From Glyncorrwg to the Globe
Andy Haines worked as a GP and researcher before realising that the greatest thing he could do for human health was to reveal its critical connection to the health of our planet. In 1991, he was one of the first people to warn that the changes expected in the world’s climate would worsen health in many ways, writing in the BMJ that ‘more resources, and some fundamental changes in policy, are needed to avert potential catastrophe’. Recognition by LSHTM when awarded the 2022 Tyler Prize for Environmental Achievement
Professor Sir Andrew Paul Haines trained in general (family) practice with Dr Julian Tudor Hart in Glyncorrwg, Wales. He was a consultant in epidemiology in the Medical Research Council Epidemiology and Medical Care Unit between 1980 and 1987 and Professor of Primary Health Care at University College London from 1987 to 2000. He was Director of the London School of Hygiene & Tropical Medicine (LSHTM) for nearly 10 years until October 2010 and continues to work at LSHTM as Professor of Public Health and Primary Care. He has also worked internationally, including in Nepal, Jamaica and the USA. He has been Chair of the UK Medical Research Council Global Health Group and a member of the MRC Strategy Board and of many other national and international committees. For full details see Wikipedia
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Let’s bring you back to the very beginning, what started your interest in medicine?
Andy Haines: That’s an interesting story because no one in my family had been to university but a key person in our family’s life was our GP. She was a really outstanding GP. She worked alone and it was quite unusual to have a female GP at that stage. She delivered me in a nursing home. I gather I was a difficult delivery. And she looked after me in my childhood when I had pneumonia at home. I was so impressed by her. I think that consciously or subconsciously, I decided at an early age I really wanted to become a doctor, modelling myself partly on her. And one of the wonderful things was that after she retired and I started medicine, I went back to see her and I said, ‘I want to thank you because you really kind of shaped my life. And it was your wonderful example and your impact on my early life that influenced me.’
DMacA: You went on to medical school but then, in your postgraduate career, you went and worked with someone in South Wales, I believe….
AH: I had various jobs. I worked in Jamaica for a few months in the emergency department and I worked in Nepal on tuberculosis treatment. I did a few locums and I was a bit directionless. I felt quite inadequate and poorly trained and I decided I wanted to get more training. I was working as a locum registrar at Northwick Park Hospital in northwest London where there was a Medical Research Council unit, an epidemiology unit. I went to see the director, Tom Meade, and I said, ‘I’m sort of vaguely interested in research.
I don’t really know much about it, but I’d really like to do it.’ And he said, ‘I’ve got an interesting job for you, working with, Doctor Julian Tudor Hart in Glyncorrwg in South Wales, where he’s integrating epidemiology into general practice. And so I went to work there, did my GP traineeship there but also got a grounding in basic epidemiology. Julian had this great vision of integrating population health with clinical practice with individual patients in a very deprived community, a former mining community.
” Julian had this great vision of integrating population health with clinical practice with individual patients in a very deprived community, a former mining community…….Julian was a very charismatic person, a tremendous thinker, always thinking, always posing interesting questions, a tremendous intellectual leader.”
Dr Julian Tudor Hart
DMacA: Tell us a little more about your days in practice with Julian in Glyncorrwg.
AH: Julian was a very charismatic person, a tremendous thinker, always thinking, always posing interesting questions, a tremendous intellectual leader. In a way he was head and shoulders above many of the other more narrowly focused people that I worked with. There was a lot of clinical work involved. We were working in the health centre, but I was also on call and in the evenings I’d be on call, not just for that practice, but also neighbouring practices. You’d be driving up and down the valleys, dealing with a whole range of different problems and you’re quite isolated so you had to think quite carefully whether to send someone into a hospital or not.
The other thing that was really striking was that many internationally renowned people were making their way to his door to Glyncorrwg. People would turn up from all over the world wanting to understand and hear about the work that he was doing. And he was a very early exponent of involving the whole community, and involving the patient, so we had a patient committee. He was very open in terms of communicating with the whole population. And of course, as you would probably recall, he was successful in measuring the blood pressure of the whole population. In fact, the last patient, the one person in the village that he hadn’t measured, he eventually cornered him and said, ‘I want to measure your blood pressure. You’re the only person who has no blood pressure measured.’ And very reluctantly, the man sat down and the blood pressure was something like 200 over 120 and he was completely asymptomatic. That really opened my eyes about how to integrate preventive care into the busy clinical practice workload.
DMacA: That relationship between Tom Meade and the MRC with general practice, that was way ahead of its time.
AH: It was indeed.
DMacA: When did you move towards epidemiology?
