Portal de Periódicos da CAPES

A Conversation with Jerry Morris

2004; Lippincott Williams & Wilkins; Volume: 15; Issue: 6 Linguagem: Inglês

10.1097/01.ede.0000142155.20764.9d

1531-5487

George Davey Smith,

Global Public Health Policies and Epidemiology

ArticlePlus Click on the links below to access all the ArticlePlus for this article. Please note that ArticlePlus files may launch a viewer application outside of your web browser. https://links.lww.com/EDE/A108 https://links.lww.com/EDE/A109 Jerry Morris was born on May 6, 1910, in Liverpool, England. He studied medicine at University of Glasgow, qualifying in 1934 and obtaining his membership in the Royal College of Physicians in 1939. He served in the Royal Army Medical Corps from 1941 to 1946, mainly in India and Burma. During the war, Morris published a series of influential papers on the epidemiology of juvenile rheumatism and peptic ulcer together with the sociologist Richard Titmuss, which took a then-novel social view of disease causation. He received his first formal training in epidemiology at the London School of Hygiene and Tropical Medicine, where he won the Chadwick prize in 1947. In 1948, he became Director of a new Medical Research Council Social Medicine Unit, where he remained until his official retirement in 1975. There he established a series of cohort studies on physical activity and coronary heart disease. In 1957, he published his widely read textbook Uses of Epidemiology, one of the first books on non-infectious disease epidemiology. In the late 1970s, Morris served on the influential Black committee, established by the Labor government to investigate the persistent social class inequalities in health. His work on both exercise and social inequalities continues unabated. Further details on his life and work are available in a symposium held to celebrate his 90th birthday.1–3 INTERVIEW GDS: Few people start with the intent of becoming an epidemiologist. Can you describe your path into epidemiology? JM: As a young medical graduate, I was already into rheumatic heart disease, which I adopted as my favorite problem. I was influenced by the patients I had seen at University College Hospital. There were a lot of social connections with rheumatic heart disease. So, I started, quite ignorantly, trying to get a community picture of it, long before I had heard of epidemiology. I was soon analyzing Registrar General statistics on mortality from heart disease among children in relation to social conditions, and so forth. I was working with Richard Titmuss; the first paper we produced together was on the social epidemiology of juvenile rheumatism and appeared in the Lancet in the summer of 1942.4 So I came into epidemiology through social medicine and public health. Epidemiology was obviously the technique, the methodology, the approach that I needed. GDS: Were you working clinically? JM: I worked clinically right through. I qualified in 1934, and did clinical work for 5 years. I enrolled [at LSHTM] for the DPH in September 1939, but then other things were happening. I picked up 5 more years of clinical medicine during the war, then did the Diploma in Public Health here in 1946. GDS: What do you think is the difference between epidemiology as it was practiced when you started your career and how it is today? JM: It is entirely different. Today epidemiology is a mature science, with journals, and textbooks, and university degrees, and university departments. It's commonplace to have an epidemiological aspect within clinical articles. In my time there was nothing like this. We were creating epidemiology as we went along. There was a tiny handful of us. I suppose you might say that nowadays, epidemiology is a major industry—huge numbers of talented people—and it is universally accepted. GDS: Whom would you single out as having the strongest influence on your career? JM: I suppose I must say Edward Mellanby, the Secretary of the MRC (Medical Research Council), who out of the blue, on the basis of what I had published, and what I suppose he picked up from his pals, invited me to set up a Social Medicine unit. GDS: Who do think of being the 2 or 3 most important epidemiologists during your lifetime? JM: Major Greenwood. I read everything he published. Goldberger, when I discovered him. Bradford Hill, I suppose, although he was mainly statistical. I would think these three. GDS: What do you see as Greenwood's contribution? JM: He showed how you could tackle problems in cancer from the population point of view, although in fact he contributed very little that was really pioneering. He wrote so beautifully, it made one feel inferior. His Latin and Greek quotations came out quite spontaneously. He was very kind to me. I remember the very first job I did, a job in Nottingham as physician to the City Council. They wanted to make an examination of all the Council workers. I remember going to see Major Greenwood. I didn't know him, and he kindly agreed to see me. We had a long discussion about the sort of things to look for. It was a great experience. GDS: You mentioned Goldberger, what do you think his contribution was? JM: Well pellagra—including the experimental work. He wrote so beautifully, quite unappreciated in this country; I cannot remember now how I got a hold of him. Well, Goldberger and Sydenstriker I suppose; Sydenstriker was the more deliberately social-medical of the two, I would say. But these people had very little impact on medicine as a whole, and how medicine should tackle problems. I more or less started from scratch in terms of establishing how coronary heart disease must be looked at in population terms, as well as in clinical terms and in laboratory terms. The very first observation we made on coronary heart disease was this difference between bus drivers and bus conductors. The main difference there was sudden death [in the bus drivers] as the manifestation