Abstract and Keywords
This chapter details the author's research and lectures on lung cancer in 1961. These include his research in deaths from lung cancer in Australia; his lecture on smoking and lung cancer during the International Statistical Society Congress in Paris; his study of lung cancer in the Channel Islands; and another major study of lung cancer and bronchitis in Northern Ireland. The author also describes his divorce from first wife Nonie and his subsequent marriage to Maria Von Braunbruck.
- No man is an Island, entire of itself;
- every man is a piece of the Continent, a part of the main.
- John Donne, ‘Devotions’
In January 1961 when Nonie changed her mind and would not agree to a divorce, I asked Maria, who had quite sufficient money at this time, if she would return to Paris, and I left for Port Elizabeth where I stayed at the Beach Hotel. Maria sold most of the furniture from the Johannesburg flat and put the three Chinese carpets into storage, and then followed me to Port Elizabeth where she soon made a number of women friends. She asked a lawyer, Marcus Jacobs, if he could further the divorce proceedings. I had no enthusiasm about this because I could see that the situation was causing great distress to Nonie and the children. Since Maria would not return to Paris, I decided to fly to Australia to undertake a study on the epidemiology of lung cancer similar to that which I had already undertaken in South Africa and which the Tobacco Research Council wanted to see repeated in Australia. Because I was adamant about going to Australia, and since I did not invite Maria to come with me, she flew back to Paris.
I arrived in Melbourne and hired a car and drove to Canberra, the capital. There I went to see Mr S.R. Carver, the Commonwealth statistician, and Mr V. Pickering, the principal of the Australian demography department and other officers in the Commonwealth Bureau of Census and Statistics. I asked them if they would collaborate with me on a study of lung cancer mortality in Australia. I also had the assistance of Sir Edward Ford, the (p.110) professor of preventative medicine, and of Professor Oliver Lancaster, the professor of mathematical statistics, at Sydney University. We studied all deaths from lung cancer in Australia over a ten-year period and found, when the deaths were analysed by birthplace and age-group, that immigrants from Britain to Australia had a higher mortality from lung cancer than the Australian-born, but a lower mortality than those who had remained in Britain. The British Tobacco Company (in Australia) provided me with estimates of cigarette consumption in Australia. Consumption in adults had changed from being slightly lower than in the United Kingdom before the Second World War, and then higher than in the United Kingdom after the war. The research in Australia confirmed that there was a ‘British factor’, probably air pollution, besides cigarette smoking associated with lung cancer and also confirmed the findings in South Africa, New Zealand and the United States.
I was still in love with Maria and the next part of the story is perhaps not rational. I was no doubt influenced to some extent by loneliness. I had previously agreed to give a lecture on smoking and lung cancer to the International Statistical Society Congress in Paris and, when the research was completed in Australia, I flew there a few weeks before the congress and joined Maria. We stayed at a flat that belonged to a friend of Maria's, where she was already living, in the Île de la Cité, near Notre Dame. The flat belonged to an artist and on the wall facing the bed was a copy of a painting by Hieronymous Bosch, ‘The Temptation of St Anthony’. In the painting St Anthony is beset by an array of grotesque demons, brilliantly visualised amalgamations of human, animal, vegetable and inanimate parts. It was a disturbing painting to wake up and see in the morning!
Paris was in a state of tension in 1961 because of the war in Algeria between the French and the Algerians. There were many Algerian immigrants in Paris who were at that time very unpopular and Algerian bodies were frequently found floating in the Seine. One evening, as we were returning home down a dark lane, two Algerians followed us. One then moved ahead of us, the other stayed behind. I realised that Maria and I were going to be attacked and we nervously started to sing ‘Cherie, je t'aime. Cherie, je (p.111) t'adore’, an Algerian song. Just as the two Algerians were closing in on us, two gendarmes, submachine guns over their shoulders, arrived in the lane on motorbikes. The ‘flics’ quickly had the two Algerians against a wall, kicking one of them badly as they did so. Both Algerians had unpleasant knives up their sleeves. We had had a narrow escape and decided to spend the two weeks before the Paris Congress at Beaulieu-sur-Mer, near Cannes, in the South of France.
After the Paris Congress we flew to London and stayed, as guests of the Tobacco Research Council, at the Westbury Hotel. Geoff Todd was impressed by Maria; he found her interesting and amusing, besides being beautiful, but he also confided privately with me his opinion that since our cultures were so different we might have problems if we stayed together. He asked Professor John Youngman, a well-known sculptor, to portray Maria in bronze and she agreed. We still have the sculpture; it is about thirty inches high.
