From the Editor-in-Chief

When I was a lad I served a term
As office boy to an Attorney’s firm.
I cleaned the windows and I swept the floor,
And I polished up the handle of the big front door . . .
I polished up that handle so carefullee
That now I am the Ruler of the Queen’s Navee!

—W.S. Gilbert, H.M.S. Pinafore

When I was a lad of only 12, I trod the boards and belted out this signature Gilbert and Sullivan patter song. To serve in the cause of full disclosure, the stage was a wood and steel platform set up in a corner of the multipurpose room at the Adlai Stevenson Elementary School of Southfield, Michigan. In the spring of 1972, my sixth-grade class performed an abridged version of Gilbert and Sullivan’s classic operetta, H.M.S. Pinafore, which first took the English-speaking world by storm in 1878 and has been continuously performed in multiple languages and nations ever since.1

I began reminiscing about my Gilbert and Sullivan experience during last summer’s confounding game of musical chairs played by various members of the US Congress, occupants of the Oval Office and West Wing, and policymakers of all stripes and sizes seeking to gut the Affordable Care Act of 2010, with suggestions ranging from full repeal to “skinny” bills.

While attending a meeting of the Board on Population Health at the National Academy of Medicine in July, we were briefed by Julie Rovner, a Kaiser Health News fellow, former NPR health correspondent, and my old classmate at the University of Michigan. After she recited the multitude of permutations which, thankfully for the health of many millions of Americans, never came to pass, I told her that her twisted tale resembled a Gilbert and Sullivan production but with none of the wit, charm, or rousing music. She laughed. I didn’t.

W.H. Smith, the First Lord of the Admiralty, was a subject of mockery and ridicule even before H.M.S. Pinafore’s premier, as seen in this October 13, 1877 issue of Punch. The caption reads: Admiral Superintendent Punch. “Well, Mr. Smith, I believe you have now seen everything—armour, turrets, torpedoes—everything! Of course you understand it all!!” First Lord. “Quite so, thank you. At least I—“ (A little “queer.”) “If you don’t mind, I think I’ll now go below.” The Lords of the Admiralty arrived at Portsmouth on their annual tour of inspection.”

William S. Gilbert (1836-1911) and Arthur Sullivan (1842-1900) specialized in what contemporary theater critics hailed as “topsy-turvydom,” a dramatic narrative where nothing at the beginning of the play stands firm through its end. Class, station, personal finances, professional experience, rank, and even orders of ruin or execution are all flipped on their collective ears by the time the final curtain is rung.2

In H.M.S. Pinafore, for example, Sir Joseph Porter, KCB (the character who sings “When I was a Lad”) became ruler of the “Queen’s Navee” without ever going to sea. Instead, he worked his way up in a law firm, grew enormously rich, won a pocket borough seat in Parliament where he always voted the party line, and “never thought of thinking for myself at all.” With consummate pride, Sir Joseph, “the monarch of the sea,” boasts, “I thought so little, they rewarded me. By making me the Ruler of the Queen’s Navee!”

W.S. Gilbert, one of the greatest librettists in the history of musical theater,was troubled by the ravages of gout as he wrote H.M.S. Pinafore—but, at least, he had access to a Harley Street physician. In the throes of great physical pain, Gilbert developed the character of Sir Joseph based on a real-life party hack and “land-lubber” named W.H. Smith, who Benjamin Disraeli had recently appointed as First Lord of the Admiralty despite never having served a day in military uniform.

To dig the knife even deeper into Admiral Smith’s side, the “fictional” Sir Joseph reminds the audience of the silly and improbable circumstances that led to his high rank:

Now landsmen all, whoever you may be,
If you want to rise to the top of the tree,
If your soul isn’t fettered to an office stool,
Be careful to be guided by this golden rule.
Stick close to your desks and never go to sea,
And you all may be rulers of the Queen’s Navee!

When we were lads and lasses, I submit, we were incapable of imagining living in a country so closely resembling the stuff and nonsense of the venerable Gilbert and Sullivan. The dizziness wrought by all the head-spinning proposals to control more than one-sixth of our economy may have dissipated, but too many Americans still face a tsunami of uncertainty over how to pay for the disaster of disease that awaits us all.

Worse, we hear blustery threats from an improbable president (who prepared even less for his post than Sir Joseph did for his) refusing to implement the laws of the land and signing executive orders that purposely sabotage them.

