Doctors in Denial

The Forgotten Women in the 'Unfortunate Experiment'

Ronald W. Jones

• Publisher: Otago University Press
• Year: 2017
• ISBN:
  9780947522629
• Edition: 1
• Topic: Medicine
• Subtopic: Ethics in Medicine

When Dr Ron Jones joined the staff of National Women's Hospital in Auckland in 1973 as a junior obstetrician and gynecologist, Professor Herbert Green's study into the natural history of carcinoma in-situ of the cervix (CIS) – later called 'the unfortunate experiment' – had been in progress for seven years. By the mid-1960s there was almost universal agreement among gynecologists and pathologists worldwide that CIS was a precursor of cancer, requiring complete removal. Green, however, believed otherwise, and embarked on a study of women with CIS, without their consent, that involved merely observing, rather than definitively treating them. Many women subsequently developed cancer and some died. In 1984 Jones and senior colleagues Dr Bill McIndoe and Dr Jock McLean published a scientific paper that exposed the truth, and the disastrous outcome of Green's experiment. In a public inquiry in 1987 Judge Sylvia Cartwright observed that an unethical experiment had been carried out in large numbers of women for over 20 years. Since that time there have been attempts to cast Green's work in a more generous light. This rewriting of history has spurred Ron Jones to set the record straight by telling his personal story: a story of the unnecessary suffering of countless women, a story of professional arrogance and misplaced loyalties, and a story of doctors in denial of the truth.

CHAPTER 1

A PROFESSORIAL APPOINTMENT

Vivat academia! Vivant professores!

‘GAUDEAMUS IGITUR’, TRADITIONAL
EIGHTEENTH-CENTURY ACADEMIC SONG

I LOVE CRICKET. Soon after I arrived at National Women’s Hospital in the summer of 1973 I was invited to join the cricket team for a local derby match against our neighbour, Greenlane Hospital, whom we played in the adjoining Cornwall Park, under One Tree Hill. The Greenlane players were better attired: most wore whites and cricket boots, and some had colourful old school cricket caps. The NWH side, on the other hand, was less well presented – some players were even in surgical theatre garb – but we had some useful cricketers, including ex-All Black captain Dr Ron Elvidge.

Another notable player was Associate Professor Herbert Green, who for two years had captained his school’s 1st XI and, according to local legend, was shod in the battered canvas cricket boots he had worn at school. David Morris – a teammate of mine in the Otago University Cricket XI in the early 1960s, a connoisseur of the game, a batsman of note, a part-time bowler and now a Greenlane Hospital surgeon – was the unfortunate recipient of three straight sixes off his bowling in one over from Green’s bat. Wives and girlfriends provided cucumber sandwiches and tea. The afternoon’s cricket gave me an early opportunity to meet and socialise with some of my new colleagues.

I felt privileged to have been appointed to a junior specialist position at NWH, an internationally respected unit with a reputation built on the excellence of its current research, clinical teaching and patient care. I had worked in London teaching hospitals made famous for their past achievements but few had earned the current international respect of this youthful New Zealand hospital. I was conscious of being the first ‘outside’ appointment to the tutor specialist post; previous occupants had spent time in junior training positions in the hospital.

The four senior professors were all well known internationally. Professor Dennis Bonham, the head of the unit, had co-authored the 1958 British Perinatal Mortality Survey, considered by some to be the most important study of its kind in the twentieth century. In 1963 Professor William (Bill) Liley had performed the first successful intrauterine transfusion for rhesus disease, an achievement that hit world headlines in the medical and lay press. Professor Graham (Mont) Liggins, one of only a very small, elite group of New Zealand doctors to be elected as a Fellow of the Royal Society of London, had demonstrated the benefits of antenatal maternal corticosteroids in reducing respiratory distress in premature babies, saving the lives of many thousands of infants worldwide.¹ These projects heralded the beginning of the new field of antenatal therapy. Associate Professor Green had published extensively on his study of untreated carcinoma in-situ (CIS) of the cervix, and although there was some uncertainty about the proportion of cases that would progress to cancer, his view was that few or none would do so.²

The international status of NWH was in stark contrast to its humble origins in 1946 as the Obstetric and Gynaecological Unit, sited in part of a 1500-bed, single-storey, prefabricated wartime building that had been vacated by the 39th General Hospital of the United States Army. The 123 hospital ‘army huts’, converted into 48 wards and other facilities, covered a 26-hectare area of Cornwall Park and were linked by a long spinal corridor. While the building was used by the Americans folklore had it that orderlies rode motorbikes in the 800-metre-long corridor; when it was reduced in size, the porters in what became known as Cornwall Hospital cycled between sections. This unit comprised an operating theatre, X-ray facilities and wards with a 135-bed capacity. Another part was converted to a geriatric unit, while much of the original army hospital was either relocated or demolished.