of coronary heart disease. How on earth do you pick this up any other way than through epidemiology? I was already in touch with the London Hospital—the biggest cardiological practice in Britain, maybe Europe, with these remarkable post mortem data on atheroma.5 When I was at the London, with this huge cardiology practice ever since James MacKenzie was there, it struck me that we never saw a ruptured heart. According to the textbooks this is a recognized complication, and then it suddenly struck me that you wouldn't expect it in the wards, just at postmortem. So I phoned up the coroner's pathologist who covered the same district as the London hospital, and I said hullo, what is going on? I never see a ruptured heart. And he said, “I get two a week”. I showed all of this to Himmsworth, secretary of the MRC, my boss in effect. He insisted that I must show these data to Sir John McMichael, the leader, the Fueher, of clinical science at Hammersmith, where the brightest physicians from all over the world used to come to do postgraduate work. I remember showing McMichael all of this, and he said, “rubbish.” That was it. We were very fortunate, compared with you people. When we came out of the war, there were three major epidemic diseases with virtually unknown causes: coronary heart disease, lung cancer, and peptic ulcer. There they were, just waiting. Because of my interest in heart disease, I went into coronary heart disease. Its etiology was unknown, little bits and pieces about biochemistry, about diet, but nothing known. No literature—a wonderful situation! You could go to the Royal Society of Medicine library and read the literature before you had tea, just leaving some German paper to be translated. We were starting from scratch. Nothing like that now. GDS: I guess lung cancer brings us to Bradford Hill as your third most important epidemiologist during your lifetime. JM: The first methodological problem I had to grapple with in 1947 was incidence. How do you define incidence of a disease like coronary heart disease? I knew from my pathology, by the time you got to middle-age, virtually the entire population has coronary heart disease. How do you define incidence in a situation like that? Bradford Hill and his textbook (which I knew by heart) didn't distinguish between incidence and attack rate until well into the 1960s. Eventually, in 1947, I spent a week at Johns Hopkins with Lowell Reed and Margaret Merrill. I brought this problem to them. They knew nothing about coronary heart disease; it was very interesting. Eventually we agreed that tuberculosis was the only sort of model they could think of that might be helpful in terms of incidence. The only thing you could realistically go on was first clinical manifestation. Then there were endless discussions about what you are missing out, and what you are risking by going for this very late manifestation. This was long before talk about life-course influences on disease and that sort of thing. The words weren't there, the ideas weren't there—at least if they were, we didn't have them. So they were very exciting times. GDS: Which has been your most influential paper? JM: It has to be the physical activity paper.6 That was published in the Lancet at great length, which was a mistake. The Lancet adopted our MRC unit and had been very taken with the sort of things we studied during the war. We published everything in the Lancet. But that paper had no impact in this country at all on cardiology. The newspapers took it up. I had no idea how to handle that; they made a fool of me. But the Americans were very excited about it. Jim Watt, director of the [NIH] Heart Institute, flew over to see me. Our data were the first indication of something new relating to this epidemic. I was immediately inundated with invitations to come over to the States, etc. etc. It took years for British cardiology to become, you might say, politely interested, never mind supportive. GDS: Which has been your most under-appreciated paper? JM: The paper about minimum incomes for healthy living.7,8 You know the fox and the hedgehog. [“The fox knows many things, but the hedgehog knows one big thing” —Archilochus.] I am a two–headed hedgehog, if such a thing is conceivable. Exercise on one hand, and equality on the other (using equality as a general term). That paper arises out of this equality thing. GDS: At the start of the work on exercise, how did you decide what you wanted to research? JM: The hypothesis (if it was a hypothesis) was related to occupation. We studied a great variety of occupational groups—London Transport, notably, a great range of Civil Service occupations, the national union of teachers—to give us information on incidence and prevalence. We did all this on clerical labor; this was pre–computer. After one year, the first results we got from London Transport showed a striking difference between the bus drivers and bus conductors. I suppose, in one of the tensest moments of my professional life, we had to wait until we got comparable data from the Civil Service, in particular from the Post Office. It came out the same—we got the same difference between drivers and conductors that we got between clerical officers and postmen. So by then, we felt we were on to something. There was no question of rushing into print, even with a preliminary statement. We spent years in testing this before we dared to publish. We tried to do as many different studies as we could to confirm the hypothesis. And we only published it as a hypothesis, in 1953. It is inconceivable in modern days that we would just sit on this. We spent the best part of the next 10 years on this. Sometime in the 1950s, Henry Taylor said you have got to learn some exercise physiology. We sat in my hotel room for a solid day in Washington, and Taylor tutored me in the elements of exercise physiology. So then I wasn't just a sheer ignoramus, I