Academic Exchange Quarterly Fall 2006 ISSN 1096-1453 Volume 10, Issue 3
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Service-Learning in healthcare education
Kevin R. Kearney, of Pharmacy and Health Sciences
Kevin R. Kearney, Ph.D., is Associate Professor of Biochemistry and Director of Service-Learning
Competing demands present a challenge for anyone wanting to include a Service-Learning (SL) course in any professional degree curriculum, particularly in healthcare education.The case for including SL requires an analysis and presentation of what it specifically can and does accomplish and how well, with respect to curricular demands.This paper describes a required SL course in a healthcare curriculum (specifically, pharmacy education), and assesses its success. Its outcomes support the presentation of this course as an exemplary model for SL in healthcare education.
In most degree programs, curricular time is at a premium; this is especially true in professional degree programs, where students must master large bodies of knowledge critical for the profession.In such circumstances, the inclusion of yet another course in the curriculum, and especially a non-traditional course, such as a Service-Learning (SL) course, requires compelling justification by the proponents.It must be shown that the course will effectively accomplish learning objectives that are essential to the education of future professionals, and that it is unique in its ability to do so.
If the above is true of professional degree programs in general, it is particularly true in the education of health care professionals.This is so because such professionals must master a broad range of material, from the social sciences, to law and ethics, to medical sciences, etc.In many of these areas, there is a rapidly expanding knowledge-base that the students must master, which creates growing demands in the curriculum.
Given these circumstances, can one make a compelling case for the incorporation of SL in such academic programs?In this paper, the argument will be made that SL-based courses do indeed make unique and important contributions to the achievement of essential objectives in the education of health care professionals.One course that may be viewed as an exemplary model for Service-Learning in healthcare education will be described: it incorporates some of the best practices in SL, it has been highly rated by students in institutional course evaluations, and various assessment tools have indicated positive learning outcomes from the course.
Service-Learning and Other Types of Experiential Education in Healthcare Education
In the present paper, the reference-point is the education of pharmacists; but what is said here applies equally to the education of most other health care professionals (physicians, nurses, dentists, respiratory therapists, etc.).The education of health care professionals has long included a significant experiential component.In the case of pharmacy education, this experiential education typically involves students working, without pay, in a hospital or retail pharmacy under the supervision and guidance of a preceptor, who is both a health care professional and an educator.Educators and practitioners alike generally agree that this experiential education is clearly justified and essential.
Service-Learning, as understood in the present paper and as generally understood by most practitioners, is different from the traditional experiential or clinical education described in the preceding paragraph.As such, it has goals and objectives distinct from the latter, and must be justified on a different basis in order to earn a place in the healthcare education curriculum.As summarized in the following two paragraphs, Connors and Seifer (1997) have differentiated SL from other types of experiential learning in the education of health care professionals, and have explained the unique educational role that SL can play.
In clinical training, students apply the theories and skills they have learned in the classroom to the care of patients.The students are generally viewed as experts in theory, who are aiming to become experts in practice.This contrasts with Service-Learning, where the students are viewed, and view themselves, more as contributor-learners.As such, they and the people and communities they serve are more reciprocal partners than simply helpers and recipients of assistance, respectively.
In internships, the emphasis is on student learning.Obviously, all parties involved assume that patients will benefit from the activities of the intern; but this may be secondary to the student's learning.Service-Learning, on the other hand, gives more equal weighting to service and learning.Though the students are not paid, their work must meet real community needs, while at the same time providing them opportunities for learning.This highlights the reciprocity of Service-Learning.
No one involved in the education of health care professionals would argue for removing clinical training or internships from the curriculum, because they meet essential educational goals.However, SL has the potential for meeting other critically important needs.
Pharmacy Education and the Evolving Role of Pharmacists
The current vision of the pharmacy profession is much broader than the dispensing of medications.(Similar statements could be made about other healthcare professions.For example, physicians view their role as broader than simply prescribing medicines to cure illnesses.)Practitioners today are more likely to speak of their role as the provision of pharmaceutical care.This includes a wide range of responsibilities, from working with other healthcare professionals to design optimal therapies to monitoring and improving health outcomes.Finally, many pharmacists highlight the importance of community pharmacy.This terminology is meant to emphasize that, in order to ensure optimal health outcomes, healthcare professionals need to be involved in the communities they serve, so that they better understand their patients, not just as consumers of medicines, but as whole persons.This is where Service-Learning can make an important and unique contribution to the education of pharmacists, and similarly, to that of all healthcare professionals.
