THE  ART  OF  MEDICINE  -  Healing  and  the  Limits  of  Technology

by  Dr. Herbert  Ho  Ping  Kong

STARTING OUT

The whole art of medicine is in observation... but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that you can do. — Sir William Osier

I always knew that I would become a doctor.

I knew it not, as one might expect, because my parents coaxed me toward the profession, but because of my childhood nanny. Let me explain.

I was the third child born — in 1939 — into a family of 10 in Summerfield, a country town in the district of Clarendon, some distance from the Jamaican capital of Kingston. My parents were both Hakka Chinese, a minority that, through the centuries, has exerted enormous influence in China's political and social history.

My grandfather had arrived a generation earlier from China to work in the Caribbean cane sugar fields as an indentured labourer — one un-glorified step up from slave. In time, some 10,000 Chinese would settle in Jamaica and, through thrift and hard work, become prosperous, particularly in the retail trade.

So prosperous, in fact, that by the mid-1960s, racial tensions with the indigenous Jamaican community were bubbling up.

From cane — the world's largest food crop and a staple of the Jamaican economy, then and now — was derived sucrose, which was used to make chocolate, molasses, rum and several other products. At one time, cane sugar was considered so valuable that empires would literally barter away valuable territories for it. It was in exchange for the sugar-cane-rich fields of Surinam, for example, that the Dutch ceded New Netherlands — New York — to the British in 1674. A century later, ending the Seven Years' War, France ceded what it called "a few acres of snow" — namely, Canada — to the English, in return for the cane plantations of Guadeloupe, Martinique and St. Lucia.

At the age of 16, my father, Percy Ho Ping Kong, came from Canton in the mid-1930s, fleeing hunger in China. He became an assistant in a Chinese-owned grocery shop. Somehow, without going to school, he managed to learn to read and write grammatically correct English. A thrifty man, he later saved enough funds to buy and successfully run his own grocery shop for many years.

My mother, Mary, arrived four years later, having been betrothed to him at the age of 12. She was also very smart — at once resourceful and creative. She knew instinctively how to build and fix things. In fact, after we moved to Kingston, my parents decided to build a house. For some reason, the hired contractor was unable to complete the job, so my mother took over and organized the entire project. We grew our own vegetables and raised ducks and chickens in the backyard. From the products of that garden and farmhouse, my mother made the most delicious meals. Her food was so good and so locally renowned, that it wasn't uncommon for restaurant owners to stop by for a small discussion about recipes. And she had healing hands: once, one of our ducks became sick, unable to move, and my mother asked me — I must have been about 10 years old — to hold it still while she performed surgery. She took a razor blade and made a careful incision in the neck. I can't say definitively whether this procedure was curative, but the next day, the bird got up and walked.

We were not rich, but almost every family with children in Jamaica was able to afford a nanny. Ours was a young Jamaican woman named Mum Robinson. One day when I was five—I remember it vividly — she told my brother Lloyd that he would become a lawyer (which he did not) and that I would become a doctor.

It was not a game — she was deadly serious. Although uneducated, she knew that the professions were important. We all had heard about a certain Dr. Robb, a distinguished physician/surgeon who lived in our district. People came from all over the country to see him. I was to be like him, she said. After that, I never thought about it again. I knew what I would become and never deviated from the path.

My parents marriage was largely happy, but my father definitely came from the old school of Chinese thinking, in which men were dominant and women were subservient. He was prepared to work hard, and he did, but he expected to be served at mealtimes and would frequently complain, usually in the direction of my mother, if he perceived something wrong. I found this increasingly hard to endure as, Fm sure, did my mother.

One day, when I was 12, he came in for dinner and set off on one of his typical rants. I was cutting cod fish in the same room and I suddenly turned to him, still chopping, and shouted, "Poppa! Enough. That's it!" I'm sure it was a shock to see his son rebuke him like that.

