History… is not the
arrangement of what happens, in sequence and in truth, but a fabulous
arrangement of surmises and guesses held up by a banner against the assault of
withering truth.
Roseanne McNulty in Sebastian Barry’s The Secret Scripture
Brutal concrete
Westmead Hospital is a fine example of
brutalist concrete architecture. It was designed by Chic Campbell, a manic
Canadian architect, after the first team of project developers were fired in
about 1972.
McMaster University in Hamilton, Ontario,
built around that time has striking similarities in design. Both used bold
colours on doors, have (or had) carpeted corridors as wide as freeways and an
unmatched sense of interior space. Both were designed to foster collaboration
among clinicians of various stripes and to make it easy to integrate clinical
service, research and education.
Brutal concrete conveys a message of
strength and defiance against inimical environmental forces – an appropriate
defence against the wild west. The land on which Westmead stands was once a
stock-car racing track and dumping ground for asbestos waste from Hardies, a
fibro manufacturer.
The pasture was more genteel in the days when
sheep belonging to Government House at Parramatta grazed there – on the ‘west
meadow’. We know nothing of its utility during the Dreamtime. Down the road was
the habitat for Aboriginal people during Macquarie’s time – known as Black Town;
now, Blacktown has only the Australian average of Indigenous people (9000) or
2.9% of the population.
With time, as with all hospitals, Westmead
has sprouted small buildings and sheds, panels of ritzy cladding, with
lightwells filled to hold clinics and bureaucratic document files.
First contact
My association with Westmead began in 1972
when, concurrently completing my PhD at USyd, I worked two days a week with
Bernie Amos. Bernie, the project overlord, was a man for whom I already had
great respect and affection from our shared experiences at Royal North Shore
Hospital. He was a loyal friend, supporting my headstrong departure, after two
years’ internship, for an interim year in the highlands of Papua-New Guinea.
That year alerted me to the importance of public health. I abandoned plans for
a career in experimental neuroscience – an outgrowth of my BSc(Med) experience
with John Pollard in 1963 – and, with Bernie’s support, returned to RNSH in
1969, completing my MRACP in 1970.
The details of the luminous ‘functional
brief’, written by the late respiratory professor John Read, were being
interpreted and turned into policy. The brief contained sections devoted to
every clinical discipline, the crucial role of education and research and much
about the desired ethos. Page after page reveals a strong awareness of, and
responsiveness to, the local community. Each section had been produced by
academics, with the USyd front and centre. The then NSW Health Commission also
featured strongly – especially through the work of several of its eminent commissioners
who had joined the clinical working parties.
The thrilling awareness of the
opportunity to create an entirely new and different teaching hospital is palpable
throughout John Read’s brief. This awareness energised and motivated many of
the original clinical appointments. Whereas the other USyd clinical schools were
grafted onto existing hospital stock, with the problems of antiquarian halls
and theatres, antiquated governance and musty, desiccated traditions, Westmead
could, by contrast, be big, bold and above all, NEW!
I don’t know the origin of the spark which
set ablaze the enthusiasm for so bold a venture as Westmead. Health Minister
Harry Jago was crucial; surgical Professor John Loewenthal and John Read were
academic champions. The vice-chancellor, John Ward, was a strong supporter. I know
little of the pre-history, stumbling onto the scene only in 1972. This period,
which I call the Westmead pre-Anthropocene, would make a fine topic for
a scholarly history.
The role of the Commonwealth was
substantial. When Gough Whitlam addressed Westmead’s thirtieth anniversary
celebrations he said, with a flourish of humility, “There was a point when they
[the NSW govt] said they would not fund it, so I said, ‘We will’! And do you know what, suddenly they declared
that they would fund it!”
Community Medicine at Westmead
In 1973, Bernie asked me to write an
implementation expansion of the brief concerning Community and Geriatric Medicine.
I worked on this two days a week. I was also completing my PhD on factors
affecting the lung function of 12,000 Sydney schoolchildren. My colleagues were
Ann Woolcock, Ruthven Blackburn and epidemiologist Godfrey Scott in the Department
of Medicine in the Blackburn Building and the School of Public Health.
The HQ of the Westmead Project Planning
Team was the old Preventicare building on the north-western corner of
Missenden and Parramatta Road. Chic Campbell arrived on the scene (I think)
towards the end of that year.
I was no expert in Community Medicine,
which might explain why my paper was well received! John Loewenthal breezed into my office one
morning to say that, after having read it, he at last understood what Community
Medicine was. I considered asking for an explanation because I was, I confess, none
too certain myself. Loewenthal was a great encourager of the Westmead people.
