The Miracle Pill

by Peter Walker

  Morris was also now not alone in his efforts, with researchers in various countries starting to build on his work. In 1961, a pair of US-based academics, Hans Kraus and Wilhelm Raab, published the first book detailing the health consequences of a world where, as they put it, physical exertion ‘has been taken over, step-by-step, by labour-saving devices’. The book, Hypokinetic Disease: Diseases Produced by Lack of Exercise, expanded its list of ailments caused by inactivity beyond heart disease, also citing metabolic disorders and mental health.21

  The fate of freshmen

  But it was another US academic who was to become Morris’s key ally, as well as a close friend, and a researcher whose achievements in the field would be seen as perhaps equal: Ralph Paffenbarger. Known universally to colleagues as Paff, he had a notably more conventional background than Morris, as the son of a faculty member from Ohio State University. Graduating as a doctor during the Second World War before moving into epidemiology, Paffenbarger began by researching the transmission of polio for the US Public Health Service, a branch of the military.

  His primary contribution, when he started to examine the impact of active lifestyles, was to support Morris’s initial findings with far larger, long-term studies. Paffenbarger also helped spark the exercise boom that swept America in the 1970s, albeit more or less by accident.

  Paffenbarger began with a study of longshoremen, or dock workers, in San Francisco. In total 3,263 men who had varying levels of physical activity in their work, and now largely extinct job titles such as shoveller, holdman, sugarman, winchdriver, cooper and walking boss, were examined for other differences such as weight, blood pressure and whether or not they smoked. In a pioneering example of the longitudinal studies which now form the bedrock of much of epidemiology, Paffenbarger and his team returned sixteen years later, by which time 888 of the men had died, 291 from heart attacks. The eventual 1970 paper found that after accounting for other lifestyle and health factors, those with the least active jobs suffered coronary heart deaths a third higher than those in strenuous roles such as cargo handling – who, the study found, expended an average of 925 more calories per eight-hour shift.22

  Paffenbarger’s major achievement was the subsequent College Alumni Health Study, a vast linear record of physical activity and associated health, begun in 1960 and initially focusing on Harvard. Covering those who entered college between 1916 and 1950 – again all men – it was helped enormously by the painstaking record keeping maintained by the elite university. Until late in the 1950s, Harvard had required all newly arrived freshmen to take a medical examination, giving an initial set of data Paffenbarger could compare with his own results. Harvard also kept a close eye on its ex-students, with the alumni office receiving a weekly ‘death list’.

  For the former students still living, Paffenbarger compiled what he called a physical activity index, getting them to fill in questionnaires on exertion, such as how many flights of stairs they tended to climb, and how far they walked, as well as details on ‘light sports’, such as golf, and ‘strenuous sports’, such as basketball and running. This was then compared to death rates and levels of illness in what Paffenbarger later called ‘a natural history of ways of life and disease in America’.

  The eventual 1978 research paper, which charted 16,936 male Harvard alumni aged between thirty-five and seventy-four, 572 of whom had suffered heart attacks, found that those who described low levels of activity had a 64 per cent higher risk of heart attack than those who were more consistently physical, with strenuous exercise bringing the most benefits. It also discovered that being a college athlete offered no apparent protection from heart attack unless levels of physical activity were maintained.23

  The study was concluded with a report in 1986, which definitively concluded that whether or not people had other risk factors such as smoking, obesity or psychological trauma, ‘alumni mortality rates were significantly lower among the physically active’.24

  Paffenbarger’s work followed on from Morris’s breakthrough, proving beyond any doubt how important physical activity is for continued health, and inspiring generations of new researchers to discover other benefits which come from such a life. One of these was I-Min Lee, whose work at Harvard includes stewardship of the seemingly never-ending college alumni project, as well as a parallel exercise chronicling the lives of nearly 40,000 middle-aged and older women.25

  Lee says Paffenbarger’s legacy is immense. ‘Now we know that one of the best things you can do for your health is be physically active,’ she tells me. ‘Ralph Paffenbarger used to say that anything that gets worse as you grow older gets better when you exercise. It’s incredibly true – not only do we now know that physical activity reduces our risk of a whole bunch of chronic diseases, helps us live longer, but it also improves our quality of life.’26

  Practising what they preached

  One of Paffenbarger’s early and notable findings was that physical activity seems to boost a person’s health outcomes even if they take it up for the first time in middle age. This was to have particular resonance for the then largely desk-bound scientist, whose immediate family included several men who had died from heart attacks in their fifties.

