Portal de Periódicos da CAPES

On Being 30

2003; Wiley; Volume: 57; Issue: 1 Linguagem: Inglês

10.1111/j.1365-2125.2004.02048.x

1365-2125

J K Aronson,

Health Systems, Economic Evaluations, Quality of Life

The first issue of the British Journal of Clinical Pharmacology was published 30 years ago, in February 1974, under the aegis of the British Pharmacological Society and the imprint of Macmillan Journals Limited. It was first published bimonthly, but has been published monthly since 1978. Since 1983 it has been published by Blackwell Scientific Publications (now Blackwell Publishing). It was not perhaps the best time to be embarking on a new financial venture. Worldwide inflation had led to large increases in the price of oil, precipitating an energy crisis. The response of the then British Prime Minister, Edward Heath, was to restrict workers to a three-day week, the imposition of which led to the downfall of his Tory Government and the accession to power of Harold Wilson and his Labour administration. Some commentators thought that British workers disliked Heath's policy because they were used to working a two-day week. Heath's problems were not made easier when the troubles in Northern Ireland spread to England, and the Tower of London and the Houses of Parliament were bombed. Ironically, Sean MacBride, who had been a militant member of the Irish Republican Army in his youth, was awarded the 1974 Nobel peace prize in company with the erstwhile Japanese Prime Minister, Eisaku Sato. And while they were in the mood, the Nobel prize committee awarded the literature crown to the Swedish novelist Eyvind Johnson, for his anti-Nazi writings, although they rather diluted the emphasis by awarding the prize jointly to Harry Edmund Martinson, for his poetic form of cosmic science fiction. Abroad things were no less turbulent. Drought and famine in Africa, floods in Bangladesh, and smallpox in India made the headlines. In the USA the Watergate scandal led to the resignation of President Nixon. In Cyprus Archbishop Makarios fled as Turkish forces invaded the island and extended their occupation of it from a relatively small barren enclave in the North to almost the whole of the island. And in Germany, Willy Brandt, the subject of ‘Democracy’, a recent play by Michael Frayn, resigned in the wake of a government scandal and was succeeded by Helmut Schmidt. Elsewhere, dictatorship suffered. In Greece, the military government that had illegally seized power in April 1967 was finally overthrown and President Karamanlis returned to power. The military coup d’état had increased the exposure in the English language of the word junta, later to be immortalized in a headline in the Sun newspaper during the war in the Falkland Islands, in punning reference to the Argentinian military government, ‘Stick it up your junta!’. And another military junta was paraded on the cinema screen in Costa-Gavras's film ‘Z’, which highlighted the murder in May 1967 of Gregorios Lambrakis, a Professor of Medicine and peace activist from Athens. In the world of science, space exploration proceeded with the US probe Mariner 10, which sent back to earth pictures of Mercury and Venus, and the Soviet Mars probes, which landed on Mars but failed to find evidence of either canals or life of any sort. India exploded a nuclear bomb, the sixth nation to do so. The Nobel prize for physics went to two British astronomers, Sir Martin Ryle and Antony Hewish, for their work in the field of radio astrophysics, which led, among other things, to the discovery and analysis of pulsars. A new subatomic particle was discovered, the psi meson, which consists of a charmed quark and a charmed antiquark. And the Nobel prize for Medicine or Physiology went to Albert Claude, Christian de Duve, and George Palade, for their work on the internal components of the cell. But even if 1974 was not the best of times (and paradise does keep on being postponed), nor was it the worst of times, at least not for the flourishing subject of clinical pharmacology. Since 1966, when Colin Dollery, then Lecturer in Clinical Therapeutics at the Postgraduate Medical School in the Hammersmith Hospital, had observed that ‘the study of drug treatment is not a highly regarded discipline’[1], the need for more clinical pharmacologists had been repeatedly stressed [2–5]. A 1969 report from a Committee of the Royal College of Physicians, chaired by Sir Cyril Clarke [6], had recognized that ‘Physicians with training in clinical pharmacology and therapeutics have an essential role to play in raising standards’, and regretted the fact that ‘considering its general significance, few training or career posts are available.’‘A priority’, the Committee declared, ‘should be the creation of regional clinical pharmacology units in each region with at least one consultant attached to each unit in the first place.’ Clarke's Committee called for the establishment of full-time clinical pharmacologists based in teaching hospitals or research institutes, and physicians with a special interest in clinical pharmacology to work in district general hospitals [7]. The numbers of posts that were declared to be necessary for the proper expansion of the subject made encouraging reading for this young clinician, about to qualify and embark on a career, as did the establishment of the Clinical Section of the British Pharmacological Society in January 1970 [8]. Moves were being made internationally too. In 1970 the World Health Organization had published a report [9] based on the conclusions of a study group that had met in late 1969, in order to discuss ‘the need to remedy the shortage of clinical pharmacologists that [is] impeding the implementation of the various WHO resolutions on therapeutic efficacy and safety of new drugs [and] to demarcate clearly the scope of the new discipline of clinical pharmacology.’ And in the USA a similar meeting was held in late 1970 [10], the conclusion being that ‘the number of clinical pharmacologists must be substantially increased in order to meet critical national needs in several areas’. The recommendation of the Royal College of Physicians that full-time posts for clinical pharmacologists be established in teaching hospitals was widely implemented. And the number of clinical pharmacologists employed by the pharmaceutical industry also increased [2, 5, 7], amidst calls for more liaison between academic departments and the industry [1, 7, 8]. However, the hope that clinical pharmacologists would also find their way into district general hospitals was not widely fulfilled, partly because of lack of funding and partly because clinical pharmacologists are for the most part general physicians. A hard-pressed hospital in need of, say, an endocrinologist, gastroenterologist, or cardiologist would not be likely to put a general physician cum clinical pharmacologist high on its list of priorities, although a few appointments of this sort were made. It was the French novelist and journalist Alphonse Karr who first remarked that ‘plus ça change, plus ç’est la même chose’, although, as is generally forgotten, he was talking about something quite specific, namely revolutions. In 1999, exactly 30 years on, the Royal College of Physicians again reported on the future of clinical pharmacology [11]. In recent years, academic clinical pharmacology has suffered from the same malaise that has afflicted academic medicine as a whole; the Calmanization of medical training, an increasingly dirigiste Government, and the Research Assessment Exercise are among the factors that have had an adverse effect, leading to inadequate funding, lack of appropriate facilities and infrastructure, lack of appropriately trained clinical scientists and a career structure to support them, and difficulties in translating basic science into high-quality clinical studies [12]. Meanwhile, in industry many pharmaceutical companies have closed their clinical pharmacology units and rely on contract research organizations, reducing the opportunities for hands-on training. And some units that have survived have not retained an identity, but have been broken into units subordinate to therapeutic groups. This time round the College Committee, chaired by Sir John Grimley Evans, called for ‘a co-ordinated approach to the recruitment, training and retention of clinical pharmacologists in the NHS and Universities in order to build on the specialty's acknowledged suc-cesses, . . . joint appointments between health authorities and trusts, . . . [and] a clear link . . . between NHS priorities, particularly with regard to drug utilization and expenditure, and appointments of consultants in clinical pharmacology and therapeutics.’ It also welcomed the joint initiative of the Association of the British Pharmaceutical Industry and the NHS Executive in instituting a national training scheme for clinical pharmacologists in the Specialist Registrar grade (now 24 in number) [13], reinforcing the view that it is important to train more clinical pharmacologists if new chemical entities are to be developed, appropriately introduced into clinical practice, and prescribed safely and effectively. And it welcomed improvements to the Calman scheme, whereby triple accreditation could be obtained in general medicine, clinical pharmacology, and another specialty (e.g. paediatrics, a much-needed initiative). ‘The specialty's acknowledged successes’ referred to in the College's report are many. Clinical pharmacologists contribute to the clinical care of patients (most are physicians in acute emergency medicine), to clinical toxicology, to public health issues (including pharmacoepidemiology), to drug safety (pharmacovigilance), and to the cost-effective use of medicines (pharmacoeconomics); they are mainstays of drug and therapeutics committees and often chair them; they teach undergraduates and train postgraduates; and they carry out basic and clinical research. They have played a major role, with clinical pharmacists and other specialists, in the