Autumn 2014

The earth revolves on its axis and its axis tilts, relentlessly marking the passage of time; and the seasons change in sequence with these revolutions and tilts. It's the passage of time that I notice most. This year I decided to mark its passage with daily photos from my balcony.  Here's a set of daily photos, beginning Oct 10 and continuing through what would have been Wendy's 89th birthday, Oct 14

October 10 2014 looking west

October 11 looking west

October 12 looking west

October 12, zooming on the maple
near First Avenue school

Carpet of golden leaves below maple beside Rideau Canal (looking east from my balcony)
October 13

October 14

October 14

October 15

October 16

October 17










At this point I'm going to quit (always try to quit when you're ahead; it's a good motto). From now on the colours will blow away rather quickly. A few years ago when I carried out a similar exercise I recall wondering whether I'd be here to do it again the following year. Well, I was. Weighing up the pros and cons, I hope I'll still be here next year, and the year after when I'll be 90. Beyond then, I'll reserve judgement.      

Ebola

Ebola was one of the 30-odd "new and emerging" diseases that I mentioned in the 2nd edition of my book, Public Health and Human Ecology (1996). I didn't mention it in the first edition (1986). It was identified in 1976 but little was known about it in 1985 when the first edition went into production. It is a viral hemorrhagic fever that until this latest epidemic, had been confined to small, remote rural village settings, and therefore all previous outbreaks had been localized and limited to a few dozen cases. This epidemic is different in several ways. Most important, it has occurred in densely settled urban centres, Monrovia, Liberia and Freetown, Sierra Leone. Numbers affected have inevitably been much larger, and the epidemic spread has been explosive. Inadequate public health infrastructure and local beliefs and burial customs have greatly enhanced the risk of spread.  The natural hosts of the pathogen, its ecology and its possible modes of spread are not yet fully understood beyond the obvious empirical observation that it is highly infectious and spread in body fluids by direct person to person contact. Other possible modes of transmission - by contaminated bedding and clothing, cooking utensils, domestic pests such as rats or household pets, passive transmission by flies and other insects, water-borne and food-borne spread - have been investigated but it isn't clear to me that these have all been absolutely ruled out. Several cases have been evacuated from West Africa to the USA and to Spain, which immediately struck me as unwise. My misgivings have been reinforced by the occurrence of a case transmitted in Spain to an attending hospital nurse. 

The causative organism is a filovirus. This has an unusual structure for a virus. its natural hosts are feral primates and possibly bats that can transmit it to rodents but it isn't known whether other mammals can harbour the virus without falling ill. Taking no chances, the Spanish public health authorities plan to destroy the pet dog belonging to one of the cases they have identified. As of early October 2014 there have been over 7000 cases since this epidemic began in March 2014, with a mortality rate over 50%. By any criteria this is an extremely dangerous epidemic.  At the time I'm writing this, early October 2014, I believe there is a real risk that this epidemic could become a global pandemic. 

Memento Mori

Lately I've commemorated several deaths in posts on this blog, among them some very good friends and colleagues, all but one older than I. Yesterday's newspaper carried the obituary of yet another, a friend and former neighbour in the condo where I live. He was born earlier in the same year as I, in 1926, so he was just a few months older than I. 

Today's emails included one with the very sad news of another death, this time a young woman, a writer, to whom I was at first an email mentor for a year or so, then Wendy and I met her and her husband, whom I already knew, stayed with them for a few days during one of our annual visits to Australia in the mid 1990s. Her husband was still a rural GP in those days, poised for the leap he soon made into academia. He followed the same path I'd trod, from scholarly general practice into epidemiology and public health. I'm pleased and proud to have been his role model. His wife and I became close internet friends as so many of us were inclined to do in the early days of email when we became 'electronically intimate.' I described her as a 'young' woman and by today's standards she was young, in her 50s I suppose. She wrote well, and my editorial suggestions probably helped to improve her collection of connected short stories which were published by an offshoot of the BMA. I understand they sold quite well, so that was a success for both of us. 

I've heard others say, and now I say it myself, that you know you are old when the deaths reported in the press and in professional journals are of people younger than yourself. That's surely happening increasingly often to me.

Tony McMichael 1942-2014

This morning’s emails include several with the very sad news that Tony McMichael has died.

I share the universal sorrow felt by all epidemiologists everywhere, although I am not shocked because he confided in me years ago that he was living on borrowed time, and on a kidney transplanted from his wife Judith. Tony had congenital renal disease.

