Harry Keen (1925-2013) was an unusual combination of clinician, epidemiologist and advocate for the person with diabetes, not to mention a mentor and inspiration to many readers of Diapedia. He qualified in 1948 and engaged in field studies of hypertension before moving on to diabetes, where he helped found the new discipline of diabetes endocrinology and propagated it via the annual Cambridge WHO/IDF seminar which has trained a generation. He helped develop our current definitions of diabetes and impaired glucose tolerance, developed and validated both the measurement of microalbuminuria and the technique of CSII, and was a passionate advocate of patients' rights.
Harry KeenHarry Keen was born in London, the son of immigrants, in 1925, and qualified in Medicine at St Mary's Hospital in 1948. He worked briefly in the Army Medical service and as a locum General Practitioner before joining George Pickering, a pioneer in hypertension research, at St Mary's.
The task was to measure the blood pressure of the population around St Mary’s Hospital to establish whether people with hypertension represented a separate subgroup or one end of a continuum, and Harry was asked to look at people with diabetes and their families, an experience that revealed the devastation caused by the vascular complications of diabetes.
His interest in diabetes took him to the Diabetic Clinic at King's College Hospital under the supervision of Robert Daniel Lawrence, and worked there for some years as a research assistant. From there he went to work with James Field at NIH in Bethesda, where he gained laboratory experience working with bioassays of insulin action. On his return to the UK he was appointed a Senior Lecturer under John Butterfield at Guy's Hospital in 1961, rising to full Professor in 1971.
Harry Keen and Kelly West (1925-1980) were the two great pioneers of diabetes epidemiology, then a totally new speciality. They jointly share the credit for introducing a rational definition of diabetes and borderline hyperglycaemia. This new definition, the basis for all subsequent work in this area, was epidemiological and based upon the prognosis of hyperglycaemia in terms of retinopathy and arterial disease; i.e. the likely harm associated with different levels of glycaemia.
The Bedford Study
This landmark study, undertaken with his long-term colleague John Jarrett, set out to examine whether people with impaired glucose tolerance have a similar risk of cardiovascular disease as those with frank diabetes. Over a 10 year follow-up period it emerged that mortality in borderline diabetes was intermediate between that seen in controls and those with diabetes. Cardiovascular risk was more marked in women than men in the intermediate group, and blood pressure and smoking were confirmed as important additional risk determinants.
The Whitehall Study
This prospective Study of 18000 civil servants in the UK (now known as Whitehall 1) began in 1967 and examined mortality rates and rates of cardiovascular and respiratory disease. It showed that lower grade personnel had higher mortality rates, largely accounted for by an increased prevalence of risk factors. Harry carried out a prospective study of glycaemia (judged by the OGTT) and cardiovascular risk. This broadly supported the conclusions of the Bedford Study and helped lay the basis for the subsequent definition of diabetes.
WHO defines diabetes
In 1980 a WHO Expert Committee met to reconsider the definition and classification of diabetes. The influence of Harry (who chaired the meeting) and Kelly West is clearly to be seen in this document, which drew also upon the work of Peter Bennett with the Pima Indians. This report, although somewhat modified since then, established the basis for our current thinking about glucose levels and diabetes.
Saint Vincent declaration
Fatalism characterised the thinking of many clinicians in the early part of Harry's career, and a meeting held in the Italian town of St Vincent in 1989 boldly set out a series of goals for diabetes management, as judged in terms of outcome measures such as amputation and blindness. This landmark statement made many diabetologists uneasily aware that they could not as yet measure outcomes, let alone change them: nonetheless it set the pattern for programmes of diabetes care around the world. Harry, needless to say, was a key agent in this development. The Declaration can be accessed at: http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0420.1997.tb00440.x/pdf
Inspired by the simplified insulin immunoassay developed by Hales and Randle, Harry and Costis Chlouverakis adapted it for the measurement of small quantities of albumin in the urine in 1963, and went on to show (with Giancarlo Viberti) that it was predictive of diabetic nephropathy and its consequences.
Continuous subcutaneous insulin infusion (CSII)
Upon learning that a colleague was using the clumsy old Mill Hill infusion pump to administer parathormone subcutaneously, Harry and John Pickup pioneered the use of CSII in diabetes in the early 1970s, and helped to develop it from an experimental technique into a feasible option for diabetes therapy.
Harry took to heart Robin Lawrence's maxim that "the patient with diabetes must learn to be his own doctor", and enthusiastically supported the introduction of diabetes nurse specialists, dedicated diabetes centres and patient education programmes.
Harry had left-wing political antecedents, and could remember taking part in a street march with his uncle at a very tender age and shouting out "down the drain with Chamberlain" (Conservative Prime Minister in the 1930s). He rejoiced in the introduction of the NHS and defended it to his dying day. Notably, he forced a High Court review of the then Health Minister's introduction of the internal market in the 1980s, and he was founder and president of the NHS Support Federation.
Insulin for the developing world
Harry was a staunch advocate for justice in every shape and form, and this found expression in his very active support of the International Insulin Foundation in its campaign to bring affordable insulin within the reach of everyone worldwide.
More about Harry
Harry KeenAn engaging set of interviews is available - highly recommended! http://www.diabetes-stories.com/interview.asp?UID=52
More detail is available from several obituaries:
^ Jarrett RJ et al. The Bedford Survey: Ten year mortality rates in newly diagnosed diabetics, borderline diabetics and normoglycaemic controls and risk indices for coronary heart disease in borderline diabetics. Diabetologia 1982;22:79-84
^ Fuller JH et al. Mortality from coronary heart disease and stroke in relation to degree of glycaemia: the Whitehall Study. BMJ 1983; 287(6396):867-870