Working at the School of Public Health

Following up the work on “The Iceberg” I had several other ideas in quick succession. The avuncular director of the School of Public Health came into my office one day, with an interesting question. The island of Tasmania with a population of about 350,000 at that time, had two cities, Hobart at the south end, Launceston at the north end; it was separated from the mainland of Australia by the usually rough sea of Bass Strait, and in those days air services were unreliable, often disrupted by poor weather. The question was this: How many neurosurgeons should there be in Tasmania? Was a single neurosurgical unit in Hobart enough, or should there be another in Launceston at the other end of the island? The two cities were several hours drive apart, and some people with severe head injuries would die in transit if they had to be taken by road from one end of the island to the other. I immediately wanted to answer a more general question: how many doctors of all kinds, in general practice and in every specialty, should there be? It was technically easier first to answer other questions: how many doctors were there? Where were they? Were they distributed equitably in the population? Were some specialties “over-serviced” and were the numbers in other specialties inadequate?  How could practicing doctors be identified and counted? There were several sources of information, all of them flawed. One immediate problem was that lists of licensed medical practitioners were separately maintained in each state, and significant numbers were licensed in more than one state. In some states, including my home state South Australia, it was possible to be licensed for life rather than renewing the license annually. I was licensed for life myself.   There was no easy way to deal with this problem other than to go laboriously through the printed lists of licensed medical practitioners in each state, strike out those with addresses outside that state, and count the totals, then adjust if possible for reduced activity by semi-retired and part-time practitioners, setting arbitrary ages or years since graduation, for retirement.. There were other sources of information: specialty societies had lists of their members. The pharmaceutical industry maintained up-to-date lists of doctors and basic facts about their practices, including useful information about the extent to which doctors were practising full-time, specialized, or focused on specific aspects of practice. They even had some figures for retired and part-time medical practitioners. This information enabled salesmen for the drug companies to concentrate their sales pitch on specific doctors and aspects of practice, and relevant drugs for this aspect when they talked to individual doctors. I recalled being asked by salesmen about my practice, and that the salesmen wrote down what I said. Very few doctors refused to see drug company salesmen, so this source of information was reasonably reliable. Even so, when my paper on “Medical manpower in Australia” was published, I commented on the shortcomings of my sources of information.  I looked also at ancillary professions such as optometry, podiatry, community nursing, physiotherapy and pharmacy, and glanced at the interactions and territorial disputes among them. These aspects of the sociology of professions were very interesting and had I stayed put in Australia I think it is likely that I would have explored this domain in greater depth.

Rebecca and David in inland Australia, 1963

While I was in the group practice in Adelaide I had published a descriptive article on the health problems I had observed among immigrant patients in my practice. This brought me to the attention of two social demographers at the Australian National University, Bill Borrie and Jerzy Zubrytsky. They asked me about my possible interest in becoming a research fellow in their group, but the salary they were offering was derisory, so nothing came of this. I’ve wondered sometimes how differently my career and our family’s lives might have evolved if it had been possible to respond positively to that inquiry.  I used to think wistfully about it in later years whenever Wendy and I returned to Canberra, sometimes to stay for a few weeks in the urbane ANU Residence in the increasingly attractive city of Canberra. It would have been a superb place to work and live…

"Where the dog sits on the tucker-box, five miles from Gundagai"

By the middle of 1963 I felt comfortable in my own skin, and that I was doing worthwhile work, carving out a niche that nobody else in Australia seemed concerned about.  In 1962-63 I wrote several original articles on these aspects of what we called ‘manpower’ in those days, now de-gendered and renamed  ‘human resources.’ These articles were published in small-circulation journals such as the Australian Journal of Social Issues and serial publications of Commonwealth and state health departments, mostly after we had left Australia again at the beginning of 1964. Home life was relaxed and very happy.

Family picnic, National Park, Adelaide Hills, 1963
L-R: Rob, David, Rebecca, Wendy, Vera Last; in front: Jenny, Kate, Peter - all of us except I who took the photo

An eminent semi-retired surgeon who was Director of the NSW Postgraduate Medical Foundation, asked me to evaluate continuing education programs for rural GPs. Data from the recently inaugurated Pharmaceutical Benefits Program had revealed upsurges in prescriptions for costly polypharmaceuticals after drug company salesmen’s visits to a district. Could I re-examine the data to find out whether educational programs aimed at discouraging use of such drugs were having any impact on prescribing habits of GPs? I did this, and wanted to expand the question. Medical insurance claims data could also be examined to explore other aspects of continuing medical education, for instance to discover whether qualified surgeons had better outcomes than GP-surgeons for frequently performed surgical procedures, appendectomy, hysterectomy, gall bladder surgery and inguinal hernia repair. In NSW in the late 1950s and early 1960s, surgeons with higher surgical qualifications performed about one third of appendectomies and inguinal hernia repairs, and two thirds of gall bladder surgery and hysterectomies. Surgical outcomes could be compared and measured by length of hospital stay, and incidence of complications such as postoperative infections and thrombosis.  All the data were available in medical insurance claims records.  I submitted a proposal to the Commonwealth National Health and Medical Research Council to conduct an analysis of records. I emphasized that such an analysis could be done discretely and without revealing any doctors’ identities; moreover it would cost very little. I submitted the proposal in the form of a letter to the secretary of the NH&MRC in Canberra.  Within a week or two, without any advance notice, two senior bureaucrats from the Commonwealth Department of Health came to my office. They stood at the corners of my desk while I sat behind it, and shouted at me, that I wasn’t ever again even to think thoughts such as those I had expressed in my letter to the Secretary of the NH&MRC. They made me give them the file copy of my letter and left, warning me that questions such as those I sought to answer were not scientific but “political” and were none of my business. I was virtually commanded never again even to think about investigating such a politically sensitive question. I found it very discouraging and frustrating to have my inquiring mind so aggressively deterred. I felt defeated, disconsolate, depressed. I described the experience in a letter to my friends in the Social Medicine Research Unit in London, telling them that Australians were not ready for this kind of health services research.