Tony grew up and went to school and medical school in Adelaide, about 15 years after me. I first met him briefly when he was still a  student, introduced to him by his mentor Basil Hetzel, who remarked that this was a young man who would go far. I got to know him well when he was a young epidemiologist, and our professional interests coalesced around the most urgent crisis of our time, the unsustainable pressure of human predation on ecosystems and environments everywhere on our fragile planet. Because of this shared interest and concern I tried to recruit him early in my tenure as department head of epidemiology and community medicine at the University of Ottawa (he resisted the temptation).

It would be hard to find anyone with the same breadth of scholarship, the same degree of knowledge and understanding of the dangers facing life on earth, the same clear vision of contributions epidemiologists can make to finding solutions, to making the world a better, happier place for humans and other living creatures.

Tony was a warmly compassionate, charismatic man, an inspiring intellectual and moral leader. Like all who knew him, I will miss him very deeply and I mourn his loss.

2014.09.22

Today is my 88th birthday. Inside I don't feel much different from the way I felt when I was 18, or 48, or yesterday. Outside it's a different matter. 

We celebrated yesterday. David came from Kingston late on the evening before and yesterday he spent much of the morning making a chocolate cake.  I took photos on my iPad and I'll add one to this post if I can figure out how to get it from the iPad to the iMac; David took several photos on his iPhone and I'll post a couple here. Unfortunately I didn't get a photo of all the family.

David made the chocolate cake according to a recipe that Wendy got from her Mum, who got it from her neighbour, an old lady called Mrs Searle; this recipe is probably over 150 years old, a fact reflected in quaint measurements like a "heaped coffee cup". I suppose this is one of those little New Zealand size coffee cups. David created his own special icing. I can't find this recipe in any of Wendy's remaining recipe books, so it's presumably only in the little school notebook of hand-written recipes that David took home with him after Wendy died.  

 Mrs Searle's chocolate cake recipe
  (Wendy's hand-written copy in David's
    cook-book)

The cake on the table while I read Rebecca and Richard's card

Better together

It wasn’t even close. In yesterday’s Scottish referendum, 55% voted to remain part of the United Kingdom, 45% favoured the dream of Scotland becoming an independent nation.  If we still lived in Edinburgh, my personal intellectual and emotional balance sheet of arguments for each side would have been closer I think, perhaps 51% for union, 49% for independence.

Altogether I lived in Scotland, in Edinburgh, for more than five and a half years: four months in 1952 when I took the advanced course in internal medicine sponsored by the Royal College of Physicians of Edinburgh; four years and nine months in 1965-69, when I was on the staff of the Usher Institute of Public Health at the University of Edinburgh, four months in 2002 when I was visiting professor at the Usher Institute and a consultant assessing health services research for the Scottish Health Department. In 2003 I returned to Edinburgh for another month as visiting professor and was admitted as Doctor of Medical Sciences Honoris Causa  of the University of Edinburgh. In 1965-69 and 2002 Wendy and I set up house in Edinburgh. In 1965 we arrived in Edinburgh with the distinct possibility of spending the rest of our lives in Scotland. We (or rather, a mortgage finance company, known in Scotland as a  Building Society) bought a lovely home overlooking Braidburn Park with a superb view south to the Pentland Hills, the loveliest home we ever had, a perfect place to raise our kids. In 2002 Wendy and I rented a flat in Eyre Crescent, north of Princes Street in New Town, just around the corner from Dundas Street and Scotland Street, the setting of Alexander McCall Smith’s stories about Bertie the gifted 6-year-old, his appalling mother Irene Pollock and all the other marvelous characters conjured up in this delightful series of books. In 1965-69 we put down roots that have never withered away, so whenever I go back again I feel as if I am coming home and wonder why we ever left this loveliest of British cities. I lived in Scotland for long enough for some of its culture and traditions to rub off on me, long enough to become fully aware of reasons why so many Scots aspired to be independent of the UK. Of course as well as actually settling in Edinburgh there have been other occasions, half a dozen or more, when I've just dropped in for a visit, most recently in 2011 when the IEA met there, 1984 for a previous IEA meeting, and several other times when I dropped in briefly. The best of visits of that kind was in the summer of 1961 when I was a visiting scholar from Australia and had a week each in Aberdeen and Edinburgh, and overnight sojourns at several community health centres or group general practices, Stranrar in South-west Scotland, Livingstone New Town between Edinburgh and Glasgow, general practices in Glasgow, and a couple of others. 

