The Miracle Pill

by Peter Walker

  In April 1939, with Morris a junior doctor in London and the slightly younger Paffenbarger about to start university, the prestigious British Medical Journal (BMJ) published a study titled The Longevity of Oarsmen, which examined the lifespans of those who had crewed the Oxford and Cambridge rowing boats in the celebrated annual inter-university race between 1829 and 1929.

  Led by the floridly named Sir Percival Horton-Smith Hartley from St Bart’s Hospital in London, it took with complete seriousness the notion that vigorous exercise could be dangerous. The authors approvingly cited the opinion of one medical expert that such a boat race was ‘a national folly’, as well as the view expressed by one early participant that ‘no man in a racing-boat could expect to live to the age of 30’.

  As it transpired, Horton-Smith Hartley’s research found that those who had taken part in the race actually seemed to live longer than average. However, he carefully caveated this finding with warnings that the sample size was small, and that the comparison death rates came from the everyday population, rather than the oarsmen’s social and educational peers.3

  Even more striking in retrospect is another BMJ study, also centring on the much-scrutinised lifespans of elite academic alumni. Carried out by Sir Alan Rook, the senior health officer at Cambridge University, it again considered the potential perils of vigorous exercise. Strikingly, it was published in April 1954 – five months after Morris’s research paper on London bus workers.

  As was still the received wisdom, Rook fretted mainly about the impact of exercise on the heart, noting this was ‘usually regarded as bearing the chief strain of athletic activities’. While it was now generally believed that exercise caused no immediate ill-effect on a normal heart, he wrote, whether or not it might bring longer-term cardiac damage is ‘the part of the problem that has never been answered satisfactorily’.

  Using the death records of thirty years of Cambridge alumni, the study compared a cohort of students who had taken part in university sports against a control group, as well as an ‘intellectual group’ and a ‘random group’. A curious amalgam of scientific rigour and highly set social assumptions, the paper talks breezily of ‘weaklings’ being weeded out by around the age of forty, and notes in passing that an alarmingly high proportion of Cambridge intellectuals from the era ended up killing themselves. But again, in the end it managed to uncover no evidence that the reckless sportsmen died any younger on average than their peers.4

  The quiet radical

  It was into this curious post-war intellectual environment that Jerry Morris arrived. The son of immigrant parents who had fled pogroms in what is now Belarus, he had emerged from an upbringing notably limited in material wealth but rich in love, culture and omnivorous intellectual curiosity.

  Morris was, according to those who knew and worked with him, a seemingly mild but iron-willed force of nature; a lifelong socialist who happily and mischievously described himself as ‘a radical – a do-gooder’; someone who thought nothing of personally telephoning ministers to lambast them about policy failures; but who also quietly helped along the careers of junior colleagues, often without their knowledge.

  According to a family history compiled by a contemporary example of Morris’s seemingly endless list of eclectic and over-achieving relatives (Joshua Plaut, who combines a role as a rabbi in New York City with being a photographer and the author of books including A Kosher Christmas: ’Tis the Season to be Jewish), Morris’s parents came to the UK in 1909, fleeing increased antisemitism in the then-Russian city of Novogrudok.5

  Once arrived, Natke Lezerovsky and Chaya Yoselovsky, in their early twenties and recently married, become Nathan and Annie Morris, supposedly adopting the surname of the friendly captain of the boat that carried them to Liverpool. They tried their luck in Glasgow, and flourished. By 1912, Nathan was headmaster of a Hebrew school in the city, later going on to take a master’s degree in literature at Glasgow University. According to one version of the family story, after finishing the degree Nathan then declared, to his wife’s dismay, that an educated man must also know about music, and spent two further years studying that.

  In a fascinating video interview from 1986,6 when Jerry Morris had already been officially retired for more than a decade but was still arriving daily at his office in the London School of Hygiene and Tropical Medicine, he described, in an accent still thick with his Glasgow roots, how he and his two younger brothers were ‘brought up on a mixture of the Old Testament and the Independent Labour Party’, a firebrand socialist grouping which had emerged in Scotland a decade or so before his birth. Morris explained: ‘It has given me a rather simple view of life. I mean, I’ve got less problems with what’s right and what’s wrong than other people.’

  Morris and his two brothers – who became a trade union leader and a paediatrician – had all grown up in a tiny Glasgow house of two bedrooms and a kitchen. ‘We were next door to a slum street,’ Morris recalled in an interview from 2009. ‘I still remember the screaming women on Friday night and Saturday night, when they were beaten by their drunk husbands. As you can imagine, I have a contact with social inequalities and with poverty that most of my colleagues only know from the literature.’7 While he played down the deprivation the family faced personally, it was an upbringing still challenging enough to leave Morris with lifelong traces of rickets, the childhood bone weakness condition so strongly associated with poverty.

