Sorrows and pleasures of old age

In Love in the time of cholera, Gabriel Garcia Marquez wrote with perception, empathy and wit about the sorrows of growing old. I know whereof he spoke. As news filters through to me of deaths in the 'family' of my medical class, the 49ers from the University of Adelaide, it's a reason for quiet satisfaction to find myself among the handful still living. The original 60 of us were reduced at last count to fewer than 10. To be living, however uncomfortably, with however many disabilities and incurable afflictions, is decidedly preferable to the oblivion, the nothingness, of being dead. I am sure there is no afterlife.  When we die, we end. We cease to be. There is no paradise, no valhalla, no doe-eyed houris to provide endless sexual gratification, no heaven, no hell. This one life each of us has is all we will have, all we will ever get. 

Maybe I haven't made the best possible use of my life, but I haven't wasted it.  I can look back with satisfaction and pride, on what I've accomplished. That's one pleasure of my old age. I do my best to shrug off the sorrows. It's gratifying   to have had recognition, honorary degrees conferred by two great universities, Uppsala and Edinburgh, the gold medal, the highest honour, of both the Canadian and American Public Health Associations (I'm 1 of only 2 or 3 people ever to have received this honour from both Canada and USA); I've been given about a dozen other awards and distinctions; and then the ultimate mark of recognition, in 2012 I was admitted to the Order of Canada as an Officer of the Order. At the banquet after the investiture, the Governor General gave me the Queen's Jubilee Medal as well. One of my sorrows is that Wendy wasn't here to share the pleasure of those two decorations in 2012.  

My greatest sorrow is that Wendy isn't beside me, holding hands as we often did when walking, or watching a DVD collection of our favourite BBC miniseries, or engaging in one of our other shared pleasures. Our supreme shared pleasure was what she sometimes called wee romps, more often earthier terms. I get vicarious pleasure from memories of those times but it isn't the same. For 55 years she was beside me, sustaining me, my reason to strive always for the best outcome of whatever challenge confronted us, or her, or me, at the time. Losing her was the most devastating sorrow I ever faced, prolonged over the 14 months of her terminal illness. She died of motor neurone disease, known here as ALS, in the  USA as Lou Gehrig's disease. It's regarded as a horrible way to die, and it is for young adults and for people in the prime of life, at the height of their vitality and productivity. In old age it lacks the dismal features that make it so dreaded. We were reassured by the neurologist who made the diagnosis and the superb palliative care physician who looked after Wendy, that almost its only impact on her would be progressively longer periods of sleep until one day she would go to sleep and not awaken. That's what happened. The most distressing aspect was that she lost her voice a few weeks before she died when the muscles she used to speak stopped working. She had no pain, no loss of intellect. Our anguish was softened by superb support services, many provided here in our apartment: personal care worker, visiting nurse, physio, appliances etc, from the ALS Society, others coordinated by the ALS Clinic or the Community Care Access Centre.

I console myself with the thought that I behaved as a gentleman should, letting her go first. 

All my other sorrows are trivial by comparison with the anguish of Wendy's final illness and death. These are almost entirely due to one or more of the incurable disorders that afflict me. I take pills to arrest or retard the progress or soften the impact of some, and rely on mindfulness meditation to help me adjust to their cumulative impact. I take fewer pills than most people in my age group, 2 in the morning, 2 in the evening, plus vitamin supplements. A cane or a walker give me confidence to walk with a sense of balance that's less reliable than it used to be. A footstool makes it easier to reach my feet to put on my socks. My vision is very good, thanks to successful cataract surgery in 2008. This enables me to keep driving my car despite slow reaction time, and this freedom of movement is a pleasure I shall miss when inevitably I have to give up driving some time soon. Nothing is as boring as a recital of someone else's ills so I'll say no more, and change the subject. 

Some collegial relationships have been better than others. Looking back over a working lifetime of well over 70 years if I include university and mature school years, I can't recall any that were detestable. Collectively and individually these relationships have generated far more pleasure than sorrow. Most pleasurable are teacher-learner relationships that became long-lasting friendships. I can't recall any of these ever going sour. Much pleasure there, and very little sorrow. I've always been a loner and since Wendy died I've lived alone in my apartment. When I need help with activities of daily living, I hope to stay here, with a personal care worker to help me, just as I now have a cleaning lady and another lady who comes in to cook for me once a week. Rebecca and Richard feed me once a week too, so between these I rarely have to cook - which is just as well because I'm a terrible cook.

