Leaping into the unknown

 

No Opera House or high-rise office towers in 1960!

 In Ingmar Bergman's marvellous cinematic performance of Mozart's Magic Flute, Tamino and Pamina set off hand in hand to undergo the unknown perils of their ordeal. Wendy and I felt rather like those two young lovers when we left the comfort and security of the doctor's home in Mile End. We were so reckless! We had no idea what would become of us, and it could have ended in catastrophe. In 1960 we lived in Sydney on my slender savings, and although I worried about our current situation and uncertain future, Rebecca and David were at delightful stages of development and we all had great fun getting to know the beautiful city of Sydney.

 Between weekends of family fun exploring Sydney, I worked very hard, mainly self-directed learning (the School of Public Health and Tropical Medicine at the University of Sydney was intellectually uninspiring).  I learned everything in the curriculum and a great deal more, especially in behavioural and social sciences.. I began also to explore psychiatry, a journey of discovery that in the end went on for about 25 years and in some respects has never ended. I was closing a major skill gap I had become acutely aware of when I was a family physician. I'll discuss this further in a future post. I studied in the well stocked library of the School of Public Health, and at our rented cottage, 93 Rainbow Street Randwick, by day in the sun room over Wendy's shoulder in this photo of the family at our front gate one morning as I set off for the university.  I did well academically and before the end of the year I was awarded a traveling scholarship - with a stipend and travel funds intended for a single man - to spend a year with Jerry Morris, the eminent epidemiologist who directed the MRC Social Medicine Research Unit in London.


Playing on Sydney beaches was more fun than the sand pit


The year in Sydney in 1960 gave me a good opportunity to widen my professional networks among public health specialists, mostly working for the Commonwealth Department of Health or the NSW Health Department, and occasional overseas visitors from the UK, the USA, Japan and elsewhere. I met and got on very well with Ron Winton, editor of the Medical Journal of Australia, wrote reviews and editorials for him, and through him met Sir Theodore ("Robbie") Fox, the eminent editor of Lancet.  I wrote occasional reviews and "Annotations" for the Lancet - brief commentaries that appeared in those days on the editorial pages. Later when I wrote my first important original epidemiological paper, "The Iceberg: 'Completing the Clinical Picture' in General Practice," it's possible that Robbie Fox gave it more of his personal attention than he might have done if we hadn't already met and clicked into the same intellectual wavelength. All things considered, 1960 was a most productive year, a credible launching pad for my new career. Equally important, Wendy and I proved to each other that we worked very well together. She especially and emphatically demonstrated what a tower of strength she was beside me, how cheerfully she could make do with very limited resources.  That year, 1960, was also when we "adopted" a wonderful latchkey kid, Kerry Edwards, then about 8 or 9, who attached herself to us each afternoon, rather than hanging around alone after school until her mother came home. Kerry became our lifelong friend. Our reckless leap into the unknown had so far turned out well, much better than we had any right to expect.  

David climbing the ladder to the slippery-slide in the park opposite our cottage, steadied by Kerry's arm, just after climbing unaided to the top, and falling with a splosh into the soft sand below; when that happened, he blinked, didn't cry, and set off immediately up the ladder again.

Kerry Edwards with Rebecca and David, Maroubra Beach, Sydney

More on Multiculturalism

A year or so before Wendy and I left Edinburgh for Ottawa at the end of 1969, an article in the Guardian or the Observer about Canadian multiculturalism aroused our interest. That may have been where I first saw the word 'mosaic' used to describe Canadian attitudes to culture and ethnicity. It was very different from the American 'melting-pot' concept. Canada's social,demographic and cultural composition was changing when we came to live in Ottawa at the end of 1969. I see this change with a perspective of more than 40 years when I look at the names and faces of our graduating medical classes. In  the early 1970s, almost all the names were male and indicated roots in the UK, Ireland or France - "white men in suits" - and barely a handful of women. There were occasional names from Poland, the Baltic states, Central and Eastern Europe. Ten years later, thanks to Idi Amin's eviction of the South Asian intelligentsia from Uganda, names and faces of recognizably South Asian origin were appearing, followed by more whose parents had come direct from India rather than via Uganda. Others came from South-East Asia, children of Vietnamese refugees and Chinese from Taiwan or Hong Kong. All the while, the proportion of women rose until now when it often exceeds the proportion of men in a graduating class. From my position at the podium looking out at classes of eager students, I rejoiced to see such variety of skin pigment, hair texture and facial features. I also saw much pairing off, not infrequently across ethnic and racial lines. I'm happy to report that among former students with whom my friendship has continued after graduation, ethnically diverse pair-bonding has usually survived the stresses of medical life and children are growing up, carrying with them the ethnic and cultural qualities of both parents.

Canadian multiculturalism is celebrated on Parliament Hill on Canada Day with performances by ethnic groups who have often preserved the songs and dances of their ancestors' homelands through several generations. In the early 1970s, Wendy and I watched a spectacular troupe of Manitoba Ukrainian dancers who were probably the grand-children if not great-grand-children of the original Ukrainians who settled and farmed the prairies. And of course there are Highland dancers, bagpipe players everywhere in Canada, and more Gaelic speakers in Cape Breton Island than in Scotland. Across Canada wherever the railroad runs, at every town large enough to support a restaurant, there is one established by a Chinese family descended from the indentured laborers who built the railroads, and left this little relic of Chinese culture like beads on a string all the way across the country that wasn't yet a nation, but became one in part at least because of this cultural infusion. These well established cultural and ethnic entities in Canada are being reinforced by more recent arrivals from South and South-east Asia, Latin America, East and West Africa.

It's acceptance of features and events like these, and the tolerance of differences, that make Canadian multiculturalism  so admirable. These qualities bind Canada together, and make it such a splendid place to live. This goodness far, far outweighs the blackness of honour killing - dishonour killing - and genital mutilation that I deplored in my last post.

Multiculturalism

About 25 years ago, a young physician told me how distressed she had been when attending the extremely difficult labour and delivery of a baby born to a teen-aged girl who had been subjected to radical genital mutilation. When she was a child, the girl's entire vulva had been excised and stitched together, leaving a scarred, deformed perineum with a small hole for menstrual fluid. Her husband had presumably battered his way through this to impregnate her.It seems unlikely that sexual intercourse could have been enjoyable for him and it was extremely painful for her. The scarred perineum had to be cut open to permit the passage of the baby. What distressed my young friend was that this 17 year old girl and her mother who accompanied her, were demanding that the girl's vulva must be stitched together again after childbirth.

The barbaric practice of radical genital mutilation, a rare and horribly perverted tribal custom, is a dark aspect of Canadian multiculturalism. An even darker aspect was brought into public view in the widely publicized trial of an Afghan man, his second wife and their oldest son, which has just ended with conviction of all three for the carefully planned murder of the man's first wife and three teen aged daughters who were said to have besmirched his honour by wearing provocative clothing, using makeup, and flirting. This was at least the third so-called honour killing to come to public notice in this part of Canada in recent years. Honour killings, in which girls and women are murdered because they have violated traditional patriarchal cultural values by asserting their autonomy, and radical female genital mutilation, are evil aspects of Canadian multiculturalism. These ancient tribal customs are not Islamic although many but not all the perpetrators and victims happen to be Muslims.

Arranged marriages in which parents select the marital partners for their marriageable children, are a feature of many traditional cultures. They generally seem to work at least as well as marriages based on love or mutual attraction. They are common and usually accepted willingly among South Asian migrants to Canada, even among Canadian born offspring who have been here long enough to have marriageable children of their own.

Arranged marriages aren't always cheerfully accepted by all parties. I have a vivid memory from my brief life as a family doctor in South Australia more than fifty years ago of a girl born and raised in Australia by Southern Italian parents. This girl came home from high school one day to find her parents entertaining a man more than twice her age who had recently arrived from Calabria as her prospective husband. I was called in when she tried to kill herself rather than accept him and give up her boy friend, a high school classmate.

Migrants tend to perpetuate the customs of their country of origin. Wendy and I did this benignly when we settled first in Scotland and then in Canada. For example we never ran out of Vegemite and Wendy’s pavlova desert was renowned for decades among our friends. We even carried one or two adopted Scottish customs such as fondness for haggis, as well as Australian and New Zealand customs, with us to Canada!

Despite the hideous dark side of multiculturalism I believe its benefits far outweigh its flaws. These benefits include widening of everyone's cultural horizons, encouragement and acceptance of cultural and ethnic differences, and creation of tolerance for these differences. These are values worth living for.