Scotland is much more than an appendage of England or the northern, ruggedly beautiful, geologically distinct, culturally different part of an island off the west coast of Europe. Scotland has been politically distinct from England for centuries, closer in ideology and political philosophy to Scandinavia than to England. Scotland is politically closer to perfection as I perceive it, than any other place on earth, a nation that practises equity and social justice and has smoothly functioning health and social services of a very high standard. Scotland is not hampered by a hierarchical class structure. There is an egalitarian educational system, and many say, the best education in the world – proof of this pudding is the fact that Scots lead influential sectors of society all over the world far beyond as well as within Scotland. Our kids, especially Rebecca, got great value from Scottish education.  I benefited from Scottish educational standards when I was the senior lecturer in social medicine at the Usher Institute of Public Health in the University of Edinburgh. I was  stimulated, encouraged and propelled to heights of excellence by my colleagues and by the top quality students I was teaching and mentoring. And I was presented with the gift of being principal investigator for several inter-related research projects on medical education, which I did for the UK Royal Commission on Medical Education.  There is universal respect in Scotland for the educator, recognition of the importance of education as the essential foundation for accomplishment and success in all walks of life. (In the 1960s this was not reflected in commensurate salaries! My peers in English medical schools had salaries and benefits 10-25% greater than mine, colleagues in USA were getting twice what I was paid).

There would have been enormously disruptive consequences for all of the UK had the referendum gone the other way, convulsive upheavals in economic and financial sectors of society. The UK survives now more on its historical reputation than its present strength; its vitality, its inventiveness, innovative technologies, cultural and artistic achievements come disproportionately from north of the border. Without Scotland, the remainder of the former UK would no longer have been able to ‘punch above its weight’ in international forums, would have sunk into irrelevance, a once-mighty nation with a stature and leverage comparable to that of Austria. Sentimentally I’d have voted for Scottish independence. With my brain and mind, however, I’d have voted for unity. And, unless promises are broken, as they may be by a slippery prime minister, there will henceforth be much greater autonomy for Scotland. The outcome may well be that the Scots achieve the best of both worlds, the benefits of unity and the flexibility and freedom of autonomy. 

Several features of the referendum process are worth mentioning. There was a very high turnout, 85% of eligible voters, including an even higher proportion in the 16-18 age group, who voted for the first time. More important, the campaign was good-natured throughout, with no acrimony or ill will; and the vanquished accepted the results without complaint. 

Flawed psyches, or territorial instincts at work?

Pope Francis, who seems to be more insightful, more in tune with the times than many who preceded him, said recently that all the conflicts raging in the world today amount to a third world war. 

I think he's more right about this than the evangelical crazies who believe the hostilities in progress in the Middle East are auguries of Armageddon. More right, yet not completely right. For one, he seems to think the wars are mainly due to mankind's aggressive spirit, a sort of original sin, and that religious belief can cure or at least ameliorate this. It's not so much a third world war as a state of perpetual war, which I believe is ultimately caused by a rapidly escalating fight for a share of very rapidly shrinking resources.

In a week's time I will be 88 years old.  I became aware of events in the world around me by the early 1930s. From then until now there has not been a single day on which people somewhere in the world were not engaged in a fight to the death against adversaries. In the early and middle 1930s it was Japanese incursions against the Chinese; Mussolini's conquest of Abyssinia; and the Spanish Civil War. Then came the 1939-1945 war, a.k.a. World War II. This didn't end in August 1945 when the Japanese surrendered: the civil war in Greece, a proxy war aimed at expanding the Soviet empire, began before then and continued for a year or more, by which time there were colonial wars of liberation from European powers in French Indo-China which became Vietnam, and the Dutch East Indies which became Indonesia. Colonial wars in Africa began before those two Oriental wars ended and some of these African wars have smouldered on ever since, with occasional brief respites and a few genocides. As well as wars of liberation from colonial overlords, there have been wars launched by mad dictators, ideological wars, wars arising from coups d'etat, and the seemingly never-ending series of wars between Israel and neighbouring states, ultimately caused I suppose by the belief that God gave the Jews a piece of land in that part of the world. I'm not happy with that simplistic classification. 

Stand farther back and all these wars, indeed almost all wars everywhere and throughout human history, can be seen in clearer perspective. They happen because a tribe, a nation, or a group of people defined some other way perceive a need for more territory, more resources, to ensure their survival. Robert Ardrey called it the territorial instinct: it defined the region a group perceived as essential to ensure survival. Ardrey's reasoning and the evidence he marshalled - really as much anecdotes as evidence - were flimsy, but his conclusion may have been rather sound. 'Instinct' is the wrong word for it. It's more accurately described as a biological imperative. This could even explain the otherwise irrational, irresponsible war that George W Bush launched against Saddam Hussein's regime in Iraq, the war that continues today with the nascent Islamic State pitted against a loose coalition of states led by the USA. 