 Little Miss Twinkletoes and her partner, in our garden at 98 Grasmere Road, Cremorne, Sydney, about September 1963

Settling in Sydney in 1962

Looking NW from our sun room at 98 Grasmere Road; Cremorne, Sydney; a sliver of water in Middle Harbour is visible above the chimneys just right of centre.

When our ship reached Adelaide in May 1962, Wendy and I paused  long enough at brother Peter's home to celebrate our niece Kate’s birthday, before collecting Helen, our dachshund, loading our trusty station wagon, and heading back to Sydney, where I had been offered a position as lecturer at the School of Public Health and Tropical Medicine, University of Sydney. My dream of combining family practice and epidemiology, which I had discussed with the professor of medicine in Adelaide before leaving the group practice at the end of 1959, had collapsed. Adelaide wasn’t ready for academic family medicine in 1962.  I wasn’t too upset by this change in direction. The year with Jerry Morris and his colleagues at the Social Medicine Research Unit had been a rich intellectual feast that equipped me with many new skills and the insight and capability to ask worthwhile questions about health services and medical care. My first priority was to prepare for publication my paper on “Completing the clinical picture in general practice” and I did this without much fuss, one back-and-forth exchange of an advanced, near-final draft between me in Sydney and Jerry Morris in London, and the paper was ready to submit to a journal. I sent it to Sir Theodore (“Robbie”) Fox, editor of the Lancet. He accepted it without any changes in the text, but gave it a new title, “The Iceberg”, keeping my original title as a subtitle. Ever since its publication in July 1963 I’ve been famous as the author of “The Iceberg.” Even now, 50 years later, this paper, and the concept of the “iceberg” of disease, what is visible and what lies below the surface, remain well-known and frequently cited. I had literally hundreds of requests for copies, and the paper has been reprinted in several anthologies of ground-breaking original articles. I am forever in Jerry Morris’s debt for giving me the inspiration for this paper, and allowing me to take all the credit. I suppose it’s fair: he had the germ of the idea, and I took it, nourished it and made it grow and flourish.

 

El Alamein fountain, King's Cross, Sydney; L-R: Jonathan (in pram) Kerry, Wendy, David, Rebecca, August 1963 

On arriving in Sydney, we rented a house in Bondi, intending to buy a home in the Eastern Suburbs conveniently close to the University of Sydney. We quickly realized that house prices in this district were far outside our reach, so we shifted focus and began to look at houses across the Harbour but close to the Harbour Bridge so as to avoid a long commute up the north shore. We found a modest small house at 98 Grasmere Road, Cremorne and settled there happily within a couple of months. We expected our stay in Sydney to be a long one, perhaps for the rest of our lives, so we took some care to select a suitable district with good schools. We set about exploring Sydney, re-discovering its many charms and attractions that we had glimpsed during our previous stay, and finding new charms on the north side of the harbour which we had barely known when we lived there in 1960. My working life was absorbing most of my time from Monday to Friday, but weekends were almost always free of commitments so we used these to discover the many delights that Sydney had to offer. We folded Kerry Edwards back into our lives, not just to help Wendy with the kids, but as a good friend to all of us. She came with us to Adelaide over Christmas at the end of 1962.

R and D with Grannie Vera Last, Cremorne, Sydney, 1963

Our children loved Sydney, settled in quickly. They enjoyed playing in our steeply terraced garden, with banana palms and a swing at the bottom and a series of terraces to lawn on a level space below the back veranda and sun-room. They enjoyed our days at the rocky harbourside pools in which they could paddle and swim safely.

 Cooling off on a hot day in Sydney

Rock pool at Mosman, Sydney Harbour, 1963

Beside a swimming pool, Mosman, Sydney Harbour, 1963






Wendy and I decided it was time to provide a little brother or sister for Rebecca and David. Wendy’s pregnancy proceeded smoothly without incident and Jonathan was born after a very short easy labour on June 9, 1963. Here again is Wendy's diary entry for Saturday-Sunday June 8-9 1963: "Had a quiet day. Did some hand-washing & tidied up. Wrote to Dodie and Jan Gilfillan [Fry]. John got lunch ready & took kids for a run on beach while I made choc cake, meringues & fruit cake. Had a rush to get ready for Cullen's dinner party. Home 11.30, straight to Mater Hosp. 3 pushes & Jonathan born." I barely had time to wash my hands and ease Jonathan into the world, because the midwife was busy trying to phone our doctor, who arrived eventually about an hour later. We managed fine without that GP, who missed the very loud heart murmur that I heard when I examined Jonathan 3-4 weeks later on a Sunday night because we were worried about his persistent cough and breathlessness.The heart murmur was so loud I could actually hear it if I put my ear close to Jonathan's chest. From then on, Jonathan was in the care of a pediatric cardiologist. Every specialist who saw him at that time thought he had a large ventricular septal defect, a "hole in the heart" that allowed blood to flow between left and right sides. We didn't know the exact nature of the problem until he was between 5 and 6 years old and had cardiac catheter studies while I was on staff at the University of Edinburgh.The problem was much more complex than anybody thought, and could be dealt with at that time by only two cardiac surgeons in the world. I will describe it later in another post.

