Connecting the dots

This is probably the last original article I shall ever get published in a prestigious peer-reviewed scientific journal (Journal of Epidemiology and Community Health, 2010, 64:105-108). I was especially chuffed to be able to quote one of David's thoughtful essays (my reference #3)


CONNECTING THE DOTS: THE POWER OF WORDS AND THE DIVERSITY OF EPIDEMIOLOGICAL INFORMATION

Words are supposedly reliable tools to communicate scientific discourse; but words are very exacting. Ideally, they communicate our thoughts precisely and concisely, but they can obfuscate, mislead and confuse, often unintentionally. That is why technical dictionaries are so necessary. Good scientists do not want to be like Humpty-Dumpty, who said to Alice “When I use a word it means exactly what I choose it to mean, nothing more, nothing less.” One incentive to compile the Dictionary of Epidemiology was the insistence by an eminent clinician-epidemiologist that “case-control study” described what everyone else called a randomised controlled trial.

Words arranged in particular ways become more than the sum of their parts. They can arouse strong feelings because of emotional overtones or cultural associations. Several kinds of imagery, especially metaphor, can enliven otherwise bland statements. A metaphor is a figure of speech in which a word or phrase is applied to an object or action to which it is not literally applicable; it is representative or symbolic of something else, but as a metaphor it can evoke emotions. For example, when a famous film star or a favourite aunt dies of cancer, we commonly say she died “after a long battle with cancer.”
Some metaphors are inept. When faced with a troubling problem like poverty, drug abuse or terrorism, American presidents are apt to declare war on it. Lyndon Johnson declared war on poverty in 1964; Richard Nixon declared war on drugs in 1971; and in 2001, George W Bush declared war on terror. The war on poverty was lost through indifference. As for drugs and terror, the “war” metaphor signifies attitudes linked to flawed policies and failed strategies. Despite vast expenditure of money and lives, the wars on drugs and terror are unwinnable with current policies, no matter how much money, how many human lives, are expended. A recent important convert to this view is the Pentagon, which may portend a transformation in policies and strategies not only by the USA but also by other nations. A trial balloon was launched in the influential Washington-based magazine, Foreign Policy in May/June 2009:

Americans are a can-do people. They believe that if something does not work, it needs to be fixed. Unless they are talking about the war on drugs. On this politically fraught issue, Washington’s elites and the majority of the population, believe two contradictory things. First, 76% of Americans think the war on drugs has failed. Yet only 19% believe the central focus of antidrug efforts should be shifted from interdiction and incarceration to treatment and education; 73% of Americans are against legalising any kind of drugs, and 60% oppose legalising marijuana. As a result of this utter failure to think, the USA today is the world’s largest importer of illicit drugs and the world’s largest exporter of bad drug policy. The US government expects, indeed demands, that its allies adopt its goals and methods and actively collaborate with US drug-fighting agencies. This expectation is one of the few areas of rigorous continuity in US foreign policy over the last three decades. A second, and more damaging, effect comes from the US emphasis on curtailing the supply abroad rather than lowering the demand at home. The consequence: a transfer of power from governments to criminals in a growing number of countries. In many places, [drug] traffickers are the major source of jobs, economic opportunity, and money for elections. Fortunately, there are some signs that the blind support for prohibition is beginning to wane among key Washington elites. One surprising new convert? The Pentagon. Senior US military officers know that the war on drugs is bankrupt and that it is undermining their ability to succeed in other important missions, such as winning the war in Afghanistan.1
Among those holding this view is General James L Jones, Barack Obama's national security adviser.

Most health and social problems associated with illicit drug use would disappear if all illicit drugs were legalised. They could be sold to licenced users in government-run stores akin to liquor stores, where drug users could be identified and get counselling, and treatment could be offered. This would eliminate much hazardous conduct associated with drug abuse. It would augment government revenues, eliminate a lucrative source of income for the criminal purveyors and perhaps cleanse society of a great deal of crime. The only nation that has decriminalised illicit drug use, Portugal, is the only one where drug use has declined, along with HIV infections and other drug-related diseases, since the policy was introduced in 2001;2 the Portuguese government missed an opportunity to generate revenue: they do not sell drugs in government outlets and did not decriminalise sales, only the personal use. That is a bit daft, but at least Portugal took one step in the right direction.

Declaring war on drugs that may be abused by susceptible youth is a hopelessly flawed policy. It leads society to criminalise victims who need compassionate treatment and prevention of dangerous complications, notably HIV infection. I am over- simplifying a convoluted problem, but many young people take mood-modifying substances to soften the harsh realities of their lives which they perceive as miserable, offering no hope of better things to come. The war on drugs is complicated by the ideological prejudices of some policy makers. They regard illicit drug use as worse than criminal: it is sinful. Purveyors and users of illicit drugs are all sinners; all must be punished. The lessons of the disastrous American experiment with Prohibition have been forgotten by these zealots.

Terrorism is more complex. It is a health problem because it causes many deaths, much maiming and mutilation of innocent bystanders. Terrorism is multifaceted. Its existence depends upon who views it: one man’s terrorist is another’s freedom fighter. Terrorism is essentially a political problem with economic, social and cultural components, and its peaceful resolution requires strategies and tactics designed by a consortium with expertise and experience in all these domains.3 The most futile, counterproductive tactics are those that rely primarily on military force, which is the worst of all possible tactics if deployed alone: the “collateral damage,” death, dismemberment, mutilation of non-combatant women, children and infants inevitably lead to vengeful retaliation. Comprehensive evidence-based policies and strategies, based in part on epidemiological and sociocultural research, are essential to overcome terrorism.

Now consider another metaphor. In 2007, I was asked in an interview about the contribution of epidemiology to society. I said:

Epidemiology connects the dots, the isolated bits of information that begin to form a coherent pattern when connected in the right way . What we learn is passed on to society through concerned citizens, media, and eventually, often lagging far behind, policy- makers, our elected leaders .. Epidemiology has been a powerful lever for important shifts in societal values, has led to social and behavioural change and improvements in the human condition. There are five ingredients in this process: awareness that a problem exists; understanding what causes it; ability to deal with the cause; a sense of values that the problem matters, and political will. These five ingredients have led in my lifetime to improved control of tobacco smoking, impaired driving, child abuse, domestic violence, environmental lead poisoning and several occupational diseases. We urgently need to apply these five ingredients to control the dangerous problem of global climate change.

The dots can come from anywhere. Identifying them demands a broad perspective, the ability to see the Big Picture. It also requires what John Ashton4 called the “epidemiological imagination,” a particular way of thinking. Sometimes the way the dots are connected is instantly apparent. Sometimes painstaking investigation and analysis are required, for instance when the problem is a common but ill-defined condition (mild mental retardation) caused by trace amounts of a highly reactive environmental toxin (lead salts in soil, food or drinking-water).

Some recent problems and how they were solved demonstrate how human behaviour, including customs, culture, level of economic development, trade, commerce and technical innovations, can influence health hazards - the diversity of the dots we must connect. These examples illustrate another interesting truth: epidemiology is the most eclectic science, using information from wherever intelligence, intuition and imagination suggest that insights and understanding may be found.

A culturally induced disease due to disruption of women’s bodily micro-environment occurred in the middle 1970s: super- absorbent vaginal tampons enabled women to keep working while menstruating, without stopping to insert a fresh tampon. But a tampon soaked in menstrual fluid and retained for hours in the warm, moist environment of the vagina is a perfect culture medium for staphylococcal enterotoxin. When this sequence was identified the nature of toxic shock syndrome was clarified, and the problem was solved.5 The epidemiological evidence (the connected dots) came from gynaecology, microbiology, toxicology, sociology and the fashion and pharmaceutical industries.

If a hot indoor environment is cooled with a dilapidated air conditioning system, the elusive pathogen, Legionella pneumo- philia can breed and is disseminated in the cool moist air. The pneumonia epidemic among members of the American Legion who attended a convention in Philadelphia in 1976, then went home to sicken and die elsewhere, was clarified when this had been worked out.6 The evidence came from clinical medicine, pathology, microbiology, vital statistics and record linkage, and from engineers who make and service air conditioners. All combined and connected the dots to solve that puzzle.

Asiatic cholera in the early 1990s in Peru, Ecuador and Colombia involved a complex causal chain. Ships trading from India discharged ballast water contaminated with a virulent strain of Vibrio cholerae in coastal waters and river estuaries. This coincided with an El Niño Southern Oscillation that warmed those usually cold waters. The warmer seas fostered an algal bloom of zooplankton, which are symbiotic with cholera vibrio; so these proliferated in seaports along the Pacific coast of South America.7 The resulting cholera epidemic lasted several years, causing half a million cases and several thousand deaths. The evidence that unravelled this sequence came from oceanography, marine biology, microbiology, international trade, anecdotes about maritime practices, all united by epidemiological insight: seemingly unrelated dots formed a coherent pattern when they were connected.

International trade brought the Asian tiger mosquito, Aedes albopictus, to the southern USA in the 1980s as larvae in pools of water in used car tires imported for retreading.8 9 The southern USA provided many ecological niches for this efficient vector for dengue and several kinds of virus encephalitis. The Asian tiger mosquito has proliferated along the eastern seaboard and west to the Mississippi Valley. With the expected global warming of the next century, the range and breeding seasons of these mosquitoes (and of anopheles mosquitoes that transmit malaria) will extend further. This is several epidemics in waiting. Epidemiological and vector surveillance reduce the risks, but tax revolts and the recession have engendered budget-slashing administrations, public health infrastructure has been weakened, and this defensive line may be vulnerable.

These and many other examples illustrate how epidemiology is combined with scientific and technical expertise from many disciplines and varieties of knowledge to investigate and control public health problems. These problems were solved by a combination of intelligent merging of information from diverse sources and disciplines (connecting the dots) and the epidemiological imagination. This approach to problem-solving is a learnt skill, so it can be taught.