A small pleasure is boasting about my age. Next month I'll be 89, and unless things change I'll mix and mingle as I do now. I proudly announce my age when I'm asked, and in some circumstances, I state it unprovoked. 

Reading is my greatest pleasure. Buying books - to support struggling authors and small independent book shops - is my one remaining incurable vice.

There's much more, and pleasures far outweigh sorrows. I am very fortunate.  

Making the world a better place

In a recent post I mentioned a bold aspiration, to make the world a better place. This is an implicit aim that many of us share as we contemplate our life's work from our different professional and occupational vantage points.  Even when we consciously aspire to make the world a better place and proclaim this out loud, which we seldom do because it seems grandiloquent, we even more rarely pause to reflect on what we mean by 'better.'

I tried to do it on September 22, 1997 in Boston, when the American College of Epidemiology gave me the Lilienfeld Award, which is the ACE's mark of distinction for lifetime achievement in epidemiology. As quid pro quo when the ACE gave me the Lilienfeld Award, I was required to give a little talk. I skimmed over the achievements of epidemiology. We all knew these achievements. Many of us recite them with pride in our introductory lecture to incoming students at the beginning of each new academic year. Instead, while all of us were digesting an unusually good meal at the annual ACE banquet, I asked - but didn't try to answer - an unsettling philosophical question.  My question can be summarized: will our descendants 100 years, or 500 years, or 1000 years, from now still regard what we did to improve the human condition, as the best, or the right thing to do? Will what we have done to clarify causes and achieve control of diseases, injuries and premature death still be considered improvements? I confessed to some scepticism and even cynicism during the discussion after my talk. It was a unique pleasure to harangue a large cluster of epidemiologists with such profound but unanswerable questions on my 71st birthday! (I'm told that my 1997 Lilienfeld Award address is posted on the ACE website, so readers of this blog can dig it up from the ACE archives if they wish).

We believe the greatest contributions of epidemiology to improving the human condition include control, sometimes elimination, of dangerous communicable diseases, clarifying the causes and initiating and maintaining surveillance systems to delineate the burden of diseases like cancer, heart disease, stroke, diabetes, industrial and traffic-related injury and death, mortality and disability of mothers and infants associated with childbirth, and evaluation of health care systems and services. All these are desirable uses of epidemiology. Governments seek our help to address questions that concern them: which health services, for instance, provide best value for professional expertise and money invested in them?  

My personal contributions have been development and application of a useful epidemiological model of many diseases; standardizing epidemiological terminology (compiling and editing the Dictionary of Epidemiology); editing a comprehensive reference textbook of public health, and helping to develop  guidelines for ethical conduct of epidemiological practice and research. I've done or taken part in a few other things too, but those four distinctly different achievements are enough to make me feel that my professional life hasn't been entirely wasted.   

There are other challenges to which epidemiologists, along with the rest of the world's intelligentsia, have had little or no worthwhile response. We've done almost nothing to relieve the burden of one of the most accursed afflictions of humankind, the scourge of depressive illness, as well as other mental and emotional disorders. We've done very little to alleviate the distress of dysfunctional families, who are often afflicted with domestic violence, substance abuse, etc. On an international scale we've done nothing to identify the causes and discover ways to prevent violent armed conflicts. The latest outbreak, the gratuitous violence and destruction of ancient historic sites, the obscene public executions, mass rapes and enslavement of girls and women by the Islamic State, has been unimpeded despite our efforts - which are demonstrably ineffectual. Public health sciences must get engaged with these problems! There have been almost no epidemiological studies of war, especially of the modern kind of unconventional war that has smouldered in the Middle East for several decades. 

As for the greatest danger to all living things on earth, global climate change, almost all epidemiologists, like the rest of humankind, continue to behave as if this isn't happening. 
I've fulminated on this often. I've included this as the key message in almost everything I've written and spoken in professional circles for more than a quarter of a century, so much that I've become like a broken gramophone record.  I feel more and more like Cassandra or Diogenes. 

