Why did you decide to get involved in social medicine?
I worked in Mozambique during the early 1990s doing child and maternal health and then came back and worked in general practice, but also doing some community obstetrics and women’s health work. In Mozambique the ‘revolving door’ that sustains health inequalities was very clear. A child would present with severe malnutrition, severe anaemia, malaria, TB and possibly HIV; a woman would present with obstructed labour and would also be severely malnourished and likely have TB and malaria.
We could treat the infectious diseases (though for a variety of reasons adults would often leave the hospital before treatment were completed). With the children in particular we could often make real improvements in their nutritional status with long-term stay and a relatively cheap feeding regime of milk, oil & sugar. But of course the people went back to the circumstances that led them to the hospital in the first place (or in many cases to death before they got there).
When I was back in the UK I suppose my eyes had been opened and whilst the extremes of deprivation were not there the ‘revolving door’ was. There was an interesting period in Bradford where I worked when the local obstetrician took exception to the number of labours and births that were managed by GPs – these were often in hospital but there were also a number of planned home births.
I remember one consultant saying something along the lines of ‘how could medics condone this when they know how unclean and unsuitable some of these homes are’ and thinking: “so they are born in hospital and maybe spend 12 hours there before going home – to their ‘unclean and unsuitable’ homes; surely if they really are so unsuitable for birth they are likewise unsuitable for an infant and child to be brought up in and ‘medics’ ought to be concerned about that”.
At the same time I was increasingly interested in medics arguing about their territories and the fact that the way someone was treated (especially on acute admission) depended as much on which consultant was on call as anything else (this was pre „evidence based medicine‟!). So I slowly realised what I was interested in was how to work out scientifically what treatments ought to be; but really more than treatments, whether we could understand how to stop the revolving door and improve people’s’ health.
What three pieces of advice would you give to an early stage researcher looking to have a career in social medicine?
1. Keep your mind open so that you are open to your ‘own’ hypotheses turning out to be wrong and so that you are able to learn about new areas of social medicine/epidemiology and their possible relevance to your work.
2. Collaborate – it’s fun, it’s important to expand knowledge and skills and it is necessary for ensuring findings are robust; it can be hard work but it mostly pays off hugely.
3. Teach – in the broadest sense – if you can explain your research and area of work to others, you are likely to really understand it.
What area of social medicine do you think most needs to be researched in the next 20 years?
The last time I saw Jerry Morris before he died, he asked me, ‘What are you doing about sarcopenia and age related physical decline?’ He pointed out that a lot of research (rightly) was looking for the causes and how to prevent dementia, but for many elderly (himself included) cognition had remained reasonably intact but even after a life of being physically active their muscles got weaker and their physical capability limited the extent to which they could remain independent. It was something that clearly frustrated him. He also said (with a twinkle in his eye), ‘It will be us Epidemiologists who get the answers, not the lab scientists’. I think he is right – ageing research – in terms of how we can maintain healthy independent living into older age has to be a key for the next 20 years.
I also think (at the other end of age) developmental origins will continue to be important – I am particularly interested in developmental overnutrition – how/ whether the obesity epidemic and associated diabetes risk might be ‘overfeeding’ fetuses and setting them on a life of increased obesity/diabetes risk. This was what my Pemberton lecture was about. I think the evidence is not clear currently, but it is potentially such an important driver of public ill-health that it has to be looked at more closely. In both of these, epigenetics may turn out to be very important. I am not an expert at all in this area, but it feels at the moment it is given as the answer to any question where there are uncertainties so of course we need good research – and good epidemiological / population level research – to really understand where these processes are important and how knowledge about them can be used to improve health.
What was your first ever publication about, in 30 words or less?
Excluding correspondence, my first ‘real’ publication was a systematic review and meta-analysis about the effect of physical activity in the treatment of depression. I did it as part of a course on systematic review skills for clinicians at the University of York (I do not know if they still do it but it was wonderful – we did a day a month at York and in small groups worked through a review of a question that was relevant to us). I thought the answer would be that there was clear benefit; that was not the case and I realised then how important robust systematic approaches were.
What is the publication that you are most proud of and why?
This is difficult because I hope that my more recent publications in general do improve on earlier ones, as I have gained more knowledge and skills and also as the field has moved forward.
So at the moment I think one of my most recent publications, the prediction tool for predicting live birth in couples undergoing IVF treatment (see below) – is one I am proud of. I think it is an important area and we have established an on-line calculator (that has been used by over 30,000 individuals) and a telephone application for doing the calculation that can be used in clinical practice.
Reference: Nelson SM and Lawlor DA. Predicting Live Birth, Preterm Delivery, and Low Birth Weight in Infants Born from In Vitro Fertilisation: A Prospective Study of 144,018 Treatment Cycles. PLoS Medicine. 2001; 8(1): http://eprints.gla.ac.uk/45918/1/journal.pmed.1000386.pdf
If you had to recommend one book (preferably a popular science book, but could also be a text-book) for an early stage researcher in social medicine to read what would it be?
‘Some lives’ by David Widgery – it is not a methods/text-book – but I guess it relates to my first answer – a mutual friend sent it to me when I was working in Mozambique. I remember reading the introduction and being worried about David’s health in trying to manage what he was trying to deal with and I guess it also opened my eyes to the ‘revolving door’ in the UK as well as Mozambique.
What is your favourite Social Medicine/Public Health related joke?
This is really old – I remember it from SSM conferences about 10 years ago but it still makes me laugh (PS others could probably deliver it better than me).
“There are three statisticians and three epidemiologists going to a conference together. The epidemiologists each buy themselves a ticket, but are surprised when the statisticians buy just one. As the ticket inspector comes round, the statisticians run off into a toilet cubicle and, when the inspector knocks on the door, they pass the ticket under the door fooling the inspector. On the way back, the epidemiologists buy just one ticket, but are again surprised when the statisticians buy none. As the ticket officer comes down the corridor, the three epidemiologists get into a toilet cubicle. One of the statisticians then knocks on the door, takes the ticket (which the epidemiologists dutifully pass under the door, thinking it‟s the inspector), and the three of them get in the other toilet.”
If you weren’t a scientist, what you be?