But he got the message. He shut up, not just at that moment, but forever after. As far as I know, he never said another unkind word to or about my mother. The incident also revealed something about me — that I could be tough when I needed to be.

For some reason, my formal education did not start until the age of seven. It began in the Jamaican equivalent of a one-room schoolhouse, with a single teacher and students that ranged in age from 7 to 16. But I was very fortunate — I befriended a young Lebanese boy named Bobby Abisted, about 13. He became my tutor and really helped me prepare for high school. He taught me how to read quickly and more critically, how to teach myself, a skill for which I remain in his debt to this day.

I attended high school at St. George's, a Jesuit institution in Kingston, founded in 1850 by 21 Spanish Jesuits exiled from Colombia during a period of religious persecution.

On my first day, the school conducted its usual outdoor assembly and roll call —1,000 students aged 12-19. They called 999 names, every one except mine. I stood alone in the square, dressed in short pants.

The headmaster, Father Charles McMullen, approached me.

"Well," he said, in his thick Boston accent. "And who are you?"

"I am Herbert Ho, sir."

He peered down at his list. "There's no Herbert Ho here."

"Don't you remember, sir? I saw you last week. I paid my fees."

"What's your father's name?"

"His name is Ho Ping Kong," I said.

"Son, your name is too short," he declared. "From now on, you will be Herbert Ho Ping Kong."

Thus was my name changed — on the spot. And thus did it remain. It was probably a good thing. There are literally thousands of people named Herbert Ho in the world, but very few named Herbert Ho Ping Kong.

Because of Bobby Abisted's tutoring, I managed to complete two years in one during my first year at St. George's. My favourite course was biology, largely because my teacher, Father Hennessy, would often engage us in more popular discussions, including girls — a rather unorthodox topic in a Jesuit school — or social issues such as slavery.

The school's teaching standards were set high. Virtually all of the teachers had earned master's degrees or the equivalent. Thus, in effect, we received university standard teaching in physics, chemistry, biology and other courses.

The Jesuits believed in educating the whole person. Thus in addition to academic performance, they stressed such things as speaking skills and athletics. I played many sports, but truthfully excelled at none of them. In the end, I was described as the school's shortest high jumper, its slowest sprinter and its slowest pace bowler in cricket. But I did captain one of the cricket teams and was named head boy of the school in my final year. Although I represented a racial minority, it wasn't unusual for a Chinese youth to win such distinction. The Jesuits saw everyone as equal and treated everyone as equal, without having to preach about it.

As head boy, I was also expected to demonstrate leadership qualities. One day, we were having an elocution lesson with the same Father McMullen. A friend, Richard Chin, was called on to speak to the class, but suddenly froze. He did not recall the assignment and was unprepared for the occasion. In retrospect, it might have been my fault for neglecting to give him the assignment. In any event, I decided to come to his assistance.

"I think I'm the one who is supposed to give the speech," I lied.

"Alright," said McMullen. "And what are you going to speak about?"

"The Yangtze River in China, sir."

And with that, I launched into an extemporaneous 15-minute speech on a subject I knew almost nothing about. I described the river's considerable length and the chromatic origins of its name, and the plant and animal life that lived along its shores.

Afterward, Father McMullen said, "You did well, Ho Ping Kong, but you must learn to pronounce your 'th' sounds better."

As I approached the end of my high school years, I went to see McMullen to discuss where I might go to university. Most of my friends were headed to the United States. And my older sister, Joyce, had earlier won a scholarship to study in Indiana.

He said, "You are not going abroad. You're staying here at the University of the West Indies to study medicine. If you go to America, you'll do four years of liberal arts and then apply to medicine. But you are smart enough to go straight into medicine here. It's a more direct route."

There was no further discussion.

