An Interview with founding BLA president Prof David Howard

In the BLA Connections: A Clear Voice episode, host Natalie Watson interviews Professor David Howard, the founding president of the British Laryngological Association (BLA). The conversation reflects on the history and development of the BLA and the vital role of laryngology in speech and language therapy. Professor Howard shares insights into his career, from his early interest in physiology and surgical innovations to his current work on a negative pressure ventilator designed to improve respiratory support globally. He highlights the challenges and opportunities of innovation in medicine, including the slow process of gaining widespread adoption.

Professor Howard also discusses his continued involvement in teaching, training, and international work. Prof Howard reflects on his experiences with the Everest medical research team, his collaboration with engineers and clinicians, and the importance of bridging disciplines to address global health challenges. 

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Transcript

Host Natalie Watson

Hello and welcome to the BLA Connections: A Clear Voice, Series 6 - this is the finale! We'll be closing with a collection of five podcasts, which we recorded back at Cutting Edge Laryngology, 2024 in London, UK. We have three amazing keynote speakers, Marc Remacle, talking about his 30 years; ‘What did I learn?’ Anais Rameau from New York, talking about AI and the future of laryngology. And Nupur Nerurkar on vocal folds, cysts, sulci and mucosal bridges.

We also listened to Martin Birchall and Marc Remacle talk on hard and soft robotics. Martin was one of our previous presidents. And we finally have the remarkable, amazing Professor David Howard, our first president of the BLA, talking about his career in laryngology, and also what he's doing now and what he is planning to do in the future.

With regards to Cutting Edge 2024, we're very pleased to announce that all the talks and presentations are live on talking slides, which you can access if you're a BLA member or delegate of the conference. We hope that you enjoy our podcast. Please do have a listen.

Host Natalie Watson

Hello and welcome to the BLA Connections: A Clear Voice podcast, I'm your host, Natalie Watson, and I'm delighted to introduce Professor David Howard. He was our first BLA president in 2012 to 2014, so welcome!

David Howard

Thank you Natalie, good morning!

Host Natalie Watson

Good morning. We're at the Cutting Edge Laryngology Conference in 2024, and we're going to firstly, talk about the history of the BLA and how it all started.

David Howard

The driving force really, at the beginning, was not myself. It was Guri Sandhu and Martin Birchall. And with Chad involved, and Declan subsequently, and they've been the main movers. And the same with the Cutting Edge. They were so determined to get a state of the art conference, and to get people from all over the world, and they have achieved that, with some help from myself.

Host Natalie Watson

Indeed, we have the David Howard Prize, don’t we?

David Howard

Yes, we do!

Host Natalie Watson

Which is very good.

David Howard

I was fortunate to be still involved at a time when there was a real desire to create the association, because obviously we already had otological, and rhinological associations.

Host Natalie Watson

Head and neck, paediatrics? 

David Howard

Absolutely. And the reason why laryngology seemed to be slow as it were, is that we've had very strong connections with the American Laryngological Association. Indeed, the history of that; it was formed after the people who formed it were here in London back in the late 19th century, and saw what was going on in laryngology here, and went back to the States. Were determined to form their association, and then we had this very long laryngological association with the RSM, and a very strong section of laryngology and rhinology in the RSM. So that didn't feel a desire to necessarily create another branch, but as has happened in the whole of ENT, and many other disciplines, people wanted more and more of their own super specialisation, and so the BLA was born.

And of course, everything in relation to speech therapy, and all the aspects of phoniatrics, all the aspects of dysphagia, swallowing and so on. I was smiling to myself a bit yesterday, quietly in the conference, because I used to joke with Philippa, who's here, and Annette Kelly and the speech therapist I've worked with over the years that they should really be called speech and swallowing therapists, and people weren't always happy with that idea, but actually it's very important in the area of dysphagia. And swallowing has been an interest the whole of my career, because I started off life, I trained through general surgery in my general surgical fellowship, and I was doing gastric pull ups as a registrar general surgery in the 70s, a few years before I came into ENT and then was heavily involved in pharyngo-laryngo-esophageal surgery, and every aspect of swallowing.

