That girl

That girl is Lisbeth Salander. Over 40 million copies have been sold worldwide of three fat books, each over 600 pages long, describing her achievements and misadventures. She is described as a tiny, waif-like thing, tattooed, pieced, sometimes wearing 'goth' makeup and clothes. She possesses uncanny computing skills that she uses to hack into the most protected computers in Sweden and tax-free havens everywhere; she fights and defeats great hulking men several times her size, using a unique combination of martial arts and cunning. She has less than a handful of true friends and allies, and a large and diverse array of enemies seeking to kill her or lock her away forever in an asylum for the criminally insane. These enemies include recognized criminals, biker gangs, corrupt police and secret service agents, lawyers, financiers, among others. But she is a superwoman who vanquishes thugs, ruthless killers, assorted criminals and a sinister secret neo-Nazi network of black-hearted villains embedded in the Swedish secret police and intelligence services. She survives mayhem that would lay low the he-man heroes of comic book legends: in the climax of the second book she is shot three times (one bullet penetrates her brain) and survives being buried alive, because she is a comic book heroine and the female of the species is stronger, more intelligent, more, more every kind of good superlative, than the male. I devoured the first book of the trilogy as a fast read that took a few hours to skim its more than 600 pages, and skimmed the other two volumes in an hour or so apiece. No doubt I missed a lot of gory detail and tedium between the blood-and-thunder episodes. If I still were flying back and forth across the Atlantic, these three fat books would have kept me amused long enough to ease the boredom of a flight each way. As it is, I can only envy the author, or rather his estate, for dreaming up this unlikeliest of heroines and amassing a huge fortune from the sale of astronomical numbers of copies in goodness knows how many languages, not to mention movies in Swedish with American spin offs to follow. But dragon tattoos, playing with fire, and kicking hornets' nests aren't enough to make for longterm survival; the world will soon pass on to better books.

Summer scenes

Looking out our picture windows on this lovely morning I saw among the exuberant green leaves of late summer the first orange and golden leaves of autumn, and realized that this summer is passing me by. This morning I decided not to allow it to pass entirely without some experience of it, so while Sharon Morrison, Wendy's personal care worker, was still here I went out for a walk along the path by the Canal. Much of Ottawa's population seemed to be doing the same, the path almost needed a traffic patrol; it would certainly have benefited from some method of separating speeding cyclists from mums and dads with babies in strollers, dawdling elderly folk like me, winter sports lovers with devices resembling skis with little wheels fore and aft, propelled by ski poles fitted with ends like midget toilet plungers, the occasional skate boarder (is skate-boarding waning? It seems so locally) and of course many, many people on roller blades,keeping their skills honed for the ice that they hope will cover the Canal in a few months from now. It required more sure-footed dexterity than I possess these days to avoid colliding with the wheeled varieties of outdoors-lovers on the wide and recently resurfaced pathway, so I retreated like many others to the grass beside the pond, where I had to watch my feet to avoid the large and rather sticky deposits left by the Canada geese that have adopted these lawns as their favourite pasture. This is the pond where carp and catfish spawn in springtime but all those large fish are now long gone, many of them down the gullets of Chinese fishermen for whom this pond is a favourite place in spring and early summer. Today the pond was chock-full, like the path alongside it, not with people but with adolescent ducks learning the up-tails-all skills of stripping the waterweed from the bottom. It's a better place to learn that skill than the canal or Patterson's inlet beside our condominium because the water is less than half a meter deep with a flat, sand or gravel bottom from which the waterweed is easily stripped. But it was hot already at 1030-1100 this morning, so I cut short my stroll in the fresh air and retreated to the air-conditioned comfort of our apartment. I hope I will have some opportunities to experience more of this splendid summer before it all ends.

Wendy's Wall Hanging

We celebrated our thirtieth wedding anniversary at a splendid sea food restaurant in Sydney, and I have photographs to prove it. But Wendy also made a wall hanging that marked some milestones of our first 30 years together. This looked absolutely splendid on the exposed bricks of our large kitchen in the row house at 34 Waverley Street in Ottawa. She never meant it to become a permanent part of the decorative art on our walls but when we moved in 1990 from that tall, narrow home to a cottage on Echo Drive, we took the wall hanging with us, and from there it came to our condo apartment. Our reason for clinging to it has very little to do with its artistic merit and a lot to do with memories evoked by the scraps of material she cobbled together to create the images on this old length of faded green fabric. They are all that remains of clothes she made that our kids had outgrown, or that she made for herself or me, and we had discarded. Every piece of material reminds us of our past in happy ways. And the images, or pictures? From the bottom up and right to left, these are a kangaroo (John) and a Kiwi (Janet Wendy); a beach in Adelaide with two stick figures (one heavily pregnant); Sydney Harbour; Trafalgar Square in London; Sydney again, with a cock-eyed Opera House; a sugaring-off hut and ski slope in Vermont; Edinburgh castle; New York, complete with the twin towers of the World Trade Center; and Ottawa, with the Peace Tower, Chateau Laurier, the Rideau Canal at sunset. I fondly think that final top left-hand image shows the influence of French impressionist art we had been admiring in Musee D'Orsay not long before the burst of creativity that produced this wall hanging. It richly merits its place just inside our apartment door, and in the book of Selected Works of Janet Wendy Last.

