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Public Health: Why We Need to Humanize the System

Public health progress is forestalled by a monumental fiction: there is no "public." There's just you, and me, and everyone else.
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At the horse farm where I ride there was a dead shrew on the ground near one of the barns the other day. Clearly, not a matter of great consequence. Driving back home after my ride, I passed both a squirrel and opossum road kill. Regrettable, but not remarkable or memorable.

The day prior, however, a hawk killed one of our six "pet" chickens. This particular chicken -- a small, fluffy bantam raised from a one-day-old chick -- had a name. Her name was Chickpea. And that, of course, made a world of difference. My wife and I continue to wince at her untimely loss. My son cries perfectly legitimate tears for the loss of a bold, curious little feathered friend that occasionally perched on his chest, and fell asleep.

There is more to one dead hen with a name than meets the eye.

And to get at the rest, let's shift our attention to 33 miners in Chile, delivered from a deep, dark, desperate place at long last. The world's attention has been riveted to their fate, as well it should be. Just as the world's attention was riveted to the fate of three Apollo 13 astronauts in 1970. As, indeed, the world's attention was riveted to the fate of just one small girl named Jessica McClure when she fell down an abandoned well in a backyard in Midland, Texas, in 1987.

And from 1998 to 2005, we were substantially fixated on the drama of Terri Schiavo and her family. Just one family wrestling over irreparable brain injury and the fate of one woman. As surrogate evidence for the power of that drama, type 'Terri Schiavo' into the Google search box, and more than 400,000 websites are retrieved.

We were certainly all affected deeply by the catastrophic Indian Ocean tsunami of 2004 that swept some 200,000 souls from the planet. And we were deeply affected again by the Haitian earthquake of 2010 that claimed tens of thousands of lives and continues to devastate the lives of many tens of thousands more.

But while deeply, if temporarily, compelling and preoccupying, such calamities on a large scale tend to reach us at a profound emotional level -- to truly evoke our passions -- only when they wear a face. An evening news report can tell us about the fate of thousands and evoke little more than "what a shame." Show us fear and tears in the face of one small, dispossessed child, and the crisis is our own.

Indelible memories, compelling impressions and passionate reactions are not engendered by the scale of calamity, but the scope of its intimacy. Part of being human, it seems, is to care more deeply about some fellow creature -- human or otherwise -- whose face we can see and name we can say, than about legions of generic, unknown humanity.

And this dissociation between the scale of disaster and the emotion it evokes is further compounded by its timeline. There is far greater drama in the blast of a bomb or the howl of a hurricane than in the creeping growth of atherosclerotic plaque; the insidious doubling of mutated cells.

We have known, since 1993 at least, when "Actual Causes of Death in the United States" was published in the Journal of the American Medical Association, that the leading causes of both premature death, and persistent misery, are chronic diseases that are, in turn, attributable to the use of our feet (physical activity), forks (dietary pattern) and fingers (cigarette smoking). These are the master levels of medical destiny for not just thousands, or tens of thousands on any one occasion, but the medical destiny of millions upon millions, year after year.

We have known, but we have not managed to care. At least, not deeply enough to turn what we know into what we routinely do.

Were we to do so, we could eliminate 80 percent of all heart disease and strokes, 90 percent of all diabetes and as much as 60 percent of all cancer. Perhaps you are mouthing "wow," but surely you don't feel a sudden surge of passion. Surely, you don't have a tear in your eye -- as you did watching the rescue of those miners.

But now forget the bland statistics of public health and ask yourself if you love someone who has suffered a heart attack, stroke, cancer or diabetes. You are exceptional if you don't.

Now imagine their face; whisper their name. Recall what it felt like to get the news. And while at it, imagine the faces of other readers like you and me, imagining beloved faces.

Now imagine if 8 out of 10 of us wistfully reflecting on intimate love and loss, on personal anguish, never got that dreadful news, because it never happened. Mom did not get cancer; dad did not have a heart attack; grandpa did not have a stroke; sister, brother, aunt, uncle did not lose a limb or kidney or eyes to diabetes. We are all intimately linked in a network of personal tragedy that need never have occurred.

The things we know, and could do, to advance public health on a grand scale deserve our passion. But they will never get it until we part the veil of statistical anonymity -- look past the blandness of epidemiology and see the faces, say the names. Public health progress is forestalled by a monumental fiction: there is no "public." There's just you, and me, and everyone else.

The bells of celebration that peal now in Chile -- like the bells of loss and lamentation that peal too soon, too often, for too many -- do not toll for "them." There is no "them." They toll for us. They toll for me. They toll for thee.

Only when we part that veil to see our loved ones looking back; only when we whisper their names; will we care enough to do something about it. Only by renouncing the myth of the "public" will the promise of public health ever be kept.

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