Growing Health

Otago Magazine, issue 28, February 2011

Over the past 125 years the Department of Preventive and Social Medicine has gone from being a oneman entity to the University of Otago’s largest department.

From its first, relatively narrow focus – mainly concerned with environmental sanitation – it is today a large, multidisciplinary department with a broad public-health outlook, with widely-skilled staff, both medical and non-medical.

Dr Warwick Brunton (Preventive and Social Medicine) has been writing a history of the department which stretches back to the early days of medical teaching at Otago.

The Early Years

To provide a complete medical degree that would be recognised in the UK, the University of Otago needed to include teaching on public health. So, in 1886, Dr Francis Ogston, from Aberdeen, was employed to lecture in medical jurisprudence and public health – a combination that was not unusual at that time.

While a number of his students went on to do significant work in public health, Brunton says Ogston’s major contribution came through his work as the District Health Officer or what is today known as the Medical Officer of Health. This was the first hint of a durable arrangement between the University and the then Department of Public Health. That institutional relationship has continued since 1901. Today’s Medical Officer of Health and staff from Public Health South at the Southern District Health Board are still involved in teaching students in the department.

“Ogston’s teaching related primarily to environmental sanitation. As the years went by that really became more dated because public health people in Britain were trying to present a scientific image linked with the development of immunology, germ theory, microscopes and laboratories.”

His successor as lecturer and then Professor of Bacteriology and Public Health was Sydney Champtaloup, a very able New Zealander who had trained in medicine at Edinburgh and won many prizes.

Champtaloup made a number of significant contributions, overseeing the introduction of the Diploma in Public Health (DPH) in 1914, the first university diploma in New Zealand. He also pushed for the Medical School to move from what is now the Geology Building to its present site opposite the hospital.

When the influenza epidemic struck in 1918 he took a practical public health approach, sending students to help in the wards, while senior students were sent out around the country.

After World War I he was granted study leave and travelled to Britain where he wrote his MD thesis and submitted a DSc thesis at Edinburgh. Sadly, bad health forced his return to Dunedin where he died of tuberculosis as a relatively young man.

The Hercus Years

Even at this stage the department was still basically a one-man band. When the University advertised the Chair of Bacteriology and Public Health in 1921, there was effectively a toss-up between two strong candidates, with the job eventually going to Charles Hercus, one of the most prominent figures in the history of the Otago Medical School.

Hercus was the first “home grown” professor. He had been an extremely bright and able Otago student and one of the first dental graduates (1911). Persuaded to take on medicine, he qualified just before World War I and went overseas with the New Zealand Expeditionary Force, serving in Gallipoli and Mesopotamia. Brunton says he was credited with some remarkable public health work, preventing malaria among New Zealand troops in Jordan and, eventually, returned with a distinguished war record.

Hercus joined the Health Department in Christchurch and undertook major research on the incidence of goitre among school children before returning to Dunedin to study for the DPH.

Brunton describes Hercus as “a man of the most extraordinary energy” who turned the place upside down.

“He was profoundly inspired by a British report on preventive medicine so, instead of it being just one subject in the medical curriculum, he was inspired to try to infuse the entire medical course with preventive medicine.”

One of his early innovations was to have every fifth-year medical student undertake a piece of original research under guidance. The fruits of that innovation are to be found in the valuable collection of some 3,400 theses or dissertations which are now housed in the Medical Library.

Hercus strongly encouraged research in the Medical School, but, as Professo rof Bacteriology and Public Health, he also pressed for research with a practical public health outcome, Brunton says.

“His focus on using research to achieve what we would now call public health gain through policy change became a very key part of the 36 years he spent in charge of the department.”

When the government decided to set up the precursor to what is now the Health Research Council in 1937, Hercus was deeply involved, driving a strong public health agenda, especially in the areas of goitre, hydatids and nutrition. That same year he was appointed Dean of the Medical School.

Hercus was also far-sighted enough to see that, in a changing world, New Zealand was a Pacific country and should encourage public health research in the Pacific.

He encouraged the making of what was probably the first health education film made in New Zealand. The 1930s silent film and accompanying script have been unearthed and will be screened this year. Hercus also added his influence to concerns about child health and what was called national efficiency, taking a particular interest in physical education.

“He did some extraordinarily solid work behind the scenes to assist the government to develop a policy and framework for physical education and, more particularly, the teaching of physical education – and the School of Physical Education is the direct result of that,” Brunton says.

Related to that was the innovative introduction of a health clinic in 1941 where students could learn more about preventive medicine in action, observing antenatal and postnatal classes, Plunket facilities, school immunisations and the like. Even the wider student population benefited from his attentions with the launch of the Student Health Service in 1946.

All this endeavour did not go unrecognised and, in 1947, Hercus was knighted.

In the 1950s the decision was made to split the department and bacteriology became what was now the Department of Microbiology, with its own chair, in 1954. Sir Charles was left with what was now called the Preventive and Social Medicine Department which he ran until he retired in 1958.

The Last 50 Years

After Hercus’ retirement, Professor Cyril Dixon, an English academic who had been the Medical Officer of Health in Whangarei during World War II took over the department. Still alive and with an excellent memory at the age of 98, he has been able to supply Brunton with many resources for his research.

When he arrived at Otago, Dixon found a department that was small and rundown with few staff. But he knew the face of preventive and social medicine was changing.

“Dixon brought in a very different perspective,” says Brunton. “He was a man concerned a great deal about health systems, about organisation and administration, planning and evaluation – a different sort of focus in many respects from Hercus.”

Brunton believes the whole development of health workforce planning, and its impact on academia in terms of training places in medicine and dentistry, go back to ideas Dixon had in the early 1960s.