More helpful equipment

It's been a busy day. Jodi Gannon, Wendy's visiting nurse, assembled the suction machine that was delivered a day or two ago, so from now on we can use it, as dentists do, to clear excess saliva and mucus secretions that occasionally build up in Wendy's mouth and at the back of her throat and cause distressing feelings of choking. Dorothyanne and Peter were here at the same time as Jodi so once again I was deprived of an opportunity to chat at leisure to Peter and find out more about his travels with Sylvie in Cambodia and Vietnam. There was time between moments getting instructed by Jodi about the suction machine for Peter to tell us that he and Sylvie will edit the thousands of pictures they took, add a commentary and get the whole thing made into a book of their travels, perhaps something like the book we made of Selected Works of Janet Wendy Last. Just as Jodi left, our expert on aids to getting about, occupational therapist Courtney Henderson arrived, soon followed by Shelly from the equipment supplier, with the good news that Wendy's power wheel chair will be ready next week. It seems that we won't much longer have to feel like Vladimir and Estragon, Waiting for Godot. The chair will be fitted with a tray table that can hold her speech synthesizer. The combination will add greatly to Wendy's mobility and capability to communicate.

More supporting stuff

If I believed in god, I'd give thanks to her for providing us with the Canadian health care system and its services. As we enter each phase of Wendy's journey with motor neurone disease (ALS) we discover that it's been anticipated by the team of supporting health care professionals, and there is a specialist professional and suitable and appropriate equipment to deal with it. This week began with a visit from the nutritionist/dietician - who explained to me the fine distinction between these two callings - and continued with the arrival of several more boxes of equipment and supplies. Last week I mentioned to Louise Coulombe, our palliative care physician, that Wendy is increasingly troubled by mucous secretions, and asked tentatively whether some sort of suction like the dentists use, might help. The boxes that arrived today from Ontario Medical Supply included an electric suction machine and all the supplies of saline etc to use with it. It looks terrifying complex in disconnected parts in its box and I dare not try to assemble it. I'll leave that job to Louise or to Jodi Gannon, our visiting nurse. Our living room and our bedroom look more and more like a hospital or clinic, and there is no doubt more to come. Wendy is hanging in there, tackling each new challenge as it arises, most of the time cheerfully and bravely - though she has complained about the discomfort of the face mask she wears when using the BIPAP ventilator. I give her a small subcutaneous injection of tranquilizer to take the edge off the discomfort, and tomorrow I will visit the supplier to see what sorts of alternative face masks are available. The one she got originally was quite comfortable to begin with, but as her facial muscles have wasted away a little bit, it doesn't fit neatly any more, so I'll try to find one that does fit. She continues to lose flesh, her arms and legs are painfully thin and the bones of her spine stick our like so many teeth. Her voice is going too, so we hope the speech synthesizer I mentioned in any earlier post will materialize soon. In case it doesn't, Jonathan is going to make some flash cards with common and important words and phrases on them. The list I already have will be a good start towards this, and in fact may contain everything Jonathan needs. I give her four square meals a day through the PEG tube, and as well she eats breakfast, lunch and dinner - almost all in liquid form, though she does have avocado and banana, mashed up but otherwise indubitably solid.

Wendy's photo is in a medical journal

For some years, the International Society for Environmental Epidemiology has been sponsoring a series they call 'Voices' in which prominent epidemiologists are interviewed in front of a video camera. The interviews are preserved in perpetuity in the Society's archives. In addition, an edited transcript is published in the Society's journal, which is called Epidemiology. I was interviewed for this project in May 2007. My interview lasted about an hour and a half, which may help to explain why it has taken so long for the edited (and much truncated) transcript of the interview to find its way into print. I was asked to supply two photographs, one dating from early in my career, the other a current or very recent photo. For the latter, I chose the photo of Wendy and me that was taken at our golden wedding anniversary banquet, expecting that it would be cropped to show me only. To my surprise, the editor of the journal left the photo intact, so I am very happy to report that an excellent photo of Wendy Last has appeared in the September 2010 issue of this prestigious scientific journal. You can see it, and the edited transcript of the interview, at:

http://journals.lww.com/epidem/Fulltext/2010/09000/A_Conversation_With_John_Last.32.aspx#

I think it's absolutely splendid that Wendy's photo, a very good photo too, will be preserved in print and electronic archives, in such places as the National Library of Medicine in Washington, DC, the Royal Society in London, England, and several thousand other medical and scientific libraries all over the world. Wendy richly merits this distinction! (The same photo appears in full colour in the blog post of July 28).

