2
801 The new office is to be equipped with a high-ranking advisory committee, and it is to contract with the Institute of Medicine, the health-policy arm of the National Academy of Sciences, for a study detailing how NIH has ignored women’s health and what’s to be done about it. The bill also decrees new protections for "whistle-blowers", a species that Congress looks to for determining what is really happening inside the nooks and crannies of the federal establishment. It directs the Secretary of the Department to add another group to the increasingly cluttered office of the Director of NIH-an Advisory Committee on Health Sciences, "for the purpose of advising the Director of NIH, the Secretary, and the Congress on the modifications, if any, that should be made in the organizational structure of the National Institutes of Health". Continuing, the bill authorises the director of NIH to spend as much as$40 million next year "for the purpose of expanding and intensifying research on osteoporosis, Paget’s disease, and related bone disorders". For assistance in carrying out this mandate, the director is to appoint an 18-member advisory board, of whom "6 shall be members of the general public who are knowledgeable with respect to such diseases, including not fewer than 1 individual who has such a disease and not fewer than 1 individual who is a parent of a person who has such a disease". Another item on the bill advises the director of the National Institute of Allergy and Infectious Diseases that, after consultation with his advisers, he may provide money for "the development and operation of centers to conduct basic and clinical research on chronic fatigue syndrome", a disorder, if it exists, that has grabbed Congressional fancy. Then there’s a major section of the bill directing the National Institute of Child Health and Human Development to establish a National Center for Medical Rehabilitation Research. The purpose is to support research, training, and education concerning "rehabilitation of individuals with physical disabilities resulting from diseases or disorders of the neurological, musculoskeletal, cardiovascular, pulmonary, or any other physiological system". There’s a directive for expanding research on infertility and contraception, and the National Center for Human Genome Research, also part of NIH, is told to spend no less than 5% of its budget for "ethical studies associated with the genome project". The bill contains other instructions for the management of priorities of NIH. But the foregoing items, in conjunction with the fetal-tissue controversy, should help to explain the absence of a glut of candidates for the directorship of the National Institutes of Health. Daniel S. Greenberg Round the World New Zealand: Treatment of CIS at National Women’s Hospital, Auckland, still an issue The June, 1987, edition of Metro, a magazine published in Auckland, carried a powerful story by Sandra Coney and Phillida Bunkle, members of a women’s health consumer group, about the inadequate management of carcinoma-in- situ (CIS) of the cervix at the National Women’s Hospital.’ As a result of the article a wide-ranging inquiry was initiated, led by Judge Silvia Cartwright. There were 32 submissions, and 145 witnesses, including overseas experts, gave evidence; the report of the inquiry was published in 1988.2 The inquiry upheld the allegations that treatment had been withheld from a group of women with a histological diagnosis of CIS but no clinical or colposcopic evidence of invasive carcinoma, as part of a research programme started at the hospital in 1966 under the direction of Dr Herbert Green. The proposal was presented at a meeting of senior medical staff at National Women’s Hospital on June 20, 1966, chaired by Prof Dennis Bonham, Head of Postgraduate School, Department of Obstetrics and Gynaecology, University of Auckland Medical School. The women were unaware that they were participating in a research study and not all knew of their condition.1 Dr Green’s views about CIS were well known world wide. He believed that "providing invasive cancer is adequately excluded at the outset the patient with diagnosed in situ cancer has only the normal chance of developing invasive cancer in the future".3 Consequently he felt that a prospective trial was justified; he recognised that "such studies can only be done by those who are unconvinced of the invasive potentiality of the lesion". Green was fully aware that world opinion was very largely against him, as was acknowledged by Judge Cartwright when she said "Adequate treatment for women who have CIS now requires that they are treated with the aim of eradicating the disease". In 1984, 2 years after Green retired, a group of researchers who were associated with National Women’s Hospital published a paper that set out to report on the outcome of the 1966 study and also included patients whose disease seemed to have been eliminated by treatment.4 This paper reviewed 948 patients, not all Green’s, and grouped them according to whether their cervical smears were normal or abnormal. The conclusion was that "patients with continuing abnormal cytology after initial management of CIS of the cervix are 24-8 times more likely to develop invasive carcinoma than women who have normal follow-up cytology". This was the paper that sparked Coney and Bunkle’s inquiries, culminating in their Metro article. The July, 1990, issue of Metro carried another article on this topic, in which a staff writer, Jan Corbett, reviewed the story. This time, however, the conclusion was very different: "It is now possible to say that the inquiry was launched on evidence that was misunderstood and misinterpreted and reached conclusions which were not justified by the evidence". This second Metro article also asked whether Green got a fair hearing or whether the inquiry was a radical feminist witch-hunt. In response to the latest article, whose sentiments were perpetuated in an editorial in the September edition of Metro, New Zealand Health Minister, Helen Clark, issued a statement on Sunday, Sept 23, in which she said that the Government had "confidence in the integrity of Judge Cartwright’s report and has proven its commitment to continuing to implement the recommendations ...". The Minister also said that "from the outset it had been made clear that the Inquiry’s terms of reference were not to be interpreted as seeking to establish findings of guilt or innocence" and that "Neither Dr Green’s name nor his work was mentioned in the terms of reference". Meanwhile, the Medical Council of New Zealand has been conducting its own investigation. As a result, charges of disgraceful conduct were laid against Green and Bonham,