Pundits bloviate falsehoods about health insurance. Facts no longer carry the day, if they ever really did. Nothing is at it once seemed or should be. Even the news documenting these current events is derided as “fake.” Who do we believe? What should we do to protect the rights of all to have access to health care? How do we protect the environment from potentially lasting damage that threatens the population’s health more than a handful of epidemics? Can we still protect the mental health and security of those threatened because of their religious beliefs or the color of their skin? To paraphrase the captain of the H.M.S. Pinafore, how can we right the ship of state both within and without our borders?

As I wearily write these words during the waning days of summer, I feel all too confident that the topsy-turvydom in Washington will only escalate.

Perhaps what all these perils teach most clearly is that while topsy-turvydom makes for a wonderful evening of theater, it is no way to run a nation.

* * *

We begin the December issue with our Op-Ed section. Our guest contributor, Ezekiel Emanuel, writes about the need to transform medical education so that it may better match the transformations in medical practice that have transpired since the influential Flexner Report on Medical Education of 1910; Lawrence Gostin provides a moving account of his father’s life, a man of the “Greatest Generation,” and his experiences with a not-so-great health care system; John McDonough considers 4 critical questions for single-payer health insurance advocates; Sara Rosenbaum reminds us of the importance of community health centers and what is at risk if Congress does not act to extend their funding; Gail Wilensky discusses CMS demonstration projects and the future of value-based care; David Rosner analyzes the role of government in the ecological disasters facing the Texas Gulf Coast communities and other areas affected by monster storms; Joshua Sharfstein writes about the double standard of broad national support for life-saving missions following natural disasters but not for the many health disasters that affect individuals every day; and Sandro Galea discusses the lack of research data on the foundational social determinants of health and what can be done about it.

The issue then presents 5 superb, peer-reviewed papers for your consideration:

  • “Barriers to Care Among Transgender and Gender Nonconforming Adults” by Gilbert Gonzales and Carrie Henning-Smith
  • “The Politics of Medicaid: Most Americans Are Connected to the Program, Support Its Expansion, and Do Not View It as Stigmatizing” by Colleen M. Grogan and Sunggeun (Ethan) Park
  • “Lessons From Analyzing the Medical Costs of Civilian Terror Victims: Planning Resources Allocation for a New Era of Confrontations” by Eytan Ellenberg, Mark Taragin, Jay Hoffman, Osnat Cohen, Daniella Luft-Afik, Zvia Bar-On, and Ishay Ostfeld
  • “On Effective Graphic Communication of Health Inequality: Considerations for Health Policy Researchers” by Yukiko Asada, Hannah Abel, Chris Skedgel, and Grace Warner
  • “Better Measurement for Performance Improvement in Low- and Middle-Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection” by Jeremy Veillard, Krycia Cowling, Asaf Bitton, Hannah Ratcliffe, Meredith Kimball, Shannon Barkley, Laure Mercereau, Ethan Wong, Chelsea Taylor, Lisa Hirschhorn, and Hong Wang

* * *

Finally, allow me to take the editorial prerogative in requesting that we take a topsy-turvy lesson from Gilbert and Sullivan and pledge to never stick close to our desks and to always go to sea in the cause of better health and health policies for all.


  1. Gilbert WS, Sullivan A. H.M.S. Pinafore. In: The Complete Plays of Gilbert and Sullivan. New York, NY: The Modern Library; 1936:101-137.
  2. Baily L. The Gilbert and Sullivan Book. London: Spring Books; 1966:151-179.

About the Author

Howard Markel is the editor-in-chief of The Milbank Quarterly. He is also the George E. Wantz Distinguished Professor of the History of Medicine and director of the Center for the History of Medicine at the University of Michigan. An acclaimed social and cultural historian of medicine, Dr. Markel has published widely on epidemic disease, quarantine and public health policy, addiction and substance abuse, and children’s health policy. From 2006 to 2016, he served as the principal historical consultant on pandemic preparedness for the U.S. Centers for Disease Control and Prevention. From late April 2009 to February 2011, he served as a member of the CDC director’s “Novel A/H1N1 Influenza Team B,” a real-time think tank of experts charged with evaluating the federal government’s influenza policies on a daily basis during the outbreak. The author or co-author of ten books and over 350 publications, he is editor-in-chief of The 1918–1919 American Influenza Pandemic: A Digital Encyclopedia and Archive. He received his AB (summa cum laude) and MD (cum laude) from the University of Michigan and a PhD from the Johns Hopkins University. He completed his internship, residency, and fellowship in general pediatrics at the Johns Hopkins Hospital. In 2008, he was elected a member of the Institute of Medicine of the National Academy of Sciences.

See Full Bio