machines that speak

Yesterday Janet Wendy and I had a useful session with Margo Butler, the speech language pathologist, and 'Frankie' Nadeau, one of the occupational therapists who specializes in user-friendly equipment at the ALS Clinic. The purpose of our meeting was to learn more about the speech synthesizer, a very fancy electronic device that can speak for her now that the muscles she uses to speak are no longer consistently receiving effective signals from nerve endings that have atrophied. That's the underlying problem with motor neuron disease (ALS): the nerve endings that supply muscles atrophy, or die, so the muscles no longer receive signals, and stop working. This happens both to voluntary muscles like those in the fingers, hands, and voice-box, and to 'automatic' muscles like the diaphragm and the muscles between her ribs that she uses to breathe. That's why a ventilator at night while she sleeps is a great help, because it gives the breathing muscles a chance to rest. It's her voice-box muscle failure that is making it impossible for her to speak intelligibly for an increasing part of the time. Eventually her voice muscles will fail altogether. So soon she will have a device like the one that the theoretical physicist Stephen Hawking uses, but a nice female voice rather than one that sounds like a Dalak or a spaceman from another planet. She and I liked the machine she tested very much and hope it can be delivered really soon; but it comes with a stand that has a very large footprint. It will fit easily enough in our spacious living room amid all the clutter of walkers, equipment tray tables, wheelchairs etc.; but I fear it's going to be hard to avoid tripping over it. However, that's a small price to pay if it works as it's supposed to. The speech synthesizer can be programmed with commonly used words and phrases, and we spent some time creating a personalized list to add to the ones already included. It will be fun to play with this, and we hope we don't have to wait too long for it. I'm beginning to sense that because Janet Wendy is in her mid-80s, she is quite rightly lower on the priority list than someone half her age who needs the same sort of equipment. I think that's the reason we have waited so long, so far in vain, for a power wheel chair. It may be the same story with the voice synthesizer, but I hope it isn't. We will know if we don't receive the equipment within3-4 weeks that she has been bumped down low on the priority list.

Connecting the dots

This is probably the last original article I shall ever get published in a prestigious peer-reviewed scientific journal (Journal of Epidemiology and Community Health, 2010, 64:105-108). I was especially chuffed to be able to quote one of David's thoughtful essays (my reference #3)


CONNECTING THE DOTS: THE POWER OF WORDS AND THE DIVERSITY OF EPIDEMIOLOGICAL INFORMATION

Words are supposedly reliable tools to communicate scientific discourse; but words are very exacting. Ideally, they communicate our thoughts precisely and concisely, but they can obfuscate, mislead and confuse, often unintentionally. That is why technical dictionaries are so necessary. Good scientists do not want to be like Humpty-Dumpty, who said to Alice “When I use a word it means exactly what I choose it to mean, nothing more, nothing less.” One incentive to compile the Dictionary of Epidemiology was the insistence by an eminent clinician-epidemiologist that “case-control study” described what everyone else called a randomised controlled trial.

Words arranged in particular ways become more than the sum of their parts. They can arouse strong feelings because of emotional overtones or cultural associations. Several kinds of imagery, especially metaphor, can enliven otherwise bland statements. A metaphor is a figure of speech in which a word or phrase is applied to an object or action to which it is not literally applicable; it is representative or symbolic of something else, but as a metaphor it can evoke emotions. For example, when a famous film star or a favourite aunt dies of cancer, we commonly say she died “after a long battle with cancer.”
Some metaphors are inept. When faced with a troubling problem like poverty, drug abuse or terrorism, American presidents are apt to declare war on it. Lyndon Johnson declared war on poverty in 1964; Richard Nixon declared war on drugs in 1971; and in 2001, George W Bush declared war on terror. The war on poverty was lost through indifference. As for drugs and terror, the “war” metaphor signifies attitudes linked to flawed policies and failed strategies. Despite vast expenditure of money and lives, the wars on drugs and terror are unwinnable with current policies, no matter how much money, how many human lives, are expended. A recent important convert to this view is the Pentagon, which may portend a transformation in policies and strategies not only by the USA but also by other nations. A trial balloon was launched in the influential Washington-based magazine, Foreign Policy in May/June 2009:

Americans are a can-do people. They believe that if something does not work, it needs to be fixed. Unless they are talking about the war on drugs. On this politically fraught issue, Washington’s elites and the majority of the population, believe two contradictory things. First, 76% of Americans think the war on drugs has failed. Yet only 19% believe the central focus of antidrug efforts should be shifted from interdiction and incarceration to treatment and education; 73% of Americans are against legalising any kind of drugs, and 60% oppose legalising marijuana. As a result of this utter failure to think, the USA today is the world’s largest importer of illicit drugs and the world’s largest exporter of bad drug policy. The US government expects, indeed demands, that its allies adopt its goals and methods and actively collaborate with US drug-fighting agencies. This expectation is one of the few areas of rigorous continuity in US foreign policy over the last three decades. A second, and more damaging, effect comes from the US emphasis on curtailing the supply abroad rather than lowering the demand at home. The consequence: a transfer of power from governments to criminals in a growing number of countries. In many places, [drug] traffickers are the major source of jobs, economic opportunity, and money for elections. Fortunately, there are some signs that the blind support for prohibition is beginning to wane among key Washington elites. One surprising new convert? The Pentagon. Senior US military officers know that the war on drugs is bankrupt and that it is undermining their ability to succeed in other important missions, such as winning the war in Afghanistan.1
Among those holding this view is General James L Jones, Barack Obama's national security adviser.

