Infinite, as it were, they really had four hours. David, this is, uh, me, Derek Hockaday recording David World 24th of March.
Um, David Whicher, actually. Did you come up as an undergraduate 1958?
And what did you thought of the admissions procedure?
Presumably you came up the previous December, perhaps like scripting in at the very last moment, the lowest form of entry.
Um, I didn't have a third year in the sixth form because I was deemed, uh, ineducable by my school.
So I was in the sixth form. I'd taken A-levels and I managed to get the entrance exam.
Christchurch was the only it was the last gasp. And really because my father had some extraordinarily naive, uh,
faith in me and felt that he wanted me to go to Oxford and all the everything up to and had mitigated against this.
When it came to the point he walked, he went round Oxford on his own, trying to persuade heads of House to give me a chance.
And it succeeded at Christchurch. So I came in, I got my entrance was with weeks to spare in fifty eight.
So I came up there. I mean, looking back my at the school form this opinion of me because I was very lazy and I was one of these late starters.
Yes. It's always made me very, very reserved about categorising people to suit.
And we're seeing now with the latest maturing entering medical students,
it's to expect someone to if vocation still exists in the in the 21st century.
I think it does. They do. But they will necessarily, um, here their vacation or arrive at their idea of their vocation at a particular age.
I think people mature very different. Is and was there anything to do with I said, do you think.
No, you had good classes at the last minute.
Thank you for providing a you know, it affected my father.
That's why it occurred to me. And I'm that dude.
What sort of entrance exam did you take or didn't you or you just interview?
No, no. It was it was an entrance exam. And, uh, having got into Christchurch, I then had to pass prelims.
And this was a bit tricky because the, uh, we took to the Cambridge board exams at my school,
Portsmouth Grammar School, and the required organisms were different.
The syllabus was different. But Christchurch was quite clear about this.
You know, if I didn't pass prelims, I wouldn't be able to take up my place by the October go.
It was very, very last minute, uh, extremely anxious. I wouldn't want to go through that again.
No, but I was very lucky and I got in. And how did you enjoy your first two years?
The sort of first. Burum Yes. Well, it was nothing less than a revolution for me.
Coming up to Oxford from grammar school, albeit a grammar school.
It had some pretensions which was out of a Portsmouth Grammar School.
Yes. And we were part of the, um, uh, we were into independent grammar school.
Um, and, um, the headmaster wants us to wear straw boaters in the summer term and things like that.
We were very much, uh uh, well, naval orientated.
My school was founded mainly to educate some of the naval officers in Portsmouth.
But, you know, in some respects, it was rather a pretentious grammar school.
But anyway, nothing could prepare me to arrive in Christchurch, which is in those days was probably one of the sloppiest colleges.
It was much populated with Etonians. That one felt there must be somewhat of a greasy pole because many of my colleagues from the West were not,
uh, tremendously impressive academically, although some were extremely impressive.
And I came to respect them very much, particularly in the orchestra, because, uh,
in the city orchestra, um, almost the entire, uh, front desk and the woodwind and so on were Etonians.
But the other the other thing about, um, coming up to Oxford was that, um, it was a place where, um,
you had your studying your energies were entirely self directed, uh, whereas at school we've been regimented.
And several of my, uh, contemporaries from the grammar school who came up to Oxford had great difficulty adapting to a system where it was up to them,
how much work they did. Mm. Yes. And what about the churches?
How did you get on to them. Well I had a marvellous tutor. He was a.
Exactly right for me, Peter Matthews, the neurophysiologist, the the, um, uh, muscle, uh, preceptor chap, the, uh, the strictures that drew muscles.
Uh, his father had been a very distinguished neuro neurophysiologist. It came from.
Yes, but Peter Matthews is absolutely right for me. He was slightly, uh, tense, edgy, highly intelligent man.
He looked at me very straight through his thick glasses. And it seemed to me he saw straight through me and quite right, too.
I remember the first lesson I wrote for him.
He said, well, this is fine, but I can recognise whole passages taken verbatim from some of the major physiological textbooks.
How do you explain that? So I said, well, because I copied the model is right.
I said, you know, within a space of a few weeks, he turned me upside down.
It made me realise that you had to read your original as far as you could, the original sources,
and you had to make your own interpretation based on your own reading of the methods and so on.
And you had to be very critical. And of course, he completely educated me about the dangers of plagiarism and, uh, just the interaction.
The one, two, one, two, two systemise with. For me, it was brilliant because I was I was sort of, um, uh, primordial clay, as it were, at that stage.
But within a few weeks, I think he'd he'd made me into something approaching a thinking scientist.
I did anatomy and just, uh, it scared me because such detailed knowledge was required and having to learn the 24 branch of internal maxillary artery,
which the clock, uh, had already done quite a lot to simplify anatomy.
And of course, his marvellous book,
Tissues of the Body and the way he viewed anatomy was very much it was very radical in getting away from this this awful business of learning by rote.
But the survivors were terrifying. And in fact, Peter Matthew's wife, uh, uh, Margaret Matthews,
one of the most terrifying of survivors and there was Dr. Crawford was also terrifying Alice Karlton and stopped her.
Yes, she's a great name. Yes. From reading the Oxford Medical School Gazette.
But I. I never met her myself. And where you found out at all by Peter Matthews in the first year?
Yes. Yes. We had Bob Torrence for cardiovascular. You know, the unlikely combination of Bob Torrance.
We call her Minnie Bannister. She was really Minnie. But he and and particularly Dan Cunningham, uh, at Univ for respiratory calls through Dan.
I met with Lloyd, you know, the founder of Brooks University, and they were very exciting pair.
And I remember, um, uh, Dan said, would you mind?
I don't believe the school. He said, what was your best time for the 400 yards?
And I told him, what would you like to go on and help us by volunteering to go on the the treadmill, you know, the the the running the machine.
And so I said, yes, fine. So I got on and, you know, he piled up the, uh, kind of metres, uh, up and up and up.
And I was quickly in very great distress. And, um, Dan Rather surprised.
And he said, oh, well, I thought you were an athlete. And I said, well, I will buy Portsmouth Grammar School standards.
I wasn't bad, but by whom you judging me?
And he said, you know, the last person who's on this roll call, Roger Maris.
I'm sure that's why he ran the four minute mark.
But, you know, at his best, he was it was on an extended dead space to the wall, you know, and then you did the first beam and then a year of school.
Yes. And we all were almost ready for a holiday if few read P, but and I really enjoyed that.
I thought you were. And that was really my big break through the, uh, uh, the, uh, the VA.
But it was still quite a struggle. And the thing I was one of the things that's changed so much.
Derek, of course, you remember this. We spent hours in the Radcliffe Science Library.
Even on one occasion when the power went off,
there were people reading by bicycle that such was the enthusiasm because the place is deserted these days.
We've been in that, you know, one goes to the library, then you go.
But trying to secure that particular paper, you want to become the current system of something which was very, quite competitive.
Did you have particular interests in that subject?
Uh, yes. Well, I was interested in respiration because, as I say, we struggled with the fluid modification of the Haldane apparatus.
Do you remember the power girl also always got through and got mixed up with the potash or whatever it was.
It was a horrific piece of equipment to clean out. And, um, but I was interested in the physiology of exercise,
but I was also fascinated by the kidney because a lot was coming out and about, as I've already mentioned, the, um,
medullary concentrating system, countercurrent system and both the nephrology and astrology,
interestingly, me, because they were quantitative even at that stage, rather than being quality.
And then you would have done a two term speth and back.
Yes. And pharmacology. And where did you go down to do your clinical symptoms?
What made you decide that? Well,
it was interesting because I went for the interview at Tavis's before I got into Oxford and they started off questioning me in a conventional way.
And suddenly the dean, Bob Nevine, leant over to the chairman and said, oh, this has been referred by Peter for from Harvard.
So the committee said, oh, that's all right. And just a disgraceful example.
Your dad is our GP to our family doctor at home who did who knew me quite well and had vouchsafed my my entrance there.
And how did you enjoy that? Well, it was a big change. As you know, in those days, most people went to London.
