Ruth was the first of five women to return to the National Women’s Hospital with invasive cancer after the publication of a study of the treatment of CIS at the hospital. It was not written by Green. The authors of the study were McIndoe, McLean, Ronald Jones, a clinician at the hospital, and Peter Mullins, a statistician at the medical school. It was published in Obstetrics and Gynaecology: the journal of the American College of Obstetrics and Gynaecologists, in October 1984.

The authors had gone back to the tissue samples and smear tests for all the women who had been diagnosed as having CIS at the hospital since 1955. The raw data for the 948 women was analysed, making it the largest study of its type in the world. The study divided the women into two groups – 817 who had normal smears after treatment by “conventional techniques” and a second group of 131 women who had continued to produce persistent abnormal smears. This second group is called in the study the “conservative” treatment group. Some had only biopsies to establish the presence of disease and no further treatments. Others had abnormal smears after initial treatment and were not treated further. For example, one woman had 22 malignant smears over 16 years after hysterectomy, but no further treatment. She eventually developed invasive cancer of the vaginal vault.

A most significant finding was that in only 5% of the group-two “conservative” treatment patients did CIS disappear. That is, 95% continued to have CIS, or worse. Twenty-nine, or 22% of these women, developed invasive cancer of the cervix or vagina.

“They went through all my personal files from the hospital and from my GP. I can only liken it to a rape case. I felt so exposed and vulnerable.”

In contrast, the group-one patients who had normal cytology after treatment rarely developed invasion. Only twelve, or 1.2%, progressed into invasion.

Such enormous differences in outcome demonstrated beyond the shadow of doubt that women with continuing abnormalities ran a very high risk of developing invasive cancer.

Twelve of the total number of women had died from invasive carcinoma as had four, or 0.5%, of the group-one women, and eight, or 6%, of the group two women who had limited or no treatment.

There is one small group of women in the study which deserved special attention. Twenty-five women had only a diagnostic punch or wedge biopsy and no further treatment, 18 of this number only ever having a had a single biopsy “with minimal disturbance of the lesion”. These were the women who could most clearly show “the natural history” of CIS.

Ten of these 25 women who only had diagnostic biopsies developed invasive cancer. Worse, almost all of the women who had continuing abnormal smears after the biopsy developed invasive cancer. There were 10 women in this group, and nine of them developed invasion.

The authors concluded the study by saying that “it is, therefore, impossible to escape the conclusion that patients with continuing abnormal cytology… run an unacceptably high risk of developing invasive carcinoma compared with women with continuing normal cytology.”

The women with abnormal cytology, that is, the group-two women, had an “18% chance of developing invasive carcinoma of the cervix or vaginal vault at 10 years, and a 36% chance at 20 years.” The study had clearly shown that “CIS of the cervix had a significant invasive potential”.

Green’s thesis that CIS was a harmless lesion, and invasive cancer a separate disease, had been disproved by his own data.

When interviewed, Green disputed the findings of this study on the basis that the pathology was incorrect. He could not accept that all the invasive cases were really invasive.

On three occasions during our interview with him, Green raised the subject of the deaths of the women. Unasked, he said: “It’s unfair to accuse me of studies which lead to deaths, when they were part of it.”

“But we haven’t said that to you,” we replied. “Who has?”

Eight of the 131 group-two women died. If the death rate in this group had been the same as the group-one women, none would have died.

Scientific method depends on the publication of results which disprove as well as those which prove a hypothesis, but Green never completed his study or published the final result himself.

McIndoe and McLean decided to work on and publish the study because they wanted to bring what had happened out into the open. It was drafted and redrafted over several years and statistician Mullins was brought in “to provide a stronger statistical basis for making the statement. They wanted to nail it down more firmly.”

“We tried to make it impersonal,” says Mullins, “so we couldn’t be accused of a witch-hunt. The ethical issues were drawn and highlighted.” Green’s name is not mentioned in it.

