Last May marked the 200th anniversary of the birth of Florence Nightingale. That her bicentennial fell during a worldwide pandemic is both illuminating and ironic. Nightingale’s experience as a nurse during the Crimean War in the mid-1850s led her to three insights that came to define her professional life, insights as revolutionary as they were unpopular:
- Medical care has the potential to do harm.
- Nurses require stringent and scientific training
- Medical care does not exist in a vacuum from the world around it.
Nightingale is best known for her work illustrating the first two tenets. When she arrived at the British military hospital in the Scutari region of the Ottoman empire in November 1854, a year after the war had begun, she was horrified to learn that far more soldiers were dying of infection and poor medical care than were dying on the battlefield. Her rigorous reforms of the wretched medical conditions — reforms which rankled the military higher-ups — slashed the hospital mortality rate from 33% to 2% over the course of a single year.
Nightingale’s approach to nursing education was equally meticulous, professionalizing a field whose standards until then had ranged from uneven to abysmal. (The nursing higher-ups at the time were similarly irritated by her ruffling of the status quo.)
The third tenet of Nightingale’s life’s work — that medical care does not exist in a vacuum from the world around it — has received less historical attention.
After the Crimean War, Nightingale turned her attention to the health of the British military in India, this time from her London home. The scope of death and suffering dwarfed what had transpired in Scutari, and these soldiers weren’t even fighting a war. While the British public muttered disdainfully about India’s “miasmas,” Nightingale focused instead on data documenting sanitation drainage, water quality, housing construction, food quality, alcohol use, and physical activity. Extending her observations to the civilian population of India, she recognized the need to target education, housing, and the legal system — things we now call social determinants of health.
Though Nightingale never budged an inch from her insistence on scrupulously trained nurses as the backbone of good medical care, she knew that this could never be enough. The conditions that people lived in were equally important — if not more so — for achieving the best medical outcomes.
As Covid-19 begins to recede in the U.S., Nightingale’s observations could hardly be more prescient. The staggeringly uneven toll of infection and death we have witnessed is a bitter confirmation of the interrelationship between health care and society. The reasons for the disparity are in plain sight: unequal distribution of economic and housing stability, jobs without sick leave or options for telecommuting, crowded homes that render social distancing elusive, long commutes to jobs and grocery stores that preclude “sheltering in place,” and heavier burdens of chronic disease that contribute to more severe outcomes with Covid.
There has been much talk about how to re-envision the health care system once we’ve achieved the much-coveted settling of the dust. There’s no doubt that the U.S. health care system needs to be more flexible and nimble in nearly every aspect — medical care, public health, research, supplies, prevention, communication, vaccination. The list goes on! But even at our creative best, the medical disparities will remain entrenched unless society is re-envisioned as well. Medical care does not exist in a vacuum from the world around it.
Contagious illnesses like Covid-19 bring into stark relief the fact that health is a both a communal good and community effort. Outbreaks can neither be created by individuals or tamed by them. It takes the oft-quoted village.
One the one hand, such interdependence goes against the grain of the rugged individualism supposedly embedded in American DNA. On the other hand, Americans exhibit a strain of community engagement that’s especially prominent on the neighborhood and local level. Witness the strengths of PTAs, dog runs, community bulletin boards, sports leagues, houses of worship, neighborhood watches, and local libraries. These institutions exemplify the ethos of public health: How we inhabit our shared community has far-reaching effects on everyone’s health.
Florence Nightingale’s efforts presaged the challenges that face us today. Even though her “day job” was as a nurse, she recognized that her mandate, by necessity, extended to educating the public and lobbying the government at all levels. (She cannily delivered her book, “Notes on Hospitals,” directly to Queen Victoria.) Like outspoken health care workers today, she was often told to stay in her lane. Luckily for the untold number of people who lived longer because of her efforts, she did not.
Perhaps the most apt metaphor for the Covid experience is the burning house. Everyone in the neighborhood has a vested interest in getting the fire controlled. Moreover, everyone has a vested interest in understanding why the house caught fire to begin with. What were the conditions that made it vulnerable? How can we build houses to make fires less likely? How can we structure the fire department to respond more effectively?
Remaking health care will mean focusing on the lanes that relate to educational quality, job security, housing stability, and paid sick leave (to name a few), in addition to the more traditional medical lanes like expanding primary care, enhancing mental health and addiction treatment, improving care coordination, controlling drug prices, detoxifying electronic medical records, improving patient safety, and achieving universal, equitable access to health care.
Florence Nightingale was a boots-on-the-ground clinician as well as a hands-on administrator. She worked in Scutari under grueling circumstances, up to her neck in infectious risks, much as health care workers have been doing during the coronavirus pandemic. These feats of heroism, regretfully, aren’t enough — then or now. Improving health for all citizens will indeed require major reconfiguring of the U.S. health care system. But we’ll only see success if we simultaneously tackle the societal conditions that foster unequal heath.
Danielle Ofri is a primary care physician at Bellevue Hospital, clinical professor of medicine at New York University School of Medicine, and editor-in-chief of the Bellevue Literary Review. Her newest book is “When We Do Harm: A Doctor Confronts Medical Error” (Beacon Press, April 2020).