Co-author of a 1984 paper blowing the lid off a controversial cancer study, Ron Jones has long fought to modernise NZ's cervical health, writes Martin Johnston
The medical and ethical earthquake over cervical cancer at National Women's Hospital - and throughout New Zealand - has never stopped causing landslides.
From the day Ron Jones became a junior specialist at the hospital in 1973, through to the Cervical Cancer Inquiry in 1987-88, and now at the end of his career, the deep fault-lines of cervical screening, and what was eventually called the "unfortunate experiment", have divided doctors - and New Zealand.
These tensions have at times been confined to professional put-downs and sniping within the hospital or medical circles but at other times have exploded on to the national stage after a muted, in-house form of whistle-blowing by Jones and his confidantes.
Jones, now aged 70 and an honorary clinical professor at Auckland University, has just retired from his post as a respected, senior gynaecologist.
He refers to himself as a whistle-blower, and indeed he was, as an author of the 1984 article in the United States journal Obstetrics and Gynecology which led, via Metro magazine, to Judge Silvia Cartwright's 1987 inquiry.
But the whistle was deliberately not shrill enough for the public to take any notice. It was pointed at doctors and medical authorities, who apparently read the O&G article, but did not act on it as intended by Jones and his co-authors.
Only after women's health campaigners Sandra Coney and Phillida Bunkle learned of the article via Dr Ruth Bonita, a health researcher at the university, and eventually wrote their 1987 Metro story, did the public hear of the hospital study.
"Given that Sandra Coney was so effective in raising the concerns," Jones says, "why didn't we go to the media in 1984? The answer is that had we done so, we would have been lynched by the medical profession and I am sure that would have been the end of my career in Auckland.
"We should have though. Attempts in the hospital failed, the 1984 paper dropped like a lead balloon. Everyone knew about it but no one wanted to do anything. The fate of the patients was completely ignored."
The 1984 paper and a follow-up published in the Lancet in 2008 looked at the risk of women going on to develop cervical cancer from a lesion then called carcinoma in situ (CIS), now referred to as cervical intraepithelial neoplasia (CIN) 3.
These analyses involved around 1000 National Women's patients, mainly from about 1965 to 1976, who were part of what Cartwright called an unethical clinical study conducted by Associate Professor Herbert Green.
Many women in the study developed cancer and some died.
By 1970, Green held the atypical view that CIS was a benign disease. He wrote at the time that his aim was "to follow indefinitely patients with diagnosed but untreated lesions".
The Lancet paper says some women with CIS received no treatment of curative intent after a diagnostic biopsy of the cervix.
It concludes that "women with untreated CIN3 are at high risk of cervical cancer, whereas the risk is very low in women treated conventionally throughout".
These findings, published in a prestigious journal, are part of the official view in New Zealand of the experiment at National Women's, reinforcing, as they do, the conclusions of the Government-appointed Cartwright inquiry.
Another view exists: that there was no "experiment" because there was no division by Green into two groups, women in the "experimental" group received "228 major treatments", Cartwright got it wrong and her inquiry "destroyed" National Women's.
This view has been promoted over the years in what Jones terms a "guerilla campaign" by some National Women's doctors and has been re-activated by the publication last year of Auckland University historian Professor Linda Bryder's book, A history of the "unfortunate experiment" at National Women's Hospital.
The dissenters from the official view include obstetrician and gynaecologist Dr Tony Baird, a former chairman of the Medical Association and the Medical Council, and Dr Graeme Overton, who is retired.
Overton's re-analysis of the 1984 paper was reported in a 1989 Dominion Sunday Times story headed "Cartwright report based on a scam".
Jones is exasperated.
"I've had a gutsful ... ," he told the Weekend Herald shortly before the publication of his latest letter in the New Zealand Medical Journal, which was accompanied by a response from Bryder.
He has issued a "put-up-or-shut-up" challenge to the Cartwright detractors, saying they should publish a peer-reviewed article in a medical-scientific journal, or be quiet.
He phrased it more politely in his letter, asserting they had "failed to publish their 1990 'independent analysis' at all. In fact I understand it was rejected by the Lancet".
