On Courage.

Today’s Note was written partly as a response to the terrible acts of violence we have witnessed in recent months. Since its completion, we have sadly seen another, this time in France; a country which has already suffered so much at the hands of hate. While details of last Thursday’s crime are still emerging, it is, I think, worth calling attention to the fact that the victims were killed while celebrating Bastille Day, a commemoration of a tremendous act of courage carried out in the face of great adversity. In the spirit, then, of Bastille Day, a Note on courage, and its importance to both public health and the day-to-day task of trying to live in an often troubled world.

It can take considerable courage to face the world as it is—a world that, as recent tragedies have underscored, can be a dangerous place. It can take still more courage to imagine how conditions could be made better, and to go about trying to implement positive change. I have frequently reflected here about the challenges we face, our aspirations to make the acceptable unacceptable, and the sense of futility we experience when we consider the simple solutions that we know could save lives. It can take considerable courage to keep believing in the potential of our efforts, and to remain energetic promoters of what it will take to improve the health of populations. For today’s Note I reach back, looking both for inspiration and perspective, at two examples of courage; one in the context of the individual and the other in the context of a social movement. Both involve work that improved the health of the public tremendously; in each case, this achievement took many years and required immense courage in the face of many obstacles. While there are many individuals and organizations who currently demonstrate bravery when confronting ignorance and injustice, I present these two cases from the past—the story of Ignaz Semmelweis, and a brief history of the movement to fight HIV/AIDS in the US—as particular examples of the kind of courage that we would do well to emulate in our own work.

In the 19th century, puerperal fever—caused by a bacterial uterine infection—was a common postpartum killer in both Europe and the United States, claiming many lives. Also called “childbed fever,” the illness would strike women in the days immediately following childbirth. It was a terrifying disease, described as “raging fevers, putrid pus emanating from the birth canal, painful abscesses in the abdomen and chest, and an irreversible descent into an absolute hell of sepsis and death—all within 24 hours of the baby’s birth.”

Ignaz Semmelweis was a Hungarian obstetrician who wanted to find the cause of these childbed fever epidemics. In the 1840s, while he was the director of the maternity clinic at the Vienna General Hospital in Austria, he started collecting data. Between two maternity wards in the hospital, one staffed by midwives and the other by doctors and medical students, he noted that the death rate was nearly five times higher in the ward staffed by doctors and students. Semmelweis hypothesized that the difference in mortality was due to the fact that the doctors, prior to their work in the delivery room, often performed autopsies elsewhere in the hospital. Though Semmelweis developed his hypothesis years before the confirmation of germ theory, he nevertheless deduced that childbed fever was the result of some type of “morbid poison” on the hands of the doctors, which they transferred from cadavers to the bodies of the women giving birth. So Semmelweis began requiring his staff to wash their hands in a chlorine solution. With this new practice in place, mortality rates in the most afflicted wards dropped from 18.27 percent to 1.27 percent.

Despite these results, the medical community did not embrace the practice of handwashing. Many derided Semmelweis’s work, and resented the implication that they might be responsible for transmitting disease. The American obstetrician Charles Meigs summed it up when he said, “Doctors are gentlemen, and gentlemen’s hands are clean.” The pushback was so strong that it eventually gave rise to a new phrase, the “Semmelweis reflex,” which is now used to describe the human tendency to reject innovation out of hand whenever it contradicts prevailing attitudes or established paradigms. Semmelweis also had a difficult personality, and refused to publish his findings for more than a decade, considering them to be “self-evident.” He was eventually consigned to a mental institution, where, in 1865, at the age of 47, he apparently died of sepsis, a condition similar to the very infection he spent his life fighting to prevent. In a final irony, Semmelweis’s death came a mere two years before Louis Pasteur first published his work on bacteria, ushering in a wider acceptance of the germ theory of disease. Joseph Lister would later use Pasteur’s research as a starting point for his own experiments in applying new standards of cleanliness to surgical practice. Troubled and combative though he certainly was, Semmelweis is now regarded as a medical pioneer and a courageous figure in the ongoing struggle to safeguard population health.