was merely an average ignoramus. I have learned a lot from my friends, one way or another. GDS: Exercise came out as an important factor in those studies. What else were you investigating with respect to the coronary epidemic? JM: We quickly took up the measurements from clinical epidemiology, which was founded at the same time as we started our kind of work. Framingham started their follow–up. As soon as we could, we took their ideas and tested them out on the busmen, and sure enough, the bus drivers and bus conductors had different lipid profiles, very different blood pressure patterns, etc. Again and again it came down to differences in physical activity. Which of course was more and more interesting as I learned more about exercise physiology, and as the exercise physiologists began to take this up. GDS: As to the other main focus of your work, social inequalities and health, how did you start off researching that? JM: We didn't start, we continued it all the time. We did studies on different towns, for instance. We worked a lot on the Registrar General statistics.9–11 Speaking in all diffidence, when the Government set up the Black committee—and I had something to do with setting up the committee—I spent a lot on of time on the Black Report. In many ways it was amateurish. But in terms of social policy, social medicine, it's an important document. And it was unpopular too, taken very badly by the Government as you can imagine.12 GDS: Are there any ideas that you didn't take forward, that you now wish you had? JM: Violence. I was very keen to study violence. It's a major national failing, that epidemiological methods could really make some contribution to. But it was too difficult. I would have had to go into it much more seriously than I could with my resources, intellectual, and otherwise. I think today it remains a major problem. I am surprised that epidemiologists haven't taken it up. GDS: What are your interests outside of epidemiology? JM: I have always been interested in politics. I have been a paid-up member of the Labor Party since October 1926, when I was an undergraduate at Glasgow University. James Maxton was our minder; he kept in close touch with us. It was a great privilege to meet him; he was a wonderful man. I have at times have been active in politics, in general and public health terms. There are three kinds of public health: public health analysis, which we all do, public health advocacy, which most of us do, and public health activism. I used to teach my students the “3 As.” They are very difficult to keep apart. GDS: What has been epidemiology's most import contribution to society? JM: Through social medicine, we have made it clear that health and disease are social as well as biologic issues. The other thing is that, in terms of medicine and research, we have shifted the paradigm, we have established the importance of the population, alongside the clinic and the laboratory, in any serious discussion of etiology and natural history. Pioneers like Greenwood had very little impact, why I don't know. But by now it is accepted. In Kuhn's terms, this is a real paradigm shift. Now, the natural phenomenon is to study the epidemiology of everything under the sun. GDS: Do you have any predictions of what the future might hold for our field? JM: We are in for a tough time because of this tremendous overselling of the biologic. Genetic studies, molecular medicine, biobanks and all that—we are in for a tough time given the exaggerated hopes for all this, particularly in the short and medium term. On the other hand, and quite importantly, the RCT (randomized controlled trial) has taken over science. You can't talk about social policy nowadays without talking about RCTs. They haven't got a clue what's involved, and the limitations of RCTs, but they feel they must talk about them, to show their respectability. We haven't created a scientific language, a scientific methodology, in terms of social policy to compare with the RCT in its field. GDS: What is your assessment of the current state of health of epidemiology? JM: I am very worried about the reduced contacts with the problems of public health and social medicine, which are as great as ever, or greater. On the other hand the discipline itself is now very sophisticated, very elaborate. But of course, they're not making the kind of discoveries that were made in the past. We did the easy stuff. I mean, you don't get a disease like coronary heart disease presented to you. Major social trends, like violence, we just haven't contributed to. It would have been a natural progression, if we had gone on developing, instead of being taken over by the RCT school. GDS: What would be the single piece of advice you would give to a new epidemiologist starting their career? JM: I think you must come in with something else. You need stats, of course. In my time it was statistics or medicine. Nowadays it can be statistics, or medicine, or molecular science or sociology. I think the most important of these is sociology. It seems to me over the years, we were investigating this before we knew what it was. We discovered concepts that the sociologists had discovered years before. ABOUT THE INTERVIEWER GEORGE DAVEY SMITH is Professor of Clinical Epidemiology at the Department of Social Medicine, University of Bristol, UK. Jerry Morris was his informal doctoral thesis supervisor, and they have written on inequalities in health and exercise together. Davey Smith is firmly of the belief that Jerry’s Uses of Epidemiology is the most insightful epidemiological textbook that has been published. ACKNOWLEDGMENTS The editors are grateful to the London School of Hygiene and Tropical Medicine for making possible the video recording of this interview. Thanks to Judy Eshelman who transcribed the interview, and to Claire Snadden who assisted in obtaining supporting materials.FIGURE 1.: Jerry Morris, 2004.