  Another legacy was adherence to a personal form of socialism, the beginnings of which saw Morris volunteer to campaign for a local Labour MP in Glasgow, being turned away because he was, at the time, aged only twelve. This childhood gave him not only a very personal insight into the many problems of deprivation, but also a grounding in what for him was the other side of the health equation: being physically active. His hugely energetic father, Morris recalled, would take him and his brothers for a four-mile walk across Glasgow once a week as children. If they managed the route inside an hour, the boys would be rewarded with an ice cream. Walk the distance in a notably shorter time and the prize was upgraded to a choc-ice.

  Morris had wanted from childhood to become a doctor, but initially studied a combination of arts and medicine at Glasgow University at the urging of his polymath father, who ‘thought that doctors were a very uneducated lot’. After the family relocated to London, Morris continued his training at University College Hospital, where his combined proclivities for quiet determination and being in the right place at the right time saw him work under first the famous cardiologist Thomas Lewis and then another celebrated doctor, Frederic Poynton. Poynton was an expert in rheumatic fever, the inflammatory disease which can badly damage hearts, particularly in children. Now almost unknown in the developed world, in the London of the 1930s it remained common. In his 1986 interview, Morris remembered the shock of being told by a senior doctor that his very first patient, an eight-year-old boy with heart valves damaged from rheumatic fever, would most likely live only a few more months. ‘It took me days to get over that,’ Morris recalled.8 The impact was all the greater when Poynton mentioned that in many years treating private patients in London’s upmarket Harley Street, and at the elite Eton school, he had never seen a single case of rheumatic heart disease. This was entirely a disease of poverty.

  Morris’s increasing belief that combating illness was a matter of changing living conditions became even stronger when he met Richard Titmuss, a celebrated researcher who more or less single-handedly established the academic discipline of social policy, which examines how governments can tackle issues such as education and health. Titmuss is another extraordinary character whose life and achievements are not as well known as they could be, particularly given his billing as one of the intellectual founders of the UK’s welfare state. The son of a Bedfordshire farmer, Titmuss left school at fourteen and found work as an insurance clerk. Hugely intelligent and often self-taught, and with a deep knowledge of statistics and demographics from his day job, he began writing books, including on
e on regional differences in public health.

  Morris read this and physically tracked down Titmuss in his London insurance office after – as he put it years later – ‘deciding, well, this is a man I must know’.9 The pair became close friends and began working on projects in what they termed ‘medicine in the matrix of society’, the emerging discipline that became known as social medicine.

  Their work, crucial in shaping Morris’s later ideas, continued even after Morris was sent abroad during the war with the Royal Army Medical Corps, the military censors allowing their endless stream of letters to pass unamended. ‘They must have had a meeting at a high level and decided to leave these screwballs alone,’ said Morris. ‘There was no danger of secret information being conveyed in these statistics on death rates in the county boroughs of England and Wales or whatever it was we were writing on.’10

  From 1942 to 1944 Morris and Titmuss published three papers now seen as the origins of social medicine, covering conditions closely linked with poverty and lifestyle – juvenile rheumatism, peptic ulcers and rheumatic heart disease. The latter, which had so cursed the brief life of Morris’s first patient, was described by the duo as a ‘social disease’, something they demonstrated in part by correlating its incidence against levels of unemployment.

  The papers attracted attention, and took Morris towards the role that would define his career, and change public health forever. In 1948, the 38-year-old Morris was made head of the Social Medicine Unit. He kept it until his official retirement almost three decades later, although in fact he never actually stopped working until weeks before his death.

  A grandly titled enterprise with humble beginnings – it started in a single portacabin in the grounds of a London hospital – the Social Medicine Unit was charged with investigating population-wide health trends and examining what might be causing them. This is now treated as routine in public health, but during the years following the Second World War was a pioneering adjunct to the conventional care which was now being provided free to everyone for the first time via the brand new National Health Service.

  In an interview many years later Morris explained his thinking in 1948: ‘Starting the unit, I asked myself, what is the great presenting problem?’11 Morris’s answer was simple: coronary heart disease. The condition, most dramatically and terrifyingly manifested in people suffering sudden and fatal heart attacks, had long been understood from a basic physiological perspective, but there had been remarkably little curiosity as to what factors triggered it. Some concern had been expressed following the war about an increase in the incidence of heart attacks, but there was little study as to the extent of the problem, let alone contributory causes, beyond some tentative guesses about workplace stress or a possible link to the bitumen being used to resurface roads amid peacetime rebuilding efforts.

  Morris began his work with the sort of thorough if gloomy endeavour familiar to many who specialise in social medicine and epidemiology: he studied lots and lots of mortality records. Morris ploughed through files detailing all those who had died from heart-related ailments at the London Hospital in the East End of the city between 1907 and 1949. After what he later described as ‘interminable hours with post-mortem folios’,12 he discovered two things: firstly that the incidence of heart disease was, indeed, rising from a previously low base; and also that it was more prevalent in men than in women. ‘It appeared that this ancient disease had been mutating from relative obscurity into the modern epidemic of heart attack,’ he wrote in 2009.13

  The next step saw Morris and his team assess coronary heart disease rates across large cohorts of people, exclusively men, who worked in differing jobs in a variety of sectors, among them postal staff, civil servants and London Transport workers. It was the latter group who provided his team with their initial breakthrough.