Only a minority, a very select minority, stayed in Oxford, I suspect, for various different reasons that go into that.
But it was very exciting to get up to London.
And Tomas's was a, uh, very conventional London medical school at the time.
We were taught in groups.
There was an outpatient teaching there, theatre where a patient would be displayed on on the stage in front of perhaps 20 or even 30 students.
I mean, by modern standards, absolutely unacceptable. It was a very good way of learning medicine.
And no, I enjoyed it. I very keen to learn it was tantalising in the master at Oxford that we wanted to see patients.
In fact, I remember that Ted Maloney and Harold Ellis took us to the very exciting.
It was just a couple of sessions where the clinic where the preclinical students were taken into the Radcliffe Infirmary and shown patients.
And for me, uh, because that's that really was my interest was clinical medicine was enormously exciting to see.
I remember the patients, not one of them had a plastic anaemia from chloramphenicol,
which the only case I've ever seen in my whole life that is not really that dangerous.
The drug. No, I got labelled because the the changes seem to be pretty reversible.
But that was very exciting, that anticipation of, uh and.
Um, but going into the hospital and seeing him in the ward, in the intensive care unit or whatever it was,
then, um, again was for me as a someone who really wants to get on the clinical work.
So to answer your question, when I got to Thomas's, um, I was, uh, I found it all very interesting, very exciting.
Having to cope in running sessions with a clinician.
No, you know, I didn't meets this fantastic chap, uh, until much later.
And he was very, very kind to me as as he was to talk to everyone.
But, um, unfortunately, I didn't get his benefit of his influence there.
And then you did his job. So of different offices. Yes.
Yes. And I actually, uh, battlegroup clerk at St. Thomas is when he came in to have a cataract operation.
And he, uh, he just, uh, he was getting very bored.
He had his eye. This was the old days of cataract operations. Yes.
And he asked if if people were willing to go in and talk to him.
So I thought this is a marvellous opportunity because, of course, it's a fascinating that he'd been initiated as a tribal member of the Kikuyu.
He'd done this work on palaeontology. He'd written a very nice book, uh, introduction book on palaeontology.
So that was another an added thing about being sent overseas.
And then you went into the services or not?
No, no. I avoided, um, a very narrow margin, avoided national service.
I was born in the 6th of October. But I think if it had been so, what eventually led you to come to Oxford?
Well, um, of course, I'd been up in Oxford as an undergraduate.
And I suppose, like many people, um, I had entertained a sort of fantasy of returning to Oxford in a situation when one was older and
and less stressed by the urgency of examinations and proving oneself in a somewhat hostile,
competitive environment. So I always thought that I might try to come back to Oxford.
But in fact, I went on from St. Thomas's to do what was then called the circuit know the, uh, Hammersmith Brompton um, circuit.
Um, I didn't go to Queens Square that, um, uh, I spent some very interesting period doing those two jobs.
And then I decided to stay to go to Harvard because I've been very impressed by more.
And Campbell. And when I was doing a house job at, uh, with him at the Hammersmith,
so I I became a registrar with more Campbell and Charles Fletcher at Hammersmith and really went into respiratory physiology,
uh, as a as a science, as a as an investigator and also in clinically.
And and so it wasn't until after I've been to, uh, Ethiopia and Nigeria, uh,
some years later that I came back to Oxford in seventy five, having left Oxford, uh, in, uh, 62.
Had you done a doctorate and was that respiratory medicine. Yeah, I did a doctorate on the work I did in Ethiopia.
So when I was at the Hammersmith, uh, one of the uh one of the I sort of Hammersmith alumni,
as it were then, was the Royal Postgraduate Medical School alumni, Rick Perry.
It worked for, uh, John Michael and, uh, and, um, put a good with the cardiologists that he'd gone to work in Ethiopia.
He was an associate professor in Addis Ababa at, uh, uh, highly selective, the first university.
And he came across a curious problem, uh, when a disease,
which no one in this country had heard about last or relapsing fever when they were treated with antibiotics,
as they had to be because the untreated mortality was very high, they developed a life threatening reaction.
Your Rituxan, the reaction far more violent than in syphilis because most of these parakeets were in the blood stream rather than in the tissues.
So it was a very violent, uh, febrile reaction which could kill them.
So elderly? Perry asked. Hammersmith asked to move back to this.
The school said, could they send someone to help him investigate this function?
I was furious and that was my big opportunity. And that's presumably how you really got into the world of, in fact, tropical infectious disease.
But, David, when you came to Oxford, what was your sort of job description?
When I first came back to Oxford in seventy five, I came back as a consult.
Physician with a special responsibility for medical admissions. Yes, and I must say, I've been recruited in Nigeria because after Ethiopia,
I then lived and worked in Nigeria for a number of years, also with Rick Perry.
And towards the end of my time in northern Nigeria, Grantly came out.
I forget why he came, but I did a wardrobe with him after meet him off the aeroplane in Kaduna.
And, uh, it was it was a marvellous opportunity for me if I wanted to impress Grant, uh,
because all the patients with the sort of conditions that I was very familiar with but which he was not.
So anyway, as a result of that meeting, he very strongly urged me and I believe promoted me for this job.
Good. Back in October.
And Chris Booth, who was my head of department at Hammersmith, uh, I got back there in 74 as a consultant, my first consulting job.
He strongly urged me to to go to Oxford and to apply for this job.
So although I was rather concerned about the the aspect of the job that was to do was very administrative.
And it sounded to me potentially very unpopular, too, because I was going to try and make peace amongst warring factions,
not just between physician colleagues, but between physicians and surgeons.
And it was quite everyone told me it was quite clear. Chris Burke gave me a very good briefing before I, uh,
before I took up the job that the simple fact was there were far too few beds and in the hospital.
And although the turnover was amongst the most rapid in the country, uh, they just couldn't keep up.
But, you know, rather than increasing the bed number, the authority decided to appoint someone to organise it.
So that was me. Now, before that, had Catherine Oppenheim have been doing it, she had.
And she wasn't a consultant, of course. No. When I went go into details about that.
But I didn't I never met Katherine. I heard very good things about her because I later got to know her, her husband, the Christchurch.
But, um, I knew she was a psychiatrist,
which I quickly realised was probably a great advantage in the personalities that I didn't inherit any of her wisdom,
unfortunately, and by the person who really introduced me to the whole system was Grantly.
And that may or may not have been optimal. As far as I was concerned, the grant had a particular view of how it should be done.
And do you feel that you were able to contribute and sort it out a bit?
Um, it was a very difficult job. There were some successes and we started the first was it admission's Ward eight in the Radcliffe Infirmary?
Um, and I think that on the whole, my relations with the consultant body were fairly good.
There were some exceptions. But I mean, the difficulty is, you know, Derek, is that in if you're a consultant,
if you're a doctor or a passionate consultant, your own patient's interests are paramount.
And you cannot blame a consultant er consultant Deibert colleges, for example, just choosing one quite arbitrarily,
who in the interests of their own patients, uh, almost demands that they be allowed to stay longer or whatever it is.
And this was a great difficulty because I had to try and um, increase the turnover in a hospital.
It was undebated. I still believe it was not inefficiency. It was underpinned.
Um, and that was an almost impossible task, that although these relationships were difficult because, uh,
my colleagues were very vehement about these matters, um, I think that I managed to at least maintain some good relations with them.
And one of the other things that I think I have helped not to achieve was rationalisation of the cottage hospitals,
because it was always known that there was a large resource of beds.
Uh, this actually is quite interesting because, you know, this this phase for putting everything into the primary,
uh, head into the community, rather, and taking away from the hospital.
It was quickly clear to me because I visited all these hospitals, they weren't being used and they were being protected.
This was territory. They were being vigorously protected by the GP's who had admitting rights there.
And again, can you really blame you know, I like to have available to them because I know that Mrs So-and-so might have one of her funny.
I have to admit it, but they were being grossly underused and that was at something at least that I brought to light.
Unfortunately, one of the consequences was, of course, that many of these, in fact, all of many of them were closed down.