The concept of a national obstetric and gynaecological postgraduate hospital extended back to the 1930s. The New Zealand Obstetric and Gynaecological Society, established in 1927 and spearheaded by the indomitable Dr Doris Gordon, set out to modernise New Zealand obstetric services. In 1929 the society advocated and raised funds for the establishment of a full-time chair in obstetrics and gynaecology at the Otago Medical School and an annual travelling scholarship to enable young New Zealand doctors to specialise in obstetrics and gynaecology overseas. In 1940 the society agreed that the time had come to set up a postgraduate centre for obstetrics and gynaecology in Auckland to complement the undergraduate centre at Otago University, and that it should be directed ‘by a teacher of empire standing’.³ This idea led to considerable friction between the Otago and Auckland University authorities.

In 1943 the Auckland mayor, Sir Ernest Davis, headed a large deputation to inform Minister of Health Arnold Nordmeyer that ‘an influential body of citizens will undertake to raise a substantial sum to ensure the creation of a centre in Auckland for the postgraduate study of obstetrics and gynaecology’.⁴ By 1947 a public appeal, led by the Rotary Club, and with Doris Gordon again providing the impetus, had raised the enormous sum of £101,231 to endow a chair, and the first professor, South African Gerald Spence-Smythe, was appointed in 1952. He resigned three years later and returned to Johannesburg, complaining that ‘there was no department, no lecture room, no laboratory, no assistant, nothing of my own’.⁵ The renamed National Women’s Hospital appointed Harvey Carey as its second professor. He is credited with establishing its reputation, particularly recognising the potential talents of young researchers such as Liley and Liggins. However, Carey’s dual role as professor and medical director created insurmountable difficulties that eventually led to a division of control between an Auckland Hospital Board-appointed medical superintendent and a university-appointed professor. In addition there were the almost inevitable conflicts between some clinicians of the existing establishment (‘town’) and the new university order (‘gown’). These were the principal catalysts leading to Carey’s resignation and subsequent appointment to the Chair of Obstetrics and Gynaecology at the Royal Women’s Hospital, Sydney.

Late in 1962 advertisements for the postgraduate chair vacated by Carey were placed in medical journals and newspapers throughout Britain, Australia, South Africa, the United States and New Zealand.⁶ Dr Harold Francis, a young New Zealand academic in Liverpool, applied but later withdrew; and Dr Douglas Robb, the Chancellor of Auckland University, asked Dr Bernard Kyle, who had been assistant medical director under Carey, to apply. He, however, declined the invitation, having already committed himself to a part-time visiting position on the NWH staff, and to private practice.⁷ Finally two applicants were considered: Dr Dennis Bonham from England and Dr Herbert Green from Auckland.

Dr Dennis Geoffrey Bonham possessed impressive credentials. Following education at King Edward VI Grammar School, Nuneaton, he went up to Cambridge University for his undergraduate degree and completed his medical training at University College Hospital, London, in 1948. He spent the next 14 years in London and southern England doing postgraduate training in surgery, obstetrics and gynaecology. This time included three years of national service at Fighter Command Headquarters, Bentley Priory. He became a Member of the Royal College of Obstetricians and Gynaecologists (MRCOG) in 1955, and in 1958 a Fellow of the Royal College of Surgeons of England (FRCS). He returned to University College Hospital as a first assistant and not only extended his clinical experience but also became immersed in the academic milieu. He had succeeded in becoming a product of the fiercely competitive, paternalistic, hierarchical British medical system and was now ready for a senior academic or consultant post.

Professor Will Nixon, one of Britain’s leading obstetricians in the 1950s and 1960s, recognised Bonham’s research potential and chose him to partner Dr Neville Butler in taking responsibility for the organisation of the 1958 British Perinatal Mortality Survey. Butler and Bonham designed, planned, analysed and reported on a study of virtually every birth in England, Scotland and Wales occurring over one week, and the neonatal deaths within the same group for the next three months.⁸ Ethics committees did not exist at the time, and neither did the concept of informed consent, but medical confidentiality was considered important and extended to the use of medical information for this type of research.

In the precomputer era, Butler, Bonham, his wife Nancie and his father laboured on the data long into the nights and at weekends. Those who later knew Bonham’s capacity for work would understand his comment that Butler would come to his home in the evening after a day of clinical duties and they would toil through until breakfast. Thus 17,205 births and 666 deaths were studied. In a prepublication press conference late in 1962 Nixon appealed for improved care for mothers and babies. His emotional comments hit the headlines: ‘If we had 50 deaths a week from air crashes something would be done, yet there are 50 babies a week dying of preventable asphyxia.’⁹ The British Perinatal Report, finally published in 1963, was Bonham’s crowning achievement. This research alone would have swayed an appointment committee anxious to improve the standard of maternity services in New Zealand.