From the 1940s onward, biomedical scientists discovered and developed powerful antibacterial drugs to treat and often cure previously lethal infections. I am old enough to remember what medical practice was like before we had antibiotics, and could do little but watch as previously fit young people died, sometimes in hours, from pneumonia or overwhelming septicaemia.

Physicians from that generation can be forgiven for embracing antibiotics so enthusiastically, and using them, we realise belatedly, too often, too uncritically. Antibiotics were weapons in our “war” against pathogenic bacteria. We declared war on them all, even bacteria that live symbiotically in our gut, assisting digestion and manufacturing vitamins.

The medical profession is not the only guilty party. Veterinarians, agricultural scientists, farmers and advisers about animal husbandry were guilty too, advocating addition of antibiotics to animal feed to ensure healthy animals destined for slaughter. These customs and evolutionary rules bred generations of antibiotic-resistant pathogens.

Also, in the 1940s, scientists discovered the insecticidal power of DDT and began using it in the “war ” against malaria and other vector-borne diseases. In 1944, when Naples was liberated from Nazi occupation, a threatened epidemic of louse-borne typhus was aborted by dusting the population with DDT. I recall rejoicing at a cinema newsreel as the story of this public health victory was told, accompanying news of military victories after years of unremitting bad news from war zones in Europe and the Pacific.

Initially, our wars against bacteria and insects succeeded. Pneumonia, septicaemia, meningitis, syphilis and gonorrhoea melted away under bombardment by penicillin and other antibiotics. Malaria was eliminated from south-eastern Europe, the Middle East, China, much of South and East Asia, Mexico and Central and South America, where previously its toll had impeded development. But proclamations of victory over infectious pathogens and insect vectors were premature. The laws of evolutionary biology soon produced antibiotic-resistant pathogens and DDT-resistant insect vectors. In a favourable environment, the generation time of pathogenic bacteria may be only a few minutes: in a few days, the length of a course of treatment, there is time for antibiotic-resistant bacteria to evolve and proliferate. The same rules apply to insect vectors, although generation time is longer. Soon DDT-resistant mosquitoes proliferated. We have had victories against pathogens and insect vectors, but we cannot win the war with these tactics. We need different strategies.

A promising strategy is to find ways to live in harmony with our microbial enemies. Vaccines that confer immunity enable us to coexist alongside pathogens. Sometimes a physical barrierdwindow screens, bed netsdcan shield us, especially vulnerable infants and small children, preventing contact with mosquitoes and other vectors.

Humans are an aggressive species, and our metaphors reflect this. We wage wars against cancer, alcoholism, epidemic diseases and bacterial pathogens. With far-reaching consequences, another metaphor boasts of conquering the environment. But the environment is our essential life-support system. We may harm, even destroy, it when we change it to suit current whims.

Every year, humans withdraw an estimated average $33 trillion of global ecological goods and services, making little or no capital return.10 We cannot go on doing this indefinitely. James Lovelock11 thinks it is already too late; we are on an irreversible path to a hotter world. We behave as though perpetual economic growth and “development” are not only possible but desirable. Perpetual economic growth is no more possible than perpetual motion, the fanciful dream of the scientifically illiterate.

In my lifetime of over 80 years, the world has become a better place for me and others in the tiny, well-educated, affluent minority; but life has not improved for the billion who subsist on a dollar a day or less, and there are increasing signs of irreversible damage. All indicators show evidence of deteriorating life-supporting ecosystems. Thirty years ago, when I first became concerned about global sustainability, we had few indicators and less sensitive models than now of trends in global sustainability, soil productivity, atmospheric and ocean currents. The signs were worrying, but the evidence suggested that serious trouble was hundreds of years away, adequate time to put things right. The evidence in the Fourth Assessment Report of the Intergovernmental Panel on Climate Change in 2007 and recent direct observations of Arctic ice and glacier melt are more urgent. The time for effective action has shrunk to a few decades or less.

Climate change has several direct and indirect adverse effects on human populations.12 It causes extreme weather (severe storms, hurricanes, heat waves, droughts, torrential rainstorms and floods); sea level rise disrupts coastal ecosystems and fisheries, destroys habitat and floods fertile coastal farmland. Storm surges over low-lying coasts drown large numbers, for example in Bangladesh, and endanger everybody in small island states. Heat waves kill vulnerable people, an estimated 50 000 in the European heat wave in 2003. High humidity and increased surface water accompanying high ambient temperatures, favour water-borne diseases, insects and vector-borne diseases: malaria, dengue, virus encephalitis, perhaps newly emerging pathogens. By 2050, an additional billion people may be at risk of malaria. Extremely high temperatures damage germinating rice and grain crops, and floods and droughts can destroy the growing crops, so food shortages, perhaps severe enough to cause hunger, starvation, famine, are another scenario. When a region is afflicted, the people have to move, becoming environmental refugees. Massive population movements and large refugee communities produce challenging public health problems. Conflict is a common sequel, as in Darfur.

Resource depletion is another aspect of global change. The most critical resource is freshwater for drinking and irrigation. The daily requirement varies with environmental conditions, physical activity, metabolic demand and other factors. Freshwater is critically short in the Middle East, South-western USA, North-eastern South America, north China, and Australia south of the “top end” that gets seasonal monsoon rains. Contrary to popular belief, Canada does not have limitless freshwater: the Great Lakes are mostly fossil water, left over from the last ice age. Canada does not have enough spare water to nourish the parched US south-west. Wars have been fought over access to water, and water shortages will probably lead to future conflicts. These and other health-related consequences of climate change are described in the reports of the Intergovernmental Panel on Climate Change (http://www.ipcc.ch) and in many other reports.

Sea levels are rising as polar and alpine ice melts. Arctic sea ice is melting, so there is open water at the North Pole in summer. The water reflects less solar radiation than ice and snow, so the warming and melting accelerate: ice-melt that previously took many decades can happen in a few summers. Regions of concern are the glaciers of Greenland and Antarctica. When these melt, sea levels could rise by 5-7 m, perhaps more. All seaports and many of the world’s most populous cities face inundation. Over a billion people’s habitat and many sources of food supplies are threatened. Food shortages and famines are part of this scenario.

Epidemiologists and front-line healthcare workers have important tasks. It is essential to identify vulnerable groups at highest risk and have plans to protect them from harm in climatic extremes (heat waves, floods, etc). Risk assessment, evaluation of intervention strategies, disease and vector surveillance, water and food security policy and disaster planning are all high priorities. Collaborative research between health scientists and environmental scientists is needed to identify critical environmental “load” limits and to develop amelioration strategies. We know very little about interactions between survival of other species and human survival; this is a field for epidemiologists to cultivate. Many more dots must be identified and connected before all the health and social problems associated with climate change are delineated, classified and solved.

SUMMARY

Words both shape and reflect our sometimes irrational behaviour, as in the unwinnable “wars” on drugs and on terrorism. “Wars” on pathogenic organisms are also irrational and unwinnable with antibiotics and pesticides because they attempt to defy inexorable laws of evolutionary biology. Logic and rational thinking are essential prerequisites in tackling intractable problems such as drug abuse, terrorism and control of diseases caused by pathogenic agents. Logic and rational thought are equally essential and are urgently needed to tackle the problems associated with climate change. These problems transcend traditional disciplinary boundaries and require innovative, eclectic approaches and unconventional solutions.
Epidemiology is the most eclectic health science. It transcends disciplinary boundaries and stretches the imagination. The environmental crisis of climate change provides opportunities for epidemiological research and surveillance, including studies of cause/effect relationships, risk identification and risk assessment, evaluation of adaptation and mitigation strategies. Many more epidemiologists must get engaged in climate change research and surveillance. Epidemiologists need wide horizons to see the big picture. It is very satisfying to see the picture emerging from the connected dots. That satisfaction has kept
me going. I hope it keeps young generations of epidemiologists going, too.

Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.

REFERENCES
1. Foreign Policy, 2009, May/June. http://www.foreignpolicy.com/story/cms.php? story_id1⁄44861 (accessed 24 May 2009).
2. Scientific American, 7 April 2009. http://www.scientificamerican.com/article.cfm? id1⁄4portugal-drug-decriminalization (accessed 24 May 2009).
3. Last DM. Transformation or back to basics? Counter-insurgency pugilism and peacebuilding judo; Paper for the conference on peace support operations, at the Truman Institute, Jerusalem, 18-19 June 2007. In: Michael K, Ben-Ari E, Kellen D, eds. The transformation of the world of warfare and peace support operations. West Port: Praeger Security International, 2009;Chapter 6. 101e21.
4. Ashton J, ed. The epidemiological imagination. Buckingham: Open University Press, 1994.
5. Davis JP, Chesney PJ, Wand PJ, et al. Toxic shock syndrome: epidemiologic features, recurrence, risk factors and prevention. N Engl J Med 1980;303:1429-35.
6. Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires’ disease: description of an epidemic of pneumonia. N Engl J Med 1977;297:1189-97.
7. Epstein PR. Emerging diseases and ecosystem instability: new threats to public health. Am J Public Health 1995;85:168-72.
8. Knudsen AB. Global distribution and continuing spread of Aedes albopictus. Proceedings of a workshop on geographical spread of Aedes albopictus, Rome. December 1994.
9. Knudsen AB. Geographic spread of Aedes albopictus in Europe and the concern among public health authorities. Eur J Epidemiol 1995;11:345-8.
10. Costanza R, d’Arge R, de Groot R, et al. Value of global ecosystem goods and services. Nature 1997;387:253-60.
11. Lovelock J. The vanishing face of Gaia: a final warning. London: Allen Lane; Penguin Press, 2009.
12. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009;373:1693-1733.

