Whose responsibility?

I%hl. IIIth. I.,,ml. (lUPl)8.4, ';'9-1()2

Whose Responsibility ? TItOMAS ANDERSON M,I)., I:.IL('.P.(I(I)IN.), I-.R.('.I ), ((II,AS.)

Ih'nry ~h'chalt Prc4b.~xm 0/" Puhlic l/ea/lh, University of Gla.wow I)c'p,¢rt,'m'nt o/I:'phk'miohJg.v au:l Preventive A,ledicin:', Ruchill tlmpi/a[, GhLWow, N. IV. Tilt I'lilt'~'qyt, o1" this forthright questiorl, as the introduction to our study period, has t_'nc<+tu-aged m+ Io t-,elicvc lhal n'iv contribution sl'lotild be at once, thoughtful perhaps-+ but ;.it the .~anlc time pro~ocali~.e. 111 trying to ttnsx,,,er the question I shall divide my talk into Ihroo t+~lrt,: a brief ~.nr\c.x' of the past to see if this has any lessons which may have \ a l u c for the l t l l t l r o : ;t C O t l l l l l e l l t a r \ Oll s o n i c aspects o f the problems of the present: aild lin;iliv ',t11 altcmpi Io ,,kclch lhc future as one pcrsoll sees it, There i<~ all arpuabtc proposition that the beneficial efl'ects of the iritroductiorl of the N<,lilicalion of Inl'cctious Diseases at the end of the 19th century may have had a deeplyharmftil el~h.',: tlpcnl niedical ihi;~king. Bv constructing a canoilical list o f crowd diseases \\hich \~crc the pI;.tgLICS of ihc time people were CllCOtlraged--hospital administrators, ph>,icians in general medicine, medical teachers, even perhaps clinicians themseh, es ,Hwciaii/ed in inik'ctious disease--to think that there was indeed a linite group of diseases \~ hich .:ould bc described as -Infectious l)iseascs". As one after another o~ these notitiable di.~ca,w~ ~ere brought under control it ~ a s very easy to conclude that here at least was one cl:aplcr of medicine \~ hich had been completed. Two thcets o f this may be mentioned. t-ir~t, the older of us Will recall that iri the early 1920"s it was decided to produce a volume ~hich \\ould \~rite up the linti] word on l)iphtheria. This volume, commissioned by the Medical Research (,\'ouncil, ~as tinally published in 1923 and was scarcely cold from the printing prcssc,~ \~hcn, i:l middle Europe. epidemics of diphtheria characterized by a high mortality despite the most adequate sere-therapy were being described. The puzzle was to be solved by the brilliant studies of" M c L e o d and Anderson from Leeds which showed that Cor.vnehacterium ¢liphtheriae was a more complex organism than the erudite microbiologists had suspected. And it might be added, is there any infectious diseasewhich has not been similarly reju~ enated ? ,,\s a restlli d iphiheria began a new epidemiological era. Second, it is interesting that the impact of British practice on India before the First W o r m War was to inculcate into the Indian scene a similar concept. The diseases which were feared by the British Authorities were smallpox and cholera. So that one could a 3'ear or two ago find, tbr example, in Madras a large hospital devoted tu the admission of smallpox and chickenpox while measles, diphtileria and even poliomyelitis could tiiil to find any specific a c c o m m o d a t i o n despite their prevalence and high mortality. This kind of thinking made new concepts slow o f acceptance. And it is still not a generally appreciated view that ihe pattern of infectious disegises in any community is a complex weaving which involves, of course, man and his bacterial and viral pathogens as important strands, mtt worked into the warp and w o o f are strong threads of environmental behaviour. That, indeed, the linal pattern of the fabric is dictated perhaps more by this environmental imposition than by the seemingly major threads of man and his pathogens. From this point of view the study of infectious disease must be seen as imposing a constant change of ~l)r Anderson's p:lper and tho~,c b', l)r~: Miller and Flev,'ecl were read in the S y m p o s i u m on "'The M o d e r n Man:igcnlcn~ of OM Pl~tguc::'" v, hich v~'as organized in 1970 hy ~hc Rc,~earch G r o u p of the S~cieiy. We hope ~o pubii~h ftlrtlv.'r pal,c',s f l o m ih[s mo,~l inicre'qing S3mpo,,ium in ¢)ur nexi two is~,ues, lid.,