On that visit to London, the TRC asked me if I would undertake a study of lung cancer in the Channel Islands. They pointed out that the research I was undertaking on lung cancer and smoking was of the greatest epidemiological importance. They did appreciate how difficult it was to leave my children and my medical practice in South Africa and promised to fund well any study I carried out. I was also influenced in agreeing by my love for Maria. I did not want to leave her, but nor did I want to take her back to South Africa.
Dr Averil Dowling was the Medical Officer of Health in Jersey. He had reported to the Jersey public health committee that the island had the highest lung cancer rates in the world and that the Jersey residents were also the world's heaviest smokers. Cigarettes are cheap in the Channel Islands because they are not taxed. In 1961 Jersey had a population of 63,000. Mortality from cirrhosis of the liver and suicide was also high, largely because alcohol was also very cheap in the Channel Islands.
Maria and I went to Jersey. I secured the approval of the Greffe, or Parliament, and with their permission noted from the Register of Births and Deaths the names and addresses of all those who had died from lung cancer between 1952 and 1961. In order to make (p.112) a comparison between those who had died from lung cancer and those who had died from other diseases, I needed controls. Therefore I obtained records about the next death in the Death Register that was not from lung cancer but was in the same sex, age-group and birthplace group – born in Jersey or in Britain – as the lung cancer death.
I then called on the widow, or next of kin, of those who had died from lung cancer and of the controls, in order to obtain information about the smoking habits of the deceased. I traced the next of kin of all 222 people who had died of lung cancer in Jersey during the decade I was studying. One in eight of the men who had died, aged 45 to 64, had died from lung cancer and by 1961 this ratio had increased to one in five deaths. In a further study in Guernsey, Alderney and Sark, one in seven deaths among the men, aged 45 to 64 years, was from lung cancer. In the ten-year period of the study, only two male lung cancer deaths in Jersey and four in Guernsey, Alderney and Sark had occurred in those who did not smoke. During the later years, the lung cancer mortality rate of British immigrants had exceeded that of locally born men, although they had smoked less than the locally born men before they had migrated to Jersey. This study in the Channel Islands confirmed the findings in South Africa, the United States, New Zealand and Australia and pointed again to a ‘British’ factor besides a smoking factor.
In Jersey we stayed with a French-speaking family and they had a ten-year-old son. He was interested in biology and one day I explained to him Darwin's theory of evolution. I asked him if he thought that mankind and the higher apes, such as chimpanzees, had a common ape-like ancestor? He looked me in the eye and said: ‘I think some of us did!’
On the smallest of the Channel Islands, Sark, with a population of just over 500 at that time and no cars, we stayed with the Dame of Sark. She told us that it was the established custom that she paid the King or Queen of England every year ‘one knight's fee’. She was a fine old lady who went about in an electric wheelchair.
Tourism was, and is, a major industry in Jersey and it was thought that it depended to a great extent on the low cost of cigarettes and alcohol. Unfortunately, Dr Averil Dowling, who had drawn (p.113) attention to the very high lung cancer rates on the island, found his views very unpopular and soon afterwards retired as Medical Officer of Health. His chief clerk, Tim Simon, still sends me a calendar of Jersey every Christmas.
In 1961, I was asked to attend a neurological congress in Rome and talk about the research I had undertaken on the epidemiology of multiple sclerosis. After the congress I agreed to accompany Maria by train from Rome to Belgrade to meet her parents. They lived in a flat in the centre of Belgrade with her brother, Nicholas, his wife, and their three small children. Fortunately, Maria's father, Stanimir, could speak German, having spent some years in Switzerland where he had been a shoe manufacturer before the Second World War, and I was able to talk to him in the poor German I had learnt as a student in Frankfurt. I was still in love with Maria but greatly missed my children and, realising that our background was so different, I returned without her to Port Elizabeth. Maria went to stay in Paris, where some of her friends were living.
I tried for the last time to make a success of my marriage with Nonie, but found it extremely difficult because I was still in love with Maria. I had been back in Port Elizabeth about ten weeks when Ron Deare, husband of Maria's great friend in Johannesburg, Netta Deare, phoned that they had received a telegram from Maria saying that she would arrive in Johannesburg the following morning. This was a great shock because I had not invited her but it was too late to stop her. A few days later, after telling Nonie what had happened, I went to Johannesburg to meet Maria. I was torn between two women. My relationship with Nonie had grown cold but I knew that she was a very fine, intelligent and good person whom I still loved for the years we had had together. I also greatly loved my three children, although most of the time they were at boarding school and not at home. Maria, in contrast, was exotic, with amusing conversation and was always excellent company. Sexually we were totally compatible. She already had a weakness, which I was only fully to appreciate later, and that was that when she had a drink, she found it difficult to stop. This is often a problem among Slavic people.