A Model SL Course for Healthcare Education
A course will now be presented as a model for SL in healthcare education.The course, offered at the , and , campuses of the or Pharmacy and Health Sciences (MCPHS), incorporates a variety of elements that tie together community involvement and reflective learning.This required course employs SL to achieve educational outcomes in a variety of areas important for students in the early stage of their professional education.
The students taking this course are in their first year of a program leading to the Doctor of Pharmacy degree, the degree now required for anyone entering the pharmacy profession.Students entering the program must have completed prerequisite general education and basic science courses, but need not have received a baccalaureate degree.
The course is offered each fall, has been being taught six times, and has evolved considerably since it was first offered.In the Fall of 2005, there were just under 200 students enrolled in the course, in five sections, on the two campuses.
For the service portion of the course, students are required to perform two hours per week of community service work for 10-12 weeks.For this service work, students are assigned to one of approximately 30 partner-organizations, based on their interests and the organizations’ needs.The types of organizations where students do their SL work include: schools and youth-service organizations (tutoring and mentoring), nursing homes and a senior center, free medical clinics, and shelters and outreach organizations.
Students are required to keep journals in which they make weekly entries.Beyond simply recording what they observe and do, they are instructed to reflect on what they can learn from their experiences.
Students meet for a one-hour seminar each week.For some seminars, readings are assigned as the basis of discussion of topics, and students are required to write short reflective essays about some topics.In the seminars, students discuss the readings and/or other topics.Seminar topics for the first half of the semester are: reflection as the key to learning, service agencies in the local community (two sessions, featuring speakers from those agencies), communication skills, assessment of service, critical thinking and public debate, and cultural diversity and healthcare.
Two of the assigned readings focus on reflection and assessment.Connors and Seifer (1997) discuss the importance of reflection for optimal outcomes from service-learning.Indritz and Hadsall (1999) identified five criteria that one could use to assess the quality of service in pharmacies, and the course highlights how these same criteria can be used to assess service-learning outcomes.
The final seminar of the first half of the course addresses the topic of cultural diversity.Practitioners and educators are increasingly recognizing the importance of multi-cultural competence for healthcare professionals (Galanti, 2005; Jones, Royeen & Crabtree, 2003; Zweber, 2002), and this seminar addresses this critical area.For the seminar, drawing on their own cultural backgrounds (more than 50% of the students represent ethnic minorities) and experiences, and the papers cited above, students write essays and give brief presentations about their own cultures, or cultures with which they may be particularly familiar.The value of drawing on students’ diverse cultural backgrounds to educate fellow students was recently described (Bodenhorn, Jackson & Farrell, 2005).For this seminar, students also draw on their current SL work experiences, often with very diverse populations.
During the second half of the semester, the students become the teachers in the course. Each week, a group of students, usually doing similar types of work (e.g., working with senior citizens, or tutoring in schools), gives a presentation about their work.Presentations are required to cover two major areas: the service the presenters are providing (goals and progress to date) and what they are learning from doing the service and reflecting on it (goals and progress).The students are also required to briefly describe some part of their experience (e.g., a memorable incident) that will communicate to the class something about the uniqueness of their work.Students are encouraged to be creative in their presentations, and, in addition to an oral presentation, often show photographs or a short videotape, play audiotapes, use PowerPoint, or perform a short skit.
Assessment of the Course
How successful has this SL course been?One can address this question in several ways.The following paragraphs describe how the present course has been evaluated.
Course Evaluations and Surveys
On institutional course evaluations, students evaluate courses and instructors based on various criteria, and are invited to offer any comments.Over the past five years, students’ average ratings of this course have been 4.5-4.7 on a scale of 1-5 (1 being least favorable, and 5 most favorable), making it one of the most highly-rated courses in the department in which it is offered.Comments have been quite positive.
Surveys have been administered to students at the beginning and end of this course for several years.The surveys, students’ responses to them, and analyses of the results have been described by (2004b).
Learning Goals and Students’ Comments
Beyond numerical ratings, students’ comments provide more information about what they learn from the course.Comments were submitted anonymously.Following are some of the key areas of learning that the course addresses, as supported by students’ comments:
1. A healthcare professional needs to provide care to a wide diversity of people, and for optimal care there should be a good rapport between the patient and the provider.The ability to establish such a rapport, or “comfort level,” cannot be taught in a classroom, but is one of the outcomes of SL experiences.