The present human predicament is that well over 7 billion humans are striving to stay comfortably alive in a finite world in which there are essential resources required for sustainable longterm survival of a much smaller population than this, I think at least an order of magnitude smaller, i.e. about 700 million humans could probably survive comfortably. The predatory manner in which resources are currently being squandered means that the number able to live comfortably on the world's available resources is inexorably shrinking. It may be 700 million now, but in another generation it could well be 500 million or less.       

The outlook doesn't encourage optimism, and is likely to be made much worse by global climate change, other environmental stresses, and escalating resource depletion.  I feel uneasy about prospects for my grandchildren.

The art and craft of Geraldine Brooks

Geraldine Brooks is one of the most interesting women now engaged in the noble art and craft of writing. Like me, she is an exile from Australia. She took a degree in journalism in Sydney, proceeded to Columbia University in New York on a scholarship, and in short order became the Wall Street Journal’s correspondent in the Middle East where she became familiar with conditions in Saudi Arabia, Egypt and Iran, among other countries. She took a particular interest in the status and roles of women in Islamic societies. She doesn't say so but I think she must be able to speak and read Arabic.

The first of her books that I absorbed was Nine Parts of Desire. This provides Brooks's perspective and intimate portraits of the lives of women in Islamic societies, particularly in the very different societies of Saudi Arabia, Egypt and Iran, and elsewhere also in the Islamic world. The main message is that women are anything but suppressed, repressed and powerless. My own very superficial observations support this. In 1998 I was briefly a visiting professor at the American University in Beirut and an invited speaker at a regional conference of the International Epidemiological Association. I had the good fortune there to get acquainted with young men and women from every country in the Eastern Mediterranean Region of the World Health Organization from Afghanistan to Morocco. I was particularly impressed by the young women - by their high intelligence, their ability, dedication, insight, and motivation. I’ve also worked in other Islamic countries, and countries with large Moslem populations - Indonesia, India, Saudi Arabia, Kuwait, Pakistan and Turkey, where it would be hard not to observe striking cultural and behavioural differences in the status of Moslem women. In Ottawa I've met women graduate students from Iraq, Syria, Iran and Pakistan, but never had many opportunities for conversation outside seminar rooms, never got to know them as well as I did in a few weeks in Beirut in November and December of 1998. It was one of these young women in Beirut, a woman from Iran, who recommended that I should read Nine Parts of Desire to gain understanding of the status and roles of women in Islamic societies. The title of this fascinating book comes from the legend that God divided desire into ten parts, gave one part to men and nine parts to women. Geraldine Brooks writes with great empathy about the Moslem women she encountered. She makes it clear that in some respects women in the western world should envy rather than feel sorry for them.

Soon after that I read the first of Brooks's historical novels, Year of Wonders, which I greatly admired for her eloquent account of the impact of a highly lethal epidemic of the plague (the Black Death) on the  Derbyshire village of Eyam in 1666. Because of the insights on the people's reactions to the deadly plague epidemic, I added this book to my recommended reading for graduate students in epidemiology. Year of Wonders, and even more so, Caleb's Crossing, which is about the first native Indian graduate of Harvard University in the 17th century. demonstrate a remarkable ability to write convincingly in the language and style of the time in which the story is set, and to get inside the head and heart of the female protagonist. Brooks does the same in March, in which the leading character is brilliantly created from the shadowy figure who is away at the Civil War, the husband and father in the background of Louisa May Allcott's Little Women. She can get inside the head and heart of a male leading character almost as convincingly as she does with women characters.  March won the Pulitzer Prize for fiction in 2006.  She had to be an American citizen to win the Pulitzer Prize, and did so because she married an American, now lives on Martha's Vineyard with her husband, two sons, two dogs and a horse.

I also much admired People of the Book. This is about the wanderings of a (fictional) mediaeval Jewish illuminated manuscript lodged in the library in Sarajevo, and a fanciful account of a few of the people who came into contact with this priceless treasure, which is ultimately purloined and taken to Israel, leaving a skillful forgery in its place in Sarajevo.  My son, who was a UN and NATO peacekeeper in Bosnia, served on a Canadian-Israeli-Palestinian peace-building advisory group, and has a Jewish wife, admired this book too, for its insightful portrayal of the troubles in the former Yugoslavia, and the Israeli-Palestinian tensions in that unhappy corner of the world.

Brooks's journalism, e.g.http://www.salon.com/2002/12/04/islamic_women/ demonstrates that she is a serious scholar on the status of women in Islam. 

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.