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Page 1: New Zealand: Treatment of CIS at National Women's Hospital, Auckland, still an issue

801

The new office is to be equipped with a high-rankingadvisory committee, and it is to contract with the Institute ofMedicine, the health-policy arm of the National Academy ofSciences, for a study detailing how NIH has ignoredwomen’s health and what’s to be done about it. The bill alsodecrees new protections for "whistle-blowers", a speciesthat Congress looks to for determining what is reallyhappening inside the nooks and crannies of the federalestablishment. It directs the Secretary of the Department toadd another group to the increasingly cluttered office of theDirector of NIH-an Advisory Committee on HealthSciences, "for the purpose of advising the Director of NIH,the Secretary, and the Congress on the modifications, if any,that should be made in the organizational structure of theNational Institutes of Health".

Continuing, the bill authorises the director of NIH tospend as much as$40 million next year "for the purpose ofexpanding and intensifying research on osteoporosis,Paget’s disease, and related bone disorders". For assistancein carrying out this mandate, the director is to appoint an18-member advisory board, of whom "6 shall be membersof the general public who are knowledgeable with respect tosuch diseases, including not fewer than 1 individual who hassuch a disease and not fewer than 1 individual who is a

parent of a person who has such a disease".Another item on the bill advises the director of the

National Institute of Allergy and Infectious Diseases that,after consultation with his advisers, he may provide moneyfor "the development and operation of centers to conductbasic and clinical research on chronic fatigue syndrome", adisorder, if it exists, that has grabbed Congressional fancy.Then there’s a major section of the bill directing theNational Institute of Child Health and Human

Development to establish a National Center for MedicalRehabilitation Research. The purpose is to supportresearch, training, and education concerning "rehabilitationof individuals with physical disabilities resulting fromdiseases or disorders of the neurological, musculoskeletal,cardiovascular, pulmonary, or any other physiologicalsystem".There’s a directive for expanding research on infertility

and contraception, and the National Center for HumanGenome Research, also part of NIH, is told to spend no lessthan 5% of its budget for "ethical studies associated with thegenome project".The bill contains other instructions for the management

of priorities of NIH. But the foregoing items, in conjunctionwith the fetal-tissue controversy, should help to explain theabsence of a glut of candidates for the directorship of theNational Institutes of Health.

Daniel S. Greenberg

Round the World

New Zealand: Treatment of CIS at NationalWomen’s Hospital, Auckland, still an issueThe June, 1987, edition of Metro, a magazine published inAuckland, carried a powerful story by Sandra Coney andPhillida Bunkle, members of a women’s health consumergroup, about the inadequate management of carcinoma-in-situ (CIS) of the cervix at the National Women’s Hospital.’As a result of the article a wide-ranging inquiry was initiated,

led by Judge Silvia Cartwright. There were 32 submissions,and 145 witnesses, including overseas experts, gaveevidence; the report of the inquiry was published in 1988.2The inquiry upheld the allegations that treatment had beenwithheld from a group of women with a histologicaldiagnosis of CIS but no clinical or colposcopic evidence ofinvasive carcinoma, as part of a research programme startedat the hospital in 1966 under the direction of Dr HerbertGreen. The proposal was presented at a meeting of seniormedical staff at National Women’s Hospital on June 20,1966, chaired by Prof Dennis Bonham, Head of

