To: Retort Via: PT Jerry Morris: Obituary (May 6, 1910 - October 27, 2009) I just was informed of the very sad news, by my colleague George Davey Smith, that Jerry Morris died yesterday, at the age of 99. Jerry played a critical role in the development of social epidemiology in the aftermath of World War II , including the 1980 UK Black Report, and who was, until the end, vitally engaged in work on understanding and rectifying health inequities. We all have lost someone who was remarkable and played a key and influential role for over a half-century in moving forward analysis and societal action linking issues of social justice and public health. As Morris forcefully argued in one of his articles published in 2007 (!), titled on 'Defining a minimum income for healthy living' [Morris et al, Int J Epidemiol 2007;36:1300-07], such work is 'directly in the tradition since World War II and the establishment of WHO for official acceptance of attainable levels of health as a human right and a prime goal of society.' Below I provide two recent accounts of his life -- one based on an interview conducted in 2004 by George Davey Smith, the other a newspaper article published this past September. For assessments on the impact of Jerry's work, especially his ground-breaking 1957 text "Uses of Epidemiology," see: -- Davey Smith G. The uses of 'The Uses of Epidemiology'. Int J Epidemiol. 2001;30:1146-1155. -- Krieger N. Ways of asking and ways of living: reflections on the 50th anniversary of Morris' ever-useful Uses of Epidemiology. Int J Epidemiol 2007; 36:1173-1180. May we all
recognize and honor the passing of someone vital to all of our work in public
health dedicated to promoting health equity and opposing the pernicious
effects of social injustice on health and well-being more broadly. October 28, 2009 Jerry Morris was born on May 6, 1910, in Liverpool, England. He studied medicine at University of Glasgow, qualifying in1934 and obtaining his membership in the Royal College of Physicians in1939. He served in the Royal Army Medical Corps from 1941 to 1946,mainly in India and Burma. During the war, Morris published a series ofinfluential papers on the epidemiology of juvenile rheumatism andpeptic ulcer together with the sociologist Richard Titmuss, which tooka then-novel social view of disease causation. He received his firstformal training in epidemiology at the London School of Hygiene and Tropical Medicine, where he won the Chadwick prize in 1947. In 1948, hebecame Director of a new Medical Research Council Social Medicine Unit,where he remained until his official retirement in 1975. There heestablished a series of cohort studies on physical activity andcoronary heart disease. In 1957, he published his widely read textbook Uses of Epidemiology,one of the first books on non-infectious disease epidemiology. In thelate 1970s, Morris served on the influential Black committee,established by the Labor government to investigate the persistentsocial class inequalities in health. His work on both exercise andsocial inequalities continues unabated. Further details on his life andwork are available in a symposium held to celebrate his 90th birthday.[1-3] INTERVIEW GDS: Few people start with the intent of becoming an
epidemiologist. Can you describe your path into epidemiology? JM: As a young medical graduate, I was already into rheumatic heart disease, which I adopted as my favorite problem. I was influenced by the patients I had seen at University College Hospital. There were a lot of social connections with rheumatic heart disease. So, I started, quite ignorantly, trying to get a community picture of it, long before I had heard of epidemiology. I was soon analyzing Registrar General statistics on mortality from heart disease among children in relation to social conditions, and so forth. I was working with Richard Titmuss; the first paper we produced together was on the social epidemiology of juvenile rheumatism and appeared in the Lancet in the summer of 1942.4 So I came into epidemiology through social medicine and public health. Epidemiology was obviously the technique, the methodology, the approach that I needed. GDS:
Were you working clinically? JM: I
worked clinically right through. I qualified in 1934, and did clinical work for
5 years. I enrolled [at LSHTM] for the DPH in September 1939, but then other
things were happening. I picked up 5 more years of clinical medicine during the
war, then did the Diploma inPublic Health here in 1946. GDS:
What do you think is the difference between epidemiology as it was practiced
when you started your career and how it is today? JM: It
is entirely different. Today epidemiology is a mature science, withjournals,
and textbooks, and university degrees, and universitydepartments. It's
commonplace to have an epidemiological aspect withinclinical articles. In my
time there was nothing like this. We were creating epidemiology as we went
along. There was a tiny handful of us.I suppose you might say that nowadays,
epidemiology is a major industry-huge numbers of talented people-and it is
universally accepted. GDS:
Whom would you single out as having the strongest influence on your career? JM:I
suppose I must say Edward Mellanby, the Secretary of the MRC (Medical Research
Council), who out of the blue, on the basis of what I had published, and what I
suppose he picked up from his pals, invited me to set up a Social Medicine unit. GDS:
Who do think of being the 2 or 3 most important epidemiologists during your
lifetime? JM:Major
Greenwood. I read everything he published. Goldberger, when I discovered him.