In her reply, Bryder said: "... Dr Graeme Overton, has confirmed ... that their review was never sent to the Lancet nor was there ever any intention to publish it."
Baird did not wish to be interviewed by the Weekend Herald and Overton's wife, Elizabeth, who occasionally speaks out herself, said nor did her husband.
But when asked if her husband wished to respond to Jones' challenge to publish or shut up, Elizabeth Overton said: "Graeme hasn't been able to put anything in since he made that remark in the Dominion Sunday Times 21 years ago. They wouldn't publish anything."
Back at Jones' first day at National Women's 37 years ago, after returning to New Zealand from his post-graduate training years in Britain, when he was among the first junior specialists at the hospital not trained there, Green invited him to lunch.
"He asked me about my views on CIS of the cervix," Jones says. "I told him my teaching had been it was a pre-cancer and should be treated.
"He listened to me and then set about demolishing my perspective. We never talked about it again. I was put down - a junior. He already had an international reputation in the field."
"Looking back, I never dreamed in a million years when I started that I was walking into a cancer-of-the-cervix minefield."
A minefield where the medical and academic loyalty may have obscured what was best for women, according to Jones. He says Green's influence was central to New Zealand not developing a national cervical screening programme until the early 1990s - as a result of the Cartwright inquiry.
Coney says Jones' involvement in writing guidelines on the management of women with abnormal smear results was instrumental in turning general practice around on the value of cervical screening, after Green's influence.
"There had to be a complete mind-shift among the GPs. They looked for signs and symptoms of cancer and were not so worried about the precursors."
Coney also credits Jones with being a leader in the development of colposcopy - cervical examination through magnifying lenses.
And she is surprised at his revelations of how difficult his life became at National Women's.
Jones says he was ostracised by some colleagues.
"I had one who said he would never speak to me again, another who said he would never work with me. There was a distinct coolness. People avoided me. The feminists were a bit tough on me too. There was the innuendo, why didn't I get out and promote it more.
"Well I was destroyed. This was an incredibly difficult personal time. My wife [Barbara] had metastatic breast cancer."
She died in 1990.
Jones received job offers from overseas but he had a young family and wanted to stay in New Zealand. Eventually he took a colleague's advice and became involved in international organisations.
He became the president of the International Society for the Study of Vulvo-Vaginal Disease and chairman of the International Federation of Cervical Pathology and Colposcopy, reducing his involvement in the "New Zealand scene" and leading to two world congresses in this country.
He also took a greater role in research and, when the cervical screening programme faltered in Gisborne because of pathologist Dr Michael Bottrill's mis-reading of smears, he was appointed a clinical adviser to the Health Funding Authority.
Last year he was made a Companion of the New Zealand Order of Merit for services to women's health.
While much of Jones' career has been devoted to cervical disease and the like, he also came to prominence over abortion law reform.
While cleaning out his office on his retirement recently, a 1977 Auckland Star poster emerged. "Doctor will risk jail to test law", it said, in reference to Jones' having told the paper he would continue to perform abortions requested when fetal abnormality had been diagnosed.
Dame Margaret Sparrow, of the Abortion Law Reform Association, says the then new law initially omitted to permit these abortions.
It was amended in 1978 to allow them up to the 20-week point in pregnancy.
Later than that they were still done, but on grounds of risk to the woman's mental health.
"National Women's at the time was pretty conservative. You wouldn't say Ron Jones was one of the liberalisers, but on that issue he was prepared to stand up, which was good."
Jones is proud of his stand which he presents as part of a record of challenging the establishment on behalf of his patients.
He says that after the Cartwright report, National Women's was "devastated and destroyed. Patients wouldn't come to the hospital with smear abnormalities because of this terrible reputation".
But he does not agree with his critics that the inquiry was responsible.
"National Women's was destroyed by a group of powerful men who wouldn't acknowledge that Green's study was doing harm."
But he says the hospital, now a division of the Auckland City Hospital at Grafton, has been rehabilitated to its old position of academic leadership and has some very "fine young staff".
As evidence, he quotes a reviewer from the journal Obstetrics and Gynecology who said, after reading a National Women's paper: "From one of the most respected units in the world".
To the reviewer the controversy must be dead. For New Zealand it will last until a whole generation has passed on.