Decisions, decisions, decisions

[This post got lost somewhere in the inscrutable nooks and crannies of cyberspace, reappeared today after I'd posted a summary of part of it, with photos]

In the period from late 1959 to late 1969 Wendy and I made three life-altering decisions and several lesser but significant decisions based on fundamental choices we made about the way we wanted to spend our lives. These decisions made it necessary to move from one continent to another, migrations which in those days we made comfortably by sea on passenger-carrying freighters. Of all the ways to travel, this, in my own and our family's experience, is far and away the best! I described our movements during that period in the memoirs that I began to write in the early 1990s and have revisited some highlights in recent posts on this blog.

We moved into the large, comfortable family doctor's home at 16 Henley Beach Road, Mile End, about 2 months after our marriage on St Valentine's Day, February 14, 1957. Rebecca and David were born while we lived there, and although it was in a grimy industrial area immediately west of the metropolitan area of the city of Adelaide, its sheltered back garden was a verdant oasis of bountiful fruit trees, grapevines, flower beds, overlooked by the north-facing glassed-in back veranda of the house. The veranda was sheltered from the summer sun by a trellis of grapevines and in winter with the sun lower in the sky, solar warmth flooded in to make it an ideal play area for Rebecca. As she grew into a toddler, the back lawn and the sand-pit, and playing with Helen, our Dachshund bitch, kept her amused. In front of the house, opening to the sidewalk, was the purpose-built consulting room suite called the 'surgery' with a waiting room, an office where I saw my patients, and a back room with a small laboratory and filing cabinets for my records.  By this time my colleagues regarded me as a competent, capable family physician and I had increasing confidence in my ability to diagnose and treat a widening range of medical, minor surgical and obstetric conditions. My family had assured financial security and long-term stability.

As I have made clear in previous posts, my attraction away from the comfortable stability of family practice began earlier, during my time as a salaried assistant in the group practice. I began to classify and count the numbers of patients I was seeing with each of several commonly occurring conditions; I began to study the social and behavioural sciences that had been left out of my medical education. I had long been fascinated by epidemiology (though I didn't yet know it by this name) and when I read Jerry Morris's mind expanding article, Uses of Epidemiology in 1957, my intellectual and philosophical conversion was inevitable.

When I'd asked about a junior partnership in late 1955 I was rebuffed.  I left the practice and became chief resident (in American terminology) at the Northfield Infectious Diseases hospital, where I saw many patients with viral encephalitis, hepatitis, some with the infectious rashes of measles, scarlet fever, etc, and soon after I started working there, a lethal epidemic of bulbar poliomyelitis that paralyzed swallowing and breathing muscles and killed many young adults in my own age group. Soon I had over 30 young adults in respirators ("iron lungs") and watched impotently as most of them died. It was the final polio epidemic in Adelaide. By the time the next late summer outbreak was due, we had Jonas Salk's polio vaccine.

Wendy had come back to Adelaide by then, and soon after we announced our engagement to marry, I was invited back into the group practice as a junior partner. I hesitated briefly before accepting this invitation. Seeing and treating epidemic infectious diseases had awakened my interest in epidemiology.  Yet I loved the work and life of family doctoring and clearly it offered a far better start to married life.  However, I did not like making money from other people's suffering and distress, and I became disenchanted by the greed, selfishness and lack of compassion of several of my partners. Wendy and I agonized and talked over and over about two alternative career pathways we could see ahead of me.

At the end of 1959 we made our choice in the first crucial joint decision of our married life. I resigned my partnership in the practice, and we left for the School of Public Health and Tropical Medicine at the University of Sydney, where I spent a year learning the basic foundations of public health sciences - epidemiology, biostatistics, environmental health, behavioural and social sciences (anthropology and sociology). Towards the end of 1960 I was awarded a modest traveling fellowship that paid my fare and a stipend for a single man without dependents for a year (1961-62) that I spent in the UK Medical Research Council Social Medicine Research Unit at the London Hospital Medical College, on Whitechapel Road in the East End of London. I'll expand on that last paragraph in another post.

Life-altering decision #1

The four photos above are the doctor's home at 16 Henley Beach Road, Mile End, immediately west of the metropolitan area of the city of Adelaide, where we lived for almost 3 years in 1957-1959; our 2 children Rebecca and David, in a little plastic paddle pool in the secluded, verdant oasis of fruit trees and garden, a secure child-friendly play area amidst a grimy industrial region; my mother Vera Last feeding her adored granddaughter Rebecca; and Rebecca showing her plastic blocks to her Great-Grandmother, my grandmother Millie Last.

By 1959 I was a confident family doctor, regarded as competent and capable by my partners in the group practice where I worked and by other colleagues with whom I worked and interacted in various ways. I was a prominent and eloquent advocate for general practice and community medicine, involved in the intellectual life of the rapidly emerging College of General Practitioners. I traveled interstate to meetings in Melbourne, Sydney and Brisbane, exchanging ideas with my colleagues across Australia. I was going through a philosophical transformation, keen to widen my intellectual horizons, to learn more about the contexts in which people got sick or remained healthy and to study underlying reasons why some were healthy and others were sick. I wanted to understand too what impact medical care, the distribution of doctors, hospitals and specialized services, were having on levels of health and sickness in the population. I needed to spend a while in full-time study and research, to try to find the answers to the questions that were increasingly preoccupying my waking hours.

Wendy and I had talked about my evolving ideas and aspirations since before we were married. We were happy in our home and the practice, getting involved a little bit in the local community, but increasingly aware that it would not be possible to achieve my professional goals if we remained in general practice. It shocked my colleagues when I announced my intention to leave just as I was getting so fully immersed in general practice,  but Wendy and I felt that it was now or never. At the end of 1959 we made the first of our life-altering decisions. I resigned from the group practice to embark on a career in public health science, specifically in epidemiology.     

Burns Day

On Burns Day in 1966, our Australian-born son David won the prize in his grade school class for reciting a Robbie Burns poem with the best Scottish accent in the class. Not bad, considering that when he'd arrived in Edinburgh a year earlier he had a Vermont Yankee accent overlaying the Australian that might have had a trace of London Cockney, or perhaps BBC English from living in London in his toddler year. He managed to cling to a faint trace of the Edinburgh burr for many years after we came to Ottawa - if I listen carefully I can sometimes still detect it. Rebecca's lovely soft Edinburgh vowels were buried deep in Ottawa Valley Canadian within a week or two, and Jonathan wasn't far behind in taking on the sounds of his surroundings. Accents are usually an indicator or our origins. My accent reveals my origin: despite living more than half my life outside Australia, I still speak as though I'd never left Adelaide. One reason I love Canada is that in this polyglot multicultural city I hear accents from all over the world, even last week in the line at the supermarket checkout, two youngsters discussing the contents of their trolley in pure Kiwi. I wanted to say "Don't let the prices rattle your dags" but I'm not sure if the phrase is still current, so I stayed silent.

And that prize-winning poem: Something about losing a "Toorie doon the stank," a marble down the drain. I wish I could remember more of it.

Rebecca, David and Jonathan just over our back hedge in Braidburn Park, spring 1968. By this time all three had lovely lilting Edinburgh Scots accents. Our home, 5 Greenbank Crescent, was the right-hand half of the middle house behind the kids.It was a splendid home, about 3000 sq feet, with a magnificent view south over the park to the Pentland Hills, as shown in the photo below, taken from our living-room window late on a summer evening, probably in 1967.

When I look at this photo and many others like it, of our home and its surroundings, and recall innumerable happy memories of those magnificent years, I wonder why we ever left Edinburgh. Well, I know why, and will relate the reasons in a future post on this blog.

