Solitude is not the same as loneliness

Last Sunday the CBC journalist Michael Enright devoted an hour of his 3-hour program, The Sunday Edition,  to the topic of loneliness.  The census shows that increasing proportions of people live alone and anecdotal evidence suggests that many are lonely. He pointed out that many lonely people suffer from mental disorders - which may be either a cause or a consequence of loneliness. The program prompted me to write the following:

I am 87, have lived alone in my apartment since my beloved wife Wendy died more than 3 years ago, after 55 years of married life. I chose to stay here on my own surrounded by a lifetime of memorabilia, rather than move into an assisted living residence for old people. I am happier on my own than being regimented to take part in group activities which I dislike strongly enough to say I detest them. Among my many consolations is the thought that I behaved as a gentleman should when I let my wife go first. I didn't particularly want to live more than three years alone, but I have a decided preference for staying alive: even alone it's preferable to being dead.

It is important to distinguish loneliness from a solitary disposition. Some people can be perfectly happy on their own.  In the late 1960s when I was on the staff of the University of Edinburgh I once discussed solitude and loneliness with the Oxford psychiatrist Anthony Storr. He wrote some profoundly thought-provoking books, including one called Solitude, which I found particularly comforting because it set out the arguments in favour of being alone. He pointed out, among other things, that creativity usually requires solitude: a novelist, a composer, a sculptor, a painter, a poet, works alone but is seldom lonely while working.

I do get lonely occasionally. This is relieved by CBC Radio which provides many hours of good company every day.  My children phone me every day to reassure themselves that I'm still alive and kicking; my daughter and her gourmet cook husband bring a meal to my apartment at least once a week throughout the winter, and in summer my younger son drives me to my daughter's home for a barbecue every weekend. My older son who divides his time between the Royal Military College, Kingston and Toronto and frequently travels internationally, phones me almost every day (often by Skype when he's elsewhere in the world). My grandchildren also communicate frequently, mostly by email.  

The consolations of solitude carry greater weight for me than the hazards of loneliness.

Values, ideology, political preferences, brain structure and function

Changing the channel (or maybe not) here are some thoughts about how my values have shaped my political ideology, attitude towards politicians, and related matters.

Among the important values I shared with, perhaps absorbed from listening to my Uncle Lester, was a sense of social justice; or is this an innate quality, hard-wired into my brain from birth? It was definitely there from a very early age, implanted in my mind before I was 10, ideas, rudimentary ideologies I could discuss (albeit not very coherently) by age 12 or 13. I clearly remember while at Brighton Public School, when I was 11 or 12 years old, feeling very firmly that some things were ‘right’ and some were ‘wrong’ with the way society worked. Probably it was at least partly innate, hard-wired in my brain, as described in scientific articles I mentioned in a post on this blog on March 7, 2012.  Although I talked about this with him, or rather listened as he talked, my Uncle Lester was very tactful. He never suggested that I should vote for left-leaning politicians when I reached voting age; he made it clear that I must decide for myself. I think almost all other members of my extended family were hereditary conservatives, unquestioning supporters of the right-wing Liberal Party, which in Australia has always taken positions well to the right of centre. Uncle Lester wasn’t of that persuasion, and nor was I, I’m proud to say. Mostly I kept my opinions to myself while I was a schoolboy at St Peter’s College, mainly because I was very shy, listened a lot but said very little. I opened up a bit during my university years, and my ideological position was firmly consolidated by my first experiences of private fee-for-service medical practice in 1950 and 1951. The idea of taking money from people rendered poverty stricken by chronic disability struck me as obscene and intolerable in an affluent nation like Australia. In 1950-51 the first steps towards tax supported payment of medical fees for old aged and invalid pensioners hadn’t yet occurred; these patients had to fend for themselves or be treated as charity cases. Only ex-servicemen got tax supported payment of medical expenses (only for service-related  conditions)  when I graduated from medical school in December 1949. We also had the pharmaceutical benefit system (PBS) which paid for “life-saving” medications such as antibiotics, insulin, vaccines and other proven therapeutic agents without which people would die or become permanently incapacitated. By the time I got back to Adelaide in 1954 after 3 years working in the British National Health Service, Australia had established the Pensioner Benefit System, tax support for payment of medical and some pharmaceutical expenses incurred by old age and invalid pensioners. I found this liberating in my dealings with these two groups of usually financially stressed patients: I could care for them adequately without worrying about who was paying for their care and how.    

I began to doubt the familial right-of-centre political ideology about the same time that I began to question the myths of Christian faith, when I was a teen-ager. As a medical student I saw chronically sick and disabled patients whose infirmities condemned them to a lifetime of poverty. Clearly a wealthy country like Australia had a moral obligation to provide a social and fiscal safety net. As we ate our lunches on the sandy hillside above the beach near Yankalilla, South Australia on the day we met, Wendy and I were talking of this, of random injustices we had seen in wealthy countries when disability condemned families to lifelong poverty. Jan Wendy was close to tears as she described young people, young families, whose aspirations had been destroyed when a chance injury permanently disabled the bread-winner and changed their family’s lives forever. I matched her stories with mine. Her father, Pop Wendelken, had been injured twice in the Great War of 1914-1918, patched up, returned to combat, then gassed, which caused permanently reduced lung function and partial disability for which he received a tiny pension. Wendy and I both perceived his fate as socially unjust: I don’t think Australia and New Zealand should have morally blackmailed or conscripted young men to fight in foreign wars but since they did, they surely had a moral obligation to care for these men adequately when they were disabled by war service. In Canada, the Harper government’s hypocrisy and weasel words of gratitude to the young men and women whose lives were ended or blighted by the war in Afghanistan are shameful, but predictable from such a rabidly right-wing bunch, cut from the same cloth as the gutless ‘apology’ to victims of the residential schools – an apology without a trace of recompense to the victims.