McLean had given some of the data at an international pathology conference in Sydney in 1982: “I got very good feedback from the top gynaecological pathologists in this field. One of the top gynaecologists in the UK came to me afterwards and the first word he said was ‘litigation’. He thought there would be some. Because of the efforts on the part of some staff here to sweep the thing under the table we wanted to bring it out into the open and let our peers judge. They’d tried to cover it up and shut me up. The finding vindicated us.

“We didn’t make it too public in the hospital that we were working on it at first, but in general the clinical staff were supportive. They were too frightened to stand up themselves, but were quite happy to let someone else stick their necks out. It’s like penguins on an ice floe. They push one in first, and if he doesn’t get eaten by the killer whales, they all jump in.”

The authors of the study hoped the academic media would pick it up and were disconcerted when it didn’t, as Mullins puts it, “make more of a splash”. “There were some reprint requests from overseas”, he says, “but none from New Zealand.” If overseas doctors saw the issues, it was not so clear to the New Zealand medical fraternity.

Although he agreed that in general scientific findings should be published, Bonham was critical of the paper. “They were unethically describing Green’s cases to some extent and poking the finger a bit at him. There are innuendoes in that paper that shouldn’t be there.”

Bonham had outlined his concerns in a letter to the medical superintendent in November 1982 before the publication of the study: “I have heard a rumour that Dr McIndoe and possibly another specialist, have being reviewing case of carcinoma in situ that have been managed in the hospital. I have no recollection of approval being given for review of in situ cases belonging to other consultants, and I wonder if they have been reviewing cases by courtesy of Miss Owen (the secretary of the clinic) without the approval of the clinicians concerned.

“This may only be a rumour, but I think it may be worthwhile your having a look at it in the first instance because any publication emanating from this hospital must be acceptable to the staff of the hospital before it is submitted for publication, as I am sure you will agree.”

Mullins said the McIndoe was motivated most to write the paper by concern for the future if Green’s attitudes continued to have influence. “He thought Herb Green’s theories would fade away and Dennis Bonham would change his mind.”

A friend of McIndoe’s told us that he “went through the agonies over writing the paper. He didn’t think anything would be served by pillorying Green, but he worried about the future, particularly about the effect on doctors trained at National Women’s who would not keep up with the research. Green’s teaching was still being followed out there amongst the GPs.”

While Ruth was visiting her specialist before her hysterectomy, he had mentioned that her National Women’s Hospital records showed that she had had a cervical smear in 1982. “This threw me a little,” remembers Ruth, for she was quite sure that she had not had another smear test after being discharged from the hospital in 1979.

When Ruth was admitted for her operation, the house surgeon also mentioned that the hospital had received smear reports from her GP. “I told him that I would like to see one of those reports. He passed me my file. On it I saw clearly in print on two occasions “Alive and well – with evidence of cancer.” I asked how in the hell my GP could say that when he was not doing smear tests”.

The house surgeon told Ruth that her GP should have been performing a smear test annually. This he had not done. What he had done, however, was fill in the hospital cancer clinic follow-up forms as if he had, and return them to the hospital. This he did in 1980, 1982 and 1984. He even provided dates when the non-existent smears had taken place.

When Ruth realised the full enormity of the mismanagement of her case she decided to take some action. She had the choice of proving medical misadventure through the Accident Compensation Corporation and thus recouping some of her sick leave or taking a case against her GP to the Medical Disciplinary Committee. “I had to decide between ACC, which would have been good for me personally, or protecting other women by exposing my doctor.” Ruth decided on the latter course.

Ruth describes the disciplinary hearing as a harrowing experience. The hearing was conducted like a trial with lawyers, people sworn under oath and cross-examination. A panel of five men, three doctors, a legal assessor and an ex-serviceman, would make the decision. The hearing lasted from 10am till 3.45pm. Ruth was cross-examined in the witness box for “what felt like 24 hours. The lawyer tried to put words in my mouth. His main thing was that at National Women’s I would have been told I should have follow-up smear tests. I got to the stage I thought I couldn’t take any more. Then, thank God, he stopped.”

