This is the Challenging Neglect podcast series. I’m Erman Sozudogru and I’m Samantha Vanderslott. Today we are here with Conrad Keating who is the resident writer in Welcome Unit in Oxford. So, thank you very much for joining us today, Conrad. If you can tell us about your background as a historian, and later on we’ll come to your links with Neglect Tropical diseases. Thank you very much.
Thanks for having me along today. It’s very enjoyable and good to meet a new generation of people. My own background is that I’ve always studied history. I’m a professional historian. My first job was a school teacher, which I failed at, but I wanted an idea of public service, but I was poor at it. And then I joined the BBC where I worked in dramas and documentaries and later ended up working on news.
My introduction to Richard Doll, the British epidemiologist, was I was sent to Oxford to make a film about him in 1996. It was the 40th anniversary of a paper he’d written on his famous British Doctor study. Richard, of course, is very important to British health, world health because he changed the health of the nation with his work on the dangers of smoking and the benefits of quitting.
When he did his first work in 1950, it was a retrospective study of people in 20 hospitals, 20 London hospitals, in fact, and he published with his mentor and boss, Austin Bradford Hill. They work just around the corner from here on Gower Street. They published a work saying that smoking was the cause, an important cause of the epidemic of lung cancer and no-one believed them, so they thought what can we do; how can we persuade people to the righteousness of our work, so they decided they’d find a group of people, find out their smoking habits, and then follow them, in Richard’s case, to extinction.
And so they wrote to every British doctor in 1951, got 60,000 replies and Richard followed them for the next 50 years, and once doctors realised smoking wasn’t just killing their patients; it was killing them, British doctors began to give up smoking, began to get statistics on what are the benefits of stopping smoking for ten years, 20 years and 30 years.
So, I wanted to get back into academic life and the Welcome Trust gave me money for a year, but it kept coming, and I eventually, after seven long years; biographies are very difficult things to do but I wrote Richard’s biography and came out in 2009. I started working on it in 2003. And that was published and I’ve stayed on.
My real interest is public engagement. People, increasingly, don’t really understand and are sometimes frightened by medical research – stem cells in America and the like, so the, my last big piece of work in public engagement was an exhibition in oxford at the Botley Library, about Oxford medicine, called 800 years of Oxford Innovation, and that exhibition went for six months and we had 55,000 visitors, and I wanted to show people in Oxford what Oxford had done to increase the health of people and to reduce the burden of disease.
In Oxford today, the medical side is enormous but it’s outside the medieval walls of the city so when people come to Oxford they know nothing about penicillin, the work of William Harvey or indeed Willis, so I wanted to have it somewhere there in the centre. And my own work today, which resonates with our meeting, is that I’m writing a piece, partly biographical, about an American called Kenneth Warren, and he started, while he was at the Rockefeller, a programme, a very important one called The Great Neglected diseases of Mankind, a rather grandiose title, but he invented really the lingua franca, so now, in your own case, this word, neglected, this is where it comes from.
And what time are we looking at when Kenneth Warren was writing this; when was this term coined?
Warren went to the Rockefeller Institute in 1977, and the first meeting was at the end of 1977, in the Abby Aldridge Rockefeller Hall, and the programme itself was from 1978 to 1988, and it was great. The reason why he got the title from because…
That’s a very peculiar title when you think about diseases.
It is, and it was great because the diseases were killing many people, children particularly, in the developing world and it was neglected, and that term came from because the new molecular sciences were not being applied to the old parasitic diseases, and also there were no big funders going in, so at the Rockefeller, we see this title and then the global attempt by Ken Warren to select people in America, but in the developing world, in Europe and they were all going to bring this new biology, this new molecular medicine to bear on the old diseases.
I mean typically what had happened in Britain, people had been out in the tropics maybe 20 years and so they hadn’t really seen this new molecular medicine that had been developing in Cambridge and Oxford and in London, and so these were young people who had never thought about parasitic diseases and he had to try and get them interested, because he knew if he could get them interested in these old diseases, they would come up with new and better ideas about the causes and the mechanism of the disease, which he was really interested in.
Do you know anything about the reception of that term to the audience that he was targeting it towards; what kind of reactions he got to this packaging of the diseases?
Yes, I do. So he recruited these people from around the world and he met David Weatherall of the Weatherall Department of Molecular Medicine in Oxford, in 1977, in some, according to David, some decadent hotel in Victoria, and David thought it was a rather grandiose thing, and he didn’t think it would ever really take off, and people, I think they were already thinking about neglected diseases. It was kind of in the air, not so much neglected diseases, but then just tropical diseases, and David was sceptical but when he heard the funding was going to be for eight years, and all you had to do to get the funding was to go to the annual meetings, he decided he’d go along to the first one so, but it wasn’t just about the money, but obviously the money was interesting. But from Weatherall’s point of view it seemed an odd title.