Most health and social problems associated with illicit drug use would disappear if all illicit drugs were legalised. They could be sold to licenced users in government-run stores akin to liquor stores, where drug users could be identified and get counselling, and treatment could be offered. This would eliminate much hazardous conduct associated with drug abuse. It would augment government revenues, eliminate a lucrative source of income for the criminal purveyors and perhaps cleanse society of a great deal of crime. The only nation that has decriminalised illicit drug use, Portugal, is the only one where drug use has declined, along with HIV infections and other drug-related diseases, since the policy was introduced in 2001;2 the Portuguese government missed an opportunity to generate revenue: they do not sell drugs in government outlets and did not decriminalise sales, only the personal use. That is a bit daft, but at least Portugal took one step in the right direction.

Declaring war on drugs that may be abused by susceptible youth is a hopelessly flawed policy. It leads society to criminalise victims who need compassionate treatment and prevention of dangerous complications, notably HIV infection. I am over- simplifying a convoluted problem, but many young people take mood-modifying substances to soften the harsh realities of their lives which they perceive as miserable, offering no hope of better things to come. The war on drugs is complicated by the ideological prejudices of some policy makers. They regard illicit drug use as worse than criminal: it is sinful. Purveyors and users of illicit drugs are all sinners; all must be punished. The lessons of the disastrous American experiment with Prohibition have been forgotten by these zealots.

Terrorism is more complex. It is a health problem because it causes many deaths, much maiming and mutilation of innocent bystanders. Terrorism is multifaceted. Its existence depends upon who views it: one man’s terrorist is another’s freedom fighter. Terrorism is essentially a political problem with economic, social and cultural components, and its peaceful resolution requires strategies and tactics designed by a consortium with expertise and experience in all these domains.3 The most futile, counterproductive tactics are those that rely primarily on military force, which is the worst of all possible tactics if deployed alone: the “collateral damage,” death, dismemberment, mutilation of non-combatant women, children and infants inevitably lead to vengeful retaliation. Comprehensive evidence-based policies and strategies, based in part on epidemiological and sociocultural research, are essential to overcome terrorism.

Now consider another metaphor. In 2007, I was asked in an interview about the contribution of epidemiology to society. I said:

Epidemiology connects the dots, the isolated bits of information that begin to form a coherent pattern when connected in the right way . What we learn is passed on to society through concerned citizens, media, and eventually, often lagging far behind, policy- makers, our elected leaders .. Epidemiology has been a powerful lever for important shifts in societal values, has led to social and behavioural change and improvements in the human condition. There are five ingredients in this process: awareness that a problem exists; understanding what causes it; ability to deal with the cause; a sense of values that the problem matters, and political will. These five ingredients have led in my lifetime to improved control of tobacco smoking, impaired driving, child abuse, domestic violence, environmental lead poisoning and several occupational diseases. We urgently need to apply these five ingredients to control the dangerous problem of global climate change.

The dots can come from anywhere. Identifying them demands a broad perspective, the ability to see the Big Picture. It also requires what John Ashton4 called the “epidemiological imagination,” a particular way of thinking. Sometimes the way the dots are connected is instantly apparent. Sometimes painstaking investigation and analysis are required, for instance when the problem is a common but ill-defined condition (mild mental retardation) caused by trace amounts of a highly reactive environmental toxin (lead salts in soil, food or drinking-water).

Some recent problems and how they were solved demonstrate how human behaviour, including customs, culture, level of economic development, trade, commerce and technical innovations, can influence health hazards - the diversity of the dots we must connect. These examples illustrate another interesting truth: epidemiology is the most eclectic science, using information from wherever intelligence, intuition and imagination suggest that insights and understanding may be found.

A culturally induced disease due to disruption of women’s bodily micro-environment occurred in the middle 1970s: super- absorbent vaginal tampons enabled women to keep working while menstruating, without stopping to insert a fresh tampon. But a tampon soaked in menstrual fluid and retained for hours in the warm, moist environment of the vagina is a perfect culture medium for staphylococcal enterotoxin. When this sequence was identified the nature of toxic shock syndrome was clarified, and the problem was solved.5 The epidemiological evidence (the connected dots) came from gynaecology, microbiology, toxicology, sociology and the fashion and pharmaceutical industries.

If a hot indoor environment is cooled with a dilapidated air conditioning system, the elusive pathogen, Legionella pneumo- philia can breed and is disseminated in the cool moist air. The pneumonia epidemic among members of the American Legion who attended a convention in Philadelphia in 1976, then went home to sicken and die elsewhere, was clarified when this had been worked out.6 The evidence came from clinical medicine, pathology, microbiology, vital statistics and record linkage, and from engineers who make and service air conditioners. All combined and connected the dots to solve that puzzle.

