Florence Nightingale : An Epitome of Nursing and the Creator of Medical Data Visualisation Tools.

Tribute to Florence Nightingale : An Epitome of Nursing and the Creator of Medical Data Visualisation Tools.

The Corona Virus epidemic has once again brought to focus some extraordinary tales of health workers, who continue to selflessly serve patients and victims of the virus attack in the very areas where angels fear to tread, risking their lives in service of larger interest of the patients they serve and so also the society they wish to protect and insulate from the deadly virus. It is only when such massive health calamities occur that we tend to cursorily - like a foot note reference - remember health workers like Dr Li Wenliang who died at a very young age of 34, affected by the very virus against which he had raised the warning bell for protecting his fellow Doctors. Visuals of Doctors, paramedics, nurses (sisters) and others serving the virus affected patients in adverse health hazard conditions, speak volumes for their extraordinary service, true to the traditions of the Hippocrates oath that the doctors take to serve the sick. This reminds me of Florence Nightingale - a Lady with a lamp - who symbolises, in true sense, what nursing is all about - selfless service to the sick and wounded. As the saga of the Corona virus continues to live on, I wish to take this opportunity to write my reverential blogpost to Florence Nightingale and dedicate this post to all those unsung health workers all across the world, particularly those in the city of Wuhan, who are serving to nurse back the sick to normalcy and prevent the spread of the virus from those affected, isolated and quarantined. A million salutations to all of you.

Incidentally this year 2020, also happens to be the 200th birth anniversary of Nightingale. On the occasion of the bicentennial  of the birth of Florence Nightingale, the year 2020  has been befittingly declared as the ‘International Year of the Nurse and Midwife’ by the World Health Organisation. This is all the more poignant considering the novel Corona virus outbreak, which is plaguing our society, particularly China. There will be scores of  articles and media coverage paying tributes to the extraordinary service of Florence Nightingale as the Nurse, my article on Medium, whose link is appended, will however also highlight her often neglected contribution as a great data visualiser and statistician.  Please spare some time to read.

I have already written about the Corona Virus, Dr Li Wenliang and the Superbugs, in which reference has been made to the extraordinary services of health workers who, with support from different stakeholders, can collectively help combat global health menace. History reveals that nurses contribution to health management is incomplete without reference to the legendary nurse the quintessential famous lady with the lamp - Florence Nightingale. Nightingale made profound contributions in the Crimean war, not just as a nurse but also as a mathematician, whose reports, containing mathematical diagrams (modern equivalent of Pi charts) of the causes of mortality, brought about revolutionary change in health management, saving many lives. Most unfortunately Florence Nightingale has not be given the credit that is due to her for her role as a mathematician and for the importance that statistics and Pi like charts play in health management. In this blogpost, I am making an attempt to highlight the contributions of Florence Nightingale not just as a nurse, for which she is remembered globally, but also as a statistician. I first learnt of the Crimean war and Florence Nightingale during my school days in Sainik School Bijapur.

Sainik School Bijapur, my Alma Mater, where I spent seven years (age 9 to 16) of my most memorable life, prepared us primarily for service in the armed forces. Unfortunately, I am one of those unlucky few who could not join the military, because of my ‘heart murmur’, which rendered me unfit for the military. Our school teachers often narrated stories of valiant soldiers and freedom fighters, to motivate us to join the armed forces (National Defence Academy). One such story, which has remained etched in my memory, is a poem, by Lord Alfred Tennyson, that portrays the valiant fight of 600 soldiers of the Light Brigade, who ‘rode in to the valley of death’. The hair raising poem recounts an extraordinary assault by 600 soldiers (Brigade) of the British cavalry. The charge of light Brigade is regarded as one of the most heroic, yet futile assaults in British military history that took place at the Battle of Balaclava, during Britain’s war with Russia in Crimea in the mid 19th century. It is during this epic battle that Florence Nightingale made profound contributions, both as a nurse and also as a statistician, to save many precious lives of war wounded soldiers, which ultimately led to the change the in future course of health management across the world. 

