Editing the Maxi-book

When we lived in Burlington, Vermont, in 1964-65, I joined the Washington-based Association of Teachers of Preventive Medicine (ATPM). I retained my membership throughout the following 5 years that we spent in Edinburgh, as an easy way to keep abreast of academic preventive medicine and public health in the USA. In 1971-72, I was elected president of the Canadian Association of Teachers of Preventive and Social Medicine (CATSPM). One of my duties was to represent CATSPM on the board of directors of ATPM, a pleasant duty that, because I was a bona fide member of ATPM, rapidly translated into active participation in ATPM’s affairs.  Among other things I was coopted to ATPM’s committee on publications. This committee soon acquired a most important task. In 1975, Sid Shindell was president of ATPM and it fell to him to discuss with the CEO of Appleton’s, a great American publishing house, the future of the bulky reference textbook of preventive medicine that had first been published in 1913, edited and largely written by Milton Rosenau who had been based at the Harvard School of Public Health. He was succeeded by Kenneth Maxcy whose base was the Johns Hopkins School of Hygiene and Public Health. Maxcy was followed as editor of this large textbook by Philip Sartwell, an eminent epidemiologist, one of the men who interviewed me when there was talk of me accompanying Kerr White on his move from Burlington to Johns Hopkins School of Hygiene and Public Health in Baltimore. Phil Sartwell’s main contribution to the bulky reference textbook may have been to change its name: it became Preventive Medicine and Hygiene, but it was better known by its eponym, Maxcy-Rosenau. In other respects the book was a failure under Phil Sartwell’s editorial leadership. It sold barely enough copies to cover production costs. Sid Shindell, ATPM president at that time, advised Appleton’s CEO that the centre of gravity of the discipline had shifted from schools of public health to medical school departments of preventive medicine, and proposed that ATPM should be charged with the task of identifying the next editor, as well as most if not all the contributors. I was coopted to the selection committee, because of my recent experience as editor of the ‘community medicine’ section of the multi-volume Edinburgh textbook, A Companion to Medical Studies, and was able to demonstrate to other members of the selection committee that I understood the role, function, and responsibilities of the editor of a multi-author reference textbook, and that I had a comprehensive vision of contemporary public health sciences and practice.

There were 3 credible candidates for the post as editor in chief of Maxcy-Rosenau. Two were getting on in years and would probably be good for only one edition; one of these had a reputation for irascibility and inability to work amicably with others, the other was known to be a rather dreamy person; his acquaintance with public health and preventive medicine was philosophical and theoretical, untainted by practical experience. The third candidate was more than a generation younger; he had edited several previous books, but had turned these into vehicles for his own ideas, rather than a platform for authoritative ideas of  authors of other chapters.  The selection committee decided to defer a decision for a few weeks, during which each of us would seek other possible candidates.  There the matter rested from the autumn of 1976 until February 1977. On a February day soon after our wedding anniversary I had a phone call from Steve Jonas, chairman of the search committee that was seeking a suitable candidate to edit the 11^th edition of the Maxcy-Rosenau textbook. Steve told me that he and other members of the search committee (Bob Berg, Sid Shindell, and Doug Scutchfield) had talked informally during a meeting they’d all attended, and had concluded that I would be a suitable candidate, on the basis of my track record, my vision of what the book needed, my reputation for getting things done, my writing skills, and the fact that I was due for a full salary sabbatical leave. An additional factor in my favour was that, thanks to my service on the NIH study section, I had a wide acquaintance network that included many of the elite leaders of epidemiology and other public health sciences in the USA. I was on first-name terms with many of them. As chairman of the search committee, Steve invited me to take the position of editor in chief of Maxcy-Rosenau Preventive Medicine and Hygiene.  I declined emphatically. It seemed absurd to me that this quintessentially American reference textbook could be edited by someone who wasn’t American, didn’t even live in the USA. Steve Jonas deployed his persuasive powers to convince me to change my mind. After a great deal of thought, discussion with the dean of the Ottawa medical school, and talking it over at length with Wendy, I reluctantly and with many misgivings, agreed to accept the invitation.