And in recent years, swallowing has become a topic in gastroenterology, etc. But at the time in the 70s, a whole range of surgery was done in ENT, general surgery, and early parts of match facts, without the surgeons having a particular knowledge of the intricacies of swallowing. It fell between the domains of gastroenterology and ENT and so on. And my background, my first degree was in physiology. And so that's always been the interest behind my interest in surgery, and it still is. Physiology is still my main love, if you like. I always take everything back to the basics of physiology and anatomy, and that's why I'm involved with my current main project, which is developing a new negative pressure ventilator respiratory support, which arose in the pandemic, because we breathe by negative pressure, there's no positive pressure involved. And although positive pressure devices grew in the 50s and 60s from the polio epidemics, before vaccination was brought in, there's a lot of respiratory damage caused by positive pressure devices. They are not physiological, and we need to go back to negative pressure. We need to go backwards, to go forwards, which is always difficult in medicine.

Host Natalie Watson

So you've done a lot of work on this. And who have you partnered with? And how has it developed?

David Howard

It came out of the COVID pandemic, literally, in the first few days of it. You might remember there was this thing called the ventilator challenge, because there is a hysteria, wouldn't be too strong a word. There was the work coming out of China and Italy saying, we're going to need vast numbers of ventilators. Unfortunately, the COVID pandemic added further to the proof that positive pressure ventilation isn't particularly good for homo sapiens, and although people have gone further towards using what is called non invasive, CPAP, there's still positive pressure. They are invasive. You can get lung damage from CPAP, and anybody who's worn a face mask for a couple of hours of CPAP, or a helmet, can't tell you how unpleasant it is. It's not the way forward in terms of ventilation.

And well over 120/130 countries of the world have no respiratory support devices. And the advantage of designing and producing a new negative pressure device, is they’re a great deal simpler, they're a great deal safer. People are awake, they can talk, they can eat, they can drink, even with full ventilation. And we can make devices for just a few hundred dollars, and we intend to do that in the future, and we want them to be in LMIC countries - 750,000 children a year just die of acute pneumonia, and most of them would be saved by a little bit of respiratory support. The child dies every minute from acute pneumonia, and everybody thinks, oh antibiotics, because the pandemic shows viruses are a major cause of utter disease, the third communist cause of death in the world.

Host Natalie Watson

Well, where are you with the actual manufacturing? These negative pressures?

David Howard

Portsmouth Aviation is our manufacturer now. We started off with a large aeronautical firm, Marshalls of Cambridge, but Portsmouth Aviation have taken it over, and they wish to become a medical manufacturer. They're a very high quality engineering company. We also have it now being produced by another high quality engineering company called Olson. It's in Pakistan.

So we have our prototypes, and we're jumping through all the hoops that are required by MHRA, and it takes a long time. We're in our fourth year, and we have plans for our critical care assessment and respiratory medicine assessments, under the leadership of Michael Grocott, the prof, and all the team at Southampton, very important that we have senior research nurses involved. We've got to persuade, we've got to show the nursing fraternity as well the medical, that this is a way forward, and then we'll move into paediatrics. It’s going to take 10 years.

Host Natalie Watson

So we’re in the prototype era, and we're manufacturing it, but is not yet ready to go?

David Howard

We’ve already done our healthy human trials. The group of us, we put ourselves in the device, and those were published in a peer reviewed anaesthesia journal, which is the premier anaesthetics journal in the world in 2021, and it was voted as one of the top 10 publications in anaesthesia that year. We've already collected a number of prizes, but MHRA are not persuaded by prizes. There's plenty to do. I know it will take a long time. I spent a decade when I was a young surgeon, assisting Archie in his development of the laryngeal mask, and it was a brilliant innovation in anaesthesia. And, yeah, he had all the same issues that we currently face, because there was a whole generation of anaesthetists who said, oh no, the only safe thing is, you've got to have a tube in the trachea. And I remember some amazing remarks that were made to Archie as the mask was developed. “Oh, that's dangerous”, “You're going to kill people”, and we are facing that difficulty. The last figures I saw were for 2019 just before the pandemic, and over 50% of all general anaesthesia in the UK was administered with a laryngeal mask.

Host Natalie Watson

Yeah, it’s revolutionary!

David Howard

But it took from 1981 to 2018 or 19 to get those.

Host Natalie Watson

And preferable, because then there's no intubation injury on the actual vocal cord.

David Howard

Absolutely, we know from looking at the research literature over the years, I think it was Martin Birchell who either led, or I remember Martin talking about this. If you look at peer reviewed literature, it's about 10 years to develop a truly new innovation, about 10 years to talk to your colleagues, present it at conferences and so on, and about another 10 years for it to become routinely used in medicine, nationally or internationally. So it takes a long time.

