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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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