An even greater disgrace is marginalizing First Nations people while failing to help them. I spoke about this at the Canadian Public Health Association’s centennial meeting in Toronto in 2010 and posted the text of my remarks on this blog on June 18, 2010. My talk was about the core values – the moral values – of public health, in the context of a session on the public health problems afflicting Canada’s First Nations. I still have a lot of fire in my belly about this set of problems. At the CPHA meeting in Toronto in 2010 I mentioned facts about our First Nations citizens that should shame all affluent Canadians, especially our hypocritical elected representatives: unacceptable water quality, higher rates of infection with the tubercle bacillus than almost anywhere else in the world, and shockingly high rates of suicide and substance abuse among school children and young adults. Housing conditions and facilities and funds for education are a national disgrace.  It passes my understanding that any elected government can be aware of these facts yet advocate and enact lower taxes while doing nothing to relieve the suffering, distress and blighted lives of native people living on reservations. The hypocrisy of the Harper government that apologizes to First Nations for the residential schools fiasco, yet does nothing to alleviate the plight of these people, sickens me.  It’s one of my reasons for remaining a socialist, more accurately a social democrat in the European sense,  although of course I was ideologically left of centre long before Harper’s days and will be for as far as I can see into the future.

There’s been some recent discussion on CBC radio about the benefits of taxes. I was encouraged to hear so many ‘ordinary’ Canadians spontaneously speaking up for the benefits we all derive from the taxes we pay. Of course there were greedy, rapacious and mouthy dissenters, even one know-nothing who said all taxation is robbery.  I’m proud to say that I pay my taxes willingly, while of course taking diligent action to minimize, but never to evade or cheat on my tax; and when possible, I get the facts on how my tax dollars are spent. The City of Ottawa aims for accountability and sets out clearly how our city taxes are spent. Our provincial and federal governments are very coy about how they spend our tax dollars.  If I had my druthers I’d be able to scrutinize financial statements from federal and provincial governments too.

Critical thinking helps. Critical thinking came after speed reading in development of my brain, but unlike speed reading it hasn’t made me happier. More often it makes me mad as hell and  unwilling to take it any more, like that movie character. Critical thinking busts myths that the manipulators of post-industrial society rely on to successfully con the populace into going along with their schemes, manipulators like the oil industry, investment bankers and marketers of cell phones and other electronic gizmos with a half-life of a few months or less.

Here are three of these myths: Perpetual economic growth is achievable. The air, water and land of our planet have infinite capacity to absorb without stress all the foul poisons we dump. The world is spacious enough to accommodate more than the 7 billion people now living on it. The hard realities are that perpetual economic growth is NOT achievable; the air, water and land of our planet are gravely harmed by the foul poisons we have been dumping; and the world has a finite carrying capacity, probably at least one order of magnitude lower than the number presently alive; we began to exceed the earth's carrying capacity several decades ago, if not longer. Prospects for humankind would be more promising if the world's population was 7 hundred million rather than 7 billion, and was stationary rather than increasing by 30-50 million annually. Loosely speaking, people to the right of centre believe these myths and live accordingly; and people to the left of centre tend to disbelieve the myths or at least are skeptical. It’s intriguing that these differences in beliefs appear to be associated with observable anatomical differences in brain structure and presumably brain function.   I commented on this and gave references to sources in a post on March 7, 2012. I’m sure there’s more about this intriguing fact on the web but I’ll leave readers to chase after it.

The life-changing decision to leave Australia

Wendy and I and our two little children Rebecca and David returned to Adelaide from London, at the end of my year at the MRC Social Medicine Research Unit, in autumn 1962. We collected our station wagon from my brother, my dachshund Helen from the family that had cared for her, filled the wagon with other essentials and set off for Sydney where we expected we would be living for the foreseeable future, perhaps the rest of my active professional life. To consolidate this belief one of our highest priorities was to buy a home of our own.

We started our Sydney existence in a rented house in Bondi, planning to find a place near there that we could afford to buy. Alas, houses in the eastern suburbs were far out of our financial reach. We settled for a small house across the harbour bridge at 98 Grasmere Road, Cremorne, a pleasant little place close to a school for Rebecca and a kindergarten for David, with a view that even included a sliver of water in one of the lesser bays of Middle Harbour. Our back garden was a series of terraces descending steeply to a level space at the bottom where there were 2 or 3 banana trees and the frame for a swing. A placid resident blue-tongue lizard and many gingko lizards didn’t diminish its child-friendliness. I had to drive each day across the harbour bridge and through the winding dockside streets that led to Grace Brothers Department Store on Broadway, whence the route to the University was straightforward. Unless I struck traffic jams on the bridge it was about a 30 minute drive. Our next-door neighbours at Grasmere Road were the Sweet family; their son Richard was often our baby-sitter, the best baby-sitter we ever had.  He was a first-year university student, so often came with me in the car. Those drives to and from the University of Sydney and the conversations that enlivened them, are among my most pleasant memories of our time in Sydney. Richard became an authority on social determinants of youth unemployment and he and soon his wife Patsy became lifelong friends. I’ll say more about them later.

