Dr James Rankin, a man ahead of his time

Photo from https://www.svha.org.au/news/latest/a-tribute-to-dr-jim-rankin: Drs Jim Rankin (left) and Barry Firkin in the early 1960s. (https://www.svha.org.au/news/latest/a-tribute-to-dr-jim-rankin). James Gerald D'Arcy Rankin, MBBS DMedSci (Hon)/Doctor of Medical Science, (honoris causa), University of Sydney Emeritus Professor of Public Health Sciences, University of Toronto. This obituary has been developed by people whose own careers were directly and indirectly influenced by Jim Rankin's contribution to the alcohol and other drugs field. It sets the scene of Jim's early work in the area during which he formed his lifelong commitment to this, and graduates and summarises his various contributions over the long 60+ years of his work. Dr James (Jim) Rankin, a major leader in developing more effective prevention and treatment services for people with alcohol and other drug problems, died late in 2023 after a long and extraordinarily influential career. Jim grew up in Sydney, graduating from medicine at The University of Sydney in 1954, and after training at St Vincent's and The Royal Prince Alfred Hospitals he worked as a physician at St Vincent's Hospital, Sydney. Here he met Pat, then training to be a nurse and they married in 1957, beginning a 66-year partnership that included creating a family of 6 children, 15 grandchildren and 2 great granddaughters. Jim died only a few months after his wife Pat's death. This family aspect of Jim's life was as vital to him as his professional career. In 1961, Jim took up a fellowship at Columbia University in New York for 2 years, pursuing research and clinical work on hepatic physiology and disease. On his return to Sydney, not finding a suitable clinical academic position for a gastroenterologist, he was encouraged by the Sisters of Charity to go to their sister hospital in Melbourne. There, Professor Carl de Gruchy, as Head of the Department of Medicine of the University of Melbourne at St Vincent's Hospital, was seeking a suitably qualified physician who might join with him to develop a response to alcohol-associated problems. Jim Rankin had just the right mix of qualities—both professionally and personally—and was appointed as Second Assistant in that Department at St Vincent's Hospital, Melbourne in 1964, concurrently becoming Honorary Assistant Physician to Outpatients. Rankin reflected that the alcohol field was an unpopular area medically and professionally at that time [1]. However, his interest in broad social and political perspectives together with his medical specialist experience and desire to pursue research made him an ideal manager to develop this, the first clinic for people with alcohol related problems within a large, public, general hospital in Australia.1 The Alcoholism Clinic opened at St Vincent's in inner city Fitzroy2 in 1964 [2]. It was a groundbreaking initiative, involving medical and psycho-social assessment and support services with embedded research, and designed to include both outpatient and inpatient (through consultation) services.3 Dr Kerry Breen, one of the first medical registrars who worked with Jim Rankin in the early days of this clinic, devoted a chapter to the evolution of this Alcoholism Clinic's growth in his de Gruchy biography [3], pointing out: ‘This alcohol service had not arisen in a vacuum. Health problems caused by misuse of alcohol had gained some attention in the Australian medical literature in the 1950s. In 1952, Dr Eric Saint and colleagues had published a series of papers entitled “Studies on chronic alcoholism” in The Medical Journal of Australia4’. Other medical specialists in Melbourne had identified alcohol use in the aetiology of medical problems. Breen notes ‘Dr John Cade (Snr.), psychiatrist superintendent at Royal Park Psychiatric Hospital (had noted in [4]) that some 35%–40% of the inpatients at his hospital were there as a consequence of alcohol misuse’. However, as Cade commented, ‘community effort directed to the prevention and treatment of alcoholism [had] been negligible’. In 1959, Dr Ian Mackay, working in the clinical research unit of the Walter and Eliza Hall Institute and the Royal Melbourne Hospital, had estimated the prevalence of alcoholism in Australia based on deaths from cirrhosis of the liver [5]. Police and corrections services also identified alcohol as a significant contributor to social disruption and crime. Alcohol-related offences were common among the inmates of Melbourne's Pentridge Prison; some with relatively short sentences under the Vagrancy Act, convicted of the informally titled offences of ‘drunk and disorderly’ and ‘with no lawful means of support’.5 At