A Paean to an unsung public health hero

For many years I have lectured on epidemiology and included a lecture on medical outcomes. In the course of this I talk enthusiastically about Codman, the american surgeon who dared to look at the long term outcomes of his surgical interventions. But, mea culpa, I have never made any mention of John Bunker.

At a time when surgeons enjoyed a god-like status, John Bunker dared to question their role. In 1977 he co-edited Costs, Risks and Benefits of Surgery, a book that became known as Bunker’s bible. The book was one of the first to evaluate surgical techniques, and in 2006 a paper in the Journal of Health Services Research and Policy included it in a list of the 26 most influential books on healthcare policy in 150 years.

Bunker’s seminal ideas on evaluating surgery were contained in a paper in the New England Journal of Medicine in 1970, in which he compared the number of operations and surgeons in the United States with those in England and Wales. He found that the number of operations and surgeons in the US was far higher per head of population than in England and Wales. “Fee for service may tend to increase the number of operations in cases in which indications are borderline,” he wrote.

Another paper he coauthored in 1979 in the New England Journal of Medicine looked at whether there was a relation between the number of operations a hospital carried out and patient mortality. It was one of the first on such scale, studying 12 surgical procedures in 1498 hospitals. The researchers found that hospitals that annually carried out 200 or more of the complex procedures – such as open heart surgery and coronary bypass surgery – had mortality rates 25-41% lower than hospitals with lower volumes. For less complex procedures the “mortality curve flattened” it was reported.

After his retirement, Bunker moved to London and for a while worked in Professor Michael Marmot’s department of epidemiology and public health. Bunker’s views on medicine were not ideological, says Marmot: “ His ethos was to look at the evidence and take a scientific approach. He was important along with others in contributing to a culture of being self critical, and he was very early in the piece,” he added.

Clearly an important man in the evolution of health policy and practice. I will certainly include him and his work in my next lecture on medical outcomes!

Paul Walker

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