Postgraduate School, Department of Obstetrics and

Gynaecology, University of Auckland Medical School. Thewomen were unaware that they were participating in aresearch study and not all knew of their condition.1Dr Green’s views about CIS were well known world

wide. He believed that "providing invasive cancer is

adequately excluded at the outset the patient with diagnosedin situ cancer has only the normal chance of developinginvasive cancer in the future".3 Consequently he felt that aprospective trial was justified; he recognised that "suchstudies can only be done by those who are unconvinced ofthe invasive potentiality of the lesion". Green was fullyaware that world opinion was very largely against him, aswas acknowledged by Judge Cartwright when she said"Adequate treatment for women who have CIS now

requires that they are treated with the aim of eradicating thedisease".

In 1984, 2 years after Green retired, a group of researcherswho were associated with National Women’s Hospitalpublished a paper that set out to report on the outcome of the1966 study and also included patients whose disease seemedto have been eliminated by treatment.4 This paper reviewed948 patients, not all Green’s, and grouped them according towhether their cervical smears were normal or abnormal.The conclusion was that "patients with continuingabnormal cytology after initial management of CIS of thecervix are 24-8 times more likely to develop invasivecarcinoma than women who have normal follow-upcytology". This was the paper that sparked Coney andBunkle’s inquiries, culminating in their Metro article.The July, 1990, issue of Metro carried another article on

this topic, in which a staff writer, Jan Corbett, reviewed thestory. This time, however, the conclusion was verydifferent: "It is now possible to say that the inquiry waslaunched on evidence that was misunderstood and

misinterpreted and reached conclusions which were notjustified by the evidence". This second Metro article alsoasked whether Green got a fair hearing or whether theinquiry was a radical feminist witch-hunt.

In response to the latest article, whose sentiments wereperpetuated in an editorial in the September edition ofMetro, New Zealand Health Minister, Helen Clark, issued astatement on Sunday, Sept 23, in which she said that theGovernment had "confidence in the integrity of JudgeCartwright’s report and has proven its commitment to

continuing to implement the recommendations ...". TheMinister also said that "from the outset it had been madeclear that the Inquiry’s terms of reference were not to beinterpreted as seeking to establish findings of guilt orinnocence" and that "Neither Dr Green’s name nor hiswork was mentioned in the terms of reference".

Meanwhile, the Medical Council of New Zealand hasbeen conducting its own investigation. As a result, charges ofdisgraceful conduct were laid against Green and Bonham,

Page 2: New Zealand: Treatment of CIS at National Women's Hospital, Auckland, still an issue

802

neither of whom sought a judicial review of the Cartwrightreport when it was released. The Council has stayed thecharges against Green because of ill health, although theywill probably never be withdrawn. The charges againstBonham, who has also been ill, will be heard on October 1.Dr Bruce Faris (part-time visiting specialist to National

Women’s Hospital) and Prof David Seddon (Professor ofObstetrics and Gynaecology, University of Otago MedicalSchool, and President of the New Zealand College ofObstetricians and Gynaecologists) face lesser charges ofprofessional misconduct arising out of the same

investigation.A correspondent

1. Anon. New Zealand: recall of women with untreated cervicalabnormalities. Lancet 1989; i: 608-09.

2. Committee of Inquiry into Allegations Concerning the Treatment ofCervical Cancer at National Women’s Hospital and into Other RelatedMatters. Report of the cervical cancer inquiry. Auckland: GovernmentPrinting Office, 1988.

3. Green GH. Cervical carcinoma in situ. Aust NZ J Obstet Gynaecol 1970;10: 41-48.

4. McIndoe WA, McLean MR, Jones RW, Mullins PR. The invasivepotential of carcinoma in situ of the cervix. Obstet Gynecol 1984; 64:451-58.