(p.114) The situation had, no doubt, become too much for Nonie and she agreed to an amicable divorce. No custody arrangements were made for the children and none were needed. When the children were at home, they would live with Nonie but often spend the weekend with Maria and me at Lauries Bay. After the divorce Nonie wrote to my father that she thought that if she was divorced I would reconsider and return to live with her. I think that if she had not agreed to a divorce so easily when I had first suggested it, we would have stayed married. Whether or not this would have been a good or a bad thing is difficult to say.
Back in London, and writing the first draft of the report about the Channel Islands for publication in the British Journal of Cancer, I was asked by the TRC to organise a major study of lung cancer and bronchitis in Northern Ireland. I knew that a study in a population of one and a half million people would probably take at least three years. I went to Northern Ireland to see if it was practical to undertake the study and to obtain the co-operation of the Northern Ireland Department of Health. The Chief Medical Officer, Frank Maine and his deputy, Sandy Elder, promised their assistance with the study. We obtained a list of all deaths from lung cancer and bronchitis in Northern Ireland between 1960 and 1962. As in the Channel Islands, we selected a control for each lung cancer and bronchitis death. We divided Northern Ireland into six areas: inner Belfast, outer Belfast, the surroundings of Belfast, urban districts, small towns and rural districts. We arranged that a market research company would interview the relatives of the patients and the controls and complete a questionnaire about the deceased's smoking habits, occupation, area of residence and other relevant factors.
Maria and I married in June 1962 and rented a one-bedroomed flat in Port Elizabeth. Shortly afterwards I had to return to Europe to attend the World Cancer Congress in Moscow and then to continue the study in Northern Ireland. Maria, Geoff Todd and I first went to Leningrad, saw the paintings in the Hermitage and the sights of Leningrad and a week later flew to Moscow. There (p.115) were more than 4,000 delegates at the conference and we were well entertained in the spacious halls of the Kremlin. Maria danced with Yuri Gagarin, the first man to travel in space; he was a small, cheerful, good-looking man. We also met Anastas Mikoyan, the first deputy to Khrushchev. We did not like the Soviet Union; we were watched everywhere we went. There was always a long wait in the restaurants and when we went shopping the shop assistants were not interested in serving customers. All in all, we found Moscow very depressing, although it was a help that Maria could speak some Russian; she had learnt it at school.
Maria and I then went back to South Africa and returned to Northern Ireland for some months in the summer of 1963 and again in 1964. During these visits we got on well with both Catholics and Protestants. There was no doubt that members of the Catholic community had a very raw deal at this time. They were barred from many jobs, for instance in the Belfast shipbuilding yards. Protestants always had first preference in housing, and the chief posts in the medical services were all held by Protestants.
The lung cancer rates in Northern Ireland were substantially below those in the rest of the United Kingdom. However lung cancer mortality was three times higher in inner Belfast than in the rural areas for light (1–10 a day), medium (11–20 a day) or heavy smoking (21+ a day). I received great assistance in the research from Professor John Pemberton, professor of social medicine at Queen's University, Belfast, and from Sandy Elder, Northern Ireland's deputy Medical Officer of Health. Sandy died shortly after the study was completed, after playing a Chopin prelude at a party for friends. Everybody was clapping loudly when he fell forward, dead. What a lovely way to exit!
We decided to undertake a major study of smoking habits and air pollution in Teesside which included the urban areas of Eston and Stockton municipal boroughs, and the rural districts of Croft, North Allerton, Richmond and Stokesley. The study included environmental factors likely to be associated with lung cancer and bronchitis and also studies of deaths from heart attacks and strokes by area of residence, smoking habits and social class. The study would not have been possible without the collaboration of the (p.116) Medical Officers of Health for these districts, in particular Dr Paddy Donaldson. Eston was a heavily polluted area and included an ICI chemical works and a big steelworks.
A similar methodology was used as in Northern Ireland and the Teesside study also showed that cigarette smoking was a major factor associated with lung cancer and bronchitis, but it was also a factor associated with death from heart attacks and strokes. At each level of smoking, the risk of death from lung cancer and bronchitis was higher in the polluted urban areas than in the rural areas. There was a high death rate among the lower socio-economic groups.
The Teesside study confirmed the findings in Northern Ireland and showed that, whereas cigarette smoking was most highly associated with lung cancer, urban air-pollution was as important as cigarette smoking for deaths from bronchitis. We also found that cigarette smoking was an important factor associated with heart attacks and strokes. Both the Northern Ireland study and the Teesside study took three years to complete but they overlapped.
Back in Port Elizabeth, I was seeing patients not only from the city but also from the country areas. Sometimes I would be asked by a doctor in a country town to see a patient who was too ill to move, living perhaps three hundred or more miles away. I would fly by private plane which usually had to land in a makeshift landing place. By flying, I could come back quickly and avoid long car journeys. I was not a ‘flying doctor’, but I did go by air perhaps four or five times a year to see a patient who lived a good distance from Port Elizabeth. On my way back I would sometimes get the pilot of the small plane to fly low over Lauries Bay and I would drop a note saying that I would be home for tea!