Was that Rosemary Rouge time or after it really, um, she had been a great promoter of them.
Yes, I think it was after her. Yes, I think it must be. Yeah. And then did you manage to slip this yoke?
No, I maintain that that responsibility until the time I, I, uh, moved on to the next phase of my career, which was to go to Thailand.
I just I moved to the Nuffield Department of Clinical Medicine, strongly encouraged and supported by David Wetherall,
ready to resume my career as a researcher in tropical medicine.
But when I came to Oxford in seventy five, I had really decided that I was going to,
uh, leave academic medicine and concentrate on being the best possible physician.
That was my ideal.
But as, uh, over the years I was in Oxford, I was only here from seventy five until 79 and I had an increasing hankering to get back to research.
And for me, by that time, research was very much to do with with the pathophysiology and treatment of life threatening tropical diseases.
And so when this opportunity arose, the Wellcome Trust, um, wanted, uh, to start a new unit in Southeast Asia.
I was very attracted by that. And that's when I resigned from the from the consulting job and from the, uh, admissions office.
A job. Had that initiative come from Brigitte Ogilvy or somebody else at the welcome
or who provided the real initiative for that job to be created in Thailand?
Well, this is rather a murky area full of revisionism there.
Yeah, uh, there are a number of published accounts by, uh, quite senior and distinguished people.
Uh, my own, um, uh, experience at the time was a bit different because what really happened was that in, um,
in about seventy seven, I was getting very restless at home, uh, in Oxford as a as a physician and admissions officer.
And I went to see Tom Hopwood at the Wellcome Trust. It was then Dan Street was a clean and green industry.
Um, and, uh, I met Tom before he joined the Wellcome Trust in as I was advising the minister of Health.
Yeah. So I knew him quite well. And I said, look, Tom, I really want to get back to the tropics and to do something to do some research,
because I realised by then that there are a lot of people are superb physicians,
but not everyone has that, uh, interest in doing in doing research that I had that interest.
Um, and Tom is sitting at his desk and behind him was an enormous map of the world with these little pins in it.
There was a pin in Nairobi, in Kenya.
There was a pin in building in, uh, Brazil, there was a pin in Vellore or in India, but there were no pins in Southeast Asia.
And Tom said, we've got a lead trustee in tropical medicine, Gordon Gordon Smith.
He was the, um, he was the, uh, uh, the director of the London School of Hygiene and Tropical Medicine,
uh, spent many years at the Institute of Medical Research in Kuala Lumpur.
And he's very keen that the trust should should support a new unit actually in Kuala Lumpur.
And, uh, would you be it he said, would you be at all interested in that?
Right. Exactly what I would like, because my disease interests, well, uh, would have been very well fulfilled by, uh, posting that sort of area.
So that's what led to marry my wife and I being sent by the Wellcome Trust on
a sort of voyage of discovery to Southeast Asia in nineteen seventy eight.
Um, we explored various places where this new this putative Wellcome Trust unit might be positioned, uh,
in Taiwan where the American Navy had very good things in Jakarta, in Indonesia, uh, in Sri Lanka and in India.
Uh, and in uh, Thailand, of course, the first choice was in Malaysia as as preferred by by Gordon Smith.
And so some of these places with. Settled through correspondence, they were not not possible, but in the end,
we went on a trip involving, uh, Sri Lanka to send in Sri Lanka and Thailand and Malaysia the cut.
Long story short, the decision was very easy when Thailand was by far the most exciting and we had the
warmest welcome to in the factory of tropical medicine in Meydan University in Bangkok.
And, uh, thanks to help from Liverpool School of Tropical Medicine, Herb Jilly's,
particularly, who's who had been responsible for setting up that faculty.
So that's that's what happened really. Just by the way, Gordon Smith, is he the father of Ted?
No, I didn't think so. Fun. And, um, was it a particular disease also that was drawing you to Thailand?
Yes, it was three diseases. It was, um, uh, snake bite and rabies.
I developed a very strong interest, a recognition that these were neglected diseases, horrific.
And, um, whose treatment was answer and prevention was unsatisfactory.
This is, uh, what I experienced in Nigeria the years I was there.
And the third one was malaria, because it is, uh, probably the you know, it's the most important protocell.
Infection kills most people of the classic tropical diseases.
And so I wanted somewhere that had a lot of malaria.
I mean, it sounds a bit unpleasant, really.
What a place to have a lot of, um, a lot of malaria and rabies and snake and Thailand fulfil that admirably.
And what was the language? Uh, Thai is right.
Not French. I don't know. And one of the very terrible things about Malaysia was that English was spoken to sign street signs in Kuala Lumpur.
In English, you get by with the English. But Thailand was much more challenging.
And Mary and I had to or we started learning Thai at the School of Oriental and African Studies in London, had a marvellous teacher there.
And so before we went out, we had a basic knowledge of, uh, reading, writing and speaking Thai.
When we got there, we did full time, uh,
language teaching at a missionary training school in Bangkok for one month and then part time for another year, uh, further to months.
And that was an essential basis, really, of working in Thailand and for our terms in Africa.
Had you been in cahoots with the London School of Tropical Medicine before you went to Thailand?
No, no. My my links of anything were with with Liverpool School, um, through the person of, uh, of her Gillett's.
This has met her to my sort of godfather in tropical medicine.
Um, the London school was, of course, an enormous presence in in the once, um, consciousness of UK tropical medicine.
But there was a curious division of the globe between these various fiefdoms in, uh, in UK tropical medicine.
And, uh, so it was the same with Thailand.
Thailand was definitely Liverpool territory viewed in that way because Bryan McGrath, you remember he was in Oxford.
Yes. Before he moved to Liverpool, Bryan McGrath had co-founded the, um, uh, Faculty of Tropical Medicine in Bangkok with with long hair in a suit.
So would you feel the Guinness leant on David Weatherill to let you go out to Thailand?
Or was David really seeing this opportunity which you thoroughly realised of getting Oxford involved in the tropical medicine scene?
David was tremendously supportive in my going back to the tropics that I remember when I arrived in Oxford to do this consulting job,
um, and went to see him, uh, just to say hello.
He said very, very polite. He said, very glad you're here.
And so I can't for the life of me, see why you're doing this.
He thought I should have just carried straight on in an academic field rather than coming to be a consultant physician.
But as I have said, Derek, at that time, that is absolutely what I want to do.
And I don't regret it because, um, you know, you can't be a sort of half hearted, uh, clinician.
I want to be a physician. You've got to do it properly. So, yeah.
And, uh, I agree that it is possible to be mainly an academic with a as a an amateur interest in.
But I I've always mistrusted that particular thing, so I think those years in Oxford and of course since I came back to Oxford in nineteen eighty six,
my years here is as a jobbing acute take positions or being really one of the most rewarding things in my career.
So how tough was the first year in Thailand? Pretty tough, actually.
Well, it was a lot of politics. I mean, there was quite a lot of politics before we went.
And David Wetherall and Peter Williams, who was the queen first, the director of the Wellcome Trust,
it was his confidence in, uh, Mary and me that really ensured the trust.
The trust support, of course, greatly helped by David Wetherall, who had a close, very close relationship with Peter Williams.
Um, and there's no doubt that that, uh,
David Weatherall was very enthusiastic about my going to Thailand because he'd already got very well-established,
uh, research with academic connexions there with several other people in his field of thylacine.
Right? Yes. So David was already very well known in Thailand, particularly in Sydney Art Hospital, and was enormously supportive and helpful, uh,
in engineering the whole thing and giving me the necessary home base,
which is the crucial element about the Oxfords approach to working in the tropics.
You don't just cut yourself off and go out somewhere on your own.
You you are very much supported at the end of an umbilical, um, chain from, uh, from your parent academic institution.
And how did you get on with the Thai doctors? Well, on the whole, very well.
There was a mission, of course. And I think this is very easily understandable.
I mean, imagine what we would feel like in Oxford a whole lot of time, and we're going to sort out all your major diseases for you.
I think it was a lot to expect, really. Were you the director of the hospital clinically, as it were, or.
