Spread too thin

It’s a tactical error I had seen others make before me. I should have learnt from observing their experience, but of course I didn’t.  When we came to Ottawa at the end of 1969 and I became head of the department of epidemiology and community medicine at the University of Ottawa, I accepted far too many invitations, got spread too thin to be effective in many of the roles expected of me. For the first few years, an under-estimated challenge was getting accustomed to a new and subtly different culture that seemed deceptively similar to others we had lived in, but was different enough to trip me up occasionally.

When I recall some highlights of the frenetic 1970s, I wonder how I did it and survived, and it's a miracle that our marriage survived.  Within a year I was simultaneously building a large university department, serving on Canadian federal and provincial research grant review committees, the US NIH Epidemiology & Disease Control Study Section, other ad hoc review and assessment panels, including accreditation teams that assessed performance of medical schools; and trying with my beloved Wendy's help to tamp down our teen-aged daughter's hormone-laden urges, fending off several aggressive militant feminist staff members, and dealing with too many other challenges to count. I did three demanding consultant tasks for the South East Asian Region of the World Health Organization; I was invited to apply for the position as foundation dean of the new faculty of medicine at Newcastle University, New South Wales (about 150 Km north of Sydney).  What a decade that was! And for the last 3 years of it, I was also editor in chief for the first time of the enormous Maxcy-Rosenau textbook of public health and preventive medicine. In 1978-79 I had a sabbatical year, which Wendy and I spent in New York City, acquainting ourselves with a great deal that this city of superlatives has to offer. There's a whole chapter about that unforgettable year.  Looking back on it, I marvel that we survived it all! What's more, it was tremendous fun most of the time.  Distance lends enchantment, but even when they were close-up, those were endlessly exciting and fun-filled times, seldom burdensome or cause for grief. 

I forgot what it felt like to have leisure time, and I lament the loss of intimacy and close bonding within our family that we all enjoyed so much in our years in Edinburgh. Yet that probably would have happened anyway as our kids grew from little children into autonomous teen-agers and all too soon became adults.

Department of Epidemiology & Community Medicine, 1970
Top row: Ineke Neutel, PhD, John Last MD etc, Anne Amberg MSW, Luciano Neri MD
Front row: Darlene Flett BScN, Ruth Barret MB, Jack Mandel MSc

When I was appointed head of the department of Epidemiology and Community Medicine, the ‘community medicine’ portion of the department was already established, because ‘community medicine’ meant family medicine. A developing department of family medicine was based at the Ottawa Civic Hospital, and in my first few months as department head I presided – if rather distantly and usually in absentia – at the birth of a second department of family medicine linked to the Ottawa General Hospital. Both were de jure bilingual, but de facto the OCH department was almost 100% Anglophone, and the OGH department was de facto almost 100% francophone; consequently I understood little of what happened there. I could struggle through written communications like minutes of staff meetings, memoranda from the dean’s office, and government announcements, but my conversational French was non-existent.  The epidemiological end of the department, in contrast was rudimentary. My highest priority was to build epidemiology up into a large and productive group, with clearly defined research themes, programs and projects. With a lot of luck, some serendipity, a smidgen of thoughtful planning, and more than a dash of seizing opportunities before they vanished into limbo, things came together, and by the mid-1970s I was presiding over a large, productive group that was advancing the science of epidemiology on several fronts. That didn’t mean I had a firm grasp of everything we were doing – awareness alone was all I could manage with some of it. Sometimes I felt as if I was sleep-walking through other parts of the experience.

With my rudimentary organizational and administrative skills, just running the academic department of epidemiology, recruiting new staff members, getting to know colleagues in the bilingual University of Ottawa / Universite d’Ottawa, and mastering French, would have been quite enough to fill my agenda, and would have left very little spare time for the family.

But I was seduced into loading ever more straws on my camel’s back. My first seducer was John Evans, dean of McMaster University Medical School, soon to become president of McMaster University.  He invited me to become a member of the National Health Grant Review Committee, which he rightly pointed out would be a superb educational experience for me, would give me a fast introduction to who was doing what kind of research across Canada. The National Health Grant was a new program, intended to kick-start important population health research and development programs and projects in all parts of Canada, some university-based, others associated with community entities such as municipal health departments, a maternal and infant health foundation, First Nations (indigenous Native) communities, some well-defined ethnic Canadian communities, occupational groups, and others. The review committee met for 2-3 days 3 or 4 times annually. As its name implies, its first task was to review and approve or disapprove proposals for research that were presented by often embryonic research groups based in a few existing centres of research excellence, and by numerous aspiring but inexperienced groups, some serious, others merely attracted by the money that the federal government was dispensing by the truck-load.  It became clear very soon that those of the aspiring research teams that had any potential needed to be educated about what research is, what it could and couldn’t accomplish, and how it was done. Dave Sackett at McMaster University medical school had a clear vision of what was required, and initiated a series of workshops (‘seminars’) each lasting 4-5 days, in strategically located university departments across Canada, including two that I hosted at the University of Ottawa.  Working on the National Health Grant review committee absorbed a considerable part of my time that might have been better devoted to learning French and planning and implementing a credible teaching program in epidemiology – but there was much more soon to be loaded on my already overloaded shoulders.