Having agreed to take on this mammoth task I faced several daunting challenges. I needed associate editors for two large and very important sections, communicable disease control, and environmental and occupational health.  I needed to meet and get to know the Appleton’s editor with whom I would work; I needed to decide how much writing to do myself, and needed to identify top quality authorities to write all the other chapters. This was a particularly important part of the planning: with such a large, encyclopaediac reference textbook, each author had to produce, or be given, an outline of the subject matter to be covered in the chapter(s) he or she would write; I as the editor had to be vigilant to detect errors of omission and commission, overlaps, duplication and contradictions when two or more authors were writing about the same or similar material.  I also wanted to produce a book distinguished by clarity, conciseness, readability, as well as having a sharp focus on the cutting edges of the discipline.  Appleton’s had a distinguished record as publishers of many eminent works including Osler’s textbook of medicine, the American editions of the works of Charles Darwin, and many other famous textbooks and monographs. I had a moral obligation to maintain this standard of excellence. For this reason I rewrote quite a large part of the book when chapter authors lacked adequate writing skills. When all the important editorial decisions had been made, Wendy and I had to decide whether to rent or sell our home on Island Park Drive during our year away from Ottawa, what to do about Jonathan’s schooling, and where to spend my sabbatical year.

The long list of potential bases for the sabbatical year included Boston, New York, San Francisco, Los Angeles, Chicago and Rochester NY, and quickly narrowed down to New York and UCLA, Los Angeles.  Before the challenge of editing Maxcy-Rosenau arose I’d discussed with Lester Breslow and others at UCLA the possibility of spending my sabbatical year with them.  I immediately saw risks of conflicts of interest if I were based in a school of public health; and on the contrary, several advantages of a New York base – apart from the cultural attraction of the Big Apple which assuredly is worth a year or more of anybody’s life. I’ll have more to say about this in another post.

On Bastille Day (July 14) 1977 I met my Appleton’s editor, Rich Lampert, in New York; it was a stifling hot steamy day and a massive power outage had closed the city’s offices and restaurants.  Rich and I conferred on a bench in the little park behind the New York Public Library on the corner of Fifth Avenue and 42^nd Street, ate street food from a barrow and toasted the book’s success in luke warm Coca Cola. Over the next 3 years, Rich and I became firm friends. On that day I reported my progress so far: I had recruited Jim Chin as associate editor of the communicable diseases section of the book, and Irving Selikoff for environmental and occupational diseases. I had recruited eminent authorities to write several chapters and was in discussions with others; all so far were people with whom I was on first-name terms, through the NIH Epidemiology and Disease Control Study Section, and was conferring with the ATPM steering committee about others. Rich Lampert agreed with me that I’d got off to a very good start.

I decided to change the name of the book to Public Health and Preventive Medicine, and gave my reasons for this change in the Preface and in a short introductory chapter on the conceptual and philosophical foundations of public health.

Most aspects of my editorial work proceeded smoothly. There were only 2 failures. I could not identify anyone to write on the economics, costs and benefits of public health programs and services. One author produced a text that would have been barely adequate as an article in the magazine section of a Sunday newspaper. I ghost wrote a substitute chapter. About half the chapters were poorly written, and I did a great deal of rewriting, for which most authors were grateful.  There were a few laggards. When the production schedule was threatened by the failure of the final laggard to deliver, I visited him in his office, confronted him and sat there until he gave me what he had written so far; I ghost-wrote the remainder. The book, which weighed in at just under 2000 pages, was published in October 1979, in time for the annual meeting of the American Public Health Association, where it sold briskly.