Victories great and small

This has been a good week, week and a bit really since Wendy's PEG. The nutritionist and the nurse between them educated me in the hygiene of changing dressings as well as how to give Wendy fluid and food through the tube. It's years, decades almost, since I did this kind of doctoring, but it came back to me quickly and easily. I'm sure PEG tube feeding has helped already to restore her nutritional status, and she is looking and feeling better. (It's done nothing to arrest the process of progressive muscle loss, which is now affecting her voice more obviously; I had a reminder email earlier today from Margo Butler, the speech language pathologist at the ALS Clinic, about our own personal list of words and phrases to add to those programmed in the voice synthesizer). I've worked out a system to make the tube feeding process as efficient as possible, and the Personal Care Workers' supervisor brought Sarah Kerrigan, the young PCW who is a student nurse, here so I could demonstrate my system which is very simple: I just lay out on a little table all the bits and pieces, syringes etc, that I need, so all is ready to move straight from one step to the next without interruption. I go very slowly, probably slower than the nurse (Jody Gannon) demonstrated, so 60 Ml sterile water, 60 Ml high protein, high calorie liquid, and a chaser of another 60 Ml sterile water, takes 20-25 minutes. Wendy says I'm "very gentle" which is high praise.

It'a been a good week in other ways too. I passed my third 'Over-80' driving assessment with flying colours. I know where this test is conducted because I've been there twice before; the assessment is made at 2-year intervals beginning at age 80. But today, instead of relying on my memory, familiarity with Ottawa's major roads, and my sense of direction, I relied on Google maps, with the consequence that I got hopelessly lost getting there and arrived half an hour late. Now I understand why so many of the diverse array of experts helping Wendy get lost trying to find our very easy-to-find apartment building; it's because they rely on Google maps instead of following the simple directions I give them over the phone. Anyway, I aced the test, passed the vision test 100%, got every answer right on the rules of the road test; then as the licence bureau where I do the paperwork to renew the licence is just around the corner from the test centre, I dropped in, expecting the usual hour's wait for my number to be called, and a once-in-a-lifetime event, the place was empty, not a soul waiting to be served, so I walked up to the counter, paid my fee, and am all clear to drive again for the next two years. That was a good morning's work, and I had time at the end of it all to pop into our friendly neighborhood supermarket for some urgently needed supplies, such as some tonic water for my G&T.

Humorous Books

A friend who is about to set off mountain climbing in the Rockies confessed that he's never read anything by the great English humorist P G Wodehouse so he is taking one of the Jeeves and Bertie Wooster short story collections. It's a good choice, provided he has the self-restraint to ration himself to one story a night, something I could no more do than eat one salted peanut, or one chocolate peppermint cream. His remark sparked a train of thought about humorous books, including ones that make you think, like Rabelais, Voltaire's Candide, much of Mark Twain, Fielding's Tom Jones, and nearer our time, S J Perelman, James Thurber, Alan Bennett, among others. The last of these, Alan Bennet,may never have been funnier than in the sermon skit he performed in the original Cambridge Footlights performance, Beyond the Fringe, and much of his recent work is the sort of humour that is as likely to induce tears as laughter. It's probably a cultural thing, that I have more affection for the English humorous writers than for any other, so Three Men in a Boat, and The Diary of a Nobody have a place in my personal pantheon.The Canadian humorist Stuart McLean, who is often funnier if not more witty than his American counterpart Garrison Kieler, in much the same way that Stephen Leacock was funnier than Mark Twain, can induce tears or a lump in the throat too, but his serious mode is often a rather mawkish sentimentality, not a profound reflection on the human condition. I have enormous respect for real humorists who have that rare ability to make us laugh yet make us think too. Perhaps no one did it better than the classical Greek playright Aristophanes 2500 years ago: in Lysystrata,he fully exploited the endless humorous potential of a situation in which the women withhold their sexual favours in order to dissuade their men from endlessly fighting and going to war. And on the matter of that book, would the unprincipled rascal who stole my copy with illustrations by Norman Lindsay please return it! I will ask no questions, offer forgiveness, and not report the theft to the authorities.

Interrupted by bull-ants

Should this autobiographical fragment appear in my Memoirs? It was played on CBC radio in Richardson's Round-up about 7-8 years ago and I got feedback of a rather ribald quality from one of my colleagues who heard it. What do you think?

Wendy and I did most of our courting in the picturesque hills behind Adelaide. One day when driving in these hills we were overcome by amorousness. We carried our rug to a grassy slope out of sight of the road where we settled down to express our affection for each other in our customary way. Before either of us had really warmed to the business at hand, my beloved suddenly screamed and leapt up, tearing frantically at her clothing. In our careless haste, we had spread our rug on a bull-ants’ nest. Bull-ants are fierce fire-red creatures a centimeter or so long, equipped with sharp pincers where lesser insects have jaws. They were displeased to have their nest and its approaches obscured by our rug, and let us know in the only way they could. Wendy sustained several savage bites that, she later told me, raised angry welts on parts of her person I was not yet permitted to see. We retreated in disarray and confusion. After that unhappy experience we inspected the site carefully before spreading our rug – or stayed in the slightly cramped but ant-free safety zone inside the car.

This story dates us: in the pre-Pill era most respectable people (and we were respectable) were rather circumspect and perhaps even a bit inhibited about sex. We were both shy too, after all here we were, both of us in or on the threshold of our 30s, still unattached. Many of our contemporaries in nursing and medicine respectively, were married and parents of a couple of kids by the time they were our age. Our courtship was a wonderful period of mutual discovery of each other's minds and bodies. I wonder whether courtships nowadays are as satisfying and pleasurable as ours was.

Using the PEG tube

After a lesson from nurse Jody Gannon, I used the PEG tube to give Wendy three square meals yesterday. She can take much more nourishment this way, and what we both found encouraging was that in addition to the high protein high calory fluid called Resource # 2.0 through the PEG tube, she also had her regular supper by mouth. Her regular supper is one of Richard's specialties, lightly curried fish or chicken pesto or one of his other tasty dishes, blended, seived, frozen into cubes, then thawed, heated, seived again and served in a soup dish. Richard's gourmet meals are delicious, so it's great that Wendy still enjoys them enough to have one of these after her high energy fluid through the tube direct into her stomach. If we can keep this up, we will soon get some flesh back on to her bones. Today is her fourth since the PEG and she is getting some bounce back into her steps, graduated from the wheelchair to the walker. At this rate, with all these high energy meals, we'll have her ready for the triathalon in time for the next olympic games.

Hiroshima

There is a shallow pond beside the Rideau Canal about 200 meters south of our apartment building. In the spring it is the spawning ground for catfish and carp. This day, August 6, it is the location of a moving annual commemoration of August 6, 1945, the first time an atomic bomb was used to kill humans in large numbers. Representatives of the Japanese government, members of the Japanese community in Ottawa, and some of us who advocate and work for nuclear disarmament gather there and float little paper lanterns in paper boats on the pond. I was a teen-age medical student in 1945 and like most of my classmates I had recently learnt enough physics to understand how such a bomb would work according to Einstein's famous formula for the relationship of energy to mass. Through most of my life from then on the threat of nuclear war has been a dark cloud over all of us. This year's commemoration seems rather higher profile than usual, for instance because the UN secretary general is attending the ceremony in Hiroshima and because the time given it in news broadcasts, the column inches in our national newspaper, are more than usual in recent years. I hope these are hopeful portents.

PEG in place

Yesterday Wendy had a PEG - percutaneous endoscopic gastrostomy - so she can receive nourishment directly into her stomach, bypassing the increasingly unreliable muscles in her throat that cause her to choke when food or fluid 'go down the wrong way.' This won't prolong her life but like the ventilator to help her breathe while she is sleeping, it will help make her remaining time more comfortable. Today I spoke to the anesthetist and the surgeon (yesterday, with David helping us, our priority was to get her home as soon as we could, rather than hang around waiting for a break between one operation and the next). The operation took six minutes, the anesthetic preparation took about 20 minutes, because the anesthetist, a caring and considerate disciple of the senior man she saw for preoperative assessment, was cautious and took great care to avoid risk of stressing her weakened respiratory muscles. Today, understandably, she has had some postoperative pain and this morning she spiked a fever (101.5 F) that alarmed me briefly; but as the day progressed, she brightened up and with enough medication to control her pain, she has had a reasonably comfortable day, all things considered. The fever went away and hasn't come back so I guess it was just one of those post-operative fevers, just a bit higher than usual. Tomorrow the nutritionist comes and we will have our first lesson in and experience of using the PEG to get adequate quantities of fluid and food into her system. By the end of the day she was looking and acting a whole lot better and brighter than she had early this morning. She's a tough old bird, it takes more than a little operation to knock her down for long.

Thanks, everyone

I can't keep up with all the email good wishes, greetings, cards, flowers etc, that come our way - Wendy's way - and I don't have time to acknowledge and thank everyone individually, so this post is a collective "Thank you!" to family members in NZ and Australia, and to friends in Melbourne, Sydney, Fife, Edinburgh, Peebles, Victoria and Vancouver BC, New York, Los Angeles, San Francisco, and... this sentence is getting too long. So thank you, everybody.

Our story

Several recent visitors have asked how Janet Wendy and I met, where we've been, what we've done over the years. I summed up a little of our story in a speech I made at our 50th wedding anniversary banquet, when this photo was taken. We think our story is a bit unusual and quite interesting, so here are the notes I made for what I said that evening:

On Sunday August 7 1955 I was off duty in the medical practice where I was the junior doctor and on my way to play golf, when I picked up two young women hitchhikers. They were on the wrong road for the place they wanted to go, so I should have dropped them ten minutes later at a corner where they could make their way to the road they needed. But before ten minutes had gone, I knew I wanted to see more of one of them, so I scrapped my plan to play golf. I was running late because I’d called at a hospital to see a mother and the new baby I’d delivered a few hours earlier and my usual partners would have started without me. It was a perfect spring day, sun shining, blossoms opening everywhere, birds singing. I offered to show them the dairy-farming and grape-growing country south of Adelaide. At the end of the day we exchanged addresses because the one who interested me, Jan (short for Janet) Wendelken, was heading home to New Zealand after several years in Britain. When she got there, we began writing to each other. Our letters became a courtship by correspondence. Jan, also known as Wendy, came back to Adelaide in June 1956. Our theoretical love affair became practical, hands-on, and much more fun. We got engaged on August 16 1956 and were married in the chapel of my old school, St Peter’s College, on February 14, Saint Valentine’s Day 1957, a searing hot 104 F but a cool change in late afternoon made the wedding reception very pleasant.