Thinking through the options

My memory of some events late in 1958 is hazy.  I couldn't stop coughing as Wendy and I flew across the Tasman Sea from Melbourne to Christchurch. We stayed with Wendy's brother John and his wife Peggy Anne, then took the train north. Wendy told me I had been delirious and had a high fever during our first night with her parents at Picton. I couldn't get enough air into my lungs, I couldn't cough up any sputum. The local GP sent me to hospital in Blenheim. I was placed in an oxygen tent with a detergent mist that everyone hoped would loosen the mucus in my lungs. For 2-3 days it was a close run affair. The physician caring for me, and I, both though I might die. Slowly I began to recover after about 4 or 5 days in hospital. The influenza pandemic had receded 2 months before I fell ill, and my influenza antibody titre in Blenheim, repeated in Adelaide a few weeks later, did not indicate that I had belatedly been laid low by an influenza virus. X-rays showed diffuse patchy consolidation of both lungs. No pathogenic bacteria were ever recovered from sparse sputum I produced with difficulty. The experts believed I had a non-bacterial pneumonia, likely caused by a virus, but were unable to identify this precisely. Whatever it was, it nearly ended my life and while I slowly recovered over the next 2 months, I had time to pause and think deeply about my life to that point, and my future, our future, because clearly Wendy was an equal partner in all this.  There was a test cricket match between Australia and the West Indies during my convalescence, not long before Christmas. I recall watching as though in slow motion, a ball that a batsman hit high in the air and deep, almost to the boundary not far from where I was sitting in hot sunshine; the nearest fieldsman ran to get under it and took a spectacular catch. As I watched this little drama on the cricket ground, my thoughts fell into place like that lazily descending cricket ball. I thought of the two I knew in my own age group who had died in the pandemic, and all the others I had seen.  I recalled my experiences in the infectious disease hospital during Adelaide's last-ever poliomyelitis epidemic when for a few months I'd left the practice where at that time I had been a salaried assistant, not a partner, and had seriously considered specializing in infectious diseases. I had always been fascinated by the interaction between humans and infectious pathogens, and  it was clear by the late 1950s that antibiotics were not the magic bullet we thought at first, but just another weapon, albeit a powerful one, that we could deploy to help us overcome some infections of some people. We needed a different strategy, different tactics, to keep entire populations free of diseases like tuberculosis and polio - with both of which I had rich clinical experience. I worked for about 9 months in a TB sanatorium near St Albans in Hertfordshire, and for 4-5 months in the infectious diseases hospital in Adelaide. I'd seen cases of rare and exotic diseases, including even cases of smallpox. Although many at that time thought modern medical science was rapidly "conquering" infectious pathogens, I thought otherwise, and events since then have proved me right. As the fieldsman took the catch, I concluded my train of thought: I wanted to study epidemiology. The challenging question that remained was to decide how, and when, and where, to go about doing this.

Speed reading

Two email correspondents challenged my claims for the benefits of speed reading. I didn't say speed reading is perfect; nothing in life is. Speed reading enhances comprehension and retention, but when I became the editor of a large reference textbook, I found I missed typos and transposed words and phrases, when I tried to read galley proofs at top speed. I was forced to slow down, and over time my visual field may have contracted so I could no longer consistently take in a paragraph or a paperback page at a glance. Reading the books about Lizbeth Salander's dragon tattoo, playing with fire and kicking a hornet's nest restored much but probably not all my proficiency. Speed reading is not the way to read poetry (nor is the sepulchral tone some poets use to read their own work).  I read Auden, Wilfred Owen, other favourites, as I would sip a fine wine or single malt whisky. I can't imagine gulping down The Love Song of  J Alfred Prufrock or The Waste Land as a thirsty man gulps cool water.

Transforming times

In recent posts on this blog I have restated in different words some of the events I described in my memoirs, written more than 20 years ago, that led to my career change at the end of 1959. I'll continue the narrative here. At the recent workshop on memoir-writing, our mentor Jon Peirce discussed 'defining moments' but I have to describe a prolonged period of decision-making. Wendy and I agonized over this for most of the first three years of our lives together. It can truly be called a defining period, but not a defining moment. Some experiences during the period were important parts of my intellectual development, and because of the way these shaped my perception of life and the culture and society in which I lived, they became factors in the ultimate decision that Wendy and I faced and made together.

I began to study several scholarly disciplines that had obvious relevance in my medical practice but had been entirely absent from the medical curriculum, notably social and behavioural sciences. I devoured some of the standard works in these domains, Sigmund Freud, Karl Jung, Melanie Klein, Margaret Mead, Max Weber, Talcott Parsons, and others. I began to explore epidemiology and environmental health, mainly in current medical and public health journals that I began to read. I began to classify and count the patients I was seeing in my office and in their homes. I read an electrifying article by J N Morris, "The Uses of Epidemiology" in the British Medical Journal, then I bought and read closely the short book with the same name, Uses of Epidemiology,  by J N Morris, and resolved that somehow I must find a way to work with and learn from him. These exciting concepts that Jerry Morris explained so clearly, and a few other seminal papers on epidemiology opened my eyes and my mind to a whole new way to think about sickness and health.

I took a speed-reading course. This had a dramatic impact: I found, as others before me had found, that as my reading speed increased from about 400-450 words per minute to 2000 words or more per minute, my comprehension and retention of what I was reading, increased too. This seems counter-intuitive until it is explained: when reading slowly, the mind is easily distracted, whereas when reading at maximum speed, the brain is totally occupied by absorbing the information on the printed page. By the time I had completed the speed reading course my eyes had become conditioned to taking in a paragraph  at a glance, and when reading a small paperback book, I could often take in a whole page at a glance - and retain the content of that page more completely, more efficiently, than when reading slowly. Of all the intellectual advances I made in the 3 years from 1957 to 1959, this was far and away the most important.

A cultural change was quite important too. I had enough Italian-speaking patients who did not speak English, to motivate me to learn enough of their language to communicate with them. Italian is a lovely language and I picked it up rapidly and easily. If you can pronounce an Italian word, you can spell it, and if you see it written down, you can pronounce it, because unlike English and French, Italian spelling and pronunciation are consistently and reliably related. I got far enough in Italian to be able to read Dante with the aid of a dictionary, and to understand the libretto of some of my favourite operas. "Che gelida manina" is so much more musical, more poetic, than "Your little hand is frozen!"  

I became active in the newly established College of General Practitioners, was appointed to committees, spoke at meetings, traveled interstate and networked with like-minded GPs in Melbourne, Sydney and Brisbane. I discussed these new activities with the professor of medicine in Adelaide, and he encouraged me to continue, to find linkages between community-based family practice and academic research. He encouraged me to think about taking a year of full-time study at the School of Public Health at the University of Sydney, then return to Adelaide where, he hoped, there might by then be scope for a university-based academic general practice.

At the same time as this, the senior partner in the group practice I had joined, was a prominent medical politician, president of what was then the Australian branch of the British Medical Association. He began to take me under his wing as a potential next generation medical politician who could succeed him and move up in the hierarchy of medical politics.  However, medical politics didn't interest me. The official medical association, soon to become the Australian Medical Association, existed to serve the interests of members of the medical profession. I was then and have always been more concerned about serving the interests of the general public. The senior partner in the practice was a gentleman through and through, a thoroughly decent man, had become a good personal friend with whom I shared many values and beliefs but I differed from him in priorities. I had absolutely no interest in serving in an organization concerned primarily if not exclusively with advancing the interests of the medical profession.

Rejecting the notion of rising through the hierarchy of the medical association was one thing. Turning away from a prosperous group practice that offered a lifetime of security and stability was something else altogether. Wendy and I agonized over this for many months, finally deciding late in 1959 that we would leap recklessly into the unknown and unknowable, leave the comfort, stability and security of general practice for a very uncertain and surely a far less prosperous life on the lowest rung of the academic ladder. I'll say more about the factors that led to our final decision in another post.

Those first three years of our married life were formative years in our marriage too. We had two children close together - Rebecca was born ten months after we married, and David followed fifteen months later. Wendy and I were both over 30 years old, accustomed to autonomy and independence and beginning to get set in our ways when we married. We had to get used to each other too, get adjusted to life as a married couple and as parents. How we managed to achieve that is another entirely separate story.                                                                                                                                      

Why do some people get sick and others not?