Reviewers and – more important – users praised the book, and Appleton’s were well satisfied with sales. All of us breathed a collective sigh of relief.  There was very little respite. Within two years I had begun to plan the 12^th edition, which was published in  1986. It was even more massive than the 11^th edition. It had 1958 pages, compared  with 1928 pages, but they were larger pages, smaller fonts and tighter design – almost 1000 words per page compared with about 750 words per page in the 11^th edition. There was another subtle difference: whereas I was on first-name terms with almost all the authors of the 11^th edition, I personally knew only about ¾ of the authors of the 12^th edition. Moreover, I knew that I had a less comprehensive grasp of the entire domain of public health sciences and practice than I’d had when I started work on the 11^th edition. I decided to invite Bob Wallace at the University of Iowa to join me as co-editor of the 13^th edition, with a view to taking over as editor in chief after me.  It was a wise decision to quit while I was ahead. The publishers recognized this too, and paid me the compliment of adding my name to the eponym: the book is now known as Maxcy-Rosenau-Last.  It has gone through two more editions, in which I am identified as editor emeritus, and in which I have written or co-authored chapters. The 15^th edition was published in 2006.

The 5 editions of Maxcy-etc with which I've been associated are on the left
of this photo, level with my upper arm.

Behind the Iron Curtain

When the International Epidemiological Association met in Helsinki in 1987, the organizers offered an excursion to Leningrad as a side trip for a few days before the meeting.  Wendy and I seized the chance with both hands. Mikhael Gorbachev had recently become general secretary of the Communist Party; it was the era of Perestroika or openness.  Gorbachev had loosened the tight bonds of the communist state significantly. Censorship of information coming into the Soviet Union had been relaxed so Soviet citizens were much better able than at any time since the Bolsheviks came to power in the last months of the Great War of 1914-1918 to read and hear more or less freely about life in the rest of the world.

Wendy about to board our train in Leningrad
 en route back to Helsinki 

On a day of watery sunshine in August 1987, we boarded a train in Helsinki for the 6-7 hour journey to Leningrad.  We traveled First Class but our carriage was uncomfortable, with little or no padding on the seats, reminiscent of ‘Hard Class’ train carriages in China. As we left the Helsinki suburbs behind us the skies cleared and the rest of the day-long journey passed by in brilliant sunshine.  We travelled first across the prosperous-looking farmland of Finland with expensively fenced, neat, well-kept fields, fat cattle, shiny modern farm machinery. The border was the most intimidating, fearsome looking border we had ever seen, with multiple rows of high barbed wire fences, watch towers and gun emplacements on the Soviet side, and shabbily uniformed soldiers seemingly on guard against a possible invasion by the peaceful tiny nation of Finland.

The contrast with farmland behind the Iron Curtain was dramatic. It was as though we had passed through a time warp to a land fifty or even a hundred years earlier. The farmland was shabby, unkempt, ancient farm machinery, single-blade ploughs pulled by an ox, not a tractor to be seen anywhere. Where were the tractors of the Soviet propaganda?  Farm buildings looked like hovels, although at least they mostly seemed to have TV aerials. It was dark by the time we reached the outskirts of Leningrad but what we could see revealed huge apartment blocks amid a wilderness of weed infested vacant lots.  We saw some more next day, huge apartment blocks that we were told had units for 1000 or more families.  Each was painted a different bright colour, presumably to convey a sense of cheerfulness, but the enormous size made them look intimidating.  Our hotel was intimidatingly huge too, run by Intourist, the Soviet state travel agency, a vast, soul-less place surrounded on all sides by acres of vacant land, presumably so we would not contaminate the Soviet citizenry with our evil capitalist ideas. The impression of vast empty space was maintained in the cavernous interior of the hotel: there was an enormous dining room that would probably seat close to 1000 people, in which our tiny tourist party, about 20 strong altogether, seemed to be almost the only guests. Our evening meal was easier to eat because we were ravenously hungry than it might otherwise have been. It consisted of sauerkraut, turnips, black beans swimming in a sludge of luke-warm gravy, and two or three thick slices of what was probably pork, although it was hard to be sure of this. It helped to wash it all down with a few mouthfuls from a large tankard of beer, which seemed surprisingly good, considering the second-rate boarding-house quality of the food.  Desert was a large bowl of gritty fruit, pears or quinces, and custard.

Next morning we met our tour guide and began our exploration of Leningrad, when our small bus took us first into the heart of what had once been the Hanseatic League city of St Petersburg, a city of graceful white mansions, tall thin spires of disused old churches and in the city centre, vast public squares, palaces and public buildings, the most impressive of all being the Hermitage museum, to which we returned next day.

