
A matter Richard
of opportunity’
M. Krause, M.D. Bethesda, Md.
It has been our belief for some time in the National Institute of Allergy and Infectious Diseases that occupational immunologic lung disease is a matter of medical importance. Because there are so many of you here, from nearly every state of the Union, apparently this is not just a case of we bureaucrats “ginning up” some extra busy work. As an aside, I can recall as a second-year medical student hearing for the first time about bagassosis. I can tell you that as students, none of us believed a disease could have, let alone deserve, a name like that. But, of course, bagassosis has a serious aspect and is a respiratory disease associated with the workplace. I shall not, in these few remarks, spell out the objectives of this conference. That is best left to those who organized this meeting and to all of you who are participating in it. But what you do here and the conclusions you come to will be of importance to all of us. In these few minutes, let me step back in time and take a brief look at the historical origins of epidemiology and preventive medicine-subspecialties that are concerned with the occurrence of diseases in the community, with occupational diseases, with diseases associated with the workplace-diseases associated with the way we live as the result of the social changes that have occurred through modern practices in agriculture, industry, and housing. The philosophical basis for the practice of medicine for centuries has been the care of the individual patient, and rightly so. And yet how fortunate we are that there emerged in the last century a few perceptive and powerful individuals who realized that disease might be related to a person’s environment, not a new idea to be sure. It was advanced by Hippocrates more than 2400 years ago. But that notion languished until the Victorian Age, when modern epidemiology was born. Much of what you discuss here will be based on epidemiology and preventive medicine. The modern origins of such medicine began with the English physician, William Farr. In 1839 he was given responsibility for medical statistics. He established a tradition for the careful application of vital data to the problems
From the National Institute of Allergy and Infectious National Institutes of Health, Bethesda, Md. Vol.
70, No.
1, pp. 2-3
Diseases,
of public health. For example, he attempted to determine the value of imprisonment on mortality. He wisely steered a wide course around the effects of imprisonment on the rehabilitation of prisoners. But, in many ways, Florence Nightingale was the midwife to epidemiology, a story I have recounted in a recent book entitled The Restless Tide: The Persistent Challenge of the Microbial World. 2 Miss Nightingale saw more clearly than most that recent knowledge concerning infection and sepsis could be applied immediately to prevent disease. What was needed was a systematic approach to treat the entire community, as it were, and not just a concern for the individual patient. This systematic approach to public health problems required a method of getting the facts together to identify the problems. The method she helped invent to get the facts was epidemiology. Armed with facts, she then applied epidemiology to improve sanitation, hospital practices, and nursing care. What do epidemiologists do? In the most simple terms, an epidemiologist counts. This is not a traditional preoccupation for a physician, either in Victorian times or today. But Florence Nightingale had been trained in mathematics as a schoolgirl, and she learned to analyze the significance of data. I will not detail all of the many achievements of Miss Nightingale. She was more than the high-born “lady with the lamp” in the Crimean War. She went on to change nursing practices in England. She went on to discover, as Semmelweis did, the importance of proper sanitation practices in lying-in hospitals. She developed a new health code for the British army. She prepared reports, but she learned early on that government reports were not self-executive. They needed hard work and follow-up. Again and again she had to work through and around those in power who were indifferent to her concerns. She had great difficulty, particularly with Mr. Gladstone, who became prime minister in 1868. She wrote to a friend, “One must be as miserably behind the scenes as I am to know how miserably our affairs go on. ” “What would Jesus have done,” she asked plaintively, “if he had had to work through Pontius Pilate?” But whether through or around Pontius Pilate, she got things done. She was what today is called “a mover and a shaker.” I must say, as one who has moved
VOLUME 70 NUMBER 1
