public health:

Don't be deceived by the Victorian-sounding name. The London School of Hygiene and Tropical Medicine is Britain's national school of public health. Celebrating its centenary this year, it has been the major source of public health research with an impact on government policy since it opened.

Current areas of research include patterns of survival in the major cancers, reproductive health in Gulf War veterans, stroke and coronary heart disease, health outcomes, hospital restructuring and the healthcare workforce, and the economics of hospital-acquired infections.

The dean, Professor Harrison Spencer, is just back from the US and Mexico, and is about to leave for Singapore, Taiwan and Hong Kong. Meeting alumni, raising visibility and recruiting students is part of Professor Spencer's role this year. He is keen to emphasise that LSHTM is 'not a medical school' but an institution 'concerned with the health of populations rather than with individuals and disease'. Headhunted from Tulane University, New Orleans, in 1996, he describes it as a school of public health, international health and tropical medicine.

Professor Spencer recalls how the deans of the 28 American schools of public health 'often sat around asking how we could make people understand' population health and how it was influenced by poverty, social class and education. Public health is also multidisciplinary, he points out, making it more difficult to pin down.

Nick Black heads the school's department of public health and policy and is professor of health services research. As well as health services themselves, he identifies two other broad areas of public health. 'The environmental causes of ill- health, like BSE or the links between air pollution and asthma; health promotion, which can be either individual - like GPs advising patients to stop smoking - or at population level, like banning smoking on public transport.'

'Particularly where public funds are involved, there is a responsibility to see that services are of high quality, efficient and provided fairly.' Individuals cannot judge this, says Professor Black, adding: 'It is also unfair to judge the quality of services on individual cases. We need to take the population approach and look at large groups.'

He is excited by the prospect that 'government now realises that public health is multidisciplinary, not just about doctors', and welcomes the advent of non-medical directors of public health.

The school has already introduced a new higher degree aimed at practitioners who wish to continue working in the field. The US-inspired doctor of public health - DrPH - qualification will be equivalent to a PhD or MD, but offers career development to those who do not want to become researchers, he says.

Inside the school's art deco building in Bloomsbury, the staff includes sociologists, political scientists, anthropologists, economists, statisticians, historians and demographers as well as clinicians. Most are from the UK, but staff members come from 35 other countries and students from more than 90. Only about a third of the latter are doctors.

Founded in the heyday of the British empire, the school has carried out pioneering work in many fields - from malaria to random controlled trials, nutrition and medical sociology.

Its mission has changed radically since the days when Britain was a colonial power (see box, below left). But the roots of the school can be traced back still further, to the aftermath of the Napoleonic Wars. In the severe winter of 1817-18, the sight of sick and destitute sailors wandering the streets of London prompted a charitable appeal which resulted in the establishment of a floating hospital in the Port of London, close to Greenwich.

There both patients and convalescents were cared for in a succession of converted Royal Navy ships, the most famous of which, HMS Dreadnought, had been commanded by Nelson's cousin at the Battle of Trafalgar in 1805. Eventually noise and congestion on the river forced the Seamen's Hospital Society to move services to dry land at Greenwich. It later built a branch hospital at Albert Dock, which became London's centre for treating tropical diseases.

But it was the high death rates from malaria, yellow fever, dysentery and plague among colonial officials and others overseas that convinced Queen Victoria's colonial secretary, Joseph Chamberlain, of the need for research and training in clinical tropical medicine when he appointed Patrick Manson, physician at Albert Dock, as medical adviser to the Colonial Office.

The original school was built next to the Albert Dock Hospital. Students from around the world came to study cases which, in its first four years, included beriberi, blackwater fever, dysentery, leprosy, malaria, plague, sleeping sickness and sprue.

The school's staff travelled extensively, researching insects, parasites and tropical diseases. In 1900, three staff members carried out a famous experiment to prove that malaria was transmitted to humans by mosquitoes. They took a specially constructed mosquito-proof hut to a malaria infested region near Rome, and by shutting themselves inside from dusk to dawn all three escaped infection. Meanwhile the infected mosquitoes they sent back to London via the British Embassy's diplomatic bag were allowed to feed on volunteers, who then contracted malaria.

This robust approach to experimentation appears to have persisted until after the Second World War, when a successful attempt to identify the malignant malaria parasite involved a healthy volunteer being bitten by a reported 770 mosquitoes before undergoing a liver biopsy. Several memoirs of the school mention an entomology professor whose legs were 'red and raw' from carrying lice in his socks, and who allegedly used colleagues, friends and students as incubators.