Oh, no, no, I was the it will be quite impossible without high level patronage.
This is the way things work in Thailand. So, um, I, my guarantor was her jealous.
And of course, David Wetherall, but particularly in the faculty of tropical medicine,
was jealous because he was as I said, it was this very strong connexion with the Liverpool school.
But the the, um, the principal people in the hospital for tropical diseases were, um,
Khunying transacted in a suiter, the wife of the the dean, uh, Chamillionaire in a suit.
And then I bunnag, uh, seen one of the senior physicians and it was their support that enabled us to establish ourselves there.
And I don't know how her had convinced them that we would like to be a good thing, that if there was a lot of doubt about this,
that David said quite David Wetherall said, quite frankly, I really didn't expect you to last for more than a few months.
So I wouldn't been surprised. And yeah, you can imagine there was a lot of discomfort, particularly the thing that was most contentious.
They felt that if we were there and did some good research, perhaps the you would choose us rather than try to be their consultants.
And that clearly was was a very major aspiration.
There was to be identified as a WHL consultant and sent off somewhere, uh, perhaps to Geneva or somewhere else as a consultant.
What we tried to reassure them,
but there were there were difficulties and things were reasonably friendly until we published our first paper in The Lancet.
And, uh, that that was a real problem because there was immediate hostility,
the feeling that we were using their material, um, and many authors on it.
Uh oh. A large number of authors include the ties to the hotel industry, which I, um.
But it was, uh, it was obviously difficult for them.
And I think the feeling that we were stealing ideas or stealing patients and that did after that very first study,
which was done in the hospital in Bangkok,
it was sort of tacit agreement that that from then on we would do all our work in the provinces and we would not work in their hospital.
And, um, and that that was a good thing in some ways because SARS, rabies was concerned.
It didn't matter because the the the dog bite cases came to another institute.
And for severe malaria, we found there was an epidemic of severe malaria in a province east of Bangkok,
a place called Canterbury, and we worked there for a number of years.
And then we worked to in country number in the west of Thailand for another few years of malaria.
Um, so that wasn't a problem in the snakebit work was done, um, in in the south in a place called Tranh.
So I think we partly solved this this suspicion by not being under their noses in their own hospital.
So how quickly were you able to formulate your first research, the first research problem?
Well, before really before we went out, we had to give some ideas to the trustees before we wouldn't have got support in the initial period,
which by modern standards was very modest support. I mean, it was enough and we're very grateful for it.
But it was it was not millions, I can assure you, tens of thousands.
And we, uh, we looked quite carefully at the ideas about the pathophysiology of cerebral malaria is an
extraordinary disease where patients become unconscious and the case fatality is quite high.
But, uh, the ones who recover, certainly the adults who who survive the attack on the whole, recover completely and fairly rapidly with no sequelae.
That was quite a demanding pathophysiology. Um, and Bryan McGrath, it had very strong ideas about that, dominated the field.
In fact, it was he who really, um, uh, stimulated me to go in to become interested in the underlying mechanism of cerebral malaria talk.
I heard him give in Athens at a meeting, but he had a particular view about this.
He said it was all due to permeability. It was a, uh, cerebral oedema that caused all his problems.
And, um, I found this incompatible with with some of the clinical evidence.
So we'd already decided that we should, uh, start looking at this and the other at that time in the,
uh, in the late 70s, uh, worldwide, the most favoured ancillary treatment for cerebral malaria.
It was high dose steroids, um, on rather flimsy anecdotal basis.
You can imagine patients waking up on the end of the needle and a few senior figures like Alan Woodruff,
who was the professor at the London School of Hygiene Tropical Medicine, uh,
saying that this was actually was he implied that it was unethical not to give steroids.
So anyway, that was the background. So we designed the first study we should do would be a, um, uh, a double blind,
placebo controlled trial of high dose dexamethasone and cerebral malaria.
And it was quite a struggle to get that through the Ethics Committee, because, as you know,
with so many of these things that are taken up and, uh, these convictions of senior physicians, it suddenly becomes unethical not to do it.
What exactly is Alan Woodruff had had said, but we got through that.
We, um, uh, got, uh, put in a protocol approved and, um, we carried out this study,
injunctive relief in a way lucky because today we have to be an epidemic of cerebral malaria.
And, uh, so we had a large number of cases and it was a colossally productive and important study for us, because not only did we do the first, uh,
randomised placebo controlled trial, uh, ever attempted in malaria,
which is a pretty extraordinary when you think of it, this is, uh, uh, nineteen eighty eighty one.
But in the course of studying these patients, we found out so many things about, uh,
the disease which we didn't know cause a good proportion of them turned out had been discovered already.
When we look back in the literature that it was still a very exciting phase and it also gave us a lot of ideas.
Now you're right in saying we allowed what was Mary doing it?
She was her own. Well, it was, um, quite difficult for Mary to justify her being employed by the Wellcome Trust in seventy nine.
Uh, there was some suspicion that this was just people taking on their wives in a sort of role to boost the salary a bit.
I mean, we had a rather awkward Tea Party at the Wellcome Trust with Peter Williams.
He said he wanted to make sure she was OK, but.
His background was very relevant. She said she although she was a physician,
I never asked if she'd gone into microbiology and had done work at Northwick Park on chlamydia and Uria Pleasance.
So she had a very strong laboratory background. She was a she was a virologist in Oxford while we were working in Oxford in the late 70s.
She was a she joined she was a virologist there with John Tobin and people like that.
And so she offered the necessary skills to set up our laboratory.
And she did that superbly well. And we recruited a number of technicians who have done fantastically well.
It's still working with Nick White's Nick Days group now.
They were the core technologists that one of them is is a PhD and, uh,
the other one is a recognised world authority on various bacteria that she's she's interested in.
So, uh, Mary set up the laboratory and established standards of laboratory behaviour, a meticulous, obsessional labelling and so on, uh,
which was absolutely crucial to the not just the success of the period seven years I was there,
but continuing it became the the tradition, the legacy of the unit find back in Oxford a bit restrictive.
Well, she had difficult compromises to make about bringing up our daughters.
And of course, it's less easy when we moved back to Oxford because whereas in Thailand,
uh, it was possible to get good, um, support at home baby nurses and cooks and things.
It's not quite the style in Oxford. Um, but I also we mean, after about a year, Nick White joined us.
He was um I had known him all that much in Oxford.
David Weatherall strongly recommended him. He'd been his half his housemate or probably registrar as well.
I forget uh so Nick came out and course with his great originality and brilliance,
introduced a whole lot of new ideas, particularly interesting, uh, antimalarial chemotherapy.
He was a proper trained pharmacologist. And when you say that, I mean, what have you done in pharmacology?
Well, he'd worked with David Graeme Smith. Right. And he understood pharmacokinetic basic concepts of pharmacology.
And he thought as a pharmacologist and he realised that this was a completely virgin field
because people were using antimalarial drugs without really understanding their basic,
uh, clearance and things like that or how they're.
Yes. Well, the mode of clearance as well as the speed of clearance. And he designed a series of very original, uh,
experiments and studies introducing the concept of a loading dose in this rapidly life threatening disease.
And also, he was he's a very good clinician. So he was able to help with with all sorts of things as well.
Who is measuring the concentrations of the drugs? Well, initially, we were, uh, they were being sent back, uh, to other laboratories.
In fact, phase one of our project in Thailand involved a lot of Oxford laboratories,
for example, Robert, turn to do with, um, the hyperglycaemic, right?
Yes. We had a dramatic patient during this, um, dexamethasone trial in the rural area who, uh,
a few days after she'd recovered consciousness, seemed to be getting better, suddenly became breathless and light-headed.
And, uh, this led to eventual discovery that this was hypoglycaemia.
It was not pulmonary embolism, which said visitors to the lab at that time thought it might be clinically presumably she was placebo was,
uh, because there's nothing like dexamethasone now as of right now.
That was great. I mean, how did you get on to this was beyond that?
We only gave them dexamethasone for 48 hours. This was beyond the maximum impact on that.
But that was a fascinating conundrum,
which which network took up with great enthusiasm and eventually published in the New England Journal of Medicine.