The historic Crimean war is inextricably linked with Florence Nightingale, who epitomised nursing. Day in and and day out, each day every day, she, equipped with that historic image of a lamp in hand, moved from bed to bed and barrack to barrack nursing the injured with her extraordinary compassion. Her efforts of visiting the wards alone every night, to comfort the men  inspired noted author Henry Wadsworth Longfellow to create a poem, Santa Filomena, which depicts the hospital scene that has cemented Florence Nightingale’s image as “the lady with the lamp”. Part of this poem goes like this;

A lady with a lamp I see
Pass through the glimmering gloom,
And flit from room to room

On England’s annals through the long
Hereafter of her speech and song
That lights its rays shall cast
From portals of the past

A Lady with a Lamp shall stand
In the great history of the land,
A noble type of good
Heroic womanhood....

The bloody Crimean battle, which created that enduring image of Nightingale as a lady with the lamp, killed over 350000 young men. Unfortunately, 90% of these soldiers, who died in this battle, was not because of their battle wounds but due  to other illnesses like dysentery and other opportunistic infections, which they cultivated while admitted at the completely ill equipped hospitals. It was here that Nightingale played a pivotal role as a compassionate nurse and an extraordinary statistician with mathematics knowledge. She applied her talent in mathematics to innovate and use statistics of battle wounded soldiers and their plight, which she compiled as scientific data, and these reports helped in bringing to light the adverse conditions of the so called hospitals where the wounded soldiers were being treated. This compelled the authorities to improve the conditions of hospitals, which helped  in reducing mortality rates. While Nightingale’s contributions as a nurse has been etched in the annals of human history, her contributions as a statistician has remained one of her enduring forgotten contributions. Most of us, at least my generation people, will remember Florence Nightingale as a tireless nurse with a lamp in hand, who was an embodiment of compassion and service.

The legend of Florence Nightingale was undoubtedly born in the misery of Crimea’s hospitals, that received hundreds of thousands of wounded soldiers. Diseases such as typhoid, cholera, and dysentery were rife in the army hospitals, where these soldiers were admitted. Many more soldiers were dying from diseases than from wounds received in the battlefield. Seeing the misery in which the British soldiers were made to lie in unhygienic conditions and in the crowded military hospitals, Nightingale developed burning desire to bring about a major social change, beginning with the medical treatment of the soldiers and keeping medical records that would invite the attention of the authorities that be. She used these medical records and statistics to prepare Pi like charts to impress upon the authorities of the dying need for the improvement in living conditions of the patients in the military hospitals particularly with regard to sanitation and nutrition. Nightingale and her colleague nurses dramatically raised standards of patient care, including sanitation and nutrition.

It is said that Nightingale saved more lives with her grasp of numbers (data visualisation) than she did with her gift for nursing. Today, data visualizations are everywhere and they are inextricably linked to every bit of planning, be it health management, business, commerce or economics. Florence Nightingale was one of the pioneers in data visualisation, which inspired massive social changes particularly in health management issues. Unfortunately Nightingale’s role as a fierce data journalist, feminist, and war nurse has been mostly obscured by the enduring image of the Lady with the Lamp. Nightingale’s contribution in preparing data visualisation tools of recording patient details are praiseworthy considering the fact that there was very little recorded information about disease and mortality in the 1800’s. The concept of public records had just taken shape and they were yet to be introduced in documenting disease, mortality and other medical records. The idea that medical data could be used as social facts, which  could be measured and analysed was very novel at that point of time. Nightingale who had learnt mathematics was a keen observer and took active interest in social reforms and believed that data visualisation could benefit society. She frequently attended scientific meetings and it was in these meetings that she realised that her mathematics skills could be used to supplement her idea that informative graphics could make her case for better hygiene more convincing to the authorities.

