Graham Dukes (1930–2023): A pillar for safe and rational use of effective, affordable, essential medicines

Maurice Nelson Graham (MNG) Dukes, MD FRCP LLM

With deep sadness we inform you that on 13 August 2023, the access to medicines community lost a legendary towering figure, Graham Dukes, the founding editor of the International Journal of Risk and Safety in Medicine (JRSM). He was a pillar for safe and rational use of effective, affordable, essential medicines.

Graham Dukes was born in Barnsley (United Kingdom), on 2 November 1930, as the eldest son of Iris Davidson and Harmer Dukes. His father was a high school principal and his mother, who had studied at Birmingham College of Art, was a craft teacher.

On his 7th birthday, Graham witnessed a visit by the family doctor, Dr Ruckley, for his sick brother. It made a big impression on him, as he wrote in his opening sentence of the first issue of this journal in 1990: “There must have been a moment in everyone’s life when he, or she, came to the conclusion that doctors were really rather special people” [1].

From the narrative by Thea Dukes, written for her father’s funeral, we learned about his youth and early professional career:

“Graham was a bright and promising young man who got the opportunity to go to Cambridge. There he went to St. John’s college where he studied Medicine, a strong wish from his father. But the day after he graduated, he started studying Law and would end up being both a doctor and lawyer. The editorship of the Cambridge Varsity journal offered him the opportunity to write, reflect and share his critical (and often witty) views on a variety of topics.”

“In the 1950s, during a student exchange in Amsterdam, he got to know his Dutch wife-to-be, Ineke Greup. He moved to The Netherlands and - typically for Graham - learnt Dutch right away.”

“In 1961 Graham and Ineke settled in Oss, where he found work as a Clinical Investigator (and later Research Manager) of Organon International. Meanwhile, their children were born, and Graham finalised his PhD thesis [on Patent Medicines and Self-Medication, Leiden, 1963].”

“Graham brought to Organon not only a medical but also a legal and ethical perspective. This job must not always have been easy, as can be seen in his later critical publications on the pharmaceutical industry.”

“In 1972 he made a radical change, and shifted to work for the Netherlands Drug Regulatory Agency in the capacities of Medical Director and Vice Chairman of the Medical Evaluation Board. In this period he started to regulate the companies he had earlier worked for, and became a very productive writer.”

Thea Dukes summarises: “Graham was thorough, accurate and highly motivated to prevent dubious drugs from entering the Dutch market. His powerful, unyielding voice can be heard in an essay that he wrote in 1984, a charge against the ‘Industrial godfathers’, in which he takes full responsibility for his views.” In this essay, ‘The seven pillars of foolishness’, Graham writes: “This essay is mine, and mine alone, and I shall not attempt to suggest that the views which I hold and the disgust which I feel at this moment are shared by anyone but myself” [2].

In 1982, he left The Netherlands and joined the World Health Organization (Europe) in Copenhagen, first as a Regional Officer for Pharmaceuticals, and from 1987 as Director of the Regional Health Programme. Drug policies became one of his many specialties.

He also acted as a legal expert in lawsuits against the pharmaceutical industry. Ellen ‘t Hoen recalls her fond memories of Graham: “He supported the DES Action Group I was a co-founder of in the eighties - which was important because we needed figures of authority to help us get heard. He later joined the Médecins sans Frontières (MSF) Intellectual Property Rights working group I set up in the late nineties. He was always kind, and generous with his time and knowledge. And always smarter than anyone else in the room.”

In 1986 Graham was appointed Professor of Drug Policy Studies at the University of Groningen, and travelled there every month from Copenhagen.

Flora Haaijer-Ruskamp recalls that Graham contributed greatly to the work of the department of Clinical Pharmacology: “He brought with him his wide and deep knowledge ranging from drug registration, to the legal framework with an open eye for reality. Actual drug use, quality of drug use and efforts to improve drug use... they all had his deep attention. What typified him was the broadness of his approach, crossing bridges between disciplines without effort. And, of course, his unique international experience. He shared his knowledge freely in his teaching, in involving the other scientists in the department in his work.”

Despite his busy schedule he was able to coach PhD students, such as Lolkje de Jong, on ‘Drug utilisation studies in pregnancy; what can they contribute to safety assessment?’ in 1992. Kees van Grootheest considers Graham Dukes “his scientific grandfather”.

In 1987, Graham married Elisabet Helsing and they moved from Copenhagen to Oslo. Travelling between Oslo, Copenhagen, Groningen, and Geneva he managed to keep inspiring many professionals.

Bert Leufkens says: “Graham was an icon. I learned a lot from him”. He remembers Graham chairing the supervisory committee of his scenario-project on the ‘Future of Medicines’ [3].