But what was his background, Kenneth, here?
Warren himself was an American. He was interested in schistosomiasis was his disease. He worked on mice in labs. He worked at Case Western Reserve. He’d spent two years in Brazil as a young doctor. He was an interesting guy in that his first degree was in humanities, in history at Harvard and then he changed; after he’d finished that he studied medicine, so it was quite an interesting thing and he always had a great love of literature.
One of the things today is we find those two empires of C. P. Snow between the humanities and the sciences, the gap is quite large often, particularly for young medics; there’s not really enough time to learn Spanish or to think about William Shakespeare in that particular way, so he was working in the field and he was trying to… he was an immunoparasitologist, and he was looking at the sort of mechanisms of schistosomiasis, and what he wanted to do was to expand this template that he’d been working on himself, to other diseases that were equally neglected, so he had a template of how he wanted to do it, and then he wanted to get people, I guess like himself, but who were working at different areas of blood diseases or, which he was really interested in – parasites.
Can you tell us a little bit more about that template and what it entailed?
Yes, so he didn’t really see patients very much, so he was really a lab technician, and when I was… so, he was a laboratory researcher, and I was talking to Bridget Ogilvy about this and Bridget Ogilvy, of course, an Australian who went on to be head of the Welcome Trust, and she was saying she saw Ken in the 1960s at meetings, and she said he was a breath of fresh air. He was actually talking about the mechanism, the molecular structure of the disease itself, where other Americans were merely doing descriptive epidemiology.
So, he was interested in what the schistosome eggs were doing in tissue. That was what he was interested in. And then he wanted to bring this idea of the bench out into the bush where we could get advances and understandings of the mechanism of the disease here, and how it could translate that. This is, you know, translational medicine. People were doing translational medicine before that phrase ever came up.
Do you think this was revolutionary, his template?
It was a new thing on a kind of a global scale. There were several things that were novel about it. One was the length of the funding, and what we’re talking about here is about £100,000 a year for eight years, so nearly $1 million, not big money, but… and in the end it was sort of a declining amount because it was always remaining the same in terms of inflation. However, during this period of the 70s to the 80s, the Dollar exchange was very good, so if you were working in Sweden or in England, you know, that money, the American Dollar, was strong so it give you, it gave you a bit more bang for the investment. So, that was novel.
The other thing that was incredibly novel and something that resonates with our talk today, the whole idea was the one of collaboration, and within a couple of years, and these were all young people mainly, there were 14 units from around the world, many in America, but in Egypt, Mexico, Sweden, Britain, and these people would meet together and they’d go, they’d meet in Oxford colleges, Kenyan Game reserves, national parks in Canada, Mexico City. These people would come together for this period of maybe ten days, talk about their work, what they’d been doing. You couldn’t get away with second rate work. You’d play tennis together, and for the first time it was true collaboration, and you’d start setting up networks with people across continents. This was relatively new. So, in that way, it was novel and it was… in many ways they were outliers for what people are trying to do today.
So, I get the vision of this as a group of people from across, but what did these people… were they all scientists or did they have anyone from outside the Science, from Humanities within that group?
No, they didn’t, no, so these people were all molecular biologists. They were interested in the mechanism of disease. What they wanted to do was come up with vaccines. Did they? No. but, you know, it takes a long time to come up with a vaccine. No, they weren’t, so there were no poets.
I’m not asking for poets but for anthropologists, sociologists, understanding what they are trying to solve in terms of developing these vaccines for?
No, they were interested in the mechanism of disease.
So this is a small bourgeois group of scientists, jetsetters.
It’s interesting; I think if you wanted to make money… I mean it’s different; doctors in America are like gods, you know, they’re almost revered and they’re paid a lot of money, but generally, if you’re in tropical medicine, you’re not in there for the money, and I think Warren thought that the life of a seven-year-old in Nairobi was just as worth as much as a seven-year-old in Brooklyn, and that was certainly one of the things. You know, he didn’t have any private patients or anything. The life of an academic scientist, you know, was… certainly, it wasn’t an impecunious profession but he wasn’t particularly there for the money.