Asiatic cholera in the early 1990s in Peru, Ecuador and Colombia involved a complex causal chain. Ships trading from India discharged ballast water contaminated with a virulent strain of Vibrio cholerae in coastal waters and river estuaries. This coincided with an El Niño Southern Oscillation that warmed those usually cold waters. The warmer seas fostered an algal bloom of zooplankton, which are symbiotic with cholera vibrio; so these proliferated in seaports along the Pacific coast of South America.7 The resulting cholera epidemic lasted several years, causing half a million cases and several thousand deaths. The evidence that unravelled this sequence came from oceanography, marine biology, microbiology, international trade, anecdotes about maritime practices, all united by epidemiological insight: seemingly unrelated dots formed a coherent pattern when they were connected.

International trade brought the Asian tiger mosquito, Aedes albopictus, to the southern USA in the 1980s as larvae in pools of water in used car tires imported for retreading.8 9 The southern USA provided many ecological niches for this efficient vector for dengue and several kinds of virus encephalitis. The Asian tiger mosquito has proliferated along the eastern seaboard and west to the Mississippi Valley. With the expected global warming of the next century, the range and breeding seasons of these mosquitoes (and of anopheles mosquitoes that transmit malaria) will extend further. This is several epidemics in waiting. Epidemiological and vector surveillance reduce the risks, but tax revolts and the recession have engendered budget-slashing administrations, public health infrastructure has been weakened, and this defensive line may be vulnerable.

These and many other examples illustrate how epidemiology is combined with scientific and technical expertise from many disciplines and varieties of knowledge to investigate and control public health problems. These problems were solved by a combination of intelligent merging of information from diverse sources and disciplines (connecting the dots) and the epidemiological imagination. This approach to problem-solving is a learnt skill, so it can be taught.

From the 1940s onward, biomedical scientists discovered and developed powerful antibacterial drugs to treat and often cure previously lethal infections. I am old enough to remember what medical practice was like before we had antibiotics, and could do little but watch as previously fit young people died, sometimes in hours, from pneumonia or overwhelming septicaemia.

Physicians from that generation can be forgiven for embracing antibiotics so enthusiastically, and using them, we realise belatedly, too often, too uncritically. Antibiotics were weapons in our “war” against pathogenic bacteria. We declared war on them all, even bacteria that live symbiotically in our gut, assisting digestion and manufacturing vitamins.

The medical profession is not the only guilty party. Veterinarians, agricultural scientists, farmers and advisers about animal husbandry were guilty too, advocating addition of antibiotics to animal feed to ensure healthy animals destined for slaughter. These customs and evolutionary rules bred generations of antibiotic-resistant pathogens.

Also, in the 1940s, scientists discovered the insecticidal power of DDT and began using it in the “war ” against malaria and other vector-borne diseases. In 1944, when Naples was liberated from Nazi occupation, a threatened epidemic of louse-borne typhus was aborted by dusting the population with DDT. I recall rejoicing at a cinema newsreel as the story of this public health victory was told, accompanying news of military victories after years of unremitting bad news from war zones in Europe and the Pacific.

Initially, our wars against bacteria and insects succeeded. Pneumonia, septicaemia, meningitis, syphilis and gonorrhoea melted away under bombardment by penicillin and other antibiotics. Malaria was eliminated from south-eastern Europe, the Middle East, China, much of South and East Asia, Mexico and Central and South America, where previously its toll had impeded development. But proclamations of victory over infectious pathogens and insect vectors were premature. The laws of evolutionary biology soon produced antibiotic-resistant pathogens and DDT-resistant insect vectors. In a favourable environment, the generation time of pathogenic bacteria may be only a few minutes: in a few days, the length of a course of treatment, there is time for antibiotic-resistant bacteria to evolve and proliferate. The same rules apply to insect vectors, although generation time is longer. Soon DDT-resistant mosquitoes proliferated. We have had victories against pathogens and insect vectors, but we cannot win the war with these tactics. We need different strategies.

A promising strategy is to find ways to live in harmony with our microbial enemies. Vaccines that confer immunity enable us to coexist alongside pathogens. Sometimes a physical barrierdwindow screens, bed netsdcan shield us, especially vulnerable infants and small children, preventing contact with mosquitoes and other vectors.

Humans are an aggressive species, and our metaphors reflect this. We wage wars against cancer, alcoholism, epidemic diseases and bacterial pathogens. With far-reaching consequences, another metaphor boasts of conquering the environment. But the environment is our essential life-support system. We may harm, even destroy, it when we change it to suit current whims.

Every year, humans withdraw an estimated average $33 trillion of global ecological goods and services, making little or no capital return.10 We cannot go on doing this indefinitely. James Lovelock11 thinks it is already too late; we are on an irreversible path to a hotter world. We behave as though perpetual economic growth and “development” are not only possible but desirable. Perpetual economic growth is no more possible than perpetual motion, the fanciful dream of the scientifically illiterate.