On the road between Adelaide and Sydney, near Canberra, 1962 

Christmas 1962. L-R: Kerry, Wendy, Vera Last

Rebecca and David, already politically active, approaching Parliament House, Canberra, 1963

Our family, December 1963

Discussing the unthinkable

Radio and TV discussions of a so-called 'preventive' war against Iran shrivel my marrow. Iran, formerly Persia, is a nation of about 80 million people, the seat of one of the oldest civilizations of humankind. In the mid-20th century its democratically elected left-leaning government was overthrown in a violent coup supported by the CIA and several European powers with interests in Iranian oil. The Shah was chosen by these western powers to rule Iran. I recall a student at the University of Edinburgh in the late 1960s, who had no fingernails on his right hand. When he was a small boy, Savak, the Shah's vicious secret police, had pulled out his fingernails in front of his father, in an attempt to persuade his father to confess to sedition against the Shah. In 1969 the Shah was overthrown and the Ayatollah Khomeini became the leader of a theocracy supported by revolutionary guards who seem to be as brutal and unpleasant as the Shah's thugs. The Shah had aspired to lead a regional hegemony possessing nuclear weapons, and so it appears, do the current leaders of Iran. Leaders of western nations, the USA, the UK and and the EU have imposed sanctions with the aim of deterring Iran from expanding its nuclear program. The Israelis have assassinated several Iranian nuclear scientists. There is increasingly bellicose talk of waging war against Iran to stave off advances in its nuclear program. Such a war would be ecstatically welcomed by lunatic fringe believers in the fantasy of 'end times' and doubtless by arms manufacturers and other misguided or just plain evil people. Americans who still cherish memories of their humiliation by the Revolutionary Guards who held US Embassy staff hostage, welcome it too. Like the Bourbons, they have learned nothing and forgotten nothing - except perhaps the calamitous fiasco of their campaigns in Iraq and Afghanistan.  I wonder if these fantasists who are talking about and probably planning war against Iran have thought through all the likely consequences. Have they considered, for instance, possible Chinese reactions, and the fact that world oil supplies would certainly be disrupted, probably for a long time, with devastating economic effects? Have they considered how Russia and the central Asian republics might react? Among my friends and professional colleagues there are several Iranians for whom I have a high regard and affection. My friend Mohsen Janghorbani, a professor of epidemiology in Isfahan, translated the Dictionary of Epidemiology into Farsi.  I admit that I haven't given deep thought to scenarios involving war against Iran, but I've thought enough to fail to visualize any scenario with outcomes that are in any way happy for anybody. If I believed in prayer, I would be praying for an outbreak of sanity among leaders of the world's nations.

Wendy's diary of voyage home to Australia, 1962

This post consists of excerpts from Wendy's diary, interspersed with a few photos. We left London by train from Liverpool Street station, for the ferry from Harwich to the Hook of Holland. Over to Wendy:
Monday 30 April 1962: Awake 6 am. Breakfast on ship [ferry]. Left by train from Hook of Holland to Rotterdam at 7.40. No trouble through customs. Couldn't get into our room at hotel until 12 MD. Walked around fine city for 2 hours then went to room and slept till 3 pm. Had sandwich in dining room then a tram ride ... excellent dinner. Kids to bed 8.30.

Left: Blitzkrieg Memorial, Rotterdam

  
Tuesday May 1: ... I packed up while John went to shipping agents. Had a chance for another look around Rotterdam - a fine city. Bought nuts, raisins etc. Had a good lunch then straight to ship [MV Morelia].  Doesn't look as ship-shape as Pretoria. Unpacked; sailed at 6 pm. May 2: ... In Scheldt estuary 10 am, finally docked at 11.30 pm. Fell into bed. Set alarm for 6 am for shore going. Children played marvelously well with Lego and dolls. May 3:... Fantastic trip into ANTWERP... A splendid city with lovely statues and buildings and huge cathedral. No time to see Rubens Museum. Bitterly cold and frozen to the bone. Back on board and knitted all day. Read to children, ironed and mended. Bed 9.30 pm.





 Antwerp, City Square


May 4:Out into Channel at 6 am. A foggy day on and off, damp, cold and calm. Children being perfect angels. Played in R's cabin while I did washing then all sat out on deck. I got on well with knitting. Both D and R fell off trapeze and on back of heads. No harm done. Read to them and did puzzle book most of PM. 8 PM: In Bay of Biscay. Quite a pitch but not too bad. Captain's welcome party. May 5: Rough. Ship bucking about a lot. Managed some knitting in the AM but sick at midday. David and John sick too. Rebecca the best sailor. Missed meals and went to bed early. Kids awake at 2 and 4 am.  May 6: A lovely day. Much calmer although ship still has a roll. Spent a peaceful morning washing, mending and reading to children who are still phenomenally good. A gala lunch for which I didn't dress then a walk around whole ship, then a good look at Portuguese coast: very rugged & lovely hotels & houses. Wonderful sunset. May 7: Another calm perfect day. Gibraltar 10 am. Sat on deck with kids who once again had a good day with only one or two boredom tantrums. Knitted all day. Enormous meals again. Another wonderful sunset. May 8: Another glorious day but a bit more windy... Sat in sun with children and read to them. Wrote to Mother and Jenny in afternoon while John baby sat. Captain's party & lots of insincere speeches, drinking & talking after dinner. Bed 11 pm. May 9: MARSEILLES. Hot, humid & hazy. Had a terrible time getting away from wharf & got involved with military loading. Finally caught a bus to city & walked down market streets - oysters, tortoises. Shops expensive, children & people shabby. Lunch at vast price in modest cafe. Back to ship by taxi.                                                      
Here is David protecting Rebecca with his toy pistol, on a sidewalk in Marseille