Hans Hogerzeil, former director of the WHO Essential Medicines Program, recalls: “Graham was the one who, from Groningen, alerted Ernst Lauridsen, [then Director of WHO’s Essential Medicines Program] to the fact that their problem-based pharmacotherapy education was so good; And that’s why I went there once. We then wrote the ‘Guide to Good Prescribing’ with Theo de Vries, Rob Henning and Daphne Fresle - the rest is history. But without Graham, we wouldn’t have known about it in the first place.”

After his official retirement from the WHO in 1990, Graham joined the World Bank, working as a Senior Consultant on Health Policy in a variety of (often war-torn) countries, in Asia, Africa and Central Europe. Wilbert Bannenberg remembers meeting Graham in Uganda, where he drafted legislation that established not only the National Drug’s Authority, but also defined the National Medicines Policy [4].

Graham had more time to write, and in 1990 he started the International Journal of Risk & Safety in Medicine, of which he became the Editor-in-Chief¹. In January 2002, Christoffel Jos van Boxtel joined Graham as a co-Editor-in-Chief to support him in his exciting and productive job. Graham remained co-Editor-in-Chief until 2006. He left us a thriving journal.

The journal, from its very inception and launch by Graham 30 years ago, has become the unique international platform which, as Chris said “has the aspiration to cover safety in medicine from the perspectives of three different disciplines, i.e. patient safety, pharmacovigilance and medical law” [5].

This in memoriam is the very right place and time to remember Graham’s vision and mission of the journal, to think it through carefully, to admire Graham’s unique foresight and inspiration and to share his wisdom with the international audience.

Graham’s vision and mission of the journal was as follows [1]:

“The technology which has enabled the doctor to achieve more is not simple to steer, and if it sometimes threatens to do harm as well as good, that may not be at all straightforward to assess, and the lessons may emerge only in a far future. As X-rays and acetylsalicylic acid approach their centenary, one is still learning how to use them safely and wisely; … The more complicated medical techniques become, the more intricate their assessment; how long will it be before we truly know the ultimate prognosis of a modified transplantation technique or the safety of ultrasound for the foetus?

It takes effort and precious time to decide which questions we should be asking, and more to determine how we shall provide the most reliable answers to them. Yet the safe practice of medicine depends upon the patient and far-sighted recording and analysis of results, including resultant risk. That is a task for the individual, but also for the institution, the specialism and the profession, and in some situations also for industry and the public health authorities. From the findings one will commonly learn how risk can be contained and where there is a need for reparation.

The International Journal of Risk and Safety in Medicine takes precisely that for its province. Research must be the starting point, but there is a great deal of room for informed opinion and debate; for policy and patient care cannot afford to wait until we have all the facts in a row…. Are we … concerned about the onslaught of the cholesterol measurers? How many of us have… found an effective way to measure our own performance in the profession? …. How … can we best approach quackery inside and outside medicine - if we know what we mean by it?

Those are not rhetorical questions; they are precisely the sort of questions which medicine needs to answer if it is to tum the technological revolution to its hand, rather than being swept up and swept away by it. To provide the answers one needs data, methods, good sense, and all of old Dr Ruckley’s [Graham’s family doctor] care for the patient. That is Risk Management in Medicine. This is its Journal.”

The team of current editors of JRSM together with the Associate Publisher, Axana Scherbeijn, are putting every effort to preserve and further the high standards set up by Graham, to ensure the continuity and uniqueness of the journal. The team treasures Graham’s legacy, his wisdom and work for making his ideas live and help people all over the world.

In 1997 Graham became Professor of Drug Policy Studies at the University of Oslo. Norwegian pharmacist Kirsten Myhr has known Graham since the late 1980’s: “He was a true globalist with in-depth knowledge of all aspects of regulatory issues. Having a broad interest in pharmaceutical policy myself, be it medicine safety, utilisation or prices it was impossible not to get to know and admire his work as well as Graham himself.”

She also remembers Graham lecturing at an annual course called ‘Drugs in Society’, for international students pursuing Masters in international health and pharmacy students. “Graham and Elisabet gathered the summer school students at their home for nice social evenings. And all friends received their annual Christmas bulletin by snail mail in which they described their activities during the year. Years filled with much more than drug policy, e.g. holidays using their vintage Rolls Royce car!”

Cees de Joncheere remembers: “In 2002 (at that time I was the WHO/Europe Regional Adviser for Pharmaceuticals) we discussed with Graham preparing a 7th edition of his masterful ‘Drugs and Money’ publication, which he had initiated in 1983, and with the 6th edition from 1992. At that time it was a groundbreaking publication on the effectiveness of medicines’ pricing policies, affordability and cost-containment schemes. As so often, Graham had been one step ahead and provided this concise publication to the international community.”