Moving from puerperal fever to another deadly disease: HIV/AIDS. Since the first cases of what would become known as AIDS were reported in 1981, 650,000 people have died in the United States alone as a result of the infection. Advances in treatment have changed the face of HIV in the US; the diagnosis is no longer as dire as it was in the early years of the illness, though some groups still face disproportionate rates of infection. While the infection is now viewed as a chronic disease that can be managed and lived with, it is important that we do not forget just how bad the AIDS crisis was at its peak. This act of remembering is particularly necessary when we consider how hard communities of people with HIV/AIDS had to fight to make their voices heard at all. Horrific as the physical reality of HIV/AIDS was and is, the stigma associated with the condition during the 1980s made a bad situation even worse. Some viewed the disease—which disproportionally affected men who have sex with men, intravenous drug users, and Haitian immigrants—as “God’s punishment” for “immorality.” The stigma borne by these marginalized groups meant that the public was not immediately receptive to the existence of HIV/AIDS. Government, too, was widely ineffective in coming to grips with the plague. The Reagan administration was slow to even acknowledge the pandemic, much less confront the entrenched homophobia and misinformation that allowed it to flourish.

In the face of government inaction, the gay community mobilized to do for themselves what the political establishment would not. Activist groups like the Gay Men’s Health Crisis, the AIDS Coalition to Unleash Power (ACT UP), and here in Massachusetts the AIDS Action Committee formed to advocate for individuals living with the disease. In 1988, ACT UP protested the Food and Drug Administration’s slow drug-approval procedure, prompting the FDA to accelerate the process. Countless individuals committed themselves to the cause, including ACT UP Founder Larry Kramer and Craig Harris, co-founder of the National Minority AIDS Council. Randy Shilts was the first journalist to cover the US AIDS crisis full-time and went on to publish And the Band Played On, a seminal look at the first five years of the epidemic. Media coverage of several high-profile HIV-positive activists, including Alison Gertz, Elisabeth Glaser, and Ryan White, also did much to dispel the stigma of the disease. Magic Johnson, too, has been an effective advocate, and an example of how it is possible to live a full, active life after being diagnosed with HIV. And the illness of public figures like Rock Hudson and Arthur Ashe helped millions of people put a familiar face to the plight of the gay community. The courage and ingenuity of the AIDS movement also found ample expression in the arts world. Plays like Kramer’s The Normal Heart and Tony Kushner’s Angels in America, and visual art like Keith Haring’s 1988 Silence = Death and the NAMES Project AIDS Memorial Quilt (conceived by activist Cleve Jones) have broadcast the experience of HIV/AIDS to the wider world. All of these efforts contributed to building social momentum, lessening stigma and creating the conditions for ever-better HIV prevention measures and treatments, bringing us to where we can now realistically hope to eliminate this disease within the coming decades.

In the case of both Semmelweis and the HIV/AIDS movement, having courage meant contending with the possibility that change might not come within a single lifetime. It meant attempting to engage with a social/political/medical establishment that was at best indifferent and at worst actively hostile to the concerns of advocates and innovators.

Given this reality, courage is no minor factor. It is central to the work of public health. It means being willing to take stands that are perhaps at the moment unpopular, and shining a light on uncomfortable truths. As an idea, this may sound noble, romantic even, but the day-to-day enactment of it can be a brutal grind. It cost Semmelweis his reputation, maybe his health; it cost the energy, reputations, and lives of countless HIV/AIDS activists in this country. The centrality of courage to public health action means that we need to teach courage as a core competency of a public health education; it means inviting examples of courage to our campus, as we have done; perhaps most importantly, it means using the context of our scholarship and study as an opportunity to ask ourselves some hard questions. Just what, for example, are the moral and intellectual risks entailed by our aspirations? How far are we willing to go to achieve our ambition of improved population health? How much progress can we reasonably expect to see over the course of a lifetime or a career, and can we live with that progress often being frustratingly incremental? These are not easy questions to consider—to ask them takes a kind of courage, to answer them honestly takes even more.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful to Meaghan Agnew, Michelle Samuels, and Eric DelGizzo for their contributions to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/