Ciin. Radiol. (1977) 28, 239-241

THE USES OF RESEARCH*

SIR DOUGLAS BLACK

Many a lecture begins, not perhaps with a fanfare of trumpets, but with a solemn proclamation of intent to 'remove misconceptions'. Before making such a proclamation, I should perhaps imitate the fiction- writer, cautious of libel, by saying that I am not ascribing these misconceptions to any particular person, living or dead; and that I am aware of the further risk, that should I even be successful in removing them - I may still be replacing them with still worse misconceptions dredged from the depths of my own tortured mind.

I have discussed elsewhere at greater length (Black, 1975) certain views held by lay people and by scientists themselves which have contributed to an undervaluation of science and research, but I may perhaps summarise them here. The lay public tends to regard science as an impenetrable mystery, and to regard scientists as remote and impersonal wielders of power; the medical scientist in particular is further suspected of unethical 'experimentation' on helpless invalids. Scientists themselves have at times restricted the scope of science, by equating it with measure- ment or with methodology, whereas, in my view, it is really about ideas and problem-solving - measure- ment and method are of course critical in testing scientific hypotheses, but it is their original for- mulation which is the more seminal scientific activity. Success in research can only (if at all) be achieved by concentration of effort, and the majority of scientists have been so bound up in their work, that they have made little effort to explain it to the society from which they draw their support; while others have been tempted, in the course of fund-raising, to make exaggerated claims.

Whatever the underlying causes, the public mood in the fifties of almost uncritical acceptance of the value of scientific research and of science-based technology has certainly given place to a much more critical approach to scientific activity, which at its extreme amounts to total rejection. Scientists are told by politicians that their honeymoon is over. In his well-known report Rothschild (1971) questioned the balance between 'pure' and 'applied' research in the publicly funded sector, and called for greater control of the research funded by Government, using the devices of the 'customer-contractor principle', and

* Crookshank Lecture delivered to the Royal College of Radiologists on 21 May 1976.

the transfer of part of certain research council monies to the control of related Departments of Govern- ment, other than the Department of Education and Science. On the grounds of energy wastage and environmental pollution, the technological base of modern industrial societies has been radically criti- cised; and medical technology in particular has been castigated by Illich (1975) as 'medical nemesis'. Some of these reactions seem to me to be extreme, and I cannot myself envisage a world without mechanical transport, television sets, piped water, and electrical supply, nor a willing universal return to third-world conditions; but equally there is a clear need, already accepted by many scientists, for a greater awareness of the social costs and consequences of their ac- tivities.

Medical research has certainly not escaped the kind of criticism which is often levelled at scientific activity in general. It has further been taxed with excessive preoccupation with rare and 'interesting' diseases, at the expense of studying common ail- ments, which are often rather ill-defined states such as 'back-ache' and even 'old age'. Considerations of personal prestige have been deemed to affect the direction of research, as well as of practice. These criticisms have not been borne out in my personal experience of the planning of research by the Medical Research Council, which gives much attention to the consideration of practical relevance, and is by no means exclusively concerned with scientific quality and feasibility, though these must also be limiting factors in what is chosen for support. While there is naturally a preponderance of medically qualified members on the Council and on its Boards, there are also members of other scientific disciplines, including sociology; and on the Council itself there are a number of lay members, including the Chairman. While the members of Boards and of Grants Com- mittees must naturally be capable of assessing scien- tific evidence in relation to applications for support, they are rarely drawn from narrow specialties, and have usually had wide experience either of practice or research, and more commonly both. Particularly at Grants Committee level (where the majority of projects are discussed) the members are often rela- tively young men, still active in research. Going beyond the choice of areas for research, there are problems of maintaining research strength in the medical field, and in the management of research teams; here the Council awards training grants and also supports career posts for research-workers, and

240 C L I N I C A L R A D I O L O G Y

its headquarters staff represents a valuable and experienced source of research management skills.

I would not, therefore, accept that medical re- search in this country has been handled irresponsibly or neglectfully, either by the MRC, the Health Departments, or the voluntary organisations which play an important independent role in research funding. Of course, not everyone receives support; but the system, while not infallible, seems to me to operate fairly, and it has certainly had notable success of a practical kind, as well as maintaining a leading role for this country in medical science. Perutz (1972) described some of the ways in which work supported by the MRC has led to advances in the prevention and treatment of major diseases, as well as to the production of substances such as cephalosporin which have had great commercial value to the country; and he has recently described how basic work on molecular biology has led to practical advances in the control of blood coagulation, and the detection of carcinogenic chemicals (Perutz, 1976).

Examples showing that medical research has done well are not in themselves sufficient to convince those wedded to the belief that it could have done better; and they would even seem irrelevant to those who hold the radical view that all evils stem from the nature of society, and that the entire scientific approach is misdirected. Misgivings of this kind are perhaps not entirely rational, but in the light of some of the stresses around us they may be understandable. But can they be satisfied? I want now to consider some of the difficulties in actually implementing the proposition that the direction of research should be determined on social rather than on scientific grounds.

I am not qualified to consider in any objective way one form which this proposition sometimes takes, that support for medical research should be dimin- ished, to allow an increase in the support for sociological research. There seem to me to be difficulties in evaluating the benefits of sociological research which go beyond even those of evaluating medical research; and I hope to be able to show that even in the relatively hard area of medical research an approach based on social priorities is not without some difficulties. In expressing a cautious view on the desirability of immediate rapid expansion in sociological research, I am influenced by the shortage of trained workers in what is after all a relatively young science, and by the lack of objectivity in some reported studies which is recognised by sociologists themselves (Brown, 1974). Both of these factors can and must change, as the subject develops; and there are already objective techniques for the evaluation of both health and personal social services which must

clearly be encouraged, at the very least to ensure that we derive maximum benefit from the very large financial provision for health and social services. But for the present I wish to consider only a more limited form of the proposition, to the effect that the direction of biomedical research should be dictated by 'health priorities'.