But it was Robert Turner who allowed us to show quite clearly this was hypertensive, anaemic hypoglycaemia, and it was triggered by by quinine.
Yes, and some of the other cinchona alkaloids, right, and this is a priority.
Well, almost, I think it was Christmas 1981, uh, that, uh, Nick Weiss and I were invited to go to China.
And we were actually sent there by the. The visit was organised by, um, uh, I think it was Glaxo.
Um, in um. No, it wasn't. It was Roche. Sorry, Roche.
Um, a chap called, um, uh, Nick Arnold, who was a Roche man based in Hong Kong.
But also it had very strong links with with Vietnam, which was relevant later.
But he was very keen that we should go and meet, um, uh, Chinese herbal doctor in in um,
uh, in Canton called Lequan Cho and who who published on the use of this herbal remedy.
And, um, so Nick and I went it was a very exciting trip.
We went by train from Hong Kong up to Canton and, uh, heard a lot about how soon the artemisinin,
um, plant and, um, we were actually offered, uh, offered the drug for clinical trial there.
And then but unfortunately, we were able to accept the offer because at that time, which was proving very, very cautious and cagey about it, um,
partly due to the drug, was being not being produced according to good manufacturing practises and, uh, sort of rather boring reasons like that.
And they couldn't see past that to its dramatic effectiveness.
anti-Communist and it was must be particularly frustrating for Nick to have to see others do the early studies.
They were done in Burma and elsewhere in Vietnam, um, before we could finally, uh,
get our hands on the drug studies were westerner's know by the local could be.
You said that. I mean you'd gone out from the capital. Where is your lab that Mary was running.
Our headquarters was also always in in Bangkok itself, the capital, and it was in the faculty of Tropical Medicine,
which is uh had its attached hospital for tropical diseases in one of the major universities in my university that,
uh, we arranged a very efficient system for managing provincial research sites,
um, and travelling backwards and forwards so that we had a sort of, uh, system.
And, uh, so we provide continuous presence, the efficient system of buses.
What sort of mileage are we talking about? Two hundred miles, that sort of thing is quite a business.
Um, and then after your first, you know, paper and the randomised trial, did you go on to do more randomised trials or what were you doing?
Yes. Well, the the dexamethasone paper that was published in the New England Journal in 1982 was, of course, a tremendous, uh, launch for us.
That was that was a we were extremely lucky that that led to lots of other studies which explore exploring different aspects of of,
um, quinine chemotherapy and, um, pathophysiology, uh, of of of cerebral malaria.
We did a study on, uh, uh, looked at cerebral blood flow.
Uh, we were helped there by Norman Viel, who worked at Northwick Park, um, who was an expert on isotope studies and on measuring cerebral blood flow.
And then all the other diseases we were studying, we'd started to look at ways of reducing the cost of, um, uh, rabies vaccination.
You know, after the time of past, uh, there was a, um, a great advance in the seventies when, uh,
rabies virus was cultivated not in animals, but in tissue culture and so much C4 killed vaccine killed virus vaccine.
Uh, so the tissue or cell culture vaccine starts to be produced.
And, um, uh, unfortunately, they were too expensive to be, uh, uh,
practicable in in countries even like Thailand, which was certainly not the poorest country in the region.
But, um, uh, Mary was, uh, that was the.
Having to find cheaper ways of giving these vaccines and we would go into a lot of detail, but the, um,
one of the ideas came from work that Mary had done with David to Northwick Park and with Carl Nicholson,
one of the other research fellows there that you could give, uh,
if you gave the vaccine by multiple sites intradermal, you could use a much smaller dose of, um, vaccine antigen.
And we did we tested this with a whole lot of other ideas, like using adjuvants to cut a long story short,
the best solution was, um, multiple site intradermal immunisation.
This was to protecting people after they had been exposed to eradicate so-called post exposure prophylaxis.
And, uh, we eventually carried out a comparison, a randomised double blind comparison of the standard treatment then in in Thailand,
which was a passed type nervous tissue vaccine with horrific complications and a lot of failures compared this with this new economical,
um, regimen using the the latest second generation, um, tissue culture, rabies vaccines.
Um, and that was very successful. We demonstrated that it is, uh, as effective and none of the patients died of rabies.
Great. Um, but, um, and following that,
there were further studies refining the regimens and looking at newer vaccines as they came, as they became available.
Had that vaccine been proven in Europe or were you the first people who really proved it?
No, it was it was had been used in the West and America and Europe for, uh, since the 70s.
Yes. Um, so there was really no doubt about its effectiveness given in the full conventional dose.
And I'm asking you to give it in. Yeah. Yeah. And we, uh, Mary established the principle that a much smaller dose, perhaps, um, a quarter of the dose,
total dose could be as effective in saving life as the expense, the unaffordable for course.
And that has been taken up. It's been used in some other viral diseases like viral hepatitis, but particularly in rabies.
It's been a very, very useful breakthrough. And our Thai colleagues came up with their own different regimens.
Uh, and these have been adopted in a number of countries. So that was a very gratifying is the World Series of studies.
How was the snakebit work? Well, that was also going on very well.
Um, uh, again, we came into a field where there had been very little research and where the,
uh, accepted antidotes, the antivenoms had not really been looked at critically.
So, again, we did randomised control studies comparing to antivenoms.
We couldn't use a placebo group in some ways, unfortunately, because the concept that antivenom was lifesaving was very, very strongly established.
Any clinician who used antivenom and seen its rapid effect in restoring blood coagulation,
stopping bleeding, raising blood pressure, even reversing, uh, paralysis.
Um, I was so convinced that it was not possible to do a placebo controlled trial, which has been a problem in the long run.
But we we found other ways comparing two different doses or comparing two different antivenoms,
um, of of, uh, of looking at this more objectively than just assuming it must be working.
And of course, there was a great deal to learn about the, uh,
distribution and import rates of imports of different species of venomous snake in Thailand.
I won't bore you with all that. But it was it was an endlessly fascinating piece of detective work that eventually allowed us to plot, um,
the geographical ranges and to, uh, direct appropriate antivenoms to redesign the Thai antivenoms, uh, in a much more logical way.
That was, uh, easier for doctors, doctors to implement just to give back to malaria.
When brain scanning came, uh, was a cerebral oedema.
We did a CT scan study, um, and there was not cerebral oedema.
I mean, there is sometimes oedema as an agonal. Event that we able to show that patients who were profoundly unconscious, you know,
Glasgow coma scores well below 12 had no evidence of cerebral deal, and that was published in The Lancet by their late colleague.
So you are is someone who was a young Thai doctor who is, as it were, given to us by our Thai patrons to to train up as part of our unit.
He eventually became dean of the faculty of trouble. It's a great success story, but tragically died the.
Yeah, what made you come back to Oxford?
Um, well, a number of things, really, um, Nick White was, uh, was was there and was full of ideas and was clearly a very,
uh, very ready to take over and steer the units in a slightly different way.
And the welcome was very keen to support that, I think appropriate ambition.
Um, but I think probably the most important reason for me was the education of my daughters.
And of course, not everyone, you know,
all parents of different colleagues of mine have stayed on that their children have been educated up perfectly well in Thailand or to boarding school.
Everyone makes a personal decision that they marry. And I decided that when Helen reached the age of five, she was showing clear signs.
And this may sound the patronising of missing the sort of environment of English speaking bright English children.
Yeah, she would have enjoyed here and access to lots of other things, like media know everything that's going on.
So rightly or wrongly, um, that was my main reason for feeling.
We should go back to Oxford. I also had a feeling that I wanted to resume a slightly more, um, normal career as a physician.
And I was also keen to be re-engaged with the Oxford Medical students teaching the Oxford Medical School student,
because we had done very well in Thailand.
In fact, I think all the tropical units that subsequently came out of this initiative have
done very well out of people graduating from our medical school at all levels.
Were they doing clinical electives, you know? Well, yes, we had a string of electives, absolutely brilliant.
People like Sanjeev Krishna was one of our earliest incredibly bright chap.