Our wedding anniversaries have been scattered about the world and many have been memorable: Our 7th was in Kingston Jamaica, when officers on the ship where I was the surgeon took us to a brothel; in Edinburgh we dined once at a very posh country inn with peacocks in the garden. Two venues for our celebrations no longer exist, a sandy beach resort in Sri Lanka that was swept away in the tsunami on Boxing Day 2004, and the restaurant on the top floor of the World Trade Center in New York that was wiped out on September 11, 2001; our 30th was at the best seafood restaurant in Sydney. On our 36th, a cold, wet day in Dunedin, New Zealand, we had an unforgettably awful meal. On our 40th anniversary, Wendy planned to surprise me with a hot air balloon ride over Ottawa but we never got off the ground because it began to rain as we were on our way to the field where the balloon was to be launched, and hot air balloons don’t fly in the rain. In the week before our 45th anniversary I performed in a colloquium at a think-tank on a cliff edge beside the Pacific Ocean north of San Francisco. I flew home anticipating an intimate dinner at a little French restaurant, to be greeted with the news that the day before, Wendy had slipped on the ice and broken her hip. Instead of our tête-à-tête dinner, I visited Wendy in the Ottawa General Hospital. On our 46th anniversary we had champagne at a resort in the Dominican Republic. I was in India working for the World Health Organization on one anniversary, but otherwise we’ve been together for all of them.

None of this was imaginable when we married. We expected to spend the rest of our lives in medical practice in Adelaide, where I greatly enjoyed my work as a family doctor, and, I think, was reasonably good at it. But less than two years after we married, when Rebecca was 11 months old and David was well on the way, I fell seriously ill with pneumonia. I (and my doctor) thought I was going to die, and during my slow recovery I began to think about our future in new ways.

I had an epiphany. Instead of dealing with sick people one at a time, it made more sense to find out why they got ill or injured in the first place, and try to stop it from happening. With Wendy’s backing, I gambled recklessly with our family’s future. I left the financial security of medical practice, and launched into a career in public health research, mainly in epidemiology. As Robert Frost put it, I took the road less traveled. It’s been a fascinating, exciting, fruitful road.

For 15 years we lived on the edge of poverty – research work doesn’t pay well – but we were very happy and life was full of interest. Looking back over it, I think we’ve had a richly rewarding life, we’ve had loads of fun and got around a lot. We’ve lived in Adelaide; Sydney; London; Sydney again where a mortgage company helped to buy our first home; Burlington, Vermont; Edinburgh, where another mortgage company bought most of our second home and our kids acquired lovely Scottish accents that sad to say, they’ve lost in Canada; we came to Ottawa in 1969, and bought our third home (with first and second mortgages); we had a sabbatical year in New York City in the late 1970s, and have lived in Ottawa ever since. In the 1980s my work often took me to Geneva or Stockholm, and after it was done we used rail passes to travel to many parts of Europe. Starting in 1987 I had meetings or work most years in or near Australia so we had a month or two away, half each in New Zealand and Australia. We’ve stayed put long enough to put down roots, get to know the cities we’ve lived in, and in each of them we’ve made good friends. As our family size and needs changed, we’ve moved six times so far in Ottawa. We hope our next move will be to the crematorium, but preferably not for a few years yet. I may have missed a few, but I can count 22 homes we’ve had in five countries; we’ve traveled half way across the world several times on passenger carrying freighters, and over large parts of it by air enough times to have lost count.

Between us, we have produced three children of whom we are immensely proud and whose progress through life we’ve watched with loving approval. Rebecca survived an armed robbery, has been executive director of a regional economic development program, the Canadian Cerebral Palsy Association, the Canadian Environment Industry Association, and now is a policy analyst in the government, a master gardener, and an accomplished public speaker. David appalled me by announcing when he was 13 that he intended to be a soldier, then demonstrated by his actions that what he really meant was that he wanted to be a peacekeeper and an expert in preventing violent armed conflict, which he has done with distinction in some of the world’s combat zones, and in high-level consultations with national, international and intergovernmental organizations. Now he teaches it at the Royal Military College of Canada. He works in another part of the same ‘prevention’ field as I do. Jonathan was born with very severe heart disease, surgically repaired when he was 7, and is carving out a career fixing and trouble-shooting computers, doing computer animations, designing exciting, innovative houses. Our three clever grandchildren all seem poised on the threshold of fascinating, worth-while careers.

Wendy has made possible everything good that has happened to us. Her talents include ability to dash off a vivid sketch and a commendable poem, paint pictures worth hanging on our walls, and to sew and mend clothes. She made what she’s wearing in many of the photos in our slide show, including her own wedding dress, and the gorgeous evening dress she’s wearing tonight, and the children’s clothes when they were young. She’s been a marvelous mother and a caring grandmother. She makes appetizing meals, manages my chaotic life, and devotes much of her time to less fortunate people, and to other good causes. Two of her most endearing qualities are her sense of fun and her spirit of adventure – the combination that plans hot air balloon rides for a pair of 70-year olds. And she has been my moral compass. I’ve dedicated my life and most of my books to her.

My love for her grows stronger every year. I think we’ve had a very happy union. For many years we kept quiet about the way we met – it was as unlikely as the improbability drive in Hitchhiker’s Guide to the Galaxy (and Wendy was hitchhiking on that August day in 1955). Now we boast about it. We’ve proved that time flies when you are having fun – it certainly doesn’t feel like fifty years! I know I’ve had a lot of fun and I’ve been happy, and I believe Wendy has been happy too. I’ve tried to react positively to her rare critical comments. I use mouth wash when she complains about my bad breath, apply scissors when she says my nose hairs are getting too obvious, don’t complain when she keeps me waiting, and try to stay calm when she criticizes my driving.

So please join me in a toast to the love of my life, Wendy.


(Dinner celebration was held in the banquet room at Beckta’s Restaurant, Ottawa, February 14, 2007)

Interventions and devices

Yesterday Wendy had the preoperative assessment to determine her fitness to undergo the minor surgical procedure involved in installing a PEG tube. It's a simple little operation done under local anesthetic with a small dose of intravenous tranqulizer to ensure that she stays calm and relaxed. It usually takes about 15-20 minutes. The assessment was carried out by Dennis Reid, a Scot from Aberdeen, a 1967 graduate, so he was a student there while I was at the University of Edinburgh. He is one of the senior, most experienced men on staff. He pronounced her fit, with the proviso that to be on the safe side she should have it done in the main operating suite rather than in the outpatient endoscopy unit -- hedging his bets a little bit. Meantime she continues on course. We have a fairly smooth routine now: I give her a small dose of the same tranquilizer she will have before the operation on August 3, except that I inject it subcutaneously rather than intravenously. We've figured out between us a quick and easy way to fit her face-mask, then we tuen on the bilevel ventilator, she drifts off to sleep and the ventilator helps her respiratory muscles do their work. In the same way, the PEG tube will help her by eliminating the uncertainty and occasional distress of swallowing 'the wrong way' and choking. I'm getting expert at doing Heimlich manouvres to help flush stuff out of her airway. She spends a good deal of her day sitting quietly, reading, and I got a neat little tilting table that is light enough for her to move easily into position to support the book or magazine she is reading. And so we go on day by day, small victories, minor setbacks, but much more often we are cheerful than misrerable.

More of the sea and sea voyages

There's been a lot of notice taken lately of what is happening in the seas that cover about four fifths of the world's surface. The huge oil spill in the Gulf of Mexico off the mouth of the Mississippi has hardly been out of the headlines since April when it happened. Today there is worrying news about the work of another oil company, Chevron, in very deep water in the stormy North Atlantic, where the deepest oil well ever, more than 2 Km below the sea's surface, is being drilled. Years ago when I was writing my memoirs I wrote several pieces that eventually ended on the cutting-room floor. One of these was about the sea and my travels on and over it.


Sea Voyages


In the early 1950s, the word ‘overseas’ had real meaning. It was the only way to get into or out of Australia – intercontinental air travel was little used and very expensive. I am happy that I was able to go overseas as a young man. In those days it was literally that. I sailed over the seas that separated my birthplace from British and European culture.

MV Adelaide Star


In 1951, the ship that took me from my home in Adelaide steamed across the Great Australian Bight into the Indian Ocean, the Red Sea, through the Suez Canal into the Mediterranean, past the Straits of Gibraltar, across the Bay of Biscay, to the English Channel and the Thames Estuary, to Tilbury Docks. Our ports of call were Fremantle, Columbo, Aden, Port Said, and Algiers, a glamorous, exotic city of excitement and mystery. Three years later I left again from Tilbury Docks to go back to Australia, hitching a ride as ship's doctor on the Adelaide Star, a freighter that carried twelve passengers. We refuelled at Tenerife in the Canary Islands, then cruised nonstop around the bulge of West Africa, across the tropical doldrums, the oily calm steel-blue surface broken only by schools of flying-fish on the day I had no shadow at noon; on south around the Cape of Good Hope for the long haul with following seas and winds, across the southern fringes of the Indian Ocean all the way to Adelaide.

That voyage from Tenerife to Adelaide, one of the highlights of my life, took four weeks without a stop at any port, although we sailed across the mouth of Table Bay on a sunny August afternoon, close enough to see the cables of the funicular that went to the top of Table Mountain, the colours of the dresses the girls ashore were wearing. I was with a little band of professional sailors and a few passengers all sharing the same wanderlust and love of the sea. A long sea voyage in company like that is a splendid way to study human nature, and to get to know and understand the sea in all of its moods.

