Sunday, 18 February 2018

Brexit Britain is not a country which would have welcomed an old émigré called Walter Holland, its erstwhile and now forgotten 'Giant of Epidemiology'

In 2016, Lord Dubs, who came to Britain as a Jewish refugee on a Kindertransport from Czechoslovakia when he was seven in 1939, sponsored an amendment to the Immigration Act 2016 to offer unaccompanied refugee children safe passage to Britain amidst the European migrant crisis. Originally rejected by the House of Commons, the amendment was accepted by the Government following a second vote in favour by the Lords. In February 2017, the Home Office abandoned the scheme after accepting 350 out of the planned 3,000 child refugees.

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Walter Holland, who has died at the age of 88, whose passing has been scarce noticed with a brief tribute from King's College and the LSE and a handful of tweets, came to Britain as a refugee from Czechoslovakia in the same year as Lord Dubs, but at the age of 10, in 1939. In his adulthood he played a big part in the branch of medicine known as 'epidemiology' and has been instrumental in improving thousands of lives of British people.

Walter was born in 1929 in Teplice in the Sudetenland area of Czechoslovakia, the son Hertha and Henry, who, with his own father, was a successful Jewish businessmen who owned a very large wholesale business that sold cotton and woollen goods which was the largest wholesaler in the country. He recalled, as a boy, the violence and unrest fomented by Hitler and the Nazi Party based on his ever shriller demands that the Sudetenland should be returned to Germany : "Almost every weekend we would leave because of the riots that used to take place and go to the mountains, or somewhere like that, which was not very pleasant really."

When, in September 1938, Britain and France gave Hitler what he wanted at Munich and he annexed the Sudetenland, the family moved to Prague and then with the German occupation of the city the following year his father moved fast : "My father was Jewish and he had helped a large number of Germans in their escape from Germany before 1938. When Prague was taken over he left almost immediately, within 24 hours and within 6–12 hours of his departure the Gestapo came for him." 

His father had made his way to Britain and a few weeks later Walter and his mother followed, leaving behind his Grandfather who died from a heart attack in 1940 and Grandmother who died in the horrors of the Theresienstadt Concentration Camp, quite near to Teplice.

His father had managed to transfer funds to Britain before his escape and, when War between Britain and Germany broke out in 1939, was working for the electrical company British Thomson Houston in the Midlands. Walter himself, knowing "only a few words of English," went to a succession of English boarding schools, including Rugby, where he combined an interest in history with the sciences.

He recalled : "I think probably, my parents suggested that I would be more likely to earn a living if I did a scientific subject than a non-scientific subject, but I decided that medicine was of interest to me. I can’t say that it was altruism or my wish to do good. I think my interest was largely because I could see an application for the physics and chemistry, biology and maths that I was learning. Various other books about what doctors could do and did also fascinate me and that’s what really I wanted to do. And I was always brought up with the feeling that I also had a duty to repay society for what it had done to help me. And I think that also there was always a feeling of gratitude about how we had been received by this country so I felt I had some debt to repay."

Having successfully sat the Higher School Certificate, Walter was still too young to start his training as a doctor at St Thomas’ Hospital in London and so started working as a Research Assistant to Dr Tom Day, Reader in Pathology for a pound a week. From Day he learned about "the need for exactitude and for being careful and so on, so that I could understand what research was about."  He also developed his taste for : "the excitement of research. If you set up a particular experiment and it works and you see the things that you hoped that you would and you discover new structures. It was really the excitement of it and the need for patience, but at the end it paid off."

He later speculated : "I think that the question of hypothesis driven science was not common in the late 1940s. It was, ‘Let’s find out how something works.’ Not, ‘I think, that this is what is going to happen, let’s see if that’s right or wrong."

Having started his formal BSc studies and in recognition of his early promise, he was one of three students, of the sixty in his year, offered the opportunity to study for an 'intercalcate degree' and chose to insert 'physiology' into his studies. He later commented : "It was extremely instructive because it was just at the time that they were beginning to do open heart operations and we were the individuals who were asked by the cardiologists to do various estimations of blood gases because we’d used a Van Slyke machine. It was a very interesting 18 months."

