What might have been but didn't happen

Dredged-up memories about missed opportunities, job offers and other attractive invitations I’ve declined, rarely reach conscious levels, let alone become a preoccupation that could trouble me if I paused to think about such hypothetical matters.  It required some effort to recall and make a list of alternative careers I might have pursued. Here are some highlights I can remember without making a special effort. I can’t guess whether readers of this post who face career decisions will derive comfort or be unsettled when they read this.

When I was about 12 I wanted to become a writer when I grew up. By then I knew I was capable of stringing words together into sentences and paragraphs that satisfied me and seemed to please others such as school teachers, admiring aunts and my mother’s friends. Alas, by the time I was 15 or 16 I had discovered that I couldn’t invent credible plots, believable characters, and had a tin ear for dialogue. Perhaps if Australia had been at peace rather than embroiled in a world war I might have been able to take a university degree in literature and learnt how to do these things; but it was never a realistic option. A university education in literature might have proved valuable in my career as an editor and medical science writer but I think I’ve managed well enough without.

Over a period of about 18 months in 1959-60, I corresponded with Professor WD Borrie, a distinguished demographer, head of the School of Social Sciences at the Australian National University.  In general practice I had become interested in determinants of the health of immigrants. I published a descriptive paper on this, and Bill Borrie offered me a position as research associate in his team, where I could explore in depth the health consequences of migration. If I had taken that position it would have led eventually to a PhD, probably to a scholarly monograph and other publications, perhaps to a lifetime on the staff at ANU. Canberra has become a lovely city with its own cultural attractions, within easy reach of both Sydney and Melbourne, and I’m sure we’d have been happy there.  There are plenty of worse fates. But I can’t imagine that I’d have reached the heights I’ve achieved if I’d accepted Bill Borrie’s invitation.

When I arrived in Burlington, Vermont early in 1964, Kerr White, who had recruited me, famously said, “Don’t unpack. We are all moving to Johns Hopkins in Baltimore.” What a thrill that was! Johns Hopkins is one of the half dozen best medical schools in the USA, its School of Hygiene and Public Health is among the best schools of public health in the world. I was almost deliriously happy when I first learnt of this dramatic turn of events. But as mentioned in previous posts, Wendy and I rapidly became disenchanted with important aspects of American culture and society and a timely invitation gave us a choice of two alternatives, Johns Hopkins in Baltimore or the Usher Institute of Public Health in Edinburgh. It was a no-brainer.

I established my scholarly reputation in Edinburgh and towards the end of my time there I received many attractive invitations. Two English universities, Newcastle and Nottingham, tried to entice me away from Edinburgh. I had invitations from so many US universities that I lost count. Those I took seriously enough to open lines of communication for 2-way exchange of ideas included Pittsburgh, NYU (Downstate, in Brooklyn); and then one I had to visit to see for myself, Harvard, a challenging cross-appointment between Harvard Medical School and the Harvard School of Public Health.  I provisionally accepted that one, despite misgivings about returning to live in the USA, and – more important – despite intimidating academic politics. On that same expedition across the pond from Scotland to the North-east corner of North America, I flew from Boston to Ottawa, and as already related, strolled beside the Rideau Canal from downtown by the Chateau, southward to the Glebe, and along quiet tree-lined streets where parents sat on their front steps while their kids played street hockey in the gathering dusk. I had an epiphany: Ottawa would clearly be a better place to raise our kids than some distant outer suburb of Boston with a long commute. I’ve never regretted choosing Ottawa rather than Cambridge, Mass.

The invitations didn’t end with the move to Ottawa.  They increased in number and attractiveness. One morning in the late winter of 1974 I had a phone call from the vice chancellor of Newcastle University in New South Wales: would I be interested in becoming dean of the medical school that was to be established at the University of Newcastle? My enthusiasm for this exciting career move didn’t begin to evaporate until I was in the air about half way across the Pacific. I began to reflect on the role, function and responsibilities of a medical school dean, began to realize that I didn’t want to be a dean.  This was just as well because it became obvious when I reached Newcastle that I was the ‘other candidate’ – brought in to ensure that the process had the appearance of honesty when the position was offered to the insider who all along was intended to get it.

Because dates clashed with unbreakable academic obligations I had to decline invitations to visit and speak at conferences in places I’d always wanted to visit: Iceland, Portugal, Rio, Moscow, Jaipur, Oslo,  Johannesburg, among others.

