Sunday, 11 April 2021

Britain is no longer a country for and says "Farewell" to its Brave and Brilliant, Prince of Public Health, Paul Cosford

Paul, who has died at the age of 57, had worked for Public Health England from its inception in 2012 and was familiar as its public face as Director for Health Protection until 2019, when he was forced to stand down after being diagnosed with terminal lung cancer two years before. He was born the son of Judith and Brian, in the Spring of 1963 in the market town of Thornbury in Gloucestershire as it emerged from the 'Big Freeze' of the winter of 1962-63. His secondary school was Exeter School, which had been founded and endowed as a grammar school for boys by wealthy Exeter merchants in the 1630s and was given the motto 'ΧΡΥΣΟΣ ΑΡΕΤΗΣ ΟΥΚ ΑΝΤΑΞΙΟΣ '- 'Gold is not worth more than virtue'. By the time Paul attended in 1974, the school was co-educational, direct-grant grammar school with most students paying fees.

He obviously excelled in his 'A' Level sciences and at the age of 18 in 1981 took himself off to St Mary's Hospital Medical School, Imperial College, London. In 2017 he told the pupils in his old school : "I chose to enter medicine because I wanted to help others and make a positive contribution to society" and of his career in public health he said : "Although I have not dealt with patients for 25 year, I take great pride in knowing the work we do is saving lives". Clearly, a brilliant student, he graduated after 6 years study with the joint degree of MBBS as a Bachelor of Medicine and Surgery in 1987.

As Dr Cosford he now followed a career in mental health, working with adults and those with severe mental illness in North West London in the poorer districts of Camden and Islington, which included children, families and people with learning disability. For the first time in his life it brought him into
contact with the realities of working class life and those with extreme social circumstances and to his credit, he continued to work on the health needs of London homeless to the end of his professional career. 

In 1990, at the age of 27, he became a Lecturer in Psychiatry at St Mary's Hospital Medical School. He stopped dealing with patients directly in 1992 and in his early thirties he was promoted to leadership and management roles in the NHS where he led programmes dealing with the problems of hospital infection and reducing the country's cases of TB. 
In 2006, at the age of 43 he began to increase his experience at the regional level as Medical Director of the East of England Strategic Health Authority (1), followed by the Regional Director of Public Health for the East of England. Here he developed successful strategies for reducing health inequalities and harm from tobacco and obesity. Then, in 2010, he moved to the national arena when he began working for the Health Protection Agency and then its successor, Public Health England.

Paul considered the biggest challenge in his career was dealing with the crisis caused by the 2014-16 outbreak of Ebola and in this he played a leading role in the response in Britain and West Africa. He said : "We closely followed the outbreak in West Africa and led the work to identify any cases and avoid the spread in Britain. In a separate UK emergency, we had to deal with an outbreak of poisoning of premature babies in maternity wards. Within 24 hours, we found the source of the poison, isolated it and treated the infected babies". He saw his role was to "consider the size and scientific aspects of the outbreak and ensure that the response was significant enough to maintain public and political confidence, without unduly alarming the public and causing panic".

In post as Director for Health Protection at Public Health England in 2018, he led its protection and emergency response to the Salisbury Novichok poisonings and advised the Government. In the early stages of the Coronavirus pandemic in 2020, he became a familiar public voice until his medical condition forced him to shield while infection rates were high. He found this hard, since he loved his job and wanted to continue to play his part. He said : "The strength of my reaction caught me by surprise – I was deeply upset. I have always considered myself fit and healthy. My way of responding to having an incurable cancer with a much-reduced life expectancy has largely been to keep calm and carry on, to live life as normally as possible including working, staying as physically active and mentally positive as I can, and spending time with those important to me, especially my family".

For Paul there was : "Nothing more fascinating than taking scientific advice, converting it into practical action and encouraging the public to understand and support the action". Nevertheless, he admitted : "I could no longer do justice to the intensity of work needed during major national incidents such as coronavirus. Nevertheless I feel privileged to be involved still through an emeritus role and able to help wherever I can as the nation responds to the present crisis".

In 2019 Paul was able to delivered a lecture at Chester University on the subject of 'The future of Infectious Diseases'.

He was both philosophical and courageous as he faced death in his country home with his wife and fellow doctor, Gillian. He said : "Perhaps it is the same for us all, whatever our age—if we know that we are approaching the end of our life, it is helpful to have a place of contemplation. I walk from the back door, along an old track and across the field that is the home of two familiar chestnut coloured horses. They raise their heads as I pass, and a poorly constructed wooden bench sits in the field beyond. It is perfectly situated for the view, which appears just as the path starts to descend a sandy ridge. Two rough planks, one to sit on, one for leaning, are fixed to the two decaying tree stumps that form its legs. It wobbles slightly but is strong enough for me to rest and ponder".