Florence Nightingale was born on May 12, 1820, to a wealthy British parents in the city of Florence, Italy, while her parents were travelling in Italy. They named her after the city in which she was born - Florence. Her elder sister Parthenope too was named Parthenope Nightingale after name of the Italian city where she was born. Her parents returned to England in 1821. The Nightingales were among the economically and socially advantaged segment of society that ruled England. Both Florence and her sister Parthenope were home schooled by their governess and became proficient in reading and writing.  At seven years of age Florence was already a prolific and keenly observant letter-writer and by age ten she had written her own autobiography, in French. She was also noted in her family for compiling very detailed lists of nearly everything around her, many of which appeared in her journals and letters. Subsequently from age 12 onwards, Florence was educated by her father William Nightingale.  In an age when girls were rarely educated, Florence was lucky to have had a father who believed that everyone had a right to an education. Her early learning consisted of a wide range of subjects— chemistry, geography,physics, history, languages (classical and modern)—but only very basic mathematics. This changed when she managed to get hold of a copy of Euclid’s Elements. It was her aunt Mai, who had a major influence in Florence’s life, who urged her sister - Florence’s mother - to hire a mathematics tutor for her daughter. Florence learned algebra, geometry and arithmetic, which she in turn taught to several children. Florence also engaged herself in a self-guided study in social and health statistics. By then the first public register of births, deaths and marriages was created by the General Registry Office, which had made social statistics a popular topic for conversation and these records were of great interest to Florence. She also studied hospital ‘blue books’ and any other data she could obtain. One of her most ambitious projects, done in 1853, was to gather her own data by sending questionnaires to hospitals regarding health administration, which she then laboriously analysed. 

Florence’s fascination with statistics and her desire to nurse were both present from her childhood. In Crimea she found the opportunity to meld her two passions into a single pursuit. One of her first acts was to institute uniform statistical recordkeeping to replace haphazard and contradictory military journals. These data would form the foundation of her later work when she returned home. The Royal Commission, charged with formalizing Florence’s reforms, would come to rely heavily on her statistical analyses, and it had as one of its goals the establishment of a “statistical department for the army”

Florence used her knowledge in mathematics and became an innovator in standardized data collection, tabulation and graphical displays. She was convinced that analysed data which could be transformed into charts served as effective visual communication. She said it was necessary to understand the real meaning of data: “the diagram which is to affect thro’ the Eyes what we may fail to convey to the brains of the public through their word-proof ears”. She worked very closely with William Farr, her associate and collaborator for twenty years, who was a medical statistician. She was also influenced by the Belgian statistician Adolphe Quetelet, considered to be the founder of social statistics.

Florence prepared many diagrams, which  represented yearly data about military deaths due to disease, wounds and other causes and these diagrams used mathematical formulae including 36 square roots, three for each month. Her diagrams and charts were drawn by hand with rulers and curved templates.  She used these diagrams in the reports which she prepared and published under the title “Mortality of the British Army.” Nightingale wanted to present the “loss of an army” in a way that could be immediately understood by the visual,look at her diagrams. She compiled tables of statistics that tracked where people had died, and why. She found that even during peacetime, soldiers were dying young far more frequently than the civilian population. Nightingale needed to convey this information in a way that it would be understood immediately and therefore she prepared her reports with bar graphs and created a brand new chart, the coxcomb, to show numbers of deaths by month along with their causes. The reports were so very easily comprehendible that at  a glance anyone  oils see how blue, representing totally preventable deaths from disease, dominated the space. These reports which helped authorities to visually understand data led to several reforms in British army hospitals and civilian hospitals.

The contributions of Florence Nightingale were recognised and she became the first woman to be elected as a Fellow of the Royal Statistical Society. She was also made an honorary member of the American Statistical Association. She received the St. George’s Cross from Queen Victoria for her Notes on Matters Affecting Health, Efficiency, and Hospital Administration of the British Army, one of the first published documents that made use of her statistical data and charts. After serving the sick and wounded for more than half a century, Florence Nightingale breathed her last in her home in London at the age of 90 years, on 13th August 1910. 

More than hundred years after her death, the nursing legacy of Florence Nightingale continues even today and nursing and care are inextricably linked to Florence Nightingale. At a time when Covid has began to impact not just China but has spread its tentacles beyond the borders of China and appears to become a global pandemic, let us all remember those unsung health workers who are tirelessly working to treat the affected patients notwithstanding the high risk they face of contracting the Corona virus, which may be fatal. 

Long live the medical fraternity, who serve humanity and may the legacy of the likes of Florence Nightingale be eternal.