I joined the staff of the School of Public Health and Tropical Medicine at the University of Sydney in the early winter of 1962. I had some idea what was in store for me, having been a post-graduate student there so recently. Even so, I found it a depressing place. Many of my colleagues were time-serving bureaucrats rather than dedicated academics or even scientific civil servants. Several times I left the building on Friday afternoons with a man whose name I have forgotten, a microbiologist, whose standard remark at that time was, "Well, that's another week out of the way." I often wanted to ask him why he was so eagerly looking forward to the end of his life. Another colleague, Godfrey Scott who did most of the medical student teaching of public health and epidemiology with a little help from me, spoke frequently and lovingly about his plans for retirement; he was then in his mid-thirties so he was thinking and planning a long way ahead. Sir Edward (“Ted”) Ford, professor of public health and director of the school, was an avuncular man with whom I shared a serious interest in antiquarian books, but his interests otherwise consisted mainly of political wheeling and dealing, conspiring and conniving to advance his friends and confound his enemies.  Bob Black, the professor of tropical medicine, was a very bright man, civilized and urbane, albeit cynical and often defeated by the bludgeoning of chance. Fred Clements who had considerable clinical skill as a paediatrician, and his friend and colleague Jim Cullen, a psychologist, were doing the only worth-while research in a field anywhere close to my own area of interest and skill. They were evaluating intervention programs aimed at educating working-class women about ways to reduce the risks of accidents to their children. This work led eventually to some excellent original articles in journals of child development, and prompted important policy changes in health and social services departments.

I had a little work to do to get my "Iceberg" paper ready for publication, and soon sent it off to Robbie Fox, the eminent editor of the Lancet. I wasn't quite sure what I would do next, when an idea surfaced as a question that Ted Ford had been asked: how many neurosurgeons should there be on the island of Tasmania?  He tossed this question to me, and it set me thinking about how many doctors of all kinds there actually were, as well as how many there ought to be, in each part of Australia. What were the sources of information about the medical workforce, could one even find out how many and what kind of doctors there were, let alone how many were needed? How was “need” defined, how were catchment areas defined? I worried away at these questions for some months, and wrote several papers that most people seemed to think were worthwhile contributions to health services research in Australia - the field in which I had begun to specialize, a field not so much in its infancy in Australia as in an early stage of embryonic development. I had many other ideas, gathered facts from wherever they could be extracted, and wrote several papers that created a stir both locally and in a few instances, internationally. It was a productive period in which work I was doing began to establish my reputation as a scholar whose ideas about health policy should be heeded.

Rebecca and David in the garden, 98 Grasmere Rd, Cremorne
Summer 1962-63

Rebecca and David were growing from toddlers into children. Rebecca started school at Cremorne, and David began kindergarten, loving it as only small boys can - though he had begun to be plagued by asthma, which no doubt would have got a lot worse had we stayed in Sydney, a notorious hot spot for allergic diseases. We decided we should have another child to keep these two company, feeling confident that we would be in Sydney long enough to provide stability for rearing three children. And so Jonathan was conceived. It was a healthy and happy pregnancy, and in due course Jonathan was born, at the Mater Misericordae Hospital in North Sydney, with me and an ill-natured midwife in attendance.  In fact I delivered Jonathan because the doctor who should have officiated was late getting to the hospital and the midwife was distracted by some other duties at the critical moment. Jonathan was a Judell like the other two; he had a florid "V" of capillary blood vessels on his forehead; otherwise he seemed OK. I suppose our doctor examined him, though he never said whether he did or not. From the outset, Jonathan seemed to have a lot of congestion in his chest, and when he was about 8 weeks old, one weekend when he wasn't responding to the medicine our doctor had prescribed for his "bronchitis," I listened to his chest myself. I was alarmed, but not altogether surprised, to hear a very loud heart murmur. My few remaining shreds of confidence in our doctor (who had been recommended as one of the best GPs in North Sydney) vanished. Clearly Jonathan had a congenital heart lesion. I thought then as everybody else did, that it was a large ventricular septal defect, a “hole in the heart.” The grounds for this diagnosis were the very loud murmur and the fact that he had never been a “blue baby” – which happens when blood low in oxygen is shunted back through the limbs. He was also hovering on the edge of congestive heart failure, and that was the cause of his juicy cough and breathlessness. We saw a paediatric cardiologist in Sydney (we never went back to the GP) and started him on digitalis, the standard treatment for heart failure, and on prophylactic oral penicillin to reduce the risk of lethal endocarditis. He continued on both medications until he was 5 and investigation by cardiac catheter in Edinburgh in 1968, disclosed the fact that he had an atypical variant of the tetralogy of Fallot,  a much more complex and dangerous problem that would limit his life expectancy to about 10 years unless he had open heart surgery. As I relate later, he had open heart surgery in 1970. By the time he started on penicillin and digitalis our lives had changed dramatically in another way as well as having this worrying health problem.