Bradford Hill, I suppose, although he was mainly statistical. I would think
these three. GDS:
What do you see as Greenwood's contribution? JM:He
showed how you could tackle problems in cancer from the populationpoint of
view, although in fact he contributed very little that wasreally pioneering. He
wrote so beautifully, it made one feel inferior. His Latin and Greek quotations
came out quite spontaneously. He was very kind to me. I remember the very first
job I did, a job in Nottingham as physician to the City Council. They wanted to
make an examination of all the Council workers. I remember going to see
Major Greenwood. I didn't know him, and he kindly agreed to see me. We had along
discussion about the sort of things to look for. It was a great experience. GDS:
You mentioned Goldberger, what do you think his contribution was? JM:Well
pellagra - including the experimental work. He wrote so beautifully,quite
unappreciated in this country; I cannot remember now how I got ahold of him.
Well, Goldberger and Sydenstriker I suppose; Sydenstriker was the more deliberately
social-medical of the two, I would say. But these people had very little impact
on medicine as a whole, and how medicine should tackle problems. I
more or less started from scratch in terms of establishing how coronary
heart disease must be looked at in population terms, as well as in clinical terms
and in laboratory terms. The very first observation we made on coronary heart
disease was this difference between bus drivers and bus conductors. The main
difference there was sudden death [in the bus drivers] as the manifestation of
coronary heart disease. How on earth do you pick this up any other way than
through epidemiology? I was already in touch with the London Hospital-the
biggest cardiologicalpractice in Britain, maybe Europe, with these remarkable
post mortem data on atheroma.5 When I
was at the London, with this huge cardiology practice ever since James MacKenzie
was there, it struck me that we never saw a ruptured heart. According to the
textbooks this is a recognized complication, and then it suddenly struck me that
you wouldn't expect it in the wards, just at post mortem. So I phoned up the
coroner's pathologist who covered the same district as the London hospital, and
I said hullo, what is going on? I never see a ruptured heart. And he said, I get
two a week. I
showed all of this to Himmsworth,secretary of the MRC, my boss in effect. He
insisted that I must showthese data to Sir John McMichael, the leader, the
Fueher, of clinicalscience at Hammersmith, where the brightest physicians from
all overthe world used to come to do postgraduate work. I remember
showingMcMichael all of this, and he said, rubbish. That was it. Wewere
very fortunate, compared with you people. When we came out of thewar, there
were three major epidemic diseases with virtually unknowncauses: coronary heart
disease, lung cancer, and peptic ulcer. Therethey were, just waiting. Because
of my interest in heart disease, Iwent into coronary heart disease. Its
etiology was unknown, little bitsand pieces about biochemistry, about diet, but
nothing known. No literature - a wonderful situation! You could go to the Royal
Society of Medicine library and read the literature before you had tea, just leaving
some German paper to be translated. We were starting from scratch. Nothing like
that now. GDS:
I guess lung cancer brings us to Bradford Hill as your third most important
epidemiologist during your lifetime. JM:The
first methodological problem I had to grapple with in 1947 was incidence. How do
you define incidence of a disease like coronary heart disease? I knew from my
pathology, by the time you got to middle-age, virtually the entire population
has coronary heart disease. How do you define incidence in a situation like
that? Bradford Hill and his textbook (which I knew by heart) didn't distinguish
between incidenceand attack rate until well into the 1960s. Eventually,in
1947, I spent a week at Johns Hopkins with Lowell Reed and Margaret Merrill. I
brought this problem to them. They knew nothing about coronary heart disease; it
was very interesting. Eventually we agreed that tuberculosis was the only sort
of model they could think of that might be helpful in terms of incidence. The
only thing you could realistically go on was first clinical manifestation. Then
there were endless discussions about what you are missing out, and what you
are risking by going for this very late manifestation. This was long before talk
about life-course influences on disease and that sort of thing.The words
weren't there, the ideas weren't there - at least if they were, we didn't have
them. So they were very exciting times. GDS:
Which has been your most influential paper? JM:
It has to be the physical activity paper.6 That was published in the Lancet at
great length, which was a mistake. The Lancet adopted our MRC unit and had been
very taken with the sort of things we studied during the war. We published
everything in the Lancet. But that paper had no impact in this country at all on
cardiology. The newspapers took it up. I had no idea how to handle that; they
made a fool of me. But
the Americans were very excited about it. Jim Watt, director of the [NIH] Heart
Institute, flew over to see me. Our data were the first indication of something
new relating to this epidemic. I was immediately inundated with invitations to
come over to the States, etc. etc. It took years for British cardiology
to become, you might say, politely interested, never mind supportive. GDS:
Which has been your most under-appreciated paper? JM:
The paper about minimum incomes for healthy living.7,8 You know the fox and the
hedgehog. [The fox knows many things, but the hedgehog knows one big thing
- Archilochus.] I am a two-headed hedgehog, if such a thing is conceivable.