"I am not an old man, but like the bench I won’t last long, but I don’t rail against the world as I sit on the bench. I’ve seen enough people die younger and in worse circumstances for that. I do watch the world go through its familiar cycles, knowing that I won’t see many more. The inquisitive lambs of spring, full of life then suddenly disappearing as their short lives end in the abattoir. The crops, subtly changing colour through hues of verdant green, then replaced by the bare soil of the ploughed fields after harvest".

Last December, the broadcaster, Pru Leith invited Paul as a guest on the BBC Radio Today Programme, where she was acting as 'Guest Editor' and started the interview at 2m 15s into the programme :  She asked him about the bench and he revealed that it was a place to "think about some of the things that seem particularly important". He said that one of the things he had "spent time contemplating, is how you actually die and it seems to be the worry more than the fact that I'm going to die. We know, all of us, that we are going to die at some point, but the actual way that you die is quite scary and quite difficult to think through".

Paul said that he liked "the idea that I could have an extra phial of morphine in the fridge so that if everything just becomes too much and the symptoms can't be controlled, I'd have an option to use that in the last few days of life and accelerate things if that was the only way of getting things under control and maintaining any sense of life that I do have, as a reasonable quality. But that's not available within the law at the moment".

In lending his support to an 'Assisted Dying Inquiry' he said : "What I think we do need to do is to have a really clear view of what the problems are that people face as they come to the end of life and what people, who are dying, facing the end of life, actually want to happen. So I think it is important to have an 'information gathering'. What are the views of the palliative care geriatricians and other specialists ? What are the views of doctors as a whole ? Certainly, from my understanding, 80% of the public think this needs to be looked at and quite possibly a law change".

He went on "The dangers that people are worried about, it seems to me, come in 3 different ways. One is that because its legal it becomes an expectation that people have an assisted death. The second is that staff involved, the palliative care physicians involved might feel compelled to participate in assist dying when have a deeply personal view that this is the wrong thing to do. And the third is that peoples lives are sometimes different from the norm, whether its because of a disability or some other issue, that their life becomes devalued in some way".

He concluded "My view is that we need to do that information gathering, then we need a group of people who are expert in medicine, in the legal profession, in public opinion and so on to look at what the potential solutions are, to look at the experience in other countries Oregon, the Netherland and elsewhere and come up with a carefully thought through set of changes. I think its complicated, but I think its not beyond us to sort this out".

Writing in the blog, 'The Hippocratic Post', Paul said : "I was in a bookshop last month and my eye was caught by a book of poems. I am not an avid reader of poetry and haven’t written any since being at school. However, there was something about the style of writing that made me wonder if I could express a little of how it feels in a poem. With apologies to those of you who are experts in poetry, here is what I came up with. As with all poems it is best read slowly, and aloud to yourself if you can do so without looking too foolish".

Paul called his poem 'Scanxiety' and ended with : 

'So how to approach the coming three months                                                                                       Till time brings along the next scan?                                                                                               Honesty tells me I don’t have a clue                                                                                                          I guess I’ll just: keep calm, carry on.'

The poem perfectly expressed the philosophy he had now adopted and he said : "The longer I live with a “treatable but not curable” cancer the more I realise how much good there is in life that I can focus on today, this week, this month. The uncertainty that treatments might work for much longer than expected helps me to keep that focus. It allows me to keep calm and carry on".

"I have found it is empowering when you face death head on. It means you focus your attention on the really important things and it makes me appreciate this life more than ever. When people complain about growing old, as I used to as well, I reply that growing old is a privilege and one that I wish now I could have".

In the event, we must assume that at the end of his life Paul did not have that extra phial of morphine in his fridge to be used by him to alleviate his pain. Much of what he has said about his condition and treatment with its CT scans struck a chord with me. Having been diagnosed with bladder cancer, I underwent a course of chemotherapy and than had a cystectomy to remove my bladder along with a dozen lymph nodes, my prostate and appendix. At the same time the surgeon removed a short length of my colon to create my new ileal conduit. That was 5 years ago. I was lucky. Unlike Paul, my cancer hadn't metastasized and travelled to other parts of my body, like my liver.

Paul, enacted, in his professional life and as a force for good, his advice to others :       

"If you want to make a difference in life, influence those who are                                             around you"                                                                                                                                                                                                                                                                                                                                                     

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