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Monday, November 5, 2012

The Professor Who Killed Smoking

Exactly hundred years ago to last Sunday, 28th October, when a male child was born at Hampton into the affluent family of the Dolls, no one knew that he would one day save millions of lives, that too, “without touching anyone”. That boy was none other than Sir Professor Richard Doll, a British physiologist—who “published 436 works—eight for every year of his working life” (by the age of 84 years) and continued to research up to his death at the age of 92 in 2005—whom the medical fraternity revered as the foremost epidemiologist of the 20th century.

Richard Doll grew up in London’s Knightsbridge in a “magnificent 18th century house.” He went to Westminster School, where his brilliance in mathematics came for praise. Much against the wishes of his parents, who wanted him to become a doctor like his father, he, intending to study mathematics at Trinity College, Cambridge, gave the mathematics scholarship exam, but due to an excess of Trinity beer the night before, failed. Although the authorities offered him a second chance, feeling embarrassed, he switched over to medicine and went to St. Thomas’s Hospital Medical School, King’s College, London, from where he graduated in 1937.

Although born into and brought up in a comfortable, middle-class affluence, right from his young age, Doll’s leanings were more towards the Left, for he believed: “Capitalist society was just not working.” As a young man in the 1930s, witnessing suffering, mass unemployment and malnutrition all around, he joined the communist party, describing himself as a “democratic communist”. He spent his twenty-first birthday money to visit the Soviet Union. He took part in the Jarrow March, the 1936 mass protest against unemployment, and offered medical assistance by way of treating destitute participants’ blisters. Despairing that only the rich could afford good doctors, he joined the Inter-Hospital Socialist Society and campaigned to the point of almost being ostracized from the medical establishment for the formation of Britain’s free National Health Service in 1948.

During the World War II, Doll served in the Royal Army Medical Corps in Cairo and at Dunkirk (1939-45). After the war, he married Joan Faulkner, a left-wing medical colleague. Returning from the war, he joined St Thomas’s but looking to the kind of sycophancy going around, he felt that instead of working as a clinical physician, he should look for a decent appointment.  Driven by this discomfort and  encouraged by Joan, Doll took a post in clinical epidemiological research in gastroenterology, where he came out with statistical evidence to the effect that peptic ulceration was caused more by stress.

Then, in 1947, the pre-eminent medical statistician, Austin Bradford Hill, head of the MRC Medical Statistics Unit at the London School of Hygiene and Tropical Medicine, a known political conservative, not minding Doll’s politics, offered him a temporary research post, believing that “once you have got obsessional about research, you haven’t got time for communism…” That is where he, along with Sir Austin Bradford Hill, embarked on their investigation into the causes of lung cancer—a disease that caused much worry to the then British scientists, for, a rare disease that it was once, had become “commoner and commoner.” Yet nobody knew the real cause of it.

Some speculated that exhaust fumes of motorcars might be causing the disease. Doll himself thought that “the rise in lung cancer was something to do with the tar on the road.” However, when Doll and Hill administered questionnaires to patients with suspected cancers in the hospital, enquiring their background, social class, where they lived, whether they owned a car, ate tinned food, smoking habits, etc. and compared the answers, they found that those confirmed patients with lung cancer almost always turned out to be smokers, while all those who got the all-clear were not smokers. It is interesting to recall how Richard reacted to the progress of this study: “It wasn’t long before it became clear that cigarette smoking may be to blame. I gave up smoking two-thirds of the way through the study.” Finally, in 1950, Doll and Hill published a report in the British Medical Journal indicating a correlation between smoking and lung cancer, for in a survey of 649 lung cancer cases, there were only two non-smokers.

Their conclusion that cigarette smoking was “a cause and an important cause” of lung cancer was however greeted with “apathy, disbelief and scientific condemnation”, writes his biographer, Keating. It was perhaps obvious, for the news came in an era when 80% of British men were smokers. Even medical scientists did not accept these findings. The government too was not comfortable with their findings, for 14% of its tax revenues were from tobacco sales.  