Until 10-15 years in Ottawa, Wendy and I both hoped we would eventually move back to either New Zealand or Australia, but opportunities to do so were rare. When the  dream job finally appeared and I was wanted enough to attract a personal visit from a distinguished Australian, the invitation came too late. My visitor, president of the Australian Medical Association, called on Wendy and me with an offer to return to Sydney as professor of public health and editor of the Medical Journal of Australia. But the enticing invitation came in 1987, too late. By them we had deep roots in North America. I was about to become president of the American College of Preventive Medicine, had just begun my second go around the track as editor in chief of the big public health textbook and the Dictionary of Epidemiology. I had several other important and worth while irons in the fire. Wendy's roots had sunk almost as deeply into Canadian social and cultural soil; and Rebecca and David both had commitments and partners who would keep them in Canada. Going back to Australia at that stage would have torn our little family apart. We realized that we were committed to Canada for life.

Critical decisions - 1: Leaving general practice

After some initial temerity I loved my life and work as a general practitioner.  I loved the variety, the challenging diversity of problems. Most of the time I loved seeing people in their natural everyday habitat when I made house calls. It wasn’t fun when I was called out to see a critically ill patient in a dimly lit bedroom in the middle of the night, but fortunately crises like that were rare. About half my house calls were to see chronic or long term sick people whom I visited regularly and got to know well as time passed.  I loved the intellectual challenges, diagnostic labeling and therapeutic decision-making. My years in general practice coincided with the infancy of the UK College of General Practitioners. I became active in its South Australian chapter, and through this I met like-minded GPs from other states and even a few from overseas. As my intellectual horizons widened and my scholarly aspirations awakened, I began to dream about combining general practice with an academic university based career. Here, however, I was years ahead of my time: Adelaide, and Australia as a whole, would not be ready for this development for 10-15 years.

In 1958 the group practice in which I was the most junior partner was hit, like the rest of the world, by a global influenza pandemic, Asian Flu, in which 4 million people died. Like the Spanish Influenza of 1919-1920, the Asian Flu struck hard at young adults who had not been alive to be exposed to earlier influenza strains and therefore had not acquired partial immunity to the virus. Two young adults the same age as me whom I knew well were struck and killed. One was a young man who drove an ambulance and was my occasional playing partner at a modest golf course on the southern outskirts of Adelaide. A few weeks after he died his mother came to my office to thank me for caring for him during his brief and terrifying terminal illness. She insisted on paying me for my fruitless home visits and my final visit to him in the Royal Adelaide Hospital, where I stood at his bedside and watched him die. That evening our accountant reported on the financial returns of the previous month – our busiest and most lucrative month ever. As my partners rejoiced, cheered and slapped each other on the back, I saw in my mind’s eye the sad face of that woman who had insisted on paying me for my useless visits to her doomed son. It was a moment of truth. I knew that I could not, would not, spend my life getting rich because my patients had the misfortune to fall ill.

Rebecca, aged 11 months,
with grandfather Pop Wendelken,
Picton NZ, November 1958

Grandma Wendy, Janet Wendy
and Rebecca, Picton NZ,
November 1958

A few weeks later, Wendy and I and baby Rebecca, 10 months old, flew to Christchurch New Zealand to meet her family. There I fell ill myself, not with influenza but with a life-threatening virus pneumonia. I spent two days in an oxygen tent inhaling a detergent mist intended to loosen the sticky mucus that was suffocating me. Both I and the young internal medicine specialist treating me, thought that I might die. When we returned to Adelaide I had two weeks convalescence, leisure time to think about my life, our lives as a family: Wendy’s life, Rebecca’s life and the life of our next baby who was a few weeks away from being born. I could stay in general practice, get prosperous, enjoy my work, get involved in the community more fully than I already was. Or I could resign from the Western Clinic group practice, go to the School of Public Health in Sydney and train to become a specialist in public health sciences, discover and test ways to keep communities and families healthy.  It meant turning my back on a secure future and work I enjoyed and felt confident I could do well.  To keep my scholarly options open I decided to start training in public health sciences as a private student paying my own way, rather than seeking employment in a state or Commonwealth of Australia health department that would eventually grant me time off to undertake formal training for the DPH, but I would be obligated to do their bidding for 5 years or more.  This meant committing my family to a life in real poverty for several years if not longer.  I soon discovered that Wendy was thoroughly conditioned to poverty, knew how to make do with what she had. She never complained about being hard up, indeed accepted this cheerfully as the natural order of things. We were both Depression era children, accustomed to poverty and penny-pinching.

