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First, Send in the Historians

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden S. Lundgren
May 19, 2023

My last column questioned whether it was a mistake for physicians to be the public face of the epidemic.  In this column, I suggest a different approach.

My MPH class included people from a variety of backgrounds, but the largest professional cohort by far was physicians. Public health is multi-disciplinary, so there were a significant number of required courses covering a plethora of subjects: epidemiology, biostatistics, environmental health and a number of others. The program was highly competitive, so we dug into learning as much as we could as quickly as we could—with one exception. The course was called “Social and Behavioral Aspects of Public Health.” The reaction of the physicians in the class was remarkable. I talked with many of them. They not only disliked the course, they seemed to think it was somehow insulting for them to be required to take it. Their contempt for the course was matched only by their contempt for the professor.

I hadn’t thought of this in years, but it came to me again when I saw Dr. Anthony Fauci when questioned about the COVID epidemic saying “Something clearly went wrong. And I don’t know exactly what it was.” I am not about to criticize Dr. Fauci. A life spent in public service and dedicated to saving lives is admirable.

So what did go wrong? I maintain the “wrong” can be laid at the feet of the biomedical model. This is a concept developed in the late 19th century. It is the basis of what we call “scientific medicine.” In brief, this model states that diseases are specific entities with specific causes. While this seems obvious to us (although maybe it shouldn’t), it presented a radical shift in medical thought. Medical thought since classical times was based on notions of “balance” within the body and between the body and the environment. The latter might include abstractions such as the position of the stars and planets and real experiences such as climate or family interactions. The essential element was the patient at the nexus of all these elements. As one mid-19th century physician put it:

Any specific treatment is just as absurd in yellow fever as in any other disease. The physician is not called to treat an abstraction, but a sick man.

Scientific medicine was the result of three trends. The first was what became known as the Paris Clinical School. Partly fueled by the social reforms of the French Revolution, this movement brought surgeons  and physicians together allowing specific symptoms to be related to certain lesions found within the body. The second was the development of laboratory sciences in Germany establishing cellular pathology and other prime accoutrements of modern medical practice. The third was germ theory. All three diverted attention from the patient to the disease. After all, why listen to the patient or worry about his/her circumstances when the diagnosis could be established by a test? And for many decades, diagnosis was about the best the new medicine could do. Therapeutics lagged far behind. Writing in 1933, Lewis Thomas described his medical training as preparing him for “diagnosis and explanation.”

Physicians bring both the successes and the failures of the biomedical model to public health, the latter owing to the singular focus on disease rather than on the lived experience of their patients. During the pandemic, the constant “virus” talk made people feel as if they were there to serve the science rather than the science being there to serve them.

What would serve them? I argue that three groups are most important. First, bring in the historians. There are certain events we can expect in almost every epidemic (e.g. blaming the first victims, withholding information). Historians can reassure us that events happening now have happened before – and we can survive them.

Bring in those with expertise in human behavior: sociologists, psychologists, anthropologists. These are the disciplines that can bring some predictive abilities as to how both populations and individuals will behave under pandemic stress and how to ameliorate that stress.

The third group most needed is communications specialists from the academy, from advertising, from faith communities or from other areas—those who will address people’s fears in a rapidly changing environment rather than prattling on about variants, those who have the communications skills to calm fears and unite people rather than driving them apart. 

And then add the politicians, lawyers and ethicists who can help inform policy.

The missing piece in the biomedical model is attention to people. This carries the same hazards in public health responses as it does in your doctor’s office. The groups I have mentioned above offer the possibility of bringing the people back into public health. After all, the people are the public, are they not?

Columnist’s Note: I have been writing about the pandemic since it began. Not surprisingly, the columns often build on each other. The columns most relevant to this one were published  2/5/20, 8/4/21, 11/4/21 and 8/5/22.

Author: Burden S Lundgren, MPH, PhD, RN practiced as a registered nurse specializing in acute and critical care.  After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk VA.  She has served as a consultant to a number of non-profit groups.  Presently, she divides her time between Virginia and Maryland. She can be reached at [email protected].

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