Is it any wonder that I've turned my back on public health sciences, and taken to writing a story for children?  

More on journeys

Reflecting on Guy Thatcher's journeys got me thinking again about my journeys. I've talked about these journeys in previous posts, probably too much, surely enough to be boring. Collectively they are to some extent the story of my life. My life has been a journey which has included several actual life-altering journeys, migrations from one country and culture to another. Those journeys were educationally and culturally enriching, sometimes almost as enriching as immersion in a new and different milieu, which happened before or after a journey that was a self-contained chapter in the story of my life. Several journeys have been unforgettable in and of themselves - long ocean voyages, long train journeys, long car trips, that I've described in previous posts and illustrated with photos I took at the time. (I've woven memories from several long car journeys in Australia into the fabric of Gloriana, my story for children).  Several journeys were enriching on a scale that exceeds all other experiences in my life by some orders of magnitude. My only regret is that I didn't keep a journal of those journeys, in which I could have set down my sensory impressions and emotions at the time, rather than recollecting them later, sometimes years or decades later.

In the 1960s when I carried out several research projects for the UK Royal Commission on Medical Education from my base in the Usher Institute at the University of Edinburgh, I worked with a  distinguished sociologist, Fred Martin. Fred identified two diametrically opposite kinds of medical students and young doctors. Of course there were several intermediate varieties. The two extremes are the one with unbreakable ties to a family and a community, who will stay in that community and adhere to family there no matter what; and the opposite extreme, one to whom 'profession' or career is paramount, 'profession' meaning specialty, opportunity and facilities to do research, potential for career advancement, promotion etc. Fred Martin coined the term 'spiralist' to describe this type - someone who is willing to go around and around in order to go up, to advance his career (it is his career: we didn't have large enough numbers for reliable or valid generalizations; but we were both quite sure spiralists were much more often male than female, at any rate in the medical profession at that time). 

Fred Martin has been dead for many years, but I know he would agree with me that I am the ultimate spiralist. I've moved around and around to the extent of migrating between continents 5 or 6 times - more than any of my academic peers - as well as making so many journeys  across and between continents and countries and cultures that I lost count long ago. This has given me a rather unique perspective, another of the collateral benefits of my peripatetic professional life. It's also carried a few costs. Apart from books, without which I could no more live than I could without oxygen, I haven't accumulated much in the way of possessions. And a reason for sadness: I haven't had a dog in my life since we left Edinburgh 46 years ago. To a dog-lover like me, that's a serious deprivation. Fortunately this is a dog-friendly condo, so I have doggy friends in several apartments, but it's not the same as having a canine partner of my own. After all these years, I still miss my faithful dachshund bitch Helen who looked after me, then Wendy and me, then Wendy and me and our kids, and who had several lucrative litters that paid for our first fridge and washing machine; and Boomer, our gallumptuous perpetually adolescent Labrador, who matured into a placid adult only after we gave him away and left Edinburgh.  

"What is the meaning of life?"

“What is the meaning of life?” I haven’t thought much, or thought very often, about this question. Douglas Adams answered it as well as anyone when he had a super-computer in Hitchhikers Guide to the Galaxy answer “42” – an answer that is as meaningful as that of many philosophers who have filled fat volumes with words that usually evade a simple answer. I don’t think there is a simple answer even to a more specific question, “What is the meaning of my life?”  I’ve tried to answer this question in my memoirs and I’ve provided hints about my answer in a few of the posts on this blog. Here are some pertinent thoughts.

Chance plays an important part in everyone's life, most certainly in mine. At about 9 am on Sunday September 25, 1955 as I was heading for my golf club I saw two young women hitch hikers ahead of me. In those days I picked up hitch hikers, applying a ‘what goes around comes around’ approach: I’d hitch hiked in Britain and Europe and owed it to other hitch hikers to offer them lifts. Within minutes of picking up these two I knew I wanted to see more of one of them than was possible in the 10 minutes before I’d be dropping them (they were on the wrong road for their intended destination).  That’s when I made the life-changing decision to scrap my golf that day and to spend the day showing them some of the lovely country in my favourite corner of South Australia. Our meeting was as random as any event in life can be. The two girls were on the wrong road, and running an hour later than they'd intended. I'd never used that road before to get to my golf club. I was on it only because I'd delivered a baby the night before in a cottage hospital on the far periphery of our practice catchment area, went back first thing in the morning to make sure mother and baby were OK. What happened afterwards wasn’t random: I made, we both made, things happen the way we wanted them to happen. Our one-day meeting led to a prolific, increasingly affectionate correspondence. Before long I was confident that our letters would bring us back together and soon after that we would be marrying. 

