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Barbara Ansell: a person ahead of her time
  1. Pat Woo1,
  2. Nico M Wulffraat2,
  3. Alan Tyndall3
  1. 1 Immunology and Molecular Pathology, University College London, London, UK
  2. 2 Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
  3. 3 Department of Rheumatology, Basel University, Basel, Swaziland
  1. Correspondence to Dr Nico M Wulffraat, Pediatrics, University Medical Center Utrecht, Utrecht 3584, The Netherlands; n.wulffraat{at}umcutrecht.nl

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In the beginning

In 1951, Barbara Ansell, a young 28-year-old physician and aspiring cardiologist, was encouraged by Professor Eric Bywaters to join him in the Special Unit for Juvenile Rheumatism, recently created by the Medical Research Council (MRC) of UK, located at the Canadian Red Cross Memorial Hospital in Taplow, Buckinghamshire, UK. She had been advised that cardiology ‘was a man’s world’. Although initially aimed at research and treatment of rheumatic fever, this unit of pathologists and clinicians morphed into a unit for juvenile chronic arthritis as the incidence of rheumatic fever gradually waned. At that time, a child with chronic arthritis would mostly be confined to bed at home, perhaps with aspirin and/or cortisone medication and bore a grim prognosis regarding both function and survival. She began her pioneering work there with her MD thesis (1965) on the classification of children with chronic arthritis. Her clinical skill and experience were legendary. Her major clinical achievements are listed in box 1. She also was actively engaged with scientists in the search for the causes of the diseases she encountered. She was ideally placed in the shared environment of MRC facilities next to a general hospital. Box 2 is a short summary of the main milestones and breadth of her work. In 1988, the world-renowned paediatric rheumatologist, Barbara Ansell CBE, FRCP, FRCS, FRCPCH, retired as director of the MRC Division of Rheumatology at Northwick Park, Harrow, UK. She left as a legacy an army of former colleagues, protegées and friends from all areas of healthcare, dedicated to children and adolescents with rheumatic diseases. By then the outcome for such young patients had improved dramatically. Gratifyingly, Barbara did see the fulfilment of her long-held dream, expressed passionately at her retirement Festschrift: the beginning of truly effective therapies.

Box 1

Barbara Ansell: Key achievements

  • Clinical skills in describing new phenotypes

  • Proposal for Juvenile Idiopathic Arthritis classification (in her MD thesis)

  • Training of fellows, allied health professionals and senior staff members

  • Commitment to initiate local national and international expertise centres

  • Started multidisciplinary clinical rounds

  • Involvement of parents and teachers

Box 2

Dr Barbara Ansell CBE (1923–2001)

Born: 30 August 1923

Awards: CBE, 1 January 1982

Fellowships

  • Royal College of Physicians 1967

  • Honorary fellow of the Royal College of Surgeons 1985

  • Honorary fellow of the Royal Society of Medicine

Qualifications

  • 1946: MB ChB (Birmingham), MRCS, LRCP (London)

  • 1951: MRCP (London)

  • 1969: MD (Birmingham) The Classification of Juvenile Chronic Arthritis

Career synopsis

  • 1946–1951: junior posts in Birmingham, Northampton and London

  • 1951–1953: registrar to Prof Bywaters at MRC Special Unit for Juvenile Rheumatism, Canadian Red Cross Hospital, Taplow, Buckinghamshire, UK

  • 1953–1955: research fellow USA, and junior post at Hammersmith Hospital, London

  • 1955–1957: registrar to Bywaters at Hammersmith Hospital, London

  • 1957–1962: senior registrar to Bywaters at MRC Rheumatism Unit, Taplow

  • 1962–1985: consultant, MRC Rheumatism Unit, Taplow

  • 1976–88: consultant and head of Division of Rheumatology at the MRC

  • Clinical Research Centre and Northwick Park Hospital; from 1985 consultant at Wexham Park Hospital, Berkshire, UK.

Committee chair of

  • British Heberden Society: secretary 1960, president 1976, treasurer 1978

  • British Society for Rheumatology, Clinical Affairs Committee 1984–1986

  • Royal College of Physicians specialist advisory, Committee on Higher Medical

  • Training (rheumatology) 1977–1980; Royal College of Physicians vice president 1987–1988

  • Arthritis and Rheumatism Council Education and Scientific Subcommittees

  • European League Against Rheumatism (EULAR) Standing Committee for Paediatric Rheumatology 1981–1991

  • Founding chair of the British Paediatric Rheumatology Group 1981–1988

Member of UK and International Committees, (advisory and charities)

  • Committee on Safety of Medicine Advisory Committees

  • Arthritis and Rheumatism Council Scientific and Education Committees

  • EULAR Standing Committee on Drugs, Executive Committee

In her 1997 book ‘Looking Back. The Canadian Memorial Red Cross Hospital 1947 1985’, she chronicled the development of the MRC Rheumatism Unit at the Canadian Red Cross Memorial Hospital in Taplow. In the text she described the introduction of multidisciplinary teams addressing all aspects of the child’s care including innovative orthopaedic procedures, ophthalmology, dentistry, podiatry, physiotherapy, occupational therapy, psychiatry and nursing. In addition, from early on, social development and education featured prominently.

