In the realm of public health, having accurate data is essential for making informed decisions to fight COVID-19. The choices made at the institutional level today can lead to life-or-death outcomes, just as individual actions, like adhering to social distancing guidelines, can have significant repercussions.

Reflecting on the current pandemic, I often think about Dr. Bill Bicknell, a former professor at Boston University School of Public Health who passed away in 2012. His extensive experience in public health policy, program implementation, and clinical medicine globally—coupled with his role as Massachusetts Commissioner of Public Health—provided him with a unique perspective. He was known for his candidness and willingness to challenge the status quo.

As an educator, Dr. Bicknell compelled us to consider the impact of public health data and decision-making on real lives, urging us to keep in mind those who may be overlooked in discussions. His teachings significantly influenced my understanding of the ethical dimensions of healthcare decisions and the role that data visualization plays in informing those choices.

Here are three pivotal lessons from his final lecture that remain relevant today.

1. Our Choices and the Data That Informs Them Can Be Life-Saving or Life-Taking.

I vividly recall my first day in Dr. Bicknell's global health policy class when he posed a provocative statement:

“Public health encompasses the art and science of determining who dies, when, and with what degree of suffering. Conversely, it also involves deciding who can lead longer, happier lives. Starting with the latter allows us to recognize the consequences of our failures.”

Dr. Bicknell asserted that “public health is often more perilous than medicine. While doctors primarily deal with individuals, we address populations. Consequently, poor public health practices can have far-reaching consequences with minimal accountability.”

The data we convey influences both personal behavior and institutional policies, ultimately contributing to life-or-death scenarios. Dr. Bicknell emphasized the importance of precise denominators in public health metrics. This is particularly pertinent as we navigate a pandemic, where the true number of infections remains uncertain, primarily due to limited testing availability. An ambiguous denominator complicates the calculation of vital statistics, such as the COVID-19 case fatality rate.

In his straightforward manner, he scrutinized the validity of aggregated data, benchmarks, and guidelines. He recalled questioning a recommendation that suggested 15% of a nation’s budget should be allocated to healthcare to adequately meet public health needs, as defined in the Abuja Declaration. He insisted that this figure warranted investigation, rather than blind acceptance.

When analyzing data, we must be prepared to interrogate the sources, calculations, assumptions, and limitations of the metrics we use, recognizing areas of uncertainty. When visualizing data, we should be cautious, as presenting numbers graphically can imply a certainty that may not be justified, underscoring the importance of addressing uncertainty in our work.

Dr. Bicknell instilled in us a sense of responsibility for the consequences of our actions, whether in times of public health crises or in efforts to enhance healthcare systems.

2. The Reality of Resource Allocation.

Healthcare systems consistently grapple with limited resources.

Dr. Bicknell pointed out that in some systems, “scarcity means that some individuals receive healthcare services while others do not. Those left without care may face earlier mortality or a more painful existence. This is the essence of healthcare rationing, which we often avoid discussing. We tend to convince ourselves that effective promotion, prevention, sound policy, and good management can eliminate the need for explicit rationing. However, this belief is dangerously misguided.”

In the U.S., the topic of healthcare rationing is often met with resistance, as it is commonly cited as a reason for maintaining our fragmented health system rather than transitioning to a single-payer model.

Americans frequently prefer to discuss healthcare “triage,” implying that every patient receives attention during emergencies, with care prioritized based on urgency. Rationing, however, suggests that some patients may not receive care at all. Both concepts hinge on the same fundamental question: Who gets healthcare when resources are limited?

Dr. Bicknell urged us to acknowledge that rationing is a reality of our healthcare system, especially under normal circumstances, and its urgency intensifies during a pandemic.

In the coming weeks, leaders in hospitals and government will have to make critical decisions regarding the distribution of COVID-19 tests, the allocation of personal protective equipment for healthcare workers, and the management of ventilators for those suffering the most severe symptoms.

To make informed decisions, we require better data on the burden of disease. Accurate case data hinges on expanded testing for COVID-19. While the U.S. is still in the early stages of community transmission—rationing tests more than ventilators—countries like Italy, which are deeper into the pandemic, face stark decisions about patient care.

As we evaluate healthcare system capacity, it’s crucial to remember other patients who require attention, not solely those suspected or confirmed to have COVID-19. Throughout this pandemic, individuals continue to give birth, suffer injuries, and seek essential healthcare services. While postponing elective surgeries may be manageable, we cannot tell a woman in labor to delay her delivery.

This necessity underscores the importance of the dotted line in graphics illustrating the flattening of the curve. Slowing the spread of infections is vital to prevent overwhelming our healthcare system.

3. Keep in Mind Those Not Present in Discussions.

“What do you need to succeed professionally?” Dr. Bicknell asked during his final lecture. “A moral compass is essential. You must understand your purpose in this field. Listening is crucial. Truly listen, and grasp the relevant details without getting lost in minutiae.”

He reminded us that those of us in healthcare, whether policymakers or practitioners, are fundamentally in the service of others—people in need of assistance and care.

Dr. Bicknell shared the story of “the Melon Lady,” a poignant reminder to consider those who are often overlooked.

A colleague from my time at BUSPH, Kate Mitchell, recounted:

“Bill often shared this story from his tenure as Massachusetts Commissioner of Public Health. One evening, after long hours at work, he noticed perfectly good melons discarded in a dumpster. After taking some home for his children, a janitor informed him that women relied on that dumpster for food.”

Every time I heard Bill recount this tale, he would conclude with a powerful reminder: “Let the melon lady guide your actions.”

While others might have merely stated the obligation to consider those excluded from discussions, Dr. Bicknell illustrated it vividly with his story.

Currently, this could represent a mother dependent on school meals for her children, now struggling to put food on the table, or a waitress missing out on tips as patrons work from home. It might also be a grandmother apprehensively absorbing news about the pandemic's implications.

The effects of this pandemic will be profound and far-reaching, impacting individuals, healthcare systems, economies, and potentially even the climate. The disruptions of March and April will be scrutinized by economists and sociologists seeking to understand the consequences of our social distancing measures. The ramifications are unlikely to be solely positive, and those most affected are likely to be those who lack the resources or flexibility to adapt.

Dr. Bicknell’s insights from his last lecture, thankfully recorded by BU, serve as a reminder of the importance of equitable and accessible healthcare systems. While his slides may not have been visually striking, his commitment to accessible design was unwavering. I believe he would appreciate the advancements in data visualization that have made information more accessible in the years since his lecture.

Dr. Bicknell passed away from cancer at the age of 75 in 2012, but I am hopeful that his legacy continues through the many public health professionals he inspired with his candid and ethical approach to decision-making.

Amanda Makulec is the Senior Data Visualization Lead at Excella and holds a Master of Public Health from Boston University School of Public Health. With eight years of experience in global health data programs, she now leads teams developing user-centered data visualization products for various sectors. Amanda is also the Operations Director for the Data Visualization Society and a co-organizer for Data Visualization DC. Connect with her on Twitter at @abmakulec.