  At the age of forty-five, in 1967, Paffenbarger decided to put his ideas to the test and take up jogging. Lee recalls him saying later that he was prompted to do this because his oldest child was newly in college and was having a difficult time. Paffenbarger wanted ‘to sort of show his son that if you put your mind to it, you can get through anything difficult. So he decided to run a marathon,’ Lee says.

  Early efforts were unpromising. ‘It was terrible,’ Paffenbarger said in a 1996 interview. ‘I was exhausted by the end of the block. I was delighted to be behind the junior high school, where no one could see me.’27 But he persisted: ‘By the second week, I was hooked.’ Notably, Paffenbarger also hailed the mental effects as a reason for his epiphany: ‘I found it invigorating. I could consider my thoughts and conflicts, I could prepare letters, ponder problems, prepare talks.’28

  According to Lee, Paffenbarger still didn’t immediately buy proper running footwear, and took part in his first Boston Marathon later that year wearing boating shoes, finishing just over five hours later with several toenails covered in blood from the chafing. But he turned out to be a natural athlete, and within four years he was running the distance in less than two hours forty-five minutes. He went on to complete about 150 marathons.

  By the time Paffenbarger was a committed runner, the first wider wave of joggers was emerging across America, many inspired by Ken Cooper, a doctor and air force colonel who in 1968 published a bestselling book called Aerobics,29 then a new term to most, setting out the importance of exercise to long-term health. But it is worth noting that when Cooper began his advocacy it was based entirely on personal belief. In a tribute in Runner’s World magazine after Paffenbarger’s death in 2007, the US runner-turned-writer Amby Burfoot said Cooper admitted he had at first made no more than ‘an educated guess’ that jogging was actually good for people. ‘As he once told me, he had no idea if all the joggers he created might keel over and die during their workouts,’ Burfoot wrote of Cooper. ‘Paff proved that Cooper was right.’

  It is a curiosity of Paffenbarger’s influence that while his work was devoted to studying the benefits of everyday movement, his extracurricular life as a committed runner meant it was also adopted by the minority who take part in such sports. His work, Burfoot said, ‘stands as the very foundation of the exercise and fitness movement we all believe in so strongly’. Burfoot added: ‘Paff was the guy who got things started. He was the pioneer.’30

  Morris, by contrast, would never have seen himself as an ‘athlete’, just someone who saw the benefit in always being physically active, including the habit instilled by his father of setting off on brisk walks whenever feasible. Liam Donaldson, who went on to become England’s chief medical officer, the most senior adviser to government on health matters, recalls that as a juni
or lecturer at Leicester University he was sent out in a car to collect Morris from the local station and drive him to deliver a talk. But on learning the distance was only one and a half miles Morris insisted they walk, and spent the trek grilling the young academic on the useful public health people he should know in the city.31

  An avid reader of other health research, Morris had noticed the findings in the 1950s of Richard Doll, another pioneering epidemiologist, into the link between smoking and lung cancer, and immediately gave up his cigarette habit. Later he began jogging, though in a manner which would seem unrecognisable to Paffenbarger, let alone to Ken Cooper. ‘I was the first person to run on Hampstead Heath, in the 1960s,’ he said in 2009. ‘Every Sunday morning, if the weather was at all possible, I took off my coat, and my little boy carried my coat, I took off my jacket, and my little girl carried my jacket, and I ran for twenty minutes. People thought I was bananas.’32

  He was also a keen swimmer, taking any opportunity that arose. Mervyn Hillsdon, an Exeter University epidemiologist who collaborated with Morris on several of his later studies, recalls attending an academic event in the 1980s: ‘I was waiting for a lift to go back up to my room at a conference. He was coming down, dressed in his swimming hat, goggles and a robe, on his way to the pool. That’s how we first met.’