Towards the end of 1957, not long before Rebecca was born, I re-established contact with a man who had been a classmate of mine at Brighton Public School, had gone on from there to the Adelaide Technical High School and then to the University of Adelaide where he studied engineering. We got to know each other well during his first year at Adelaide Tech and my first year at St Peter's College, traveling together on the train from Brighton to Adelaide, always engaged in earnest conversation. We never ran out of things to talk about. His name was Robert (Bob) Culver. We re-established contact because his mother was one of my patients, and I was delighted to renew our friendship. His wife Cassie (Cassandra)  was a bright person too and got along very well with Wendy. Bob had become an academic engineer, was doing research in a field called rheology, the study of ways fluid flows through confined spaces - important in such diverse applications as water storage and conservation, and blood flow through arteries and veins. Bob was studying basic, seemingly simple questions about fluid flow that nobody previously had addressed or apparently thought about. I told him I was interested in basic questions too. The College of General Practitioners was born about that time, I had attended its meetings, and at one of these I had posed the question at the head of this post - "Why do some people get sick and others not?" It generated some discussion; someone wrote it down, and about 30 years later it turned up as the title of a book that for a while was quite famous. Bob and I kicked this question around too and concluded that interaction between personality, social environment, and disease agents like micro organisms and poor diets accounted for a good deal of illness, but the seemingly simple question held many complexities.  It surely does, and in the years since, a great many person-years of diligent research by battalions of epidemiologists, immunologists, behavioral and social scientists, have clarified some of the confusions that previously perplexed us. Those conversations with Bob Culver in our garden at 16 Henley Beach Road, Mile End, taught me a great deal about ways research workers must think, what constitutes original research, and what a wonderful exciting life it can be in academia.  So Bob Culver and all I learned from him about ways to think and frame questions, also played a part in shaping my my career.

Bob and Cassie Culver lived in the Adelaide Hills. Their home and all their possessions were destroyed in one of the disastrous bush fires that ravaged South Australia, some time in the early 1960s if my memory is accurate.  I wonder if they are still alive. It would be splendid to re-establish contact with them again after all these years.

Slings and arrows of outrageous fortune

The young ambulance driver I mentioned in my last post who died of the overwhelming toxaemia influenza can cause, was one of two siblings I had known since school days. Let me call him Bob Monkhouse - not his real name. He and his sister Jessie (not her real name either) had gone to expensive private schools. Jessie's plans, or her mother's plans for her, included a 'finishing school' in Switzerland, something almost unheard of  in late 1940s Adelaide. Bob Monkhouse had gone to Geelong Grammar School, reputedly the best boys' school in Australia and surely the costliest, was destined for the diplomatic service after he finished his degree in law. Their mother threw the most lavish parties in Adelaide. They could afford all the frills:  Mr Monkhouse, a meek-looking man, was the Adelaide head office manager of one of Australia's biggest banks and his wife came from an old established  land-owning family. I was surprised when I got back from England in 1954 to find Bob Monkhouse playing golf at my grotty little club. I'd have expected him to play at the Royal Adelaide Golf Club, with its pristine fairways, manicured greens and challenging bunkers. As for Jessie, instead of a finishing school in Switzerland, she was a shop assistant in a department store. I discovered what had happened when I became their family doctor. Meek and mild Mr Monkhouse had run away from his family and his bank, with a very large amount of the bank's money and one of its young female clerks. His wife had sold their gracious  home, her jewelry, their cars, and much else, to pay in part for her husband's misdeeds. Her name and accounts of her children's glamourous parties no longer appeared in the social pages of the Adelaide Advertiser. Bob and Jessie took their lumps rather well, all things considered, Bob especially so. He was a modest, caring young man, committed to doing good. He had been obliged to abandon his law degree and get a job to help support his mother. It was his choice to work as an ambulance driver. He felt he was doing something worth while and although I didn't know him well, he didn't seem to me to regret the diplomatic career his mother had sought for him.

In about the second week of the influenza pandemic of 1958, Jessie phoned early one morning, asked me to come to see Bob who, she said, was very ill. They lived nearby and fortunately I called first thing. He was indeed very ill, high fever, semiconscious, very breathless and a nasty colour. There were no anti-viral drugs in those days. I was concerned enough about him to go back to see him mid-morning. I found him much worse, indeed critically ill. I sent him to  the Royal Adelaide Hospital, where he was placed in what passed in those days for intensive care. I went back to see how he was doing early that afternoon, got there just in time to be present at his death. When I had first seen him about breakfast time that day, he had said a strange thing: "I forgive you all," he said, "even Dad."  Thinking about it a few days later when I had time to pause briefly in the midst of that hectic pandemic, I concluded that he must have had a premonition of his impending death, one of very few similar experiences in my life as a family doctor. His death was the end of the family. Without his moral fibre to sustain her, Jessie followed her mother's lead into alcohol dependence. I saw her by chance on one of my return visits to Adelaide about 20-25 years later, and wouldn't have recognized her if she hadn't made herself known to me. She told me her mother had died and her father had surrendered to police a few years earlier and was in prison. She was still a shop assistant, by then in charge of a whole department

Bob Monkhouse's rapidly fatal illness, and the very similar death of a midwifery nurse in the hospital where I did most of my obstetrics and whom I had also known since her childhood, were two events I recalled during my convalescence from a life-threatening bout of virus pneumonia that laid me low a couple of months after the Asian influenza pandemic had subsided. The deaths of these two fine young people made me reflect on how much more worth while it would be to spend my own life trying to find ways to prevent such deaths. So it's true to say that these deaths played a role in shaping my career.

Defining moments, defining events, defining situations

At the recent workshop on memoir-writing, our mentor Jon Peirce discussed defining moments. That is not the best way to classify several of the important turns my life has taken, although it does describe the most important event of all. I told the story publicly for the first time in a CBC Radio classical music request program on our 40th wedding anniversary, February 14, 1997. On the first sunny spring Sunday of 1955, I was off duty in the group medical practice in Adelaide where I was working at the time and on my way to play golf, when I stopped to pick up two young women hitch hikers. They were on the wrong road to reach their intended destination but I said I would take them to a junction where they could make their way to the road they needed. A few minutes conversation with one of these hitch hikers so impressed me with her spirit of social justice and her sense of fun, and her smile so entranced me, that I decided to abandon my plan to play golf that day, and said I would drive them myself: two defining moments a few minutes apart that changed the course of my life. 

In 1958, the Asian Influenza pandemic led to life-changing decisions following a moment of truth. I shared those decisions with one of those hitch hikers to whom by then I was married, and at that time we had an infant daughter. My partners and I in our group practice worked almost around the clock during that pandemic. Those who died included a young ambulance driver whom I knew socially. He was the sole support of his family, and about a month after he died, his mother came to see me and insisted on paying me for the fruitless visits I had made when her son was dying. That evening we had the monthly meeting at which our accountant presented the financial figures: we had never before made so much money in a single month. As my partners cheered, clapped and slapped each other on the back, I sat silently, seeing in my mind's eye the sad face of that woman as she thrust banknotes into my unwilling hands. It was a moment of truth, a moment in which I realized that I did not want to spend my life getting rich from the sickness, suffering and death of other people. That was one of several episodes that led to the decision Wendy and I made a little over a year later, to leave general practice and begin a new career in public health sciences. In a future post I will talk about other events that influenced this decision.

More on Wendy's diaries

My intermittent reading of Wendy's daily diary record of her life and times has reached 1991, and my respect and admiration for her intelligence, empathy, crap-detecting capacity, ability to define the caliber and character of friends, continue to grow. Her diaries routinely record banalities like weather, household chores etc, but interspersed with this are uninhibited and perceptive remarks about many of those with whom she had daily or occasional contact. Although she tolerated fools when in their company, she let herself go in the privacy of her diary, completely confident by then that no one but she would read it. She trusted me when I told her truthfully that I never looked at her diary even though she kept it in plain sight on her desk. She berated herself for what she perceived as her own shortcomings, and in this she was her own harshest critic, finding fault with herself when I and others close to her had nothing but praise and admiration for her. She referred to me as "his nibs" when she wanted to ventilate about my misdeeds and sundry inadequacies - which she usually discussed with me face to face as well; and I'm happy to report that as the years passed and we drew closer to each other, critical comments about me became infrequent as (I like to think) I became a better person under her guidance. She was unsparing also in her remarks about her friends and other family members, recording her criticisms frankly. Her irrepressible humour shines through all. Often as I read, it's as though she is there beside me talking, which is a good enough reason for spinning out this pleasure as long as I can, continuing as I have so far, to take her diaries in small doses. She kept up her diaries when we traveled as we began to do more often from the early 80s onward, and when we got home from travels to South Asia, China, Central Europe, Scandinavia etc, she usually typed up a more detailed report that she sent to her mother and sister in New Zealand. I hope I find copies of these among the boxes of her papers that I have yet to read!

  Wendy at her desk, 34 Waverley Street, Ottawa, with a floppy hat to keep the sun out of her eyes as she writes. Her diary for 1984 is on the front left-hand corner of her desk.