Apart from her lawyer, Ruth had no support in the courtroom. “They went through all my personal files from the hospital and from my GP. I can only liken it to a rape case. I felt so exposed and vulnerable.”

Ruth’s lawyer called a National Women’s Hospital cervical cancer specialist, Dr Murray Jamieson, to question him about the hospital’s handling of Ruth’s case. The committee also wanted to know why the hospital had not acted on the GP’s report of continuing cancer. Jamieson replied that many doctors filled the forms in improperly, and anyway, it was assumed that if there was evidence of continuing cancer, the doctor should have done something about it. Responsibility then was laid at the door of the GP.

Four weeks after the hearing Ruth’s lawyer received the committee’s written decision. Her GP was found guilty of professional misconduct and censured, but in mitigation the committee noted that Ruth had not asked for a smear after being discharged and said that her doctor had been “influenced by the over-optimistic opinion” of the National Women’s specialist. The GP was ordered to pay the court costs of $1551 of Ruth’s legal expenses. This left her with a bill of $1500 for legal fees.

She did not have the satisfaction of helping other women because the committee also ordered that there should be no publication of the doctor’s name in the New Zealand Medical Journal and no publication of details of the findings “in such a way as to identify either the complainant or the doctor” in any other media. For this reason we have been unable to use Ruth’s real name in this article.

“I felt the whole thing had been a bit contradictory. In no other court in the land does a person found guilty have their name suppressed without a very good reason. Why should doctors be immune from the normal laws of society?”

They say “… some southern authorities have promised New Zealand an epidemic of that disease. Every woman should be screened. We are told that cervical cancer is a sexually-transmitted disease. True, the victims are not eaten by worms, but gnawed away by cancer (or fear of it). The wages of sex is a positive smear."

On the surface this further sad chapter in the mismanagement of Ruth’s illness could be seen as just bad luck. Perhaps Ruth was unfortunate to be under the care of a sloppy GP. There is another more likely explanation.

The attitude of Ruth’s GP suggests the whole climate of training about cervical cancer has been affected. Ruth’s GP had done his post-graduate training at National Women’s Hospital in 1976. Consequently he may have felt justified in not taking further smears if he had been taught that smears were inaccurate, of limited value and cervical cancer relatively unimportant. Especially when he read the letter of referral from Green which said that Ruth had no more risk of developing invasive cancer than the next woman. It seems that Green’s attitude has spilled over into a negative, sceptical attitude to cervical cancer screening among doctors.

The investigation for this article met with great discouragement from doctors. With one or two exceptions, they said to leave it alone, it was in the past and no good would be served by revelations in the lay media. It was seen as a matter for the medical profession, not the public. Most doctors refused to talk at all; others were encouraging, but declined to be quoted.

However, cancer experts overseas were more forthcoming in their opinions. Most knew about “the unfortunate experiment” at National Women’s. It was not necessary to explain to any doctors, local or overseas, what the experiment had been about. Yet whatever their personal views, the New Zealand medical profession closed ranks to protect the reputation of their fraternity.

The unfortunate experiment is not an issue of the past. It has continuing repercussions for the women who were part of it, who have to live with cancer now or in the future. But it also has implications for the treatment of cervical cancer today, and for the future of New Zealand’s long overdue cervical cancer screening programme.

The cervical cancer rate has dropped in countries that have a programme of screening women by systematically taking cervical smears, but in New Zealand which has no population screening programme, the number of cases has not declined. The rate of deaths from cervical cancer is gradually increasing, and some doctors talk about an alarming “epidemic” of the cancer among younger women who rarely showed cancer in the past

Many women in New Zealand do have cervical smears taken by general practitioners, family planning clinic doctors or during ante-natal care, but the coverage is haphazard and the groups most at risk are the least likely to have regular smears. Of 40 cases of invasive cancer at Wellington Women’s Hospital in 1986, 14 had had a previously abnormal smear which had been ignored. Others had been treated for gynaecological problems but had not been given a smear test, while several women had asked for an examination and been refused.