Rob Griffin, the first Director of Medical Services and one of many imports
from the RNSH (including John Dowsett), told me how JL would drop into his
office weekly “just to see how I was going.”
The ambitious plan was to combine hospital
community outreach (the community health program was still in its infancy) with
geriatric inpatient, outpatient and community-based care, and to offer a
general practice clinic.
The first Westmead property – now gone!
To give visibility to the Community Medicine
concept, we bought the house on the corner of Railway Parade and Hawkesbury
Avenue and labelled it Department of Community Medicine, Westmead Hospital.
It served as the base for the recently-formed community nursing group – the
forerunner of Whitlam’s ‘community health centres’ – and we accommodated a
local branch of the Family Life Movement (now Relationships Australia). The
cottage remains the property of the Western Sydney Local Health District. Community health centres, different from the
original model, persist. The cottage was demolished recently to make way for
the new Parramatta to Westmead light rail.
The Community Health Program, funded by
the federal government in 1972, was a major initiative in the newly created Western
Sydney Health Region (similar, but not identical, to the current WSLHD) ,
developed by the NSW Health Commission and directed by Gary Andrews, later Founding
Professor of Community and Geriatric Medicine at Westmead. The teams of nurses
were commissioned with due ceremony, at Lidcombe (I think). As they filed onto
the stage to receive their badges from the Minister for Health, several had arms
in slings or were supported on crutches. They had been equipped with
fault-ridden Leyland’s Marina cars! This was an inauspicious start for
an idealistic service built on the concept of health beyond the reach of
clinical medicine.
I gained a good feel for Western Sydney,
driving around with Bernie in his Holden Statesman (he was a superb
driver) stopping for Chinese lunch. He considered it important to have an idea
of the community we were proposing to serve. We attended the opening of the Mt
Druitt polyclinic, with Health Minister, Kevin Stewart, where we were accosted
by a disappointed local resident who told Kevin, in stern words, that the local
citizens wanted a hospital, not a clinic with one bed! I met her again in 2016
– at Mt Druitt Hospital – when the WSLHD Board was visiting – and we shared
happy memories.
My life in the late 1970s and early 1980s
In 1974, our family moved to London for
me to pursue an NHMRC post-doctoral fellowship in clinical epidemiology at St
Thomas’s Hospital in Lambeth with Walter Holland, the father of British
epidemiology, and Charles Florey, son of the prince of penicillin. That was a splendid,
rich 18 months of cultural and academic experience of unparalleled depth. I
often felt that I had come ‘home’ – my paternal grandparents had come from a
farm in Thaxted in Essex – where I met another Stephen Leeder, much my age!
The AUD was so buoyant that my salary
exceeded that of Walter Holland. While consuming a dreadful coffee and bun in
the pre-war cafeteria, I recall watching snow beat up the Thames. Bomb damage
was still visible in sections of the hospital building and weeds grew in the cracks.
At various points, rationing occurred – butter for example. The Brits thrived
on this nostalgia. One day, walking to St Thomas’s, I encountered a 50-metre
queue outside a small store. I asked a happily humming man what he was queuing
for. “I don’t know!” he said, “but it’s such fun!” he replied, resuming his
tune. There was a little corner store near St Thomas’s where I bought lunch
occasionally. This was 1974. On one occasion, a woman was asking for butter. “I
have only German butter,” the proprietor told her. “I’ll leave it then” was her
disgusted reply.
The McMaster epiphany
In 1975 we moved to McMaster University
in Canada for a year. I was intrigued by David Sackett, one of the progenitors
of clinical epidemiology and subsequently of evidence-based medicine. He had
been at St. Thomas’s while I was there. He had made clinical epidemiology
educationally interesting. Most prior public health education I had encountered
had been dry and eminently forgettable. Sackett was an educational magician. By
integrating epidemiology with clinical practice and making it the foundation
for quantitative research he achieved the impossible! No major research
activity or educational development at Mac was devoid of a clinical
epidemiological contribution and collaboration.
Everything about McMaster was
stimulating, from the architecture to the happy and creative atmosphere
(including the massive cafeteria where everyone was expected to turn up for
lunch). Moran Campbell, a dazzling
respiratory physiologist, was a major intellectual force: he co-authored a Lancet
paper ‘What is the probability of a committee meeting?’ He and his
co-author compared the turn-up at formally organised meetings (laborious) and at
a spontaneous gathering of the same group at lunchtime! Lunch won!
The design of the McMaster University
Medical Centre favoured flexibility in the future use of space. There were no internal structural walls, so
that rooms could be demolished and reinvented without much effort, according to
desire. To enable repurposing, enough space was left between floors for workers
to walk about, moving utilities to fit – plumbing and electrical outlets, for
example.