New city sights

Ottawa has a rather boring skyline. I see it when I look north from my apartment and always think it looks better at night when only the city lights, not the profiles of the humdrum city buildings, are visible. Wendy never tired of the changing effects of light and shade as the sun moved across the sky, and I'm chuffed when I remember what pleasure she got from gazing at the city buildings although I never completely shared in that pleasure. Today as I made my monthly pilgrimage northward on Colonel By Drive and across the Ottawa River to the SAQ store where I replenished my favourite strengthening medicine, I caught glimpses of the skyline from other perspectives and saw up close some new buildings and one still under construction on the University of Ottawa campus, that are exciting architectural additions to Canada's national capital. I can see from my apartment windows the top few floors of the new high-rise tower on the campus. As I came closer to it I was very pleased to see how handsome this tower looks. When it's completed it will be an ornament to the city and its skyline, which is fitting. Canada's national university in Canada's national capital is the proper place for innovative and architecturally elegant buildings like this. Another newcomer is the new Convention Centre which has no impact on the skyline but has a striking profile that overlooks the Rideau Canal. Only a handful of other public buildings in Ottawa, the National Gallery, the Museum of Civilization, two or three office buildings, and the Chateau Laurier (which must be getting on towards 100 years old) are worth a second glance. It's unfortunate that the splendid setting of this city, at the confluence of three rivers and with potentially great natural beauty, has not inspired a greater number of aesthetically thrilling and architecturally exciting buildings. I hope the few new ones on the U of O campus and elsewhere will inspire other architects and planners to do better. 

Defining moments

Yesterday I took part in a workshop on memoir writing. There were about a dozen of us with a leader who set several exercises that obliged us to think and reflect critically on what we were doing, how we were doing it, and encouraged us in various ways. For instance one way to construct a memoir would be around a setting like a family home. We focused on defining moments or events that shaped the subsequent course of our lives. I had no trouble with this, was pleased when the workshop took this direction because this is how I have structured the memoirs that I first began to write about 20 years ago. In the opening chapters about my early childhood the setting into which I was born and spent my early formative years, I have described how I believe that setting and the events of that time contributed to my emotional makeup. In later chapters it's easy to identify defining moments that shaped the course of my life from that time on. However, on further reflection, I think only one could truly be called a 'moment' - the others were decision nodes, times when I faced a fork in the road of life and had to choose whether to go one way or the other. Several of these were like Robert Frost's famous poem about two roads that diverged, and taking the road less traveled by, "... and that has made all the difference." This has assuredly been my experience.  There was one precisely defined moment when I stopped to pick up a pair of hitchhikers, and a little over two years later was married to one of them who shared with me in all the subsequent defining moments, or rather in all the decision nodes.On a few occasions, a moment of truth led inexorably to a decision node, but after Wendy came into my life the decision was always a shared one, and came at the end of a build up of circumstances and events which forewarned us of a decision that we would soon have to make. So yesterday's memoir-writing workshop was reassuring about the structure of the memoirs I've been assembling; and yesterday as I was reading a few excerpts aloud to the dozen or so memoir writers in attendance, I spotted ways in which I must revise them to make them more readable and interesting. There is no doubt that it was an extremely well spent day.

Seasonal gifts

Because David and Desre were traveling back to Toronto from Johannesburg on Christmas Day, our seasonal gathering was delayed until the New Year weekend, which included Rebecca's birthday on New Year's Eve. That evening I took the family, i.e. Rebecca (minus Richard who stayed home with a bad back), David and Desre, Jonathan, and my grandchild Chris, now 25, to a delicious dinner at the Green Papaya, Ottawa's best Thai restaurant. On New Year's Day we gathered at R&R's home for the annual seasonal gift exchange. As usual I gave everyone books, and in return I got several books and other things I had asked for. The most exciting and unexpected gift I got was a painting, from Chris, an under-water view of a swan, its long neck and its beak reaching for succulent weed on the bottom of a pond. Here it is on the living room wall, next to the Indonesian woodland sprite on top of the piano. It's acrylic paint on canvas, and I will explore ways to frame it, although it looks good on the wall as it is, unframed. 

Jonathan gave me a DVD of the recent movie Contagion, which accurately portrays how an Epidemic Intelligence Service (EIS) Officer from the Centers for Disease Control and Prevention (CDC) investigates every significant disease outbreak in the USA - in this case, an extremely dangerous pandemic with very high case fatality rate, somewhere between 30% and 50% (about the same as the Black Death pandemic in 1347-1350). It's a plausible scenario, and didn't greatly over-dramatize what could be expected if such a deadly pandemic were to occur. Jonathan also gave me a CD on which my blog is preserved from its first day, February 22, 2010, until just before Christmas 2011. Rebecca and David each gave me books I had asked for, by expatriate incumbents of endowed chairs at Harvard. Rebecca gave me the latest book by the Scottish economic historian  Niall Ferguson, Civilization; the West and the Rest, which I've already got far enough into to be very favourably impressed. David gave me the Canadian Steven Pinker's new book, The Better Angels of our Nature, which is about the decline of violence and Pinker's hypothesis and speculations about the reasons for this. I'm sure I will be commenting further on each of these books in future posts on this blog, so watch this space....

 Chris in the kitchen at 11A/300 Queen Elizabeth Drive, 31 December 2011

 Clockwise from L: Gilles, John, Chris, Richard, Desre, David, at R&R's, New Year's Day 2012

Locked out of my car

Twice when I was a family doctor many years ago I locked myself out of my car. The memory of these minor misadventures bubbled to the surface recently for no obvious reason. One occasion was commonplace. I had a car door that locked when I shut it if I pressed a button on the handle. I saw my keys dangling from the ignition switch just as I slammed the door. Many of us do this at least once. The other time I locked myself out of my car wasn't commonplace. I had my car keys in my hand as I slammed the car door, trapping both ends of the heavy woolen tie I was wearing, a few inches below the knot, forcing me to stand slightly stooped. That car had a keyhole only in the door on the passenger side not the driver's side, presumably because it was an Australian version of an American designed car. I was part way through my daily round of house calls, so I had my medical bag which contained a pair of scissors and I might have been able to cut myself free, but when I dropped the bag at my feet, my trapped tie prevented me from bending down to open it. I was on a quiet suburban street in mid morning and there wasn't a soul in sight. It began to rain, gently at first, then harder. By the time the postman came by delivering mail, I was soaked, and when I handed him the keys so he could set me free, he was laughing so hard at my predicament it took him an extra moment or two to get the key into the lock. After that I always made sure when buying a new car that both front doors had keyholes.

"Annual report"

To round out the year, here is the email greeting I fired off into cyberspace 10 days or so ago, to scattered friends around the world; it sums up my long-winded posts throughout 2011 --

 This year has been quiet, compared to the past 55 eventful years.  My children have been looking after me very well. Rebecca and Richard have consistently provided at least one meal every week at their place or mine; if at their place, Jonathan drives me out there. David phones almost every day from Kingston or Toronto (or wherever else in the world he happens to be; this week he's in Botswana). Just about every day I see and chat briefly to one or more neighbours in the condominium where I live. Even so, I get terribly lonely living here on my own. I miss Janet Wendy more than it’s possible to express in words. I have photos of her strategically located in several rooms in my apartment, and sometimes when I’m alone I talk to these photos. I’ve done very little traveling: over to Waterloo to talk to the new intake of MPH students, to Hamilton to stay with Karen and Pradeep Kumar and see a couple of plays at the annual Shaw Festival in Niagara on the Lake; and in August I flew to Edinburgh to attend the World Congress of Epidemiology, where I saw and shook hands with many old friends and made some new ones, and at times felt a bit like the Eiffel Tower because so many people wanted their photos taken standing next to me: I still seem to be famous among my fellow epidemiologists, get asked to give talks and write papers that purport to be learned. I flex my literary muscles with posts on my blog, originally a convenient venue for progress reports on Wendy’s condition, now a repository for whatever thoughts are uppermost in my mind at the time.  It’s a form of occupational therapy. When I reread my posts they strike me as boring and turgid, but to my surprise my blog has 20-30 regular readers and has had over 8,000 “hits” since I started it in February 2010. No doubt this includes shadowy spooks from secretive government agencies, but I don’t let that thought deter me from expressing my outrage and disgust at some of the actions of our current crop of elected leaders. It’s no consolation that they didn’t get my vote. 

I hope you have had a good year and that you are looking forward to a happy future. There are occasional photos posted on my blog if you can be bothered to scroll through all the verbiage.

My love and warmest best wishes to you all. 