the time Rankin was developing the Alcoholism Clinic, services for homeless men (later, also women) were evolving including St Vincent de Paul Society's Ozanam House from the 1950s6 and the Salvation Army's Bridge Program, specifically for those needing alcohol-related rehabilitation.7 Similarly, an independent organisation, using experience from the Fitzroy-based Brotherhood of St Lawrence researching and responding to poverty, initiated Hanover Welfare Services (taking the name from the Fitzroy Street where it was first located), in 1964. Parallel to Jim Rankin's commitment to research, they declared: ‘Much exact information is required as a basis for planning further work with the men. The methods of the agency should be regarded as experimental, and results evaluated and reported. Client's case records would be compiled so as to allow elucidation of common patterns, and special study might be made of such subjects as excessive drinking and employment difficulties’. Recalling the very first clinic at St Vincent's, Rankin, when interviewed by Breen, recalled that the first (and only) patient of the clinic on the first day ‘was “Ray S.”, a homeless man with a long history of alcohol dependence, who was brought to the clinic from Pentridge Prison. Ray had been injured at around the time of his arrest and had been seen in the Casualty Department at St Vincent's, where a resident doctor had given him an appointment to the new clinic. If he had not been in prison, it is highly unlikely that Ray would have kept the appointment. From that first visit, Ray abstained from alcohol, and became a respected member of the community and a strong supporter of Alcoholics Anonymous (AA)’ [3]. AA was to become an intrinsic part of every clinic and was offered (not insisted on) to all patients of the clinic for many years. As the out-patient clinic grew, it began to hold three clinic sessions each week; two in the evenings, recognising the needs of people who could not get there during the day. Jim set up detailed patient data collection and, subsequently, an internal consultancy service to the rest of the hospital, insisting that all the hospital could and would be supported to consider and, where appropriate, treat or refer patients to the ‘Special Clinic’, the title adopted to avoid stigma. The specialist focus provided an invaluable base of education for junior medical staff, and Jim's belief in teamwork meant including the social worker and the clinic nurse in all aspects of the Clinic's work, including consultancy and research; it encouraged consideration of broad assessment of the person's situation, beyond their biology and drinking history, and meetings with family members were initiated. Others he involved included the hospital dietician, Bev Wood, who would go on to complete a PhD and be a successful advocate for thiamine fortification of bakers flour to prevent Wernicke-Korsakoff syndrome, previously a major cause of morbidity and mortality among chronically alcohol dependent people [3]. Jim had an impact on many who subsequently went on to complete research and further qualifications related to prevention and treatment of alcohol-related harm. Jim introduced alcohol content into undergraduate teaching for all students of the Melbourne medical school, as well as undertaking supervision of senior medical officers who rotated through the clinic. This was a forerunner to the later federal government-funded positions for every medical school in Australia, the Coordination of Alcohol and Drug Education in Medical Schools [6, 7]. An inquiry that was to become the Phillips Royal Commission [8] had started in Victoria prior to Jim's arrival, in response to growing community concern about the social impacts of alcohol and increasing recognition of the contribution of alcohol to illness, and severe injuries and deaths being reported by the police surgeon. There was a demand to deal with the ‘six o'clock swill’—the rapid drinking of alcohol (nearly always beer) between leaving work and the compulsory closure of hotel bars at 6 pm. Jim Rankin became an advisor and this began what was to become Jim's commitment to alcohol-related policy advice to governments. Jim and colleagues started to describe the clinical profile of the Alcoholism Clinic's patient data and several publications resulted, especially identifying morbidity and the social profile of patients presenting to the Alcoholism Clinic [9]. Breen [3] identifies these early publications ‘documenting, in Australia for the first time in a large consecutive series of patients, the extent of physical injuries linked to alcohol misuse and identifying evidence of effects of alcohol on driving efficiency