On voyages later with my wife and children, I went back and forth on passenger-carrying freighters between Australia and England. On the way to England in 1961 we stopped in Fremantle, Aden, Port Said, and disembarked in Liverpool. Going back to Australia in 1962, we joined our ship in Rotterdam, sailed to Antwerp, then Marseilles, Genoa, Livorno (with time to visit Pisa and Florence), through the narrow seas between Sicily and the toe of Italy, with spectacular views of the island volcano of Stromboli spewing red-hot molten lava, and then Iskanderun in the angle at the North-Eastern corner of the Mediterranean between Turkey and Lebanon, through the Suez Canal, down the Red Sea, and across the Indian Ocean to Fremantle and Adelaide. In early 1964, all the family had a 7-week voyage across the Pacific Ocean from Australia through the Panama Canal into the Caribbean and the Atlantic Ocean. We travelled on a refrigerator ship carrying about 20,000 tons of frozen meat. We unloaded several thousand tons each in Kingston, Jamaica; Vera Cruz, Mexico; Charleston, South Carolina; Norfolk, Virginia; Philadelphia, Pennsylvania, where I disembarked to fly to Burlington, Vermont; and Boston, Massachusetts where the rest of the family left the ship. We were moving from Australia to the USA where I had a new academic position at the University of Vermont, and that voyage early in 1964 was our last. After that, air travel replaced ships on all my own and the family's journeys across the world. Our only sea voyages since have been on ferries that took us and our car across the North Sea or the English Channel on European holidays when we lived in Edinburgh, Scotland in the 1960s, and a couple of brief cruises in the Mediterranean. I look back fondly on those vanished days of sea travel. Comely freighters have been replaced by ungainly container ships that don't have wide decks for adults to walk and children to play, and from what I’ve seen of them at sea, they appear to pitch and roll much more than the old style freighters, so they’d be uncomfortable for many seafarers.

A great oak tree's branches must bend before the wind, or they would break. So too, a ship's timbers or steel frame must yield before the force of the sea, or the ship would break up and sink. Every vessel I was ever on: yachts, a Greek caique, an Arab dhow, fake Chinese junks in Hong Kong Harbour, large ocean liners, little coastal steamers around South Australia in my childhood, and all those wonderful passenger-carrying freighters, all moved in the water like living creatures. You can hear, sometimes feel, them seemingly breathing as they move with the sea. They are living, they are breathing. Is that why we call a ship ‘she?’

On all these ships I've been most aware of the movements of the ship's protective skin in my bunk before drifting off to sleep. Behind the never-ending heartbeats of the engines that drive the ship forward through the sea are other sounds, comforting sounds of the ship bending and stretching as she moves with the interplaying forces of the sea. Perhaps the sea is getting heavier, the gently swelling rhythm of the waves is evolving into a storm, the pitch and roll are increasing. With every wave the steel spine and ribs and the steel skin of the ship are moving, quietly at first then more, as the waves gather force. The creaking of the shifting plates and rivets gets louder until it becomes a complaining sound closer to a shriek than a creak, too loud to be pleasurable. There are other noises then, the crash of the waves against the deck that make the whole ship shiver - the old sailor's oath, ‘shiver my timbers’ means what it says. There is a rushing sound of water along the hull, the shuddering roar of the propellers biting at the air instead of the sea as the stern lifts momentarily while the bows dig deeply into the next wave. There is a bang from time to time as a hatch not properly fastened slams shut, or the sound of a glass breaking as it falls from where it had been carelessly stowed to shatter on the deck. At times like that I enjoy more the sight of the ship battling against the sea than the sounds I hear in my bunk.

From the safety of the shore, a storm at sea is a grand spectacle. It looks as if the waves are mounting a charge. The breaking waves are aptly named white horses with their foaming manes. Each is a warrior that will attack and destroy a little piece of the shoreline. Turner's seascapes capture the flavour. In the early 1940s when I was a schoolboy one such storm was so violent that even in the sheltered waters of the gulf where the city of Adelaide nestles, the jetties along the foreshore were destroyed, and a warship on patrol was driven ashore. Seaside homes and hotels were badly damaged, the wide sandy beach scoured away, leaving a rubble of rocks. Shorelines were not recognized for what they are - dynamic, negotiable territory that changes hands between land and sea. In their pride and boundless faith in their infallibility the elders of my childhood had built great sea walls to mark the boundary between land and sea. But the boundary moved. The sea proved to be stronger than they believed. Everybody who knows Cape Cod knows this. In 1973 I saw a reinforced concrete house tipped on its end near Provincetown because somebody had not learnt the lesson about building on shifting sands. By now, I dare say, what was once somebody's comfortable home has disappeared beneath the sea, not like Port Royal in Jamaica because of a violent earthquake, but because the sea and the sandy shore are forever moving about, and in the end the sea almost always wins.

Like the worthy captain of the Pinafore, I'm hardly ever sick at sea. Two or three times is all, and never in a really severe storm. The first time was in the Mediterranean out of Port Said. A hot dry wind off the Sahara, laden with dust and grit, whipped the waves into choppy breakers that hit us beam on so we rolled, a shorter sharper roll than we had become accustomed to in the Indian Ocean. All my shipmates looked as I felt, white-faced, sweating, nauseated. Too much beer the previous night into a youthful stomach might have had something to do with it. A couple of other times on other ships it was the same, an unfamiliar motion that the organs of balance weren't expecting and couldn't handle, combined with eating or drinking not wisely but too well.

A storm at sea is an exhilarating experience as observed from a sturdy freighter with a well balanced and securely stowed cargo. Crossing the southern fringes of the Indian Ocean in the Roaring Forties (forty degrees south latitude) we ran for days before gale force winds, and for two or three days, the wind strengthened to Force 10, a full gale (over 62 mph). The dining saloon on that ship was below the bridge, facing forward. It had sturdy armoured glass windows, not portholes. I shared a table with the first officer. We had the fiddles up, movable slats at the edge of the dining table to stop our plates sliding off as the ship pitched and rolled. We had to sit spreadeagled, legs braced wide to keep from sliding with our heavy, splay-legged chairs to the far side of the saloon, and the steward had to place our food carefully in front of us a little at a time. Soup was off the menu. I loved those mealtimes. I had a perfect view of the ship burying her bows in deep green seas, shaking herself free of each wave as it broke over the forepeak, surged back across the hatch covers and ventilators to slam into the superstructure of the bridge, sometimes high enough to cover our windows momentarily. One moment we are in a deep valley of the ocean, the approaching wave is a mountain higher than the cross-trees of the foremast, closing in to port and starboard; the next moment we struggle to the summit of the mountain, and for a few seconds we see beyond the next great wave to a whole mountain range of waves. All have white caps like snow. The spray is flying away from us - we have a following sea in the Roaring Forties, a gale blowing us towards Australia. Those waves really looked like snow-capped mountains. Many times since I have flown high over the Swiss Alps, the Rockies, other snow-clad mountains. They are mundane and boring compared to the close-up view of the mountains and valleys of a storm at sea. On one of those days in that gale in 1954, the ship's log recorded the greatest distance she had ever travelled in a single 24-hour period, thanks to that powerful following wind and sea.

Even in the strongest winds and wildest seas of that storm the albatross never left us. Two or three of them picked us up after we rounded the Cape of Good Hope and came with us all the way to Investigator Strait, the narrow sea between Kangaroo Island and the South Australian mainland, before deserting us to follow another ship. They could hover for hours at a time, hardly moving a muscle or a feather, poised in the slipstream above the stern, their beady eyes darting everywhere, alert for any titbit. When the slops from the galley were tossed overboard, they would bank steeply, glide down and snap a mouthful from the bubbling, boiling wake, then soar up again to resume their place as sentinels over the stern. They must be able to stay aloft for weeks at a time without sleep, because far from land and in stormy seas there is nowhere for them to rest. When I looked out over the stern late at night, they were still there, on guard, alert and wide awake.

Fifty years ago in the 1950s those southern seas were rich with life of all kinds. We saw huge jellyfish, great translucent brownish or green creatures up to two meters across, shaped like the smaller Portuguese man-of-war, the poisonous stinging jellyfish of tropical waters. We saw killer whales, sharks, hammerhead sharks, huge schools of tuna chasing smaller fish that leapt in panic and in vain above the waves trying to escape their fate but were gobbled up anyway. We saw not only the albatross who followed us all the way, but gannets, terns, mutton birds, sheerwaters, far from land – though we knew there were islands, and one day we saw land, shadows rising from the mist to what looked like a high volcanic peak in the distance. This was St Paul Island, confirming if we needed confirmation, that we were deep in the Roaring Forties about halfway across on the great circle route from the Cape of Good Hope towards landfall off Kangaroo Island, South Australia.

In 1964 crossing the Pacific from Brisbane to the Panama Canal we ran head-on into a powerful storm, almost a hurricane, and for three days battered our way into the teeth of fierce winds and huge seas. This was a much stronger storm than the one I had experienced in the Southern Ocean, enough to clear the dining saloon of all but three or four of us when it was at its height. The dining saloon faced aft on that ship; the best vantage point was the bridge, to which I had access as a member of the crew, the ship's doctor. I spent many hours on the bridge discretely out of the way aft of the wheel and the instruments that told us how this storm was slowing our way through the ocean, at times almost bringing us to a stop. It was fascinating to see huge waves breaking over the bows and surging back, with the wind helping them gather force before they crashed into the superstructure, making the ship, sometimes those watching too, tremble. The open decks were dangerous, and if I ventured out the spray hit my face with the force of shots from a gun. I felt then the full power of the sea when it is angry. The dining saloon for officers and passengers thinned out during those days, the table cloths were dampened to stop plates sliding about, the fiddles were raised and our heavy chairs firmly fixed to the deck.

When the storm passed and the sea was calm again, we could see the ocean all around us ablaze with ghostly light on moonless nights from myriads of tiny phosphorescent plants and animals. If you flush a ship's toilet in the dark at such a time, it’s a dramatic sight - ship's toilets use sea water so the luminescent little creatures can be seen there too as well as in the wake and all around the ship.