Were they jetsetters? I mean, one of the things that I think annoyed people about the GND was that it was a club. If you’re inside the club it was this great feeling. If you’re outside the club, you notice them. And I think there were accusations of these Johnny-come-latelys. People thought Warren was a kind of a Johnny-come-lately. I think Bridget, from our own point of view, one of the points of criticism she said, you know, I thought he was doing great work but he would give somebody $100,000, we’d give them £1 million and he’d take all of the credit for the findings of that group. So, you know, I think he was trying to magnify the contribution of the GND and some people would say, you know, that was politically motivated but he certainly rubbed people up the wrong way.
I think there was an element, and it’s interesting, the quality of the cohort he chose have gone on to be people who have been enormously important in their separate fields, so I think that’s good, you know, if there’s something today for Paul Nurse: how do you choose good people for the future? Do you actually put them together with these open-minded other people; show them the benefits of collaboration, and then get them to do experiments across frontiers and this becomes a very good mechanism for discovering these diseases or sometimes cures, but in other ways sort of better treatment for people, so I don’t think it was glamorous but I think it was certainly a thing people did feel a loyalty to the Rockefeller Foundation, a loyalty to Warren, and a loyalty to the group.
You just mentioned Paul Nurse there; do say a bit more about what that parallel is.
Well, I think Paul Nurse is on a very much bigger scale. Paul Nurse is one of our most distinguished scientists. He did his work at the William Dunn School in Oxford that earned him a Nobel Prize. He ran the Rockefeller Foundation, of course, and the Royal Society, which he’s still at. He’s a brilliant administrator. Now he’s the custodian and leader of the Crick Institute here in London. This is blue sky thinking and the objectives of it are to discover new and better drugs for whatever. It will be interesting to see what will happen over the next ten years or if ten years is, you know, too short a timescale. But the GND lasted for ten years, and I think what’s interesting is that I think it was very influential that Warren himself has been neglected so I thought in that way, it’s important and, of course, today, as we know ourselves, diseases are fighting to be put into this neglected square so he invented an interesting sort of language and he, himself, has been forgotten.
So what happens between GND from 88, you said, til 2000 where we see momentum in neglect of tropical diseases research, so Peter Nurse is now planning and coming up with the first group of neglected tropical diseases. There seems to be a time lag between… so if you can tell us what happens to GND, what happens in 90s, and because Europe trained them as GNDs, they’re a sort of precursor to what we’re having now?
I think what happened was that Warren was director of Health Sciences at the Rockefeller Foundation and he was there for ten years. You know, ten years is an age. In the end was he pushed out? Did somebody new come in and think okay, let’s do something about non-communicable diseases? You know, I’ll come in; we’ve got a limited bit of money. We’ve had ten years of this. It will either sink or swim. You know, things sort of change. So when you get a new director, that new director might have their own ideas, might think, like, well, you know, schistosomiasis – is it such a dangerous disease? People can live quite happily with it. So, the GND itself after 88, the funding ended, and sort of, as a Rockefeller funded agency, it didn’t exist anymore.
Now, in Oxford, the… David Weatherall Institute, the Oxford Welcome, who were sort of coincidental, but at the first meeting in New York of the GND, the then head of the Welcome Trust, Peter Williams and David Weatherall were there. They met independently. They were there together and they had a conversation, and from that we have the Oxford Welcome Units, which, of course, when Oxford University Medical School, in 2012, referred to the best medical school in the world, better than Harvard. The thing that the Times Higher Educational supplement, which had this league table, the metrics of it, it sort of published; some of the, it said the quality of its external networks were the things that really stood out, so they were set up in the 1970s and 80s. The present head of the Welcome Trust, Jeremy Farrow, head of the unit in Vietnam, so those things certainly lived on.
The school of parasitology at, in Sweden, at the Karolinska Institute, directly came out of the funding of the GND, so I’m sure in other countries which I don’t know about, these things may live on. But that was its period of existence and I think, you know, you get people who say Warren, you know, he was forced out, but, you know, you talk to other people who say well, you know, ten years, what do you expect. If you look at your career, you know, when you begin to develop more, then you look at ten years working someplace; it’s a period of time. One would wonder if you’d like a change or if you should be somewhere else so I think it had a kind of a natural lifespan but it was never really taken up in the same way, and the Rockefeller has never really… I mean it’s playing a much smaller role. It’s just got different priorities, as funding agencies do.
What would you say the priorities are now, and how does that connect with the legacy of the GND, if it does at all?
