This post concerns my father-in-law, Dr. Richard (“Dick”) Morrow. He died recently from a fairly rapidly progressive illness that, while surprising and cruel, nonetheless afforded him time to say goodbye to close colleagues and family. It occurred to me to write this post because, while I know a decent amount about his work from stories and family conversation, I’d never really looked into his publication history. Dick was a lifelong academic, teacher and mentor, and though it’s true that his lasting contribution will be his personal influence on his legions of colleagues, friends and students throughout the world, I thought it would be interesting and a worthwhile tribute to peruse his academic record. A gedenkschrift is a “memorial publication” to celebrate the works of an academic scholar who has passed away. I have seen a couple of festschrifts (for those still living) in Family Medicine academic journals recently, and so i thought I’d try my hand at the genre.
A couple of caveats are needed from the outset. While I may not be the LEAST qualified person to write a gedenkschrift of Dick’s work, I’m close to it. This is a personal blog, however, so I get to set my own standards. One of those standards is that I don’t pretend to have actually completely read many of these articles. I’ll definitely keep the list and hopefully make my way through many of them over my lifetime, but for now – I’m engaged more in getting a sense of the general directions in his overall thoughts and career. And only his. He would be the first to acknowledge the other authors and team members invovled in these publications. But, as I say, this is personal blog, so I’m keeping it personal. Here goes…
First is a very brief sketch of his career. Dick started out as a medical student at Washington University in St. Louis, MO and finished his residency in internal medicine at Strong Memorial Hospital in Rochester, NY. He went to Ghana shortly after this to work in the clinical care of malaria. After rotating back to the US, and around the time of my wife’s birth, he finished a Masters in Public Health at the Harvard School of Public Health. He then moved to Uganda, working in public health and tropical disease research. In the 80’s, he moved to Geneva, Switzerland to work in the World Health Organization for 11 years. Around the time of my marriage to his youngest daughter, he moved Baltimore, MD to work for the Department of International Health at the Johns Hopkins School of Public Health.
His initial publications, as indexed in PubMed, concerned unusual presenations of tropical disease: viral hepatitits, tropical splenomegaly, malaria, sickle cell disease, and Burkitt’s lymphoma. These publications continued from the first in 1967 to the mid-1970’s. At that point, his work broadened to investigate additional diseases that plagued those regions of Africa – schistosomiasis, trypanosomiasis and other soil-borne diseases. These publications continued into the mid-1980’s. In 1983, he published an interesting letter to the International Journal of Epidemiology called “Clinical Epidemiology for Developing Countries“. For the author of a blog about evidence-based medicine, this letter holds particular interest, as it offers perspective on the burgeoning discipline of Clinical Epidemiology as professed by the now-known “home” of EBM – McMaster University. Dick (and co-author Carol Buck) advocated that the skills of Clinical Epidemiology – critical appraisal of medical literature, basic research design, measuring quality, and economic evaluation of health care – are needed even more in developing countries than in western, more developed countries. He argued that these skills are integral to the practice of all medicine, and in areas of decreased resources and urgent health problems, clinical epidemiology was critical to advancing the health of these populations.
It is after the publication of this paper, that his work on prioritizing health problems, for which he is arguably best known in public health circles, began. His first paper on this topic, The application of a quantitative approach to the assessment of the relative importance of vector and soil transmitted diseases in Ghana, discussed a method for quantitatively assessing the impact of diseases on a population by looking at incidence, case fatality, and disability to arrive at an approximation of healthy life lost due to a disease. For a developing country that depends on a health workforce for economic development, the suggestion that the ministries of health prioritize health spending on those diseases that had the biggest impact on healthy life lost appears to have been relatively novel. His conclusions about the state of health in Ghana fingered malaria as the overall most impactful disease in the nation. Onchocerciasis also factored highly; it was not often considered an important disease, but its effect on chronic disability was evident when taken into account in this more quantitative approach.