construction of the new-style British National Formulary, first introduced in 1981, and have developed a national curriculum for undergraduate medical students [14–16] and a web site for continuing professional development [17]. Clinical pharmacologists have also played important roles in drug regulatory authorities. The Committee on Safety of Drugs, chaired by the then Professor of Therapeutics in Edinburgh, Sir Derrick Dunlop (and therefore also known as the Dunlop Committee), was established in 1963 in response to the thalidomide disaster [18]; it became the Committee on Safety of Medicines following the promulgation of the Medicines Act of 1968, which also led to the establishment of the Medicines Commission. The Medicines Control Agency (MCA), now the Medicines and Healthcare products Regulatory Agency (MHRA), since the recent amalgamation of the MCA with the Medical Devices Agency, was established in 1989; its European counterpart, the European Medicines Evaluation Agency (EMEA), in 1995; and the National Institute for Clinical Excellence (NICE) in 1999. Clinical pharmacologists have been and are active members, and often the Chairmen, of all of these committees and organizations, which would not function properly without them. Mae West thought that a man had more character in his face at 30 than at 20 and the Journal has certainly changed the character of its face over the last 30 years. Table 1 contrasts the contents of the first issue in 1974 with this, the first issue of 2004. Later this year we hope to publish a supplement celebrating the highlights of those 30 years. What is striking, clear even from this abbreviated comparison of only two issues of the Journal, is the way in which the Journal has become more eclectic over the years in its scope of topics. There are still gaps (immunology, for example, and paediatric clinical pharmacology), but the strength of the Journal is evident from the breadth of its coverage. Clinical pharmacologists have never been proprietorial about the use of drugs in man. The discipline covers the whole waterfront of medical specialties, and from the start they have encouraged members of other disciplines to develop their interests in drug therapy: ‘every physician should also be a clinical pharmacologist’[5]. There are in any case too few clinical pharmacologists for the involvement of others not to be encouraged, particularly if excellence in prescribing by an increasing number of prescribers [19] is to be a realistic goal. The spectrum of specialties represented in papers published in the Journal has broadened in the last 30 years (Table 2), and it is to be hoped that this is a sign that the influence of clinical pharmacologists on their colleagues in other disciplines is increasing. In another change of face, we are celebrating our thirtieth birthday with a new design, which we hope makes each manuscript more accessible, with important information obvious at a glance. Details about the corresponding author, keywords, and received and accepted dates have been moved into a graduated panel on the first page of each paper; tables now have a grey shaded background and are separated from the text by bold lines; references have been reformatted and standardized; and headings and subheadings have a more clearly-defined hierarchy. The typographical font is also new – Times New Roman instead of Bembo. Thirty is not a bad age to be. Socrates, according to Plato (The Republic, Book V), thought that a man was in his prime at the age of 30, and it was the age at which a man became eligible for jury service in ancient Athens. At 30 Honoré de Balzac published his first successful novel Les Chouans, e e cummings his first book of poetry, tulips and chimneys, Jerome K Jerome his best-seller Three Men in a Boat. Beethoven's great second period, the years during which he produced symphonies 2–5, the B flat piano concerto, the violin concerto, the triple concerto, the Appassionata sonata, the Rasumovsky quartets, and his only opera, Fidelio, began when at 30 he realized that his increasing deafness was becoming serious and wrote the Heiligenstadt Testament. And at 30 Picasso was inventing cubism with Georges Braque, who was only a year older. At 30 the Journal is in the full flush of its maturity, well placed to contribute significantly to the further developments in clinical pharmacology and practical drug therapy, the teaching of students, and the training of prescribers that will be required of the discipline as it continues to grow in strength. The mission statement of the British Pharmacological Society is ‘Promoting the disciplines of pharmacology and therapeutics and providing advice on standards of teaching and practice to policy makers.’ Although the specific subjects that feature in the Journal may have shifted over the years, the potential range of subjects has not changed. It is and will continue to be, according to the original stated scope of the Journal[20], ‘all aspects of drug therapy and human toxicology’.