2. The distribution of medications is certainly one of the central responsibilities of pharmacists, but if positive health outcomes (maintenance and improvement of health) are the ultimate goal of pharmaceutical care, pharmacists need to keep this broader goal in mind.SL experiences can help them develop the habit of thinking broadly in this way.
3. If health professionals are to provide optimal care, they must understand not only drug therapy, but also their patients.This requires capacities such as patience and empathy, and the ability to listen.Such abilities are best fostered and learned not in a classroom, but through experiences and practice, such as are gained through SL.
4. Understanding diverse cultures is a critical ability for healthcare providers today.Classroom discussion of this topic, coupled with experiences in their SL work, contributes to the development of students’ cultural competence.Several students indicated that they had appreciated and learned from the discussion of cultural diversity in the classroom, as well as learning from their SL work experiences.
5. Finally, one of the key educational advantages of SL is that it brings students into regular contact with “real life,” and often a side of life which is less “rosy” than what most of us experience regularly; and that it asks students to reflect, think, and learn about how to improve the situations they encounter.Ordinarily, in the classroom, teachers try to organize material in such a way that students can learn it well.However, unlike this, life is often ‘messy’ and unorganized.SL has the ability to help students learn experientially from such real-life encounters, and so can better prepare them for these realities when they enter their profession.
The spontaneous and anonymous (and therefore presumably honest) comments of the students point to some of the probable learning outcomes of this course.They are, of course, somewhat subjective, but the students’ ability to articulate what they have learned, without any specific prompting, suggests that the course has succeeded in terms of leading students to the desired learning outcomes.
Institutional Evaluation and Support
Another way to evaluate success is to consider what the educational institution does to support Service-Learning.MCPHS allocates part of the work-time of two professionals to overseeing and teaching the Service-Learning program at its and campuses.In 2005 the College unveiled a new three-year strategic plan which explicitly noted the importance of community outreach and Service-Learning programs as part of its mission (Massachusetts College of Pharmacy and Health Sciences, 2005).These are indicators of the institution’s support for Service-Learning.
Support for the program also comes from outside the institution.The Accreditation Council for Pharmacy Education has accredited the MCPHS-Worcester curriculum with the understanding that the Service-Learning course meets part of the Council’s requirement for Experiential Education for pharmacy students.Locally, community partners from the organizations where students do their SL work have offered overwhelmingly positive feedback about the program.Several of them have invited the Director of Service-Learning to serve on their advisory boards, strengthening the ties between these organizations and the College.These community links affirm the value of the SL program in the eyes of the local community.
In order to justify its inclusion in the healthcare education curriculum, SL must contribute to the achievement of educational objectives that are essential for healthcare professionals.These outcomes include goals that lead to the education of community-focused healthcare professionals, an emphasis which is increasingly understood to be critical in healthcare education.
The value of SL in the education of healthcare professionals is recognized by many, and is supported by various organizations, such as Community-Campus Partnerships for Health.Within pharmacy education, many educators value and practice SL, and the American Journal of Pharmaceutical Education recently dedicated a special issue to this topic (, 2005a).
One way to assess the value of Service-Learning is to consider it with reference to generally accepted educational outcomes.The American Association of Colleges of Pharmacy specifies the expected outcomes for the education of pharmacists, and many of these could be applied broadly to the education of a wide range of healthcare professionals (Center for the Advancement of Pharmaceutical Education [CAPE], 1998). The SL course described above contributes to the achievement of many of these outcomes, especially the following:
The outcomes speak of the ability to exhibit “empathy and a caring attitude,” abilities developed in the SL course.They highlight the importance of critical thinking, being open to new ideas and avoiding ethno-centricity; all these, as noted above, are addressed in the course.
One of the outcomes reads, “Demonstrate the ability to place health care and professional issues within appropriate [contextual] frameworks, and demonstrate sensitivity and tolerance within a culturally diverse society.” The SL experiences of students in this course bring them face-to-face with many of these contextual issues – especially the cultural, social and political frameworks – and the seminar addresses the issue of cultural diversity.
Another outcome reads, “Demonstrate an appreciation of the obligation to participate in efforts to help individuals and to improve society and the health care system.” This course is based on the premise that it is important for healthcare students and professionals to help individuals, and aims to reinforce the conviction that professionals have the ability and responsibility to improve the society in which they live and work.
By examining this course in reference to these educational outcomes established by the pharmacy profession, this paper has demonstrated how this course successfully contributes to the achievement of these outcomes. This validates SL as a pedagogy within healthcare education.Even though these comments are somewhat subjective, the students’ ability to articulate specific learning outcomes, unprompted and without the prospect of receiving any reward for what they might say, suggests that the reported outcomes are real.