Ironically it was Bonham, not Green, who first became involved in investigating normal and abnormal changes in the cervix. In 1961 Bonham participated in a symposium at the Royal Society of Medicine in London, presenting a paper on his research on the physiological and pathological changes to the pregnant and postnatal cervix. Bonham commented on the natural history (the outcome in the absence of treatment) of cervical ‘erosion’ and discussed the early diagnosis of CIS of the cervix. He observed that obstetricians and gynaecologists ‘have both a great responsibility and a unique opportunity of screening our patients [with smear tests]’, and lamented the poor cytology facilities in Britain.¹⁰ The discussion of his paper was led by Professor Hugh McLaren from Birmingham, who would later vigorously debate the natural history of CIS of the cervix with Herbert Green.

Bonham also became involved in basic laboratory studies involving examination of vaginal fluid for enzymes thought to be associated with cervical cancer and precancer, which was seen as a possible alternative screening test to the Pap smear (see p. 00).¹¹ He was supported in his research by the British Empire Cancer Campaign. He pursued these studies after coming to New Zealand, but the test was ultimately discarded because it was non-specific.¹² In applying for the position at NWH, 39-year-old Bonham was following the advice of his mentor, Professor Nixon, who recommended to aspiring young academics they should follow his example and, at least initially, ‘Go east, young man.’¹³ Soon after his arrival in New Zealand, Bonham contributed an article for the Family Planning Association Journal in which he observed: ‘Death from carcinoma of the cervix could be eliminated in this country before the end of the century.’¹⁴ This was one of 12 similar quotes from articles written in the 1960s which Green distributed to students to emphasise the prevailing international opinions regarding the benefits of cervical screening.¹⁵

The second candidate for the chair, Dr George Herbert Green, came from a South Otago farming background and received his secondary education at South Otago High School in Balclutha, where he was head boy. In 1935 he entered Dunedin Teachers’ College and studied part time at Otago University, completing a BA in 1938 and a BSc in 1940. He also worked part time in Sir Horace Smirk’s laboratory at the medical school. This broad education prepared him for medicine, teaching, research and his later interest in medical history. Green entered Otago Medical School in 1941 and graduated in 1945. Companions at Knox College remember him as being older, rather grumpy and a heavy cigarillo smoker.¹⁶ He used his height and well-built frame to advantage, particularly in rugby and cricket. His teammates in the University Senior B rugby team frequently needed to restrain him when he repeatedly disputed refereeing decisions.¹⁷ Green’s combative nature was already established.

After spending two years as a house surgeon in Dunedin, Green moved to Auckland to begin his specialist training in obstetrics and gynaecology at Cornwall (later National Women’s) Hospital. It was during this time he first became interested in the study of cervical cancer and its pathology; in 1949 he wrote his MRCOG commentary on ‘The early diagnosis of cervical cancer’. He also remembered being influenced by the distress of one of his Balclutha school teachers who had developed cervical cancer.¹⁸

The old Cornwall Hospital building was a haven for fertile stray cats. Professor Barbara Heslop, then a sixth-year medical student, recalled Green spaying stray female cats on the operating theatre table during the evenings – ‘cat gynaecology’. Nursing staff prepared a ‘cat instrument tray’, medical students caught three or four cats per session, gave the anaesthetic and were instructed to spray escaping fleas with ethyl chloride and remove them with forceps from the operating table. The theatre was then cleaned in preparation for the following day’s human surgery. This, Heslop noted, was ‘Herb’s idea of a social service and I guess we concurred. If this sort of thing happened today, questions would be asked in parliament! In so many resp...

Table of contents

• Front Cover
• Title Page
• Copyright
• Contents
• Dedication
• ACKNOWLEDGEMENTS
• FOREWORD
• INTRODUCTION
• CHAPTER 1 A Professorial Appointment
• CHAPTER 2 The Evolution of a Misbelief
• CHAPTER 3 An Unnecessary Experiment
• CHAPTER 4 Expressions of Concern
• CHAPTER 5 Whitewash
• CHAPTER 6 Phoebe’s Story
• CHAPTER 7 Nineteen Eighty-Four
• CHAPTER 8 Annus Horribilis
• CHAPTER 9 Irreconcilable Differences
• CHAPTER 10 Aftermath
• CHAPTER 11 Right or Wrong: Heal or Harm
• CHAPTER 12 Mabel’s Story
• CHAPTER 13 A Profession Divided
• CHAPTER 14 Mea Culpa
• EPILOGUE
• POSTSCRIPT Revisionism and Denial
• APPENDIX Summary of main findings of the Cartwright Inquiry
• ENDNOTES
• BIBLIOGRAPHY
• PHOTOS
• INDEX