Besides my work on the "Iceberg" paper and on medical workforces in Australia, I had been working on the data I had collected when interviewing general practitioners in the north of England; this led to involvement in another study of general practice, this time in Australia, that had been started and left unfinished by the South Australian GP Cliff Jungfer, one of those who had originally encouraged me to pursue my studies. I had to process and analyse all the "records" (such as they were) of Cliff Jungfer's interviews with a grab-sample of general practitioners in Australia. That led to another paper in which quixotically but unnecessarily I put his name in first place, though I had done all the work except the original data collection (to which I added other facts from publicly available sources). Cliff Jungfer, like other eager enthusiasts in Australia at that time, hadn’t taken the time and trouble to learn how to conduct interviews or to consider what facts are useful and what facts are useless. In fairness I must add that my own education in questionnaire design and interview techniques was far from ideal, but at least I’d had some training and knew enough to recognize unsuitable and inadequate methods!

The analysis of this set of facts about general practitioners led me to examine other facts that were available from the medical benefits program, a tax-supported voluntary medical insurance system. I realized that it would be very simple to analyse data from the medical benefits program to compare the outcome of common surgical operations like hernia repair and appendectomy, hysterectomy and gall bladder surgery, when the operation had been done by a general practitioner or by a specialist surgeon respectively. I wasn’t trying to demonstrate that one was “better” than the other; I had a completely open mind. I just wanted to find out if it make a difference whether a common surgical operation was done by a specialist or by a GP.  I wrote a proposal to the secretary of the National Health and Medical Research Council, suggesting that I could very easily do this analysis and that it would cost hardly anything to do it. Within days, I was visited by two senior bureaucrats from the Commonwealth Department of Health in Canberra, one known to me already, the other not. My letter to the secretary of NH&MRC had been referred to them because the question I wanted to examine was "political." These two “thugs” came into my office at the School of Public Health and stood at the corners of my desk while I sat behind it, and shouted at me that I wasn't ever again even to think thoughts like those I had suggested in my letter proposing this modest little study. I worked for the Commonwealth Health Department, they shouted, and I must not get any grandiose ideas about becoming an "academic" or doing “research” – I was there to do what I was told, not to think for myself. (This wasn’t quite true I later discovered: my salary was paid by the federal government but I was seconded to the University of Sydney; however I could be transferred at the government’s pleasure to any part of the federal bureaucracy). I was appalled and demoralized by this episode. I wrote to John Lee, my friend at the Social Medicine Research Unit, and without telling him chapter and verse, sent a distress signal to the effect that the sort of health services research he was doing in England, and that I would like to get started in Australia, was not permissible in my country’s hostile climate.

There were, of course, other things I could do, other things I was already doing. Another exercise that preoccupied me briefly was an evaluation of the system of postgraduate weekend courses, that Sir Victor Coppleson, a retired surgeon and friend of Clarrie Rieger, my former colleague in the Western Clinic, the director of the NSW Postgraduate Medical Foundation asked me to do; as the Foundation had paid for my fellowship, enabling me to work with Jerry Morris, I could hardly refuse, though this exercise was scut work to put it mildly. Nonetheless, I did it and wrote a detailed report. In short, despite the setback over my proposal to NH&MRC, I had other worth-while things to do. The main problems were prohibition of some lines of inquiry for political reasons and the total absence of encouragement and intellectual stimulation. The thought of spending years, perhaps the rest of my professional life, in this stultifying atmosphere was deeply depressing.

With Grannie Vera Last in our garden at Cremorne

Keeping cool in our back yard on a hot Sydney day

All these events happened over a brief period. It was Christmas 1962 and we went to Adelaide to celebrate it with the family there. We returned to Sydney to find a letter containing an invitation to me to join a research team headed by Kerr White at the University of Vermont, in the USA.

This invitation offered an escape from what increasingly I could perceive as a dead-end job in the School of Public Health, and a potential turning-point in life of far greater magnitude than any that had preceded it. The implications of accepting Kerr White's invitation were life-changing. It would mean that we would have to become migrants, resembling the many people I had seen when I was in general practice, who had left their homeland and become rootless newcomers in another country far away on the other side of the world. Not only had I seen many such people I empathized with them, observed their adjustment problems first-hand and I had written papers describing their problems.

One of my first thoughts as I tried to weigh the pros and cons of Kerr White's offer was of the impact it would have on our sense of identity. Yet this was a false fear, I soon realized. After all, I had come back to Australia after 3 years in London feeling alien and disconnected, and Wendy wasn't even Australian. Our children were too young to have put down roots, they would soon adjust to life in a new land. Even so, it would be a very great upheaval, a leap into the unknown, a bold and reckless move that many might call irresponsible. To uproot and resettle so far away, and with somebody I had never met as my host and chief, no matter how illustrious his reputation, would be the act of a gambler, not a wise husband and father with responsibility to provide stability and security for his family. As to providing for the family, the pay was considerably better than I was getting at the School of Public Health. As to Kerr White's reputation, I had heard quite a lot about him, was familiar with some of his published work. He had preceded me at the Social Medicine Research Unit. I had heard my friends talk about him - mainly in tones of admiration, though I recalled at least one conversation that led to misgivings, because there had been a suggestion of lack of principle in his dealings with colleagues. At the time I’d stored the memory of that conversation away, and now I wrote to John Lee, asking as carefully and tactfully as I could, for his opinion and advice about going to work with Kerr White.

