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A-rise, Sir Richard (p>0.001)

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You've probably seen him at a conference somewhere. If it was a decade or two ago, possibly he sidled up to the rostrum in jeans and open-necked shirt. He may have looked anxious, with head bowed, eyes flickering up, perhaps assessing the chairman's tolerance of what he was about to do. Then he back-swiped a nervous hand through an unruly fringe of hair, and said: “I'm not going to give the paper I was supposed to present today. I've decided to tell you about something so much more important that it would be just plain wrong to let the opportunity go by.  . . .” And there will have followed a devastating tour of the latest statistics on morbidity and mortality from tobacco. This was Richard Peto,enfant terrible of epidemiology, passionate and angry at the impossibly large burdens of disease caused by totally preventable factors, especially tobacco, and unafraid of rocking a few boats to get his message across.

More recently, however, you may have noticed a steady growth in his profile, the jeans giving way to a suit, the appearance after his name of FRS—the exclusive Fellowship of the Royal Society—shortly followed by a balancing bookend at the beginning, the rank of Professor at Oxford University. Now easily recognisable as one of the world's leading epidemiologists and medical research scientists, Richard Peto was knighted by Her Majesty Queen Elizabeth II in June 1999.

Originally best known as collaborator with Sir Richard Doll since the 1960s, perhaps more than any other epidemiologist of his generation Sir Richard Peto has coupled brilliant scientific skills with a keen awareness of the need to convey his results to ordinary people in terms to which they could relate. His creativity and energy in delivering user-friendly explanations of risk has led to dialogues and collaboration with government ministers, international and national health organisations, and a large output of vitally important publications.

Peto's clear, simple messages range from his classic 1980s British projections of the early deaths that would occur among 1000 young smokers, to his more recent work with the World Health Organization's Alan Lopez and others, analysing mortality data in Europe, and projecting global mortality from tobacco. But probably his greatest achievements so far are associated with China. Peto was among the first to realise that China's vast size, with some provinces having larger populations than the entire United States, coupled with sharp inter-regional gradients for certain key causative factors, and high standards of science, offered exceptional potential for research, especially with regard to cancer. It is no surprise that the research unit Peto co-directs with Professor Rory Collins in Oxford has a significant number of Chinese scientists, and is working on several important Chinese studies. At the end of last year, his idea for a massive “counting the dead” study evaluating the present and future burden of tobacco-induced mortality in China came to fruition, gaining widespread media attention around the world. China means a lot to Peto: he is often to be found there—whether it is using a large briefcase stuffed full of scientific papers to cleave a place in a crowded Shanghai bus, hand-writing overhead transparencies at the last minute while his long-suffering Chinese host writes the translations alongside him, or attending a meeting with senior government officials, he is truly in his element here. Colleagues have witnessed new studies being thought up in the coffee break of a Chinese conference, and heard an already vastly over-stretched Peto agree to yet another collaboration.

As his Chinese work demonstrates, a mathematician's grasp of size and scale colours and informs all Richard Peto's work. His philosophy might be summarised as: “Given limited resources, what can we do to bring the biggest possible health benefits to the largest number of people?” This not only explains why chronic diseases, especially cancer and cardiovascular disease (CVD), are at the core of the unit's work, with a concentration on epidemiological overviews and meta-analyses, but it has also dictated the course the unit's non-epidemiological work has taken.

For although tobacco control advocates think of Peto as an epidemiologist, he and his unit are equally well known in research on pharmaceutical therapies. Peto has looked beyond the point where other scientists have quit, trailing a string of phrases behind them in their papers, such as “not statistically significant” and “would need further research on a much larger scale”. Well-founded hints of important benefits or disadvantages in a therapy used to treat one of the big chronic diseases have led Peto and his colleagues to set up massive, randomised studies, whose statistical power is so great that they can answer the questions once and for all. They might turn out to have been just the play of chance in the original, small studies, or they might be real: only a really big study can find the answer. Whichever it is, it could change clinical practice all over the world, and let research proceed unimpeded by the baggage of previous uncertainties.

If even a small benefit is found in treatment affecting huge numbers of people, it will contribute far more than a miracle cure for a very rare disease. Thus the unit's work has included the Isis trials which, among other results, showed the benefits of the humble aspirin over far more expensive drugs in first-line treatment after myocardial infarction; the Heart Protection Study, over four times bigger than any other trial evaluating the effects of a cholesterol-lowering statin on those prone to CVD; the giant, international Atlas trial, to see whether breast cancer sufferers will do better with 10 years' tamoxifen rather than the usual five; and a new study of anti-worm treatment that may benefit some of India's poorest people.

In little more than three decades Sir Richard Peto has already contributed more to world health than most people could aspire to in a lifetime of daydreams. The world of tobacco control is fortunate to have him on its side.

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