It would be a great pity if fading memories after the passage of 21 years were to allow this revisionist history to obscure the true facts about a sad saga in the history of New Zealand medicine, one that we cannot afford to forget."
Sir David Skegg is deeply troubled by Professor Linda Bryder's book A History of the 'Unfortunate Experiment' at National Women's Hospital. The vice-chancellor of Otago University is the most high-profile academic to date to join a chorus of concern over Bryder's research which received a $345,000 Marsden Fund grant.
Since the book was released last month, debate about its merits has raged in the Listener, the Herald, Radio New Zealand and on websites including Public Address.
That academics would break ranks to publicly criticise another's research is unusual enough, but for a vice-chancellor to do so is almost unprecedented.
There's a bitter irony in Skegg's words too. It was he who first coined the phrase "unfortunate experiment" in January 1986, referring to the practice of Dr Herbert Green, beginning in 1966, at Auckland's National Women's Hospital. At issue is what Green did, or rather didn't do, for more than a decade for a group of women presenting with abnormal cervical lesions called carcinoma in situ (CIS).
The normal practice is to remove these types of abnormalities, detected by routine "pap smear" tests, to prevent them developing into cervical cancer. But Green adopted a "watch and wait" process, his so-called "conservative" treatment. It was like showing a doctor a dodgy-looking mole, having half of it cut out to be sent for testing, then watching to see whether the remaining half developed into cancer.
Many of the women Green treated this way did go on to develop cancer and had to undergo radical treatment such as hysterectomy as a result. If the invasive cancer wasn't caught in time, the inevitable consequence was death. Not surprisingly, when Green's practices were exposed, first in a 1984 medical paper by some of his colleagues and then by an article in Metro magazine in 1987, there was outrage. That led to an inquiry headed by Judge (now Dame) Silvia Cartwright who in 1988 found Green's treatment unethical and the management of his patients inadequate.
Bryder's book, 21 years later, turns history on its head. There was no experiment and nothing unfortunate. Cartwright's inquiry got it wrong - the good judge apparently captured by the feminist agenda of the times.
It's a history that has Skegg incensed. In an opinion piece in the Herald on Tuesday about the triumph of New Zealand's national cervical screening programme, he wrote: "A social historian can hardly be blamed for misunderstanding scientific evidence, but her [Bryder's] book's factual errors and selective quotations make it seem more like an exercise in polemic rather than academic scholarship."
We asked him to explain. What scientific evidence had Bryder misunderstood? "I must assume that Professor Bryder misunderstands the scientific evidence about Green's study, because otherwise she would be guilty of deliberate obfuscation. For example, she does not fully appreciate the crucial difference between mild cervical abnormalities and (what used to be called) carcinoma in situ."
Skegg, an internationally renowned cancer researcher and a professor of preventive and social medicine at Otago University, says Bryder is also confused about the so-called "two groups" in various reports of Green's results. It's a point much argued in her book to show that there was no experiment.
"Ironically, through credulous interviews by Kim Hill (on Radio NZ) and Joanne Black (in the Listener), Professor Bryder seems to have convinced many people that Judge Cartwright was herself misled or confused about this." Skegg has no doubt that Cartwright fully understood the issues. He was not a party to the Cartwright Inquiry, but was invited as an expert witness by Judge Cartwright.
Bryder quotes from Skegg's publications and from his evidence before the inquiry. But she made no attempt to contact him during her research. Skegg is mystified as to why. "I could have given her access to unpublished letters and other documents that would have been relevant."
The phrase "unfortunate experiment" was first used in a letter published in the New Zealand Medical Journal. Skegg was responding to criticisms by Green about the benefits of cervical screening and about the significance of the paper in which Dr Bill McIndoe and his colleagues had documented the results of the management of patients with CIS of the cervix at the hospital.
Skegg wrote: "The case for the effectiveness of screening does not rest on the unfortunate experiment at National Women's Hospital, in which women with abnormal smears were treated conservatively and a proportion have developed invasive cancer. But Green tries to dismiss these results as being due to either inadequate exclusion of invasion at the outset or over-diagnosis of invasion later. The latter explanation is hardly credible in the case of those women who have died from their disease, and the whole argument betrays circular thinking. If the experiment was incapable of falsifying Green's hypothesis, why was it carried out? Moreover, if invasion could not be excluded confidently at the outset, were the patients warned of the risk that was being taken?"