Having graduated in 1954, Walter was required to serve his two years National Service in the RAF from 1954-56 and it was as an RAF doctor that he discovered the particular area of research to which he would devote a substantial portion of his professional life : respiratory disease. It was his first foree into epidemiology, the branch of medicine dealing with the incidence, distribution, and possible control of diseases and other factors relating to health.

His term of duty wasn't over when, in 1956,  he joined the Central Public Health Laboratory in Colindale in North London to work on testing a new vaccine developed by Glaxo for use against the respiratory illness, adenovirus. It proved to be fortuitous that the vaccine failed its safety tests because Glaxo forgot to switch the incubator off over Christmas and so the specimens were “fried” and the company offered him the opportunity to study Asian Flu, affecting S.E.Asia and expected to reach Britain in the winter of 1957. So he put aside the opportunity to work in the Institute of Aviation Medicine : "I decided that flu was a once in a lifetime opportunity whereas the physiology I could do anytime and so I stayed at Colindale."

With his non-hypothesis based approach he said : "The question posed for me was why did flu only appear when the weather got cold, in the winter months?  So we set up a system of surveillance to identify when the first cases of influenza reached this country." His boss at Colindale was Professor Corbett McDonald who was to carve a career as an occupational epidemiologist, whose work led to the universal recognition of the toxicity of asbestos.

As a result he visited : "all the RAF recruit training stations every 2 weeks and examined and took blood specimens from every recruit who was ill at the time. I hadn’t got the faintest idea of what epidemiology was, that was really where I learnt what it was about. I found it fascinating and very interesting."

He followed this up with an investigation of two outbreaks of Q Fever, one in the Isle of Man in Jurby in the Officers’ Training Camp where he "was able with reasonable certainty to show that it came from the officers having a smoke in a shepherds hut where the lambs had had their young." The other was at St Mawgan in Cornwall where he "was able with reasonable certainty to show that the infection can be spread from man to man, which had not been described before."

In 1957, at the age of 28, with his National Service over he returned to St Thomas' Hospital as a Clinical Lecturer in Medicine and conducted an epidemiological study of respiratory infections of patients in hospital. Two years later he moved to the London School of Hygiene and it was here that he served his apprenticeship when he worked with (left to right) : Sir Austin Bradford Hill, Richard Doll and Donald Reid, who "had a completely shared ethos on epidemiology and epidemiological research. They were all three very hard nosed, very, very good methodologists."

Walter then left Britain for a year to earn some decent money by filling a substantive post at Johns Hopkins University in the USA where he started a study to look at the effect of air pollution on respiratory disease and devised an investigation which examined post office and telephone van drivers in four different locations in Britain with different levels of air pollution, could be used in the States and whether it could demonstrate that the finding that respiratory disease was commoner in Britain than in the USA was true.

He returned to Britain in 1962 "with the idea of developing epidemiological research at St Thomas" and two years later he was placed in charge of the newly created 'Department of Clinical Epidemiology and Social Medicine' within the Department of Medicine.

He recalled : "On appointment as a Senior Lecturer I was given Honorary Consultant status and I continued to hold a clinic once a week for patients with chronic respiratory disease. That was the research field that I was studying and I felt it was important to maintain my clinical links." He taught his students on his clinical ward rounds, he thought it was crucial to be in touch with patients in order to learn.

At the same time he recruited statisticians and also social scientists from a non-medical backgrounds and developed a close relationship with the London School of Economics and Professor Richard Titmuss but confessed that his main interest remained "hard-nosed epidemiology."

Walter was working at a time when respiratory disease was one of the major causes of death and disability in Britain, problems of air pollution were manifest and he himself recorded that he had lived through the Great Smog in London in 1952 "so I knew what it was about." He was interested in why disease affected some and not others : "Part of my work in the Air Force had suggested to me that factors in early life could be important in making individuals more susceptible to develop chronic disease in later life. Nobody was really doing any work on that so that I thought that that was an interesting area for exploration."