Rock pool, Mosman, summer 1963

There was another important consideration. I identified strongly as an Australian. I’d just returned from a mind-blowing year of intellectual stimulation in one of the world’s most exciting and original research units, supported by an Australian research grant (never mind that it was an inadequate grant!). I felt a strong obligation to pass on to aspiring scholars in my country some of the knowledge and skills I had acquired. I wrestled with my conscience about this. My attempts to educate others and to make maximum use of my acquired skills were being frustrated. It would make sense to go away again, acquire more skills and experience, and return when the academic climate in Australia was more hospitable and encouraging.  Later I tried very hard to do exactly this: while I was at the University of Edinburgh I applied for three academic research and teaching positions in Australia, and was passed over for all three, in two of them for a less well qualified but well connected person whose claim to be given the appointment was based in part on having influential patrons.

Young swimmers, Mosman, Sydney Harbour, 1963

The thought of dismantling our home just when we were getting established, of disposing of my aging and ailing dachshund bitch, Helen (she’d developed an ovarian tumour, had a canine equivalent of nymphomania for which treatment was expensive surgery or euthanasia); the thought of moving even further away from relatives in Adelaide, especially my mother; the thought of schooling for our children in a foreign land with values and a culture we felt were alien; the thought of deciding which books and other possessions to take, which to store, which to get rid of... all these daunting thoughts made deciding what to do both extremely difficult and protracted. Wendy and I took several weeks, discussing over and over what to do.  Eventually in a decision we shared equally, we decided to accept Kerr White’s invitation, to uproot and resettle in Burlington, Vermont, albeit with many misgivings.

We had become attached to Sydney, even if I had not become attached and committed to my work at the School of Public Health and Tropical Medicine. We had settled into our little home at 98 Grasmere Road, Cremorne, were developing habits and establishing neighbourhood networks of friends. I had made contact with some relations in Sydney, my mother's cousin Joan and her husband Rupert Vallentine; theirs was the first wedding I could remember attending. Rupert was like my Adelaide friend Bob Culver, an academic engineer - head of the department at the University of New South Wales, later to become dean, then vice-chancellor of the University of New South Wales, a real academic high-flyer though in the social setting of the family a very ordinary chap.

Our lives were beginning to be orderly and predictable for the first time since the convulsive upheaval of leaving general practice. Rebecca had started at school and David was attending - and revelling in - kindergarten. He was a very adventurous little boy, very fond of climbing, if not always able to get down again from high places such as the top of our revolving clothes lines, and the tree by the fence between our place and the Sweet’s.

We were exploring and often discovering new and delightful aspects of the cosmopolitan and wonderful city of Sydney. Had we stayed there, I think our lives, Wendy's especially, would very likely have unfolded socially much as they have in Ottawa. She would undoubtedly have got herself involved in local affairs and voluntary activities just as she has done in Ottawa.

Family, December 1963 just before leaving Australia

As for me, it is impossible to know. I clearly could not have put up much longer with the stultifying atmosphere at the School of Public Health and Tropical Medicine. But I was beginning to establish a modestly promising reputation both nationally and in a small way internationally. I suppose I would have continued to make my way in academia, would have eventually become a senior lecturer, perhaps even an associate professor in an academic department somewhere in Australia, perhaps in Sydney at the University of New South Wales where a department of public health was planned in a few years. But it would have been a slow and uncertain progression, and the opportunities to become a world leader in my field as I have done would surely never have arisen. Of course none of this was foreseeable in 1963 as we tried to weigh the pros and cons. Setting off for the USA was a leap into the unknown, with unknowable consequences.   It was fitting that Wendy and I went over and over again and again, considering all the pros and cons from as many perspectives as we could imagine. It was a decision that in many ways was much more intimidating than the decision to leave general practice.

Medical practice in Adelaide 1954-59

When I met Wendy in September 1955 I’d been working in the Western Clinic, for about 15 months. This was a suburban group medical practice of ten doctors in partnership. I was a salaried assistant with a chance of becoming a partner. By the latter part of 1955 I felt increasingly competent and confident. My years of hospital experience had paid off. I made several diagnoses that impressed my colleagues. I detected a chorion-epithelioma, a rare and deadly malignancy that resembles pregnancy, identified several other cancers that none of my colleagues had detected, identified patients with tuberculosis and syphilis, correctly diagnosed diabetes in a youngish man (mid 40s) who complained of inability to perform sexually, and recognized an unusual presentation of ringworm, among much else. Several young women selected me to watch over the progress of their pregnancies and assist at the birth of their babies.

I demonstrated convincingly that I could manage difficult patients competently. I acquired quite a large following of the elderly chronic sick and infirm, almost all of whom I saw in their own homes. I loved those house calls: seeing patients in their natural everyday habitat was a far better way to get to know them and to understand the dimensions of their problems, than seeing them in the unnatural surroundings of my office.