Department staff, 1975

Some members of the Survey Research group, 1975

The Ontario Ministry of Health set up its own research and development program. The bureaucratic heads of this initiative were Grainger Reid, a rather flamboyant Englishman, and Duncan MacEwan, a quietly competent Scot. The academic leadership came from Fraser Mustard at McMaster University medical school. Like the National Health Grant, the Ontario Demonstration Models program was mainly but not exclusively based in university departments. I joined my peers, department heads or their delegates in departments like mine in other Ontario universities, as a member of the Ontario provincial review committee, to pass judgement on the applications for program funding. The demonstration model for which I secured funding at the University of Ottawa was a community health survey research group, with the focus on interview survey methods. Throughout my 8-year term as department head, we developed a strong survey group and carried out several well designed interview-based community sample surveys. I ran into trouble with this venture, however, when an aggressive, militantly feminist project director with her own research agenda sought to divert the goals – and the funds – of our community surveys to her own research aim of providing raw material for her PhD. After I’d sorted this out, everything went smoothly and when I departed for my sabbatical year the survey research unit seemed robust and solidly embedded in the department, ready, willing and available for use by anyone with a research design that involved survey methods. Sadly, Bob Spasoff my successor as department head, wasn’t able to make use of survey methods and the group soon disintegrated.

NIH Epidemiology & Disease Control Study Section, 1975
(Members names listed below under "comments")

One morning in 1971 as I sat at my desk the phone rang and I found myself in conversation with Glenn Lamson, executive secretary of the Epidemiology and Disease Control Study Section of the National Institutes of Health, US Public Health Services. He told me he had heard good things about me, had read my “Iceberg” paper and a few other things I’d published; he was impressed that I was strategically placed in Ottawa, Canada’s national capital; he wanted me to serve for five years on the NIH Study Section. This met for 3 consecutive days 3 or 4 times annually, usually in a building on the NIH reservation in Bethesda, Maryland, just outside the DC boundary that delineated Washington. We had occasional meetings off the reservation, in Los Angeles, Boston, New York and Chicago. In addition to the study section meetings there would be several site visits annually to research centres where interesting, costly, or controversial research projects and programs were proposed or already under way.  Service on the NIH Study Section provided me with superb research experience, albeit vicariously. It gave me an unrivalled opportunity to meet and interact with prominent epidemiologists, both generalized and specialized in the domains of cancer, cardiovascular, respiratory, genetic, pediatric, geriatric diseases, trauma, musculo-skeletal disorders and other specialized branches of epidemiology. My friendship and acquaintance network expanded rapidly, as I met and befriended just about everybody who was anybody in the USA and sometimes beyond, ranging from Nobel laureates like Linus Pauling to up and coming youngsters who have since gone on to become world renowned. Among other things, I had several opportunities to expand my existing interest in ethical and philosophical problems that can arise in epidemiological research, practice and teaching. The chairman of the study section, Brian McMahon, gave me the task of developing some guidelines on ethical problems, including informed consent procedure and rules, discrimination against minority groups, and conflicts of interest. Brian McMahon was followed as chairman by Tel Work, then when he fell ill, Joe Stokes III took over.  When my 5-year term ended, I continued to serve occasionally as an ad hoc member of site visit teams, e.g. to Linus Pauling's group in Palo Alto, a space-age trauma centre in Seattle, and cancer genetics teams in Omaha and Salt Lake City. 

During those same years I was playing an increasingly prominent role in the affairs of two American organizations, the Association of Teachers of Preventive Medicine and the American College of Preventive Medicine. I played a lead role as president first of ATPM then of ACPM, in bringing the two organizations together to co-sponsor a new journal, the American Journal of Preventive Medicine, which has become an internationally recognized leader among journals in this field. I also helped to get launched an annual ‘Prevention’ meeting, always in Atlanta in the springtime in the years that I led it. A small personal bonus was the opportunity to escape from Ottawa, which was often still firmly clutched in winter’s grip in early April to the balmy warmth of Atlanta where azaleas and other flowers and magnolias were in full bloom and in the evenings we strolled outdoors without coats.

In 1972, 1974 and 1976 I had short-term tours of duty lasting from 3 weeks to 2 months as a consultant to the South-East Asia Region of the World Health Organization, in Indonesia, the southern region of Tamil Nadu in India, and Sri Lanka. Wendy joined me in Sri Lanka for a few weeks of that assignment, and we had a couple of weeks touring in India after the work was over. These three experiences, and others that followed, are described in another chapter.

John Last "presenting" dean Gilles Hurteau with a joke book
of cartoons about doctors and teaching, signed by all at the retreat

In 1976 at a Faculty of Medicine retreat where the prevailing mood was gloomy about the lowly status of the Ottawa medical school, I made some morale-boosting remarks: our strengths included all the resources of the National Capital region, a small medical school in a large city with two large bilingual hospitals, rich clinical resources; we had nowhere to go but upwards. My remarks changed the mood in the room.

Something had to be sacrificed to get all these things done. By rights, I ought to have immersed in French in each of the summer breaks from teaching, in my first few years in Ottawa.  I simply wasn’t ever able to spare the time. So although our family remained intact, thanks mainly to my beloved Wendy’s efforts, and although I was able to manage a credible performance in all my manifold duties, the casualty was proficiency in French, which I never achieved.