Um, but no, we had a whole succession.
Um, and, uh, but the idea that the Oxford medical students and other medical graduates had this opportunity to go do something, um, quite exciting,
ambitious, unusual in one or more of the tropical units that I was very keen to to sustain that, uh, that I felt I could play a stronger role of.
I was back in Oxford. So you came back as word consultant physician with special interest in infectious disease or.
No, I came back as a mainly as a member of the of the NDA.
Right. And I was quickly made professor of tropical medicine.
Oh, I then I was made the first director of the Centre for Tropical Medicine because by this time things were expanding.
I didn't mention that we founded a unit in Kenya. So I was wondering when that had happened.
And in Vietnam, while you were still in Thailand, this was happening?
Uh, the no, the Kenya unit happened a bit later than that.
Uh, these things were being thought about. Uh, uh, in fact, Kenya was started, I think, in eighty nine.
Um, I forget I forget when Vietnam was, uh, it was quite, um, uh, creation.
Um, and I think that was a little earlier. But the whole thing was expanding.
The number of people in Thailand was larger as well. And we felt that there was need to be more coordination.
And the Oxford and how I was honorary honorary, uh, consultant physician in Oxford.
And although I'd never had any formal training in infectious disease, I learnt all that,
almost all of from Betty Williams, who when I came back from Nigeria in in seventy five and got back to Oxford,
they generously invited me to come and join in and then Slaid it really it was a uh, it was a training that would not be permitted these days.
And um he was good.
Fantastic. Yes.
Because as you know, he's a debateable figure and I'm delighted to hear that because I well I think it's I think it was an absolute judge.
And I think he's one of the most underestimated people in medically in Oxford.
I think that certainly his brilliance was appreciated in in the humanities areas of Oxford.
Uh, that I think he was it was a remarkable, um, intellect and, uh, of course, the absolute.
Devoted to the student body here and encouraged exploration expeditions, his links with the Royal Geographical Society.
I was devoted to bed. I have I very much regret that I wasn't able to take advantage of that.
His great learning. Mm hmm. But apart from Ethiopia, etc., that area he didn't go to, say, Thailand or Nigeria, is that right?
Well, he visited us in Thailand, but no, Ethiopia was his passion.
And that arose out of an Oxford University Exploration Club, uh, trip to look at the rock.
Futures disintegrate. And Ben just ignited and became so passionate that he learnt two of the local languages, American girls,
and, uh, became an authority on Ethiopian manuscripts and almost everything to do with him.
And he also sort of fought in the civil war, the European Democratic Union, and advised of what medicines to buy, etc.
Yes. Um, so back in October, you were doing Ontake Take Medicine as well?
That's right. Oh, yes. Yes, I thought so.
And in fact, that was the thing I found most in a way, most fascinating, most challenging, the most rewarding was doing and so called unselected take.
And although, uh, as you know, as the years went by, um,
and the younger Ontake physicians looked rather disparagingly at what they called Gentleman Ontake
physicians who didn't sort of get down to putting in intravenous lines and so on on the ward.
Yeah, um, now, when you came from the demonstrators to Oxford after, you know, a few weeks,
months, but did you actually think of Oxford compared to London hospitals that you'd been.
Well, I was spoilt for nursing. And Thomas is of course, Thomas is of course, they're marvellous nurses everywhere.
But if you want a hard comparison, the style of nursing wasn't quite the same.
Um, originally I was in the in the hatchet wards.
Do you remember? I do. I love the old Radcliffe Infirmary. I had a marvellous atmosphere.
I think it structure encouraged, uh, sort of into collegial interaction.
Walking down the main corridor. You always be certain of meeting almost anyone you wanted and or in the dining room is.
So I very much regretted leaving, uh, the Radcliffe Infirmary.
Uh, I thought it also it esprit de corps was marvellous as well.
It was a really good feel about it.
Everything about it, I thought was was was the practise of hospital medicine.
As I said, I thought it should be, uh, the move to the John Radcliffe Hospital course.
It was very driven, very delayed and quite difficult. I remember going up there, looking around the fort.
It properly opened and thought it was a rather sterile,
austere sort of environment compared to the director's infirmary that we know we eventually adapt to it.
And looking back on all those years from well, from when I came back to Oxford in eighty six until I retired from the National Health Service in 2007,
um, I found it enormously rewarding and enjoyable.
And I, I find it impossible to identify what I read in the papers now about the NHS in decline with the my experiences in Oxford during those years.
You know, I had enormous confidence in my colleagues. I had marvellous colleagues, um, at all levels, um, certainly the nurses,
marvellous nurses and also enjoyed wearing board, which was our specialist ward, uh,
outstanding nursing wear and marvellous conservative colleagues you could absolutely rely on and a succession of very good junior staff,
um, almost without exception. So, uh, that may sound a bit too rosy and naive.
It really is a bit of a contrast from from mid staffs and the current perception of what's happening in the NHS.
And you endured the clinical students very much indeed.
And I think the best teaching format is the Ontake round, where they see the consultant often quite stressed, having to, uh,
implement the principles that they've been taught about, um, uh, meticulous but highly focussed history taking and and basic examination.
And, uh, also a lot of, uh, Natalie, when we had enormous takes, I once had thirty five one take the need to, uh, to sort of prioritise,
uh, and to to make the best use of time because the consultant, you can't just you can't take your Waldron's for twelve hours or something.
You've got to bear in mind that the junior staff have to go off and actually do things, have to implement the decisions made on the road, you know.
But you know, yeah, I think it was a superb system.
Um, when I first came back to the job to Oxford in seventy five, we had joint consultant Waldron's, which I must say were not easy.
I had Grantly and then Julians on my joint Waldron's and these were extremely difficult.
I won't go into further detail and I can imagine it a bit.
And in a way I like the idea of it was a great luxury to have, uh, a discussion amongst consultants, but that quickly dropped out.
Was that just once a week or when you're doing it more? No, twice a week.
The IT wardrobe's. Yeah, yeah. We only did it once a week and often, but in uh of course with in infectious diseases,
which became my speciality, um we also had joint Waldron's once a week, which were very, very useful.
We had people like uh. And to Peter and I have a bar and, uh, to turn it around, uh, a really good discussion and also to have a microbiologist,
I think John Tobin and job cuts were the last ones who actually came on the rounds with us.
It was tremendous to have a microbiologist as well to help. So I think the concept of multidisciplinary round is very good.
How much was AIDS affecting the infectious diseases? Well, this was this was another great revolutions in my career, uh,
where I came back from Thailand in 1986, which there had been a few cases of HIV in Thailand.
They were generally reckoned to be foreigners, um, uh, who'd been infected.
And, uh, there was some suggestion that there was a dawn of an epidemic amongst, um,
heterosexuals associated by the very high levels of sex workers and so forth, which Bangkok is famous.
That and, uh, it really hadn't taken off.
It hadn't made much impact on the clinical patients we saw in in, uh, in Thailand, the province at that time,
because back back in the U.K., uh, was it an enormous issue for colleagues working in Africa?
And Richard Dole was very quick to involve me in this.
And I was very grateful to him for that.
And it was, um, I think partly through his influence that I was asked to be chairman of the Marci's HIV, um, uh, Therapeutic Trials Committee.
And that introduced me as a completely new world, the the primadonnas of HIV in London, in the different London hospitals.
They were quite a to deal with. I think that's why I was brought in, because I was regarded as being outside the Mafia,
a simple yes, but of course, an immensely absorbing and challenging study.
And I the international meetings, we had joint studies with the French, with Maxime Seligman, the brilliant, uh, French immunologist.
He was the head of the French side. I was the head of the, uh, UK MRC side.
And we collaborated in a number of, uh, really epoch making, getting a bit hyped up here, uh,
trials in the early days of antiviral therapy, um, leading to finally to the concept of combination therapy has been very effective.
Um, so that was all new, all new learning the to an outsider and I may have this quite wrong.
You know, the AIDS scare brought a lot of money into infectious diseases and in a sense,
too much, it seemed at the time, but it did infectious diseases good.