David and Desre got safely back from Botswana and South Africa yesterday, so we'll have a family reunion, celebration of Rebecca's birthday, and belated seasonal gift exchange on New Year's Eve.

A White Christmas

Very light snow has been falling since the small hours on this overcast day, so rather to my surprise we have a white Christmas. It has covered the green grass of the little park below my north windows and the rooftops below the west windows. If the 7-day forecast is accurate, this light coating of snow may stay there until at least New Year. Until now the mild weather has fooled some migratory birds including Canada geese that have been able to gorge on fallow corn fields that are normally snow covered by this time of year; perhaps now the geese will belatedly head south. I am comforted by the thought that the shortest day is behind us now, and I can look forward to longer days, imperceptibly to begin with but soon the sun will shine again into my north windows, no doubt lifting my spirits further even though it will mean I must tilt the Venetian blinds to reduce the sun's impact on coloured fabric and the spines of my books. 

I took Rebecca and Richard, and Jonathan,  to a Christmas Day dinner at the Lord Elgin Hotel. I remember an elegant, well-appointed restaurant in that hotel, light and airy, with a very good table and excellent wines. It was one of Ottawa's top quality eating places in former times. Now, alas, like several other hotel restaurants, it's fallen on sad days indeed, just a rather grotty greasy spoon sort of place with a special set price menu for Christmas Day. The "home made" butternut squash soup was acceptable, but the meal went downhill after that. The plate on which my roast turkey, gravy and vegetables arrived, was hotter than the almost cold meal which all tasted as if cooked some days if not weeks earlier, and the banana fritters that rounded off our lunch were ice cold, not even re-heated. At least I had a glass of Canadian bubbly white wine to wash my meal down; none of the others had any alcohol to soften the impact.  I'll know better next time, will reserve a table at the Chateau Laurier well ahead of Christmas Day. These days the Chateau may be the only place in Ottawa that still serves a special Christmas Day feast.

It's no longer the season of peace and goodwill, if indeed it ever was. Today it was an extremist Islamic  sect in Nigeria that chose to demonstrate its ill will towards mankind, rather than one of the Middle Eastern or South Asian hate groups. We humans just don't seem able to get along in harmony with one another. What  an unhappy world it is!      

Don't miss this

Turn on your sound and visit
www.classicalarchives.com/feature/dont_miss_this.html.
I've sent the coordinates of this wonderful flash mob orchestral performance to many correspondents so it remains only to urge my unknown readers to look and listen too. Think of it as my seasonal greeting to you!

Iraq and other mistakes

Yesterday the last contingent of American combat troops left Iraq. I wonder how many of them felt ashamed, discomforted, guilty about what they did to that country. The war cost over 100,000 Iraqi lives, about 4500 American lives, and about $1trillion, and left the USA mired in debt that may prove insurmountably burdensome. Yes, they deposed a brutal dictator and a power elite that for decades had dominated that artificially contrived nation, and yes, they installed a form of governance that masquerades as a democracy. But most Iraqis are worse off than they were before their country was invaded, its infrastructure wantonly destroyed, its priceless museum of antiquities looted, sectarian tensions inflamed, indiscriminate violent death a daily reality. Under Saddam, despite his brutality, Iraq had efficiently functioning health care, universal state-financed education, little or no discrimination against women. The Iraqi physicians and other professionals I've worked with in WHO and interacted with in other settings were all very knowledgeable, well trained, competent; and about 50% of the physicians were women. Years ago one of my friends in WHO showed me proudly the superb dental work he'd had done in Baghdad when he'd broken a tooth while working there and consulted more or less randomly the first dentist able to see him on a street where there were several practising dentists.

I remember watching the discussion at the UN Security Council when Colin Powell, the US Secretary of State showed photos of what he said were storage sites for "weapons of mass destruction" and thinking at the time his presentation lacked credibility. Now we know it was all lies, that the entire case for war, like the sanctions and "no-fly zones" inflicted on Iraq between the two Gulf wars, was based on lies, that the Bush administration came to power determined to bring down Saddam Hussain's regime and install a puppet state in its place, one that would do America's bidding (and, inter alia, remove one potential threat to Israeli security). For a few years it looked likely that Saddam's fascist regime would be replaced by a failed state. That didn't happen, but 2011-2012 Iraq is certainly a fragile state with the potential to descend readily into the same kind of anarchy and violence  as Somalia.

American foreign policy has been inept for decades. They mistook the Vietnamese war of liberation from colonial rule by the French for an expansionist frontier of the People's Republic of China, when a less paranoid view would have had them helping the Vietnamese break free from French colonialism, helping Vietnam to become a democracy instead of an authoritarian state. That mistaken. paranoid policy cost many thousand American lives, perhaps ten times as many Vietnamese lives, catastrophic genocide in Cambodia, tropical forests destroyed by toxic herbicides, and a generation or more of birth defects caused by dioxins in the herbicides used to destroy the forests.  In Latin America they have repeatedly supported dictators rather than democratically elected leaders. In South Africa they supported the apartheid regime, the CIA led that regime's agents to Nelson Mandela and approved his imprisonment. Almost everywhere they have made enemies of people who could and would have been their friends. If Egypt, Libya, Tunisia and other Arab countries are soon ruled by Islamic fundamentalist governments, it will be because American foreign policy in the region backed dictators rather than encouraging nascent democracies.

As a friend of many Americans it saddens me deeply to spell out these American mistakes, but many more voices than mine are needed to speak these truths to American power, and turn US foreign policy in righteous directions.

The cultural mosaic

Almost every weekday, Rita Celli, the host of the noon hour CBC Radio program, initiates dialogues with her listeners on an interesting topic. This is the very best kind of talk radio, because Rita Celli does not shy away from controversial or highly sensitive subjects. Indeed I believe she deliberately selects sensitive and controversial topics. She is an excellent journalist, knows how to ask questions, how to draw out from the people she interviews the responses that they are sometimes reluctant to provide. As moderator of these daily discussions, she generally preserves her impartiality and equanimity Today she invited her listeners to comment on the announcement by the minister of citizenship and immigration, that women taking the oath of Canadian citizenship would no longer be permitted to do so while their face is concealed by a niqab. The topic of the niqab has come up before in other contexts, for instance in relation to the photo ID requirement for passports and driver's licences. As usual, today's program generated a lively discussion and as usual I was full of admiration for Rita Celli's tact and skill in the face of a few very emotionally fraught comments. On the whole, however, I thought the discussion illustrated very well the cultural mosaic of this wonderful country of Canada and the tolerance that Canadians in general mostly have for cultures and customs different from their own. I found myself in full agreement with one listener's comment that the Minister's decision to ban the niqab at citizenship ceremonies was a demonstration of the meretricious behaviour of the present government which encourages divisive and intolerant conduct   Today's discussion was another vivid demonstration that Wendy and I made the right choice when we chose Canada rather than the USA as the country in which to raise our children.    

Day 1: Feb 22 2010

Monday, February 22, 2010

Day 1: Feb 22 2010

This was my very first post, which got lost when I first posted it. Now, mysteriously, it's come back, out of sequence. It was my first attempt to record some of the events in the lives of Janet Wendy Last and myself. We began our married lives in Adelaide, South Australia early in 1957, having met about 18 months earlier in circumstances I have described publicly twice, first in a CBC Radio broadcast on our 40th wedding anniversary in 1997, then in a little speech at our 50th wedding anniversary banquet. Later I inserted one of those anecdotes in this blog. We have moved about quite a lot in our married lives, though not as much as many immigrant Canadians. I will insert from time to time a few pictures of us at various stages in our lives. Here on the left is a photo of us at Cochem Castle on the Moselle River in Germany, on our  European holiday in 2007. That turned out to be our last European holiday, indeed our last holiday.

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Pandemic influenza

It's been a busy week so far. Yesterday morning I was invited to give a keynote address to open a two-day national workshop on pandemic influenza, convened by the Public Health Agency of Canada. I chose to widen the scope to talk about pandemics in general and to consider some broader issues than control of pandemic influenza. It was a very interesting workshop, which included the perspectives of the World Health Organization, the UK and the USA. Here is the text of my opening talk, which seemed to find favour with many participants who spoke to me afterwards and at the dinner last night.

