Why Generalists Matter

It is both the irony and the saving grace of certain among the most beautiful places on earth that they are also so very far removed from those who might call them so.

We are above one of these places now, flying out in a little plane with Masaai-design-fabric covered seats and boxes of plumpy nut strapped along the floor in the back and I am thinking, This is What the Earth is Meant To Look Like; miles and miles of forested landscape, breaks for rivers and waterfalls, the depths of canyons barely visible between the green.

I think of all who live here and sustain it, and by all I do mean all (animal, mineral, vegetable) and not only those waves of humans flying in and out, some armed, some running from those with arms, that I hear of later. Later I will think of them in these terms and so as acronyms (groups and refugees) but for this moment I do not know any of the history and so I am still thinking of them, simply, and wholly, as Chain and Circle: food and life, the way the natural world works, far more insects and amphibians than mammals.

Yet, in spite of this division, this week I have seen more newborn human beings than ever before.

The Extremes of Life

The very beginning of life and the very end of life are not moments that the majority of us in the West see much of anymore. Whereas birth and death used to occur in the same houses as the ongoing-living, now dead bodies and newborns are nearly entirely removed from the usual thoroughfares, shuffled to the pervues of specialists.

Not so here. At one of our projects there are more than 600 births a month in the catche-ment area: more than 600 new people coming into the world, in just this one little corner of Congo. At any given point so many people are having children, or minding chidlren, or losing children, that it would be impossible to avoid interaction with the process. One mother we saw was on her 10th pregnancy (at age 38) and when I mentioned this astounding fact to a hospital nurse later, she said, "Oh, yes, well today we helped a woman deliver her 14th."

In the six months that I have been working with a medical organization my public health degree has catapaulted to a new degree of relevance. There are so many population level questions: questions of water and sanitation, the nature of epidemics and disease transmission, the possibility of gene mutations in vectors and in pathogens, how to assess behavior and how to extropolate from raw data the most effective line of inquiry.

It is not knowledge of treatment regimens that is needed to respond to these questions, but rather a global mindset that sees representation in symptomatic presentation, and opportunity in the OPD. What is required to answer these questions is the ability to step back from the details, squint, and see a pattern.

Transmission Between: Information and Pathogens

We think of vectors and pathogens particularly now because malaria is rising, accounting for more than 60% of all inpatient admissions at one hospital, and higher than 70% at another. And so we are asking ourselves, what is the reason? Is it at the level of household behavior (nets being used for garden covers and dresses instead of sleep-time barriers?)? Is it a matter of health-seeking behavior and access (who comes and can afford to come, who goes first to traditional healers so that when they do arrive they are so much more ill?)? Or is the problem complicated by more than this (insecticide or treatment drug resistance? environmental factors altering vector behavior?)?

So this is how the process happens: at one place someone remarks on a spike in illness and then the cranking chain of Asking Questions begins: first around the collective dinner table, then mentioned in a report, then picked up by some specialist, who may or may not then contact another specialist, and it is this collaboration that determines where it goes from there.

But what limits this process is specialization. A medic is usually not trained in epidemiology and so when cases of malnutrition are on the rise they may  be able to chase the origin back to an outbreak of measles peaking 4-6 weeks ago, but as to where the epidemic goes from here, or where it came from and what transmission pathways are the most likely to peak again, this the medic probably does not know, nor have time to consider in the midst of individual treatment.

When we wish to answer the question why- in the midst of a global decline in the incidence of malaria -  we are seeing a DRC-wide explosion in morbidity and mortality due to this disease, the question requires both a bird's eye view and also the collaboration of specialists, so that the medic noticing the peaks in cases speaks to the malaria specialist who calls in the entomologists and the epidemiologists and biostatisticians and all then bring their focused knowledge together.

But this collaboration is tricky. People forget to ask if someone else has already asked a certain question before. People forget to tell other people that they have. Humanitarian workers forget to talk to development workers, and vice versa. Both forget to speak to scientists. Politics and turf-wars get in the way of good sense and efficiency.

Which is why you need generalists, so that someone on the team is at least aware of the facts that are there to be aware of, and the resources available to each of the fields, and can argue for their sensible use.

Back to Center

It is both the irony and the saving grace of certain among the most beautiful places on earth that they are refuge to some of the most catastrophic of human affairs; ironic as the violence contrasts with the abundance of beauty, and lucky by way of the same contrast, that it is the division of these things that brings forth such a strong sense of injustice and empathy, and a desire to lesson the distance between the two extremes.

With the same centering impulse we must also pull in the extremes of specialism and generalism to intelligently ask, and answer, questions like: why are morbidity and mortality from malaria in DRC rising exponentially?

And why is it that in one of the most stunning countries on Earth, of those 600 children born in one little corner this past month nearly 120 die before they reach the age of 5?

It is not chance that dictates these life expectancies or disease patterns; it is the movement and decisions of human beings: decisions that we must all consider, and movements that we must all decide: will we step aside? Will we join?

Or will we bring the two corners together, as bedsheets are folded, and thus span the distance between specializations to neatly pack the questions and address the problems?


Disclaimer: The views and opinions expressed in this blog, and in any of its associated articles, are exclusively those of the author and do not necessarily reflect the views or opinions of any associated organizations or entities mentioned herein, unless otherwise mentioned.