 

 May 10: GENOVA (Genoa). A clear fine day. Berthed about 9 am. Went ashore soon after 11 am & walked to the old city & window shopped until siesta time then had an excellent trattoria lunch. Then walked to city centre and spent hours looking for a 'gabinetto' - finally relieved R & self! Back to ship feeling mangled by 5 pm. Ashore again at 8 pm, returned `10 pm very tired. May 11: Another fine warm day. Went by organized bus up to Righi to have a good dinner at the Company's expense. A lovely view. Back to town at 3 pm, walking around & shopping. Back to ship by taxi quite exhausted. May 12:Set off with Billie Warren [fellow passenger] shopping in old city. Bought frock, shoes, Mother's jersey. Met John for lunch, then more shopping and back to ship for dinner. Off again after dinner to look for a newspaper. 

Statue of Christopher Columbus, Genoa

May 13: Raining heavily. Children played very well on deck until lunch time while I knitted and John worked. After lunch took funicular up to Righi where we had a wonderful view, then bus downhill, back to ship to feed children, then out to Crespi Ristorante with Billie Warren and Chief Engineer and pub crawl along waterfront (Black Cat and Golden Gate). May 14:Washing, ironing. John rushed into town for shopping.Took children for walk in sun around wharf. After lunch took funicular up hill to Marvonolo, had delightful amble through village on hilltop. Sailed at 9 pm, bed 10 pm. May 15: LIVORNO Cold, dull morning. Berthed at Livorno 8 am. Went by hired car to Pisa and Florence through lovely Tuscany countryside, even lovelier when the sun came out.  
          
                                                                                                      
                     Wendy & Rebecca stride by Leaning Tower


 Saw Leaning Tower and Battisterie, then on to Florence; saw Piazza della Signore. Had lunch, then down to Ponte Vecchio, back up to Duomo (cathedral) and marvellous golden doors; on to Piazza Michelangelo, Straw Market. Back to Livorno on autostrada. Bedded kids down then out to spaghetti dinner. May 16: Still in Livorno. Another lovely day. Left  ship about 10 am, walked through town to hospital, back to zoo - very neatly kept with animals in concrete cages but not much exercise space or logs to jump on or claw at. Back to ship for lunch then ashore again after lunch.                                                                                                         
Wendy & Rebecca, Ponte Vecchio, River Arno
                           

May 17: Sailing along Italian coast. Saw two islands in afternoon, through Straits of Messina at 11 pm. We saw red hot lava from Stromboli and later John saw Mount Etna on Sicily; I slept through that. Children played house in morning with cardboard cartons. Captain's party and get-together. Rather drunken, melancholy evening. May 18: John sat with children, made them a wigwam of rugs while I knitted striped jersey. Two ill mannered passengers spoiling voyage for rest of us. Typed letter home. May 19: Saw snow capped mountains of Crete in distance; passed many islands including Rhodes. A glorious day, calm and sunny. Saw many seagulls, porpoises. Sat in sun aft with children, read to them for an hour early and got quite sunburnt. ... May 20: Another gorgeous day. Sat on Port side, watched coast of Turkey.. Surprisingly little shipping or fishing activity. Wonderful moonrise over entrance to ISKANDERAM at 10 pm. May 21: Up at 7 am, two large barges alongside already loading trucks. Hung around all morning, learning German way to knit while awaiting passport inspection. Finally went ashore after lunch; three hours ashore in most interesting town, highly polished brass pots etc. We bought earthenware amphorae and a brass teapot. John gave me surprise ear-rings.

Iskanderam, Turkey (at the North-East corner of the Mediterranean Sea)








The above are merely excerpts; I've just quoted some highlights. Wendy's diary goes on to describe our passage through the Suez Canal, down the Red Sea, a brief stop to fill the oil tanks in Aden, across the Indian Ocean to Fremantle, and finally on to Port Adelaide. But this post is already rather long, so I'll leave the story suspended mid-voyage. She's described enough to explain why we loved sea travel on passenger-carrying freighters. We had our best voyage ever, our final one, at the beginning of 1964, across the Pacific from Sydney, through the Panama Canal to Jamaica, Vera Cruz Mexico, then up the eastern seaboard of the USA. I'll talk about that voyage in future posts.

Life in London 1961-62

Our London home 1961-62 was the one on the left with the round window. The partly visible windows to the left were our bedroom. The lower photo is the view of Newington Green from our bedroom window. Our full address was Cromwell Lodge, 30 Newington Green, London, N1; the district was called Islington, now a very up-market trendy part of London but rather dilapidated and down at heel in 1961.