  Amid the paternalistic culture of the era there was masses of data already available about such people from their employers, not just sickness rates and statistics for those who became ill or died from heart disease, but details on social background and work practices, even in some cases the waistband sizes of the uniform trousers issued to them.

  Morris and his colleagues pored over figures for 31,000 London Transport staff working on buses, trams and the Underground. One anomaly soon emerged: bus conductors had about half the rates of heart disease of their colleagues who drove the vehicles. Their backgrounds and other biographical details tended to be similar, so it must be the jobs which had the impact. But how?

  In the 1986 interview, Morris said he initially looked back to his cardiology teachings under Thomas Lewis, much of which would have been familiar to a Victorian doctor, and concluded it was most likely down to differing levels of work stress. The research team spent many hours observing both occupations in action, but started to question this hypothesis. ‘Eventually we managed to articulate between us that both of these jobs were stressful,’ Morris said. ‘But what was interesting about this was, [the researchers] said if they had to pick one of these jobs as being the more stressful they would say it was the conductor, and for why, because the conductor had to deal with people whereas the driver only had to deal with traffic.’14 Body weight was also considered, thanks to the London Transport records on trouser sizes. But although the bus drivers tended to be fatter on average, conductors with a certain body type still suffered fewer sudden cardiac deaths than the equivalent-shaped drivers.

  However, the long observations had uncovered another difference. ‘The drivers were prototypically sedentary and the conductors were unavoidably active.’ Morris recounted. ‘We spent many hours sitting on the buses watching the number of stairs they climbed.’15 It turned out that in an average working day, conductors climbed and descended between 500 and 750 steps.

  The decision was made. ‘In the face of much collegial scepticism, we chose to focus on physical activity,’ Morris wrote in 2009, adding that ‘British cardiology was quite uninterested in what we were doing.’16 Morris was, of course, correct in this hypothesis, which was backed up by the data. However, desperate to be certain he was correct, he and his team spent three further years checking their conclusion and gathering more evidence.

  ‘Nowadays we’d have rushed this into print overnight,’ Morris remarked to a fellow academic many years later. ‘In fact we decided to test it every way we could before publishing.’17 This testing came in two variants. Firstly, Morris called in other academics to scrutinise the findings. ‘We brought in outside people with no blood in their veins, no interest, to destroy it,’ he recalled.18 But they could find no error. Then, finally, evidence started to arrive from the other occupational studies set up by the team. In what Morris later called ‘one of the tensest moments of my professional life’,19 he received data about postal workers, which showed that postmen who delivered mail by bike or on foot also had roughly half the incidence of heart disease as their inactive colleagues, the clerks and counter staff.

  Finally convinced his hypothesis was sound, Morris submitted the article to leading medical journal The Lancet, where it appeared in issue 6795, on 28 November 1953, under the sober and succinct title, Coronary Heart Disease and Physical Activity of Work.

  As part of my research into the family history, I visit Tamara Lucas, whose father was Morris’s cousin and grew up alongside him in Glasgow. By coincidence, Lucas works for Elsevier, the publishing giant whose titles include The Lancet. We meet at its central London office, where she leads me to the magazine’s archive, a small room with floor-to-ceiling shelves filled with original copies, many pages featuring the authors’ handwritten corrections and annotations.

  She pulls down from the shelves the bound volume containing the relevant magazine issue.

  Morris’s study, with his name one of five academics at the top, begins with the modest aspiration that it hopes to ‘gain some knowledge of coronary heart disease as a problem in public health’. Over five densely typed pages, embellished with tables and hand-drawn graphs, the authors expla
in how the finding that active bus conductors had lower rates of heart disease than drivers was then backed by observations of postal workers, including civil service postal staff. It concludes: ‘We felt that the main interest of these findings in postal workers and civil servants lies in the support they provide for the idea suggested by the observation of the transport workers – that physical activity at work is important in relation to the coronary heart disease of middle-aged men.’

  The article prompted, as Morris put it more than half a century later, a wave of interest ‘that I had no idea how to handle’. A good proportion of this was hostile. Could a desk-bound professional life – the norm for millions of middle- and upper-class men, and a major aspiration for those who still laboured for a living – really be to blame for the new epidemic of heart attacks?

  It can be difficult from a modern perspective to appreciate how radical Morris’s conclusions were. I-Min Lee, the Harvard epidemiology professor we met in the last chapter, is generally considered the successor to Morris and Paffenbarger. She stresses how much of a risk Morris was taking with his hypothesis: ‘He did this at a time when nobody believed activity was important,’ she says. ‘People thought this was a crazy thing he was doing.’20

  But for the critics there was one problem: the evidence kept on arriving. Morris and his team expanded their observations to non-work activity, tracking the health of thousands of relatively senior civil servants, none of whom were physical in their jobs. Among this group, he found, men who undertook reasonably vigorous exercise, for example swimming, cycling or brisk walking, had lower rates of heart attacks than their more sedentary peers.