In my lifetime of over 80 years, the world has become a better place for me and others in the tiny, well-educated, affluent minority; but life has not improved for the billion who subsist on a dollar a day or less, and there are increasing signs of irreversible damage. All indicators show evidence of deteriorating life-supporting ecosystems. Thirty years ago, when I first became concerned about global sustainability, we had few indicators and less sensitive models than now of trends in global sustainability, soil productivity, atmospheric and ocean currents. The signs were worrying, but the evidence suggested that serious trouble was hundreds of years away, adequate time to put things right. The evidence in the Fourth Assessment Report of the Intergovernmental Panel on Climate Change in 2007 and recent direct observations of Arctic ice and glacier melt are more urgent. The time for effective action has shrunk to a few decades or less.

Climate change has several direct and indirect adverse effects on human populations.12 It causes extreme weather (severe storms, hurricanes, heat waves, droughts, torrential rainstorms and floods); sea level rise disrupts coastal ecosystems and fisheries, destroys habitat and floods fertile coastal farmland. Storm surges over low-lying coasts drown large numbers, for example in Bangladesh, and endanger everybody in small island states. Heat waves kill vulnerable people, an estimated 50 000 in the European heat wave in 2003. High humidity and increased surface water accompanying high ambient temperatures, favour water-borne diseases, insects and vector-borne diseases: malaria, dengue, virus encephalitis, perhaps newly emerging pathogens. By 2050, an additional billion people may be at risk of malaria. Extremely high temperatures damage germinating rice and grain crops, and floods and droughts can destroy the growing crops, so food shortages, perhaps severe enough to cause hunger, starvation, famine, are another scenario. When a region is afflicted, the people have to move, becoming environmental refugees. Massive population movements and large refugee communities produce challenging public health problems. Conflict is a common sequel, as in Darfur.

Resource depletion is another aspect of global change. The most critical resource is freshwater for drinking and irrigation. The daily requirement varies with environmental conditions, physical activity, metabolic demand and other factors. Freshwater is critically short in the Middle East, South-western USA, North-eastern South America, north China, and Australia south of the “top end” that gets seasonal monsoon rains. Contrary to popular belief, Canada does not have limitless freshwater: the Great Lakes are mostly fossil water, left over from the last ice age. Canada does not have enough spare water to nourish the parched US south-west. Wars have been fought over access to water, and water shortages will probably lead to future conflicts. These and other health-related consequences of climate change are described in the reports of the Intergovernmental Panel on Climate Change (http://www.ipcc.ch) and in many other reports.

Sea levels are rising as polar and alpine ice melts. Arctic sea ice is melting, so there is open water at the North Pole in summer. The water reflects less solar radiation than ice and snow, so the warming and melting accelerate: ice-melt that previously took many decades can happen in a few summers. Regions of concern are the glaciers of Greenland and Antarctica. When these melt, sea levels could rise by 5-7 m, perhaps more. All seaports and many of the world’s most populous cities face inundation. Over a billion people’s habitat and many sources of food supplies are threatened. Food shortages and famines are part of this scenario.

Epidemiologists and front-line healthcare workers have important tasks. It is essential to identify vulnerable groups at highest risk and have plans to protect them from harm in climatic extremes (heat waves, floods, etc). Risk assessment, evaluation of intervention strategies, disease and vector surveillance, water and food security policy and disaster planning are all high priorities. Collaborative research between health scientists and environmental scientists is needed to identify critical environmental “load” limits and to develop amelioration strategies. We know very little about interactions between survival of other species and human survival; this is a field for epidemiologists to cultivate. Many more dots must be identified and connected before all the health and social problems associated with climate change are delineated, classified and solved.

SUMMARY

Words both shape and reflect our sometimes irrational behaviour, as in the unwinnable “wars” on drugs and on terrorism. “Wars” on pathogenic organisms are also irrational and unwinnable with antibiotics and pesticides because they attempt to defy inexorable laws of evolutionary biology. Logic and rational thinking are essential prerequisites in tackling intractable problems such as drug abuse, terrorism and control of diseases caused by pathogenic agents. Logic and rational thought are equally essential and are urgently needed to tackle the problems associated with climate change. These problems transcend traditional disciplinary boundaries and require innovative, eclectic approaches and unconventional solutions.
Epidemiology is the most eclectic health science. It transcends disciplinary boundaries and stretches the imagination. The environmental crisis of climate change provides opportunities for epidemiological research and surveillance, including studies of cause/effect relationships, risk identification and risk assessment, evaluation of adaptation and mitigation strategies. Many more epidemiologists must get engaged in climate change research and surveillance. Epidemiologists need wide horizons to see the big picture. It is very satisfying to see the picture emerging from the connected dots. That satisfaction has kept
me going. I hope it keeps young generations of epidemiologists going, too.

Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.