Having recognized the interesting ethnic and linguistic diversity of the people we served I began taking lessons in Italian and brushed up my German, making it possible for me to communicate in their own language with many of the ‘New Australians’ who attended the Western Clinic.  This was greatly appreciated by these immigrant families and some of them gravitated to me from other doctors in the group.  I’d have liked to tackle Greek too, but although we had many Greek-speaking patients, the different alphabet and linguistic distance from familiar western European languages were deterrents. I decided to postpone learning Greek for the time being. Nevertheless the fact that I had visited Greece – I’d back-packed there in the summer of 1952 – attracted some Greek families to me.

But I wasn’t happily settling back into Adelaide. After living for three years at the epicentre of western civilization, I felt considerable culture shock. Adelaide in 1954 was a small-minded, dull little city. Conversations in Mary Martin’s book shop provided almost the only breath of the culture that I craved. My medical school classmates and other friends were all married, almost all with small children and I felt very much an outsider, a lonely onlooker. At that time there were no resident theatres, no interesting restaurants, no night life in Adelaide.

After a few failed attempts to connect with one of the rare available young women, including a few who were friends or relations of patients, I met and began dating a young woman who was a cousin of my cousin David Judell’s wife. It was a relationship born of desperation and was never emotionally, culturally or intellectually satisfying to me, nor I suspect, to her, even though we did establish a tolerably satisfying sex life. That young woman was a bore; she was interested in gossip about movie stars but very little else. I think she found me boring too. After that magical day when I met and began to fall in love with Wendy, I dropped her like yesterday’s newspaper. My excuse, a true one, was my decision to turn my attention to further medical studies, aiming, for want of anything else that was credible, towards a specialist qualification in internal medicine.

In December 1955, after being told there was no immediate prospect of a partnership, nor any likelihood in the foreseeable future, I left the Western Clinic and took a position as senior registrar (senior resident) at the Royal Adelaide Hospital. I began this phase of my career at Northfield Infectious Diseases Hospital, where I spent almost 6 months from November 1955 until early winter 1956.

My timing was very good. As well as a wide range of all the common infectious diseases, I saw many patients with viral encephalitis, a serious mosquito-borne infection, and as that epidemic subsided, we were hit by a nasty epidemic of paralytic poliomyelitis – the last ever epidemic in South Australia as it turned out, because the following year the Salk vaccine became available. The 1955-56 polio epidemic hit young adults particularly hard; moreover, it was a seemingly more aggressive strain of poliovirus than usual, and often attacked the nerves in the upper region of the spinal cord and the base of the brain. When nerve roots in these regions are attacked, respiratory muscles and muscles involved in swallowing are knocked out. Case fatality rates are very high and the epidemic becomes much more dangerous than usual. Before long I had about 30 patients in ‘iron lungs’ – the large, cumbersome respirators we used in those days to maintain respiration. Only about half the patients in iron lungs ultimately survived, and even smaller proportions of those whose swallowing muscles were affected. In the 1950s we were still uncertain about the precise mode of transmission of the polio virus. We know now that it is transmitted by the fecal-oral route, that the virus must be ingested, not inhaled, spread by droplets or transmitted directly from person to person. I was seriously afraid that I might be infected by the patients I was treating; but I did what I had to do, I treated them because it was my duty to do so. The thought of keeping my distance from them never even entered my head.  Of course we observed “universal precautions” – we wore gowns, gloves, masks, washed hands and changed gloves, gowns and masks between each patient.  About 50 years later in 2006, I led a discussion with final year medical students in Ottawa and described what I had done and my fear of being infected and perhaps dying of bulbar poliomyelitis. Some of the students thought I’d been daft. They claimed they would never put their own lives at risk as I had done; they said their first duty was to look after their own families and therefore look after themselves, do whatever they had to do to avoid placing themselves at risk, for example the risk of exposure to HIV infection. My discussion with students about the duty to care for patients even at grave personal risk involved the entire class of 84 students. It was an animated, at times almost vituperative argument in which virtually the entire class participated. About two fifths of the class took the view that they would put their own safety first, asserting that they owed this duty to their families. The remainder, the majority, adhered to conventional Hippocratic ethics, in which physicians treat the sick even if they risk infection and possible harm to themselves. It saddened me to discover such a high proportion of senior medical students with this self-centered view of their role in caring for the sick. Nonetheless I vividly recall that argument as an excellent example of medical education at its best. At the end of it, perhaps a few of the self-centered students had been won over, and every one of the students who put care of their patients first, had been consolidated in their values and beliefs.

After almost 6 months at the Northfield Infectious Diseases Hospital in 1955-56, I moved into the Royal Adelaide Hospital as medical registrar (chief resident in north American terminology) to one of the ‘honorary’ visiting physicians, Ken Hetzel, father of Basil Hetzel who some years later became a good friend of mine when he switched career from internal medicine to epidemiology. I enjoyed the work but found it less challenging, less stimulating than in the London hospitals where I’d worked in 1951-54: the Adelaide specialists were much less intellectually curious than those with whom I’d worked in London.

At about this time, the doctors in the Western Clinic were finding that I was much missed. The fact that I would soon be getting married made me a more attractive proposition than I had been as an unattached bachelor. I had been at the Western Clinic long enough to bond with enough patients who asked the other doctors what had become of me, was I ever coming back. I was invited to come back to join them as a partner in the practice, and did so in September 1956, during the early months of the ‘hands-on’ phase of courtship in which Wendy and I were getting to know each other’s bodies just as our prolific exchange of letters had enabled us to get to know each other’s minds. Looking back on it over 50 years later I am sure that first getting to know each other’s minds and only then getting to know each other’s bodies was an ideal sequence, at any rate for Wendy and me. I think that this sequence would suit many others who manage – unsuccessfully, as often as not – with the reverse. Rates of marital breakdown would, I feel sure, be lower. It’s too bad that this hypothesis can’t be tested in a randomized controlled trial! 