  Morris was by then in his mid-seventies, and continued swimming well into his nineties. He only stopped, Hillsdon says, because the aftermath of a broken hip made his walking uneven and he was ‘a bit nervous around the edge of the pool in case he fell’. Morris himself said he gave up because he was embarrassed by people rushing to help him when he got out of the water. Even afterwards he would still walk on Hampstead Heath and trek up the stairs to his office. ‘He really believed that on every day of his life he should take some exercise,’ Hillsdon said.33

  According to Lee, Morris can perhaps best be seen as ‘more of the everyman for physical activity’, as opposed to the marathon-running Paffenbarger. ‘He walked, he swam, and he swam into his nineties. So he did the kind of things that people can do when they get old. Ralph Paffenbarger is a bit of an anomaly. I think it might be a bit harder to identify with him. He turned out to be genetically very good in terms of exercise. But, interestingly, I don’t think he’d have known it if he hadn’t taken it up.’34

  Both regimes clearly worked. Paffenbarger remained trim and energetic to the end of his life, while Morris appeared to barely slow down even in very old age. ‘Jerry Morris is one of those lucky few in whom the ageing process starts normally, then admits defeat and gives up,’ began a BMJ tribute to him on his ninetieth birthday.35

  Morris never wavered in either his habits or his advocacy of them to others. ‘It’s the only way in which I feel entitled, as an old buffer, to give advice to people,’ he said shortly before his death. ‘I’m constantly being asked: “Your long life, what would you advise?” and so forth. To start telling other people what to do, I’m very reluctant. Except on exercise, where to a large extent I feel it’s what I’ve done myself that’s contributed to longevity.’36

  It marches together with the human condition

  While they worked on opposite sides of an ocean, and never directly collaborated on any studies, the ties between these two figures who pioneered the discovery behind this book remained close, and the wider academic community recognised the connection in their achievements. Perhaps the ultimate sign of this influence came in 1996, when, at the Atlanta Summer Olympics, Paffenbarger and Morris were jointly awarded gold medals for sports science by the International Olympic Committee, the first time such a prize had been given.

  Paffenbarger eventually died from complications connected to heart disease aged eighty-four, having reputedly been not just delighted but surprised to outstrip his family history of early male deaths.

  Lee says that Morris and Paffenbarger used to speak by phone every week, and when the latter died, she stepped in: ‘They were very good friends. When Paff died I felt like I had almost inherited a relative from him, and I should continue calling Jerry. We didn’t manage it as often, but I’d call to see what he was up to.’

  In legacy, however, the two researchers can be seen as slightly different. Paffenbarger’s direct influence is arguably more connected to his academic peers, as the scientist who pioneered the mass-scale, years-long population studies which are the foundation of modern public health research. Aside from further proving Morris’s ideas about physical activity, Paffenbarger’s work expanded the list of conditions affected by activity, such as strokes, and introduced a series of ideas which remain the inspiration for current studies, for example the impact of exercise on people of different weight types.

  In a tribute published soon after Paffenbarger died, Lee and some colleagues noted the statistics which highlight his influence. Most academic papers are never cited by any other studies, she wrote, and even those which are mentioned generally gather fewer than ten citations. Those with 50 are viewed as ‘classics’. Over his long career, Lee noted, Paffenbarger published 187 research papers, which had by then amassed more than 20,000 citations, and were gaining at least another 1,000 every year.37

  Much as with their respective sporting efforts, Morris could perhaps be seen as more of a real-world academic, closely connected to the ways in which his ideas affect people in their everyday lives, sometimes to an almost unlikely degree of detail.

