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A seminal book that has been read and assessed during past decades by many public health students and practitioners is now 64 years old. Can it still offer insight, inspiration, and renewal for public health as it approaches 65, or should it be pensioned off?
This reader friendly narrative covers many interesting and educational themes, public health scientific (communicable diseases) issues of the day, and helps illustrate the work of a GP and also rural life in Wensleydale through the 1930s. However, it is important to dwell on the overall feel about Pickles that comes from this work.
Pickles demonstrates key elements of a public health leader; good (written and listening) communication skills, being ahead of his time, exploring challenging issues for science and society, systematic interest in health and disease and its determinants, a good humanitarian empathy for real people and their problems, and a seeming aptitude for partnership work to support the grand, more strategic project of his local epidemiological profiling.
Lessons from Pickles’ work still have resonance in contemporary and future scenarios for public health and primary care. Geographical well demarcated village communities facilitated the clear identification and sense of ownership by Pickles with the local population. Also living within them as neighbours and in social activities was part of the continuity and understanding built up over years of practice. It is still feasible for rural GPs to do this, but also for urban GPs with their own registered population can look at the health of those people with their own partners, as part of neighbourhood or locality public health, or within the primary care trust’s overall public health remit, or indeed within the wider local public health network.
Pickles acted as a narrator and recorder of the health experience of the local population. This was legitimate in that there was no competition, rivalry, and fear from other practices, as he and his partner covered a defined population of their own. His legitimacy also stemmed from his position as part time medical officer of health. His scientific and organisational credibility was probably enhanced by links to public health officials and academics. He was able to recognise potential for partnership and developing public health capacity; demonstrated in looking to his wife and daughter for support in his recording and in harnessing interest of school head teachers. The latter in recognition of his interest in schools as population groups and as opportunities for understanding spread of infection.
His systematic recording and presentation of charts of infection was noteworthy, as was his attention to details of history of travel, occupation, social interaction, and clinical features including onset dates.
His amusing insights into human behaviour have resonance today. The grim statistics of re-emergence of sexually transmitted diseases might have more striking impact if they were written about in a more rounded fashion, giving qualitative and personal experience more prominence alongside the statistics. This was partly evident during the original documentation of HIV and AIDS transmission and risk behaviour.
The clinical typification he used has more recently been witnessed as fundamental underpinning of understanding and responses to new diseases like vCJD and SARS. His work on mumps echoes down the years, given the recurrence today among unprotected older teenage groups in secondary schools and colleges. His demonstration of outbreaks of Shigella sonnei and hepatitis A (epidemic catarrhal jaundice) evoked memories of some of the school based outbreaks I investigated in the 1980s.
What, in consequence of the above, about the future relevance? I would propose several lines of inquiry to take Pickles’ work towards its centenary in 2039.
GPs and other primary care clinicians need support to enable them to undertake public health and epidemiological roles within the modern primary care setting. Although medical leadership is important, relevant work with school nurses and locality nurses are great opportunities for showing local population needs. The GP role could be facilitated by, for instance, the following:
Review of existing strengths (for example, sentinel surveillance and leading edge projects) and weaknesses (problems with data capture, quality, and sharing).
Taking advantage of electronic patient records in primary care to produce higher quality patient datasets amenable to systematic analysis. This may build up from recent experience in setting up mental health, diabetes, and CHD other chronic disease registers. Much in incorporate epidemiology is still missed.
Recognition of GP involvement in leading some work on relevant clinical health problems within the primary care trust LIS. The new GP contract offers scope for GP specialisation and attendant remuneration. Such work could also count for GP personal development and revalidation, including gaining credits for additional qualifications, CPD, audit or research or teaching.
The position for several interested GPs in each as “health recorders” could be linked to primary care trust public health departments and supported through analytical support, training, and publishing facilities. Perhaps such recorders should be asked to produce a five yearly account on the population.
The academic credibility of Pickles’ legacy could be strengthened by establishment of repositories of output from recorders (linked to public health observatories), prize giving, awards, and celebration of good practice, by publication of innovation or new evidence.
Pickles’ wider work with schools and communities can also be taken forward. Partnerships with local education authorities should take the opportunity to harness local interest in ICT (information and communication technology) to produce regular account of pupil/student health from school absence registers, surveillance, and assessments of health. Community, voluntary, and statutory agencies can collaborate to produce health profiles that are wanted and needed.
A putative ‘Pickles collaborative’ has as much resonance as those of “Cochrane” and “Campbell” for future public health.
↵* W H Pickles. Epidemiology in country practice. Torquay, Devon: The Devonshire Press, 1939 (reprinted by the Royal College of General Practitioners, London, in 1984, 128 pages, £16.50, ISBN 0-85084-097-X)