The McMaster year showed me how truly
integrated research and education could work, how the combination could be
clinically relevant, and how much fun working in a collegial environment could
be. It was also a revelation as to how medical education could be changed from
conventional didactic boredom into an exciting activity in self-directed
learning. The course lasted three years. There was no formal assessment.
Students defined their own learning and used the faculty as resources. They
integrated with the various departments and research programs in the medical
centre.
The Newcastle years
From McMaster, we returned to Newcastle. David
Maddison had recruited me as the foundation Professor of Community Medicine.
That, too, was exciting – a completely new venture where we had the opportunity
of introducing new methods of medical education akin, but not identical, to
what had been pioneered at McMaster.
In Newcastle, with its accessible and
contained Hunter Region community, its own media and politics, I had an active
decade undertaking population-based NHMRC- and Cancer Council- supported research
with colleagues from the Faculty of Mathematics (Annette Dobson and Bob
Gibberd) in cardiovascular disease (the WHO MONICA project), an RCT of
school-based smoking prevention and more. I was deeply involved in developing
the entirely new curriculum and was put in charge of assessment.
The new medical school was
community-focused, treated the students as adults, emphasised the importance of
clinical problems as the basis of medical education, assisted students to learn
how to work in teams and to direct their own learning, and assessed their
progress in terms of acquired skills. Communication
skills were strongly emphasised.
These were also years when I had
extensive international engagement. Because of my McMaster contacts, I became
the founding director of the Rockefeller-funded Asian and Pacific Centre for Clinical
Epidemiology and Biostatistics. This trained top-flight young clinicians from
Thailand, Indonesia and other countries in these dark arts. This centre was a
part of an international training network – INCLEN – including training units
in hospitals in SE Asia and major resource centres at Pennsylvania, McMaster
and Newcastle.
Newcastle was also where I formed a close
relationship with Denis Butler, the deputy editor of The Newcastle Herald. He
encouraged me to write (heavily and instructively edited) op-eds, including a
series after Laurie Brereton decided in1981 to cancel the construction of a
combined clinical school and cancer centre at the Newcastle Mater Hospital. Huge
community pressure reversed that decision.
Denis also supported my writing Saturday
book reviews. His friend, Tom Naisby, the poetry editor, did likewise with my
poetic efforts. They were wild men in their own ways and added to the rich
diversity of Newcastle’s cultural life. After David Maddison, a heavy smoker,
died suddenly in late 1981, much changed. That was a great sadness and a terrible
disruption.
Westmead revisited
In early 1985, I considered that ten
years in any place was long enough and took on the directorship of the Westmead
position in the hope that experience gained in Newcastle would help develop the
department about which I had written in 1973. I started there the same day that
Andrew Wilson commenced as my first Registrar.
It was not a happy scene. We soon lost
the geriatricians who felt we were not medically kosher and who detested
the rehabilitation physicians. General practice was always restive in their
department and increasingly identified with the ED.
In their place, we established strengths in
health economics (Jane Hall and the Centre for Health Economics and Evaluation,
now a thriving unit at UTS) clinical epidemiology, health promotion, statistics,
and related disciplines. Andrew Wilson, Bob Cumming, Ross Lazarus, Karen Webb,
Penny Hawe, Simon Chapman, Bin Jalaludin, Allen Sheill, Stephen Jan, Beth
Stickney, Jason Grossman and Vicky Flood passed through the department and went
on to assume major academic and managerial positions in ageing, nutrition,
environmental health and more.
My national commitments continued over
this period, serving on the Better Health Commission, the Health Goals and
Targets committee and various other groups with the strong support of the then
federal health minister, Neal Blewett and the secretary of the Department of
Health, Bernie Mackay. These appointments led to the first set of goals and
targets for Australia’s health. NSW counterparts also took my time and energy.
During this time, when Medicare was established, Blewett also set up the then
Australian Institute of Health – to gather statistics as we could not easily
identify these when we needed them for the Better Health Commission. He also commissioned a review of public
health education and research in Australia with Kerr White from the Rockefeller
Foundation and Johns Hopkins University.
Kerr White had founded INCLEN. One of his suggestions was that the
school of public health at USyd should be wound down and the resources applied
at Westmead – a highly provocative suggestion that led to fury at Camperdown!
During this period the Public Health
Association was reinvigorated and given federal support for a secretariat. I
became the first national president. The enthusiasm was palpable.