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outlook: the pathogens of }esterday are replaced by new one.', which ~ere lorn~ert.~ disregarded: tkose of today ~ill .just as certainly disappear: and. not least important, di~l,mt almust forgotten conditions may impose ] modern hazard and surprise the st+phisticatcd community. It is correct that we should t~ach that infectious disease is a practical exercise in microbiology: but it is an exercise which takes place not in a test tube but iu an individual or a group of individuals :~hose response will be complicated by a whole range or" demographic, cultural, behavioural and genetic variables, many of which can onl,, he t'ullx appreciated by hindsight. A third aspect of the past is to recollect the relative simplicity of bacteriulog} up till perhaps the middle thirties, in nay visits to the London Count5. Council ttospital.,, in the early thirties t was often filled with envy o f the specialist bacteriological se, vices ,p+ailablc to the clinician, But, on rellection, I \vas conscious that the lahorator} disciplines in~po~,cd by Brownlee at Belvidere and Ruchill from the beginuing of the century which demanded that each medical officer ~.as responsible l\+r the bacteriological studics of his own p;.ttictlts had a profound etTect upon one's later development. Indeed one could claim not or~h that this method produced balanced clinicians but was the seed-bed ~hich encouraged the growth of some of our best epidemiologically minded microbiologists. It is a saddunin~ thought to me that the modern consultant in communicable disease can reach this eminence very often, I tear, without the period of laboratory discipline which I \xould claim is essential in this medical specialty+++more perhaps than in any other. This perusal of the past may be concluded by observing thal the pre-eminent: of the clinician in that period could not be,easily challenged. He could indeed achieve his eminence as a result of a closely integrated ~linical experience which ~as sometimes indeed almost uncanny and ahvays impressive. And moreover in these halcyon days he could somctime~ combine within himself the three r61es o f clinician, epidemiolngist and micro, bioh+gis~. The name of John Snow perhaps in'tmediately springs to mind ....even i!" hc could conduct his work and reach his conclusions before Pasteur had conceived the science of bacteriology. But the often repeated story of John Snow and the Broad Street Pump is u: sally told as if this were the end of the story. Sno~v's great work contains two other aspects pertinent to our discussion. His much more important conclusions were drawn, first, from his less well remembered controlled experiment in the area in which the domestic water was supplied by both the Lambeth and the Vauxhall Water Authorities and. second, by his then going on to condtlct "'laboratory" experiments u p o n the salinity of the water from eacL o f these supplies. The lesson to be learnt from S n o w - - p u t into its modern setting--is that the understanding of the behaviour of communicable disease :equires an intermingling of three disciplines ..... clinician, epidemiologist and microbiologist. And that each discipline imposes a more sophisticated approach than was necessary in the last century. Conspectus of the present position discloses a much more complex picture. But there may be no harm in a single person trying to underline from his owa experience the needs o f the three parts clinician, microbiologist and epidemiologist . . . . . of a communicable disease service. The recognition that each o f these areas must interlock and that each must work together with the mutual respect of participating partners is essential. So far as the clinician is concerned emphasis should be placed u p o n the importance of a properly designed senior registrar period. It is assumed that by this time he will already possess a membership o f one of the Royal Colleges and this will attest (a) his possession of a broadly based medical training and (b) his potential to become a specialist and consultant. In de.~ining his senior registrar training I believe that it should not be simply stated Hint he spend some time "'in an infectious disease unit". "l-hose who are concerned for the |'uture

Wt-IOSI; RIiSI~ONSIBI LITY ?

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of this clinical specially must be prepared to name tile units in which training is pern:h.ted and to enumerate tile requisites which these training units must possess. 1 would regard tile !kdlowing as essential: (i) Undergraduate and postgraduate teaching must be conducted in the unit. lit) At least weekly, internal teaching exercises of the nature of clinico-pathological conferences must be conducted. These must be attended by invited "visitors" such as specialist clinicians in related fields, general practitioners, microbiologists, pathologists and epidemiologists--so that the members of the unit are constantly cxpos,;d to abrasive criticism. There should be adequate audio-visual aids. tilt) It m u s t be regarded as part of the training that groups of cases should be the subject of delailed re'+iew which would form the subject of prepared communications. ~ix,) The unit must be engaged in ~.ontinuing research activities. (x) The unit should be so close to microbiological laboratories that daily meetings belwcen microbiologist, epidemiologist and clinician are a natural extension of work 111 |he \v;.tl'ds.