Exercise on one hand, and equality on the other (using equality as a general
term). That paper arises out of this equality thing. GDS:
At the start of the work on exercise, how did you decide what you wanted to
research? JM:The
hypothesis (if it was a hypothesis) was related to occupation. We studied a
great variety of occupational groups - London Transport, notably, a great range of
Civil Service occupations, the national union of teachers - to give us information
on incidence and prevalence. We did all this on clerical labor; this was
pre-computer. After one
year, the first results we got from London Transport showed a striking
difference between the bus drivers and bus conductors. I suppose, in one of the
tensest moments of my professional life, we had to wait until we got comparable
data from the Civil Service, in particular from the Post Office. It came out the
same - we got the samedifference between drivers and conductors that we got
between clerical officers and postmen. So by then, we felt we were on to
something. There was
no question of rushing into print, even with a preliminary statement. We spent
years in testing this before we dared to publish. We tried to do as many
different studies as we could to confirm the hypothesis. And we only published it
as a hypothesis, in 1953. It isinconceivable in modern days that we would just
sit on this. We spent
the best part of the next 10 years on this. Sometime in the1950s, Henry Taylor
said you have got to learn some exercise physiology. We sat in my hotel room for
a solid day in Washington, and Taylor tutored me in the elements of exercise
physiology. So then I wasn't just a sheer ignoramus, I was merely an average
ignoramus. I have learned a lot from my friends, one way or another. GDS: Exercise
came out as an important factor in those studies. What elsewere you
investigating with respect to the coronary epidemic? JM: We
quickly took up the measurements from clinical epidemiology, which was founded
at the same time as we started our kind of work. Framingham started their
follow-up. As soon as we could, we took their ideas and tested them out on the
busmen, and sure enough, the bus drivers and bus conductors had different lipid
profiles, very different blood pressure patterns, etc. Again and again it came
down to differences in physical activity. Which of course was more and more
interesting as I learned more about exercise physiology, and as the exercise
physiologists began to take this up. GDS:
As to the other main focus of your work, social inequalities and health, how
did you start off researching that? JM:We
didn't start, we continued it all the time. We did studies on different towns,
for instance. We worked a lot on the Registrar General statistics.9-11 Speaking
in all diffidence, when the Government set up the Black committee -and I had
something to do with setting up the committee - Ispent a lot on of time on the
Black Report. In many ways it was amateurish. But in terms of social policy,
social medicine, it's an important document. And it was unpopular too, taken
very badly by the Government as you can imagine.12 GDS:
Are there any ideas that you didn't take forward, that you now wish you had? JM: Violence.