Historical and other aspects of pandemic disease

The struggle for supremacy between mankind and infectious microbes has fascinated me since I was a medical student nearly 70 years ago. Pandemics are an aspect of this struggle, in which, for a time, microbes gain the upper hand. The world’s population passed 7 billion in October 2011. A crowded world is heating up, its infrastructure is deteriorating, and millions are restlessly moving. UNHCR reported 47 million refugees in 2010; at least that many or more migrated from rural to urban areas. Every year about 200 million migrate internationally, and 600 million or more travel internationally by air. Future pandemics are a certainty, probably soon, perhaps due to new pathogens. Some pandemics have affected the course of history and probably will again in future. Difficult moral and ethical issues can arise in epidemic and pandemic disease control.

Ancient fears and superstitions

A large outbreak of an often mysterious disease that strikes people down seemingly at random has always been a terrifying phenomenon. Such events were explained in ancient times as god’s punishment for the people’s sins, the work of the devil or evil spirits, probably summoned by malign individuals like witches, or those perennial scapegoats, the Jews. Someone had to be blamed and punished, so witches were burnt at the stake, Jews were driven out of the community. Pandemics, even localized epidemics, still have the power to awaken atavistic fears among ignorant and superstitious people, as they did in the Middle Ages. People look for scapegoats, try to find someone to blame. They turn to fundamentalist aspects of faith, make sacrifices to appease vengeful evil spirits or the wrath of god. The economy suffers, hurting those who worship Mammon.

An Adelaide GP’s perspective on the 1958 Asian influenza pandemic

My experience as a GP (family doctor) in Adelaide in the 1958 pandemic of Asian influenza shaped my career. In June 1958, I was 8 1/2 years out of medical school, 4 years in general practice in Adelaide. Asian influenza reached Australia in early winter, in June. In Melbourne, the eminent virologist Macfarlane Burnett (later a Nobel laureate) headed the Walter and Eliza Hall Institute at the University of Melbourne and working with Frank Fenner at the Commonwealth Serum Laboratories, began preparing a vaccine. Small quantities of the vaccine reached Adelaide in July, and were given to highest priority public officials, including ambulance attendants, emergency room staff, police (but not GPs). In July, August, early September, my partners and I worked nonstop. We did a lot of house calls in those days; during that pandemic I did up to 30 house calls on many days, as well as seeing patients in my office. Public service radio announcements urged people with flu symptoms to avoid public places like hospital emergency departments (but not GPs’ waiting rooms!). Worldwide deaths in the 1957-58 influenza pandemic were over 2 million. The pandemic struck close to home. It killed two young health professionals I knew very well: a nurse in the maternity department of the hospital where I did most of my obstetrics, and an ambulance driver with whom I played golf. Both had flu vaccine a few days earlier…

In October after the pandemic receded I fell critically ill with a non-bacterial pneumonia. I and my doctor thought for a few days that I would die. I had a daughter aged 10 months and my wife was pregnant with our second child. It was a career changing experience. During my convalescence I thought deeply about what to do with the rest of my life: I decided to leave general practice where I was happy, financially secure, and I’m told, was regarded as a good doctor. Instead I decided to train in public health sciences, especially epidemiology, with the aim of keeping people healthy rather than waiting for them to get sick. That career change brought me to Ottawa 42 years ago.

Pandemic diseases in historical perspective

The outcome of many wars has been determined more by pathogenic micro organisms than by military strategy, tactics, bravery, or superior weapons. The plague that afflicted Athens at the end of the first year of the Peloponnesian War (426-425 BCE) was described in detail by the historian Thucycides, who was there and got the plague, but fortunately survived it. It was not a pandemic but a localized epidemic, probably louse-borne typhus. The next historically memorable epidemic (or pandemic) was the plague of Justinian, emperor of Constantinople; this afflicted the Empire of Byzantium in 541-542 CE, and was probably bubonic and pneumonic plague.

The Black Death, bubonic, pneumonic and septicemic plague devastated Asia Minor and all of Europe in 1347-1350. That pandemic killed up to 30% of the people of Europe and may have set back the advance of civilization by several hundred years. That was followed in 1485 by the first wave of a mysterious contagious disease called the sweating sickness (or ‘sweats’). This caused severe epidemics in Britain and Europe until 1551, after which it disappeared forever. We have no idea what this was. It might have been a variety of influenza but contemporary accounts don’t sound like influenza. Several medieval epidemics of smallpox and typhus were widespread pandemics.

Influenza and cholera are the best known among lethal pandemics in the past 200 years, a period during which we have had good clinical and statistical records, and increasingly good microbiological and immunological tools. This combination has removed much, but not all, of the superstition, hysteria, ‘fear of the unknown’, victim-blaming and stigmatizing that often occurred during lethal outbreaks of contagious diseases in earlier times.

Cholera has swept across the world in seven pandemic waves since the early 19th century; the seventh cholera pandemic seems to be subsiding now, apart from sporadic outbreaks in Haiti and refugee communities in Africa; but no doubt we haven’t seen the last of cholera.

Influenza

Hippocrates (4th Century BCE) described a disease that sounds very like modern influenza and several writers described outbreaks in Europe as early as 1580. The first European occurrence that we can confidently call pandemic influenza was in 1830-1833. A pandemic in 1880-1882 invaded Europe from Russia. About the same time there were influenza epidemics in China and India. The first truly global pandemic was the ‘Spanish’ Influenza in 1918-1919. This attacked predominantly young people (born after 1882) and had a case fatality rate of at least 2% in people aged under 40. Estimates of worldwide deaths vary from 20 to 100 million. It certainly killed more than all killed in the Great War of 1914-18.

Several potentially catastrophic pandemic waves of influenza have fizzled out or been aborted since 1976, most recently swine (H1N1) and avian influenza (H5N1) which had a higher case fatality rate. We can’t know for certain, but strain-specific vaccines and other counter-measures like isolating and killing infected domestic poultry flocks may have aborted or prevented what could otherwise have become major pandemics possibly with high case fatality rates.

Since its onset in the early 1980s, the HIV/AIDS pandemic has killed about 35-40 million people, but the epidemiology, natural history, and control measures for HIV/AIDS are so different from other pandemics that they require separate discussion, and I won’t go into details. The threat remains real from outbreaks of new and emerging pathogens that could be natural or man-made.

Pandemic disease as a war weapon

In North America and in Australia in early colonial times, blankets used by smallpox patients were given to indigenous aboriginal tribes with the deliberate aim of infecting them with smallpox. These were genocidal acts of biological warfare. About 300 years earlier, the spectacular success of the Spanish invaders against the Aztec empire in Mexico was due less to their guns and steel swords than to the viruses of measles and smallpox that they brought with them; the Spanish invaders were resistant to these viruses but the Aztecs were not, and were decimated. The Spaniards did this unwittingly, but during the plague of Justinian a thousand years earlier, corpses of plague victims were catapulted into besieged cities in Asia Minor with the deliberate intention of starting a plague epidemic. Infected corpses have been dropped down wells to contaminate drinking water since biblical times, so this is an ancient aspect of military tactics. In World War II, the Japanese experimented with plague, and Winston Churchill’s government experimented with anthrax among other organisms, rendering an island near the entrance to the Firth of Forth unfit for human occupancy– it was still “Off Limits” when I worked at the University of Edinburgh in 1965-69. Other nations also experimented with highly contagious pathogens, and no doubt continue to do so. A terrorist group or a small, weak nation with malice aforethought could severely damage a larger, wealthier, well-armed nation, using biological weapons. My son had 30 years in the Canadian forces and worked among other things on security threats to Canada; he told me that NDHQ (like the CIA and NSC in USA) takes this threat seriously – although they haven’t taken the Canadian people into their confidence about this. (The public might be more cooperative with pandemic control measures if they knew about such threats).

Pandemic disease in food crops

The famine in Ireland in 1845 was man-made but it was potentiated by potato blight, a fungus disease that wiped out the harvest of potatoes upon which Irish peasants and city people depended for their survival. One reason I deplore the infatuation of agribusiness with genetically modified food crops such as corn is that these monocultures could be terribly vulnerable; they might be susceptible to invasion by virus, bacteria or fungus which could destroy in one blow the food crops of an entire region. This nightmare scenario is less likely to occur if we encourage biodiversity, avoid monoculture and genetically modified food crops. This biological reality seems to be better understood in Europe than in USA and Canada. However, I don’t really know what I’m talking about here. These may be the ravings of an old man in the process of losing his marbles, so ignore me, or heed me as you wish.