Host Natalie Watson

It takes a long time. Moving forward to your amazing career in surgery. You were saying just before we were chatting that you are still operating and training in all areas of the world. Can you tell me a little bit about your work there?

David Howard

I've been fortunate. I have wonderful teachers. You will know that I'm married to Valerie Lund, in many countries, I'm known as the man with Valerie Lund. Then they usually say, what's his name? But I have enjoyed my career enormously in terms of teaching. I had many remarkable patients, and I am still in touch with many of them, and that is a massively enjoyable part of being a surgeon, but so is the teaching and training. And when I come to a conference like this, and I see the people that I've taught, or have helped to teach. I've been one of their teachers and helped to train. It's fantastic. It's at my stage of my career. It's perhaps the most enjoyable aspect. The research can be head banging and I chair the charity that is making the new ventilator, and some of that can be very head banging stuff. So the teaching and training is really just enormously enjoyable.

Host Natalie Watson

And you've moved from doing that in the UK now, to doing that in countries in Africa?

David Howard

Yes, I didn't quite manage 50 years in the NHS. That's 49 years! But I still work in Tanzania and in Ghana, three or four or five times a year, depending on. And in fact, Prof Emmanuel Kitcher, who's the head of the department in Ghana, I started working with him 25 years ago. He's actually here at the conference. Conferences are great from a point of view of catching up! There are still a couple of people I haven't caught up with. Brent Uren, who's one of my former fellows, who's a senior consultant now in Melbourne. This is quite amusing now, because a lot of my former fellows are professors and heads of department. It's very nice to see, really, and okay, I played a part in their development. But when, particularly when fellows come for a year, you can really have an impact on their training and what they subsequently do. Fellowships can still be very…

Host Natalie Watson

Life changing! My fellowship is completely life changing. Teaching me in office work and yeah.

David Howard

I'm not under any illusions. I know that some of my fellows used to come because they'd be saying in Australia, New Zealand or America, I imagine them saying, because they were mainly male, but Valerie did have lady fellows, female fellows. But you can imagine them saying to their wives, we can go to so and so, or so and so, or we could go to London for a year. So I think some of them are for the whole environment that London offered. And actually that was very beneficial at the Royal National Throat Nose and Ear, because we had people from every part of the discipline. And in fact, I lost a number of my fellows during the year, some very notable ones, actually, who came to do head and neck, but they would keep popping into Valerie’s theater. And then after a month or two, they'd say, Oh, is it all right if I do a bit more rhinology? And you know. And one eminent gentleman who subsequently became very eminent indeed in facial plastics and so on. In America, after just a couple of months, spent most of his time with Tony Bull, who was a very well known teacher and master of Rhinology.

Host Natalie Watson

It's an amazing hub, and still is to this day.

David Howard

Yes, and in fact, only oh, six weeks ago, a young lady consultant from the department in Ghana where I've worked in, she came and spent a period of time with the team at the Royal National ENT, as it is now it. And at Great Ormond Street looking at cochlear implants, because we're starting a cochlear implant programming in Ghana,

Host Natalie Watson

Yeah, amazing. We're very blessed in the UK to have all this resource. You've also helped in other less resourced places, like Nepal? Can you tell us about your experiences there?

David Howard

That's when I actually knew Professor Michael Grocott, when he was a young registrar. So I've known Mike a very long time, and University College London Hospital. And in the old days, I used to go regularly to the Middlesex Hospital as well. I had a number of honorary consultancies around London at Great Ormond Street, the National Hospital for neurosurgery. I was very fortunate in the 80s and 90s to work with many people. I was just chatting to Michelle and, of course, Ben from GOS, you know. I’ve spent a long time working in those other hospitals and Moorfields as well. And Valerie became the professor in the orbital clinic at Moorfield. Had some very enjoyable associations with other hospitals, and occasionally I'm traveling around the UK to go and operate elsewhere as well.

But it was actually Valerie who was invited to go with the Everest team in 2007 to do medical research up at base camp. It's one of those amusing stories where the person who wrote to her, was thinking that she was a him. And she wrote back a very amusing letter that she'd never been in a tent and she wasn't about to start and didn't think her high heels would be okay for the walk up to base camp, but she knew somebody who would. She improved my rhinology knowledge over a month or two, and I joined the group and worked at base camp for a while. Then I became quite ill, and I spent four days in intensive care myself in Kathmandu.

Host Natalie Watson

Yeah, you did, oh my goodness

David Howard

At one point, about two months into the trip, yeah, I got high altitude pulmonary edema going up the mountain too quickly. I've been going up and down, and it was a very interesting time.

