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.