Pickles of Wensleydale revisited in the light of the COVID pandemic

One of the most celebrated practitioners of the British art of general practice was Will Pickles of Wensleydale, whose publication of Epidemiology in Country Practice in 1939 became an instant classic and set a standard for hands-on research based on the everyday observations of a dedicated clinician working far from the bright lights of academia and the metropolis. ¹

In his preface to the book, renowned epidemiologist and medical statistician from the London School of Hygiene and Tropical Medicine, Major Greenwood, drew the comparison between Pickles’ observational approach to his surroundings and the infectious diseases that afflicted his patients and that of the famed naturalist and early ecologist, Gilbert White. White’s careful observations in Hampshire and Wiltshire paved the way for those such as Huxley and Darwin who followed him. It is of note that in his detailed description of the geology of Wensleydale, Pickles demonstrated a resonance with Hippocrates in 4 BC, who had reflected in his book, On Airs, Waters and Places, on the causal relationships between human diseases and their environments, or what today we might describe as ‘habitats’. ²

Greenwood’s comment that he regretted the segregation of what are called ‘researchers’ into a category of ‘experts’ aloof from everyday practice seems especially apposite as we begin to digest the lessons from the handling of the COVID pandemic in which the early period was characterised by an over dependence on the ‘expert’ opinions and conjectures of those most remote from the frontline. ³

Born into a medical family, Will Pickles lived in the exquisite but harsh beauty of Wensleydale for more than 50 years, much of it as a general practice partner based in Aysgarth where he also fulfilled the responsibilities of Medical Officer of Health. From the age of 42, he spent the next 25 years recording the epidemiological details of 6808 patients with specific infectious details, supported by his wife Gerty, who transcribed his daily clinical notes into beautiful informative charts; a supportive senior partner in the practice, Dean Dunbar; and by annual visits to the London School of Hygiene and Tropical Medicine for academic nourishment. Epidemiology in Country Practice brings together the findings of his insatiable curiosity, described by Dr William Goldie as ‘ almost nosiness’. ¹

Pickles’ descriptions included a wide range of mostly then common, but also some rare, infections such as Sonne Dysentery, Undulant Fever, Pink Disease, Epidemic Myalgia (in which he was pipped to the post by a published description from the Danish island of Bornholm) and the then under-investigated condition of Epidemic Catarrhal Jaundice (later to be known as infectious hepatitis). The reflections made possible by his simple charts, so many years before the advent of computers, enabled him to offer insights into the importance of lines of communication in the spread of infection including the social rhythms of markets, festivals, pantomimes and community excursions in the days before mass personal transport; asymptomatic transmission; partial and naturally acquired (‘gutter’) immunity; incubation and infectivity periods; the role of immunisation; and the vexed questions raised by proposals for school closure to nip outbreaks in the bud together with the potential jeopardy inherent in admitting patients to hospital risking secondary outbreaks in clinical settings. We are reminded once again of the failure to register the lessons of history in the handling of the COVID pandemic.

The riches to be found in Pickles’ short offering of just over 100 pages are difficult to overstate. He stresses the importance of an epidemiologically minded head teacher of the local grammar school as an accomplice in providing relevant intelligence and argues convincingly the case for all general practitioners to be making systematic clinical observations at a population level. Observations that may seem too trivial to write down may assume importance in the aggregate, serendipity certainly favours the prepared mind in the frontline, and the public health concept of ‘shoe leather epidemiology’ is brought to life when a country general practitioner walks for miles over snow laden fields to care for patients while capturing important data. Geoffrey Rose’s incitement for clinicians to have ‘clean minds and dirty hands’ sits powerfully beside Major Greenwood’s contention that ‘statistics are patients with the tears wiped off’. ⁴

Throughout the COVID pandemic, lessons that should have been in the DNA of health and healthcare systems from epidemics past have had to be re-learned, drawing our attention to how few medical schools have medical and public health history at their heart. Even before Pickles in the influenza pandemic in 1918/19, rural Texan family doctor Loring Milner had been the first to register the new virus among his patients, only to be ignored by the U.S. Public Health Service in his efforts to bring it to their attention. ⁵

The asymmetrical domination of healthcare by hospitals and the neglect of public health, primary and social care in most countries has led to recurrent crises with each new wave of infection and there is still little sign of radical readjustment. The proposed new Integrated Care Systems for England have a strong feeling of the Empire Striking Back, with top-down centralised plans reminiscent of the five-year plans of the former Soviet Union; to paraphrase comedians Morecambe and Wise, ‘Playing many of the right notes but not in the right order’.

Yet models exist from elsewhere that reinforce the vital importance of Pickles’ work to what is needed for the future. A South African public health team led by Sidney Kark developed a public health model of primary care based on the 1930s Peckham Pioneer Health Centre in London, and when they were driven out of South Africa by the apartheid regime, encouraged its development in Jerusalem and elsewhere.^4,6,7

Julian Tudor Hart took Pickles’ work to a new level in the valleys of South Wales, training local coal miners as epidemiological support workers to record data on the whole population; and the global Global Strategy for Health for all by the Year 2000 proposed that healthcare systems should be reorientated to be based on a public health model of Primary Care^8,9); and some U.S. medical schools have public health practice units serving inner city communities, addressing real-time, real-life, public health challenges such as that of violence using an approach based on local epidemiology and community co-production.

However, perhaps the only full-blown European model of public health-based primary care is that in Finland, where for almost 50 years it has been the statutory basis of the healthcare system, while in parts of Scandinavia such as rural Norway it is still the tradition for local general practitioners to be the local Medical Officer of Health; now there is an idea! As we approach the centenary of the publication of Epidemiology in Country Practice, that would be an appropriate legacy.