Longevity and mortality of epidemiologists

So far as I know, nobody has studied the epidemiology of epidemiologists - life expectancy, causes of death, and so forth. If this is so, it's surprising. I'm out of touch, haven't been reading epidemiological journals for a few years, so if somebody has published a learned article on the topic, I'd not have seen it. But surely I'd have heard about it. If one of our graduate students in the 2014-2015 intake is searching for a thesis topic, I'll suggest this, and an inquiry into causes of death.  Most epidemiologists seem to die of old age. None die of smoking-related diseases. About 99% of epidemiologists are non-smokers, thanks to the findings of two or three of our great ones.  All, so far as I know, have retained intact minds until their death.

I've reflected on this odd fact than no epidemiologist has studied the defined population of epidemiologists in light of the latest die-off of distinguished elderly epidemiologists. All my personal role models, heroes and mentors are now dead, almost all of them after living productive and long lives well into their 90s. Austin Bradford Hill, deaf as a post from his middle 90s onward, just made it to his centennial. So did John Pemberton, WHO consultant in Indonesia with me in 1972. Richard Doll and Jerry Morris almost made it: both died at 98; Lester Breslow was almost as old, 97 I think. And my American mentor, Kerr White, has just died at 97, followed a few weeks later by Mervyn Susser who was 93. Pat Buffler, who was to have become president of the IEA this month, died unexpectedly a few months ago, but she was at least 20 years younger. There have been a few other eminent leaders of my trade who died younger, but the modal age at death seems to be well into the 9th or 10th decade. I have only 2 years and 3 weeks to go to reach 90, and on present indications I seem rather likely to make it. I'm not entirely delighted to say this. I feel that I've lived long enough, I often get lonely without my beloved Wendy, and were it not for curiosity about what might happen tomorrow, and what my grandchildren will be doing ten years from now, I'd be content to fall off my perch today.

Kerr Lachlan White, 1917-2014

Several distinguished epidemiologists have died in recent weeks. Among them was my mentor and friend Kerr White. Responding to the past president of the International Epidemiological Association, I wrote the following memorial note for the IEA Newsletter (lightly edited here):

Kerr L White, MD, IEA President 1974-77, died July 22 2014, at Westminster Canterbury of the Blue Ridge, Virginia, USA.  Kerr White was born in Winnipeg, brought up in Ottawa, and educated in economics and medicine at McGill University in Montreal. He did graduate studies in economics at Yale University and in epidemiology and biostatistics at the London School of Hygiene and Tropical Medicine. After a residency in internal medicine at Hitchcock Clinic, Dartmouth, New Hampshire and the Royal Victoria Hospital in Montreal, he worked for 10 years in the department of medicine at the University of North Carolina, Chapel Hill, where he conducted research on primary medical care. For over fifty years he remained involved in health services research, investigating problems of organizing, managing, financing and evaluating health services in the USA and other countries. Application of epidemiological and statistical methods to problems of health services, with emphasis on social and emotional factors in health, sickness and medical care, were preoccupations throughout his professional life. As director of health sciences at the Rockefeller Foundation, he founded the training program in clinical epidemiology that became known as the International Clinical Epidemiology Network, INCLEN for short. Initially this had five sites in USA, Canada and Australia; now there are clinical epidemiology training programs and clinical research units in more than 80 medical schools in more than 33 countries. Kerr White was a leader of thinking about health policy and practice throughout the world.  He served on many influential committees and governing boards, including the visiting committee of the Harvard School of Public Health, the technical board of the Milbank Memorial Fund, the advisory committee on population health of the Canadian Institute for Advanced Research, and the Institute of Medicine of the National Academy of Science. He wrote or edited important books on health care, health policy and health statistics and gathered an impressive personal collection which is now held at the University of Virginia and accessible on line.

In 1964, responding to his invitation, I left Australia with my family and joined his research team at the University of Vermont. Kerr White had an impressive appearance, tall, handsome. Speaking quietly and courteously but firmly, in clearly articulated sentences he could sum up succinctly essential points that had emerged in prior discussion, no matter how disorganized and incoherent some speakers may have been.

In 1980 as one of his first acts at the Rockefeller Foundation and one of his last as past president of the IEA, he released funds to compile a Dictionary of Epidemiology sponsored by the IEA. He asked me to edit this dictionary and gave me much help and encouragement in its early development. He provided funds for a five-day meeting at the Rockefeller Foundation’s head offices in New York, attended by most of those whose names appear on the title page of the first edition of the Dictionary. At that meeting we thrashed out and reached agreement on wording of definitions of the most important concepts and methods in epidemiology.

 He was my mentor and my friend, to whom I owe a great deal. I miss him and mourn his loss.