Finally. tlle need For consultants with special training and experience in communicable disease should be seen as a national need and as a consequence their deployment dhring senior registrar training should not be viewed in parochial terms. There should be a natioqal committee of selection which would include microbiologists and epidemiologists apd this committee should review tile candidate's progress and give necessary advice and encouragemen', at interxals during the training period. If the clinical speciality is to survive it must hc seen to make the s~mle intellectual demands as are required for the cardiologist or the neurolo,fisl But one final aspect of tile modern changed Infectious Diseases Unit must be remembered. It has ceased to be the major Watching Post which alerts the community. "['he great imporlance of tile Infectious Diseases hospital prior to 1950 was that it kept a finger on the pulse for lhe Medical Olt~cer of Health. To a limited extent this is still possible but only when tile specialist Communicable Disease Physician constantly adopts an attitude with his surrounding practitioners o f an anxiety to admit the bizarre---the non-notifiable diseases. For in the modern world, tile good general practitioner will prove the best Infectious Disease barometer. Microbiology has perhaps suffered most from its growing complexity. Increasingly the University Departments find their most exciting entertainment in the unravelling of the immunological minutiae or in the mysteries of" molecular biology. The excitement of epidemiologically-lbcussed microbiology is not fostered in such an environment, in England and Wales the chances of war dictated the conception o f a Public Health Laboratory Service which, grown to sturdy m a n h o o d , has attracted a remarkable team of persons who have constituted the real bones and muscles of the corrtmunicable disease service. But the very complexity of this discipline has had two effects. First, it is difficult to accept the shortterm worker whose need is more a savouring of the rigours of a bench discipline as a'mere part o f his preparation for a life-work at the bedside. The "'L" plate is only tolerable if it is se,:n as the beginning of a career structure. Second, the new bacteriological specialist feels best served by continual contact with his own specialist milieu; few occasions arise when the disciplines intermingle. So thai it is easy for the microbiologist to have little dayto-day contact with the clinician and vice versa. I am sure that it is no longer possible for either specialist to "'dabble" in the work o f the other. But continual familiarity with each other cart result in the clinician appreciating the inexactness of even the sternest laboratory discipline and the microbiologist sympathizing with the constraints which are often imposed on the clinician. The further away the laboratory bench is from the bedside the more the

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stature o f both clinician and microbiologist is studcnl, i have sceu this, fro example, in the diagnosis of tuberculous meningitis. In a coun!ry where cOlllal.'l \~,;1~ n~inimal a high proportion of the cases were 11o1 conlirmed bacteriologically. In Ruchill it ,,va,~ otlr pride that confirmation was 100 i!,, ; and this arose because cliniciam bacteriologist ;.tilt[ tcchuicia~3. vied with each other (in a friendly way) so that specimens ~ere properly .~ubmitted amt adequately examined. A happy marriage demands cohabitation .....and indeed in Scotland the legal emphasis is oil cohabitation I A further aspect of the complexities of both bacteriology and x irolog) lies m lhc xcrx specificity of their modern contribution to diagnosis. There is no disease I~m~adavs \~ hich can be adequately studied by the clinician who is not prepared ta co-opcra{e with to work alongside--the laboratory. And I would add to this b> averring thaL ahhough much additional knowledge can be acquired by co-operative clinical studies in diffcren! cemres so that large series of cases may be accumulated much learning can still be gained nm~l indeed be g a i n e d - - f r o m tile detailed co-operalixe studies by t~vo workers cliniciall and virologist, lbr exarnple.---of a small sample. My tinal partner in the triumvirate is the epidemiologist. I.tc in truth is expected to l~c the "'wonderman*'. For he must have a good clinical expcriellcc and a good ~orki,ng knowledge of the laboratory methods as well as the understandiilg of Ihe d isci plincs im posed by his own subject, Here again one must imagine that men with thi.~ lhc in their bell\ ~ ill not be numerous. For this reasoll I no longer see tile Medical Officers of Heahh as supply mg the c,eed. The magnitude o f the other tasks imposed upon them ll,ust rftake them temt to reD.gale the infectious diseases to an a~ea of low priority, l belic~ c that confirming SUl-Vei[lzmt.c of a wide variety o f non-notifiable infections and, indeed, other diseases which are nol infectious is essential in modern society, and that ¢tlis should no~ be cond~Jcted by a group of persons whose whole time is spent in the subject There i,,, a need. ihcrcf,.)rc i,~ create a national epidemiological service of experts continuously concerned wit h t he su r~ oillance of communicable disease. England and Wales is. I believe, too large to be co~ered by a single team no matter how distinguished. ~And I should pay tribute at once :.o the valuable contributions which have been made by the Colindale team.) But in this sophisticated world, with a more educated public, every outbreak should be seen to be under lhe supervision of a person or persons conversant with all the problems which each situation can produce and clearly authoritative in his pronouncements. Finally, as 1 try to gaze into the future I recognize that the m a n p o w e r scarcity ~ ill be most felt in the fields o f clinical experience and good surveillance. It seems almost certain that the epidemiologicat focus o f the Public Health Laboratory Service is now so tirmly lixed that it will continue to attract and train first class men, it is possible to foresee lhat the c a r e of the individual patient or o f small groups of cases by well-trained clinicians could be continued in a variety of ways. Epidemiology and surveillance like microbiology requires a special training--a special type o f individual who is attracted to the study of the population as his patient, Tile creation o f a speciality o f C o m m u n i t y Medicine will provide a base in which training and experience in epidemiology will be a paramount requirement. Teams o f "'epidemiologists" need not be wholly medical and indeed many of the tield workers could be drawn from other disciplines. To conclude, therefore, ! see the responsibility for the surveillance and epidemiological study o f the exotic and endemic infections as dependent upon primarily an expanded epidemiological service, supported by and integrated with a microbiological service whose prime concern is with infection in tile c o m m u n i t y and both o f these acting as stimulants of a clinical service which will perhaps increasingly be supplied by persons whose community concern is not uppermost.