Our courtship, marriage, family formation and early married life were crowded with memorable events described in other chapters of these memoirs.  Here I’ll focus on my professional and intellectual life.

An immensely important ‘self-improvement’ activity was a course in speed reading that I took at the School of Mines, Adelaide’s equivalent of a community college.  This ran for about 12 weeks. It worked by conditioning the retina to absorb information from a progressively larger field of vision. When I started the course my reading speed was about 350-400 words per minute, which was well above the average of 250-300 words/minute.  When I started the course I was already reading groups of words or phrases, sometimes entire short sentences, at a single glance. At the end of the course I was reading 1300-1400 words per minute, usually taking in whole paragraphs at a glance.  Tests showed great improvement in my comprehension and retention of information as well. I continued on my own for the following year or so, as advised by the teacher who ran the course, and although I rarely timed myself, I estimate that my reading speed with ‘light’ reading like newspapers, popular novels and intellectually undemanding material in medical journals, maintained or increased my speed to well over 2000 words per minute. By then I was absorbing a page at a glance when reading novels, as Oscar Wilde was reputedly able to do. I tested myself when Wendy and I had been married for about 18 months, with a popular best-seller, Neville Shute’s well known novel, A Town Like Alice, which I finished in just under an hour. Wendy had read and admired this book. She watched me taking in a page at a time, turning over pages every 1-2 seconds. She tested my comprehension and was satisfied that I’d really read the book, not just skimmed it. She was very impressed, and about 14 years later, she and David took a similar speed reading course in Ottawa, with similar benefits. At that speed, the brain is totally occupied absorbing what is on the printed page; there is no spare brain capacity to get distracted, and retention of written material is much more efficient. This had a dramatic impact on my intellectual life, as it did later on Wendy’s and David’s. Over the following few years, my intellectual life exploded into a most satisfying period of research productivity that was the basis of my academic success. Ability to read at high speed and to comprehend and retain the information is an almost essential prerequisite to academic success.  Years later when I became an editor of journals and books, proof-reading slowed me down and I think my habitual reading speed has slowed, although I can still read light fiction very fast, a 300-page paperback novel in an hour or so. This can be a disadvantage at times, for instance on intercontinental flights when I was obliged to take half a dozen paperbacks, all of which I would have read between London or Paris and Ottawa. Electronic tablets – Kindle, Kobo, etc. – were just coming into vogue when my frequent intercontinental air travel ended. David uses them on his frequent travels and they have become indispensible to him.

During my remaining years in general practice in 1957, ‘58 and ‘59, I was reading widely and deeply: scholarly monographs in sociology, anthropology, psychology, as well as several weekly and monthly medical journals. I was exploring several fields, not yet sure which interested me most, which mattered most. It would have been impossible to accomplish even a small portion of all this without boosting my reading speed and comprehension.  I was drawn more and more to the notion that a scholarly academic life was where I really belonged. About this time I re-established friendship with Bob Culver, a classmate in Brighton Public School days. I met him again when his mother was a patient of mine and told me her son Bob was keen to get together with me.  He was a senior lecturer in engineering at the University of Adelaide and his description of how he passed his time filled me with envy. Everything he told me about academic life made it seem irresistibly attractive (probably he didn’t mention the time wasted by academic committees). I was very happy in general practice, but not with its greedy consumption of my leisure time, leaving me no time for reflection and thought. Also, I was unhappy ideologically with the fact that my income in fee-for-service practice came in large part from people who were in a distressing life crisis.

Several research-oriented questions intrigued me. These were mainly in the unexplored borderland between clinical medicine and social and behavioural sciences. Some profoundly sick patients seemingly were untroubled by their plight, whereas others who were often less sick suffered greatly. I thought at least some of this difference in illness behavior related to their cultural origin, especially if they were immigrants from Holland or Germany on the one hand, or from Italy or Greece on the other, the latter wearing their emotions closer to the surface. Sickness behavior seemed to have some sort of relationship to culture and ethnicity. I discussed this at meetings of the recently established College of General Practitioners, and with Norrie Robson, newly appointed first professor of medicine at the medical school. Did it make any difference, I wondered, to the ultimate outcome of their clinical condition? I had a hunch that usually it didn’t. At one of the meetings of the College of General Practitioners, I asked a related question: “Why do some people get sick, and others not?” Someone wrote the question down and we discussed it for a while. About 25 years later, this question turned up as the title of a book that became famous. I asked one of the co-authors of that book where they’d got the idea for the title, but he didn’t know. I’ve sometimes wondered if it could have been traced back to my question at that meeting.  

