Public Health
The decisions that shape the outcome of a public health emergency are usually made before most people know there is an emergency. Triage protocols, containment recommendations, resource allocation, surge capacity triggers: these are set in motion early, under uncertainty, by professionals whose judgment determines what the next weeks look like for thousands of people who do not yet know they are affected.
PHILADELPHIA AND ST. LOUIS • SEPTEMBER–OCTOBER 1918
A TALE OF TWO CITIES
One of the deadliest pandemics in modern history. Two cities. One parade. A public health lesson that has never expired.
In September 1918, during the pandemic’s deadly second wave, Philadelphia’s public health director, Wilmer Krusen, allowed a Liberty Loan parade to proceed on September 28. Roughly 200,000 people crowded the route. Cases and deaths rose sharply in the days that followed. Within six weeks, more than 12,000 Philadelphians had died. Hospitals, morgues, and burial systems were overwhelmed; more than 500 bodies awaited burial, some for over a week.
St. Louis faced the same influenza wave and chose a different course. Public health commissioner Max Starkloff moved quickly to close schools, theaters, churches, and public gatherings. The policy demanded political resolve, but the city’s mortality rate remained far below Philadelphia’s: 358 deaths per 100,000 residents compared with 748.
“The public health officer who makes an unpopular decision absorbs the political cost of a restriction whose necessity may only become visible in the counterfactual. St. Louis and Philadelphia faced the same virus. They did not record the same outcome.”
WEST AFRICA • 2014–2016
Ebola
More than 11,000 people died. The outbreak turned when community health workers built enough trust for people to come forward. Many of those workers came from the communities they served.
The Ebola outbreak that began in Guinea in December 2013 killed more than 11,000 people across Guinea, Sierra Leone, and Liberia. It was the largest Ebola outbreak in recorded history and the first to spread widely through major urban centers.
The response required something that medical facilities alone could not provide: trust. Families had to decide whether to bring loved ones to Ebola treatment units rather than care for them at home. In communities where treatment units were associated with separation and death, that trust had to be earned.
The community health workers who traced contacts and went door to door were central to controlling the outbreak. Many were members of the communities they served. They understood local concerns, customs, and relationships. Women led many of these efforts, often without guaranteed authority or safety. They built trust one conversation at a time.
“The community health workers who helped turn the Ebola outbreak were not outsiders. They were neighbors. They built trust where it had to be earned, one conversation at a time.”
BERGAMO, ITALY • MARCH 2020
COVID
Physicians making decisions that medicine had rarely required them to make before, and returning the next morning.
In March 2020, Bergamo’s hospitals showed the world what COVID-19 could do when a health system was overwhelmed. Intensive care demand rose faster than capacity. Military vehicles transported coffins from the city because local burial systems could not keep pace. Physicians and nurses worked with limited protective equipment while clinical knowledge and treatment guidance evolved in real time.
The weight carried by Bergamo’s clinicians was not only the volume of patients. It was the decisions. When intensive care demand exceeds available beds, equipment, and staff, clinicians must make allocation decisions under extraordinary pressure. Guidance was emerging, but the uncertainty and consequences remained profound. They made those decisions shift after shift, and they returned the next morning.
Public health professionals who worked through COVID-19 globally, including contact tracers, epidemiologists, ICU nurses, medical examiners, and vaccine coordinators, held the boundary under extraordinary conditions. Most were never publicly recognized for it. They did not do it for recognition.
“They made consequential decisions with limited resources and evolving guidance. Shift after shift, they returned the next morning. That is what holding the boundary looks like from the inside.”
The second disaster is the one that public health emergency management exists to prevent. Not the earthquake, but the cholera outbreak that follows it. Not the mass casualty event, but the secondary infections in overwhelmed hospitals. Not the pandemic, but the collapse of routine healthcare that runs alongside it. That work happens in the background of every crisis, conducted by professionals whose success is measured in things that did not occur. It is among the hardest work to sustain politically and institutionally, because the case for it can only be made in the counterfactual.
We Serve Those Who Serve Others.