All the time that I spent productively expanding my mind as described in the previous post, Wendy was caring wonderfully with the slenderest of resources, for Rebecca and David. We had to make do with a stipend intended for a single man, and what remained of my savings from the few years in general practice. We were really, really poor. Yet it was one of the happiest years of our lives. Our house in Newington Green was a fascinating old place, over 200 years old, with a new kitchen to replace the one destroyed by a bomb during the blitz. We had a modern kitchen with a new “wetback” stove that heated the kitchen, a decent-sized fridge and a washer and dryer for the laundry. There were parks nearby, Tufnell Park, Clissold Park and Finsbury Park, and of course the little scrap of grass in Newington Green itself. Wendy walked to and from the Ridley Road market a mile or so away to get provisions for us, often bringing back a stroller piled high with spuds, cauliflower, carrots, mincemeat, etc, and one or both kids perched precariously on top. We quickly learnt which of the abundant child-friendly entertainments were available at no or very low cost all over London Town. Feeding pigeons in Trafalgar Square cost the bus fare plus tuppence for two little bags of corn, one each for the kids. We were too poor to take many photographs that year, but the few we have confirm how happy and carefree we were in that year of financial anxiety. While I worked, Wendy explored London with Rebecca and David; she has many stories to tell. 

I never confided fully in Wendy at the time, how close we were to total bankruptcy. On a few occasions I had just enough money to buy that week's food. She knew, of course, that we were very hard up, and cooperated wonderfully in scrimping and saving to make ends meet. Looking back from our affluence now, I recall with immense pleasure the innumerable simple ways we entertained ourselves and the children. We discovered free museums all over the nearby parts of inner London, and cheap ways to entertain Rebecca and David. Riding on the top deck of the Number 73 bus from Newington Green to Oxford Circus, or further, along Park Lane to Hyde Park Corner; visiting the statue of Peter Pan in Kensington Gardens and discovering the little bronze fairies, elves, goblins all around its base; feeding pigeons in Trafalgar Square; watching the wizened elderly mariners with exquisite model ships that sailed the Round Pond; all these and more were some of our entertainments, and cost no more than the bus fares.

Our social lives were rather circumscribed. We met my father and his miserable wife Margret - a sour woman who never in all the years I knew her had a good word to say for anybody. My father was pleased and interested to meet Wendy, and showed a transient and superficial interest in our children; but never lifted a finger to help us, showed not the slightest concern about our welfare. We had far more affectionate concern from strangers who were our neighbours, the pretty French girl Marie-Christianne and her South-African Indian friend Ismael Patel - who got her pregnant and married her while we were there, and brought them to Canada soon afterwards, where they re-entered our lives years later when we too came to live in Canada. Our other neighbours included a biochemist friend of our landlord, Arnold Rosen; her name was Dora and she lived on the top floor of the house, visited from time to time by her boyfriend. Anne Windsor, a pretty young red-headed school teacher was our other live-in neighbour, also occupying a bed-sitting room on an upper floor; she was a built-in baby-sitter, who later had a tragedy in her life when her fiance drowned while they were holidaying in Spain.

The house at Newington Green had a large old garden with an overgrown frog pond and two little statues at the bottom end of it, just below a high wall that separated us from a school ground. Our children played happily there, and came with us on buses and the Underground at weekends when we explored the parks, museums and many other sights and sounds of London. It was wonderfully happy, carefree year, despite our poverty, or perhaps because of it. 

We were too poor to afford a Christmas Tree, but in our back garden, Wendy found a large branch of a shrub that had broken off the main trunk. She brought it inside, stuck it in a bucket of sand, and decorated it with little bells made by pressing aluminium milk bottle tops on a lemon squeezer. Milk bottle tops were gold if the milk was very rich and creamy, red if the milk was homogenized, and silver for skim milk. Our little bells were a mixture of all three. Then a miracle took place: the bare and leafless branch came to life indoors in the warmth and with its base in the moist sand, it burst into leaf, so our bare branch turned green with little leaves sprouting forth all over it. Rebecca and David, and Wendy and I, were enthralled by this minor miracle. The Wheelers invited us to spend a few days with them at Christmas; they were tigers for punishment! But Bill fell ill, so we stayed with them only for a couple of days instead of the week or so for which they had invited us.

In the early spring of 1962 we allowed ourselves our only extravagance. I rented a car, we drove to Oxford, and on to the Cotswolds where the kids fell in love with the model village at Bourton on the Water. Rebecca is on the bridge in the model village in the upper of these two photos, both kids are on the real bridge in the lower photo. A few years later when we were living in Edinburgh in 1965-69 we managed to revisit the model village in Bourton on the Water several times.

Our “year” in London lasted only about 11 months. Our homeward bound passenger carrying freighter was ahead of schedule. We had to get ourselves to Rotterdam to embark about 3-4 weeks before the originally scheduled sailing date. This was a minor disadvantage of choosing to travel on passenger-carrying freighters rather than regularly scheduled passenger ships. Our journey home will be the subject of another post. 

Waiting for a Number 73 Bus in Newington Green

 Marie-Christianne and Ismael with baby Rebecca, and our Rebecca and David in the back garden at 30 Newington Green, London N1, spring 1962

L-R: Anne Windsor, Dora, carrying David,
Wendy, Rebecca, Dora's boy friend (Eric?) in the garden at 30 Newington Green

The Social Medicine Research Unit in 1961-62

John Lee, Jean Marr (background) Stuart Morrison, Jerry Morris, at SMRU party, December 1961

 

[The following is excerpted from my memoirs, written in about 1991]

In 1961 the Social Medicine Research Unit (SMRU) occupied the second floor of a set of office and laboratory buildings behind the London Hospital Medical College on Whitechapel Road in the East End of London. I could get there from our home in Newington Green on buses or the Underground, or on foot, via Aldgate and Hatton Garden - a 35-40 minute walk through part of the top end of the City, and along Whitechapel. I walked most often because we were very poor. I barely had enough for us to live on after the rent was paid. This was when Wendy demonstrated her truly sterling qualities, and I realized that she was a women of unparalleled excellence.I wasn't surprised: we were children of the Great Depression, conditioned to thrifty ways of living. 