AH: Well, I think it was really working with Julian. Working in Nepal, of course, I’d seen a lot of tuberculosis in the clinic. It was all happening in the community and I wanted to get out into the community and case find. But that wasn’t possible, we didn’t have the resources. But in working with Julian, he very clearly indicated the practical uses of epidemiology and how you could integrate it with clinical medicine. So that very much fostered my interest in epidemiology as a scientific discipline. When I went back to Northwick Park in London I worked with Tom Meade on the Northwick Park Heart study, which was looking at the role of the clotting factors in the haemostatic system in heart disease. But, of course, being a GP at heart I wanted to spread my wings a bit and to integrate epidemiology into primary care. So when I got a practice in Harlesden in north west London, on a housing estate, I started to take on new partners and integrate research into the very busy clinical setting. We were doing studies looking at, for example, the epidemiology of middle ear effusions at one point because I was intrigued by that. And we found a lot of middle ear effusions in children who were apparently normal. So we knew it was a spectrum. And we did a whole host of other studies. We did a lot of work, particularly with the late Professor Paul Wallace. on detecting heavy drinkers in general practice and intervening and showing that even a brief intervention by a GP could influence the biochemistry, what people said they drank, and the objective indicators. There was a whole range of different studies that we got interested in, not just describing patterns of ill health, but also intervening, using mainly many randomized trials, not with drugs so much but more with behavioural interventions.
“I was very much influenced, emotionally also, by the testimonies of the Hiroshima survivors and the fact that they had had the courage and the fortitude to recover from their extraordinary experience.”
Image taken from an article by Taras Young which you can access at the Wellcome Collection
DMacA: You were involved in another organization, which nowadays people may have forgotten about, the medical campaign against nuclear war. That was a very interesting time.
AH: It was indeed. And, of course, we’re now returning to a time of great international tension and almost back into the Cold War and in many ways, almost a hot war. In the early 1980s I worked in California for a year on sabbatical from the MRC. When I was there I became very aware of the nuclear tensions and Cold War. In 1982, I think it was, there was a meeting at University College London, an inaugural meeting to set up something called the Medical Campaign Against Nuclear Weapons, which was the voice of health professionals speaking out. I was very much influenced, emotionally also, by the testimonies of the Hiroshima survivors and the fact that they had had the courage and the fortitude to recover from their extraordinary experience. Seeing some of those photos of Hiroshima and Nagasaki really made it very clear to me that as a health professional I had a duty to speak out. We couldn’t just accept the tensions of the Cold War, we had to also try to communicate with, what were then our Soviet counterparts. Very soon after that I was invited to a meeting in Airlie House, in Washington, where a group of physicians from the west met with Russian physicians. That was organized by the famous cardiologist Bernie Lown who worked with Dr. Evgeni Chazov, who was Brezhnev’s personal physician and a cardiologist. They collaborated on cardiological research and were able to use that as a basis for overcoming some of the incredible distrust and sometimes very dangerous levels of confrontation. We were able to go to the USSR, for example, and speak to people about nuclear war because one of the criticisms at the time was that the Russians knew nothing about all the evidence coming to us in the west and they were being told that they could win a nuclear war. We were able to speak at meetings which were televised and we could speak openly about the medical effects of nuclear weapons. We tried to keep it very medical. And that’s how the International Physicians for the Prevention of Nuclear War was founded, which was awarded the Nobel Peace Prize in 1985.
Sadly, of course, we didn’t complete the job. We weren’t able to. Once the Reagan- Gorbachev summit occurred, everyone thought the problem would be solved. But, of course the weapons were never abolished. And so now we’re back in a very dangerous situation.
Climate Action: Protecting the right to health. Read more from LSHTM
https://planetary-health.co/sir-andy-haines
DMacA: Let’s bring you back to the academic track and the London School of Health and Tropical Medicine.Tell us how that evolved.
AH: I was in practice and I was a professor at University College London, the inaugural professor in primary health care, and was quite happy in my work. I also had a three year part time position with the NHS Executive, as Regional Director of Research and Development, which I enjoyed very much. But, around about 2000, I had a call from a colleague who said that the London School of Hygiene and Tropical Medicine were looking for a new Director, and they wanted to appoint someone from outside the school. I’d worked to quite a high level in the NHS and had also worked W.H.O. and internationally, and the selection process was interesting. My boss was Lynda Chalker, Baroness Chalker, who was Thatcher’s longest serving minister and a tremendously committed person in terms of international development. I wouldn’t say that our politics would necessarily always agree but I’m a tremendous fan of Lynda Chalker. And it did show me how people, whom you may think are different politically, can work very constructively together as long as there is mutual respect. Lynda has a tremendous commitment to improving development in Africa so it was, actually, a very positive relationship. And she was, in a sense, my boss, because she was the chair of the board, which ultimately appoints the director.
I did two terms at the London School and then decided it was time to step down because I wanted to focus on what has become my major concern now, climate change, health and environmental change more generally, and the impact that’s having on human health and how that will increasingly make it difficult to achieve good health in the future. That’s my focus now, documenting that, and also thinking about solutions.