To understand the real role of smoking in lung cancer, Doll and Hill wrote letters to 40,000 doctors in Britain in 1951, enquiring them if they smoked. During the next three years, they compared these answers with the information about doctors who developed lung cancer. Based on this statistical information, Doll then co-authored a paper with Hill confirming the link between smoking and lung cancer. This prompted the then UK health minister to call a news-conference and declare, ironically chain-smoking throughout: “It must be regarded as established that there is a relationship between smoking and cancer of the lung.” This study, besides bringing down the percentage of smokers from 80% in 1954 to 26% by 2007, ultimately became the foundation for all subsequent research on the impact of cigarette smoking on health. Which is why, it is often said that Doll’s findings saved millions of lives all over the world.

Indeed, Doll, strongly believing  “Death in old age is inevitable, but death before old age is not,” actively engaged with public policy and litigation cases pertaining to cancer causation. Although initially he had chosen to act as a scientist simply to present the evidence and allowing the concerned to act on it, in later years, he testified in courts against tobacco industry and even advocated banning tobacco promotion.  

Having established the relationship between smoking and lung cancer, Doll turned his attention to study the role of asbestos in causing mesothelioma—a rare form of cancer that develops from transformed cells originating in the mesothelium, the protective lining that covers many of the internal organs of the body; harmful effects of nuclear radiation; role of electrical power lines in causing cancer; the relationship between drinking alcohol and breast cancer, and the link between the contraceptive pill and thrombosis and its preventive effect on certain cancers.    

In 1961, on Hills’s retirement, Doll became the Director of MRC Statistical Unit. In 1969, he moved to Oxford as Regius Professor of Medicine. Despite the initial hostility from the fellow doctors for his known left-wing orientation, he enjoyed an intensive decade of work at new frontiers. Besides training many young medical researchers, he developed his cancer epidemiology research unit, and established Green Templeton College for medical students. In the process he made Oxford a world center for epidemiology.

All through his research life, Doll was driven by the philosophy of caution, thoroughness and social responsibility. In the words of Keating, his biographer: “[Doll believed that] if an investigation found something that was unexpected and which was going to be of social significance, then there was an obligation to make sure that the answer was right before publishing the results to the world.”  Doll thus “ushered in a new era in medicine shaped by the intellectual ascendency of medical statistics”, indeed a new “philosophy of epidemiological research.” His concern for the human welfare well reflects in what he said: “The objective of science is to gain power to control nature in the interests of humanity.”

His pioneering work on many fronts won him countless awards, the notable being the United Nation’s Award for cancer research in 1962; Knighthood from Queen in 1971; Bruce Medal from the American College of Physicians in 1981; Royal Medal from the Royal Society in  1986; Gold Medal from the European Cancer Society in 2000; and Norway’s King Olaf V Award for outstanding work on cancer.

Even this known lifelong socialist, whose only concern was welfare of mankind, could not avoid allegations—after his death, articles appeared alleging that he failed to disclose payments received from a chemical company. The prime focus was on the money received from Monsanto. But his biographer Keating says that Doll never hid his relationship with industry, but was careful to record all his dealings, as could be seen from the documents deposited with Welcome Trust Library. It is said that all the money received from Monsanto was handed over to charity. Keating argues that “Dolls’ reputation was built on integrity.”

A streak of this personal philosophy of Doll perhaps reflects in his plea made from his deathbed. In 2005, as his life was nearing its end, Doll had asked the Oxford GP and the consultant cardiologist attending to him at the John Radcliffe Hospital to suspend their Hippocratic oaths and expedite his death, for, according to his biographer, Conrad Keating, “He strongly believed that it was wrong to spend large sums of money trying to keep an old person alive for a few months when, by spending less money, a young person could be kept alive for 50 years”.

That is Sir Richard Doll, the patrician-turned-revolutionary—a revolutionary in the realms of politics, medical science, academia, and public health.



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