In my final 2½ years at the Western Clinic I entered an aspect of the work and life of the Adelaide medical school. I was appointed to the outpatient staff of the Adelaide Children’s Hospital. For 2 mornings a week I saw patients – infants and small children brought in by parents (usually the mother) with various ailments. This carried with it an opportunity to attend and take part in academic activities such as clinical-pathological conferences and lectures by distinguished visitors, further widening my intellectual horizons. At one meeting I ruffled a few feathers when I remarked that I was more interested in ways to preserve and improve the health of infants and children than in exploring the minute details of rare and strange diseases that affected one in 1,000 or fewer of the population. Everyone else in the room seemed to regard this sentiment as close to blasphemous. The medical superintendent of the hospital, a pompous self-important man for whom I had limited time and less respect, clearly regarded my comment as a personal insult.  

After the pandemic of Asian influenza in 1958, I realized during my convalescence from the near-fatal attack of pneumonia that followed shortly after the Asian influenza pandemic subsided, that what I really wanted to do was to find ways to keep people healthy, rather than wait for them to get sick and treat them one at a time. This was a philosophical conversion to the notion that it’s better to find ways to keep the population healthy than to wait for individuals in that population to get sick or injured. Along with my ideological aversion to collecting a fee each time I saw a sick person, this philosophy of medical care unfitted me for life as a family doctor in those days when the emphasis was almost entirely on treating the sick. Yet family doctors cared for pregnant women and immunized their babies against common infectious diseases, activities that were aimed at protecting good health. All I sought was to expand, enhance and emphasize that part of the family doctor’s role, to maximize the emphasis on preserving good health. Ideally I would have liked to combine general practice and a scholarly academic life. In the late 1950s that would not have been feasible in Australia.

In 1959 I tried to discuss with Clarrie Rieger, a thoughtful surgeon and a medical politician (past president of the British Medical Association in Australia) who was the senior partner in the Western Clinic, a scenario in which I would work about 80% time in the clinic, and devote the rest of my time to research. By then the College of General Practitioners had not only been established, it was flourishing to the extent that there were possibilities to get funds for research. I had become very active in the College of General Practitioners, serving on committees, developing ideas for research.  Clarrie had said that he saw me as a successor to him as a medical politician, actively engaged in advancing the interests of the medical profession in its negotiations with the government. I had zero interest in this. I wanted to explore public health sciences, epidemiology, medical sociology, and anthropology. I don’t think Clarrie Rieger grasped what I was trying to describe and explain to him, but insofar as he did, he was unsympathetic, said forthrightly that there was no way the partners in the Western Clinic would tolerate a situation in which the youngest, presumably most energetic partner in the group, worked only part time in the clinic.  I didn’t know my putative field well enough, was not articulate enough, to explain my inchoate ideas effectively.

About then I met several times with Norrie Robson, the new professor of medicine, to discuss with him possible ways for members of the College of General Practitioners to collaborate with the medical school’s department of medicine. At these meetings I was the designated representative of the College of General Practitioners, and as well I had a strong self-interest: I was seeking career advice, seeking ways I could blend my evolving interest in research questions with my career as a general practitioner in a large group practice within a 15-minute drive from the medical school. Norrie Robson was very helpful and supportive. He was an Edinburgh graduate and was already thinking of ways to establish in Adelaide a general practice teaching program, along similar lines to the recently established General Practice Teaching Unit at the University of Edinburgh. I volunteered myself and my practice to accept medical students, and recruited two or three friends to do likewise (not partners in the Western Clinic but GPs in other parts of the metropolitan area). We found that because of the crowded curriculum and absence of suitable time slots, the logistics were more complex than we had anticipated: it was hard to find suitable blocks of time other than holidays. In the end I managed to take two students under my wing, one each in two successive holiday periods when they were able to accompany me on home visits and observe, occasionally help me deal with patients in the office.

At those meetings with Norrie Robson I got some wise career advice. He emphasized that I would need academic credibility, which I could enhance by research, publications, higher qualifications than my basic graduating degree. I was working on a simple paper, describing a few of my observations of illness among ‘New Australian’ patients. This paper, “The health of immigrants; some observations from general practice,” was published in the Medical Journal of Australia January 30, 1960 – a month after I had left the Western Clinic with Norrie Robson’s advice to begin training in epidemiology and public health at the School of Public Health and Tropical Medicine at the University of Sydney, the only place where such training was available in Australia.

I had realized that Wendy and I and our two little toddlers would have to move on, start a new life, a new career.  It was a bold, almost deviant thought, a reckless, irresponsible action, to give up a secure position where my family’s lifetime prosperity was guaranteed, to leap into the unknown where future work prospects were unknown but precarious, and failure would have dire consequences. An important consideration was that our move meant we would have to leave Adelaide, perhaps for the rest of my working lifetime. I felt close to my extended family, and regarded the ties to my mother, my aunts and uncles and cousins, as very important. We would be moving away from all of them, cutting the strands of a fragile yet sturdy support network.  Wendy and I talked about all of this, albeit rather vaguely, superficially. She was preoccupied caring for our two little children, left the decision almost entirely to me – unlike other life-changing decisions later that we made jointly.  We set off to begin this new life at the end of 1959, when I left the Western Clinic. Early in 1960, we loaded our station wagon with some of our possessions, space-occupying kids’ paraphernalia, as many of my books as the car’s springs would tolerate, and set off for Sydney, where I spent the academic year as a private student at the School of Public Health and Tropical Medicine. I was beginning a new life with no idea at all where this would lead us.

Picnic lunch en route Adelaide to Sydney, early 1960