While some of his publications of the 1980’s and early 1990’s continued to look at clinical disease (Burkitt’s lymphoma as well as the new interactions of HIV with the known tropical diseases), he continued to advocate in various ways for clinical epidemiology and ground-level research in these poorer nations as a way to address their most pressing health problems. His work at the WHO led him to publish (with co-author MA Lansang), an article advocating the development of national research strategies based on the epidemiology of the impact of disease in a country. The topic sentence of the abstract for this article is telling in that he advocates the development of this research capacity not only for health needs but for overall “equity in development”. Dick was an ardent believer in science as an essential tool for advancing social justice. One of my wife’s favorite sayings of his, “without health, there is no choice” provided the foundation of his work – that health is fundamental to the proper, equitable development of all nations. He believed that states had a duty to provide for health for every individual, and strived to make the case that this was not only moral, but was in the long-term best economic interest of the state itself.
His work thereafter contined to refine and explore the measurements of health impact – using and improving the concepts of DALY (disease-adjusted life years) and later HeaLY (health-adjusted life years) to make these points and investigating the conceptual and ethical aspects of these measurements. One frequently cited article, “Health Policy Approaches to Measuring and Valuing Human Life: Conceptual and Ethical Issues” provides a nice summary of the development of these measures and their application in international health. In the conclusion to this paper, Dick and his co-author (John H. Bryant) argue convincingly for the rational approach to health priority setting using the measures discussed, but also make clear statements about the absolute value of human life no matter what tools are used to attempt to measure productivity and quality of life.
He also began writing about quality assurance in international health programs – a principal focus of his time at Johns Hopkins. Throughout all these later papers, there is clear evidence that he was constantly re-evaluating and refining his ideas. Around this time, he and I began playing chess together. His one rule for every game was that we were allowed to take-back any move if it was a mistake or obviously flawed. (Of note, I believe he only used this once in our games…whereas I tended to use it with abandon.) This rule is entirely consistent with his approach to science – constant re-evaluation to make the important work of health (and the important “play” of chess) as good as it can be.
Publications after this time (mid-1990s) reflect his role as senior scientist and mentor. He published a couple of articles on road safety in Pakistan (here and here, I am not aware that these were driven by personal experience, but I am not certain) and the measures to improve safety in the serivce of overall health. He also co-authored a paper with another of his daughters dealing with one of the anthropological determinants of HIV spread in Africa.
In 1991, he and Peter Smith published a textbook of “Field Trials of Health Interventions in Developing Countries: A Toolbox.” This is a very practically written text aimed at global health workers and researchers in order to improve the quality of research in these settings and to ensure that the money used to support this research was used wisely on high-quality projects. This textbook is cited heavily in subsequent articles and books on international public health, clinical epidemiology and research design, and has clearly been one of his most influential works. He wrote a handful of other textbook chapters – all focusing on the application of epidemiology to public health issues. (examples: Measures of Health and Disease in Populations, Disease Burden Measurement and Trends).
One book chapter of particular interest was his chapter on Malaria in “The Development of Modern Epidemiology: Personal Stories from Those Who Were There” In this chapter, he details the impact of his time taking care of patients with malaria in Ghana, and his understanding of the importance of epidemiology in solving public health problems. He references, in this section, his randomized controlled trial of teaching mothers to recognize and treat malaria in their children without additional medical intervention. He acknowledges this trial (published in the Lancet in 2000) as “controversial” but as an important step in challenging conventional paradigms of malaria treatment. I would recommend the introduction to this chapter (structured as a personal remembrance) as an excellent companion to this post.
Dick was an excellent physician, public health professional, husband, father and father-in-law and I consider myself very lucky to have had him in my life. My goal in writing this gedenkschrift, which was successful in ways that I did not predict, was to better understand the trajectory of his academic career and to become more conversant in the considerable impact he has had in international public health and epidemiology.