Host Natalie Watson

That's incredible that you weren’t put off by that! I mean, obviously you went back!

David Howard

Well, the circumstances were such, but the second time I went in 2013 I also had a mishap. I broke my ankle. My track record for working in the Everest team is not great, but I got to know this marvellous group of people.

Host Natalie Watson

Everything happens for a reason, doesn't it? It all seems to slot in, the physiology degree, the networking, the links with the anaesthetists, and then merging it all together, and then a COVID pandemic to just spark it off, to bring it all together and then create this extra special interview!

David Howard

Absolutely, because the Everest team is mainly anaesthetists and critical care, respiratory medicine folks, and scientists.

Host Natalie Watson

Yeah, and I think that was one of the things that the COVID pandemic really did for me, and it was just bringing people together from all the different disciplines. So the scientific community, the medical community, sometimes they're the same people, bringing those together, and the public and the governments, and then bringing all of this. It's just that you don't easily do that. As you said, it takes 30 years normally, to innovate, and I think during the COVID pandemic, some things happened to speed that development.

David Howard

They did. Unfortunately, with the situation under control, then that speed has diminished tremendously, and we're back to what is a very slow process. It's difficult. It's not a criticism of MHRA. You have to have enough staff in these types of departments. You have to have enough expertise. And there are so many new ideas during the pandemic. But we're back to physiology again you see. All the people in the extreme Everest medical research expedition, they’re all people with a big commitment to understanding, back to basic physiology all the time. Looking at, in this case, hypoxia, the importance of oxygen, and all the immune markers and factors and so on. We did a colossal amount of research, and a lot of that is still going on, and continues. And the whole conference, the knowledge conference, sprang out of that.

Host Natalie Watson

And we’ve published 35 papers out of that particular group already.

David Howard

Oh yes. And it will continue. And when, I wouldn't be surprised if Michael and the team go to Everest again in the future, because like all true research, it's thrown up some new research questions. But it's all mainly related to critical care. And when we introduce the new ventilator, which, in the first instance, has a very simple component, which we call CNEP, where you're just in a continuous negative pressure chamber. And it's amazing how much just a simple continuous negative pressure will promote respiration, without starting cyclical negative pressure ventilation. It's the equivalent of CPAP, in a sense, but with negative pressure. There's lots to learn from that.

We do know a surprising amount from the eye and lung era of the 30s, 40s and 50s. So we have a whole base of information that we can use, but it is a question of gently showing and persuading a whole generation of anaesthetists, critical care doctors, respiratory medicine, to change their thought process.

Host Natalie Watson

Yeah, and I think we were just listening to the keynote lecture on AI, just going into a completely new mindset of how we could be working in the future.

David Howard

Voice evaluation, that magical measurement that we'd all like to have, which is so complex, could really be helped by AI, because basically, it's a way of analysing huge amounts of data, and there's an awful lot of data! But you’re measuring.

Host Natalie Watson

Yeah, well, the big shifts, is what I'm saying. Big shifts in voice recognition, big shifts in how we work. And as we say with the new intubation, a different mindset is needed for us all. An amazing career in kind of general surgery, head and neck, ENT research, training, being the mentor for hundreds, if not thousands, and the first BLA President!


David Howard

You’re being very kind!

Host Natalie Watson

Absolutely an amazing career, and still going!

David Howard

I'd like to live to be about 300 years of age, but it's probably not going to happen!

Host Natalie Watson

We'll bring the philosopher's stone in!

David Howard

Yeah, there's so much to do and so many interesting things, but there we are.

Host Natalie Watson

We're so thrilled that you're still interested and developing these what will be life changing and world changing things.

David Howard

Yes, I’ll have to be back with Valerie. It's a very hard task.

Host Natalie Watson

It's great. I love it. It's brilliant. Coming from a medical couple as well, I understand it. So thank you very much for everything and also continuing to support the BLA.

David Howard

It's my pleasure. Thank you very much.

Host Natalie Watson

Thanks. We hope you've enjoyed listening to  BLA Connections: A Clear Voice, I've been your host, Natalie Watson. Please do tune in next series for more laryngology topics. We would also love to hear from you. If you have any ideas for next series, please feel free to email with any topics you would like us to explore, any questions you have, along with any other suggested experts you would like to hear from. Also, if you'd like to contribute yourself to these podcasts, please email emailenquiries@britishlaryngological.org  

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