On that Pacific crossing, thousands of miles out from Panama, we also saw long rows of brightly coloured buoys stretching into the distance, sometimes over the horizon. They marked drift nets, and twice we saw the trawlers that had set these terrible traps for the indiscriminate capture of fish, dolphins and seabirds. Those trawlers flew no flag identifying their nation. One we saw close enough to focus on with binoculars had oriental letters on her stern – a port in Taiwan, perhaps, or Japan or Korea. The rape of the ocean was well under way in 1964.

Once in the late 1990s flying at night back to North America from Tokyo, far out over the Pacific I looked down through the blackest night to what looked like a large scattered settlement – it was the lights of a huge fleet of fishing trawlers, using lights to attract their prey. The pillage continued at night as well as by day. Soon there will be nothing left alive in the sea. Since 1965 my views of the seas and oceans of the world have mostly been from high above, from airplanes. I’ve seen calving icebergs breaking off the Greenland glaciers and scattering in what looked from 10,000 meters above to be calm blue sunny seas; I’ve seen breakers and spray on the rocky cliffs of the Western Isles of Scotland. I’ve seen the brilliant green of coral atolls and volcanic islands in the Pacific. I’ve seen the scattered remnants of rocks and islands which are all that remains of what was once a large island in the Eastern Mediterranean until a massive volcanic explosion blew it to pieces about 3500 years ago, destroying the Minoan civilization of Crete in the process. I’ve flown high above the Bosphorus (and seen it from sea level). On a bright sunny day the blue seas of the Black Sea and the Sea of Marmora are dark brown around the Bosphorus, as they are near outflows of all the rivers that empty into the Mediterranean. As well as being pillaged, the sea is being poisoned by raw sewage and industrial effluents. Where great rivers drain into the sea the runoff contains not only industrial toxics and raw sewage but large quantities of fertilizer that collectively disrupt marine ecosystems and ultimately create huge ‘dead zones’ devoid of all life except pallid jellyfish. I am glad to have seen so much of the seas of our blue planet before they had been so damaged by stupid humans that there is a real risk of irreparable harm.

Memories of a seafaring man

My adventures as a ship's surgeon on passenger-carrying freighters plying the seas between Australia and Europe and later across the Pacific and through the Panama Canal into the Caribbean and on to the USA, have come up in recent conversations. At the risk of boring family members who've heard these before, I'll paste two stories here. These happened on a wonderful voyage in 1954, on the Adelaide Star, a Blue Star line freighter that carried 12 passengers and a crew made up mainly of junior ship's officers about my own age with whom I bonded better than I did with any of the passengers; after all, as the ship's surgeon, I was a member of the crew too.

This anecdote was published as a column-filler in British Medical Journal in 1993

Pushing teeth

In the 1940s when I was a medical student, I had a card with a long list of procedures to perform under supervision and get signed up by clinical tutors: reducing and plastering a Colles' fracture, performing a lumbar puncture, passing a catheter, and so on. At the end of the list was "extract two teeth." Why two? I never discovered the answer. But like some of my classmates, I extracted a great many more. The dentist who supervised us had a sensationally beautiful chairside assistant, and we went back again and again to gaze at her longingly and attempt to invite her to our parties (to no avail; she disdained sex-starved medical students suffering from arrested adolescence). But thanks to her, I soon excelled at extracting teeth. The dentist knew well why I was there, and ensured that my time wasn't entirely wasted.

The secret of dental extractions is not to pull the tooth, but to push it out: push the wedge shaped points of the dental forceps well down alongside the roots of the tooth so the wedge loosens the roots; extraction then is usually easy.

This skill came in handy a few years later. I was hitching a ride across the world as ship's doctor on a Blue Star freighter. Shortly after we had rounded the Cape of Good Hope en route from London to Adelaide, the chief engineer, a curmudgeonly tyrant, bit savagely into a bread roll and broke the cusp off a bicuspid. He was in agony. I had to deal expeditiously and well with this acute dental emergency or my life in this small, closed and highly critical community wouldn't have been worth living. The surgery on this ship was very well equipped; I could have done a craniotomy or a destructive operation on a foetus. And of course there was a full set of dental forceps.

First I premedicated the Chief with a tumbler of brandy. The hard part was injecting local anaesthetic; even semi-stupefied, the Chief didn't like this part at all. The heavy seas of the Roaring Forties were no help, nor was my choice of a dental chair without adequate support for his head and neck (I hadn't planned this part as thoughtfully as I ought to have done).

The rest was easy. I carefully positioned the dental forceps blades beside the broken tooth, and pushed down as hard as I could. The tooth popped up and out like a pea out of a pod. It was so simple I felt like clearing the rest of that side of his mouth while it was numb, but self-restraint prevailed. For the rest of the voyage across the Southern Ocean perhaps it's as well that my reputation for competence wasn't tested further. I've never again been called upon to extract teeth. Pity, really. I think I could have become a master of the art, thanks to those hours of unrequited lust and useful experience in the dental clinic behind our teaching hospital.



Fortunately the other memorable episode happened a few days after I took out the chief engineer’s tooth. I submitted this to Richardson’s Roundup on CBC Radio but if Bill Richardson ever played it, I didn’t hear it.

Catching an albatross

Few of life’s pleasures can beat a long ocean voyage. In 1954 I hitched a ride as ship’s surgeon on a freighter, a cheap way for young doctors to travel between England and Australia in those days. The voyage lasted nearly two months, including four weeks without a port – from a refuelling stop at Tenerife in the Canary Islands to Adelaide. We sailed past Cape Town without stopping, on a sparkling sunny day, so close we could see the colours of the dresses the girls ashore were wearing. It was nearing dusk as we rounded the Cape of Good Hope, and several albatross took station as escorts above our stern. For two weeks, until landfall off Kangaroo Island in South Australia, these great, graceful creatures glided effortlessly in our slipstream. It was the best journey in the world. It was a good time to read Apsley Cherry-Garrard's classic, The Worst Journey in the World.

Cherry-Garrard described how, before reaching Antarctica, he caught sea-birds, including an albatross, by trailing a weighted line in the wake of the ship (this was for scientific observations he was making). The weight bobs up and down on the surface, sustained there by the momentum of the fast-moving ship. To an albatross, it looks like a fish, a tasty morsel worth swooping to swallow; but because the albatross comes in from ahead and to one side, the weight causes the line to tangle about the bird's wings or feet, so it can be hauled aboard. Apsley Cherry-Garrard didn't say what happened after that.

It works. At the first cast, the largest of our escorts swooped down, and just as Cherry-Garrard described, the weighted line wrapped itself around the bird's legs, and we hauled it aboard, its wings flapping ineffectually.

An airborne albatross is one of the noblest sights one could ever wish to see. On the pitching and rolling deck of our ship on a blustery sea in the Roaring Forties, it was disconsolate, deeply embarrassed, very frightened, very angry – and very incontinent. At both ends. I can't recall all these years later which came first, the vomited-up half-digested fish, or the voided bowels; or whether both happened together. It covered most of the well-scrubbed deck with a stinking mess that had the consistency of fish glue and smelled unimaginably abominable.

There was another problem. Mindful of the Ancient Mariner's fate, we wanted to release our albatross, but it couldn't or wouldn't take off from the deck. It was unfortunate that the ship's captain, a descendent of Bligh of the Bounty I shouldn’t wonder, chose to make his daily inspection of the decks while we were wondering what to do. Observing him, I tried to be a detached clinician: Was I about to see a man actually having an apoplectic stroke? Gritting his teeth, he ordered us to get rid of the bird and clean up the mess. His demeanour made it clear that failure to comply, and quickly, would have dire consequences.

In the end one of the other officers launched the bird by running along the deck with it, like getting a kite aloft. Not before he'd slipped and slid on his bottom in the guano, however. We three miscreants who had started all this didn't escape so easily. We were on our hands and knees until after dusk, cleaning and scrubbing the deck to restore it to its pristine pre-albatross condition. Next day the pants I'd been wearing went over the side, stinking past all hope of ever being cleansed of the mess that covered them. Good pants too, my second-best pair.

In those days, the standard British Board of Trade rate of pay for ship’s surgeons who got a free passage across the world in this way was a shilling a month, plus keep. I should have received two shillings. When I collected my discharge certificate in Sydney at the end of what was, all things considered, a voyage that I still regard as one of the highlights of my life, I got only one shilling. I didn’t dare ask why.

Independence and self-sufficiency

Last weekend was very pleasant. David and Desre came up from Kingston, bringing John along with them; Rebecca and Richard, and Jonathan also came over, and Dorothyanne dropped in briefly on her way to the 60th wedding anniversary of her aunt and uncle. So all but our other two grandchildren, Christina and Peter, were gathered here at our apartment for a family party (Christina was working in Peterborough and Peter was in South-east Asia, in Vietnam we think). Jonathan took some photos but we haven't seen these yet. When we do I may add one or two to this post. The original plan had been for all of us to gather in Rebecca's garden beside her pond, but it was a steamy-hot and very windy day, would have been unpleasant there whereas here we sat in air conditioned comfort; an afternoon thunderstorm confirmed that we had made a wise choice. Since then, Janet Wendy has become more breathless, even a little distressed at times, and very willing to use the ventilator to assist her respiratory muscles. She's just skin and bone now, not much muscle left on her neck, back, and arms, but still does her best to be independent. As her legs remain quite strong, she uses the walker to get about and despite our pleas to let us do things for her that she doesn't need to do, she continues on her independent way. For example at meal times she gets up from the table, gets behind her walker, and goes to the kitchen to change the volume on the radio, instead of asking me, or Sharon, to do this simple little thing. She likes to be independent and self sufficient, but it bothers us who try to help her that she wastes her limited energy in this way, with the result that she doesn't have enough left over to breathe comfortably. No amount of gentle persuasion, nagging or -- her word -- bullying, seems capable of changing her lifetime habit of independence and self-sufficiency. It's inevitable I suppose that she should be like this, and we just have to accept it.