And that's exactly what I did. In 1959,1 entered a six-year program that began with basic science and led to a degree in medicine. The class numbered 29 students. We shared a campus residence with older students who became our mentors. I particularly remember a fourth-year student, Hornet Seawar from Guyana, always immaculately dressed in a white hospital coat. His behaviour was likewise exemplary. They taught not only how to dress, but to always act professionally and to never miss a call. Like the Jesuits, they taught us as much by example as bywords.

ONE OF MY SEMINAL, CAREER-FORMING experiences took place in the emergency ward at University Hospital of the West Indies in Kingston in 1968. The ER department was a busy place, seeing 40 to 60 patients a day, although most of what we saw and treated was not medically complex. One day, I was asked to see a 21-year-old man who'd been shot by police, while he was fleeing a robbery attempt. The report said he had an abscess on the back of his right leg, at the entry site of the bullet wound. My assignment was to make an incision and drain it.

Examining the leg, I noticed that it was red, hot, tender and pulsating, an indication to me that the patient had developed what is known as a popliteal aneurysm. I could hear the leakage of the artery when I put the stethoscope on it. Fortunately, I did not use a scalpel to drain the presumed abscess. Instead, I used my eyes and ears to diagnose what was really happening.

It was perhaps my first powerful object lesson in the importance of not always relying on the evidence already assembled — and using my hands, eyes and ears to make the diagnosis. Nowadays, the aneurysm would likely be detected with ultrasound scanners but, as this case indicates, such tools, while important, aren't essential if a primary care physician uses the basic human skill set of his senses.

Sometimes, the correct answers can be found just by knowing how to ask the right questions. I recall another case from those early years of residency — a young man who presented with severe abdominal pain and a history of a gastric ulcer. The general concern was that the ulcer might be perforating. After posing a set of questions, I learned that he was diabetic, but had not taken his insulin for three days. He was badly dehydrated and hyperventilating. I was pretty sure I knew what the trouble was — diabetic ketoacidosis, which, in its acute stages, can give you severe abdominal pain. Undiagnosed, dehydration sets in and blood volume declines, complicated by severe electrolyte imbalance. Untreated, it is potentially lethal. So understanding a patient's history is vitally important.

Not long after, I was to confront another case that would change my life forever. The late American physician Walsh McDermott, who edited the textbook that became the bible for many internists (Cecil Textbook of General Medicine), used to say that the best doctors were allowed to make no more than five serious mistakes in their career. I was about to make my first.

A young man of 27 arrived in the emergency department complaining of headache and a slight weakness on his right side. Our initial diagnosis, based on a lumbar puncture, was encephalitis, an inflammation likely caused by a virus infecting the lining of brain. His blood-sugar ratios seemed to support this hypothesis. The mistake I made was in not paying sufficient attention to the so-called localizing signs — in this case, his right-side weakness. That should have suggested something other than encephalitis, probably a space-occupying lesion.

I was at the end of my shift and went home for 12 hours. But the case stayed with me and, the more I thought about it, the more certain I became that something else was going on. When I returned to the hospital the next morning, I promptly ordered a carotid angiogram. It turned up evidence of a cerebral abscess. We immediately tried to drain it, but we were too late. The young man died. Had I not waited those critical 12 hours, he might have been saved. We should have done the angiogram right away.

My mistake haunted me. The condition was something I was aware of and should have detected, but Pd been misled by the test results. Had I bothered to discuss the case with colleagues, they might have reminded me to consider other possibilities. Since then, and to this day, I make it a practice to confer with other physicians, even students, on difficult cases, because you never know where a good idea might come from. It's always helpful to talk about the case. The sorrow of that unnecessary death lingered with me for months. Two weeks later, just as my shift was ending, I heard a commotion coming from the nursing station of the main ER ward. A patient, already admitted for headaches, suddenly appeared to go crazy. He'd left his hospital room, leapt on top of the nurses' station and begun to urinate. I heard people screaming, "Call the police!" I approached him carefully.

"Sam," I said, "are you still having the headaches?" "Yes, doctor, really bad headaches, like I told you before." "Well, come down and go back to your bed and I'll look after you."

