Public Health Rulez, OK?

The psychology of power is enigmatic and poisonous, and it infects more than just the ruthless and the mercenary. Principled men and women of medicine succumb, even at their moment of apparent triumph, when a whole society kneels in submission before their authority in the hope of a cure or more miraculously yet, a vaccine for a new disease. It is that very submission that transmits the infection of power since it inspires in even the compassionate medicine man the excessive belief in his remedy.

The virtue of clinical medicine, or the good practice of a treating physician, is empirical testing and observation, not models, not statistics, and not sweeping recipes for living divorced from all the particular affections to which we are prone. The religion of the true doctor, this Religio Medici, we might say, is not mathematical, not regulatory, but strangely peculiar and idiosyncratic: for each patient, there is but one truth, which may only be manifested in the dialogue of I and thou.

The same principle does not govern the behaviour of that unusual branch of medicine, Public Health. This discipline, under whose iron-fisted rule we all today shelter shackled in our homes, describes itself in terms distinct from the good Sir Thomas Browne who knew the fragile uncertainty of all knowledge, and the brittle experiments of all ideas:

“I could never divide my self from any man upon the difference of an opinion, or be angry with his judgment for not agreeing with me in that from which perhaps within a few days I should dissent my self.”

Sir Thomas Browne, Religio Medici, sect. 6

The Oxford Textbook of Public Health defines its field:

“Public health is the art* and science of preventing disease, prolonging life, and promoting health through the organized efforts of society. The goal of public health is the biologic, physical, and mental well-being of all members of society. Thus, unlike medicine, which focuses on the health of the individual patient, public health focuses on the health of the public in the aggregate. [emphasis added] To achieve this broad, challenging goal, public health professionals engage in a wide range of functions involving technology, social sciences, and politics. Public health professionals utilize these functions to anticipate and prevent future problems, identify current problems, identify appropriate strategies to resolve these problems, implement these strategies, and finally, evaluate their effectiveness.”

The Oxford Textbook of Public Health, 5th edition,  eds. Roger Detels, Robert Beaglehole, Mary Ann Lansang, and Martin Gulliford (* art is presumably used without irony here)

Not mere physicians, but rather problem solvers, evaluators of their own solutions, engineers of society and the very soul. Not individuals in their enigmatic and alone manifestations, but populations in the aggregate, as those sums are revealed through the dull haze of statistics. Not mere medicine, but a broader reach of functions – technology, social sciences and politics – that seek not to cure disease, but to rearrange the organised efforts of society, no less. So, the dark dream of the non-medicine man is spoken.

In the telling of the sacred keepers of the tradition, public health emerged as the saviour of degenerate and unhealthy mankind, prone to that memory of distant times, infectious disease, and was led by patient and incontrovertible evidence of modest statisticians, such as John Snow, in some eyes the founder of that peculiar curse of these times, epidemiology and its weird sister, data science. By looking at the data, John Snow by this account traced the true source of the cholera epidemic in his district, the Broad Street Pump. So, by reaching beyond his individual practice of medicine, perhaps symptomatically in Snow’s case anaesthesia, public health’s use of political levers saved mankind from at least one horesman of the apocalypse.

So began in this hagiographical tradition, a “‘golden age’ from 1880 to 1970, when public health rationales were relatively unquestioned.” (The Oxford Textbook of Public Health) But from that time, people began to question the doctor’s orders, and to doubt their wisdom outside their narrow field. A brief resurgence of the faith emerged with the combined campaign of public health and social zealotry against tobacco smoking. But public health’s later frustrating inability to achieve much more with chronic or non-communicable disease left it on the margins of government.

Until that is the outbreak of the coronavirus. Suddenly, specialists in that dying category of medicine, infectious disease surged back into public view, and sensed an unprecedented crisis, and a moment to never waste a crisis. Within weeks, the technical terms of epidemiology littered popular media – exponential (if rarely sigmoid) growth, contact tracing, and, of course, social distancing. The tools of medicine changed again, in favour of the epidemiological non-medicine man. Distancing, not drugs, tracing, not therapy, models, not medicine became all important. The specialists in these tools surrounded the powerful, and formed a new court of unprecedented power, in which they declared on the basis of their own convictions emergency powers to be used by themselves to defeat an enemy on a battlefield cloaked in the fog of ignorance.

One thin prophet from London came to symbolise this new power in the world – Professor Neil Ferguson – epidemiologist, infectious disease modeller, professor of mathematical biology, professor lockdown, false prophet of the plague times. Emblematically for the field of public health, Professor Ferguson is the ultimate non-medicine man. His training was in physics, and his doctorate in theoretical physics – no less than the “interpolations from crystalline to dynamically triangulated random surfaces,: whatever that means I confess in my ignorance of science. Yet this untrained physician who was more knowledgeable in derivative calculus than in disease cures prescribed a mass quarantine for the entire world.

For a few short weeks, Professor Ferguson was giddy with fame, celebrity and power. His Imperial College model changed the course of politics and this pandemic. He was the prime expert on the curiously named SAGE group that advised the UK Government. But then, as things do, his model began to fall apart. His predictions lasted barely a fortnight before being walked back before a Parliamentary Committee – cutting his prediction of deaths from the virus by over 90 per cent. People pointed out the false predictions he had made, based on the same mathematical fallacies, in past pandemics. Questions were asked about the reliability of his bizarrely byzantine and occult code. Then his own hypocrisy was exposed, as he was publicly shamed like a wicked priest of old for breaking the vows of isolation he had imposed on the world. Bizarrely he explained his breach of his own standards – illicit visits from his married lover, after he was infected with coronavirus – with this confession of being drunk with Faustian knowledge:

“I acted in the belief that I was immune, [emphasis added] having tested positive for coronavirus, and completely isolated myself for almost two weeks after developing symptoms. I deeply regret any undermining of the clear messages around the continued need for social distancing to control this devastating epidemic”

The Guardian, 5 May 2020, quoting Neil Ferguson

The non-medicine man appeared to forget his ignorance of medicine, and assumed a knowledge entirely impossible still.

So, we may hope that the quieter practitioners of true medicine might come to the fore before too long, and this brief Puritanical Commonwealth of Lockdown may come to the end. As Sir Thomas Browne said, “We all labour against our own cure, for death is the cure of all disease.”

Image Source: Dorothy, Lady Browne (née Mileham); Sir Thomas Browne, before 1679, EnglishNational Portrait Gallery via wikipedia