They got a lot of knowledge, did a lot of things. You see a number of around the world.
I also hadn't gone into a lot of detail about the other things I was doing.
But I started working in Brazil in 1989 and the most famous infectious diseases hospital in Sao Paolo,
um, uh, was about to close because it's just running out of patience.
So, of course, the arrival of the HIV and in its wake to a surge of tuberculosis and other opportunistic infections, uh,
meant that all of these hospitals were suddenly large drugs being closed and certainly an enormous amount of money came into HIV.
And this is made mainly, I think, because it was a it was a disease.
It was a new, uh, recognised infection that involve Westerner's and, you know,
in the United States, it was supported very high level sort of Hollywood and everyone film stars.
And it was a colossal level. Well, an appropriate level of compassion, uh, compassion for the whole sexual victims and others.
And, uh, inevitably, this this brought vast amounts of money.
This wasn't entirely good because it was sometimes confusing.
I remember, um, Keith McAdam and I went to welcome centres to, uh, Nairobi and Kampala to,
uh, to to to set up a collaborative research study on clinical aspects of HIV in Africa.
And it was very difficult to, uh, keep any, uh, local African doctors because they would be tempted away.
Some American institution will come in and immediately offer four or five very attractive fellowships to Seattle or somewhere,
and that could be very distracting when you were trying to build something up on the ground in the country.
So, um, but no, you're quite right.
That unprecedented amounts of money and of course,
the effects of that was seen in this rapid development of antiviral drugs may have gone on improving.
Yes. But also a lot of interest in research, uh, tremendous amount of publications.
It's become a subject in itself and it's dominated the practise of infectious
diseases that a few years ago there were complaints from one American hospital,
Infectious Diseases Centre, that the, um, that they're treating these we're not getting the full experience.
All they learnt about was HIV. And now did the world come ever felt to back you when you were wanting to set up places?
Um, and I'm sure they did, but I can tend to remember the very positive things.
You know, they've supported me not only first in Ethiopia when I went out from Warren Campbell's department in 1968 to work with Rick Perry,
that was welcome support. They supported me in a much Baylor University in, uh, Nigeria from 70 until 77.
Uh, they supported us, of course, in Thailand, continue to support us.
They supported the, um, start of the United Khaleefa and Nairobi in 89.
And they supported first Nigeria No Khalifa's Kenya coast of Karnataka.
That's where Kevin Marsh set up his fantastic, uh, uh, unit to look.
Initially, it was a childhood cerebral malaria.
Um, and it was a very interesting comparison across continents and across age groups between the studies that,
uh, uh, Nick and I were doing in Thailand, adults and the children, uh, Kevin was studying in Kenya.
And then they welcomed supported me in Papua New Guinea as well.
Uh, workers on snakebit there. So, um, I'm sure they have in fact, they they did they they withdrew their support.
We we had, I thought, very exciting projects.
I mentioned going to East Africa with Keith McAdam, who was the London School of Hygiene, uh, to set up work on HIV.
And, um, uh, my team leader there was Charlie Gilks.
There was a very bright young chap who's gone on to achieve very great things in the world of international HIV AIDS here.
The next generation down from the other. Yes, yes.
Um, and, uh, he was, uh, he was, um, uh, uh, till quite recently head of the United Nations HIV project in India.
He's in Delhi. Anyway, um, he did some excellent work in Nairobi, working, uh, in Kenya at a hospital there on the, uh, uh,
causes of death in Kenyan patients who became HIV immunosuppressed during that very early stage of immunosuppression.
They could fall victim to common or garden infections like pneumococcus and and salmonella.
Um, but our project there was terminated by the trust, which was very disappointing.
Um, so, I mean, it's always very competitive with the welcome.
And not all our applicants for senior four principal fellowships have been successful.
But on the whole, successive directors, after Peter Williams, it was Bridget Ogilvy.
Um, and, um, subsequently, uh, we've we've had a lot of support from from, uh, port.
Um, really, we we've been extremely lucky and extremely fortunate.
You've earned it. But I associate your snakebit work with Africa somehow.
Is that fair? Well, it started in Africa. Yes, it started when I was working in Zarya.
And, uh, and that was actually I had a slight problem with the work and with that project because, um, they'd funded me to go.
And there are other examples of this. Uh, my proposal was centred around epidemic meningococcal meningitis, which is a phenomenon of this,
uh, this strip across Africa like, uh, meningitis belt, which is sub-Saharan Africa.
And based on previous seasons in Zaire, uh, we.
We could guarantee you the three years I was going to be there, I stayed for much longer, uh, uh, 10 percent of all the hundreds of patients,
uh, with meningococcal meningitis would have cardiovascular complications, you know, sort of thing.
The horrific pictures you've seen meningococcus see me.
I was shocked. So high case fatality.
But when I got out Nigeria, almost inevitably, the epidemic seemed to change their pattern.
There was lots of meningitis, but we just couldn't find anyone with any problems with the way they had other problems, horrible problems.
They didn't have shock. And so I of course, rather than sitting around, uh, I looked at other diseases.
And so my interest in rabies arose, my interest in snake bites arose, interest in asthma arose.
And none of these things were on my proposal.
And so Peter Williams and Chris Food were a bit tough with, you know, you were meant to be going out there to study this.
You seem to be doing something rather different. And I was being blamed for opportunism.
I always have been blamed for lack of focus and also for phenomenology.
And I plead guilty to all three. Yeah, they're all good, I think.
Well, not no, I do anyhow.
Now then the actual book takes the medicine. That must have taken a bit of time.
Yes. And I was that was in the just before I left Oxford for Nigeria, that that was, it was its inception.
And I was of course enormously flattered when I was about the youngest consultant that, uh,
David Wetherall asked me, uh, and John Ledingham to to join him to edit the first edition.
That was a colossal breakthrough for me. I was deeply, deeply flattered.
Um, and, um, uh, of course, it was a fascinating experience to sit with people like David Wetherall and John Ledingham.
Well, they, on one hand worked through all the great names of English medicine, deciding who and who not,
uh, might be suitable, uh, um, as authors, but also the selection of material and,
uh, discussed well, just the design of the book and then going through these early editions and gradually developing much stronger,
more definite ideas. Uh, that was more or less.
But it was it was very time consuming. It was it was very enjoyable.
And it kept me from being too, uh, focussed on these, some would say, rather esoteric diseases.
I was studying in tropical countries. And you were talking about infectious disease and what else?
Um, yes. What we divided up. I, uh, I've always done infectious disease and environmental, uh, disease and toxicology.
And I think in the early edition, aged respiratory disease,
because of my early training in Risborough Allergy and a few other odd piece of dermatology.
Uh, so we divided it, um, roughly. And you mentioned asthma out in Africa, uh, because that's the first time you mentioned asthma.
Obviously, the chest work came out of that really well.
That, too, was fascinating. And that was phenomenology, uh, because, all right.
I was a I'd been interested in asthma when I was training the chest physician.
In fact, um, uh, in fact, I published quite a lot on asthma when I was at Hammersmith with with Charles Fletcher and Byron Campbell.
We were looking at new drugs, like I said, in cromoglycate, different I would tolerate not Colin Dolorean bronchodilators.
Um, and so, uh, so when I got out to Nigeria, um, a phenomenon was increasing numbers of people coming with asthma.
In fact, so many that I was asked if I'd set up an asthma clinic and, uh, the drugs were very limited indeed.
We only had an oral bronchodilator and they didn't have inhalers initially and they didn't have any,
um, uh, anything to measure the degree of airflow obstruction.
Um, so I took this on and very quickly accumulated very you know,
what it's like to run a chronic disease clinic is a very loyal group of followers like you diabetics.
Um, and lots of interesting findings.
You know, they were fat. They were asthmatic families. Uh, they were people at.
Developing asked very different ages and whether they were rural or urban.
And it was beautifully tied because this phenomenon was being observed in many other countries.
In Papua New Guinea, for example, an epidemic of bronchial asthma, which seemed to be associated with, as you might say,
civilizational contact with Westerner's and inevitably no use of vaccines, antibiotics and the behind.