In using the word "experiment" Skegg was referring in particular to the group of women who received only small, incomplete diagnostic biopsies. He says he used the term because in epidemiology and in clinical studies of humans, there are two broad kinds of investigation: observational studies and experimental studies. The fundamental difference is that in an experiment the conditions are under the direct control of the investigators. They do not merely observe what is going on, but can intervene - such as the administration of a new treatment or (less commonly) the withholding of conventional treatment. Skegg says Green's own publications left him in no doubt that "experiment" was an appropriate word for the research.
In a 1967 paper Green reported that "in a special series of young women under 35 years of age in whom clinical, cytological and colposcopic examination has excluded invasive cancer as far as is possible, only punch biopsy (for diagnostic purposes) is being performed." As Skegg points out the words in brackets implied that treatment was being withheld.
Green described this special project again in 1969: "Providing the biopsy did not remove the entire significant area, or reveal invasive carcinoma, there was to be no further treatment."
In 1970, Green wrote: "The only way to settle finally the problem of what happens to in situ cancer is to follow indefinitely patients with diagnosed but untreated lesions. This is being attempted." This explains why Skegg concluded that Green's study must be classified as experimental, not observational. "It was a planned investigation in which conventional treatment was withheld from a carefully defined group of patients. The purpose was to test the hypothesis that cervical carcinoma in situ would not progress to invasive cancer."
Skegg says his description of the experiment as unfortunate was a deliberate understatement to highlight the fact that a significant number of women did develop invasive cancer and some died.
We asked Skegg also to respond to Bryder's argument about the omission of the word "invariably" in relation to Green's 1966 proposal.
"As far as I am aware, no-one thought that CIS invariably progressed to invasive cancer," says Skegg. Where both Green and Professor Dennis Bonham, who headed the post-graduate school of obstetrics and gynaecology at the hospital, got it wrong was that during the inquiry they both insisted the minutes recording Green's proposal were incorrect - that it should have read "the aim was to attempt to prove that carcinoma in situ is not invariably a premalignant disease".
Asked about this during the inquiry, Skegg said: "I hope that the minutes are correct and that Professor Bonham's memory is incorrect because if he says the purpose was to show that carcinoma in situ does not invariably progress, that means that it was thought justified to prove that point, to withhold treatment from the proportion of women in whom it would progress, and in fact to prove that it does not invariably progress, one would have to go on until every single woman had developed invasive cancer."
Bryder shows the same misunderstanding of scientific method by omitting Skegg's rebuttal in her book.
Skegg says far from making significant new discoveries about Green's work and the inquiry it provoked, Bryder has recycled a whole raft of arguments raised around the time of the inquiry, thoroughly discussed, and found to be invalid.
He finds it strange that the book uses quotations from interviews of doctors at National Women's Hospital, but that Bryder made no attempt to test her ideas by interviewing some key participants in the inquiry. "This leaves her open to the accusation that she may have been 'captured' by some of the people who were unhappy with Judge Cartwright's findings," says Skegg.
"One of the doctors interviewed and quoted was found by the judge to have misled the public during the inquiry."
BRYDER: I STAND BY MY APPROACH
One of the key participants in the Cartwright Inquiry to express disquiet that he was not approached by Linda Bryder in the course of her research is Dr Ron Jones.
The Professor of Obstetrics and Gynaecology at National Women's Hospital is the only living medical author of the 1984 McIndoe et al scientific paper that blew the whistle on Dr Herbert Green's research.
Jones, who worked with Green for some years, says he was interviewed by Bryder's researcher, but only about the general history of the hospital, not the saga relating to the unfortunate experiment.
Another expressing dismay is Sandra Coney, the co-author of the 1987 Metro article that brought the National Women's research to public attention. "I am astonished that Linda Bryder, with all the resources at her disposal, could write her revisionist history of the Cartwright Inquiry without interviewing me, Phillida Bunkle [Coney's co-author], our lawyer Rodney Harrison, Charlotte Paul [a medical adviser to the inquiry], the judge's counsel Lowell Goddard, or other people centrally involved in the events, nor seek our documentary records," says Coney.
Bryder says there never was any intention to conduct focused interviews with the inquiry participants. She says the oral testimonies gathered will be used, as appropriate, in the forthcoming "second volume" about the history of National Women's Hospital - as outlined in the original proposal for the $345,000 Marsden Grant she received.
Bryder says there is no convention among historians that oral testimony is vital. She quotes support from Professor Janet McCalman, of the Centre for Health and Society, at the University of Melbourne: "I stand by my first judgment that she has written a careful and judicious account of a very difficult controversy. I think she was absolutely right not to use oral history because memory plays terrible tricks when people are justifying past actions and seeking to avoid criticism. And once you have interviewed someone, you are beholden to them."