The SMRU was doing several things. The most famous were Jerry Morris's studies of London busmen, on which many papers had been published, showing the relationship between physical activity at work and reduced risk of coronary heart disease. David Pattison physically examined the busmen, Jean Marr took detailed dietary histories, Austin Heady did the number-crunching. Stuart Morrison was looking at factors associated with raised blood pressure. He left the SMRU for a post at the department of social medicine in the University of Edinburgh, where he re-entered my life again later.

When I started working at the SMRU I told Jerry Morris that I wasn't very interested in his busmen, but wanted to learn how to use epidemiology in studies of the working of health services, the other main preoccupation of the Unit, and the part of its work that was mainly in the capable hands of John Lee, a tall, fat man with a loud hearty laugh. I attached myself to him, and through him I met Miles Weatherall and Dick Joyce of the department of pharmacology; they had done some elegant randomized trials of teaching methods, demonstrating the superiority of small group problem-solving exercises over lectures or assigned readings. I was fascinated by this display of scientific rigor in evaluating teaching methods. They were keen to study determinants of prescribing habits of GPs and specialist physicians.

I soaked up ideas and techniques like a sponge. I got involved in helping Jerry revise his superb little book, Uses of Epidemiology - my name appears in the Acknowledgements because I spent many hours collecting and analyzing data from all sorts of available and less-available sources, learning more in a few months than in all my previous life put together. While gathering data for a table on "Completing the clinical picture" I had the idea for a little paper that might relate this to what goes on in the "average" general practice; thus was born the idea for "The Iceberg" - a paper that is still quoted 50 years later, the paper that established my scientific reputation. There was much more, not only all sorts of odds and ends of data-gathering, but an opportunity to capitalize on my background in general practice by interviewing a random sample of general practitioners in Stoke-on-Trent, Wigan and Middlesborough, three industrial county boroughs in the north of England, characterized by striking differences in the rate at which GPs prescribed sedatives, mood-modifying drugs, analgesics, etc for their patients. It was arranged that I would interview about 100 GPs, and so I spent a while learning how to design questionnaires and interview schedules, and with John Lee as my principal investigator and allied with Dick Joyce and Miles Weatherall, I began commuting between London and these three large towns, which I soon came to know as well as I had once known the western suburbs of Adelaide. The work I did then led to a couple more publications, but a lot of it remained unpublished until it appeared as the centre-piece of my MD thesis a few years later, along with my other epidemiological studies of general practice.

There were many other ways in which that year at the SMRU was a richly rewarding experience. I attended Michael Balint’s weekly psychotherapy seminar series at the Tavistock Clinic, where I learned a great deal about neurosis, anxiety, obsessive disorders and other emotional aberrations that are compatible with functioning (more or less) in daily life. I was introduced to the Keppel Club, an elite discussion group of public health specialists in London and elsewhere in the UK, that met once a month at the London School of Hygiene. I joined the Royal Society of Medicine, and attended meetings of the Section of Epidemiology and Preventive Medicine. I met Richard Titmuss, Peter Townsend, Ann Cartwright, Margot Jefferys, Donald and Roy Acheson, Tom McKeown and many others. I met visitors from the USA, Canada, Scandinavia who dropped into the Social Medicine Research Unit. No Australians came through while I was at the SMRU; I was the first and only one.I was in the vanguard of the little band of GP-epidemiologists who were starting to examine rigorously what went on in general practice. When I presented my theoretical model of the "average general practice" which then consisted only of a few tables with hardly any narrative linking them together, a large crowd turned out to hear me. This was at the Keppel Club, so there were people from as far away as Birmingham and Manchester. The group from Manchester included Bob Logan, who "borrowed" my raw data and actually published parts of it without attribution; but fortunately all those who needed to know, knew that it was my work, not his, and I got the credit.

Among the people I had introductions to in London was Robbie Fox, Theodore, later Sir Theodore Fox, editor of the Lancet; I owe that introduction to Ron Winton, editor of the Medical Journal of Australia, and am forever in his debt for putting me in touch with the greatest living medical journal editor of that generation. Robbie Fox took me to lunch at the Atheneum, an unforgettable experience in itself; he was keenly interested in the work I was doing with Jerry Morris, especially the model of the "average general practice." I showed this work to him before leaving London, and sent back to him the revised paper that also had the benefit of all Jerry Morris's amendments. I submitted it as "Completing the clinical picture in general practice" and he wrote to accept it with just one change, a change in title. That is how it came to be called "The Iceberg."  

There is so much more to say about that wonderful year, especially about our daily family lives. I'll save that for a future post.

The voyage to Britain in 1961

Wendy, Rebecca, David and I left Adelaide for the UK in May of 1961, on MV Pretoria, a freighter that carried 12 passengers. The top photo shows the Pretoria berthed in Adelaide and loading cargo on the afternoon before we set off on a rather rough crossing to Fremantle.  After Fremantle, we had a near-perfect voyage across the Indian Ocean, where the kids were captivated by the frequent sight of flying fish. Occasionally one landed on the deck, and if it was alive we threw it back into the sea. We paused in Aden long enough to fill the oil tanks, then sailed on up the Red Sea, through the Suez Canal into the Mediterranean.