and family relationships’. The size of the problem of alcoholism was extensively reported on, as was the related problem of alcoholic liver disease. The unit also studied alcoholism in women, reporting on 60 new patients over the first 30 months (out of a total of 416) [10].8 Rankin worked beyond his own team to identify and include others who had interest in alcohol-related problems. In 1966,9 he and de Gruchy initiated an all-day seminar, bringing together people from many other medical, psychiatric and welfare establishments, police, the police surgeon, prison personnel, homelessness services and church groups. From this emerged what became an annual symposium: The St Vincent's Hospital Summer School of Alcohol Studies (later to become Studies on Alcohol and Drugs). Many topics were covered over the following years, including alcohol and road safety and alcohol and the family [11]. Breen [3] reports that the first 5-day Summer School attracted 270 registrants, including many from interstate. Its broad program gained wide publicity and a resolution passed by attendees at the end of the conference declared that ‘alcoholism was a “medical disability”, thereby confirming the medicalisation of the problem; a great help in overcoming stigma at that time’.10 Terminology has been ever-changing in this field, and with the emergence more recently in Australia of ‘addiction medicine’, the ever-thoughtful Jim Rankin commented to Breen in 2017 that he was ‘uncomfortable with [this term], believing that, while undoubtedly some of the problems caused by alcohol are indeed a reflection of its addictive properties, focusing narrowly on addiction is unlikely to help a community to solve the wider problem. In addition, the term may suggest that addiction medicine specialists have a “magic bullet” for alcohol misuse, leading to failure to look at the whole person who is in trouble and seeking help, and failure to look at the problems from a whole-of-society viewpoint’ [3]. Jim's early career involvement with clinical treatment of individuals, his interest in research and evidence and his parallel advisory role in the Victorian review of Liquor Licensing had contributed to his understanding of the relationships between individuals presenting to hospitals and the patterns of alcohol use of the whole community. Thereafter he pursued links between treatment, amelioration and prevention of alcohol and drug harms and progressive approaches to all arms of the response to these problems. Only a month prior to his death he was still working on trying to develop grand theories and overarching conceptual schema to make better use of these links in the interests of prevention. In 1970, Professor Rankin moved to Canada to a joint post as Director and Physician-in-Chief of the Clinical Institute of the Addiction Research Foundation of Ontario, which was a new University of Toronto teaching hospital, and Associate Professor in the University's Department of Medicine. ‘At that time, the Institute was a year away from completion. It was to be a 100-bed clinical research and training centre operated by the Addiction Research Foundation and also a teaching hospital of the University of Toronto. The expectation was that the centre would be fully operational by early 1971, a daunting challenge’ [12]. In Rankin's own words, ‘over [the next 8 years] time, The Clinical Institute developed a full range of clinical services for the management of alcohol- and drug-related health, behavioural and social problems. These included emergency, outpatient and residential services. A research programme was developed which included biomedical studies in epidemiology (Dr Mary Jane Ashley), clinical pharmacology (Drs Edward M. Sellers, Richard Frecker, Claudio Naranjo and Stuart McLeod), neurology (Dr Peter Carlen) and hepatology (Dr Hector Orrego). The focus was alcohol- and drug-related medical problems, their prevention, diagnosis and treatment. The other major area of research, developed by Dr Frederick Glaser, concerned treatment systems and methods’ [12]. Thinking that he had achieved the expectations and goals he set for himself in Toronto, Jim Rankin returned to Australia and from 1978 to 1981, was the Director of the Drug and Alcohol Division within the NSW Health Commission. In this role, he was instrumental in helping establish a network of alcohol and other drug units across the state's hospitals, with senior academic, medical and nursing appointments at each site. The then NSW Premier, Neville Wran, was committed to eliminating the crime of public drunkenness as part of a broader commitment to eliminate victimless crimes. Dr Rankin persuaded Premier Wran that while law