So he climbed down and went back to his room. I thought the erratic behaviour might be evidence of a brain abscess on his frontal lobe — thus the lack of inhibition demonstrated on the nurses' desk. I promptly ordered a brain angiogram, which confirmed my diagnosis. We rushed him into neurosurgery to drain his abscess and managed to save his life.

Would I have made the same decision if, just two weeks earlier, I hadn't failed to consider the possibility of an abscess and had lost that patient? I'd like to think so. But there's no doubt the proximity of the two cases made me more alert to the possibility of abscess. In any event, it provided a valuable lesson for me: even when you make a mistake, you can't allow it to affect your performance. Feel regret, certainly-— but don't get too down, because you can access the experience, like an archive, in future cases, and learn from it.

I was able to do just that with two patients I treated some 40 years apart. The first was a Jamaican woman who presented with a swollen abdomen and a distended vein in her neck. Chest x-rays later provided the diagnosis: constrictive pericarditis, the calcification of the pericardium, the double-layered membrane that surrounds the heart. Her condition — very rare — was likely the legacy of a previous bout of tuberculosis, but it had persisted for so long that, by the time we saw her, nothing remedial could be done. That was 1966.

Four decades later, a colleague at Toronto's Mount Sinai Hospital asked me to examine Edna, a 29-year-old young mother of three, who was complaining of fatigue, shortness of breath and a stomach swollen with seemingly inexplicable fluid buildup (ascites). There was no peripheral edema (leg or ankle swelling); this was an important consideration because, if her legs had been swollen, it might have suggested right-sided heart failure. But there was a history of rheumatoid arthritis.

Edna had been to see both a respirologist and a cardiologist, and made several trips to the emergency ward, with no diagnosis and no relief. But almost as soon as I saw her, I knew what the problem was — constrictive pericarditis. Despite the rareness of the condition, or perhaps because of it, the telltale sign was immediately apparent. She had the same distended neck vein (known as a jugular venous distension) and ascites (an accumulation of fluid in the peritoneal cavity) that I had seen years earlier in Jamaica, but without peripheral edema. I had not seen it since.

"Don't worry," I told her. "I know what's wrong with you. We can treat you."

A cardiac MRI verified the diagnosis and indicated that the pericardium was four millimetres thick, instead of what it should have been — one millimetre. Using a relatively simple but tedious surgical procedure, the calcified "wallpaper" around the membrane was removed — pericardial stripping. Within three weeks, she was back to normal. Fortunately, she has been trouble-free since then.

I was sometimes, though not always, the top student in medical school, but I worked hard and earned respectable grades. In addition to the formal academic program, I routinely spent another 30 hours a week studying and reading journals and related material. If I only spent 20 hours at these activities, I felt guilty. My only real "downtime" was Sunday mornings, when I listened to classical music on the radio and read the newspapers.

Hard work paid off in the end, as I earned the gold medal in medicine at graduation. At the time I was close friends with Robin Sahoy, a Guyanese student who became a surgeon. He spent many long hours, as I did, trying to memorize parts of Gray's Anatomy, the classic medical text. One day, he made me a bet: that he could stay awake longer than I could. I took the bet. I was 22 years old and, as young men often do, thought I was invincible. We had a biochemistry exam scheduled for seven nights hence. I stayed up the entire time; he succumbed to sleep after six nights. I earned an A plus; Robin got an A minus.

I haven't done anything quite so foolish since then. But the experience did show me that, thereafter, being on call for 24 or 48 hours would never be a problem.

I studied under many brilliant physicians in Jamaica. One of them was Dr. Donald Gore, an upper-crust Jamaican surgeon who had worked at the Columbia University-affiliated New York Presbyterian Hospital and then returned home to practise. He had great technical skills in the operating room, as well as unerring judgment but, to the chagrin of many of us, a very short fuse as a teacher. That veneer of toughness, of course, is considered part of the makeup of surgeons generally, but in my experience, the stereotype was wrong. Most of them were gentle souls; Gore was the exception.

