LAUSR

www.thelancet.com Published Online September 11, 2017 http://dx.doi.org/10.1016/S0140-6736(17)31993-1 1 Although it’s trivial, the first thing I notice on meeting Andrew Bush is his colourful bow tie. All sorts of motives are ascribed to men who favour this form of neckwear, and few are entirely flattering. So the succeeding 40 minutes come as a relief. Far from an attention seeker, Bush is a quietly spoken and thoughtful man: a selfdeclared work junkie with a commitment to paediatric respirology that’s equally divided between research and clinical work. “For me, they go hand in hand. It’s like someone asking me if I prefer running with my right leg or my left leg. You need both”, he says, adding that “I’ve been very lucky in having had a lot of very good collaborators. It’s all been teamwork.” The work itself has ranged across any number of diseases affecting children’s lungs. “Many of us are curious (about illness),” says Thomas Ferkol, Alexis Hartmann Professor of Pediatrics at Washington University School of Medicine in St Louis in Missouri. “Often times when you are too curious and moving off in many directions you kind of loose focus, and don’t move your research forward. Andy is one of the people who can pull this off. Whether it’s energy or drive or remarkable collaborations, he’s been able to maintain momentum in many different directions.” Bush originally wanted to become a scientist. But having enrolled to study natural sciences at Cambridge University he switched to medicine. “I wanted some people contact”, he says. “I didn’t want to spend all my life in a laboratory.” That said, the interest in science remained—so academic medicine was the obvious route. “If you’re doing clinical medicine you’re going to have questions”, he muses. “What should I be doing, how can I do it better?” Academic jobs offer the holders an opportunity to answer their own questions. As for respiratory medicine in particular, it was a choice prompted partly by the satisfaction of being able to measure things. “I started thinking I was going to do adult medicine, but the work got more and more paediatric.” He made the switch when he was 30 years old, and has never regretted it. He is now Professor of Paediatric Respirology at the National Heart and Lung Institute, a consultant physician at the Royal Brompton Hospital, and Professor of Paediatrics at Imperial College London. Among Bush’s early research topics, back in the 1980s, was the use of respiratory mass spectrometry. This foreshadowed an ongoing interest in non-invasive methods, particularly for use in airway disease. “We haven’t made sufficient progress in terms of what’s going on in the airways. We do too much blind treatment. We’ve got to find better non-invasive ways of measuring the illnesses we’re treating”, he explains. But we’re getting there, he thinks. “Already, by analysing just a few exhaled breaths, we can see chemical patterns that allow us to distinguish different airway diseases.” Inflammation of the airway is, not surprisingly, another preoccupation. “We’re in an era of increasingly large numbers of very specific biologicals... but how do we match the biological to the child?” You have to understand the chemical pathway that’s at fault before you can know the best way of interrupting it, he points out. One of his hopes for the Lancet Commission, After asthma: redefining airways diseases, is that it will contribute to a greater demand for precision in diagnosing asthma and identifying its treatable components. Peter Sly, Director of Children’s Lung, Environment and Asthma Research at the University of Queensland in Australia, knows Bush well and is also impressed by the breadth of his research portfolio. “Besides asthma and cystic fibrosis”, he says, “Andy’s done things in environmental health and in health-service delivery, for example. He’s helped to put paediatric respiratory medicine in the UK on the same footing as adult respiratory medicine, particularly through his work at the Brompton Hospital...He gets on and changes the way people think about things. He does it by leading from the front. But he doesn’t take himself too seriously, so he has a good way of disarming people who might want to have a go at him.” Heather Zar, Director of the School of Child and Adolescent Health in the Red Cross War Memorial Children’s Hospital of the University of Cape Town, South Africa, draws attention to another aspect of Bush’s interests. “Lung health is a key global issue”, she says, pointing out that respiratory physicians can’t help but be aware of the pneumonia and tuberculosis killing children worldwide. But Bush is more than simply aware of it. “He’s a great advocate for child health globally”, she adds. “He understands the issues in lower and middle-income countries as well as high-income settings, and he’s able to cross that divide. He has a very broad expertise.” Bush holds an honorary professorship in Zar’s Department of Paediatrics and Child Health. Finally, back to the bow tie. Before leaving Bush’s office in the Imperial College medical school I can’t resist enquiring about it. He used to wear ordinary ties, he says, but stopped when the government ordained that they were prone to spread infection. “An open neck shirt to me is holiday and relaxation, and not for a formal setting. So I switched to bow ties. Completely ridiculous and completely personal.” As if in further justification, he points out that because he’s a paediatrician it’s a comic tie. So it’s really for the children. Like everything else.