In the Rockefeller, I’ve no idea. I mean, I try, as a historian, to look forward a bit and to try and have a look at the relevance of things to today’s world, but as in life, the only thing we have to go on is the background. You know, we just don’t know the future, so I’ve no idea, but the Rockefeller, generally, plays less and less part in funding direct things to do with health. It’s much more, its philanthropic sort of avenues are expressed in different ways.
But there’s no doubt about it, that the whole idea of tropical medicine, to medicine and to tropics, has changed because of that, and I think if you look at the amount of papers that are GND produced, if you look at the amount of people who were funded in the developing world, it was about, of all of the scientists in it, I think it was something like 56% were in the developed world and the rest in the developing world so it wasn’t, this wasn’t sort of colonialism, so in that way it was a much, much fairer system.
What was their exact remit in terms of the diseases, the people that they involved, the countries, the funding and some of their objectives?
Yes, they had 14 foundational units, and these 14 would have the leader of the unit, somebody from that country, and somebody from the country they were working in, so we’d have three people, 3×14, you can tell it’s less than 50. Then there’d be other people, maybe Bridget Ogilvy, coming along to monitor the style of the work and the quality of the work there, and they would have, so they had 14 diseases, so they would go from hook worm, which we’ve already… to de-worming techniques, to schistosomiasis, malaria, which the group in the Karolinska were working on, so they’d all have a different disease. People would be working in Kenya, and then they would go off.
Some people would work in the bush for three months or in the field for three months and then they’d meet up annual, and their main thing they were doing was trying to have a greater understanding of the mechanism of disease. There wasn’t so much… there was some epidemiology but not so much. So, that was their real ideal, and the people who they had, who worked in that group of people like cohort, when you talk to them, they say it was the most exciting period in their scientific life, and of course they went away and they ran institutions themselves, so one would imagine they took some idea of the methodology that they’d learnt, that they thought had been so fruitful for them, and maybe they distilled that into their own labs as well. But no vaccines came out of it.
Yes, I was going to ask you a question about the, as a historian, what sources do you use in writing their history of GND? Did they have annual reports after these meetings or did they publish individually and you’re putting these narratives together?
Very good. They published papers. It was a tremendously productive period for people. There is a book, a kind of a synopsis of the decade of it that was edited by Warren and a colleague of us. Nearly all of the people who, many people are alive, so I’ve been to see them. Other people have written about Tony Cerami and David Weatherall, of course, is Lasker winner, so I’ve known David Weatherall for about ten years. He was a podcast [?] of mine.
So, I like to have a fusion of their own papers themselves, things that were produced by the Rockefeller, and also I had the opportunity in October to go to the Rockefeller archive in Sleepy Hollow, where the correspondence you can see setting up, the failures, the overspends, and it’s good to have a look at the kind of nuts and bolts that actually held it together and then talk to people, go and see them, look them in the eye and interview them just the way you’re doing here.
Sometimes, as we will, as I found out, people lie inadvertently, they mis-remember things, they get the dates wrong, but it’s all part of that kind of tapestry of trying to develop… when you sit down, having heard someone’s voice, it sort of helps you as a writer, to try and get the story down because, you know, as EH Carr said, history is how you tell the story, so I try and find the truth, if it’s there, and I try and…
It would be interesting to see how the book develops, whether I’ll go about it in a biographical way or whether I shall look at it as a kind of anthropology of diseases. I haven’t decided quite which way. At the moment I’ve now sort of got my arms around what I call the writers material. You know, you need that because I’m not writing fiction. You need some historical documents and they’ve left a very good trail.
And as a historian, how would you see this current movement in neglected tropical diseases research? There is the London Declaration to eradicate these diseases. Do you kind of find similarities in narratives when GND first started and from those, what you can, what differences you see, and do you think these differences, if they exist, are for the better or we can learn from our previous mistakes?
I really don’t know so much about the contemporary field, you know, so what I do know, I know about emerging diseases in those countries, but I don’t know about what people feel about them, so I’m just looking at the sort of period as a snapshot of where it came from and this group of people, but in the contemporary scene I think that might be too big a gap to try and make up.
It’s interesting, as a historian, you have these ideas but there’s a tremendous amount of knowledge that you’d have to know all the way through, and I try not to go too far into that future where I don’t know, so I try and have a kind of period and then have a look at that, not in isolation, but I don’t want to take it as something, looking from the 1920s up, and then, you know, the colonial period and moving up there. I think that’s for somebody else to do.
What about the draw-out of what you found from the GND about public awareness of those diseases, the policy impact and some of the beginnings of institutional building that you might have drawn across, looking at that particular period of time for neglected diseases?