It was a beautiful city – or rather, it had been a beautiful city, probably in the days of the Hanseatic League.  Now it looked shabby, down at heel, dilapidated.  All the buildings needed sprucing up, a coat of paint, sidewalks tidied, cracked and broken windows replaced. It reminded me of the more down-at-heel sections of Surabaya,  Columbo or Calcutta, more like a third world city than the second city of the second-greatest world power.  We passed but didn’t stop at a large department store with sad looking window displays, but saw no interesting little shops. There were a few kiosks that sold newspapers and magazines.  Another surprise was how empty the city seemed to be. Unlike a  western city, Paris or Amsterdam for instance, the sidewalks were almost deserted, no throngs of happy shoppers.  I don’t recall seeing any sidewalk cafes.  Leningrad is the Venice of the Baltic, a city at sea level with many canals and bridges, some of which were very attractive although very shabby.

Our next stop was the Summer Palace, which had very recently been renovated and was really spectacular with a wonderful display of fountains, many emerging from recently “gold”-plated statues.  We saw this in bright sunshine and it was a most spectacular sight. The whimsical display of fountains outside the Pompidou Museum in Paris is the nearest comparison that comes to mind for sheer entertainment value, but of course these fountains at the Summer Palace are much grander. 

We also saw (from a distance) large numbers of huge apartment blocks, most 20-30 stories tall, occupying an entire city block.  Each was painted a bright colour that was different from any other nearby tower block, I suppose in an endeavor to dispel the intimidating image that might otherwise be conveyed by the sheer size of these warehouses for people.  Leningrad was besieged by the Nazis for almost two years during what the Russians call the Great Patriotic War.  Most of the city was reduced to rubble under incessant bombardment during which more than a million died (significant numbers died of starvation, as well as from war wounds) and these vast apartment blocks were hastily erected soon after the war to provide homes for the survivors. Wendy and I would have liked to visit an apartment or two and meet the occupants.  We’ve seen photos of course, and they look comparatively spacious.

We got back to our vast hotel late in the afternoon but in high summer at that high latitude it was daylight until about 1030 at night so we strolled outside after our evening meal on a balmy mild late afternoon. Our hotel was a long way from the nearest part of the city and suburbs of Leningrad, surrounded on three sides by acres of waste land and on the fourth by an estuary or inlet from the Gulf of Leningrad on which we could see two quite large yachts in the distance.  The waste land was much used by local people to exercise dogs, mostly large dogs, well cared for Siberian huskies, collies, spaniels and mixed or unidentifiable breeds. Clearly there were many dog lovers in Leningrad.  Some were accompanied by entire families, others by a single person, usually a man, and some of these men appeared to be very keen to make our acquaintance, to engage in trade or barter with us. Unfortunately neither we nor any others in our party had anticipated this, so we had nothing to trade but it was at least possible to exchange friendly gestures.

We spent most of the next day in the magnificent Hermitage Museum, one of the world’s greatest collections of art.  It was a hot, humid day, and the museum was packed with people. We saw whole large galleries of French impressionists, an entire room full of magnificent paintings by Monet, Renoir, Picasso and other masters who flourished in the late 19^th and early 20^th centuries, just before the revolution.  Thank goodness this rich treasure trove survived the revolution, and survived the Great Patriotic War. (Our guide didn’t know what was done to protect this priceless collection during the war).  I hope this collection survives the throngs of people who come to see it nowadays, and I hope a better climate control system has been installed by now as well as a better system to control the number of daily visitors. At one stage in a gallery of Spanish paintings the crowd was so dense that inadvertently my shoulder brushed against the surface of a large canvas by Velazquez.  As far as I could see, the varnish protected it and I left no marks upon it.  But I saw another visitor running his fingers over the surface of a Picasso and I shuddered to think of the damage these throngs of visitors could do.

Next  day it was back on the train, back to Helsinki, back to luxury, back to civilization.  Wendy and I were very glad to have had this opportunity to glimpse, however briefly, this little corner of what was clearly a totalitarian empire on the verge of its final collapse.