In Community Medicine we led the
development of the intranet within Westmead with the help of Ross Lazarus. Deirdre
Degeling led major health promotion community programs such as Healthy
Hearts West and Karen Webb, with Penny Hawe, did excellent work with the
Penrith City Council developing a ‘healthy city’ program. The department provided
methodological support for many clinical researchers. We developed applied
public health research and had a team of over 30 by the time I left ten years
later.
But Western Sydney had been a totally
different ballgame from Newcastle – huge diversity, much larger, complex
economically and socially. I had had culture shock for months. I wrote this
poem about the experience:
HEADING
WEST
In the
hinterland of life
west
of the coast
by
25km of traffic
dense
as dust we must
confront
the size
of the
problem.
My
brown shoes
have
lost their shine
and
their soles worn –
urban,
ethnic, aged,
alcohol-obliviated,
club-dominated,
fast-food
saturated,
Diet
Coke burpurated:
is it
any wonder?
Suburbs
built without amenities
create
misunderstandings,
offend
sensitivities;
concrete
poured and walls built
in
haste against imaginary winds
provide
no rhyme, no reason
nor do
random roads and rusting gates,
yet
Map 241, F13 still marks
the Mt
Druitt of my soul,
and
public transport is crap.
I moved to the USyd Camperdown campus in
1986, first as head of the School of Public Health and then as dean of the
Faculty of Medicine in the era of the new curriculum and the devolution of
authority to the clinical schools. The Westmead department of community
medicine, which could have come into its own in the current era of community
re-orientation and integrated care, was slowly wound up.
During my USyd career, I chaired the
Health Advisory Committee of NHMRC for three years when Michael Wooldridge was
health minister. I served on the Senate as a staff representative for eight
years. I learned a lot about politics in academe! I continued my involvement at
Westmead, serving on the board and assisting with the Respiratory Ambulatory
Care Service run by Mary Roberts and John Wheatley at Blacktown Hospital. That
gave me a deep understanding of home care for people with serious and
continuing illness. Brilliant. I was also on the SWAHS Board at that time.
Craig Knowles as state minister for health
did many constructive things to bring clinical perspectives into health
district management, including establishing an advisory group chaired by John
Menadue, former head of Prime Minister and Cabinet with Whitlam. That committee
developed and fostered the idea of research Hubs, and we pushed that concept
with great success in western Sydney, building on the initial work of Tony
Cunningham and others.
After a little over five years I finished
being dean. I then had 18 months at the Earth Institute with Jeffrey Sachs at
Columbia University, and the Mailman School of Public Health, with colleagues
Susan Raymond and Hank Greenberg. We worked on the economic impact of
cardiovascular disease on low- and middle- income countries. On my return to
USyd, I directed the Menzies Centre for Health Policy, initiated by Michael
Frommer and colleagues and now headed up by Andrew Wilson.
At the end of this interval, I returned to
Westmead, chairing the WSLHD, editing the Medical Journal of Australia, and
directing, with Helene Abouyanni’s superb support, the WSLHD Research and
Education Network. It has grown include about 700 researchers and educators: we
are a network, not a department. We are more a ‘community of interest’ than a
bureaucratic structure. The difference is profound.
Many of our members are researchers and
educators, helping manage education and research, research and governance
oversight of research, financial management, intellectual property development,
and statistical and support with writing papers and grant applications
throughout the WSLHD. We assisted in establishing conjoint chairs in pharmacy,
nursing, clinical education, allied health and preventive public health practice.
We oversaw the development of a strategic plan for nursing research and, most
recently, a statement of strategic intent for research and education. This was
endorsed enthusiastically by the WSLHD board in March. The recent arrival from
the UK of Peter Hockey, professor and director of education, ushers in a range
of new options in our educational efforts.
In my most recent incarnation as Chair of
the WSLHD Board, we saw great things planned through the commitment of Health Minister
Jillian Skinner – leading to the redevelopment of Westmead and Blacktown/Mt
Druitt Hospitals. During my term (the
past ten years) as director of the Research and Education Network, we began by
having to sort out terrible financial tangles in the support of research and to
re-energise the relations between the local health authority and the research
community.
It has been exciting to watch the amazing
achievements of Tony Cunningham and colleagues in establishing the Westmead
Research Institute and, with Jeremy Chapman, consolidating the unique and
special relationships with all research entities in the precinct in the
Westmead Research Hub.
This is the year I retire. I do so after
much happy experience, the joy of knowing and having worked with splendid people
and having seen many achievements. We are still, as a hospital and a district,
yet to fully accept our mandate to contribute to enhancing the health of the
community, but that is growing.
I leave to others to describe and assess
the massive redevelopments. That is a whole other story, bursting with exciting
potential, and only just beginning!
A new age is dawning. Westmead – make the
most of it!
