A new book, published today, gives an inside account of the professional arrogance and denial of the tragic “unfortunate experiment” scandal at National Women’s Hospital in Auckland. Our excerpt is from the book’s foreword by Neville Hacker, a past president of the International Gynecologic Cancer Society.
Thirty years after the Cartwright Inquiry endorsed the reality of the “unfortunate experiment”, there are still individuals who are denying the truth.
I was completely unaware of the study Associate Professor Herb Green had begun in 1966 into the natural history of carcinoma in-situ (CIS) of the cervix until the long-term results were published in 1984 by Drs William McIndoe, Malcolm McLean and Ronald Jones (with statistician Peter Mullins).
I never met any of the key players, but in this book Professor Ron Jones brings each character to life. Herb Green was a “tall, balding man with a shambling gait”. He was trusted by his colleagues, and there was a degree of sympathy for him as he had missed out on the postgraduate chair in 1963. He was considered to be a good teacher, but “held unconventional views” and had an “uneasy” relationship with his departmental chair, Professor Dennis Bonham.
Bonham was a “large, intimidating man”, who could easily fly into a rage. His professorial position and difficult character isolated him from many colleagues, but he supported Green whenever there was any challenge to Green’s experiment. Bonham tried unsuccessfully to obstruct publication of the 1984 article that exposed the experiment, and was ultimately found guilty of “disgraceful conduct” by the Medical Council.
Dr William McIndoe was a warm, quietly spoken, meticulous man with strong Christian beliefs. His expertise in colposcopy was used by Green to exclude invasive cancer at the outset. He privately suggested that Green was retrospectively manipulating the data, and withdrew his colposcopic services from Green’s study in 1973. Dr Malcolm (Jock) McLean was appointed head pathologist at National Women’s in 1961. Somewhat eccentric but unpretentious, he was “an excellent and much respected teacher” who clashed regularly with Green over the interpretation of cervical pathology.
On several occasions, both McLean and McIndoe expressed strong concerns to the medical administration about patient safety in relation to Green’s experiment. These complaints led to an internal whitewash inquiry.
Green was correct in his assertion that CIS cervix was being over-treated by hysterectomy in the early 1960s, and cone biopsy of the cervix, which had Green’s endorsement initially, was a major advance for New Zealand women. However, he progressively became convinced that CIS was not a premalignant condition at all, which led him to oppose cervical cancer screening with the Papanicolaou smear (Pap screening). When evidence from Sweden and Iceland demonstrated decreasing mortality from cervical cancer with regular Pap smear screening, Green’s continued failure to acknowledge this fact set the introduction of organised cervical cancer screening in New Zealand back 20 years.
In 1966 Green initiated what can only be described as a controversial experiment. At the time, there was almost universal agreement that CIS was a premalignant lesion. In 1950 the International Federation of Obstetricians and Gynecologists (FIGO), which is responsible for defining the stages of gynaecological cancer, introduced Stage 0 for carcinoma in-situ, implying that it was a premalignant lesion. As a former member of the FIGO Cancer Committee, I am aware that no staging recommendations are made without very strong supporting evidence. In spite of this, Green proposed cytological observation only, for women with biopsy-proven carcinoma in-situ. This experiment was accepted by the Hospital Medical Committee, but most women had no idea they were being used as guinea pigs.
Green published a number of reports between 1966 and 1974 to justify his position, but a retrospective review demonstrated that some pathology results had been manipulated to justify his hypothesis. Although Green retired in 1982, his experiment continued, despite the findings of the seminal 1984 paper by McIndoe and his colleagues. This paper clearly demonstrated that women with CIS who continued to have persistent smear abnormalities, irrespective of their initial management, were 25 times more likely to develop invasive cervical cancer than those who had normal follow-up smears.
It took the attention of feminists and a media response to highlight the tragedy, and the Cartwright Report of 1988 to confirm that an unethical experiment had been carried out on large numbers of women for over 20 years, with disastrous results for many.
It’s difficult for an outsider to comprehend how this could have happened. Green was an intelligent but domineering individual, who had no insight into his own limitations. He bullied colleagues who disagreed with him and had the tacit support of his head of department. These circumstances created the perfect storm for a tragedy to happen, and the repercussions are being felt to this day.
When revisionists tried to discredit the Cartwright Report, Professor Ron Jones felt a moral duty to tell the inside story of a saga that had long bedevilled National Women’s Hospital. He had endured the silent disapprobation of colleagues who had remained loyal to Green and Bonham, and he kept meticulous records of all written material and conversations relating to the experiment. In addition he became an acknowledged expert in lower genital tract cancers, and was invited to speak on the subject all around the world.
This book is a major contribution to the history of the darkest era in academic medicine in New Zealand. It is written with candour, integrity and wise reflection by an insider who has lived and breathed the controversy for many years. The book provides a portrait of the social environment in which medicine was practised in the second half of the twentieth century; it acknowledges, also, the state of medical knowledge and the culture of the times; and ultimately comes to the only conclusion possible – Green’s “study” was an unethical experiment on women, which ended for some in cancer and death. Future generations will reflect on this sad era in New Zealand gynaecology with total disbelief.
Doctors In Denial (Otago University Press, 39.95) by Ronald W Jones is published today.