                                                                                                                                           

Race

In early autumn 1964 when we’d been living in Burlington, Vermont, for about 6 months, Wendy and I had to choose between two invitations. Should we accept my mentor Kerr White's invitation to accompany him when he moved from the University of Vermont to Johns Hopkins School of Hygiene and Public Health in Baltimore, Maryland? Or should I accept the invitation from Stuart Morrison, to become senior lecturer in social medicine at the Usher Institute of Public Health in the University of Edinburgh, Scotland? The salary in Edinburgh was significantly lower and there were fewer benefits. Even so, the decision took barely a microsecond of thought and discussion. It was a no-brainer. We chose Edinburgh where we had five wonderful years, during which I consolidated my academic reputation and Rebecca, David and Jonathan acquired lovely soft Edinburgh Scottish accents, which sadly they lost long ago, to be replaced by Canadian, variant Ottawa Valley.

I set out the reasons for our decision in a post on this blog in 2012. The most important reason was our philosophical belief in the virtue of collectivism rather than individualism, which dominates all aspects of American life. Quite a long way down on the list of reasons for choosing life in Scotland rather than in the USA was the problem of racial prejudice. This is not so much a scar on the American body politic as a running sore that shows signs of being incurable. Of course racist attitudes and beliefs are far from unique to the USA and apartheid era South Africa. They are pervasive, at any rate among many people of 'white' or European ethnic origin, including my father - an intolerant racist bigot, for all his many talents. 

Wendy and I talked about this a few times, for example after parties we’d hosted or attended where remarks or behavior of others revealed their affliction with this terrible disorder. Wherever we lived we made friends, conducted ourselves with other people, regardless of their skin pigmentation, hair texture, facial cartilage and bone structure or other aspects of their appearance. Occasionally we ran into socially tricky situations. Once at a dinner party in Edinburgh our host asked all of us to toast the racist leader of what was then called Southern Rhodesia in his “struggle against the forces of darkness” or some such euphemism for the indigenous inhabitants who were taking power with British government support. Wendy and I remained seated, did not raise our glasses, and left that party without waiting for desert. Among our closest friends there are several whose appearance instantly identifies them as members of a racial group other than European. We discovered long ago that appearance is irrelevant. Attitudes are often revealed amid polite conversation, as at that dinner party in Edinburgh, and in the request of a beautiful, soft-speaking young woman who wanted me to alter the definition of ‘race’ in the Dictionary of Epidemiology to reflect her views.

In the USA, the running sore of racism festers and ulcerates, and summer often brings the inflammation to a head. This year it’s come to a head in a suburb of St Louis, Missouri. Years ago I had a friend in St Louis who belongs to what we call in Canada a ‘visible minority’ - not African American but Chinese American. He spoke of tiers in St Louis society in which he was below white but above black Americans. Thank goodness Canada doesn’t seem to have that kind of convoluted social structure, but we aren’t immune and ominously some traces of it seem to be sneaking into the social fabric even in mutlicultural, multiracial Canada.

When people speak on the radio, it’s often impossible to detect their racial background, unless accent or dialect reveal it.  There's a distinguished Scottish writer who speaks with the lovely Edinburgh lilt. She has a Scottish mother and a Nigerian father, and her pictures show her imposing and very darkly pigmented appearance. On the radio all you can hear is her musical Morningside voice. I wonder whether the tension in St Louis would be lowered if representatives of the opposing groups engaged in dialogue behind screens that concealed their outward appearance so only their words and their sentiments would be revealed. I doubt if this would work now that tension is so high, but it might be worth trying next time such tensions arise. The problems associated with race and racism in the USA and elsewhere are so deep rooted now, however, that facile suggestions like this one of mine don’t stand much chance. I’m just relieved that we evaded the problem (and other problems endemic in the USA) by turning our backs on the country.

Borgen

Borgen means 'fortress' in Danish, and is the word used to describe the Danish legislative assembly in Copenhagen. Danish national television has produced a riveting political drama about power, the cut and thrust of politics, the alliances - lasting, intermittent, or evanescent - among key players; the betrayals, love affairs, hate affairs, family dynamics and personalities in Danish politics and the media that report on and analyze political events. The leading characters in the drama are the prime minister, her husband and two children (an adolescent daughter and a small boy); her 'spin doctor' and an elder statesman/mentor; an ambitious, intelligent and attractive TV journalist, her boss and her colleagues; key players in other political parties, leaders of industry, commerce, the armed services and other sectors of society that interact with elected officials. The ten one-hour programs of the first series include both ongoing stories of the evolving, ever-changing political scene and self-contained stories that usually reach resolution by the end of that episode - though some probably will come back later to bite the protagonists in the bum. At the end of the final episode of the first season, the idealistic prime minister's marriage has broken up. Her husband has asked for a divorce and the two children are becoming alienated from her because she has been unable to balance the perpetual crises of political life with her previously harmonious family life. Complex and difficult ethical problems are presented with clarity and compassion, including freedom of choice versus right to life; clashing values of male chauvinists and well educated articulate feminists; several kinds of conflicts of interest, and culture clashes between urbane and sophisticated Danes in Denmark and deeply held traditional beliefs of Inuit peoples in the former colony now client state Greenland. The prime minister has had to jettison her old friend and mentor who has been her finance minister in order to save the coalition government she leads, and her rather fragile coalition seems to be fragmenting in spite of this personal and political sacrifice. My bare-bones description of parts of the plot make it sound like kitsch. It's far from it! This miniseries is a very well constructed drama, played by excellent actors. The crisp Danish dialogue appears in easily legible English subtitles. Many threads of the plot are unresolved at the end of the first season's ten episodes, and I am looking forward to the second and third seasons where I anticipate some, perhaps most loose ends, will be tidied up, although no doubt other complex problems and issues will arise.  This is that extremely rare experience, very thoughtful TV drama for intelligent grown-ups. I highly recommend this series. 