Nigeria: Talking about mothers

Nigerian women have a 1 in 21 chance of dying in pregnancyor childbirth. The large number of maternal deaths wasnoted by General Ibrahim Babangida, President of theRepublic, when he met a delegation from the Society ofGynaecology and Obstetrics of Nigeria (SOGON) in Lagosrecently. He called for a massive enlightenment campaignand confirmed his interest in the possible setting up of anational institute of maternal health. To bring the nation’sattention to the problems of maternal mortality andmorbidity SOGON has held several regional safemotherhood workshops in various parts of the country inrecent months, in preparation for the international SafeMotherhood conference in September. Prof WilfredChukudebelu, president of SOGON, has pointed out thatsince the Nigerian situation seems to be worse than that inmost developing countries, there is something that is notbeing done right in Nigeria.

Operational research projects are being conducted invarious parts of the country to assess possible correctivemeasures. Recent data have shown a drastic decline in

hospital births in most university teaching hospitalsthroughout the country, accompanied by an increase in theincidence of maternal deaths in the hospitals. For example,at Ahmadu Bello University (ABU) Teaching Hospital,Zaria, the number of obstetric admissions declined from7450 in 1983 to 5437 in 1985, and to 3376 in 1988, whereasthe maternal deaths in the hospital increased by 56%between 1985 and 1988. Some researchers have attributedsuch changes to a delay in the decision to use the hospitalservices because of new or increased hospital fees. Hospitalworkers traditionally highlight the culture and traditionalfactors that make women reluctant to use their services.

Recently, there has been an increasing number of

complaints about deterioration of the hospital services dueto lack of funding. But, as the Minister of Health, ProfOlikoye Ransome-Kuti, pointed out earlier in the year,achievement of the aims of primary health care is not

handicapped by funds alone. More disturbing, he noted, is

the attitude of the doctors. Recent "focus groups" studies insome rural communities have shown that the people therefeel that the modern health services are often too far off, tooalien, and too costly (made worse by the need to tip), and thatthe staff-young pompous doctors and rude midwives-aretoo unapproachable. The long waiting time at clinics,compared with that in urban areas, is another criticism.

Although most rural women either do not voice theirconcerns or accept the complications of childbirth as one ofthe unavoidable penalties of womanhood, some women’sorganisations are becoming increasingly active in

highlighting the plight of rural mothers. For instance, tocope with the high prevalence of obstetric (vesico-vaginal)fistulae and the long waiting lists for treatment, many havemobilised resources to build theatres; wards, and hostels forthe treatment of these fistulae; mobilising gynaecologistsand surgeons to offer their services has, however, provedmuch more difficult. Meanwhile, traditional birthattendants are smarting under the accusation, from aprofessor of obstetrics, that they are part of a "dangeroussystem of health care". How, they ask, are they to cope withemergencies in the middle of the night when there is notransport and no hospital nearby to provide back-up?At a recent workshop on prevention of maternal mortality

in Nigeria, Professor Lucas, chairman of the CarnegieCorporation’s programme for strengthening humanresources in the developing countries, which has sponsoredsome of the important aspects of the safe motherhoodresearch programmes in Africa, pointed out that the creationof multidisciplinary teams of researchers for the maternalmortality activities had been one of the goals of his

programme. Some years ago social scientists and doctorswere not talking to each other. Then they began to talk ateach other, and gradually they are listening to and talkingwith each other. To prevent maternal deaths the need for therural communities and the medical workers to talk to eachother is just as great.

Farhang Tahzib

Conference

IPPNW in a changing worldAs the 5th European symposium of International Physiciansfor the Prevention of Nuclear War assembled in Coventryon Sept 13-16, reports were arriving of up to 450 nuclearweapons marshalled in the Persian Gulf aboard warships ofthe United States, Britain, France, and the Soviet Union.This response to Iraq’s annexation of Kuwait hung grimlyover all the proceedings in Coventry and injected unforeseenurgency into the renewed words of peace and reconciliationevoked by the 50th anniversary of the German onslaught onthe city from the air. The symposium, attended by over 400people from 26 countries, had been planned, under the titleHealth and Security 2000: New Thinking in Europe, as aforum for IPPNW’s European affiliates to discuss theirresponse to the rapid reformations in the fragmentingCommunist union and to the almost unbelievable prospectof a world in which the United States and the Soviet Unionwere no longer in deadly confrontation. What was IPPNWto do now? Should it still be a campaign with the singlepurpose expressed in its title? Or should it expand and join,with many other organisations, in the defence of a planet