enforcement was not the answer to the problems resulting from alcohol intoxication in public, what the people concerned really needed was adequate health and social assistance. These programs established a national benchmark for statewide hospital-based services and a foundation for future academic development.11 In 1981, Dr Rankin was invited by the then NSW Minister of Health on behalf of the NSW Premier to chair a committee to investigate the then burgeoning problem of street heroin use and develop recommendations to lessen the impact of heroin use. The first recommendation was for a trial of prescribed pharmaceutical heroin to be conducted in people with severe problems from street heroin who had been refractory to conventional treatments.12 Over this period Rankin contributed to and was the first President of the Australian Medical Society on Alcohol and Other Drugs, now the Australasian Professional Society on Alcohol and Drugs, detailing the Society's first years in the first of the annual orations named after him in 1991 [13]. He subsequently was also the first President of the Canadian Medical Society on Alcohol and other Drugs (now the Canadian Society of Addiction Medicine). What emerges as we trace Jim Rankin's career is his forever pushing forward, reflected both in his work focus and in pursuit of new roles. Once satisfied that he had achieved a goal, he felt impelled to move to new challenges. This underscores his commitment to many new initiatives, especially as he pursued his overarching intent to reduce alcohol and other drug related harm. This was reflected in his movements between Australia and Canada over four decades. Jim Rankin returned to Canada in 1982, in part due to the funding changes by government in NSW constricting opportunities, and with consideration of his children's educational opportunities and interests. He became the Director of the Canadian Liver Foundation's Epidemiology Unit and a Professor in the Department of Preventive Medicine and Biostatistics at the University of Toronto, working closely with his former colleague at the Foundation, Dr Mary-Jane Ashley, who was now the Head of that Department. From 1985 to 1993, he served again as Head of Medicine and Physician-in-Chief at the Clinical Institute. In a further move, Rankin returned to Australia in 1994 as Clinical Professor at the University of Sydney and Chair of the Central Sydney Area Drug and Alcohol Services. His review of these services led to a major restructure involving the closure of long-term inpatient programs and expansion of ambulatory care. Jim Rankin was as much a knowing social and political analyst as a medical practitioner and clinical leader. He noted over years the societal attitudes and practices regarding alcohol and other drugs, the complexity of vested interests in the field, and the enormous effort required to have evidence surface and be used as the key driver of planning and service development. Among other topics, he quietly pronounced on the often-knee-jerk responses to drug-linked crises, and the loss of content knowledge in the public service as it moved toward generic managerialism; he was cynical about politicians' inevitable involvement in drug policy, noting that ‘governments largely see committees of inquiry as a means of defusing a difficult situation, without necessarily needing to respond to eventual reports and recommendations’. [12]. After his official retirement in 2000, he continued pursuing his interests in the alcohol and other drug field. Honours awarded him include Honorary Fellow in the Australasian Chapter of Addiction Medicine, The Royal Australasian College of Physicians, and Honorary Life Memberships of the Canadian Society of Addiction Medicine and Australasian Professional Society on Alcohol and Other Drugs. The James Rankin Oration at the annual conference of Australasian Professional Society on Alcohol and Other Drugs and Rankin Court within the Drug and Alcohol Services at St Vincent's Hospital, Sydney have both been named in his honour. In 2017, the University of Sydney awarded Dr Rankin a Doctor of Medical Science (honoris causa). His family noted, in announcing Jim's death: ‘Despite a busy family life and career, Jim had a multitude of interests that gave him so much pleasure – politics, photography, cooking, travel, model boat and His family him as an His commitment to and and his strong and to His professional colleagues him Jim of drug and alcohol field not into professional it is and both its professional and its political [12]. Jim his and over 60 years of commitment to and have been to have Jim in his early career and to have

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