Beyond the achievement of educational outcomes by students, the support of the educational institution that offers this course is a mark of success.As noted above, the college supports SL by the allocation of personnel, and by including SL in its strategic goals.
Finally, the comments and actions of community partners indicate their positive assessment of the SL program.They are pleased to have students contributing to their organizations, and they have shown an interest in collaborating with college personnel in various ways, not just through the SL course.
Bodenhorn, N., , A.D. and Farrell, R. (2005). Increasing personal cultural awareness through discussions with international students. International Journal of Teaching and Learning in Higher Education 17, 63-68
Connors, K. & Seifer, S. (1997). Service-Learning in health professions education: What is Service-Learning, and why now?In A Guide for Developing Community-Responsive Models in Health Professions Education (pp. 11-17).: Community-Campus Partnerships for Health, for the Health Professions
Center for the Advancement of Pharmaceutical Education () of the American Association of Colleges of Pharmacy (1998). Educational Outcomes. Retrieved October 28, 2005, from http://www.aacp.org/Docs/MainNavigation/ForDeans/5763_CAPEoutcomes.pdf
Galanti, G.-A. (2005). Cultural Diversity in Healthcare. Retrieved October 28, 2005 from http://ggalanti.com/
Indritz, M.E.S., & Hadsall, R.S. (1999) An active learning approach to teaching service at one college of pharmacy. American Journal of Pharmaceutical Education, 63, 126-131
Jones, R.M., Royeen, M., & Crabtree, J.L. (2003). Cultural considerations in patient assessment. In Jones, R.M., & Rospond, R.M., Patient Assessment in Pharmacy Practice (pp. 9-20). : Lippincott Williams & Wilkins
, K.R. (2004a). Service-Learning in pharmacy education. In American Journal of Pharmaceutical Education, 68 (1). Retrieved October 28, 2005, from http://www.ajpe.org/view.asp?art=aj680126&pdf=yes
, K.R. (2004b). . In American Journal of Pharmaceutical Education, 68 (1). Retrieved October 28, 2005, from http://www.ajpe.org/view.asp?art=aj680129&pdf=yes
of Pharmacy and Health Sciences (2005).A strategic plan for the college.Retrieved November 4, 2005, from http://intranet.mcphs.edu/planning/docs/StratFINAL.pdf
Zweber, A. (2002) Cultural competence in pharmacy practice, American Journal of Pharmaceutical Education 66, 172-176
Meanjin, Vol. 61, No. 2 (2002)
‘Where’s the present tense / now that we need it?’
I am sitting in the kitchen reading John Forbes’ Collected Poems while my sons fire cap guns across the table at each other and run shouting down the hall. The battle is for possession of the best weapon. The youngest learned long ago to hold out, yelling at the top of his lungs until we can take it no longer. ‘Give it to him,’ someone barks, ‘or you’ll never see that gun again!’ John, himself the eldest of four boys, would have enjoyed this, I imagine.
Among the many regrets I have in the wake of John’s premature death in 1998—sorry that I didn’t invite him to dinner more often, sorry that he’ll never wander into my office again, sorry that he didn’t get to reap the rewards of celebrity while he could still enjoy them—is a feeling that it’s too bad he never had a family. I know that in many respects this is a ridiculous notion. John was like the anti-father: he hated steady work, he never had any money, he was a drug addict, he gambled, he drank, he disdained compromise. Reading back over his poems and the reminiscences of his friends, collected in Homage to John Forbes (edited by Ken Bolton, Brandl & Schlesinger, 2002), I am struck again by his wit, his charm, his brilliance, of course, but also by the steadfastness of his march down the path of self-destruction. Sometimes I think it was the artist’s vocation—what Bolton calls, only partly mockingly, ‘the principled romance of leading the poetic life’—that did him in. Sometimes I think it was just his habits.
John was as warm and kind and generous a person as ever lived. He was patient, loyal and fundamentally honest. He had, in many ways, the only qualities that count in a father, perhaps in a human, and I think he knew this about himself, the way he knew, despite the lack of public recognition, that he was a major poet. But somehow this part of his life—that is, his life as opposed to his writing—remained unsatisfactory, full of absences, longings and regrets. One of my most vivid memories of him is the night he came to St Vincent’s Hospital shortly after I’d given birth to my second son. There were complications after the delivery and I’d been given a jolt of pitocin, which is like starting labour all over again, and some heavy-duty drugs to kill the pain. John had brought me a book, In the Garden of Good and Evil, but he had to leave it at the nurses’ station because I didn’t want to see him. It was just too soon. I’ve always felt a certain regret about turning him away, but also a niggling curiosity as to why he came. I once went the same way, too precipitately, to see someone who’d had a baby. It was someone I didn’t even know very well and I now recognise the impulse for what it was: a desire, almost a compulsion, to get near the event.