This sounds simple and reasonable, but two questions at once arise - 'Whose priorities?' and 'How are they to be determined?'

The meaning, and the difficulty, of the first of these questions may become clearer if we split it into subsidiary questions. Are the priorities to be those as seen by the caring professions, which probably equates with medical dominance? If not, are we to lay stress on the individual patient, as in the traditional clinical model; or on the community, as in the epidemiological model? If we accept the second of these, laying stress on the community, do we work to a global index, such as life-expectancy; or do we divide the community into special groups, commonly known as client-groups, such as children, the aged, the physically and mentally handicapped? If the latter, how do we assess the relative claims say of children and of the elderly? These seem to me questions on which doctors can give some advice in terms of feasibility, but which ultimately must be decided by 'society', which probably means the political and adminstrative agents of society, not uninfluenced by a variety of pressure groups. What seems to me likely to emerge from this approach is a series of statements of good intent, varying in emphasis from time to time, rather than any clear rating of priorities which could form the basis of planned research. Paradoxically, it is easier to define, or at least to state, priorities for the provision of services than it is to state priorities for research; since the time-scale of research subsequent development is usually longer than that of decisions on ser- vice-provisions.

There is a further difficulty (and this brings me to the second question set out above) in translating 'health priorities' into" requirements for biomedical research. This lies in the lack of correspondence between the needs of client-groups on the one hand and the traditional organisation of medical research in terms of the systems of the body and particular diseases. For example, there are disease like bron- chitis or peptic ulcer which may affect members of all client-groups; and on the other hand, some client- groups may have multiple biomedical disabilities. It follows that the delineation of priority for a client- group does not directly point to appropriate bio- medical research. In an attempt to evade value-, judgements on the relative importance of client-

THE USES OF RESEARCH 241

groups, we have looked at biomedical categories in another way, assessing the burden which they impose on the health services (Black and Pole, 1975). We rated 54 categories o f disease in terms of five indices of health-service burden - in-patient days; out- patient visits; consultations with family doctors; sickness benefit (which applies only to insured persons, but is nevertheless a partial index of cost to society); and mortality, expressed as loss of life expectancy.

For each of these indices, it turned out that the number o f disease categories which added up to 50% of the total burden was comparatively small, ranging from three (in-patient days) to nine (GP con- sultations). This partly reflects the rather broad categories of illness which we had to adopt to keep our list down to a manageable size; but it is still a striking finding that, for example, 52% of loss of life expectancy is accounted for by ischaemic heart disease, tumours, and cerebrovascular disease.

More disconcerting, however, is the widely dif- fering rank order of illnesses for the different indices which we used. In effect, this means that having escaped from one form of value-judgement (as be- tween client-groups) we have landed ourselves with another (as between say mortality and hospital-bed occupancy). To take that last example, the three major causes of mortality, as already stated, are ischaemic heart disease, tumours and strokes; whereas almost half the hospital-bed occupancy is attributable to mental illness and mental handicap. It seems clear that any ranking of biomedical priorities based on 'health service needs' would necessitate a prior ranking of objectives - whether to save life, to empty the hospitals, to alleviate misery, or to diminish sickness in the working population. These are de- cisions for society, and they are far from easy, given the desirability in fact of all the objectives which I have just stated in simplistic terms. In our pub- lication, we evaded this issue by a straight averaging

of the five indices of burden which we used; and on that crude basis a quarter of the total burden is accounted for by mental illness and respiratory diseases, and a further quarter by ischaemic heart disease, bone and joint disease, accidents and suicide, and tumours. But this cannot mean that the other 48 conditions in our list can simply be neglected.

Although I have indicated some of the difficulties encountered in an attempt to derive 'health service priorities' from indices of burden, I would still maintain that this is 'a legitimate component in the consideration of priorities for biomedical research'. Certainly, it involves value-judgements, but perhaps no more so than do considerations of scientific merit and feasibility. Success in research depends on the conjunction of what is desirable with what is in fact attainable; and a critique of desirability is perhaps worth seeking as one component of the ultimate alchemy.

REFERENCES

Black, D. A. K. (1975). Research - some Anglo-Saxon attitudes. Journal o f Laboratory and Clinical Medicine, 85~ 707-710.

Black, D. A. K. & Pole, J. D. (1975). Priorities in biomedical research: indices of burden. British Journal o f Preventive and Social Medicine, 29, 222-227.

Brown, G. W. (1974). Sociological research - how seriously do we take it? Inaugural Lecture, Bedford College, University of London, 1974.

Illich, I. (1975). Medical Nemesis - the Expropriation o f Health. Calder & Boyers, London, 1975.

Perutz, M. (1972). Health and the Medical Research Council. Nature, London, 235, 191-192.

Perutz, M. (1976). Fundamental research in molecular biology: detection of relevance to medicine. Contribution to CIBA Symposium on Research and Medical Practice Elsevier/Excerpta Medica/North-Holland, Amsterdam.

Rothschild (1971). The organisation and management of Government R & D. In A Framework for Government Research and Development, pp. 3-25. Cmnd. 4814, HMSO, London.