Preventive Medicine in Wales

1. Preventive Medicine in Wales Peter Elwood Cochrane Institute of Primary Care and Preventive Medicine Cardiff University Eyecare Conference Optometry Wales: 19th September 2012

2. Eyecare in Wales • My aims in this talk: • To encourage you in the life-changing and • life-enriching work you do • 2. To challenge you to ‘up your game’ and to • ‘widen your horizons’

3. Epidemiology - clinical studies →effects of treatment; prognosis etc - laboratory studies → mechanisms in disease - epidemiology and Public Health - The Truth • There are three sources of evidence in medicine:

4. Epidemiology - clinical studies →effects of treatment; prognosis etc - laboratory studies → mechanisms in disease - epidemiology and Public Health • The prevalence and the importance of disease • to plan services more effectively and efficiently • to evaluate the importance of services more precisely 2. To identify factors predictive of disease to obtain clues about possible preventive measures • There are three sources of evidence in medicine:

5. Epidemiology - clinical studies →effects of treatment; prognosis etc - laboratory studies → mechanisms in disease - epidemiology and Public Health • The prevalence and the importance of disease • to plan services more effectively and efficiently • to evaluate the importance of services more precisely ‘Efficiency and effectiveness’ ‘Evidence-based practice’; ‘cost-effective practice’ 2. To identify factors predictive of disease to obtain clues about possible preventive measures ‘Prophylaxis, rather than ‘therapy’ • There are three sources of evidence in medicine:

6. Cochrane believed that epidemiology can make important contributions to every area of clinical practice Archie Cochrane 1909-1988

7. The Ferndale Study of Eye Disease 1964

8. The Ferndale Glaucoma Survey 1964

9. The Ferndale Team Tom Benjamin, Diana Seys Prosser, Archie Cochrane Hugh bates ? . ? , ?, Peter Graham ? Gwillam Jonathan, Irene Calford, Fred Moore, Glenys, ?.

10. The Ferndale Survey 4,246 people aged 40-75 were seen and examined AIMS: 1. Determine the prevalence of eye diseases 2. Define the distribution of intraocular pressure 3. Determine the prevalence of glaucoma 4. Test a treatment of glaucoma in a randomised trial 5. Conduct long-term follow-up studies of the population to study the development and the prognosis of various eye-diseases

11. General examination: - details questionnaire on health and social issues - blood pressure measurement

12. Ophthalmic examination: - general examination, with ophthalmoscopy - field examination with the Friedman multiple pattern type machine - instillation of fluorescine and local anaesthetic - slit lamp examination - applanation tonomotry - Schiotz tonomotry

13. Output: Hollows FC & Graham PA. Intraocular pressure, glaucoma and glaucoma suspects in a defined population.Brit J Ophthal 1966;50:570-586 McGuinness R. Association of diabetes and cataract. BMJ 1967;i:416-7 Graham PA Screening for chronic glaucoma. Symposium on Presysymptomatic Diagnosis Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal detection of registrable blindness.Brit J prev soc Med. 1968;22:238-41.

14. Output: Hollows FC & Graham PA. Intraocular pressure, glaucoma and glaucoma suspects in a defined population.Brit J Ophthal 1966;50:570-586 McGuinness R. Association of diabetes and cataract. BMJ 1967;i:416-7 Graham PA Screening for chronic glaucoma. Symposium on Presysymptomatic Diagnosis Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal detection of registrable blindness.Brit J prev soc Med. 1968;22:238-41. “Unless a follow-up is successfully concluded the value of eye screening tests in preventive ophthalmology would seem to be doubtful.” ophthalmologist

15. Output Hollows FC& Graham PA. Intraocular pressure, glaucoma and suspects in a defined population.Brit J Ophthal 1966;50:570-586 McGuinness R. Association of diabetes and cataract. BMJ 1967;i:416-7 Graham PA Screening for chronic glaucoma. Symposium on Presysymptomatic Diagnosis Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal detection of registrable blindness.Brit J prev soc Med. 1968;22:238-41.

16. Fred Holllows (1929-1993)

17. Fred Hollows Fredworked with Archie Cochrane on the Ferndale Eye Study in 1964. He then left and went to Australia.

18. Fred Hollows ‘Companion of the Order of Australia’ Yet Fred was a Maverick and one writer describes him as “The wild boy of New Zealand’

19. Fred Hollows ‘Companion of the Order of Australia’ Gabi Hollows Orthoptist named as one of Australia’s 100 Living Treasures and given an Advanced Australia Award for community service ‘worked tirelessly with Fred until his death. Together they set up The Fred Hollows Foundation to continue the work of eyecare in Australia and overseas’

20. ‘Hollows took up the cause of the Aborigines. He set up ‘The Aboriginal Medical Service’ and ‘The National Trachoma and Eyehealth Programme’. ‘Over 100,000 Aborigines were examined and tens of thousands treated.’ ‘Then, despite increasing ill health, he expanded his work to Eritrea, to Nepal and to Vietnam.’