In 1917 an explosion at a nearby munitions factory severely damaged the buildings at Albert Dock, and in 1921 both hospital and school moved to the former Endsleigh Palace Hotel in Gordon Street, near Euston station. Working conditions were not ideal there either, as the building was described as 'dark, awkward and inconvenient'. The library air was thick with tobacco smoke and every afternoon waitresses from the nearby ABC teashop appeared with urns to dispense tea and buns.

In the 1920s, academic links with the US-based Rockefeller Foundation led to plans for an 'institute of state medicine' to unite public health teaching under one roof. The foundation's gift of $2m enabled the school to buy the Keppel Street site. The first stone was laid in 1926 by the health minister, Neville Chamberlain, son of the colonial secretary whose vision had created the original school.

Today a grade II listed building, the building was officially opened by the Prince of Wales (later Edward VIII) in July 1929. He told the assembled dignitaries that he had personal experience of 'the appalling loss of life due to tropical diseases', and expressed his hopes that 'fresh research will lead to the solution of problems not yet solved and to the prevention of much ill-health'.

A staff member present at the event gave a different perspective on this occasion, revealing that the prince had arrived late and appeared 'distracted' and 'out of humour'. When he visited the workmen eating their midday meal in a tent adjoining the site, one of them shouted (twice): 'What are you going to do about the unemployed, prince?' whereupon the royal visitor 'stiffened, whitened, turned on his heel and left'.

The carved frieze around the outside of the building commemorates the great and good of public health and tropical medicine. It has frequently been noted that these are all male, and the secretive committee who chose the 23 names are said to have rejected the only woman considered - Florence Nightingale - on the grounds that her name was too long to fit the space. But a cursory glance at the others reveals that this cannot have been the real reason.

An imposing array of gilded insects and parasites also adorns the school's facade, prompting The Lancet to comment at the time that this must surely be 'the first appearance of the louse as a decorative emblem'.

In the late 1930s the school took on a particularly influential role. Under its then dean, Wilson Jameson, it was, according to NHS historian Charles Webster, the think tank for the development of the post-war NHS.

In 1939, a small but highly influential group chaired by Jameson met regularly at the school to discuss the reorganisation of health services after the war. Jameson was reluctantly persuaded to leave the school in 1940 to join the coalition government's health ministry as chief medical officer. He saw this as his patriotic duty, in spite of confiding to a colleague that he found the atmosphere there 'like a girls' school' because of the constant battle between the medical and administrative sides.

The staff's tropical expertise was much in demand in both world wars, and experts at home played an important part in developing the government's 1939-45 food policy. But the post-war climate of accelerated social change brought a revolution in teaching and research which gave increasing prominence to social sciences, another area in which the school can claim to have led the field. Abroad, the end of colonial rule brought demands for different relationships and more active partnerships around the world.

Today the school is influential in both national and international policy arenas. Areas of international research include safe motherhood in 13 countries, diarrhoeal diseases in developing countries and the economic aspects of healthcare reform. The dean sees global links as vital for the future and points out the school's many international partnerships.

Under a previous dean, Richard Feachem, the school was closely involved in writing the World Bank's 1993 World Development Report.

The school also has longstanding ties with the World Health Organisation - the present dean is one of many staff to have worked in either Geneva or Copenhagen - and played a key role in the 1996 Ljubljana conference on health reforms in Europe.

The school has always had close ties with the NHS. Many senior staff hold joint appointments and recent work includes research on the costs of HAIs, systems analysis and nursing policy research.

The school has also just won two important NHS contracts: the National Centre for Health Outcomes Development (run jointly with the Unit of Healthcare Epidemiology at Oxford) will be developing clinical indicators, while the NHS National Co-ordinating Centre for Service Delivery and Organisation Research and Development aims to promote the use of research evidence on improving service organisation.

Asked to identify the public health challenges for the new century, the dean produces a long list: 'Inequalities in health, ageing populations, emerging infectious diseases - old ones we thought we'd conquered, as well as new ones - global environmental changes, urbanisation, mental health, homicides, road accidents - cardiovascular disease, poverty...'

A former student at

the school himself,

Professor Spencer says: 'There's something about the school which causes people to feel very passionate and emotional about their attachment to it. It's a very special place.'