Hope Springs Eternal

Tuberculosis was endemic where I grew up. It was common to hear about someone who became sick from the disease and about families being ravaged by the illness’s spread. Upon entering medical school, our entire class was unceremoniously marched into our lecture hall one day to receive a BCG (Bacillus Calmette-Guérin) vaccination against tuberculosis. Nobody questioned why and certainly no one resisted the personal intrusion. I doubt anyone was even identified as an “anti-vaxer” back then.

Early into my residency, I was intubating a patient with massive hemoptysis and my head-neck region became covered with bloody sputum in the process. I learned the patient’s diagnosis shortly thereafter: diffuse pulmonary tuberculosis!

Personal safety precautions were not a big thing back then, and of course the BCG vaccine made it such that my TB screening skin test was always positive. So I was caught in this twilight zone of how best to proceed for myself after this dense exposure, and whom to listen to for advice. The patient succumbed, and I ultimately survived without treatment.

Later, as the HIV virus took hold in our communities, several of my peers and I were often exposed to HIV-positive patients. As can be predicted in the world of trauma surgery and surgical critical care, we occasionally sustained needle sticks and cuts from exposed bone shards or broken teeth that penetrated our double gloves, providing us with similar conundrums: when to empirically start ourselves on a course of anti-viral treatment and when to simply observe for telltale symptoms.

The decisions were neither simple nor easy, and we made them time and time again, as did those before us who faced smallpox, typhus, radiation exposure, and countless disease outbreaks, epidemics, endemics, and pandemics.

Around the world today, beyond the COVID-19 pandemic, several persistent outbreaks are creating untold illnesses and death, while physician leaders continue to lead through them with confidence, always hopeful a good outcome will prevail.

Mosquito-borne malarial disease and malnutrition still consistently remain at the top of the disease burden profile maps (see Figure 1). For example, in 2018, an estimated 228 million cases of malaria were diagnosed worldwide (down from 231 million in 2017). Most malaria cases were in the World Health Organization (WHO) African Region (93 percent). Children younger than 5 are the most vulnerable group affected by malaria and accounted for 67 percent of all malaria deaths worldwide in 2019.

Figure 1. Global deaths due to various causes and COVID-19

Funded by the Bill and Melinda Gates Foundation, the Global Burden of Disease (GBD) project is annually reported in The Lancet. The 2019 report shows global health has steadily improved during the past 30 years as measured by age-standardized, disability-adjusted, life-years (DALY) rates. But, after taking into account population growth and aging, the absolute number of DALYs has remained stable.

Since 2010, the pace of decline in global age-standardized DALY rates has accelerated in age groups younger than 50 compared with the 1990–2010 time period, with the greatest annualized rate of decline occurring in the 0–9-year age group, as detailed in the Oct. 17, 2020, issue of The Lancet (www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30925-9/fulltext ). (See Figure 2.)

Figure 2. Global chronic disease burden - 1990–2020 (by disease group in developing countries)

The trend data from numerous other sources also clearly indicate the world’s health has consistently improved with each passing decade, albeit gradually. And the point of this reflection on data? To reassure ourselves that medical science research, coupled with population health initiatives and improved clinical care practices, does indeed gradually improve the overall quality of life in our world. The professional commitment of so many experts in their respective fields, and across their various career paths over the course of time, is indeed profound.

This point is all the more poignant when we consider what has been demonstrated over the past 18 months with the rapidly executed approaches toward managing the COVID-19 pandemic. Resilience and professionalism are core traits found within the healthcare industry as a whole. These traits have been, and continue to be, on prominent display, and have become better appreciated with an increased awareness from the general population and government policymakers.

Healthcare as an industry has clearly risen to the pandemic’s challenges, and we shall continue to improve the overall health and well-being for our world in the course of time.

Physicians’ clinical practices have always included some element of inherent risk. And as physician leaders, there is always a need to have the confidence to help lead others through crises. As well, physician leadership has often been at the vanguard for progress made in times of public health challenge, not only recently, but in the past as well. It is a heritage we should embrace and remain proudful of. For us all, hopefulness is always critical during any crisis.

In periods of reflection, I often find it insightful to consider historical context to better appreciate that current, or immediate, concerns will gradually abate and pass. Philosophy, the arts, poetry, and literature have elucidated the trials and tribulations over the millennia.

With that consideration, Jane Austen (Dec. 16, 1775–July 18, 1817) was an English writer who is recognized as the first author to give the novel its distinctly modern character through her treatment of ordinary people in everyday life. I believe this quote, from Pride and Prejudice (1813), is relevant for today’s environment:

“There is a stubbornness about me that never can bear to be frightened at the will of others. My courage always rises at every attempt to intimidate me.”

Similarly, Alexander Pope (May 21, 1688–May 30, 1744), generally regarded as the greatest English poet of the 18th century, is best known for his satirical verse and his translation of Homer. Most of us recognize the initial line of the following quote from An Essay on Man (1734), but the remainder of the passage is equally relevant for our world’s future adjustment in coming months and years:

“Hope springs eternal in the human breast;
Man never Is, but always To be blest.
The soul, uneasy, and confin’d from home,
Rests and expatiates in a life to come.”

Yes, hope does spring eternal, and our courage has risen when every attempt was made to intimidate us. A refreshed culture of optimism for healthcare is indeed possible following these many months of challenge.

Leading and creating significant change in healthcare is our association’s overall intent. AAPL focuses on maximizing the potential of physician-led, interprofessional leadership to help create personal and organizational transformation that benefits patient outcomes, improves workforce wellness, and refines the delivery of healthcare internationally.

We must all continue to seek deeper levels of professional development and to recognize ways we can each generate constructive influence at all levels. As physician leaders, let us become more engaged, stay engaged, and help others to become engaged. Creating a broader level of positive transformation in healthcare — and society — is within our reach.

Our patients will appreciate the outcome.