The captain set a strict rule about meals: Wendy and I and Lynne and Bill Haskell, parents of a little girl about David's age, must dine with the other adult passengers, the captain and the ship's senior officers. We had to arrange to feed our small children before luncheon and dinner. David bellowed like a bull the first time he was fed by a plump woman steward instead of by Wendy. He was teething, and bit her, leaving deep tooth marks on her fat arm, but all was forgiven and they became best friends before the tooth marks faded.. David got used to the system; and so did we. We loved the luxury of having child care! We soon established the habit of feeding and bathing the kids ahead of time. To save time, we bathed them together. Sometimes Rebecca gave her dolls a tea party in our cabin while we dined in style at the captain's table.

  Lifeboat drill worried us: no one, especially our little kids, would have survived more than a few minutes in the ship's lifebelts! We went through the Suez Canal on a baking hot day. All of us, adults as well as small children, were fascinated by the close-up sight of parched desert sands and rich irrigated fertile fields beside the Canal. 

Our luxurious voyage from Adelaide to Liverpool lasted about 4 weeks, the first of our family's superb intercontinental sea journeys - luxury living on freighters that carry 12-20 passengers is by far the best, most comfortable way to travel across the world. (I'll describe our other voyages in future posts). A fast train took us to London, where we were met by my father, and by Bill Wheeler, the chest physician with whom I had been a fellow resident at Hillingdon Hospital, near Heathrow Airport in 1951-52. The inexhaustibly hospitable Bill and Hazel Wheeler accepted the unruly Last family as house guests - accepted Wendy, Rebecca and David, that is: I set off a few days after we arrived at Toogoolawah, the Wheeler's comfortable Surrey home, to visit departments of preventive and social medicine throughout the UK. I visited Aberdeen, Edinburgh, Manchester, Birmingham and Bristol, and several prominent and famous GPs, most memorably Will Pickles of Wensleydale in Yorkshire, author of Epidemiology in Country Practice. While I was "in orbit" Wendy moved into 30 Newington Green, the fascinating old home we had rented from Arnold and Verna Rosen; he was a biochemist at St Mary's Hospital Medical College. There is so much to say about that house and our year in London that I will save it for another day. 

Speaking truth to power

Speaking to the closing plenary of the Durban climate conference on December 10, 2011, youth delegate Ms. Anjali Appadurai of Maine's College of the Atlantic declared: "I speak for more than half the world's population. You've given us a seat in this hall, but our interests are not at the table. What does it take to get a stake in this game? Lobbyists? Corporate influence? Money?  You have been negotiating all of my life. In that time, you've failed to meet pledges, you've missed targets, and you've broken promises."   [Quoted by Tad Homer-Dixon in his latest newsletter]

Right on, Anjali! Sometimes I think that members of your generation, all humans under the age of, say, 25 years, would be justified in a bloodless coup and take-over of world power and decision making from the self-interested, complacent  "business-as-usual" creatures who are running the world at present. These older generations, including mine, the oldest, have convincingly demonstrated incompetence, dishonesty, corruption, greed, blindness to hard scientific realities, and utter unconcern for the fate of descendents, that make them - us - unfit to lead the world.    I have been thinking, speaking, and writing about the health impacts of climate change since the early1980s. In the early 1990s I chaired an expert committee of the Royal Society of Canada that studied and reported in 1995 on our conclusions about the dire consequences we could expect if nothing was done to mitigate climate change. Nothing was done, so it is now quite certain that our world's climate, which has been stable and predictable for the last 10,000 years,will change in ways that will be less hospitable to humans and other living creatures. The changes are readily visible in northern latitudes like Ottawa and its environs.

Species extinction rates now are as high as in the last great extinction 65 million years ago, and most can be attributed to climate change or to this combined with human population pressure on fragile ecosystems. Our government in Canada is either incredibly dense and stupid or willfully irresponsible if it knows and understands the scientific facts. There is persuasive evidence that our government is engaged in a mixture of obfuscating the facts, suppressing the facts, and "shoot the messenger" approaches to aspects of science that reveal the truth about, for instance, the dramatic ecosystem changes in the Canadian Arctic and the permafrost regions that already are irreversibly changing the earth's climate by altering air and ocean current flow. Perhaps the most alarming facts relate to the permafrost regions, which are releasing huge quantities of methane as the permafrost thaws Methane is much more powerful as a "greenhouse" gas than carbon dioxide, which is the main product of carbon-based fuel combustion. This is adding tremendous force to the "greenhouse" effect of atmospheric carbon dioxide, which has been increasing relentlessly since the beginning of the industrial revolution. 


In July 2003, Wendy and I were in Edinburgh (where I was awarded an honorary degree) as the lethal heatwave began. Edinburgh experienced unprecedented hot weather. We went south to London, then across to Paris by Eurostar; we arrived in Paris, intending to stay about a week, on the first day that the heat wave became a lethal heat emergency. We escaped after 3 days to Switzerland, which was only a little better. That European heat wave killed at least 35,000, maybe as many as 50,000 people. In Paris alone, at least 15,000 deaths were attributable to heat stroke. Mosquito-borne diseases (malaria, dengue, encephalitis and hemorrhagic fever) are extending their range into formerly temperate zones, and water-borne diseases also are becoming more prevalent and more lethal as the world warms up. But, as Ronald Reagan said in a different context, "We ain't seen nothing yet!" The full impact of heat-related diseases is still some decades away. The impact of hotter weather and more frequent violent extreme weather is even greater on grain-producing regions where floods and droughts are already making bountiful seasons less reliable, less predictable, than at any time in the past historical record. 

