A Tribute
Remembering John
Last With Humor And A Smile
And Giving Him The
“Last Word”
We learned this month
of the passing of John Last, a beloved colleague (see Notes on
People, this issue).
He is often credited
with having developed the metaphor of “tip of the iceberg” in
epidemiology. As defined in the Dictionary of Epidemiology he helped
to create, the “iceberg phenomenon” is “that portion of disease which
remains unrecorded or undetected despite physicians’ diagnostic
endeavors and community disease surveillance procedures [and] is
referred to as the ‘submerged portion of the iceberg’”
Suggestion Letter
The Epidemiology
Monitor received a letter several years ago crediting John Last with
an “invaluable contribution to the terminology of epidemiology” but
complaining that the metaphor was awkward or inappropriate to use in
tropical climates. The writer (Michel Thuriaux) challenged our
readers to suggest an equivalent metaphor for “iceberg” less obviously
limited to polar or subpolar climes. We obliged and ran a contest with
a $100 prize for the best substitute metaphor that readers could
suggest.
Last Letter
One of the submissions
was from John Last himself who wrote to say that although he was the
author of the paper called “The Iceberg”, he did not actually invent
the term but credited it to former Lancet editor Robbie Fox.
Nevertheless, his name
is associated with the metaphor and so we thought it would be
appropriate to honor John this month by reprinting some of the entries
in our metaphor contest from way back in 1993, including the favorites
selected by the editors at the time. It was a fun contest that many
readers enjoyed.
Sample Entries
Below is a sample of
the entries.
1. Dear Editor:
I would like to suggest “fin of the shark” as an equivalent for the
more commonly used metaphor “tip of the iceberg”. …It refers to the
small portion of a dangerous entity that can be readily seen. This
metaphor would be understood around the globe.
--Kathleen
Daly,
2. Dear Editor:
Twenty years ago, Barker suggested a substitute for “tip of the
iceberg” better suited for Africa, Indonesia, and all places that have
zoos in the following paragraph. “For such reasons, (e.g., unreported
and unrecognized cases) the extent of many epidemics is not clearly
defined at first. Only the ears of the hippopotamus are visible but
the bulk lies below the surface of the water!” (Barker DJP. Practical
epidemiology. Edinburgh. Churchill Livingstone, p. 138. 1973. I think
the prize should go to Barker.
--George Comstock,
3. Dear Editor:
I question the suggestion in your February issue that sharks would be
more familiar than icebergs to residents in Switzerland, Burkina Faso,
or Tibet. I also tend to believe that hippopotamuses keep their
nostrils, rather than their ears, out of the water. I suggest “tip of
the icecube”. The ratio of the tip to the whole is the same as the
iceberg, and the part under the surface can be seen through most
liquids, making the metaphor more didactic; it is also portable for
easier use in the field, and I challenge your readers to identify a
place on earth where you could find the Epi Monitor but not icecubes.
--Bernard Moriniere
4. Dear Editor:
Instead of “tip of the iceberg” I would like to suggest “the peak of
the curve”.
--Paul
Etkind
5. Dear Editor:
My suggestion is only the “first raindrops of the rainstorm”. I don’t
think the shark fin has meaning to inhabitants inland, or the
hippopotamus to non-Africans.
--Andrew Brunskill
6. Dear Editor:
My suggestion for “tip of the iceberg” is “the handle on the pump” or
“the pump handle”. The Broad Street pump handle could be considered
the “tip of the iceberg” for the cholera epidemic in London as 1) if
it hadn’t been there, the water could not have been consumed, or 2)
its removal was one of the first of many instances of primary
prevention. Further, the entire Broad street incident could be
considered the “tip of the iceberg” of the science of epidemiology
itself. Of course, reflecting on the contribution of John Snow, I’m
not so sure the “tip of the iceberg” is totally inappropriate anyway.
--Beverly J Volicer
7. Dear Editor:
An equivalent metaphor for “tip of the iceberg” not restricted to one
part of the globe but found in every zoo is “the tail of the elephant”
or “the camel’s hump”. It imparts the same idea, i.e., small parts of
a larger body.
--Michele Alexander
8. Dear Editor:
I would like to suggest “cover of the book” as a generic yet effective
equivalent to the more colloquial metaphor “tip of the iceberg”. The
cover of the book is the prelude (tip) to a greater story which lies
ahead. This metaphor would be understood around the globe as most
areas, including third world countries
that I have traveled to are aware of what a book is and what it
contains.
--Patrick Scott Alban
9. Dear Editor:
In response to your announcement, I would suggest “front of the
parade” for a global equivalent to “tip of the iceberg” used in an
epidemiologic context.
--Daniel Fife
10. Dear Editor:
As a tropical alternative (Puerto Rican to be specific) to the
“tip of the iceberg” I’ve been using for years the “Antillean
phenomenon”. The Antilles, from Cuba to the Virgin Islands, are the
visible tips of ancient mostly submerged volcanoes. Everybody knows
that in these parts.
--Jose G Rigau
11. Dear Editor:
I would like to suggest “event horizon of a black hole” as a
metaphor to replace “tip of the iceberg”. An event horizon of a black
hole is the edge of the black hole before everything disappears into
it. This metaphor is certainly not restricted to one part of the
globe. Indeed, one might say that it has universal applicability!
--Tim Rohan
12. Dear Editor: I have listed several metaphors that may be
universally equivalent to “tip of the iceberg”. Each begins with an
incomplete/deceptive description of something too great and complex to
be one-dimensional:
♦
Beauty of a woman
♦
Eye of the hurricane
♦
Calm
before the storm
♦
Rattle of a snake
♦
Rash of syphilis
♦
Cough of
TB
♦
Dance of
a cobra
♦
Title of a book
♦
Campaign
promises of a candidate
♦
First
aches of labor (in childbirth)
♦
Brilliance of lightning
♦
Goodness
of God/Wrath of God
♦
Happiness in a marriage
--Barbara W Harrell
13. Dear Editor:
In reference to the “tip of the iceberg” question, I suggest avoiding
clichés in general. When, in a specific context, one needs to convey
the idea that what is unknown or unseen is much greater than what is
known or seen, simply describe the situation. This should be “easier
than falling off a log.”
--J Mac Crawford
14. Dear Editor:
Re: No Icebergs in the Tropics, there is a relevant metaphor
already in use in Africa: the head of the hippo. Even if western
epidemiologists haven’t got a hippo in the backyard, I think the
appearance of this animal is more familiar than that of an iceberg.
Unless you come from Greenland, of course.
--Lars Ake Persson
15. Dear Editor:
My suggestion for an equivalent metaphor for “tip of the iceberg”
would be “first zephyr of the typhoon” since this is both melliphorous
and menacing.
--Tony Boxwell
Editor’s Challenge:
Readers are invited to
remember or guess which new suggested metaphor was selected as the
winner of the contest back in 1993. Send us your guess at
editor@epimonitor.net. Whoever guesses right or remembers right
will be recognized in a Letters to the Editor feature in a future
issue.
Last With The Last
Word
It is worth pointing
out that while John Last gave credit to a Lancet Editor for coming up
with the term iceberg, he did however display some possessiveness
about the metaphor and his sense of humor when in his same letter to
The Epidemiology Monitor he added “It would be sad to discard the
image of the iceberg. The concept is widely understood, even by
dwellers in hot places with whom I’ve discussed it. The Saudis, after
all, or was it the Kuwaitis, did consider towing icebergs from
Antarctica to solve their water shortage problem.”
We’ll remember that
John!
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