  He was intimately aware of how these social factors could change. While his 1930s patients faced conditions like rheumatic heart disease due to a lack of available medical care, as the decades went on, poverty affected people’s health in different ways. When more than fifty years later Morris contributed to government work on deciding a new minimum wage, he ordered officials to price in the cost of a decent pair of walking shoes, as well as the cost of tea and biscuits a certain number of times a week, recognising that mobility and sociability are both significant factors in good health outcomes.38

  Morris completely understood that public health is shaped by the physical and cultural environment. He endlessly lobbied for more sports facilities – ‘Swimming means there must be pools,’ he said39 – as well as routes for safe cycling and convenient walking. He was hugely interested in how his field was dealt with in the media. ‘Jerry is the only person who tells me I ought to watch more television, not less,’ remarked Michael Marmot, one of the most eminent current epidemiologists, who led a landmark 2010 study into UK health inequalities.40

  This broad approach was fed by an omnivorous attitude to knowledge typical of the son of the much-educated Nathan Morris. Tamara Lucas recalls that when, as an anthropology student, she would visit him, he would generally take her on a long walk to a swimming pool. On the way Morris would quiz her endlessly about her subject. ‘He knew about everything,’ she says. ‘He was one of those very erudite people. I can’t imagine what I would have been studying that he wouldn’t have been interested in.’41 Hillsdon notes that Morris’s small social medicine department included not just epidemiologists but a series of other disciplines, for example physiologists and historians: ‘He loved spending time with people who came at the same topic that he was interested in from a completely different methodological approach. It’s something he told me all the time – always have conversations with a really broad range of disciplines and specialists, because otherwise there’s a risk of becoming too narrow in your thinking.’

  This external-facing view of his science saw Morris not just produce the raw evidence for the benefits of more widespread physical activity, but spend increasing amounts of time trying to persuade people to act on it. According to Hillsdon, Morris regularly penned handwritten letters to government ministers and others in positions of influence to warn them about the consequences for public health if they did not take action. Hillsdon adds: ‘If they simply ignored him he’d get on the phone and say, “I’m surprised you didn’t have the courtesy to acknowledge receipt of my letter. I’m wondering whether that meant it didn’t arrive
?” ’42

  Morris was the lead researcher in one of the first official reports to fully highlight how inactive the UK population had become. The National Fitness Survey carried out exhaustive interviews and fitness tests with thousands of people during 1990, with the subsequent report highlighting not only the number of Britons unable to carry out even fairly basic physical tasks, but a worrying lack of awareness among many people about their own lack of fitness.

  The study found that over two thirds of women and nearly a third of men would find it difficult to maintain an average-speed walk (at 3mph) up a slight gradient. Among older people, those aged fifty-five to seventy-four, more than half of women and almost a third of men would struggle to do this even on level ground, having to slow or stop after about ten minutes. In practical movement terms, this amounted to having a disability.43

  Throughout his life Morris worked to produce more such research – in later years often omitting his age from grant applications to boost the chances of success – and badgered successive generations of government ministers and chief medical officers. But even he could not stem the tide. This was, Hillsdon says, a source of endless frustration: ‘It used to drive him nuts. Jerry always said, “My great failure has been that I never really influenced policymakers, and they never really took physical activity seriously enough.” It wasn’t about his science – it was about his ability to influence people who could change policy as a result of the science.’ In the interview from 2009, Morris was more blunt: ‘Just imagine what historians in the future are going to say about the way we’ve allowed this epidemic of childhood obesity. “Disgrace” is a sort of mild word.’44

  Even as the importance of physical activity for health becomes ever-more prominent, the two men who did most to prove the link remain generally unknown outside academic circles. When they died, Morris and Paffenbarger received brief if glowing obituaries in a handful of newspapers, but if you mention either to someone outside a relatively limited field of public health or associated fields, you’re likely to get a blank look.