DMacA: Before we move on to climate change, talk a little about your international work because you’ve had remarkable achievements in primary care, particularly internationally.
AH: Well, I never really practiced in primary care Internationally. My work as a young doctor was in TB, and in a vertical program. But, at University College London, we had an opportunity to run an international course, which attracted GP’s from many parts of the world. I worked with my now wife, Anita Berlin, who was a major leader in those international courses. And, because of her language skills, she’s particularly linked with the Spanish speaking world. But I also had the great good fortune to meet Carlos Dora who became quite senior in W.H.O. He was a primary care physician from Brazil. He actually came and worked in my practice for a few months in the north London and he invited me to Brazil. That was the beginning of a long standing program of interchange with colleagues, particularly in Rio Grande do Sul, which is in the southern part of Brazil, closer to Argentina.
But I was very fortunate because I got in at the beginning of the Programa Saúde da Família, which is a family health program of Brazil, and was able to visit Brasilia on many occasions, talk to many Brazilian colleagues about the wonderful work they were doing, often in the favela communities of Brazil. And I realized very early on that it was a two way process. It wasn’t just us telling them how to run things because they had a lot of very good examples of excellent practice for us, particularly the engagement of the community, which I think is where British primary care still lags behind. And one of the things that really impressed me was the use of community health workers. These were people who, with only six weeks training but using standard protocols, would visit in the community. They’d have about 150 families or so on their books and they would visit every month. They were like the eyes and ears of the family doctor in the community so the team was made of the doctor, the nurse and the community health workers. I found this to be a very powerful model. And it’s a wonderful bridge between the primary health care model that you see in Africa, where they don’t have enough doctors, and the very professionalized model we have in the UK and elsewhere in high income countries. I felt that the UK could learn a lot from that. In fact, I still do.
When I was in general practice, I often wished I’d had community health workers who could visit the people I never had time to do with sufficient frequency. They would know them better than I could ever know them, and could communicate to me whether things needed addressing, whether someone might be declining or might need a particular input, and it would have greatly magnified the kind of reach of primary care. And I still think that’s a valid comment today.
https://planetary-health.co/sir-andy-haines
DMacA: And finally, let me ask you about your real passion at the moment, which is climate change which of course, which was recently recognized with the Tyler Prize. Talk to us a little bit about that.
AH: In the late 1980s I began to be aware of this idea of climate change and I had this feeling very early on that it must affect human health because I remembered those ancient treatises of Hippocrates on Airs, Waters, and Places, which I never actually read, but I thought if Hippocrates thought environment impacted human health thousands of years ago, and I’ve seen it myself as I’ve worked in different countries where there are very different disease patterns, climate change must affect human health. And, when I started writing, and nobody else was writing, I wrote, a leader in the BMJ saying if we don’t do something about this, climate change could have potentially catastrophic effects so we need to act. And of course, that meant reducing fossil fuel combustion and also making our food systems more sustainable because they also contribute about 25-30% of greenhouse gas emissions.
At that time, really no one else was interested apart from a guy called Tony Mc Michael, who was a brilliant professor from Australia who eventually wrote a book called Planetary Overload, published in 1993, which was a preeminent and very visionary piece of work. And he and I also did work for the World Health Organization, starting to put together the evidence on climate change and health. Nobody wanted to fund it in terms of research so a lot of it was opinion pieces or pulling together data from different sources. But over the years its become much more accepted that there would be, and there are, increasingly effects of climate change on human health. And now we’re focusing very much on solutions. And there were two types of solutions: Adaptation- adapting to the change that we can’t prevent, and Mitigation- cutting greenhouse gases. In recent years I’ve been very much involved with documenting the benefits of moving towards a net zero carbon economy with reduced air pollution, improved access to healthy diets, more physical activity through more sustainable transport systems, and of course, the health care system itself, which we recognize now is responsible for about 5% of emissions.
So in delivering health care, we’re also making climate change worse. There’s also an important role there for the health care system, and that’s very much my focus at the moment. And more broadly, in 2015 I was asked by The Lancet and the Rockefeller Foundation to chair the Planetary Health Commission and that looked more broadly than climate change at this concept called planetary boundaries. At that time there were seven known planetary boundaries and now there are there are nine: fresh water and biodiversity, novel entities, pollutants, aerosols and so on. The problem is that human society has breached six of the nine planetary boundaries due to the inequitable patterns of consumption. So, we have to change consumption patterns very quickly, develop much more adaptable resilient health care and other systems, but also achieve human progress at much lower levels of environmental footprint than we do currently. And that’s going to be a big challenge, a big political challenge, a technological challenge and a behavioural challenge, but one which I’m a very, concerned with at the moment.
DMacA: You started off by telling us you had a difficult birth and how you kept the doctors on their toes from the very beginning. And you certainly have throughout your life. Thank you on behalf of all of us for all your work and thinking deeply about the problems that are facing us.
