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51 LESSON 8 USE DATA TO SET POLICY Research is like peeling an onion. You’re ignorant at the start, you take off more layers, and you find it more and more concentrated ; a denser and denser node of ignorance. And all the time you’re weeping about how much it costs to get there. francis d. moore Enlistment in the Epidemic Intelligence Service and my experience in Bangladesh transformed my interests and the trajectory of my career. Having experienced the thrill of discovery and the immense, immediate impact data could have on the health and well-being of whole populations , I delayed my ophthalmology residency to become formally trained in epidemiology. As a result, I began my ophthalmology training with an entirely different mindset from that of my peers. Fortunately my ophthalmology chief, Edward Maumenee, the longtime professor and director of the Wilmer Eye Institute at Johns Hopkins Hospital, was more than tolerant. One day, relatively early in my training, Maumenee casually remarked, “Al, wasn’t that a great article about the relationship between diabetes and mortality in this month’s American Journal of Ophthalmology?” In my (commonly) unsubtle fashion, I replied, “No, it was pretty dumb. The study was full of biases, poorly analyzed, and inappropri- 52 TEN LESSONS IN PUBLIC HEALTH ately interpreted. In fact most ophthalmic clinical research is poorly done, because most clinical researchers have never learned basic epidemiology.” Ed was a generous and supportive mentor. “That’s very interesting, Al; you should write an editorial on the subject.” All I could think was, “Sure, I’ve just begun my ophthalmology training and I’m about to tell the ophthalmology world that they do lousy research. Besides , who has the time?” Some mentors are good at motivating you; some are brilliant ! Three days later I received a letter from Frank Newall, longstanding editor of the AJO. “Dear Dr. Sommer, Professor Maumenee has told me about the brilliant editorial you have written. I look forward to receiving it within the week.” I spent the next five days writing a “brilliant editorial,” replete with graphic illustrations culled from the publications of highly respected “giants” in the field (I didn’t consider it sporting to gore only undistinguished oxen). The editorial was well received, and those I “gored” graciously forgave my youthful indiscretion. By July 1976 I had completed my epidemiology and clinical training and had come to three realizations: (1) I was one of the few ophthalmologists trained in epidemiology; (2) I had extensive experience working in underdeveloped nations , and I loved it; and (3) I could make a bigger difference using my interests and skill set working on problems in the developing world than by pursuing a traditional academic path. It was therefore no surprise that, late that summer, we found ourselves settled in Indonesia. One night, while supervising teams conducting a countrywide survey of vitamin A deficiency and its blinding complication , xerophthalmia, I was put up at a guest house in Surabaya that belonged to the university’s eye hospital. This house was a local shrine of sorts. It had been the home of Johanna Ten Doeschatte, a devoted Dutch ophthalmologist USE DATA TO SET POLIC Y 53 who had spent most of her professional career working at the hospital and training its young Indonesian ophthalmologists . I awoke at one o’clock in morning having dreamt that a huge cockroach was sitting on my face. (Despite having lived in many places where cockroaches abounded, I still detested them.) It turned out that my nightmare was true: a huge cockroach was sitting on my face. Dozens more were scrimmaging in the center of the floor. I went berserk, squashed all I could reach with the sole of my shoe, and then huddled, pulse racing, in the center of the bed. There was absolutely no chance I would fall back to sleep. Instead, I prepared the outline for a simple book on epidemiologic and statistical principles, to help ophthalmologists conduct more meaningful clinical research. This book, I thought, would be my contribution to correcting the unhappy state of affairs I had described in my “brilliant” editorial. I envisioned a book that would be clear, crisp, brief, and cheap; something the average ophthalmologist could master in a single evening. To keep ophthalmologists’ interest, every principle would be illustrated by examples drawn from the ophthalmic literature. I completed the manuscript over the course of the next month. Ron Michaels, my former chief resident, encouraged me to send my manuscript...


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