21. ‘A Tireless Innovator, Healer & Campaigner’ ‘A passionate ophthalmologist…’ ‘He restored the eyesight of countless thousands of underprivileged people in developing countries‘. ‘He had a passion to improve their health in every way possible.’ ‘It has been estimated that through his work, over one million people had their sight restored around the world.’ Fred Hollows (1929-1993)

22. Shortly before his death, Fred organised the setting up of a factory in Eritrea to manufacture inexpensive intra-occular lenses for use in underprivileged communities

23. A year before he died, Fred and Gabi set up the‘Fred Hollows Foundation’ to continue the work he had started amongst the Aborigines and amongst many other under-privileged communities would continue. The Fred Hollows Foundation is is now a major international charity

24. 1981: Advance Australia Award for Aboriginal eye care. 1985: was a consultant to the World Health Organisation (WHO). 1985: offered appointment as an honorary Officer (AO) of the Order of Australia. 1990: received Human Rights Medal 1990: named Australian of the Year 1990: received a second Advance Australia Award, for Medicine and Overseas Aid 1991: named Humanist of the Year 1991: named a Paul Harris Fellow by Rotary International 1991: received Honorary Doctor of Medicine and Doctor of Science, University of New South Wales 1991: appointed Companion of the Order of Australia (AC) 1991: awarded Honorary Doctorate of Science, Macquarie University 1991: named the first honorary citizen of Eritrea 1992: received Honorary Doctorate, Queensland University of Technology 1993: received Albert Schweitzer Award of Distinction, Chapman University, USA 1993: received Rotary International's highest honour, the Rotary Award for World Understanding. 1993: received the Royal Australian College of Ophthalmologists Medal for his years of distinguished meritorious and selfless service – presented to him the night before he died. 1993: posthumously named a Melvin Jones Fellow of Lions Clubs International. 1993: Fred Hollows Reserve in Hollow's hometown of Randwick, NSW Australia established to preserve a natural rainforest gully and save it from future development. 2004: entered into the 'Hall of Fame' at the inaugural NSW Aboriginal Health Awards, in recognition of his "outstanding contribution and achievement to Indigenous health in Australia". 2005: an operating theatre was named after him at Canberra Eye Hospital, ACT, Australia. 2005: named one of "New Zealand's Top 100 History Makers" by Prime Television New Zealand. 2006: named one of the "100 most influential Australians" by The Bulletin magazine.[15] 2010: featured on $1 Coin from the Royal Australian Mint as part of the Inspirational Australians Series Hollows received twenty three National and International awards

25. In 1993 Fred Hollows died, aged 63 He was given a state funeral.

26. Commerative stamps in Australia

27. Commerative stamps in Eritrea

28. Commerative coin in Australia

29. Fred Hollows worked in Wales! In his autobiography, Hollows wrote: “The most important influence on me in Wales was Archie Cochrane… Archie and I co-operated in the Ferndale Study of Eye Disease. Without that project in Wales, my later work amongst the Aborigines and in other countries would not have achieved what it did’. (Quotation slightly adapted) Yet, there is no record of Hollows in Wales and only a very few remember him!

30. Sadly, and remarkably, there seems to be no record of Hollows in Wales and few seem to remember him “Fred was a delightful man to work with. He had a lovely way with subjects, especially if they were nervous…. Three years after Ferndale I went to Australia and worked with Fred on one of his mobile teams in the bush. It was hard work but everyone enjoyed working with him. He was a truly dedicated person and he himself worked very hard indeed.”Diana Pritchard Diana Pritchard Ralph Marshall (Seys Prosser)

31. Fred Hollows worked in Wales! I have therefore proposed that a panel is erected in the Cochrane Building, with Fred’s image, an account of his work in Ferndale, and details of his work in Australia and in other countries. With postage stamps from Australia and from Etreia and two Australian coins

32. Fred Hollows 1929-1993 An inspiration to all of us in healthcare and especially to you in Eyecare in your life-changing and life-enriching work in the community

33. To encourage you in the life-changing • and life-enriching you do • 2. To challenge you to ‘up your game’ and • to ‘widen your horizons’ • My aims in this talk:

34. Fred Hollows 1929-1993 An inspiration to all of us in healthcare A challenge to widen your horizons!

35. Wales holds many records! Smoking Alcohol abuse Obesity Lack of exercise Inappropriate diet

36. Health in Wales! Cost of unhealthy behaviours to NHS Wales* Smoking £386 m Obesity £ 86 m Lack of exercise ? Inappropriate diet ? Alcohol abuse £ 70 m 10% of total NHS costs! * * Making the economic case for prevention: a view from Wales. Welsh Government Report: Hale, Phillips, Jewel 2012