“Graham had invited me, Flora Haaijer-Ruskamp and Ad Rietveld, as an editorial group for the 7th edition to meet at his home in Oslo for a writing session. He had told me that he would pick me up at the Oslo airport. On the cold winter evening when I arrived, a long queue was waiting for a taxi, but suddenly a beautiful old Rolls Royce Ghost drove up the airport taxi area: Graham, immaculately dressed as chauffeur with cap, came to collect me. I got in the back seat, Graham drove off and left the rest of the queue wondering who this man was that had just gone off in his RR.”

Cees concludes: “Graham - erudite, ahead of his time, sharp, and with such a warm personality, modest, and with a great sense of humour. Elisabet took good care of us with her warm hospitality, and we spent a productive weekend at his home, and prepared the outline for the Drugs and Money 7th edition, which was published in 2003.”

Kirsten Myhr recalls several quotes from Graham that she used in her own lectures on medicine prices and access:

Typical was also his view on the different types of truths:

All along, Graham kept participating in various expert- and advisory groups, related to pharmaceuticals, such as:

In his capacities as Professor of Drug Policy Science (Groningen) and Professor of Drug Policy Studies (Oslo), he was able to share his critical views on Drug Policy and to pass them on to the next generation.

Graham committed his life to a better, more balanced and righteous drugs policy at a global level. And he had important lessons on how to deal with the side-effects of the pharmaceutical industry:

“The pharmaceutical industry exists to serve the community, but over the years it has engaged massively in corporate crime, with the public footing the bill. This readable study by experts in medicine, law, criminology and public health documents the problems, ranging from false advertising and counterfeiting to corruption, waste and overpricing, with unacceptable pressures on doctors, politicians, patients and the media. Uniquely, the book goes on to present a realistic and worldwide solution for the future, with positive policies encouraging honest dealing as well as partial privatisation of enforcement and greater emphasis on creative research to develop the medicines that society needs most.” (Cover description of his 2014 book “Pharmaceuticals, corporate crime and public health”)

Tim Read of Health Action International comments: “Graham was the dearest of men, with an incisive mind, articulate narrative, and sharp wit. One thing is for sure, Graham didn’t take prisoners! His in-depth knowledge and critique of the pharmaceutical industry and its fallacious claims to justify high drug prices continue to inspire us in our mission today.”

In an interview with Sarah Boseley from the Guardian, Graham stated: “The big drug companies exaggerate the cost of research and, in any case, concentrate their expenditure on medicines for people in rich countries" [6].

During his career, Graham has acted both as an author and editor of various medical and legal books, articles and magazines. Graham was a skilful writer. Among his principal books are:

But Graham also wrote non-pharmaceutical books:

Graham authored more than 300 scientific papers. Some of the more important texts remembered by his friends:

Graham’s best-known work was probably ‘Meyler’s Side Effects of Drugs’, of which he was Editor-in-Chief from 1975 to 2000. In 2000, the publisher organised a symposium in his honour, held in Verona, where he was awarded a Netherlands Royal Medal: Officer of the Order of Orange-Nassau. It expressed a tremendous appreciation for his professional contribution to the field.

In 2006 he received a Lifetime Achievement Award from the International Center for the Study of Psychiatry and Psychology in Washington D.C., ‘for his dedication to the psychological and legal rights of citizens worldwide.’

And in 2013, London’s ancient Royal College of Physicians, which had already admitted Graham as an Honorary Member, went on to elevate him in an impressive ceremony to a Fellowship.

Graham’s health deteriorated in May 2023. His daughter Thea Dukes told us: “At the nursing home in Oslo where he spent the last few weeks of his life, on 8 August 2023, less than a week before he died, he wrote a final note [and I quote a part of it]:”

“[…] In situations like this, the important thing for me has always been to be left alone, to do the things I do best – reading and writing. I am an author of stories, essays, poems and teaching texts and have, for example, more than 55 books, medical, legal and historical, to my name. Unfortunately, my very recent neurological problems (paralysis) appear to have become a serious obstacle to this work.”

Graham could be happily surprised to find people used his work in remote areas of the world. For example when he found a Mongolian translation of a text that originated in Groningen in a rural hospital during a field visit in Mongolia in 1997 he said, “This happens to me often in this work, and makes me intensely satisfied. Then I realise that all the effort and adversity is not in vain” [8]. His work will continue to influence many generations of health and legal experts to come.

Graham Dukes died peacefully in Oslo on 13 August 2023, and was buried by his close family and friends in Oslo on 23 August 2023.

For messages to his family, please contact his daughter Thea Dukes ([email protected]).

Wilbert Bannenberg, MD, Pharmaceutical Systems Expert

Liliya Eugenevna Ziganshina, MD, Editor-in-Chief JRSM