This was before I had any children of my own, and it had something to do with curiosity but more with a weird kind of magnetism that is difficult to explain. Perhaps I make more of this than I ought. And yet, there is an interesting exchange in an interview John recorded with Cath Keneally in 1991. In it Cath talks about poets, especially male poets, being what she calls ‘nebulously personal,’ by which I take her to mean something like incidentally revealing. ‘There was a poem that you read the other night,’ she says, ‘that I don’t remember much about except it said … it was partly about “No babies.”’ John laughs and explains that the poem, ‘Chapel Street,’ was written shortly after he moved to Melbourne and that it describes a mood of mixed elation and misery. The poem begins with a series of images from the street—‘raunchy rock’n’roll hits’ (a sign in a window), ‘a suave Asian half-seen through / Plate-glass’, a stack of six ‘cutprice colour TVs,’ and then it shifts from outside to in:
Today’s the day to be a bulbous public twit & think
‘Who me?’ then twice walk past the pharmacy, distracted
By my lack of happiness in living colour & 3D.
It happens but & even that Bob Marley song
‘No Woman No Cry’ could be wrong. ‘No Baby No Cry’ should
Play on cue but you want that crying in the night
That first you curse & later, it’s all right. Not me yet.
It’s very close to if not actually sentimental, and John goes on to say in the interview that the words ‘Not me yet’ are ‘meant to sound Poor, poor pitiful me.’ But a student in his writing class at the time had a completely different interpretation. She thought ‘it was more like (with snappy bravado): Not me yet. Wouldn’t catch me in that racket—No! No way.’
JF: So it could read as a sort of They haven’t managed to nail me down yet! Though it’s interesting: the person who made that remark was an elderly lady, who would probably construct something like that in those terms of, you know, dodging …
CK: That’s right—‘feckless young man’.
JF: Well, feckless middle-aged man. Whereas that’s not the case at all.
At some pains to deflect this image of himself as the ultimate bachelor, John nevertheless seems taken with the idea of the poem’s ambiguity. In a way that he probably realized, the elderly lady had nailed him, no matter what he might say.
There is little doubt that the absence of connections—no partner, no children, no home—left John feeling bereft and lonely a lot of the time. But it was also something he obviously chose: no irons, no chains, no shackles. The last few lines of ‘Chapel Street’ are instructive. Immediately after ‘Not me yet’ the poem soars away from the shabby realities of Prahran, away from the pharmacy and the codeine habit and the vexed question of happiness or its lack, making, as its penultimate gesture, one quick ironic swoop—a sort of poetic signature:
Some search the sky for signs & portents (forgetting
Each person with a Porsche is certain of a portion)
But I can see them in the shape of clouds, backlit
Brilliantly & racing towards neither Melbourne nor me
Yet purely 19th century, coming from behind Geelong.
One could hardly imagine a more spirited defense of a life led purely in the service of poetry, or a more resounding dismissal of one’s day-to-day tribulations. ‘It’s important to be major,’ he writes in ‘Lessons for Young Poets’, ‘but not to be too cute about it—I mean it’s the empty future you want to impress, not just the people who’ll always be richer & less talented than you.’
Much has been made, and rightly, of John’s artistic integrity, his dedication to his craft, his cool and penetrating critical analysis, his sometimes harsh assessments of other people’s work. There is a sense in all this of a vocation, a calling, not unlike the priesthood, which cannot be combined with other modes of life. Of course, John would never willingly have subscribed to this overtly romantic notion—‘I don’t think I ever felt le sang des poètes in the full sense of “the blood of the poet courses in the veins,”’ he says to Cath Keneally—but he lived according to its strictures nevertheless. In his essay ‘The Working Life’ he writes, for instance, about his many jobs, all but one or two of them blue-collar: storeman, removalist, factory hand. Of a brief stint in the Public Service he writes, ‘[I] hated it … You needed to use just enough of your brain to make the work distracting without there being any compensatory interest.’ It is a description of a particular job (checking doctors’ repat. claims), but could stand for almost any white-collar, entry-level position—that’s what white-collar means: you use your brains, not your muscles. But John preferred to reserve his brains for the one true work of writing poetry. Only late in his life, when his body betrayed him, would he countenance the idea of making money with his mind.
