Memorial Day is our country’s holiday to remember the men and women who have died defending the United States. Many of us have personal connections to war, either through family members, friends or acquaintances (for me, a childhood friend: Col. John McHugh, who was killed four years ago in Afghanistan). It is important that in the midst of holiday hype – the unofficial start of summer, the barbecues, the sales – we don’t forget the reason for the holiday.
Another thing occurring to me in my moment of reflection this weekend is the appropriation of military language in medicine. Think of how we talk about the efforts to oppose diseases: we are in a global fight against AIDS; trying to combat antimicrobial drug resistance, engaged in a war against cancer. We are allies with our patients as they fight their individual battles against a legion of acute and chronic diseases.
As a U.S. Air Force officer (back in the day), I took an oath to protect the country “against all enemies, foreign and domestic”.* In the context of healthcare as battlefield, we have numerous “domestic enemies”. Internists know many of these foes well: heart disease, cancer, COPD and diabetes, to name a few. While we encounter them every day in our practice, it can be instructive to look at data about burden of disease. The Institute for Health Metrics and Evaluation has created an excellent, interactive data visualization that allows you to look at causes and risks of death or disability, by country or section of the world, and by percentage or absolute numbers (I encourage you to spend some time with it). It leads me to think of the aforementioned diseases more as the agents of death and misfortune, while the enemies launching these weapons are tobacco use, dietary risks, high BMI, high blood pressure, etc. Taken even further: poverty, poor health literacy, sedentary lifestyle are the seeds that foment this rebellion against health and vitality. Maybe I have pushed the metaphor too far. But when you think about the vast numbers of “casualties”, you can understand why this terminology is so frequently used.
As with any military campaign, we need strategy, tactics and logistics. We need the resources and personnel to carry out the strategy. We’ve enjoyed some successes. But what might the landscape look like if it were easier to choose healthy food? If daily life was more conducive to physical activity? If people didn’t have to choose between eating and buying their medicine? If mental health services were more abundant? If we had more resources for chronic disease management? These are big public health items that would make life in the trenches of healthcare easier. There is recognition that these are important issues. But new strategies are needed. In the meantime, we continue to fight; small skirmishes and battles in the overall conflict. And we remember the fallen.
[* technically, it was to “support and defend the Constitution of the United States against all enemies, foreign and domestic”, but defending the Constitution against disease didn’t fit the metaphor well.]