I was very keen to study violence. It's a major national failing, that
epidemiological methods could really make some contribution to. But it was too
difficult. I would have had to go intoit much more seriously than I could with
my resources, intellectual and otherwise. I think today it remains a major
problem. I am surprised that epidemiologists haven't taken it up. GDS:
What are your interests outside of epidemiology? JM:I
have always been interested in politics. I have been a paid-up member of the
Labor Party since October 1926, when I was an undergraduate at Glasgow
University. James Maxton was our minder; he kept in close touch with us. It was
a great privilege to meet him; he was a wonderful man. I have
at times have been active in politics, in general and public health terms. There
are three kinds of public health: public health analysis, which we all do,
public health advocacy, which most of us do, and public health activism. I used
to teach my students the 3 As. They are very difficult to keep apart. GDS:
What has been epidemiology's most import contribution to society? JM: Through
social medicine, we have made it clear that health and disease are social as
well as biologic issues. The other thing is that, in terms of medicine and
research, we have shifted the paradigm, we have established the importance of
the population, alongside the clinic and the laboratory, in any serious
discussion of etiology and natural history. Pioneers like Greenwood had very
little impact, why I don't know. But by now it is accepted. In Kuhn's terms,
this is a real paradigm shift. Now, the natural phenomenon is to study the epidemiology
of everything under the sun. GDS:
Do you have any predictions of what the future might hold for our field? JM: We
are in for a tough time because of this tremendous overselling of the biologic.
Genetic studies, molecular medicine, biobanks and all that - we are in for a tough
time given the exaggerated hopes for all this, particularly in the short and
medium term. On the other hand, and quite importantly, the RCT (randomized
controlled trial) has taken over science. You can't talk about social policy
nowadays without talking about RCTs. They haven't got a clue what's involved,
and the limitations of RCTs, but they feel they must talk about them, to
show their respectability. We haven't created a scientific language, ascientific
methodology, in terms of social policy to compare with the RCT in its field. GDS:
What is your assessment of the current state of health of epidemiology? JM: I
am very worried about the reduced contacts with the problems of public health
and social medicine, which are as great as ever, or greater. On the other hand
the discipline itself is now very sophisticated, very elaborate. But of course,
they're not making the kind of discoveries that were made in the past. We did
the easy stuff. I mean, you don't get a disease like coronary heart disease
presented to you. Major social trends, like violence, we just haven't
contributed to. It would have been a natural progression, if we had gone
ondeveloping, instead of being taken over by the RCT school. GDS:
What would be the single piece of advice you would give to a new epidemiologist
starting their career? JM: I
think you must come in with something else. You need stats, of course. In my
time it was statistics or medicine. Nowadays it can be statistics, or medicine,
or molecular science or sociology. I think the most important of these is
sociology. It seems to me over the years, we were investigating this before we
knew what it was. We discovered concepts that the sociologists had discovered
years before. REFERENCES 1. Berridge V. Celebration: Jerry Morris. Int J Epidemiol.
2001;30:1141-1145. 2. Davey Smith
G. The uses of 'The Uses of Epidemiology'. Int J Epidemiol. 2001;30:1146-1155.3.
Loughlin K. Epidemiology, social medicine and public health. A celebration of
the 90th birthday of Professor JN Morris. Int J Epidemiol. 2001;30:1198-1199. 4. Morris JN,
Titmuss RM. Epidemiology of juvenile rheumatism. Lancet. 1942;ii:59-63. 5. Morris JN.
Recent history of coronary disease. Lancet. 1951;1:1-73. 6. Morris JN,
Heady JA, Raffle PAB, Roberts CG, Parks JW. Coronary heart disease and physical
activity of work. Lancet. 1953;2:1053-7, 111-120. 7. Morris JN,
Donkin AJM, Wonderling D, Wilkinson P, Dowler EA. A minimum income for healthy
living. J Epidemiol Community Health. 2000;54:885-889. 8. Morris JN.
Commentary: Minimum incomes for healthy living: then, now and tomorrow? Int J
Epidemiol. 2003;32:498-499. 9. Morris JN,
Heady JA, Dly C, Stevens CF, Morrison SL. Social and biological factors in
infant mortality. Lancet 1955;1:343-349, 395-399, 445-448, 499-503, 554-560. 10. Morris JN.
Health and social class. Lancet. 1959;1:303-305. 11. Morris JN.
Occupation and coronary heart disease. In: Current Medical Research. Medical
Research Council, HMSO, 1960;1-4. 12. Berridge V
(Editor). Inequalities in health: before and after the Black Report. Contemp Br
Hist. 2002;16:1-256. 2) 'The man who
invented exercise', Simon Kuper Published:
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