There was a similar sort of intransigence in his relationships with women. He complained constantly about his love life, but women were always drawn to him despite a certain gaucherie in his manner. I remember arriving at the Meanjin office one morning and meeting him at the gate.
‘You look—’ he said, studying me closely with a concerned expression.
‘Haggard,’ I replied, with mild sarcasm.
‘Yeah, that’s it!’
‘Thanks, John,’ I said. ‘Thanks a lot.’
‘As I remember it,’ writes Bolton, ‘girls were irritated and miffed with John when he was in his twenties—or hugely impressed. In his forties I know that the women I knew all felt very tenderly towards [him].’ Recalling John’s last visit to England, Tracy Ryan writes: ‘There were the usual unattainable women in Cambridge, some of whom became firm or fleeting friends, often through the medium of his heartfelt outpourings—one said to me she began to feel like his mother.’ This, of course, was not what he wanted. As he wrote to Laurie Duggan from Darwin in 1988, ‘If I meet another girl who likes me for my mind I think I’ll have a lobotomy.’ But he did not, in fact, ever suffer a shortage of female attention—it’s just that it wasn’t exactly the right kind of attention or didn’t come from exactly the right girl. In the eighties, when I first met him, John talked endlessly to me about another woman, who, it seemed to me, was the one he really missed. I urged him to make it up with her. No, he said, it would never work. What I didn’t know then was that this was his MO: he only ever wanted what he couldn’t have. The distance was integral to the desire, or, as Peter Porter once said of his political sympathies, ‘A lost cause with an inflexible dogma always appealed to John.’
John could, if he wished, have had most of the things he complained about not having. Money, for instance, or a girlfriend. One has to assume, I think, that there was something in it for him in not having what he said he desired. Certainly, artistically speaking, self-pity proved the perfect foil for his withering irony, humanizing what might otherwise have been a tiringly ‘I’m-cleverer-than-you’ take on the world. And I think he was really ambivalent about all those other responsibilities. He had the focus, the concentration, the commitment, the narcissism actually, that are necessary for a certain level of artistic success. Or, at least, that was how it seemed. But there was something else that kept him in trouble, kept him broke and probably alone, something he tellingly kept quiet about while he was pining for some postgraduate or carrying on about the rent.
Even people who were not on intimate terms with John knew that he had a history of using drugs. It was not something he denied or lied about, but he kept it out of view. For his friends it was just part of the picture, just another one of his eccentricities, like dropping his paycheck at the TAB. John was ‘from an early date’, writes Laurie Duggan, ‘a notorious user of pharmacological substances, yet there is in his work no romantic blurring of drugs with art … Poetry required full attention; drugs and alcohol were for those other, less satisfactory parts of life, those gaps when nothing else was happening.’ As a description of John’s hierarchy of values this seems perfectly accurate: drugs were (at least at first) recreational, poetry was serious stuff. But as a description of the role that drugs actually played in his life, I think it falls short.
There was widespread shock in the literary community when John dropped dead of a heart attack at forty-seven. It was partly that he had been so strong. A powerfully built six foot-something, he withstood a remarkable level of abuse for a remarkable length of time. Indeed, I think it would be fair to say that what John did to himself would have killed most other people much faster. One should not discount the element of bravado—John’s own Kokoda Trail—but increasingly I see this issue in terms of a mass delusion, encouraged by John and accepted by his friends, that he could shrug off the effects of addiction the way he shrugged off debt. At some point along the way, however, the tail began to wag the dog.
Ken Bolton’s description of John’s last visit to Adelaide is chilling. He was showing the signs of serious liver damage and was ‘I think, afraid, and also disgusted and embarrassed or embittered as this was self-inflicted and seemed an injustice.’ Laurie had warned a year before that John was destroying himself, and he was not alone in seeing the writing on the wall. Peter Porter writes of John’s last visit to England that ‘it was plain that he was declining physically. His intellect appeared undamaged but he gave off a sense of emergency, of things closing in.’ To anyone who knew him in those last years his appearance was frequently alarming, and yet he seemed incapable of doing anything to help himself. On the contrary, he seemed almost to have decided that the matter was out of his hands, and because this was his shtick anyway, it was difficult to see the difference between the pretense of impotence and the real thing. But while his vocation periodically made him unhappy, it was the drugs that got him in the end. He died much younger than he should have, and that is what I regret most of all.