Meantime our prime minister of Canada, and most other world leaders, go mindlessly on their way, extolling Canada as an "energy super-power" and disregarding altogether what happens when that potential energy from tar sands is combusted. Prime Minister Harper is obviously less concerned about the world he will bequeath to his children and grandchildren than I am about the world I am bequeathing to my grandchildren and those who come after them.   


About a year ago I promised myself to avoid discussing climate change on this blog. It's such a depressing subject! But when I saw what Anjali Appadurai said, I was impelled to support her totally. For once I wish my blog had many more readers, and greater influence on public opinion!

 To see and hear Anjali Appadurai, go to
http://www.homerdixon.com/speaking-truth-to-power/

More psychiatry

When my public health studies in Sydney ended in early December 1960, we piled our belongings and ourselves into our Holden station wagon and drove back to Adelaide. I must mention that during our year in Sydney I spent one late afternoon every week at an acute psychiatric hospital, observing through a one-way window group psychotherapy sessions in which 10 emotionally disturbed patients engaged in dialogue with David Madison, associate professor of psychiatry. The group psychotherapy session was followed by 1-2 hours of discussion between David, several trainee psychiatrists, and me. By the end of the year, I knew David Madison, and most of these patients, really well. More important, I was beginning to understand a little about how the mind works. I had about 6 months before my traveling fellowship began. There was a vacant position for a senior resident physician at the acute psychiatric receiving hospital in Adelaide, so I took this, and spent 6 months on full-time care of acute mental and emotional disorders. I was caring for patients with acute mania, profound depression, early stages of schizophrenia, alcohol-induced delirium tremens, and several with the comparatively rare disorder of acute paranoia. I learned a great deal about the diagnosis, and a little about the prognosis and treatment of acute psychiatric disorders during that 6 month period. It was no comfort to me that the most senior and experienced psychiatrist on the staff misjudged the mental and emotional state of a middle-aged woman, whom he allowed to go home on weekend leave. She used the opportunity to critically injure her husband, and to kill herself in dramatic fashion. I learned from this that even a richly experienced psychiatrist can't always tell when a patient presents high risk of harm to self or others. This did not assuage my feeling of guilt for failing to recognize the distress signals that my nice young Czech patient had tried in vain to transmit to me. 

Missed signals

Peter Strazs was a young man from Prague, a lonely, friendless lad who signaled  his cultural sensibility when he likened himself and his situation to something out of Kafka. He said his grandfather had known Franz Kafka, and he, Peter Strazs, knew Kafka's tiny cottage just below Prague Castle (years later Wendy and I visited Kafka's cottage, saw for ourselves how tiny it is).  Peter Strazs worked in one of the small manufacturing plants in the neighbourhood, spent his weekends rambling in the Adelaide hills or, in wet weather, in the Art Gallery of South Australia. With much help from the surgically qualified senior partner in the group, I took out his inflamed appendix, and got to know him a little better during his postoperative recovery. Culturally we had much in common, as Wendy and I felt we did also with our German immigrant friends, Dodie and Harald Ziemer. I invited Peter to join us one evening in late summer 1959, but when I said our other guests were migrants from Germany, he shuddered, said he didn't like Germans, and declined. About then he repeatedly tried to see me at home, but Wendy protected me with determination from out-of-hours callers at the front door, until one day he saw me in the hall behind Wendy, called out that he had a gift for me. He produced the water colour of ghost gums in Central Australia that has hung on our wall since that day.  I wish we had invited Peter in that day, instead of thanking him in a rather perfunctory way and dismissing him. I saw him twice after that. The first time he said he had to see me urgently: his loneliness was worrying him badly, he said.  He came to the clinic when I was midway through repairing a severe laceration but I put down my forceps and threaded needle, told him I was very busy, as he could see. He could either wait, or come back next day. I gave him a prescription form with my name, next day's date and a time when I could see him. I saw him for the final time about midnight the same day when the police found this prescription form, asked me to identify his body. He had put a shot-gun barrel in his mouth and blown off the top of his head. His face was unrecognizable but the recently healed scar from the appendectomy, and a hairy pigmented birthmark on his belly were unmistakeable. The wall behind his body was decorated with a well chosen selection of prints from the Art Gallery, many now spattered with blood and bits of his brain. The books in the bookshelf opposite the bed on which his body lay, included volumes of poems in Czech and English, Kafka's The Trial, Metamorphosis, and Amerika, in German and English, and other works that identified him as a genuine intellectual. I cried as I looked at his books and the blood-spattered prints. I had dismally failed this young man, completely missed the distress signals he had tried desperately to transmit to me. Seeing his body, reflecting on how my failure to detect his distress signals had led to his death, gave me a powerful motive to learn more than I knew at that time about how the mind works, some of the things that can go wrong with it, and how modern medicine and psychiatry might be able to put things right. It's a poor sort of memorial, but I thought of Peter Strazs, and still think of him and my calamitous missed diagnosis, whenever I look at the water colour of ghost gums that he gave me, whenever I'm studying anything about how the human mind works.