I worked with him for three months. On ward rounds, he would demand that we succinctly summarize a patient's case in no more than three sentences.

He'd typically say to one student, "Okay, describe the case."

"This is a 25-year-old man admitted yesterday with abdominal pain and a fever."

"Three sentences, doctor. Three sentences."

"His pain was crampy and he had vomiting."

"One sentence to go, doctor."

"His mucous membranes were pink."

"That's three. Diagnosis?"

Then, he'd cut the student off and we'd be left hanging, with no diagnosis. Then he'd do the same thing with another student doctor, and then another. No one seemed able to distill the essence of the case into three sentences.

"Sorry, guys," he'd say. "You obviously don't know the cases. We are finished teaching for this week. When I say three sentences, I mean three sentences."

The next week, it was my turn.

"Okay, Ho Ping Kong, what have got for me?"

"Sir, this is a 35-year-old man who presented with weight loss, tachycardia, a pulse rate of 140 per minutes. He has Stellwag's sign [an indication of Graves' hyperthyroidism in the eyes] and I believe be has Graves' disease. We need to operate on him after we control it."

Onerous as his challenge was, we all eventually learned to synopsize the essence of the case in three sentences.

Although technologically medicine in Jamaica often lagged behind other parts of the developed world, our clinical care was on par. That was largely owing to the presence of such giants as Dr. Eric Cruickshank, a former prisoner of war who taught us internal medicine and neurology, and Dr. Ronnie Irving, a British-trained Jamaican who may be the most astute physician I ever saw. Irving had extraordinary powers of intuition; he could diagnose you simply by sitting at your bedside.

In terms of a specialty, my first choice was nephrology. My mentor, Dr. George Alleyne, had studied the same field in Boston with a group that would ultimately make major advances in our understanding of the body's acid-based balances —William B. Schwartz and Arnold S. Relman. Alleyne invited me to spend a year doing research at his Tropical Metabolic Research Unit in Kingston, and I agreed, launching a project to examine renal' malfunction in sickle-cell anemia, an often fatal genetic blood disorder common in the West Indies.

With sickle-cell anemia, patients experience acutely painful crises —ischemia and/or infarction of the lungs, bone and other internal organs. The prevailing theory was that the pain was caused by acidosis. In healthy people, the acid would be eliminated in the urine. The hypothesis was that sickle-cell anemics carried a defect in urinary acidification, and thus had trouble excreting an acid load.

In my first experiment, we administered ammonium chloride, a recognized method of testing the kidneys' ability to deal with acid loads. Our studies confirmed the defect. I owe my Ph.D. to that research project, which was supervised by Dr. George Alleyne and ultimately published in the Lancet.

The theory, however, wasn't entirely accurate. My patients were not as acidotic as we expected. In fact, their general PH levels were significantly higher than what the medical literature suggested — largely because the hyperventilation associated with the disease and pain yielded what is known as respiratory alkalosis. Our second paper, recording these additional observations, thus changed basic views of physiology: acidosis was not always the cause of painful crises for sickle-cell patients.

But I was not destined to become a bench researcher. What I really wanted to be was a clinician and a teacher.

In 1970, to continue my studies in nephrology, I went to Britain on a Commonwealth Scholarship. Dialysis, as a medical treatment, was still in its infancy, but we had been the first to deploy peritoneal dialysis for leptospirosis, a bacterial infection that causes kidney dysfunction and can be fatal. After a few months in London at St. Thomas Hospital, I planned to join the new dialysis unit at the Royal Infirmary of Edinburgh to complete my training in internal medicine and nephrology; after nine months, I would become a specialist in nephrology.