Bryder does not believe there was anything to be gained by interviewing Jones about the 1984 paper since the focus in the history "was on the interpretation by others" of its findings. "I also do not see how interviewing Professor Skegg et al about the 1984 paper would have added anything to my understanding of its contents."
Asked about being selective in her research Bryder says: "There was no selection process in the conducting of interviews. While Dr Jenny Carlyon [Bryder's researcher] conducted over 90 interviews for the project, I only listed those directly referred to in the text of this book in the bibliography."
Bryder also rejects criticism about factual errors in her book or that she has misunderstood the science. "These issues are fully dealt with in my book. I explained the debates around the use of the word 'invariably' (pp. 24-25) and in the piece in the Listener responding to Charlotte Paul and Linda Holloway's critique."
She also doesn't accept that a number of participants made attempts to engage with her about her research, but that she declined their offers including an invitation to attend the "Twenty Years After The Cartwright Report: What Have We Learnt?" conference in 2008.
"I was in Britain at the time of the 'anniversary' last year, attending another conference. I have spoken in several forums about my research and I have always allowed questions. I had a very long discussion with Dr Ron Jones when I presented my research at the Auckland Hospital in February 2008."
The Marsden Fund confirms that there are no issues with Bryder's contractual obligations and that its final assessment (which was glowing) was made in February. The fund confirmed that there was no assessment of Bryder's proposal by anyone with a scientific or medical background. All Bryder's assessors, including the international referees, were from the history/humanities field.
Similarly Auckland University Press, which published the book, knowing it was going to be controversial got four, rather than the usual one, external referee reports - one from New Zealand and three from overseas. Director Sam Elworthy says the referees had medical history or sociology of medicine backgrounds. He says he got "a reading" from a medical science expert, but would not say what field.
"Everybody on the AUP board - and it took a while - came around to the belief that we had a substantial work of scholarship to be published."
HISTORIAN'S DUTY TO BE FAIR AND BALANCED
"Historians have a professional duty to produce balanced and fair accounts," says Professor Barbara Brookes, head of the department of History and Art History at Otago University.
She says Bryder's book is based on selective evidence of the thousands of pages of written material surrounding the Cartwright Inquiry.
"Professor Bryder has chosen to tell her particular story of good men wronged. She has reversed what she sees as the Coney story as one of good women wronged."
Brookes, who teaches the history of medicine at Otago, says it's good to reappraise the past from different angles. But Bryder's view that Green was merely doing his best for his patients was rehearsed fully at the Cartwright Inquiry. "It seems odd to then present this as a new angle - especially since journalist Jan Corbett, apparently an important source for Bryder, more important indeed than local medical experts, had already raised these issues, and had been rebutted."
Brookes sees it as the historian's duty to interview key participants because there is so much that doesn't make it on to paper. She says it's puzzling that Bryder had her junior research assistant interview 90 people involved with National Women's about the history of the hospital, but didn't undertake any interviews herself of the key actors in the Cartwright Inquiry such as Clare Matheson, Sandra Coney and Ron Jones - the only living gynaecologist author of the important 1984 paper.
"By questioning Jones about the paper and its intent, many of the author's concerns about misinterpretation might well have been cleared up. Speaking to Clare Matheson [a key patient adversely affected by Green's practices] might also have enlarged the author's understanding but she deliberately chose not to."
Bryder's reluctance to interview participants in New Zealand might suggest she formed preconceived notions, something historians should guard against, says Brookes. "At the very least she should have detailed why she chose to speak to some people and not to others."
Brookes finds Bryder's arguments about historical change confused - arguing on the one hand that change would have happened without the Cartwright Report, but on the other implying that no change was necessary because doctors at National Women's were behaving well. "It was feminists, Bryder suggests, who were behaving badly. This attempt to have it both ways means that the author herself appears muddled and can only muddle her audience."
Brookes points out that Judge Sylvia Cartwright heard and received submissions from a wide variety of sources and assessed them. Bryder's argument, she says, seems to be that the inquiry was the result of a feminist conspiracy that had nothing at its core but the desire to bring down doctors. "Yet Judge Cartwright found, on the basis of extensive evidence, that there was, indeed, a troubling story at the core - one of patients who had their trust abused in the interests of one man's theory."
Bryder refers to 24 of the 128 women traced who had "cervical abnormalities" and that four of them had hysterectomies and the others were given treatment appropriate to their condition. "Bryder then concludes her paragraph with the astonishing sentence: 'No dramatic consequences emerged from this exercise'," says Brookes. "What does this dismissal of the experience of the 24 women [with] abnormalities mean? Presumably if the women had not been recalled, the consequences for some of those 24 women may have indeed been 'dramatic'."
Brookes says it seems as though the women's experience was not of interest to Bryder.