REFERENCES
1. Foreign Policy, 2009, May/June. http://www.foreignpolicy.com/story/cms.php? story_id1⁄44861 (accessed 24 May 2009).
2. Scientific American, 7 April 2009. http://www.scientificamerican.com/article.cfm? id1⁄4portugal-drug-decriminalization (accessed 24 May 2009).
3. Last DM. Transformation or back to basics? Counter-insurgency pugilism and peacebuilding judo; Paper for the conference on peace support operations, at the Truman Institute, Jerusalem, 18-19 June 2007. In: Michael K, Ben-Ari E, Kellen D, eds. The transformation of the world of warfare and peace support operations. West Port: Praeger Security International, 2009;Chapter 6. 101e21.
4. Ashton J, ed. The epidemiological imagination. Buckingham: Open University Press, 1994.
5. Davis JP, Chesney PJ, Wand PJ, et al. Toxic shock syndrome: epidemiologic features, recurrence, risk factors and prevention. N Engl J Med 1980;303:1429-35.
6. Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires’ disease: description of an epidemic of pneumonia. N Engl J Med 1977;297:1189-97.
7. Epstein PR. Emerging diseases and ecosystem instability: new threats to public health. Am J Public Health 1995;85:168-72.
8. Knudsen AB. Global distribution and continuing spread of Aedes albopictus. Proceedings of a workshop on geographical spread of Aedes albopictus, Rome. December 1994.
9. Knudsen AB. Geographic spread of Aedes albopictus in Europe and the concern among public health authorities. Eur J Epidemiol 1995;11:345-8.
10. Costanza R, d’Arge R, de Groot R, et al. Value of global ecosystem goods and services. Nature 1997;387:253-60.
11. Lovelock J. The vanishing face of Gaia: a final warning. London: Allen Lane; Penguin Press, 2009.
12. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009;373:1693-1733.

Victories great and small

This has been a good week, week and a bit really since Wendy's PEG. The nutritionist and the nurse between them educated me in the hygiene of changing dressings as well as how to give Wendy fluid and food through the tube. It's years, decades almost, since I did this kind of doctoring, but it came back to me quickly and easily. I'm sure PEG tube feeding has helped already to restore her nutritional status, and she is looking and feeling better. (It's done nothing to arrest the process of progressive muscle loss, which is now affecting her voice more obviously; I had a reminder email earlier today from Margo Butler, the speech language pathologist at the ALS Clinic, about our own personal list of words and phrases to add to those programmed in the voice synthesizer). I've worked out a system to make the tube feeding process as efficient as possible, and the Personal Care Workers' supervisor brought Sarah Kerrigan, the young PCW who is a student nurse, here so I could demonstrate my system which is very simple: I just lay out on a little table all the bits and pieces, syringes etc, that I need, so all is ready to move straight from one step to the next without interruption. I go very slowly, probably slower than the nurse (Jody Gannon) demonstrated, so 60 Ml sterile water, 60 Ml high protein, high calorie liquid, and a chaser of another 60 Ml sterile water, takes 20-25 minutes. Wendy says I'm "very gentle" which is high praise.

It'a been a good week in other ways too. I passed my third 'Over-80' driving assessment with flying colours. I know where this test is conducted because I've been there twice before; the assessment is made at 2-year intervals beginning at age 80. But today, instead of relying on my memory, familiarity with Ottawa's major roads, and my sense of direction, I relied on Google maps, with the consequence that I got hopelessly lost getting there and arrived half an hour late. Now I understand why so many of the diverse array of experts helping Wendy get lost trying to find our very easy-to-find apartment building; it's because they rely on Google maps instead of following the simple directions I give them over the phone. Anyway, I aced the test, passed the vision test 100%, got every answer right on the rules of the road test; then as the licence bureau where I do the paperwork to renew the licence is just around the corner from the test centre, I dropped in, expecting the usual hour's wait for my number to be called, and a once-in-a-lifetime event, the place was empty, not a soul waiting to be served, so I walked up to the counter, paid my fee, and am all clear to drive again for the next two years. That was a good morning's work, and I had time at the end of it all to pop into our friendly neighborhood supermarket for some urgently needed supplies, such as some tonic water for my G&T.

Humorous Books

A friend who is about to set off mountain climbing in the Rockies confessed that he's never read anything by the great English humorist P G Wodehouse so he is taking one of the Jeeves and Bertie Wooster short story collections. It's a good choice, provided he has the self-restraint to ration himself to one story a night, something I could no more do than eat one salted peanut, or one chocolate peppermint cream. His remark sparked a train of thought about humorous books, including ones that make you think, like Rabelais, Voltaire's Candide, much of Mark Twain, Fielding's Tom Jones, and nearer our time, S J Perelman, James Thurber, Alan Bennett, among others. The last of these, Alan Bennet,may never have been funnier than in the sermon skit he performed in the original Cambridge Footlights performance, Beyond the Fringe, and much of his recent work is the sort of humour that is as likely to induce tears as laughter. It's probably a cultural thing, that I have more affection for the English humorous writers than for any other, so Three Men in a Boat, and The Diary of a Nobody have a place in my personal pantheon.The Canadian humorist Stuart McLean, who is often funnier if not more witty than his American counterpart Garrison Kieler, in much the same way that Stephen Leacock was funnier than Mark Twain, can induce tears or a lump in the throat too, but his serious mode is often a rather mawkish sentimentality, not a profound reflection on the human condition. I have enormous respect for real humorists who have that rare ability to make us laugh yet make us think too. Perhaps no one did it better than the classical Greek playright Aristophanes 2500 years ago: in Lysystrata,he fully exploited the endless humorous potential of a situation in which the women withhold their sexual favours in order to dissuade their men from endlessly fighting and going to war. And on the matter of that book, would the unprincipled rascal who stole my copy with illustrations by Norman Lindsay please return it! I will ask no questions, offer forgiveness, and not report the theft to the authorities.