It was not to be. Not long before I was scheduled to leave London, a colleague in Edinburgh called to report that, in a matter of a few weeks, four staff members — doctors and nurses — attached to the dialysis unit had died from acute liver failure. Fulminant hepatitis, a lethal swelling of the liver, was suspected, although, at the time, we did not clearly understand that hepatitis manifests itself in different forms, A, B and C. We now know that this outbreak was caused by hepatitis B.

I was immediately told that, unless I had no previous exposure to hepatitis, I would not be allowed to join the group. As it happened, I'd had such exposure. When I was 16, I'd attended a summer camp in Jamaica, which used septic toilets. I became jaundiced — I could not swallow my saliva, it was so nausea-inducing — and was soon diagnosed with hepatitis. The sight, taste, even the thought of food made me want to vomit. There was no treatment, but the presiding physician assured me I would not die. I had contracted hepatitis — as we later discovered, the milder A version.

My history with the disease would have prevented me from gaining entry to the unit, although I likely would have made the same decision on my own. I would be in England with my wife, our three children and my mother-in-law and would not have wanted to expose them to whatever germs I might have picked up in the Royal Infirmary of Edinburgh.

I was naturally disappointed but, having been trained as a general internist, I was able to shift course and join Edinburgh's Western General Hospital to hone my skills in general medicine. I was, by this time, more than a little cocky about my talents — in fact, too cocky. I'd been a top student, had published research in the best medical journals and earned my Ph.D. in physiology. But I was about to earn my comeuppance.

To earn my MRCP — a diploma of Membership of the Royal Colleges of Physicians of the United Kingdom — I had to pass two exams. Two weeks after arriving in London I breezed through the multiple-choice segment without any problem. Moving from London to Edinburgh I encountered Dr. Batty, my stately, imperious Scottish examiner for two case studies involving live patients.

"Dr. Ho, where are you from?" he began.

"Kingston, Jamaica, sir."

"Ah ... A great place ... And how long have you been here, Dr. Ho"

"Two weeks, sir, in Edinburgh."

"Hmmm," he said. "Not long enough."

We were not off to an auspicious start. The patient presented to me was a 50-year-old woman. I began by examining her spleen and found it massively enlarged — I'd seen about 50 similar cases in Jamaica — and was, as usual, confident about my diagnosis.

After no more than 15 seconds, I said, "Sir, this woman has a massive splenomegaly [a very big spleen]. There are only four things that could cause it. In Africa or Malaysia, it could be kala azar or malaria. But in Scotland, it's either going to be myelofibrosis or chronic myeloid leukemia."

Dr. Batty turned to me. "I did note that you had not been here long enough."

I said, "Sir, if you show me the patient's blood slide, I will confirm the diagnosis."

So he passed me the slide and the problem was indeed transparent. "Sir, the slide clearly shows a leuko erythroblastic picture [a combination of abnormal red and white blood cells]. This patient has myelofibrosis." It had taken me 30 seconds.

He said, "Doctor, you have not been here long enough."

As a result, he failed me — the first and last time I failed an exam in my life. I was devastated and deeply despondent.

My wife and our three children and I lived in an apartment overlooking Edinburgh's Holyrood Park, within sight of the city's famous Holyrood Palace. We often went for walks on its grounds. The park called itself home to 1,000 sheep, only one of which was black. After failing the exam, I spent a lot of time looking for that black sheep, which obviously I identified with myself.

Was it racism? I really don't know. Perhaps Dr. Batty genuinely believed that one had to be immersed in British culture and medicine for at least a year before earning the MRCP designation.

The next day I was summoned to an audience with Dr. John Macleod, chairman of the department of medicine at Western General Hospital and editor of a definitive textbook used at the time, Davidson's Principles and Practice of Medicine.