Chance again: In December 1955, early in a long, hot summer, I was senior registrar (= chief resident) in the infectious diseases hospital in Adelaide during the last-ever epidemic of paralytic polio. It was a particularly nasty epidemic. The polio virus was knocking out the nerve-muscle junctions for breathing and swallowing, a strategic viral assault that often had a fatal outcome.  Record numbers of young adults in my age group were in ‘iron lungs’ – artificial respirators – and more than half of them were dying. I did what I had to do, while applying with super diligence all the procedures of universal precautions to protect myself against polio. I didn’t get polio, but it was not because of those universal precautions, which we now know do not protect against infection with the polio virus, but by chance alone.  Chance, not 'universal precautions,' spared me from paralytic poliomyelitis, and perhaps premature death. 

I know more now than I did in 1955 about the mathematics of epidemics, as well as about the modes of transmission of infectious organisms. We know now, but didn't know in 1955, that the polio virus is transmitted mainly, perhaps exclusively, by the fecal-oral route. The same laws of chance govern all biological events and processes, including the chance events of evolutionary biology, which led to the evolution of humans. With variations set by quantum theory the laws of chance apply to the stars and planets of the universe, and what happens inside atoms. The laws of chance placed our earth in an orbit that allows H2O to exist in liquid form, an essential prerequisite for life as we know it. The laws of chance apply also to evolutionary biology, enabling humans to evolve to the status and condition we see all around us, with all the joys and sorrows attendant on this status and condition. (As of the latter half of 2015, I think the status of Homo sapiens is equivocal, and the condition is precarious. There is a finite albeit small probability that Homo sapiens will soon join the vast majority of other species that have existed since life as we know it became possible, and will become extinct. That too will be determined at least partly by chance.) But in this post I’ll stay away from speculating about that possible outcome.

My life acquired meaning and purpose after I met and fell in love with Janet Wendelken, a.k.a. Wendy. Until then, I’d existed and enjoyed most of my experiences but my life was aimless. I mostly just let things happen. After September 25, 1955 I knew, if in a rather inchoate way, what I wanted to do with my life. I wanted to fulfill the potential of my medical education. I wanted to help make the world a better place. These aspirations merged and mingled when I gave up treating sick people one at a time and started my training in public health sciences. I aimed to do my best to elevate the health of the whole population by applying the full spectrum of my knowledge and skills to this end.  Wendy’s moral compass, and her conspicuous altruism, became part of my persona too.

 In the winter of 1958 when we'd been married less than two years I worked on the front line of the Asian Influenza pandemic which killed 2-3 million people worldwide, and several in my practice, including a young ambulance driver with whom I sometimes played golf, a nurse in the hospital where I did most of my obstetrics, and several other young people I knew who were about my age and Wendy’s. Soon after the pandemic subsided I fell dangerously ill with virus pneumonia. Both I and the young specialist physician treating me thought I was going to die. During my rather long convalescence I had time to think about the future I almost didn’t have. I talked it over with Wendy, and decided to leave the group practice where I was very happy and by all accounts, was doing a competent job. For a year we lived on my savings while I retrained in public health sciences.  I got a traveling fellowship with a stipend intended for a single man without dependents, and spent a year in the Medical Research Council Social Medicine Research Unit in London. By the end of that year I was a well-trained epidemiologist. The combination of rich clinical experience in general practice and very good training in epidemiology gave me a profile much in demand – though ironically, not in Australia where there was still massive indifference to anyone with this skill set. That's how we ended up in Canada, but that's another story for another time.