37. And so, a number of our colleagues in Public Health have launched…. Champions for Health Stakeholder Briefing A new campaign for a healthier Wales A new campaign to encourage all NHS staff in Wales to adopt a healthier lifestyle themselves and become role-models and encourage patients and the public to do the same

38. A healthy lifestyle its effectiveness and its up-take in Wales The five healthy behaviours Non-smoking BMI 18-25 ½ hour exercise daily ‘Five a day’ Alcohol within the guidelines

39. The Caerphilly Prospective Study THE CAERPHILLY PROSPECTIVE STUDY 1980 - 2,500 men aged 45-59 yrs; First examined in 1980 re-questioned and re-examined every five years since then

40. The effectiveness of a healthy lifestyle HEALTHY BEHAVIOURS at baseline in 1980 Non-smoking Body weight Diet Exercise Alcohol intake Recorded for 2,500 men aged 45-59 yrs OUTCOMES during the following 30 years Diabetes, vascular disease, cancer, dementia and all-cause death Output: Around 400 reports published in medical journals

41. The effectiveness of a healthy lifestyle REDUCTIONS (based on ORs) over the following 30 years All relationships adjusted for age and social class And dementia for baseline cognitive function

42. The effectiveness of a healthy lifestyle REDUCTIONS (based on ORs) over the following 30 years All relationships adjusted for age and social class And dementia for baseline cognitive function

43. The effectiveness of a healthy lifestyle REDUCTIONS (based on ORs) over the following 30 years All relationships adjusted for age and social class And dementia for baseline cognitive function

44. The effectiveness of a healthy lifestyle REDUCTIONS (based on ORs) over the following 30 years All relationships adjusted for age and social class And dementia for baseline cognitive function

45. The effectiveness of a healthy lifestyle REDUCTIONS (based on ORs) over the following 30 years Another measure of benefit: The number of years before disease in subjects following a healthy lifestyle will become the level in those who follow no healthy behaviour All relationships adjusted for age and social class And dementia for baseline cognitive function For heart disease and stroke……..up to 13 years For dementia ………up to 7 years For death ……… up to 6 years

46. The effectiveness of a healthy lifestyle REDUCTIONS (based on ORs) over the following 30 years Yet another measure of benefit: Had the subjects in this 30 year study each been urged at baseline to adopt one additional healthy behaviour, and if only half them had complied, there would have been…. All relationships adjusted for age and social class And dementia for baseline cognitive function 12% less diabetes; 6% less vascular disease 13% less dementia; 5% fewer deaths

47. Eye disease and Healthy Behaviours ?Eye disease and a Healthy Lifestyle?

48. Eye disease and Healthy Behaviours Two to three-fold increase in cataract in smokers, and a two to three-fold increase in macular degeneration American Council on Science and Health Obesity increases risk of macular degeneration (Arch Ophthalmol. 2009) ?Increase cataract, glaucoma and diab. retinopathyIsrali claim Mediterranean diet (fish, nuts, and olive oil) beneficial Cheong; Tan Sat. fats increase macular degeneration (Arch Ophthalmol. 2009) Beneficial impact on ocular perfusion pressure and glaucoma,macular degeneration 30% lower Brit J Ophthal. Uncertainty about relationships with the eye Wang S, Wang JJ, Wong TY.Surv Ophthalmol. 2008

49. Healthy Behaviours in Wales Two to three-fold increase in cataract in smokers, and a two to three-fold increase in macular degeneration American Council on Science and Health Possible increase in macular degeneration, cataract, glaucoma and diabetic retinopathyClaim in a report from Israel Prospective epidemiological studies are invaluable! Some records of the Ferndale study are still available The Speedwell Prospective Study in Bristol, set up in 1979, has data on healthy behaviours and on macular degeneration Obesity increases risk of macular degeneration Mediterranean diet (fish, nuts, and olive oil) beneficial Cheong; Tan Sat. fats increase macular degeneration (Arch Ophthalmol. 2009) beneficial impact on ocular perfusion pressure and glaucoma,macular degeneration 30% lower Brit J Ophthal. Uncertainty about relationships with the eye Wang S, Wang JJ, Wong TY.Surv Ophthalmol. 2008

50. The effectiveness of a healthy lifestyle Overall summary…….. Following a healthy lifestyle substantially reduces the risk of diabetes, heart disease and death….. and….. risk of certain eye diseases reduced and….. during the extra years of life, the risk of dementia is reduced BUT, the bad news is…….