When Wendy and I talked about the options we had only vague ideas about what might ultimately become of us. What, exactly, I would be doing, and where, were unknowable.  However we agreed without hesitation that this course of action was what we both wanted to do.   Then, and countless times in the years after we made that joint decision, I realized how blessed I was to have Wendy for my wife. Her spirit of adventure and her sense of fun, along with her amazing capacity to make all her own clothes, our children’s too and even some of mine, carried us through many anxious and penurious times over those years of precarious uncertainty.   

outline of revised memoirs

So far all the revisions and fine-tuning of my memoirs have preserved the original chronological structure.  After reading Salman Rushdie's Joseph Anton and Robert Hughes' Things I Didn't Know and a few others I've begun to work on a rearrangement that departs from conventional chronological retelling of my life, to discuss the important events, experiences, thematic highlights under specific headings.  So far, the headings are the following:

Life-altering event: meeting Wendy

Moments of truth and Critical decisions

-       Leaving Western Clinic (1959)

-       Leaving Australia permanently (1964)

-       Leaving Edinburgh (1969)

What have I done that’s made a difference?

-       Epidemiological model (The “Iceberg” concept)

-       Editor in chief reference textbook of public health

-       Conceptual approach to public health practice

-       Definitions – Dictionary of Epidemiology

-       Philosophical (ethical) foundations

Missed opportunities – What might have been?

-       Alternative histories (creative writing)

-       Social demography at Australian National University

-       Cross-appointment Harvard Med School, School of Public Health

-       Foundation dean, Newcastle Medical School

-       Johns Hopkins School of Hygiene, UCLA, Milwaukee, Pittsburgh

Mentors, teachers, advisers

-       Profiles of notable people I’ve worked with or met  

Marriage and family life

-       Evolution of our family

-       Movements (migrations)

Travels and Third World experiences

What would I do differently if I could relive my life?

Lessons learned

            -  Carpe diem

            -  Overcome shyness

            -  Foster teamwork

Probably I'll add to these, for instance experiences with being taught and teaching others myself. 

Transforming decisions and moments of truth

The writers' workshops I've been eagerly anticipating have been cancelled. The token fee of $50 per day to 'rent' a meeting room in the Library and Archives building was raised without warning to $2157.75. This outrageous move - typical of actions by the present government - dealt a fatal blow to the aspirations of workshop leaders and participants alike. To be truthful, I really don't need either workshop, but I'll miss the collegiality and mutual stimulation we would all have provided, and I'll miss the networking and opportunities to widen my friendship and acquaintance horizons.  

Instead, I will spend as much of the weekend as I can stand in solitary efforts to lick into shape my attempts to describe some of the transformative events of my life. I've said something about all of these events in posts on this blog,  and there are descriptions of them all in successive drafts of my memoirs. 

Wendy shared in making all the important decisions and I had hoped to find her views of them in her diaries. Unfortunately her diaries haven't helped as much as I'd hoped. Her diaries for 1957 and 1958 are missing, two stormy years of adjusting to each other, and years in which we made life-altering decisions. Perhaps in her 1958 diary she described our conversations about getting rich from fees I collected when people had the misfortune to be disabled by chronic debilitating diseases or serious injuries, and my growing realization that much as I loved being a family doctor I was increasingly attracted to a more scholarly life. 

In several posts in January 2012 I described a moment of truth when a grieving mother thrust banknotes into my unwilling hands to pay for the fruitless house calls I made to see her son before he died of influenza during the Asian Flu pandemic of 1958; and the intellectual, philosophical decision to seek a more scholarly career than general practice.