At the instigation of the famous statistician, Joseph Berkson, I decided to undertake a study on all causes of death among the different peoples of South Africa and compare the mortality for different diseases between the white immigrants and the white South African-born. Dr Berkson thought that the reason for the high lung cancer rates in British immigrants might possibly be due to their constitution and not the environment.
Dr H.M. Stoker, the director of the South African Census (p.117) Bureau, Pretoria, agreed to decode the Hollerith cards, an information system based on punched cards, for all South African deaths reported during the three years 1957, 1958 and 1959 and for certain causes of death for longer periods. The deaths were analysed by sex, age-group, place of residence and place of birth. At the same time I undertook a study on the causes of death among the white, Coloured, Indian and black South Africans. The long report was published as a special supplement in the South African Medical Journal (SAMJ) in 1965.
South African-born white men and women, in spite of, or because of, their high standard of living, had a higher death rate up to the age of 65 than men and women in the United Kingdom, the Netherlands, Germany and France. The death rate for the white population was considerably higher in the cities than in the rural parts of South Africa.
Immigrants from the United Kingdom to South Africa had a lower mortality than the white South African-born but not as low as those who had remained in the United Kingdom. In South Africa heart attacks were the major cause of death in white and Indian men. The white South African-born had significantly higher death rates than in the United Kingdom for cancer of the stomach, prostate, uterus and skin, for heart attacks, cirrhosis of the liver, accidents and porphyria. They had lower rates for cancer of the bowel and of the lung, for bronchitis, multiple sclerosis and ulcerative colitis.
The Asian community consisted chiefly of the Indians of Natal. They were often traders and middlemen. Their closely knit family life and strong business sense protected them from many of the hazards of poverty, and their expectation of life was much better than in India. However, many died from raised blood pressure, strokes, heart attacks and diabetes.
The Coloured people, who lived mostly in the Cape, occupied an intermediate position in the social scale between the whites and the blacks. They had largely adopted a western way of life. Like the white population, their mortality statistics were fairly reliable. Many died in infancy, mostly from gastroenteritis. Their birth rate was high, compensating for their raised mortality rates.
I found that the black population had neither the medical (p.118) attention nor the necessary level of death certification to make possible detailed comparisons with other South African racial groups. Their death rate at this time was very high. When I first went to Port Elizabeth in 1947, about half the black children died in their first year of life. By the time I left in 1968, it had dropped to 20 per cent, with a resulting big increase in population as the birth rate remained high. I concluded in the 1965 report in the SAMJ that Africans should be taught the advantages of limiting the size of their families and that smaller families, among whom most of the children would survive, would result in improved living standards.
My conclusions on the causes of death in South Africans showed that the most important factor affecting their health was the environment. The diseases of the Coloured and African people were mostly the result of poverty and of the white and Indian people their affluent lifestyle.
After completing the study, I thought I would look at the causes of death of my own profession. In 1969 there were only ninetyeight medically qualified black doctors in practice in South Africa. Because of the small number of black doctors, there were few deaths. Perhaps because of their relatively high income and few opportunities to spend it, they appeared to be unduly susceptible to alcohol-related disease. The Coloured doctors had the same pattern of death as occurred among the white doctors, in particular heart attacks. The Indian doctors had a high death rate attributable to heart attacks, high blood pressure, strokes and diabetes. White South African doctors had a considerably lower mortality rate than occurred among the general white South African population. Nevertheless they had a high death rate from heart attacks and lung cancer – at this time most of the South African doctors were still smokers – and from suicide. White, Coloured and Asian dentists had a very similar death pattern to doctors.
I finished my report, published in the SAMJ in 1969, by suggesting that doctors should pay more attention to the health of their colleagues, who are often slow to obtain expert advice about their own health. Doctors are more prone than average to alcoholism and to suicide, perhaps because they often work long hours with little time for social relaxation.
(p.119) It is becoming increasingly possible to identify ‘high risk groups’ for different causes of death. Those in these groups can often be advised how they should alter their way of life, to lessen their risk of early death. Affluent societies should give much more attention to the effects of our way of life on health – for instance a high calorie diet rich in animal fat, excessive use of the car and a lack of daily exercise, smoking, the abuse of alcohol and air pollution.
In 1976, two doctors, Richard Doll and Richard Peto, showed that doctors in Britain, who by and large had stopped smoking, had a fall in their lung cancer mortality and also in their risk of dying from heart attacks, strokes and chronic bronchitis, strong confirmatory evidence that cigarette smoking was a major factor in causing these diseases.