Interrupted by bull-ants

Should this autobiographical fragment appear in my Memoirs? It was played on CBC radio in Richardson's Round-up about 7-8 years ago and I got feedback of a rather ribald quality from one of my colleagues who heard it. What do you think?

Wendy and I did most of our courting in the picturesque hills behind Adelaide. One day when driving in these hills we were overcome by amorousness. We carried our rug to a grassy slope out of sight of the road where we settled down to express our affection for each other in our customary way. Before either of us had really warmed to the business at hand, my beloved suddenly screamed and leapt up, tearing frantically at her clothing. In our careless haste, we had spread our rug on a bull-ants’ nest. Bull-ants are fierce fire-red creatures a centimeter or so long, equipped with sharp pincers where lesser insects have jaws. They were displeased to have their nest and its approaches obscured by our rug, and let us know in the only way they could. Wendy sustained several savage bites that, she later told me, raised angry welts on parts of her person I was not yet permitted to see. We retreated in disarray and confusion. After that unhappy experience we inspected the site carefully before spreading our rug – or stayed in the slightly cramped but ant-free safety zone inside the car.

This story dates us: in the pre-Pill era most respectable people (and we were respectable) were rather circumspect and perhaps even a bit inhibited about sex. We were both shy too, after all here we were, both of us in or on the threshold of our 30s, still unattached. Many of our contemporaries in nursing and medicine respectively, were married and parents of a couple of kids by the time they were our age. Our courtship was a wonderful period of mutual discovery of each other's minds and bodies. I wonder whether courtships nowadays are as satisfying and pleasurable as ours was.

Using the PEG tube

After a lesson from nurse Jody Gannon, I used the PEG tube to give Wendy three square meals yesterday. She can take much more nourishment this way, and what we both found encouraging was that in addition to the high protein high calory fluid called Resource # 2.0 through the PEG tube, she also had her regular supper by mouth. Her regular supper is one of Richard's specialties, lightly curried fish or chicken pesto or one of his other tasty dishes, blended, seived, frozen into cubes, then thawed, heated, seived again and served in a soup dish. Richard's gourmet meals are delicious, so it's great that Wendy still enjoys them enough to have one of these after her high energy fluid through the tube direct into her stomach. If we can keep this up, we will soon get some flesh back on to her bones. Today is her fourth since the PEG and she is getting some bounce back into her steps, graduated from the wheelchair to the walker. At this rate, with all these high energy meals, we'll have her ready for the triathalon in time for the next olympic games.

Hiroshima

There is a shallow pond beside the Rideau Canal about 200 meters south of our apartment building. In the spring it is the spawning ground for catfish and carp. This day, August 6, it is the location of a moving annual commemoration of August 6, 1945, the first time an atomic bomb was used to kill humans in large numbers. Representatives of the Japanese government, members of the Japanese community in Ottawa, and some of us who advocate and work for nuclear disarmament gather there and float little paper lanterns in paper boats on the pond. I was a teen-age medical student in 1945 and like most of my classmates I had recently learnt enough physics to understand how such a bomb would work according to Einstein's famous formula for the relationship of energy to mass. Through most of my life from then on the threat of nuclear war has been a dark cloud over all of us. This year's commemoration seems rather higher profile than usual, for instance because the UN secretary general is attending the ceremony in Hiroshima and because the time given it in news broadcasts, the column inches in our national newspaper, are more than usual in recent years. I hope these are hopeful portents.

PEG in place

Yesterday Wendy had a PEG - percutaneous endoscopic gastrostomy - so she can receive nourishment directly into her stomach, bypassing the increasingly unreliable muscles in her throat that cause her to choke when food or fluid 'go down the wrong way.' This won't prolong her life but like the ventilator to help her breathe while she is sleeping, it will help make her remaining time more comfortable. Today I spoke to the anesthetist and the surgeon (yesterday, with David helping us, our priority was to get her home as soon as we could, rather than hang around waiting for a break between one operation and the next). The operation took six minutes, the anesthetic preparation took about 20 minutes, because the anesthetist, a caring and considerate disciple of the senior man she saw for preoperative assessment, was cautious and took great care to avoid risk of stressing her weakened respiratory muscles. Today, understandably, she has had some postoperative pain and this morning she spiked a fever (101.5 F) that alarmed me briefly; but as the day progressed, she brightened up and with enough medication to control her pain, she has had a reasonably comfortable day, all things considered. The fever went away and hasn't come back so I guess it was just one of those post-operative fevers, just a bit higher than usual. Tomorrow the nutritionist comes and we will have our first lesson in and experience of using the PEG to get adequate quantities of fluid and food into her system. By the end of the day she was looking and acting a whole lot better and brighter than she had early this morning. She's a tough old bird, it takes more than a little operation to knock her down for long.