The result was 'The Kent/Harrow Research Project' and working with the Medical Officers of Health in both areas and chose the districts he and his team would investigate by their environmental and social factor affecting populations of children. The Project lasted a total of seven years. In Harrow they started from birth and followed the children to the age of five and in Kent started at age five and went to age 14. He recalled working with his colleague John Colley, later Professor of Epidemiology at Bristol University : "I was then not married and neither was he, and so we each spent one evening a week visiting families in Harrow. That was considered normal. In my day, medical researchers would start at nine o’clock in the morning and usually work till nine, ten in the evening."

He reflected that in 1960s and early 1970s, there was no pressure to provide quick results : "The pressure was to provide results that were valid and good, not quick and dirty. And, in fact, studies that were quick and dirty were looked down upon by my generation, and still are." 

The results were published at the end of the 1970s and were tabulated with the use of early computers and confirmed the :

* influence of air pollution on the development of respiratory symptoms and respiratory function from birth.
* occurrence of illness in the first year of life was important in terms of predetermining the liability for respiratory infections in later life.
* importance of cigarette smoking by parents on respiratory illnesses in 1-year-olds,
* importance of social factors and deprivation on height and weight and on nutrition in school- aged children.
* growth of obesity, particularly in the deprived groups in Kent.

He noted that in the 1960s : " the realisation that health services research was important began to permeate." In 1967–1968 he created a Department of Health-funded unit, which indicated the Government's recognition of the importance of his work, linking public health and clinical medicine. In 1968 he became Britain's first Professor of Social Medicine.

The new unit was born out of the role he and his team played in the rebuilding of  St Thomas’ Hospital when they "were challenged to provide some ideas for doing this and we eventually said we’d do what we knew how to do, namely a population survey in Lambeth, find out what illnesses people had, what services they received and from that try to design the hospital."

The proposal to build a new hospital at Frimley on the basis of more outpatient facilities than in-patient facilities provided Walter with the opportunity to undertake his next research project which produced "unexpected findings."  The first involved the early discharge of patients : "We showed that actually the costs were almost exactly the same if you included the social costs, which everybody always excludes." Another was that : "the major cost of minor operations was not in the hospital but it was the time off work, which was the same whether you were in for 2 days or whether you were in for 7 days." 

He was now approached by the Medical Research Council if he would like to put for a proposal for a major study of ‘Smoking in School children.’ He found the reception of his study frustrating :
"We showed that children began to take up smoking before they went to secondary school, so that if you wanted to have an affect you had to do it in primary school. We suggested various ways for doing this. We were completly blocked by the educational establishment who were uninterested in doing anything among primary school children and who were unwilling to change their curriculum to take into account what we said, which was to teach that children had to take responsibility for their actions rather than how to learn to read and wrote only."

In addition, he came up against : "complete resistance by the local politicians and central politicians as well, to admit that children below the age of 11 could take up smoking! They didn’t want to believe this! This was so foreign to their ideas that they couldn’t understand that, perhaps, between 3 and 7 per cent of children below that age were already smoking when they entered secondary school."

With the advent of screening services in Britain in the 1970s, Walter and his team "were asked to do a large randomised control trial of multi-phasic screening, which was a sort of ‘MOT’ of everybody" and after 8 years had the results of the trial, which showed that essentially there was no improvement : that multi-phasic screening did not improve mortality or morbidity. As a result his findings were then accepted by the Department of Health and multi-phasic screening was not introduced into the NHS. He saw his groundbreaking paper on validation of medical screening procedures, published jointly with fellow epidemiologist Archie Cochrane in 1971, became a classic in the field.

Walter was interviewed about what he called 'the milieu of screening' in the 1960s in 2016 :

Walter said, with self-effacement : "I think that the things that I have done over the years have been concerned with the health of populations and with the factors that cause disease and improve health. Certainly some of the work, and certainly a greater proportion of the work that I did in my final years was to enable others to do that and provide them with the opportunities to do it rather than doing it myself."

Those 'things that he had done' included the publication of over 315 articles and books, his editorship of the Oxford Textbook of Public Health and the International Journal of Epidemiology from 1971-1977 and Presidency of the International Epidemiological Association from 1987-1990. In addition, he was he was President of the Faculty of Public Health and in 1992  was made a CBE in recognition of his contribution to the field.

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With grateful acknowledgement to Christopher Cook's 2004 interview with Walter, without which this post could not have been composed..

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