New Zealand lags behind the rest of the world in every area of the management of cervical cancer. Some of the country’s major diagnostic laboratories still use outmoded Papanicoloau grading system which has been abandoned in more advanced parts of the world. The care of women with cervical abnormalities is haphazard and casual. Women are brought back endlessly for repeat smears when they should be referred for colposcopy. There are under 20 colposcopes in the country where there should be twice that number. Consequently, at Middlemore Hospital “older” women are not referred for colposcopy after an abnormal smear but proceed straight to a “blind” cone biopsy, a practice frowned on by cancer experts. There are only two lasers, the treatment technique that is the least damaging in many cases.

National Women’s is the primary teaching hospital in gynaecology. It controls undergraduate teaching in gynaecology at the Auckland Medical School and is the home of the Post Graduate School of Obstetrics and Gynaecology where doctors are trained in the speciality.

Professor Green controlled the teaching on cervical cancer until he retired in 1982. In his view “screening is the biggest hoax ever perpetrated on New Zealand women”. He thinks cervical smear tests for screening are a waste of time and money. He contends that more women will die from hysterectomies because of false negatives than if they had been left to die of cervical cancer.

The only way to prevent cervical cancer he says would be to stop “fornication”.

When we asked how you would detect CIS before it became invasive without screening, he replied” “You won’t. All you can do is reduce the effects [of invasive cancer] by early diagnosis.”

He emphasises the importance of history taking, asking women about any unusual bleeding or discharge which can be signs of invasive cancer. These symptoms, however usually only appear once the cancer is invasive and the woman’s prognosis worse than if the cancer had been detected at an earlier stage.

Green believes there are “vested interests” in the current push to set up a nationwide screening programme for women. There are academic careers to be built, he maintains, and talks of the “colposcopic empire” – gynaecologists motivated by the prospect of a great increase in expensive colposcopoic examinations.

This contention is contradicted by the fact that most colposcopes in New Zealand are in public hospitals where no private financial interests are involved. Twenty colposcopes hardly constitute an empire.

Green is undismayed that his views are regarded as idiosyncratic outside National Women’s Hospital.

Green’s successor as teacher and head of the cervical cancer team at National Women’s is Dr Murray Jamieson. The son of a non-conformist minister, Jamieson became a Rhodes Scholar before going as a surgeon to Vietnam after a stint in the territorials. Later he became Green’s registrar at National Women’s.

Jamieson is one of the new generation of “baby boom” doctors. Many believe that he is being groomed by Professor Bonham to be his replacement when he retires.

At his invitation we attended one of Jamieson’s lectures on cervical cancer. It was impeccable and taught the generally-accepted position on cervical cancer screening. Jamieson said he had always taught this way. However, two years ago the head of one of the hospital’s other clinical teams was so disturbed at one of Jamieson’s lectures that he stood up and presented an alternative pro-screening view.

Like Professor Green, Jamieson prefers early diagnosis of invasive cancer to prevention by screen. There is an 80% cure rate for invasive cancer, he says, “a great deal higher than any other cancer”. The other way of looking at this, of course, is that at least one in five women with invasive cancer will die, women who might have been saved by earlier treatment.

In August 1985 Jamieson and Petr Skrabanek, a Hungarian working at the University of Dublin, published at letter in The New Zealand Medical Journal entitled Eaten By Worms: A Comment on Cervical Screening in which they quote classical and Biblical beliefs that sexual misconduct was the cause of genital cancer. They say “… some southern authorities have promised New Zealand an epidemic of that disease. Every woman should be screened. We are told that cervical cancer is a sexually-transmitted disease. True, the victims are not eaten by worms, but gnawed away by cancer (or fear of it). The wages of sex is a positive smear.