Under him the department grew to about 10–14 teaching staff and a range of diploma programmes were launched, including in occupational health. He also opened up the DPH to international students – particularly from the Pacific.

“They not only swelled the numbers, but they put public health – classical public health – back into the degree programme,” says Brunton. “And there were some quite amazing results with three future Pacific prime ministers and one Governor-General coming through the department as students. There is still a Pacific link that continues from there.”

Dixon retired in 1976, but by the time Professor David Skegg took control in 1980 he found a department in difficulty after a three-year gap without a permanent head of department.

“I really wondered whether the department would survive. I remember thinking that we could end up being a unit attached to the Department of Medicine.”

The biggest threat to the future of the department was the effort that had been put into teaching the Postgraduate Diploma in Public Health which was set to be phased out.

“For me, I wasn’t sorry for the DPH in its previous incarnation to be going, because I saw it as a millstone around the department’s neck. A very small staff had to teach across the whole field of public health. They had little time for new research because they were spending all their time in the classroom teaching small classes.”

Skegg made building up the research side of the department a priority, along with developing undergraduate teaching, particularly in the key science of epidemiology.

“This was also an area that the Medical Research Council was wanting to make a priority because it was seen as a field of great potential in health research.

“I therefore made it a priority to develop research programmes on things such as cancer epidemiology and multiple sclerosis. Then, when the AIDS epidemic started, I was doing work with WHO and Charlotte Paul and I persuaded the Department of Health that our department should become the national centre for AIDS epidemiology and monitoring.”

The AIDS Epidemiology Group was just one of a number of new groups and units that were either started in Preventive and Social Medicine or migrated to the department while he was in charge.

The Hugh Adam Cancer Epidemiology Unit was added, the Dunedin Multidisciplinary Health and Development Research Unit came over from Paediatrics, while the National Poisons Centre and the New Zealand Pharmacovigilance Centre – which was then called the Centre for Adverse Reactions Monitoring – also came under the Preventive and Social Medicine umbrella.

The Injury Prevention Research Unit was launched, while the Ngäi Tahu Mäori Health Research Unit was started in partnership with Te Rünanga o Ngäi Tahu. The New Zealand Environmental and Occupational Health Research Centre was also set up under a joint initiative with Auckland University, funded by the Health Research Council.

They were eventually joined by the Cancer Society Social and Behavioural Research Unit and, in more recent times, the Centre for International Health, something Skegg had been working towards while head of department, although it did not come to fruition until after he had left.

It builds on the department’s longstanding Pacific and international focus, supervising overseas postgraduate students as they undertake research in their own country.

“The old DPH programme for Pacific doctors made a great contribution in its day, but I think that we are able to make an even greater contribution by building up the research capacity in those countries themselves.”

Because of all these research groups growing, the department itself also grew substantially. “From about a dozen people in 1980, it had grown to 130 by the time I left. This had never been my intention, but it happened incrementally over the years.”

Skegg says it was fortunate that the things he wanted to do were appropriate for the department at the time.

“I had 25 very happy years in that department – it was a happy place to be. You’re fortunate if you are in a department where there is a collegial atmosphere, so you collaborate in research and teaching, but also become very good friends.”

The Department Today

Current head of the Department of Preventive and Social Medicine, Professor Jennie Connor says the uniqueness of the department still lies in its population health perspective, in contrast to the rest of the medical disciplines, which focus predominantly on the health of individuals.

Today’s department is a major centre for public health research as well as delivering research-led teaching, and services such as the National Poisons Centre and New Zealand Pharmacovigilance Centre.

While part of the Dunedin School of Medicine and employing a number of Public Health Medicine specialists, the majority of the department staff is no longer made up of doctors, in keeping with the multidisciplinary nature of modern public health.

They include statisticians, economists, geographers, psychologists, dentists, and a variety of social and other scientists.

The department’s biggest single teaching task comes before students get into medical school with a compulsory paper – Foundations of Epidemiology – which is taught in the Health Sciences First Year course and was taken by around 1,200 students in 2010.

Staff go on to teach components in all years of medical school, and courses such as health promotion, epidemiology and health policy for other undergraduate students.

The Postgraduate Diploma and Master of Public Health programmes attract graduates from a range of disciplines and with a variety of career paths in mind, including some who progress through a PhD to a research career.

Connor says the department’s strength lies in having many committed researchers who want to progress their own programmes.

Central to that are the established research units which have fashioned excellent records, but there is also a wide range of research being done by staff in teaching roles – with interests in infectious disease, alcohol-related harm, pharmaco-epidemiology, and healthy ageing among others.

Looking ahead, Connor can see growth in the nascent research units such as the Centre for International Health, established in 2008, and the Centre for Health Systems, launched late last year.

“However, environmental health is one of the areas we need to grow. The biggest global public health issue now is climate change and, in the local and national sense, one of the contributors we need to tackle is transport.

“We also need to better understand the health risks of climate change, and how to mitigate them, because some climate change is happening regardless of changes we make now.”

A Last Look Back

One of the things that has struck Brunton when looking back at the 125-year history of the Department of Preventive and Social Medicine is the impact it has had through its teaching and service roles, expanding from a largely local environment, to a national and now international one.

He also acknowledges the continuing emphasis on practical measures to improve health levels. There is both a science and art to public health.

He says the true impact on health of a department like this is hard to gauge, but every doctor who has graduated from Dunedin, would have received training there.

“So, obviously, in terms of what they learned about immunisations, about how to discuss with patients healthpromotion issues and what they can do to prevent illness or injury, this department can bask in the reflected glory of what has been achieved in the changing pattern of illness and mortality in this country. You cannot easily put a figure on that.

“Somewhere in the statistics of life expectancy and the changing patterns of disease, improvements in the social, economic and physical environments that affect our level of health as a country, this department has played a role.”

MARK WRIGHT