The photographs throughout the book are very impressive—children and team members engaged in all aspects of daily life in the hospital. There were extensive tributes made to secretaries, lay persons involved in fund raising and all those individuals who enabled such an ambitious enterprise to flourish. In this current age of effective targeted therapies, the images of the children are especially moving; Cushingnoid little faces, stunted growth, deformed joints in splints and children using walking aids or tricycles to move around, all attesting to the limited success of the available therapeutic options at the time. What is completely absent from the text are references to her own seminal contributions to the whole enterprise, a reflection of Barbara’s innate modesty. All members of the allied health professional team were sent to congresses, junior doctors were encouraged to perform clinical studies with experienced team members or laboratory projects with established scientists and had their names first on most publications. Moreover, she was particularly welcoming to fellows from far and wide.

The public record of Barbara’s achievements is widely available on Google and rather than simply repeat this, we would like here to share those qualities she exhibited which in our opinion made her so special.1–3

Innate powers of observation and synthesis of clinical patterns

Barbara’s memory was phenomenal. She could ask a young patient about the new bicycle he had received for Christmas 6 months later at the next visit. Kids (and parents) truly appreciated this ability. Team members who had forgotten to carry out her requests often did not get away with it, thus earning her a fearsome reputation. However, this trait was an important foundation of her ability for pattern recognition, and her world renowned clinical skills.

She was not afraid of calling something ‘atypical’. The little notebook kept in her white coat pocket during ward rounds and clinics was a familiar sight to her visitors and trainees.

Her MD thesis in 1965 was a classification of juvenile chronic arthritis based on her observations of presentation and course. This remained essentially the basis of all later refinements of the classification. Her keen observations also led her to describe novel rare syndromes without the need for sophisticated laboratory data. One of many examples is the publication with E. Bywaters and F.M. Elderkin, in the 1975 Proceedings of the Royal Society of Medicine.4 They published the case of two siblings with an unknown syndrome, together with their normal sister. In the text they concluded: “because of these children’s similar appearance and mental deficiency, rash, occasional fever, uveitis, leucocytosis and epiphysial disorders we suspect this is a genetic disorder probably involving some biochemical defect in the inflammation process, just as haemophilia is determined by biochemical defect in a defect in the clotting process. So far we have no idea of its mechanism.” In her typically collaborative fashion she shared this experience internationally,5 thus began the era of autoinflammatory cryopyrin mutation disorders.6

Team building and collaboration

Visiting clinical fellows arriving at Taplow from afar soon learnt that their medical degrees or seniority was no automatic passport to hierarchical importance. In fact they were slotted into the extensive clinical team at a modest level, to learn about physical therapy, the special emotional needs of sick children living a long way from home and so many other critical skills.

Barbara supported all members of the team to attend conferences and workshops with funds generated mostly by her through grants, invited talks and side projects. We accepted this as normal and only realised later as we assumed our own departmental responsibilities what a constant effort that requires.

Her collaboration with and the respect from colleagues in other disciplines were legion, and unusual in those days. She was elected fellow of separate medical and surgical societies, and awarded the Queen’s honour of CBE for her work. This respect was not based on her powerbase but purely due to the fact that her clinical opinion was unparalleled. She worked as a rheumatologist for children, adolescents and adults, thus allowing her to have a unique long term evolutionary view of some diseases. It also opened doors for us junior colleagues to experience cross specialty wisdom long before the expression ‘thinking out of the box’ was invented.

One of Barbara’s long cherished aims was the decentralised care of children and young people with rheumatic diseases and she devoted enormous time and energy into achieving this. She set up regular peripatetic clinics in UK and abroad. Although Taplow was her showpiece, where national and international pioneers emerged from spending time there, she always recognised the trauma experienced by children being so far from home. For example, when asked once why the functional scores in children in clinical studies on Friday could be so much better than on Monday, she simply said “of course- the family comes to visit on the weekend—and after they are gone, the children are sad”. Holistic medicine and ‘Patient Reported Outcomes’ were evident long before their time.

Capacity for work including international networks

A hapless junior colleague once pleaded fatigue as the reason for not delivering his draft manuscript on time: “I stayed up until midnight working on it!” “I didn’t go to bed at all last night” was the unsympathetic response. Indeed, after a busy clinical day, Barbara would then retire to her office to work on the many administrative and political aspects of running her large department, frequently after everyone had left for the day. She famously said that she would ‘stay up all night once a month to keep up with her paperwork’. It was always impressive to those around how much she achieved, despite an intense travel and committee schedule. Her committee work as detailed in box 2, reflected her comment “I like to keep my fingers in many pies”. She was appointed as the first chairperson of the European League Against Rheumatism (EULAR) standing committee on paediatric rheumatology in 1981. During her tenure, she included paediatricians who care for very young children with rheumatic diseases: “they see more systemic diseases in children’s hospitals” and was keen to reach out to all. By 1997, even though she was retired, she nonetheless threw her support and influence behind the proposals by her successors to provide education and research infrastructure in paediatric rheumatology, and supported them in the creation of a professional society: the Paediatric Rheumatology European Society (PReS) (figure 1).