He asked me to sit down and said, "On behalf of the Royal College of Physicians, I need to apologize to you, Dr. Ho. You did not really fail the exam. Unfortunately, the mark has been formally entered and we cannot undo it. What we can do, however, is remove Dr. Batty from the examining board, and that has already been done. Moreover, for the duration of your stay here, we'd like to offer you a position as a paid tutor, at a salary of six pounds per week." In 1970 terms, that was a small fortune.

I accepted the position and his comments with gratitude, and my wife promptly went out and bought a set of Royal Doulton china, which we still have 43 years later.

But I still felt badly about what had happened. That failure would change my life, for the better. It made me less egotistical, a little less assured of my opinions. I had modelled my behaviour on brilliant but very no-nonsense physicians I'd known in Jamaica, such as Drs. Cruickshank and Irving. After this, I softened a bit and became a little more tolerant, I'd like to think, of people who failed. Thus, I hope, did many others ultimately benefit from my unfortunate exam experience.

I had my first opportunities to do that almost as soon as I returned to Jamaica, in the fall of 1971. As a newly minted lecturer in medicine, I introduced the country's first coronary care unit (a grand total of two beds); the local Chinese Benevolent Society put up $10,000 for our first machines. I also trained young doctors planning to do medical fellowships in the U.K. on how to prepare for their exams. At least, they would not have to deal with the likes of Dr. Batty.

One day, just before dinner, I received an urgent call at home. A 19-year-old woman — the fiancee of one of my interns — was recovering from surgery for appendicitis, when her heart rate suddenly began to spike to 200 beats per minute, a potentially life-threatening situation. Even with infections, heart rates are seldom faster than 120 to 160 beats per minute. I rushed to the hospital.

Her temperature, when I arrived, was about 105 degrees Fahrenheit. There was no evidence of septicemia, though I doubted whether that condition would induce such a massively elevated heart rate. I did think briefly about malignant hyperthermia, the result of exposure to certain anesthetic drugs.

However, on examination, I observed and felt a swelling in her neck, and listening (with the stethoscope) detected a bruit over the thyroid. I immediately concluded that this was a thyroid storm, an episode of acute hyperthyroidism that, untreated, would certainly take her life. We promptly injected beta blockers to reduce the heart rate and used ice and fans to bring her temperature down, and rehydrate her. It took 12 hours, but she was eventually stabilized and her life was saved.

Some 40 years later, an old Jamaican friend of mine was visiting Greece when, by coincidence, he met this woman and her husband; they had married and subsequently relocated to the United States. I was delighted to learn that after that very close call, she had enjoyed a long and productive life.

My work in Jamaica was challenging and fulfilling, but at that time the country was undergoing social and political turmoil, precipitated by its socialist leaning and Fidel Castro-admiring prime minister, Michael Manley. I had no objection in principle to the notion of income redistribution that his ruling party championed; the growing problem was that its ideology was accompanied by a campaign of social stigmatization and violence directed at anyone deemed to be part of an economic or intellectual elite. Manley's policies were effectively polarizing the nation.

Years earlier, the venom had been aimed at Jamaica's Hakka Chinese community, which maintained a virtual monopoly on retail trade, owning the vast majority of dry goods shops and supermarkets. A series of riots broke out in 1965, during which eight people died and several Chinese-owned stores were burned to the ground, including, on the evening before my final medical exam, my father's. It was a traumatic experience. He never worked again.

Now, half a decade later, members of the university staff were becoming the targets of renewed violence. The other doctors and I needed police escorts to reach the hospital safely.

One day, I attended an academic lecture that was to be delivered by a prominent visiting professor from Glasgow. We were comfortably seated in the auditorium when a group of protesters burst into the room and declared, "We've come to get the white man," referring to one of my fellow lecturers. The chairman managed to stare them down, but the event crystallized my thinking and ultimately my resolve.

I went home, shed my tears and decided to emigrate. My wife, Barbara, fully supported the decision. "I can't continue to work like this," I told my supervisor.

Thus, in 1972, with a heavy heart, I actively began to explore professional opportunities abroad.

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