recently into the government bureaucracy, I do wish she had prepared a primer on this matter of mastery of government. Two years ago I attended a play entitled Semmelweis, by Harold Sackler, author of The Great White Hope. The play told the story of the 19th century Viennese physician who proved that childbed fever was transmitted by physicians with contaminated hands. Childbearing was a risky business in those days. The play closed after two weeks, but Semmelweis-the man and the play-lived on for me. Through the eyes of Sackler, a poet and a playwright, the significance of Semmelweis’ discovery was endowed with a special humanity. Semmelweis was greeted with doubt and derision. He was discredited by the entrenched position of the medical establishment, those “gravediggers with‘forceps, ” as Samuel Beckett has called us physicians in Waiting for Godot. The tragedy of Dr. Semmelweis is humanity’s tragedy, and so the play is not a success story but a morality play. “The whole world is our hospital,” observed T. S. Eliot. Writing about his play, Sackler has this to say, “We stand in the face of suffering ultimately helpless, yet the measure of man is the degree to which he refuses to live by the commonplace that we are ultimately helpless. Somehow to intervene even briefly between our fellow creatures and their suffering is our most authentic answer to the question of our humanity . ’ ’
Introductory
remarks
3
Much of what you will be discussing throughout the day will be concerned with immunologic mechanisms that are involved in the occurrence of occupational lung diseases, and I cannot review here, as I have done for epidemiology, the debt we owe to Pastuer, Koch, Ehrlich, Metchnikoff, Landsteiner, Avery, and others, all of whom laid the basis for the modern immunologic studies that we employ today. Epidemiology, of course, if it is to be a vital science, must employ all of the new information that comes from immunology, microbiology, toxicology, and now the sociology of the living place and workplace. From this amalgam you must identify significant risks if they exist; and then as physicians we must minimize those risks to prevent disease. I shall follow with keen interest the work of this symposium, and I can assure you that the Institute and the Department of Health and Human Services will examine carefully those suggestions and guidance that you can give on the prevention of occupational immunologic lung disease. REFERENCES 1. Krause National DHEW 2. Krause microbial tion of
RM: A matter of opportunity: a report from the Director. Institute of Allergy and Infectious Diseases. U. S. Publication No. (NIH) 78-1499, 1978. RM: The restless tide: the persistent challenge of the world. Washington, D. C., 1981, National FoundaInfectious Diseases.
of opportunity’
M. Krause, M.D. Bethesda, Md.
It has been our belief for some time in the National Institute of Allergy and Infectious Diseases that occupational immunologic lung disease is a matter of medical importance. Because there are so many of you here, from nearly every state of the Union, apparently this is not just a case of we bureaucrats “ginning up” some extra busy work. As an aside, I can recall as a second-year medical student hearing for the first time about bagassosis. I can tell you that as students, none of us believed a disease could have, let alone deserve, a name like that. But, of course, bagassosis has a serious aspect and is a respiratory disease associated with the workplace. I shall not, in these few remarks, spell out the objectives of this conference. That is best left to those who organized this meeting and to all of you who are participating in it. But what you do here and the conclusions you come to will be of importance to all of us. In these few minutes, let me step back in time and take a brief look at the historical origins of epidemiology and preventive medicine-subspecialties that are concerned with the occurrence of diseases in the community, with occupational diseases, with diseases associated with the workplace-diseases associated with the way we live as the result of the social changes that have occurred through modern practices in agriculture, industry, and housing. The philosophical basis for the practice of medicine for centuries has been the care of the individual patient, and rightly so. And yet how fortunate we are that there emerged in the last century a few perceptive and powerful individuals who realized that disease might be related to a person’s environment, not a new idea to be sure. It was advanced by Hippocrates more than 2400 years ago. But that notion languished until the Victorian Age, when modern epidemiology was born. Much of what you discuss here will be based on epidemiology and preventive medicine. The modern origins of such medicine began with the English physician, William Farr. In 1839 he was given responsibility for medical statistics. He established a tradition for the careful application of vital data to the problems
From the National Institute of Allergy and Infectious National Institutes of Health, Bethesda, Md. Vol.
70, No.