I rented it from Glebe Video; it's probably available elsewhere, e.g. Ottawa Public Library.

Momentous dates in August

Yesterday was commemorated all around the world as the 100th anniversary of the outbreak of the Great War of 1914-1918; tomorrow, August 6, is remembered as the anniversary of the day in 1945 that the atomic bomb was dropped on Hiroshima. Both dates have ominous portents. August 4 1914 was the day on which events set in motion 37 days earlier, when Gavril Princip shot the arch-duke Franz Ferdinand of Austria, came to a catastrophic climax with declarations of the war that killed maybe 20 million young men, brought down empires and may yet prove to have been the beginning of the death knell of European civilization. August 6 1945 introduced the ultimate transformation of war from industrial scale annihilation of armies on battlefields to annihilation of entire bustling cities and all who live in them. It was a very small bomb, just a few kilotons; now the weapons makers have multi-megaton bombs that can annihilate entire countries, could probably destroy everything living on earth if nuclear weapon-dropping were to become epidemic. 

There have been other momentous events in other Augusts, the dog days of summer. But nothing matches Aug 4 1914 and Aug 6 1945 for sheer horror. The saving grace of both dates is that we don't celebrate either, just remember them, shudder, and go on with our lives.  

One man's terrorist is another man's freedom fighter

In the spring of 1943, the victorious Soviet Russian army had rolled back the remains of the German wehrmacht to the outskirts of Warsaw, where the Nazis had sealed up over 300,000 Jews in the Warsaw ghetto. The Nazis had been systematically exterminating the Polish Jewish community in the concentration camps at Treblinka and Auschwitz. The Warsaw ghetto Jews knew they were destined for extermination by the Nazis, so armed with pistols and a few machine guns they revolted on April 19, confident that the Russian army would arrive in time to liberate them. Instead, in one of the most obscenely cynical actions in his bloodstained career, Stalin ordered his army to pause on the outskirts of Warsaw, to allow the Nazis time to crush the Warsaw uprising. Stalin didn't like Jews. By May 18, the Nazis had defeated the Warsaw Jews, and accelerated their extermination program. I was 15 at the time and remember vividly how all of us in the western alliance were appalled and watched helplessly as this tragedy took place. We called the Jews of the Warsaw ghetto courageous freedom fighters. The Nazis called them terrorists.

Now, for 8 years, the Israelis, including perhaps a few survivors of the Warsaw ghetto uprising, have bottled up 2 million Palestinians in the Gaza strip, an area of land about the size of the National Capital territory of Ottawa. A small faction  of the Palestinians, the Hamas "terrorists"/"freedom fighters" [you choose] is fighting fiercely in an attempt to draw the world's attention to the plight of all the Palestinian people deprived of basic freedoms we all support, in the Gaza strip. Hamas is armed with small rockets that have no guidance system, carry very small explosive charges, do slight property damage and have killed or injured less than a dozen  people in Israel. They have also dug many tunnels under the separation wall and fences between Gaza and Israel, but if these have been used to make incursions into Israel, there are no reports of damage, deaths, or injuries as a result. 

Nonetheless, the Israeli Defence Force has retaliated against these irritating pinpricks with a massive air, land and seaborne assault in which as of today, almost 2000 Palestinians have been killed, many thousands injured, densely packed residential districts have been laid waste, essential infrastructure including Gaza's only power plant, have been destroyed. The overwhelming majority of those killed and injured Palestinians are non-combatant infants, children, women and old men. Hospitals and schools, including schools run by UNRWA that were sheltering thousands of Palestinians whose homes had been destroyed, have been targets for aerial and land-based bombardment. This is collective punishment on a grand scale, a Nazi tactic that the IDF has copied. 

President Obama, and of course Canadian prime minister Harper, have said repeatedly that the Israelis have a right to defend themselves.  Do the people of Palestine not also have a right to defend themselves? 

This perpetual war between Israel and Palestine is a tragedy of Sophoclean proportions, writ large. I can see no sign of a solution in my short remaining lifetime and I suspect there may be no solution even in the lifetime of my grandchildren.