Illusion

This story won a prize in the City of Ottawa annual competition in 2007 for ‘novice writers’ (i.e. previously unpublished) aged 55 and over. She qualified with a quarter century to spare.

ILLUSION

Janet Wendy Last

Betty blinked in the glare at the threshold of her pension. It was already scorching hot with the light rippling on the Mediterranean below, and although she should have started earlier she did enjoy the leisurely breakfast. This was her first holiday in years, and after a week on the island she was beginning to relax and enjoy the slower pace. She wandered off along the cobbled street between whitewashed stone houses with bright window boxes. No wonder the people here seemed open and friendly with so much colour in their lives. Strangely though, the population seemed to consist mostly of old women dressed uniformly in black, with very few young people. Of course the children would all be up the hill in school at this time of day.

As she explored, she tried to keep on a horizontal tack, because she had no climbing muscles in her legs. After being flat on her back for so long what muscles she had were pretty flabby. The absence of cars, calmed her: since her traffic crash even the sound of wheels on pavement unnerved her.

Between the two-storied houses the path was shaded, making the air pleasantly cool, but the sun on the higher walls caused sunbeams to dance off the mullioned window panes opposite. Cats were on every window sill, doorstep or on walls by the houses. Several times one jumped up and run in front of her. Was it good or bad luck for a black cat to cross one's path? She wasn't sure but it didn't matter.

At intervals when paths crossed her way the sun flooded through and she got a glimpse of the bay below where the golden sand contrasted with the turquoise water which lazily rolled up the beach.

When one of the bigger roads up the hill intersected she had a view towards a cathedral on a large square and the corner nearest to her had an inviting striped awning and cafe tables where old men sat with their coffee playing dominoes. She decided to rest there.

The road down was steep and by the time she sank into a chair in the shade her knees were wobbly. She really had a long way to go to get back into shape. Who would have thought that these same legs could downhill ski for hours just a few months ago.

From her table she had a different view from the one at her pension which gave onto the east end of the bay where small fishing boats were moored behind the breakwater. She hadn’t seen the west end before and studied it as the sun lit up cliffs and fissures in the rock wall, enormous boulders cascading down as if some giant had thrown them.

She ordered a coffee and baklava and decided to stay under the shade for a while. Just then the cathedral doors opened and some women came down the steps into the square to linger by the fountain while three small children splashed each other with the water spewing from the cherubs' mouths. She felt a deep calm as she gazed at this peaceful scene.

When she could no longer prolong her coffee and the proprietor was bustling about polishing the tables and looking at his watch, she paid him, left a generous tip and wandered off on a side path. The fierce heat had gone out of the sun, and a breeze was whispering off the sea. She wanted to see what was on top of and beyond the cliff.

After about fifteen minutes the character of the streets changed. There were wooden barriers lying about haphazardly, sand was drifting against the walls, litter was blowing around and there were no colourful window boxes. The houses looked empty, shutters nailed up, weeds growing through cracks in the walls. She turned up the inclined path determined to see what was at the top and explore the ruins she had seen from the cathedral square. The ruins came into view as she climbed higher.

It was then that she heard a piano, children’s voices and laughter, so odd in this desolate place. She turned the corner to find a big door propped open, so she paused to look inside. The slanting sun was highlighting the dust motes through which she could dimly see a woman playing a piano. A game of musical chairs was nearly finished as only four chairs remained in the centre of the hall, where five children were racing and pushing to get a seat. About fifty others were grouped around the walls of the room, cheering on their favourite to win.

Betty moved closer to get a better look when a nun dressed in a grey habit came up to her, carrying a large tray covered with a heavy towel. “There you are,” she said in an unmistakable Irish accent, “I’m Sister Brigid. We've been waiting for you. Please take this to Kristos.. You'll need some one to show you the way. Nikos. Come here please!” A small black haired, barefoot kid, with a merry face and a broad grin ran up to the nun. She gave instructions to Nikos who beckoned to Betty and turned to go through the door and along the path to the top of the hill. The going was difficult because she couldn't see her feet below the tray and there were drifts of sand and lumps of rock strewn along the path. It didn't help that Nikos hopped about like a puppy, sometimes hiding and then jumping out at her. The first time that happened she nearly dropped the tray, while he whooped with laughter.

They climbed over a low stone wall into what had been a wonderful formal garden, but now overgrown with oleander and aloe cactus. The central path led to the house door, massive carved wood with a knocker beyond the reach of her small guide. He picked up a rock to hit the door several times, but there was no response. Nikos led the way around the house to the other side where a smaller door opened half way as they approached it. A little boy with a puppy stood there, and after an exchange of words, Nikos indicated that she should put the tray on a wobbly urn standing by the door. Carefully she balanced it, happy to be rid of the weight on her arms. Once more Nikos beckoned her around the house to the wall on the edge of the cliff. He disappeared, and in a panic, feeling responsible for him, she looked over the wall to a sheer drop to the rocks below, now covered by surf blown by the much stronger wind.

“Nikos” she called, and was answered by a shrill whistle carried on the wind. Looking over the wall again she saw a tousled dark head and a wide smile emerge from a small cave about two meters down the cliff. Using hand gestures she called out “Come up please,” but the head vanished again into the cave. Feeling tired, worried and impotent she stepped back from the wall to look around the garden. Her rational mind argued that there must be some secret passage to the cave, maybe a well, or a hole, but she could seen nothing nearby and because Nikos was as agile as a cat she figured he would be alright.

The afternoon shadows were lengthening, and having come this far she felt impelled to see over the crest of the hill to the country beyond. She followed the wall away from the cliff, and came to a steep set of stone steps leading to the top of a sand bank. With difficulty she climbed the narrow steps and started to walk on the sand which oozed away from under her feet and glissaded down the slope to the deep valley below. Caught by surprise she had the luck to fall on her hands and knees and hook her foot over the top of the stone step, thankful to be on solid ground.

She looked down on a large sandy basin, high walled on four sides, the country beyond not visible except on the south slope where the almost vertical sand wall finished at the coast. A hissing noise startled her, making her look landward. On the horizon of the far sand dune, a row of goats was silhouetted against the sky, and the sand they dislodged was cascading down to the floor of the valley, starting like a small waterfall and building to an avalanche. The goats disappeared over the other side. She shivered as the wind picked up, and she hastily climbed sailor wise, backwards down the steps.

The afternoon was nearly over and with no twilight and a strict dinner hour where she was staying she lost no time in retracing her steps to regain the town. At the end of Kristos’s garden she looked over the cliff and called ”Nikos” as loud as she could but there was silence, and no tousled head showed at the cave entrance. The wind on the water blew salt onto her face as she bent over the wall. She paused at the church hall which was empty, the piano and chairs tidied away and the door swinging to and fro on its one hinge.

Taking a lower route than before, she stumbled along the uneven path and was surprised to see the cathedral square open in front of her much sooner than she had expected. The cafe, now full of families having dinner was on her left, so she crossed in front of it and glad of the hand rail on the wall, climbed the steep hill to her main path leading to her pension.

As she entered she saw that the other guests were already being served, but she felt so dirty she had to wash and change before eating. By the time she sat at the table the others were finishing and her hostess seemed put out.

“You will have to hurry if you are going to see the start of St.Anthony's parade,” she said, “This year is the fiftieth anniversary of the great earthquake and they are dedicating a statue in the Square.”

“Who is the statue of?” asked Betty.

“The victims of the big earthquake on this afternoon fifty years ago. A huge wave washed over the cliff as it fell into the sea. The church at the top and many houses just dropped into oblivion. All the school children, their mothers and Sister Brigid were in the church hall celebrating St Anthony and nearly all perished. Only two children survived. Kristos, who had run home to see to his new puppy and Nikos who was found two days later wedged in a cleft of the crumbling cliff. Poor lad had been severely injured, was flown to the mainland for treatment and came back months later in a wheel chair, but he didn't thrive and died soon after. Many of the fathers who were fishermen also perished. A few bodies were washed up along the coast weeks later. The tsunami caused a huge build up of sand on the north shore of the island and that is where the dunes are. Very dangerous, with whispering, unstable sand which has engulfed many an animal and person who has ventured out on them. It is forbidden to go up there.”

“What happened to Kristos?” asked Betty.

“He was taken to Canada by his uncle, and this year he has sent money for a statue of Sister Brigid and the others. Tonight it will be unveiled. ”

Betty arrived late at the square after most of the villagers had left for home, so she could see Nikos clearly with his merry face and broad grin standing next to the nun she had seen earlier, but now they were part of a marble statue.

That oil spill in the Gulf of Mexico

On April 20, soon after it first began, I made a few remarks in this blog about the oil spill off the coast of Louisiana near the Mississippi delta. Today for the first time it seems possible that the unending flow into the formerly rich seas of the Gulf of Mexico has been stopped. It has done horrendous damage, from which the local and regional ecosystems will take decades, perhaps centuries, to recover. The blow-out occurred at a depth of about 1.5 Km below the sea surface, so deep that only robot miniature submarines can operate and the water temperature is zero C or even below zero. The sea remains liquid only because of the immense pressure. But human stupidity and greed are even deeper, indeed bottomless: this ecological catastrophe has not daunted the oil companies that intend to go ahead with undersea oil drilling at even greater depths in the far stormier north Atlantic ocean on the edge of the continental shelf off the coast of Newfoundland; and plans are well advanced to drill in the Beaufort sea off the north coast of Alaska and the frozen tundra of far northern Canada. Will this insanity never end?

