Stark global data inequalities mean that countries with the least resources also face the greatest challenges due to COVID-19 and its wider impacts (World Bank, 2020a). Governments and civil society continue to rely on national statistics offices for accurate and timely data to understand the health, economic, and social impacts of the pandemic (World Bank, 2020a). Florence Nightingale’s systematic improvements in data collection initiated this vital precedent.

Nightingale (1820-1910) is often regarded as the founder of modern nursing but is less frequently hailed for the importance she placed upon statistics and her pioneering work in the visual presentation of information (ASA, 2020). During the Crimean War in 1854, Nightingale took 38 nurses to a military hospital in Turkey, marking the first time women were allowed to officially serve in the army (BBC, 2020). She deemed the Barrack Hospital unclean and unsanitary upon arrival, and mobilised resources and nurses to clean it (BBC, 2020, Science Museum, 2020). Her commitment towards patient care during the Crimean War and afterwards, earned her the title ‘lady with the lamp’ (Science Museum, 2020), as she frequently walked through the wards of wounded soldiers with a lamp in hand during the night-time.

Her strong credentials within statistics saw her become the first woman inducted into the Royal Statistical Society in 1858 (WEF, 2020a). Unlike statisticians and mathematicians of the Victorian era, who preferred tables over graphics for data presentation, Nightingale favoured visualisations (ASA, 2020). She utilised her statistical analysis knowledge to display data in an understandable format to inform and educate long before the age of infographics and data visualisation known today (World Bank, 2020a). Arguably her most notable design was the coxcomb, which presented complex information within a single space (World Bank, 2020a).

The coxcomb visualisation strengthened the argument that reforms implemented by Nightingale, around areas such as sanitary conditions, had a huge impact on reducing mortality

Coxcomb diagrams created in 1854–5 (right) and 1855–6 (left) following reforms to the hospital and nursing practices. Each wedge represents a month, and its area shows the corresponding number of soldier mortalities. The blue, red, and black sections indicate deaths from preventable diseases, battlefield wounds, and other causes, respectively (4). Source:https://thisisstatistics.org/florence-nightingale-the-lady-with-the-data/.

The coxcomb visualisation strengthened the argument that reforms implemented by Nightingale, around areas such as sanitary conditions, had a huge impact on reducing mortality. This underlined soldier mortality being linked to preventable diseases during the war, rather than solely wartime injuries (Science Museum, 2020). The coxcomb mortality diagram highlighted the impact of infectious diseases caused by unsanitary healthcare and conditions such as bad drainage, poor ventilation, overcrowding and contaminated water (ASA, 2020, Science Museum, 2020, Vanderbilt School of Nursing, 2020). Nightingale used this to inform government and army officials how unsanitary conditions in hospitals were linked to infectious disease spread (Science Museum, 2020). Her campaigning for better sanitary conditions helped to reduce peacetime military deaths and improve the sanitary design of hospitals and working-class homes (The Nightingale Society, 2020). She was keen on effective hospital design and architecture, especially after witnessing the negative effects of poorly designed hospital buildings on patients (The Florence Nightingale Museum, 2020). This remains integral, as a review of over 600 articles identified a correlation between the physical hospital environment (such as single-bed or multiple-bed rooms) and the health outcomes of patients (Urich R., et al, 2020). These lessons are vital during the COVID-19 pandemic where public health systems are under increasing pressure, and the development of speciality hospitals with sanitary designs can provide effective high-quality medical treatment for patients (Lua H., et al, 2020).

There are striking similarities between the infectious diseases that were prevalent in Nightingale’s time (fevers and bowel diseases) and COVID-19, including the absence of an effective vaccine.

There are striking similarities between the infectious diseases that were prevalent in Nightingale’s time (fevers and bowel diseases) and COVID-19, including the absence of an effective vaccine (The Nightingale Society, 2020). However, the healthcare methods adopted by Nightingale, including an insistence on frequent hand washing, sterile surfaces, and infection control, remain vital to prevent COVID-19 transmission today (WEF, 2020b).

Nightingale’s visionary outlook and astute scientific enquiry have helped shape modern epidemiological research (Sauerbrei, W., 1997). Her statistical analysis and request for systematic improvements in health data are crucial for accurate and timely tracking of epidemics (The Nightingale Society, 2020) and therefore pertinent in the COVID-19 era . A prime example is her call for data on health status and housing to be routinely collected as part of the census (The Nightingale Society, 2020), which relate to modernised data collection programs as vital functions of national data systems (World Bank, 2020b).

Nightingale’s calls for improved data collection are pertinent in the modern age where statistical capacity is being stretched, with low-income countries having limited resources to invest towards this.

Nightingale’s outlook on housing as a factor impacting health status speaks to the social determinants of health model by Dahlgren and Whitehead (World Bank, 2020b). This considers broad social and economic circumstances as determining population health (Public Health England, 2020). It remains crucial, as many elements within the social determinants of health — such as ethnicity, physical environment, and income status — can significantly impact COVID-19 outcomes (Abrams, EM., et al, 2020).


Main determinants of health, Dahlgren and Whitehead Rainbow Model (Dahlgren G, Whitehead M. 1991)

Nightingale’s calls for improved data collection are pertinent in the modern age where statistical capacity is being stretched, with low-income countries having limited resources to invest towards this. An example is the risk of delayed or even cancelled 2020 census schedules due in over 120 countries, which would reduce the assurance of representative data for guiding policy making and government interventions (WEF, 2020c).

The imperative to provide shared insights into the global impact of COVID-19 (Sauerbrei, W., 1997) requires greater investment. Despite challenges faced two centuries ago, the essential visualisation and collection of health data that Nightingale pioneered has still to be globally augmented today.

By Michael Baser

A member of the Cov360 Public Health team

7 October 2020

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