Living in harmony with pathogenic organisms

The laws of evolutionary biology dictate that we can never win a war against pathogenic organisms using antibiotics and anti-viral agents. Micro organisms have generation times of minutes or less in favorable conditions, so resistant strains rapidly evolve. History and headlines every day tell us that humans have never yet learnt how to live in harmony with enemies of our own kind. But we have learnt and continue to learn how to live in harmony with many of our microbial enemies. Safe food and water, kitchen hygiene, vaccines, sera, antibiotics, window screens, bed nets and condoms have enabled us to co-exist with an increasingly wide range of pathogens. Recent genome studies offer great promise of future developments, including creation of non pathogenic strains of dangerous pathogens that could “out-breed” the pathogenic varieties, and genetically enhanced resistance to pathogens like common cold viruses.

Studies of blood group frequencies in countries around the world as long ago as the 1960s demonstrated striking differences; the occurrence of sickle cell anemia in regions where malaria had long been endemic is further evidence to support the hypothesis that regional impact of epidemic, endemic and pandemic disease in previous generations led to these differences in genetic makeup: it is caused by the impact of these diseases on particular genotypes. Plague, smallpox and influenza epidemics in particular appear to have had considerable influence on the genetic make-up, including blood group frequencies, of populations in Southern and Western Europe, Egypt and the Middle East, and India. All this was known about the time Crick and Watson discovered the DNA molecule. Since DNA analysis was perfected, further studies have enlarged our understanding of relationships between genetic makeup and susceptibility or resistance to many diseases, including those such as influenza that have the capacity to cause pandemics. Medical science will surely develop techniques of gene transplant or transfer, or other ways to manipulate the human genome so as to enhance herd immunity to specific viruses, enabling populations to live in harmony with pathogenic micro-organisms that caused devastating epidemics in earlier times.

What happens when we relax mass vaccination?

Paralytic poliomyelitis, measles, diphtheria and whooping cough epidemics occurred when mass vaccination broke down after the USSR collapsed. Small, localized outbreaks have occurred in unimmunized sub-groups such as members of the Dutch Reform Church who have religious objections to vaccines. Cases of measles, rubella and mumps occurred when parents withheld their infants from MMR and other vaccines after the scoundrel Wakefield published a paper, later shown to be fraudulent, claiming an association between MMR vaccination and autism. As formerly common infectious diseases of childhood become vanishingly rare, sporadic cases and even epidemics will return if herd immunity falls below the critical level, which can be calculated for each of these diseases, using mathematical models developed many years ago by Norman Bailey (since refined by others). One of our best defenses against epidemics is maintenance of herd immunity. This can become a challenge when the risk of an adverse reaction associated with each specific vaccine approaches (or exceeds) the risk of acquiring the disease, raising ethical dilemmas about balancing risks and harms against benefits.

Ethical and moral concerns

Fear of contagion is a variation on the theme of fear of the unknown. We think of it as an out-dated emotion but it occurred during the SARS epidemic in Toronto in 2003. ‘Contagion’ (suspected contagiousness) is stigmatizing, harmful, potentially lethal: being Chinese in Toronto during the SARS epidemic could have led to being burnt at the stake if it had happened in medieval times. These sentiments were detected on talk radio in Toronto in 2003. Epidemic control officers have a moral or ethical obligation to dispel these irrational emotions by educating the public, being open and truthful. During the SARS epidemic I was asked by the CBC to give many interviews, the aim being to educate the public and eliminate the tendency to stigmatize groups suspected of disseminating the SARS organism (at that time the nature of the organism was unknown). On one memorable morning I gave 14 separate interviews to 14 breakfast radio programs from St John’s to Victoria, White Horse and Yellowknife. The questions were much the same each time but probably correctly, the CBC producer wanted live programs aimed at the local audience, rather than a single nation-wide interview. The aim was to inform and educate, to avoid the moral problem of stigmatizing the innocent. The World Health Organization didn’t help: WHO officials should have known better: their travel advisory cost Toronto $35M/day in lost business.

The procedures of epidemic control, surveillance, locating cases, notifying, isolation, quarantine, raise ethical challenges. Surveillance reminds us of George Orwell’s 1984, that Big Brother is watching; identifying and notifying cases is potentially stigmatizing. Isolation restricts freedom of cases. Quarantine denies freedom to contacts of cases. The question pandemic control officers must ask is “How can I eliminate the risk that control measures cause harm to anyone?” Other troubling questions arise when we use the “police powers” of public health.

Philosophical considerations

One purpose of history is to help make informed guesses about the future. A few months before I graduated from medical school in 1949, I wrote a gloomy essay about future prospects for humanity. One theme I explored was what I perceived as an alarming, unsustainable population increase. In 1949 the world’s population was 2.4 billion, increasing by 20 million/year. In October 2011, the world’s population passed 7 billion, and it is increasing by 75 million/year. Demographers, agronomists, security analysts in the CIA, and other experts, agree that the world can’t sustain such increasing numbers; the population is projected to reach 9-10 billion by mid-century; at the same time we are losing agricultural land to urban sprawl, soil erosion, desertification, sea level rise, climate change; and the oceans, formerly the source of 30% of human protein needs, are depleted and polluted. Are we about to hit Thomas Malthus’s wall? Is the irresistible force of population growth hitting the immovable object of declining global resources? This is happening now in parts of the world. It is responsible for the increasing number of environmental refugees, from 5 million in 2005 to 47 million in 2010. Wait a wee while and one of the Four Horsemen of the Apocalypse will bring you down. What’s your preference? War? Famine? Pandemic Disease?

Perhaps we should welcome rather than take counter-measures next time a pandemic strikes. That would be one way to reduce the surplus population.

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Today I had to miss the second part of the workshop on pandemics to attend a U of O function at which my presence was almost mandatory; this had to do with plans for the period from now to 2020 and beyond, to which I've already contributed in a miniscule way. I was very happy to hear from a bright young man in the Development Office about the ways in which the U of O is encouraging and promoting transdisciplinary activities and groups, helping to break through the watertight compartments that sometimes block communication among disparate groups and individuals in the scholarly community.

Bah! Humbug!

At this time of the year I feel really sorry for the people who work in shopping malls, in the few surviving department stores, and this year for the first time even in the neighbourhood book shop. How can they endure hour after hour of carol music? They deserve extra wages for the hardship. I love many Christmas carols but the versions chosen for endless repetition as background to the shopping spree the vendors hope for, are chintzy schlock. Today I heard far worse. A so-called ballad singer was inflicting on CBC Radio's audience her souped up versions of It Came Upon a Midnight Clear, Away in a Manger, Come All Ye Faithful, and Stille Nacht (Silent Night) with her horribly out of tune high and low notes and thumper-thumper instrumentation. If she had come within reach I'd have cheerfully garrotted her. Then there are Christmas lights. Sure, they brighten the long nights, but increasing numbers of people leave their twinklies on for months, until daylight saving summer time begins in April if not longer.

Climate and human health

The latest issue of the British Medical Journal to reach me had a report of a conference in London last month on the health impact of expected climate change in the next 50 years, in the lifetime of my grandchildren. This was attended by leading experts on public health, climate science, agronomy, entomology, strategic studies, food science. It makes grim reading. The consensus is firmer than ever that in the absence of immediate action to reduce carbon dioxide emissions, there will be a 4-5 degree C increase in average global temperature by 2060, increased frequency and ferocity of droughts and floods, and sharp decline in productivity of all the world's grain-growing regions. This will lead to hunger, starvation, famine, massive refugee movement and widespread conflicts. More than half the world's population will be living in regions where mosquito-borne diseases occur. Our government denies the need to do anything about these predictable dangers, indeed is doing all it can to prevent any steps towards mitigation of climate change at the conference now in progress in Durban, South Africa. The smugly complacent woman columnist in our national newspaper as usual finds a dissenting voice among the climate scientists and quotes this triumphantly: don't worry, be happy, all those experts are wrong, here is a scientist who says all is well and the observed rise in global average temperatures over the past quarter century, the increased number of extreme climatic events, the melting polar and alpine icecaps are "normal events" and just passing trends. Even more frightening, smart-arse engineers and others assert that they have a solution, just load the upper atmosphere with a bit of sulfur dioxide or other stuff to reflect solar radiation back into space and bring the temperature down that way, while continuing to load the atmosphere with more greenhouse gases. The economy, so say the investors, is more important than survival of grain crops, life-supporting ecosystems, even humans, so long as we can continue with business as usual, continue to "grow" the economy, continue to make profits. A species that acclaims such sentiments doesn't deserve to survive, and won't.