1, pp. 2-3
Diseases,
of public health. For example, he attempted to determine the value of imprisonment on mortality. He wisely steered a wide course around the effects of imprisonment on the rehabilitation of prisoners. But, in many ways, Florence Nightingale was the midwife to epidemiology, a story I have recounted in a recent book entitled The Restless Tide: The Persistent Challenge of the Microbial World. 2 Miss Nightingale saw more clearly than most that recent knowledge concerning infection and sepsis could be applied immediately to prevent disease. What was needed was a systematic approach to treat the entire community, as it were, and not just a concern for the individual patient. This systematic approach to public health problems required a method of getting the facts together to identify the problems. The method she helped invent to get the facts was epidemiology. Armed with facts, she then applied epidemiology to improve sanitation, hospital practices, and nursing care. What do epidemiologists do? In the most simple terms, an epidemiologist counts. This is not a traditional preoccupation for a physician, either in Victorian times or today. But Florence Nightingale had been trained in mathematics as a schoolgirl, and she learned to analyze the significance of data. I will not detail all of the many achievements of Miss Nightingale. She was more than the high-born “lady with the lamp” in the Crimean War. She went on to change nursing practices in England. She went on to discover, as Semmelweis did, the importance of proper sanitation practices in lying-in hospitals. She developed a new health code for the British army. She prepared reports, but she learned early on that government reports were not self-executive. They needed hard work and follow-up. Again and again she had to work through and around those in power who were indifferent to her concerns. She had great difficulty, particularly with Mr. Gladstone, who became prime minister in 1868. She wrote to a friend, “One must be as miserably behind the scenes as I am to know how miserably our affairs go on. ” “What would Jesus have done,” she asked plaintively, “if he had had to work through Pontius Pilate?” But whether through or around Pontius Pilate, she got things done. She was what today is called “a mover and a shaker.” I must say, as one who has moved
VOLUME 70 NUMBER 1
recently into the government bureaucracy, I do wish she had prepared a primer on this matter of mastery of government. Two years ago I attended a play entitled Semmelweis, by Harold Sackler, author of The Great White Hope. The play told the story of the 19th century Viennese physician who proved that childbed fever was transmitted by physicians with contaminated hands. Childbearing was a risky business in those days. The play closed after two weeks, but Semmelweis-the man and the play-lived on for me. Through the eyes of Sackler, a poet and a playwright, the significance of Semmelweis’ discovery was endowed with a special humanity. Semmelweis was greeted with doubt and derision. He was discredited by the entrenched position of the medical establishment, those “gravediggers with‘forceps, ” as Samuel Beckett has called us physicians in Waiting for Godot. The tragedy of Dr. Semmelweis is humanity’s tragedy, and so the play is not a success story but a morality play. “The whole world is our hospital,” observed T. S. Eliot. Writing about his play, Sackler has this to say, “We stand in the face of suffering ultimately helpless, yet the measure of man is the degree to which he refuses to live by the commonplace that we are ultimately helpless. Somehow to intervene even briefly between our fellow creatures and their suffering is our most authentic answer to the question of our humanity . ’ ’
Introductory
remarks
3
Much of what you will be discussing throughout the day will be concerned with immunologic mechanisms that are involved in the occurrence of occupational lung diseases, and I cannot review here, as I have done for epidemiology, the debt we owe to Pastuer, Koch, Ehrlich, Metchnikoff, Landsteiner, Avery, and others, all of whom laid the basis for the modern immunologic studies that we employ today. Epidemiology, of course, if it is to be a vital science, must employ all of the new information that comes from immunology, microbiology, toxicology, and now the sociology of the living place and workplace. From this amalgam you must identify significant risks if they exist; and then as physicians we must minimize those risks to prevent disease. I shall follow with keen interest the work of this symposium, and I can assure you that the Institute and the Department of Health and Human Services will examine carefully those suggestions and guidance that you can give on the prevention of occupational immunologic lung disease. REFERENCES 1. Krause National DHEW 2. Krause microbial tion of
RM: A matter of opportunity: a report from the Director. Institute of Allergy and Infectious Diseases. U. S. Publication No. (NIH) 78-1499, 1978. RM: The restless tide: the persistent challenge of the world. Washington, D. C., 1981, National FoundaInfectious Diseases.