Back to the drawing board

Next weekend is wall-to-wall workshops organized and sponsored by Ottawa Independent Writers, a day on editing and a day on memoir-writing. I probably don't need to learn much more about editing, I might already know more than the expert who is leading the discussion, but I'm sure that I will learn something new. I plan to attend with the expectation of learning enough new things to make the day worth while.  The day on memoir writing is a different matter. As regular readers of this blog know, I've posted quite a lot of abridged excerpts of memoirs that I began to write a quarter of a century ago. I've written my life story in chronological order, but lately I've had second thoughts about such a conventional, stereotyped approach. Instead in my most recent revision I've begun with the life-changing event, the day I met my beloved Janet Wendy. I'm not yet happy about my composition. I've tried out several attempts in posts on this blog, and several others that have remained private. I'm sure I'll get it right eventually but I don't feel that I'm quite there yet. It's great fun trying though, so I'll keep trying, and probably I'll post on this blog some of my future attempts to get it right.  There have been several other life-changing events or episodes in my family's life story, and it may make sense to write at some length about each of these, then fill in briefly, sketchily, the spaces in between. That's what I hope to get some guidance on next weekend.  No doubt I'll return to this topic with further remarks after next weekend.

Wedding Anniversary

Today would have been our 56th wedding anniversary if Wendy still lived. I can best commemorate it by posting a few photos:

In the garden, 238 Melbourne Street, North Adelaide,
14 February 1957

Cutting the wedding cake

In the back garden, 5 Greenbank Crescent, Edinburgh, Scotland,
Summer 1969

 Janet Wendy's Birthday, 14 October 2001

Golden Wedding 14 February 2007

30th wedding anniversary, Sydney, NSW, 1987

Mentors, advisers, and others

The Canadian Oxford Dictionary defines mentor as an experienced and trusted adviser or guide. In Homer's Odyssey, Mentor was tutor to the youthful Telemachus, son of Odysseus. Having been very effectively mentored as described in my previous post, I became mentor to occasional medical students in a series of relationships. The longest-lasting of these dates back 40 years and it has evolved into a collegial friendship. I'll consider the mentor's perspective later, but first there is more to say about my perspective as a receptor.

The relationship to a mentor is usually long-lasting and can evolve into a two-way mutually beneficial friendship with emotional bonding and social, cultural interactions. In addition to a handful of mentors, I've had wagon-loads of advisers, some ephemeral, some for long periods, occasionally years. I like to think that I am always receptive when I ask for advice, and often even when the advice is unsolicited. Whence comes this advice? Just about anywhere: colleagues, peers, those higher up the food chain than  I, and those who are lower. Looking back over a long lifetime I can't recall many occasions when the advice or suggestions were inappropriate, wrong, or unwise; and only one or two that were malicious or ill-intentioned. That came from a pair of militant feminists when I was a newly appointed department head. It never occurred to me that colleagues in whom I had placed my trust would deliberately set out to betray my trust, but in retrospect I saw that it had been a useful experience because it made me aware that even in the ivory tower of academia there are people motivated by malice rather than good will towards their colleagues. Over the course of half a century in academia I've observed malicious motives at work no more than a small handful of times, and my own career has been almost entirely free of such unsavoury influences. On the other, the good side of the ledger, there must have been hundreds of times when good and wise advice has helped to steer me towards right decisions and desirable outcomes. A good example appears in the Acknowledgements in the Front Matter of the second edition of my book, Public Health and Human Ecology. The names listed there are those of people whom I was able to identify, whose advice, suggestions, or responses to specific requests, helped made that a better book than it would otherwise have been. Similar lists of names appear in the Front Matter of other books that carry my name on the title page.  I assembled a list of names of people and organizations to thank when I prepared annual reports of departmental activities for the Dean of the medical school, during the years that I was head of the department, but someone deleted this paragraph when the reports were printed - I suppose in the interests of uniformity because other department heads hadn't provided comparable data.  What these data show is the fact that the quest for excellence is a collegial, collaborative activity, in which team work of a very high order is a sine qua non.  

Mentors and other career-shaping influences

Judged by conventional criteria I've had a productive and successful career.  Once I had decided what I wanted to do - a collective, collaborative decision shared with my beloved Wendy - I had to decide, we had to decide, where I would work and with whom, and  what aspects of the work would get highest priority. Chance and good luck played a part in this early in my career, along with willingness to take chances and to seize opportunities.  My motto could have been carpe diem, seize the day. Looking back over the trajectory of my lifetime career, I can identify half a dozen or more critically important diems that I carped. I've mentioned a few in earlier posts on this blog and and I'll examine these and others in the future. Today I want to focus on a few mentors who helped  by steering me in the most favourable directions.  

I've been especially fortunate in my choices of mentors on several occasions. At other times I've had support and encouragement from colleagues, usually my seniors, who were not mentors but nevertheless gave me good advice at times when I needed it.