Figure 1

Picture taken at Loch Lomond, Scotland, during the inaugural Paediatric Rheumatology European Society Meeting held jointly with the European League Against Rheumatism conference organised by the British Society for Rheumatology, 1998. Barbara Ansell surrounded by some of her successors in paediatric rheumatology. Left to right: Patience White, Alberto Martini, Barbara Ansell, Taunton Southwood, Patricia Woo.

Support for women in medicine

Whether her initial exclusion from a career in cardiology on the grounds of gender, or simply that she had an innate sense of fairness, Barbara always supported women in building their careers. She strove to facilitate part-time specialty training to allow women to be both mothers and specialist physicians. However, this was not to the detriment of the male team members, many of whom built their further careers on the experiences under her tutelage.

There were many notable examples of men and women who have gone on to establish de novo centres for children with rheumatic diseases in UK and abroad. Some in addition contributed to innovations in academia and healthcare. Of these Patience White is a good example of an international Rheumatology trainee at Northwick Park, set up a paediatric rheumatology centre in Washington, DC on return, and went on to become a pioneer and advocate for an orderly transition to adolescent and adult services. She is working at the heart of government on this subject.

A former junior colleague, Carol Black (figure 2), paid tribute to Barbara in her 2017 article for the Royal College of Physicians ‘Women in Medicine’.7 Dame Professor Carol Black, an international leader in scleroderma, former president of the Royal College of Physicians, is also principal of Newnham College, Cambridge University and expert adviser on health and work to National Health Service England and Public Health England.

Figure 2

Dame Professor Carol Black on paying tribute to Barbara Ansell at the Royal College of Physicians (taken from https://www.rcplondon.ac.uk/projects/women-medicine-carol-black-and-barbara-ansell).

Barbara’s ‘unfinished business’ was taken up by Patricia Woo, a former protégée, who established clinical and research units at Great Ormond Street Children’s Hospital, and University College London. Figure 3 depicts her among patients at the opening of the rheumatology unit of the Great Ormond Street Children’s Hospital. Together with Anne-Marie Prieur, Wietse Kuis, Alberto Martini, Tauny Southwood and other members of the EULAR standing committee, she set up the European Society for Paediatric Rheumatology (PReS) in her role as its first president. Within this framework, continuation of the ethos of friendship, research and collaboration with colleagues throughout Europe and beyond has resulted in better training of physicians, allied healthcare workers and researchers in the field of paediatric and adolescent rheumatology, bringing it into the modern era of genomic medicine and effective biological therapy.

Figure 3

Barbara as guest of honor at the official opening of the rheumatology ward in Great Ormond Street Children’s Hospital, London, 1995.

Lifelong friendships beyond work

Early on Barbara attracted a group of peers from all parts of the globe who remained loyal friends and collaborators during and after her professionally active years. There are too many to name here, but many have been her colleagues, especially from the EULAR Standing Committee that she chaired.

In turn, these colleagues and friends often exchange the next generation of fellows.

So a network of collaborators and friends was established and continues to this day. Having ‘done time’ with Barbara became an unofficial passport to acceptance in both the paediatric and rheumatology worlds.

It must be mentioned that this ‘time’ was not always halcyon—she expected the same rigorous standards from others as she set for herself and at times this could be quite stressful to the recipient.

Fun and hospitality

Barbara enjoyed entertaining and for many of us fellows a long way from home, Sunday lunches at her Dumgoyne home in the Thames Valley were wonderful social affairs. Many long-term friendships blossomed from these gatherings. We juniors watched in bemusement as our tough demanding boss transformed into an attentive, hostess and housewife under Angus’ affectionate, almost paternal gaze. Heaven help the junior who transported this familiarity to the wards on Monday!

Postscript

Barbara Ansell is remembered first for her unique contribution to paediatric rheumatology which still echoes down several generations of practitioners. Those who knew her well understood that under her tough exterior, resided a truly committed and passionate person who dedicated herself to her work. But dedication alone is not enough to move a field forward—there must also be a degree of intuitive genius to achieve this and Barbara Ansell certainly had this.

For those of us who knew her well, we also relish the many idiosyncratic aspects of her complex character which made her such a special person in the course of our training. Time often blurs the moments when game changing paradigm shifts occur, but not the fond personal memories of those special people who facilitated them.

References

Footnotes

  • Handling editor Josef S Smolen

  • Contributors AT, NW and PW all contributed to the tekst and reviewed the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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