What I understand of evolutionary biology, mathematics, statistics, quantum physics, astronomy, philosophy, and history, among other aspects of knowledge, leads me to conclude that chance has had an important role in the human condition, as well as in my own life. Chance determined the position of planet earth in the solar system, the origin and evolution of life and of humans, and to a large extent, the course of human history.  If Gavril Princip’s pistol had misfired, or if he had arrived 10 minutes later at his chosen position to assassinate Archduke Ferdinand, the Great War of 1914-1918 probably would not have happened.  On a larger, cosmic scale, I am sure there is ‘life’ elsewhere in the cosmos, although whether it is life as we understand it or something beyond our comprehension, is unknowable. There may be ‘living’ crystalline species, or ‘living’ forms of gases or vapors. By ‘life’ and ‘living’ I mean something that has the ability to grow, to reproduce, to be born and to die. Crystals have these qualities and so do free-flowing gases and vapors.  So do colonies of ants, termites and bees.  I embrace James Lovelock’s concept of Gaia as a living entity. If I have faith and belief, it is belief that Gaia is a living entity and faith in Gaia’s capacity to withstand the appalling harms inflicted by predatory and aggressive humans over the course of history. Our current concept of the early history of planet earth is that cyanobacteria proliferated in an atmosphere of hydrogen cyanide and methane, transformed the atmosphere by producing oxygen as a metabolic product, and although the oxygen was lethal to cyanobacteria, oxygen enabled life as we know it to come into existence. Humans and machines powered by carbon-based fuels are transforming the global environment again, rather rapidly rendering this environment hostile to many living creatures – plants, animals, and ourselves – so that a very real possibility exists that we too might soon become extinct. If so, we will be as much responsible for our own extinction as cyanobacteria were for theirs.

All this, all the evidence, leads me to conclude that there's not much more, if anything, I can do to shape my own destiny, let alone anyone else's. However, along the way towards shaping my destiny and my family's, I've had a wonderful, exciting, eventful life. Fun-filled too. Nobody could ask for more, or better. 

Journeys

The most interesting of the diverse group of writers at the Ottawa Independent Writers’ ‘Retreat’ in June was Guy Thatcher. He is in his late 70s. He is a former officer in the Canadian Forces (Tank Corps, helicopter pilot). He is a widely traveled man who has walked the entire Camino de Santiago. He first walked the Spanish segment from Pamplona to Santiago, a westerly route inland from the south shore of the Bay of Biscay. He returned three years later and walked the French portion, the Chemin de Saint-Jacques, from Le Puy in the Massif Central, South-West to Roncevalles across the Pyrenees, to Pamplona. Walking the Camino, even the Spanish portion, is no walk in the park. It is about 700 Km from Pamplona to Santiago, and a more demanding and stressful 875 Km from Le Puy to Pamplona. Guy Thatcher was in his early 70s when he walked the Spanish part of the Camino and entering the second half of his 70s when he did his second walk. He has written two lovely books, Journey of Days, and Journey of Days Continues, about his walks, about the people he met and places he passed though; but mainly about the people.

I highly recommend these two books.  Anyone who reads this blog and is interested should visit http://www.guythatcher.com, where more information can be found about Guy Thatcher, as well as ordering information.

He struck a particularly unpleasant year of atrocious weather for the first half of the second walk. His description of this is daunting. I’ve been a walker all my life, have walked large distances exploring bits of country and a good many cities in Europe and the UK, and to a lesser extent in USA and other parts of the world. Insofar as I know my way around cities in Britain, Europe, America and Asia and a few famously beautiful rural regions, it’s because I explored them on foot (on a bike in New York). In a limited way I’ve explored Shanghai, Beirut and Bangkok, constrained by absence of street signs in an alphabet I could read.  But all my walks were puny compared to Guy Thatcher’s.  An advantage he had over me should I have attempted to walk the Camino is a good grasp of desirable languages, French, German, and enough Spanish to get by. Years ago I could have coped in German and Italian, perhaps could have understood when spoken to in French but could not have replied to anyone in French. I’d have sunk without trace on the Chemin de Saint-Jacques and probably even more rapidly on the Camino de Santiago.