When I talked to Nick White, he was saying when he went into tropical medicine in the 1970s as a doctor, it had a very, very low status, and today, certainly in Oxford and I think in London, the brightest and the best want to go into tropical medicine. Now, is that because of the application of science, the cutting edge of science? And I think, I mean it was interesting; at the first meeting of the GND, so he got these people, young biologists, who’d never heard, didn’t know anything about a snail or a vector, you know, they were just people who were in at this new science for some reason, and the two people he got to speak to them in New York were George Nelson, and another great giant of British parasitology, and these were able to infuse these people with incredible stories about, you know, being out in the field in South America, and getting these people sort of interested in tropical diseases. So, what he wanted to do was to get people with the skills and then try and imbue them with an interest and supercharge their interest in what was going on.
Now, of course there were plenty of people, brilliant parasitologists from Britain – look at the Nobel, you know, Britain’s first Nobel Prize in medicine, so of course, certain, and we have, you know, the two great schools, the Liverpool and the London School, so that was true, but getting the new scientists interested in new science, that was the ideal that he wanted to do so that was very important.
Public awareness, I don’t know. What I was looking at was just the awareness within the profession that could do something about it, and I think it wasn’t true but when you talk to people that were in GND, you know, unless you had been bitten by a snake, unless you’d live in the jungle for 35 years, there was a little bit of you’re a Johnny-come-lately. But, of course, what they had, they could just see huge windows of opportunity for their science even if it wasn’t, you know, coming up with the vaccine they so much hoped.
So, the one about public awareness, I’m not sure about that. I think it was true, the quality of the people of the two schools, both in Liverpool and London, has had this great reservoir, really, of incredibly talented people who were coming about. One interesting thing to do, and Gillies [?] is still alive – he lives in Malta – who head of the Liverpool School, and Ken Warren and his great colleague, Adel Mahmoud, they wrote a huge encyclopaedia of tropical medicine, tropical and geographical diseases, in 1984, and if you wanted to do something good, you can get the Gillies, Encyclopaedia of Tropical Diseases, Mansons [?], the great one, and Warren and Mahmoud, and when you look at them, all from the 1984 edition, there’s more science in the… you know, so there’s more science coming in, and I think that may be the thing that attracts young men and women in that period since 1980s and why Britain is such a leading player in the world. I mean obviously you can’t get rid of colonialism.
David Bradley, the great tropical medicine academic, he sort of started life, wanted to be a missionary; there’s an element of that. There’s an element of a sort of Africa/Asia divide. Nick White was… he went to school in Singapore. You know, they tend to gravitate to the bit they kind of know, diseases, you know, that feeling of denial and they want to sort of go back there.
So, they have some sort of personal connection.
They often do and maybe that religious thing: you know, his tremendous work out in Africa and Ethiopia on hypertension, very austere person. These people are altruistic-minded. I mean, the idea of medicine is healing, you know, of healing people but there is, there are these things you see in the tropical group, that maybe are not apparent as in other.
You need that personal connection to care about somewhere so far away from you that you don’t get reminded every day, so how many of us think about African sleeping sickness or Congo or Chagas disease and Dengi Fever every day in Brazil so we need to have this personal connection perhaps. Maybe that’s an interesting; that’s another thing.
But there’s also this idealism that you touched upon in that yes, there’s a faraway place that might need some help, so I think that’s motivated a lot of early scientists working in the area.
I’m sure that’s true and Kevin Marsh, and something that’s been in the news just this week about the malaria deaths and the success of bed nets; that work in Kilifi on the east coast of Kenya, very important and Kilifi, and Kenya’s a very sort of politically difficult country at the moment, but the Welcome laboratory there is wonderful, you know, educating 800 people, 800 Kenyans, you know, it’s… this is not some sort of colonial ideal at all.
And you know, one of the reasons, you know, malaria’s so successfully treated and some of the ideas that have been perpetuated in the last 20 years sometimes emanate from Britain and certainly people who were involved in a GND and Warrell, who was the first director of the Thailand unit in Thailand, he knew Ken Warren well, and, of course, his boss, David Weatherall, was part of the GND.
It was great to get your perspective on this because so far in our podcast we only talked about the current research and philosophical ideas about the definition of neglect, and this, another episode from their recent history on these diseases being very, very insightful in the way they reflect about what we hear from the practitioners today and how we can further our conversation about tropical diseases as not just these esoteric bunch of scientists working in the lab. What I’m trying to say is these disease has been in our focus for longer than the last 20 years, and thank you very much. I think it’s a great pleasure to have you here. Thank you very much.