Next steps

Yesterday we saw the gastroenterologist, Dr Sylvie Gregoire. She agreed that Janet Wendy is fit enough to undergo the minor surgical procedure of inserting a PEG tube. Because it is summer holiday season the earliest date that this can be done as an elective procedure is August 3; the consensus is that she will be OK until then without this intervention, but if her difficulty with swallowing gets any worse we can always reconsider and do it as an emergency procedure, or pass a conventional stomach tube to provide enough nourishment to keep her going. She is certainly getting painfully thin, so a few days ago I got a case of high-energy liquid compound to give her to try to build her up a bit, or at any rate to ensure that she doesn't lose any more weight. It's also getting harder to understand her speech. Sometimes, especially when we have visitors, she seems to make an extra effort, but when she and I are alone she may get more relaxed, less 'on her best behaviour' and sometimes she becomes unintelligible, has to rely on sign language and gestures. There are many ways we can deal with this problem and we are already using a few low-tech methods. Maybe we will augment these with some high-tech devices like a very fancy electronic touch-screen device that Margot Butler, the speech language pathologist at the ALS Clinic, demonstrated to us last week. But despite all, we can still find things to laugh and joke about, so our remaining time together is mainly fun, not at all a doom laden gloomy period of our lives.

Janet Wendy's status and what's being done about it

Last week we had two sessions at the ALS Clinic, where we saw the neurologist, the respiratory team, the speech language pathologist and the nutritionist. Wendy and I are well aware that she is weaker now than she was last month; she is more breathless and her speech is sometimes hard to understand, and she is having more difficulty swallowing. The challenge of swallowing worries her most and has led her to reconsider her earlier decision not to have a peg tube (stoma or stomach tube) to bypass her throat, so the main agenda item last week was to assess her fitness for the relatively minor surgical procedure involved in providing an artificial opening into her stomach. The consensus of the experts about her fitness is that she qualifies for the surgical procedure -- just. As our palliative care specialist said, they don't like it when patients die on the operating table, or when they have to go to the intensive care unit instead of home after the minor operation to bypass her throat. The gastro-enterologist who does this procedure has just returned from holiday and Wendy will see her tomorrow. Meantime, a community based specialist in ways to deal with difficulty swallowing came to see her today, reiterating the advice and suggestions we've already had from the staff at the ALS Clinic. At the drug store I picked up a whole case of high-protein, high-energy drink that she can swallow very easily. She has lost a lot of weight, is beginning to look quite frail, but she remains in good spirits, and we can still find things to laugh about. So stay tuned for another bulletin after she sees the G-E surgeon.

The Wedding of Desre Kramer and David Last

July 11 has taken on a special new significance. It is the date of David's wedding to Desre. All went smoothly, none of our anxieties about missed flights or other mishaps proved justifiable. Desre and David flew to Los Angeles on July 8, and the two of David's kids who are in North America at present, Christina and John, flew to L.A. on Friday, July 9; we had worried about them arriving too late at Toronto's Pearson airport to catch the early morning flight, but our worries were misplaced: everything went smoothly and according to plan. David phoned to confirm their safe arrival, and phoned again today to report that the wedding ceremony went off without any glitches. There were many photos, and David told us on the phone just now that two laptops were aimed at the celebrants to beam the entire event direct to Desre's family members in South Africa and Seattle by Skype phone. David sounded rather regretful that he hadn't taken his laptop to California too, but said that had he done so there would have been too many people aiming laptops in the right direction and not enough to take part in the service, which was conducted mainly in Hebrew; David had to learn a few words to make appropriate responses but he's a very good linguist so picking up a few words and phrases of Hebrew would not have been a challenge. Christina and John are flying back to Toronto today, and Desre and David will follow tomorrow. They will have a honeymoon in Paris and a walking tour in Brittany and Normandy in August. I'll attach a picture or two to this post:

The lower picture is a scene during the ceremony, showing the bride and groom exchanging vows; Christina and John are standing beside David. The upper picture shows the bride and groom in all their glory.

Green going

Years ago I was among those who lamented the medical school's move from the main downtown campus of the University of Ottawa to the suburban setting of the developing health sciences campus about 6 Km from the city centre. One of the factors I weighed when considering whether to accept the invitation to leave Edinburgh and come to Ottawa was the location of the university in the heart of downtown Ottawa, just a few hundred meters from Parliament hill. Like the ancient University of Edinburgh, and like my own university in Adelaide, South Australia, Ottawa University is intimately entangled with the city, town and gown are entwined. The sylvan setting, the vista of green lawns and trees visible from the picture windows of the staff lounge helped me to get over the pangs of separation. But over the years since then, as the health science centre expanded and budded off satellite buildings, those lawns and trees have disappeared. There was a pleasant little view of trees through the windows of the walkways linking the health science centre to the Ottawa General Hospital on one side, and the Children's Hospital of Eastern Ontario on the other side, at any rate for a while. The trees and lawns on the CHEO side went years ago, but those on the OGH side survived at least in part despite the orgy of building and the new paved parking lots for the cars of those who work in these new buildings ... until this summer. Lately as I've strolled along the walkway to the OGH, the floor has shuddered to the rhythm of heavy earth moving equipment, some of the glass is covered over with opaque plastic and where a window remains translucent the view is dismal: the green has gone, the ground is scarred by a deepening hole, the future basement of yet another new building. I suppose eventually all that will survive of the green spaces will be a few shrubs in tubs. We must adjust and adapt to new realities. Ottawa is a big city these days, the health science centre, the hospitals, the other buildings for research centres and so forth, must expand to keep pace. But I'll miss all that greenery.

We're having a heat wave

It's sometimes called an ear-worm, that irritating problem of a jingle or a tune that keeps on returning again and again no matter how hard you try to think of something else. Today I've been afflicted with a tune from the musical Kiss me Kate, that I've put above as the title of this post. It really is a tropical heat wave, with temperatures in the mid-30s and very high humidity that makes it feel like the mid-40s or high 40s, like Delhi or Bangkok just before the monsoon. If it were not for air conditioning, our apartment with its huge west and north facing picture windows that get the full force of the sun from noon until sunset, would be uninhabitable. Our well being hangs by a delicate thread. There was a power failure in Toronto yesterday; another like it here in Ottawa would be a real challenge to our stamina; and we will be very fortunate if we escape even just one power failure during this heat wave, which is forecast to continue all week and into the weekend. I've considered what we could do if we are hit by a power failure. Retreat to the basement, to the swimming pool, would be one option I suppose. Outside all day and greatly accentuated this afternoon, the air was thick and smog-laden too, as well as heavily humid, the combination of environmental conditions that are quite dangerous for the very young, the very old, and all whose health is precarious because of breathing problems. It's the combination we both have, each in our different ways. All we can do is hope our electric grid holds together...

Altruism

In the book our kids and I compiled of Selected Works of Janet Wendy Last, I stole a few pages to say something about her selfless altruism and other lovely qualities that make her such a unique and wonderful person. As the saying puts it, What Goes Around Comes Around. Our little family, our friends, and our neighbours in the condominium apartment building who have become our friends too, have been demonstrating in innumerable selfless acts of kindness that they too can come to the aid of others in need, bestowing on Wendy the same devoted concern and care for her that she has demonstrated for others throughout her lifetime. We have been provided with splendid, tasty and abundant meals, our apartment is always full of flowers, and almost every day since she fell ill there have been cards, phone calls, emails from near and far, and of course a constant stream of visitors - family, friends, acquaintances - all of whom are sensitive to her need to conserve her energy and don't outstay their welcome. It sustains me and comforts her to know that there are so many good people in the world.

Canada Day

My birthplace homeland and my adopted homeland both have national days that carry the nation's name. I've lived about half my life in each and therefore claim both as my homeland. Australia Day, January 26, commemorates the day in 1788 on which the 'First Fleet,' a small flotilla of sailing ships, arrived to establish a permanent British colony. Canada Day, July 1, commemorates the day in 1867 on which all the territories, colonies and dominions comprising Canada as it then was met in Charlottetown, Prince Edward Island, and agreed to form a confederation. It was an untidy affair because Newfoundland, technically the oldest (albeit non-permanent) European settlement, established in the late 15th century, remained a separate British dominion until 1949. There had been a few non-permanent European settlements, mainly whaling seafarers, in Australia too, before 1788. The European colonists in both Canada and Australia did not acknowledge that the lands they were colonizing had been inhabited for many thousands of years by indigenous people who had their own traditions, cultures and languages. The indigenous peoples were decimated by imported diseases, their traditions were scorned, their cultures largely destroyed. Genocidal actions included fabricated wars, deliberate infection of family groups with smallpox, and segregation of survivors on reservations, usually in remote places with harsh environments. We who are descended from European colonists look back now, apologize for what our ancestors did to their ancestors, grudgingly admit that the indigenous peoples deserve reparation, are our equals, not our inferiors. Not much if any of these aspects of history get mentioned on Canada Day (or Australia Day). It is a national holiday for celebration, festivities, fireworks after sunset, speech-making by leaders and heads of state, performances by popular entertainers. This year the queen is here and our own head of state, the Haitian-born vivacious governor general Michaelle Jean, is away on an official visit to China. Over a million Canadians in the total of 35 million, are ethnic Chinese; about another million have roots in the Indian Subcontinent and close to another million can trace their ancestry to Africa. Increasing numbers have been coming also from Middle-Eastern nations. Canada is truly a rainbow nation. One of the things I like best about Canada is that it is in large part 'colour-blind.' School children, university students, shop and office workers, sports teams and their supporters and spectators, are a multi-coloured free and easy mixture. The 'assortative mating' that I used to observe among medical student classes quite often takes little or no account of ethnic differences. There are rare isolated outbreaks of the kind of mindless and vicious hatred that once led white mobs to lynch black youths in the southern states of the USA, but such outbreaks are extremely rare in Canada, even more rarely violent and lethal. There are also some ethnic gangs, mainly in Vancouver, engaged in gang warfare to gain control of the illegal drug trade, prostitution, protection rackets etc, but these don't seem to threaten the national or even local body politic. At the other end of the spectrum, on Canada Day especially, are displays and celebrations of ethnicity, traditional Ukrainian, Portuguese, Hindu dance and dress, delicious meals of traditional ethnic dishes, recognition that Canada truly is a multicultural nation in which we all get along pretty well together. I hope it will always remain so!