This first happened during my last two years or so in the Western Clinic, the 10-partner group practice in which I was the newly recruited most junior partner.  Clarrie Rieger, one of the most senior partners, a surgeon whom I'd first met when he'd been one of my teachers in medical school, was an eminent medical politician, president of the Australian Medical Association, negotiating with the federal government about conditions and fee for service payments in the tax-supported medical benefits system that had begun to take over from private insurance as the way to finance medical and hospital care in Australia. He wanted to groom me as future medical politician, a societal role for which I had no taste at all; but through him I met and interacted with senior medical politicians throughout Australia.  I respected and liked almost all of these men - they were all men, not a woman among them in those days - and they liked me. Several gave me good advice as I was making the transition from private practice to salaried academic life and work.    At that vitally important decision node in my professional life and in our family's life (Wendy and I had two toddler children by then,  Rebecca 3, almost 4, and David 15 months younger) I had helpful suggestions also from Norrie Robson, recently appointed professor of medicine at the University of Adelaide.

In my time there, the School of Public Health and Tropical Medicine at the University of Sydney was not a stimulating academic centre; it was intellectually moribund. For the greater part I set my own goals, wrote my own study programs and got a great deal out of my time there. By aggressively challenging two or three senior staff members I managed to get more out of my interactions with them than anyone ever previously had managed to do.  I also made intellectually valuable contacts elsewhere in Sydney, notably with David Madison, professor of psychiatry who mentored me as I set about learning psychiatry; Ron Winton, editor of the Medical Journal of Australia; Ian Maddocks who came closest to practising social medicine; and several of the movers and shakers in the nascent College of General Practitioners.  

Towards the end of my time in general practice I read an article in the British Medical Journal on "Uses of Epidemiology" by Professor J N Morris, and then I read his small book with the same title. This article and his book which expanded his ideas changed my life. I wrote to Jerry Morris to explore the possibility of working with him in the Medical Research Council's Social Medicine Research Unit. I got a modest traveling fellowship from the Australian Postgraduate Medical Federation which covered the cost of my travel from Australia to London and paid a stipend intended for a single man for six months. I finagled this into almost 12 months - the most mind-expanding year of my life - and Jerry Morris became my first real mentor.  I learnt more from him in that year than I'd learnt in all my previous educational experiences, not just about epidemiology but also about other public health sciences. During that year I met almost all the stars in the firmament of British Social Medicine and became friends with all of them. Jerry was the son of a rabbi in Gorbals, the Glasgow slum. He never lost his Glasgow working class accent, or the iconoclastic attitudes that went with it.  He was a marvellous mentor and implanted in me for life his critical, sceptical, evidence-based approach to epidemiology and the other public health sciences that relate to it.  

John Lee, Stuart Morrison, Jerry Morris, at the MRC Social Medicine Research Unit,
December 1961.  All three played important parts in shaping my career

I had a second mentor in the Social Medicine Research Unit: John Lee, a tall, plump man with a loud laugh, whose main interests at that time were the cause or causes of an uptick in death rates from many unrelated conditions around the time of adolescence, and the biological as well as epidemiological determinants of cancer. I learnt a great deal about ways to collect and display evidence to the best advantage from John Lee.

My predecessor as a visiting fellow in the Social Medicine Research Unit had been Kerr L White, MD, a Canadian who had moved to the USA and was head of the department of epidemiology and community medicine at the University of Vermont at the time our lives first intersected. He became my next important mentor. I learnt much from him when I worked under his supervision at the University of Vermont for a year in 1964-65; and after that he intervened in my life at several critically important times with attractive career opportunities, always accompanied by wise counsel.  Kerr White is exactly 10 years older than I, so he would be 96 if he still lives - as I think he must because I'd have heard if he had died. I know his father lived to a great age, so Kerr is probably following a similar genetic pathway.  His most important influence on my life and career came when as president of the International Epidemiological Association he selected me to compile and edit the Dictionary of Epidemiology.  Many of our peers regard Kerr White as a cold, aloof man. This was never my perception, or Wendy's.  He admired Wendy's unwavering support for me, and my dedication to my family and to my career, and both Kerr and his wife Isobel showed great kindness to all my family. 

Many other people have played prominent roles in shaping my career, but this is enough for  now.  I'll have more to say about some of those others in future posts on this blog.