THE END OF WAR (METAPHORS)!
Metaphor, properly deployed, often accomplishes what facts alone cannot. Daniel Federman, long the dean for medical education at Harvard Medical School and an eminent clinician and scholar, famously greeted each incoming medical school class with a lecture on, of all things, the analogies between medicine and music. To be more precise, it was a talk about the forms of medical interaction and their parallels among the varieties of musical performance: the duet between patient and doctor; the trio when a child entered the pediatrician's office with a parent; and so on, up to and including the entire orchestra that symbolized the full symphony of activity that comprises the modern academic medical center. Analogies like these can go far in making medicine more transparent to the layperson and practitioner alike—for medicine is a field that deals with the manifestation in the flesh of that which is in fact invisible to the unaided eye (think viruses, bacteria, immune cells, amyloid plaques, etc.), compounded by the unseen nature of most private medical encounters. By reaching outside medical facts, Federman elegantly provided newly enrolled students with a heuristic that would help bind their diverse experiences over the coming years of training into a comprehensible map of the ecosystem of medical practice. [End Page 83]
Left out of Federman's talk, however, was the "other" (nonclinical) side of medicine that is typically lumped under the heading of "public health." As illustrated by the seemingly unending onslaught of zombie apocalypse shows on television these days, modern society ceases to function effectively when the basic but often unseen pillars of public health fall apart. Safe air and water, sanitation, access to power for refrigeration and cooking, information infrastructures to apprise populations of health threats—these are the products of generations of investment in public health science and practice, providing the backdrop against which access to medical care is almost the icing on the cake. Threats to this basic regime can come from within (for example, the gutting of environmental regulations that ensure clean air and water, for the benefit of corporate interests) or from without. Those "withouts" have included the pantheon of outbreaks that altered, in large or small ways, the course of human history through their societally disruptive impacts, such as the medieval Black Death; the smallpox, cholera, and yellow fever outbreaks that shaped the Enlightenment and Early Modern periods; the 1918–19 H1N1 influenza pandemic at the dawn of the modern age; and in the current era, the intersecting epidemics of human immunodeficiency virus (HIV), tuberculosis, and malaria.
For most of its history, medicine was content with an uneasy but obliging coexistence with pestilence and disease, largely because of its impotence in the face of what we now know to be an expanding set of deviously brilliant pathogens that evolved to exploit the patho-physiological systems that keep us alive (the modern understanding of the subcellular process by which cholera can kill a person in hours by hijacking their gastrointestinal ion channels is perhaps the crowning testament to this claim). Then, with the advent of arsenical antibacterials and the subsequent discovery of natural antibiotic agents (ie, penicillin), things got personal. What had been seen as a complex ("miasmatic") interplay between individual and environment became a dyadic war between patient and pathogen. The recognition that certain diseases such as malaria were carried by mosquitoes and other [End Page 84] animals simply served to "shift the target" from the pathogen to the vector (Figure 1). Campaigns against pestilence adopted increasingly militaristic jargon during and after the Second World War as public health became synonymous with fortitude in the face of strategic threats, both military and political. To this day, major journals and international health bodies speak of a "war on disease," marshaling statistics such as decreasing global age-adjusted mortality to prove our strategic advantage over the pathogens. And yet this need to prove victory with numbers rings somewhat hollow if we recall the manufactured sunny statistics of Secretary of Defense Robert McNamara and company before the bottom fell out of the Vietnam War effort in the 1970s...