Guy Thatcher’s two lovely books about his walks on the Camino are at their best when he writes with empathy and insight about the people he met along the way, his fellow walkers (pilgrims) and some of the unusual people who maintain the lodgings for pilgrims that are located at strategic intervals along the way.  He has great capacity for developing these insights and writes movingly and with compassion about some of them. He has obtained their permission to publish these often intimate details, and deserves high praise for the skillful, sympathetic  way he has written about people, some of whom had experienced great travail and personal sadness.

About halfway through his second walk Guy Thatcher, not a particularly religious man, finally figured out why he was walking the Camino. It was to understand better both himself and the human condition, and large philosophical questions about why we are here and what is the meaning and purpose of life. I’m trying to delve into these questions in my memoirs, although the excerpts that I’ve posted so far on this blog have rarely addressed these questions. I’ve posted what I recall of my childhood, school life, medical education, some of my travels, and the life-changing day I picked up the hitch hiker who became my beloved wife. I’ve written but not yet posted some thoughts about the meaning of life, my life anyway, and the lessons I’ve learnt as my own life has moved towards its end.

I hope Guy Thatcher will do this next: write a memoir about his life, the lessons he’s learnt, and what he has come to understand about the meaning of life. I would find his thoughts on these questions helpful as I try to clarify my own ideas about these large questions.

Hiroshima + 70

August 6, 1945: I was 18 years old, 7 weeks short of my 19th birthday, a second year medical student, first-year physics fresh in my memory: I understood atomic physics. At the time my main emotion was relief that the war would soon be over. The full horror came a few days later with newsreels and photos of the devastation of Hiroshima and of survivors with horrible burns. The horror was accentuated when the New Yorker devoted an entire issue to John Hersey's article on Hiroshima on August 31, 1946. Our world changed forever on August 6, 1945. Seventy years later I still feel horror.

The two atomic bombs used in war were dropped by the Americans on Hiroshima on August 6 1945 and on Nagasaki on August 8 on the orders of President Harry Truman. The ethics and morality of Truman's decision to use atomic weapons have been much debated. The immediate devastation and huge numbers of casualties were unprecedented; delayed mortality caused by exposure to lethal levels of nuclear radiation pushed the numbers killed by those two small bombs to over a quarter million. 

Since 1945 the power of nuclear weapons has been immensely enhanced: the Hiroshima and Nagasaki bombs had explosive forces measuring a few kilotons. The average nuclear weapon nowadays has an explosive force measured in multiple hundreds of megatons. One well-placed modern nuclear bomb could destroy the entire megalopolis of Bos-Wash, the cities of Boston, New York and Washington and all the other cities large and small in that densely settled north-east corner of the USA. Montreal, Toronto and Ottawa are near enough to suffer some physical destruction as well as casualties. Many deaths would be slow but just as lethal, caused by exposure to fatal levels of ionizing radiation. A widespread nuclear war, probably even a regional nuclear war such as might break out between India and Pakistan, would cause a 'nuclear winter' - a sudden sharp decline in solar radiation reaching the earth's surface, because the massive amounts of dust and smoke in the air would occlude sunlight. It could take several years for this effect to subside, so a new ice age would be likely. The astrophysicist Carl Sagan developed theoretical models of this phenomenon. It alone would cause mass extinction of many plant and animal species, as well as massive famines due to crop failures.

The world has come quite close to a nuclear holocaust several times since 1945, although fortunately the hotheads have always stepped back from the brink in time. I fear a trigger-happy Israel more than North Korea but that's just a personal bias based as much on the combination of Israeli paranoia about Iran and the probable size of the Israeli nuclear arsenal as on the likelihood that North Korea has only one or two atomic bombs rather than a large arsenal of weapons as the Israelis are reputed to possess. The way armed conflicts have evolved since 1945 has been almost in the opposite direction from confrontation between great powers like USA and the former USSR.  Now the world is afflicted mainly with so-called low-intensity conflicts and unconventional warfare, such as the long-running wars in Central Africa and the former Belgian Congo, Burma, Colombia, etc. And, of course, the much more ominous low-intensity war being waged by the Islamic State in Iraq and Syria. Pakistan has nuclear weapons and another scenario to be greatly feared is a takeover of Pakistan by ISIS: if ISIS gained possession of nuclear weapons the probability of a nuclear war between ISIS and Israel would be greatly increased. 

That's more than enough gloom and doom for this pleasant summer morning.