This was the hygiene hypothesis, the idea that if you wiped out these early childhood exposure to to to bacteria,
you might divert the immune system down the street to pathway and enhance the sort of anaphylactic phenomena typical of the topic disease.
People who are, um, prone to those, um, with, uh, bronchial asthma and an eczema and, uh, hay fever being some of the patterns of disease.
And we looked into that and I was very lucky in that area.
I had some brilliant colleagues, Brian Greenwood and Anthony Bryce, and set up the MRC immunology lab there.
So we were able to measure things like immunoglobulins. Um, and, uh, we also, uh, looked for the causative allergens that we found,
incredibly dense populations of house dust mite, the bits of these asthma victims.
So without getting into any more detail, it was a very rewarding experience because with simple means,
we eventually introduced the use of bronchodilators. And, uh.
So what did you think was the causative drive, really?
Well, I believe very much in the hygiene hypothesis. I didn't there's anything else that would would explain this, uh,
almost global emergence of asthma and other ectopic diseases as people came under
the influence of what most of us would regard as highly beneficial things in India.
And this has been demonstrated even in European populations, for rural populations in, um,
in Switzerland or Austria, where children brought up, uh, close to farm animals and things like that.
You know, you might say around in a very contaminated environment, uh, show very little,
uh, uh, risk of a very toxic disease because there's a lot more to it than that.
And it's still it's still only a hypothesis. And it is controversial.
I think it's right to say that at this moment in, uh, 2014,
there is increasing evidence in favour of the hygiene hypothesis we're getting towards the end.
What happened last year about the Richard of. Um.
Missed opportunities, frustrations, disappointment, which are the big ones, which are the big ones?
Oh, don't you want to talk to them? Well, I'm very disappointed.
I haven't been able to do more for some of the neglected diseases, some of what I call of lost causes.
Um, I put a great deal of effort into snakebit, not just in the countries where I worked, but internationally through WHL and other UN agencies.
And I haven't been able to convince really almost anyone that snakebit is and it's an important public health issue.
And a few years ago, I was introduced through Richard Peto here in Oxford to, um, Prabhjot, who's a, um, uh,
an ethnic Indian who leads a group based in Toronto who set up a series of fantastic studies in India called the Million Deaths Study,
was originally structured to look at the, uh, effects of tobacco smoking.
But because they've got this nationwide very well designed randomised sampling system, they're able to look at other diseases.
And they were able to look at the mortality of death by, uh, snakebit in, uh,
in India and found the extraordinary figure of forty six thousand people dying of snakebite, least in 2005 in India.
And that's a staggering figure when you think that it that one snake by death for two HIV deaths in India.
And that finding was published in the journal.
But it was it has been almost totally ignored in India and it just hasn't been possible to to raise the profile of snake bite.
Um, none of the these marvellous agencies like the the Gates Foundation, uh, take any interest in snake bite.
They say, well, it's not an infection. It can't be eradicated. You can't vaccinate against it.
So we're not interested. And I think that there is a deep seated prejudice against snake bite.
It's the usual reaction is one of humour. If you mentioned snake bite, you think it's somehow love, perhaps it's fear of it.
It's it's that's a major disappointment because I feel very much for the suffering of snake bite victims.
They're nearly always impoverished. Country people are often children, 40 per cent of them are children.
We have effective antidotes available. And a great deal is known about how you should treat snake bite that because of
a whole lot of problems of not being including the included in the curriculum,
untrained people,
the problem of the peripheral levels of the health service where you don't have, um, well qualified people even who give intravenous injections,
all these things mitigate against, um, improvement in the management of snake bite.
And that for me is is a major disappointment. But at the same, uh, I feel very sorry that we have built more about rabies.
Um, and, uh, you know, again, with with very effective, um, vaccines, uh, one of the first vaccines ever developed.
People are still dying of rabies. We don't know how many, but it's probably sixty or seventy thousand a year at least die of rabies.
Uh, and even those who don't die are subject to a prolonged period of anxiety.
Is this the east, would you say? Oh, it's well, the deaths are largely in Africa and Asia, right?
Yeah. And the thing that I missed out, uh, very early on is the pattern back to to terms.
How did you enjoy that pharmacology, too? Yes.
Well, we were lucky with our teachers and we came in contact with Howard Florelle, people like that.
And, of course, with Bill Paten in pharmacology. Um, no, they were good.
It was slightly makes slightly, um, anticlimactic after finals.
And I for one, I think I reacted very badly to doing quite well in finals.
I relaxed a bit too much and started listening to music.
I know, but it was I did enjoy those two terms and I think is absolutely right that one should have that emphasis on these really basic subjects.
I mean, from what you say, I guess you got a person, did you? That was great.
And but you also said earlier on hostile and competitive.
That year, and I was a bit surprised. I mean, did you feel that the world of Oxford was against you?
I think more I felt somewhat inadequate.
It was an inferiority complex, faced with so many confident people who were more articulate than I was, who are wealthier than I was as well.
I mean, there was a bit of a chip and that class related chip.
Had you come to terms with the Internet and then. Well, I got to know some of them very well and good.
I mean, Christchurch was a really extreme example in those days.
It was not far from Brideshead Revisited. The Bullingdon Club was there and there were excesses of of spending and so on.
There was a chap who drove off a whole lot of golf balls to the windows in Pequots.
There was another who hosted a party where he was champagne and lighting cigars using five pound notes.
And there was a strong political figure.
You never got to Brideshead in the vacations, as it were.
I mean, you never visited Great Home. No, no, no, no.
I was I was very mixed in with such people.
Then last question. Unless you've got something else to say, the NHS in Oxford directive hospitals, do you feel it's changed four to one now?
And if so, in what way? And what do you describe it?
Or maybe you don't feel it's changed? Well, I told you the initial problem faced me when I came to Oxford.
First came in at, what, seventy five was the tremendous pressure on beds,
the problem of admission and pushing people out as quickly as possible and not being able to to move them around,
as one felt, might be most effective. And I don't think that's changed.
And we still have enormous pressure. Uh, you know, there were times as admissions office where I had to put up red alert to do closing the hospital.
And I always used to say, why can't we put up extra beds?
Because I worked in Africa and in Africa. You never you put two patients in the bed, you put them under the bed.
If you've got them, you put up extra days. But that was completely rejected in in Oxford.
It was it was one of the rigidities of our system. And of course, they were very good reasons given, you know, we can't nurse under these conditions.
We have can't have crowded with who's not safe. You know all the reasons against it a bit.
But the simplest thing,
you've got a patient in urgent need of admission rather than sending them to regrading or keeping them in casualty on a trolley,
everything is put up an extra bit. Yeah. So I didn't think things change very much.
There was still this pressure. There's still a feeling that we were a very popular hospital or at least a very popular a very pressurised hospital.
Did you think the administration changed the civilian administrators when you were not get in?
I just wanted to touch on is interesting that recently I've started I've got to know Nigel Crispier now he's Nordquist,
but he's very interested in global health and has been very helpful in promoting various things.
I know doing my new manifestation, but it's the call it.
Yes, yes. But Nigel, of course, was an outstanding chief executive here and his style of management was was so absolutely right.
You know, if there was if things were really bad down in Casualty, he would come down.
Right. And that hands on management, that idea that you're not secreted up in an office, segregated and protected from the realities of the system.
Yeah.
So, of course, I share the antipathy towards many aspects of our administration and most of the managerial class and the decreasingly medical well.
Clinical experience of the managerial class.
So, yes. Do you think protocols have been imposed too much?
Well, this is a this is certainly a change. If you're a junior doctor now, you have to work by guidelines a lot.
And on the one hand, you know, I prove the concept of a consensus arriving at an optimal way of management.
But I think the guidelines are far too constraining. Uh, I don't think that's education.
I didn't think teaching people to follow a guideline is medical education.
It's just the opposite. That's been a marvellous interview.
If you agree, I'm going to start. But if you want to say something else, do.
That's quite enough of me there. So much for indulging my reminiscence with nostalgia.
Thank you very much, David. Absolutely. Super.