“In the 30 years from 1953 to 1982 no more than an average of 90 women a year have died of cervical cancer, compared with almost 2000 persons who died in 1982 from accidents, poisoning and drowning, or to the 34 suicides and 41 homicides in that year.”

The letter concludes that screening is therefore hardly worth the considerable effort involved. “Why then do we fuss so much about cervical cancer? Every woman should have smear, correct? Every woman should be reminded there is a danger? Why? Is it because the fear of being eaten by worms is a healthy fear? Should one million New Zealand women over the age of 19 live in daily fear, though only 0.009% of them will enter the final statistics? Listening to and asking leading questions of patients is far, far better than screening in the control of cervical cancer.”

Dr Jamieson says this letter is not evidence that he is opposed to screening. He dismissed it as a joke. Intended as a lampoon.

Professor Green describes himself and Jamieson as particularly “close’.

Today Dr Gabrielle Collison, National Women’s medical superintendent talks of “two camps” in the hospital, a “pro” and an “anti-screening camp”. Professor Green says the pro group consists of the part-time clinicians; the anti group of the professorial school.

However, Professor Bonham insists that doctors who see National Women’s as anti-screening have all been reading “bunkum from Skragg” (sic) whose views he calls “false and libellous”.

Professor David Skegg, an epidemiologist from Otago Medical School, has been one of a number of doctors not connected to National Women’s who have been trying to persuade medical opinion of the need for a screening programme. He is the author of the Skegg Report, published in The New Zealand Medical Journal in 1985, which reviewed the evidence for the effectiveness of screening and provided a model for a possible programme in New Zealand.

While in many countries such a programme might not be necessary, says Skegg, in New Zealand it was “because National Women’s Hospital, which is very influential, has over about 15 years contained some people who have been very anti-cervical screening, and I think it would be impossible to overestimate the effect that has had on medical training.”

Other New Zealand doctors talk about the National Women’s “party line”. Dr Ian St George, a lecturer in general practice at Otago Medical School, said that through National Women’s role as a teaching hospital Green’s theories have had a “profound influence” both on practice and on the lack of screening in New Zealand. If doctors were to be educated about the value of screening, he says, it would be necessary to “address the issue of Herb Green and the influence his teaching has had in New Zealand, and show that it was wrong; there are still plenty of people who rationalise their lack of effort in taking cervical smears on that opinion”.

Dr Allan Gray, medical director of the Cancer Society of New Zealand put it more strongly. “They are totally up a gum tree. It’s like belonging to a political party. Teaching at National Women’s is not authoritative on this issue. It’s a big disaster area. All the teaching at one medical school is totally out-of-date and incorrect. They’ve taught several generations of doctors the wrong thing. A lot of practitioners won’t do smears because they don’t believe in them. They have been taught that it’s useless.”

It is clear, then, that National Women’s Hospital is a crucial factor in the success of any nationwide cervical screening programme. But no one has been prepared to directly confront its power. Even doctors who want screening avoid rather than confront the problem at National Women’s Hospital.

The cervical cancer symposium held at Auckland Medical School in 1986 was organised specifically to counteract the National Women’s Hospital influence. “The Cancer Society,” says Allan Gray, “paid for the two overseas speakers in the hope of bringing in a glimmering of light.”

No one was prepared to publicly confront Professor Green about “the unfortunate experiment” at National Women’s. He retired with his career intact. A eulogy written by his colleague Professor Liggins in the Auckland University News only praised Green. “His views which were condemned in the 60s as revolutionary and dangerous were largely vindicated in the 70s to the extent that as he retires he has the satisfaction of seeing worldwide acceptance of his conservative approach.”

The silence stems from the medical profession’s rigidly-enforced loyalty among its members. Doubtless the doctors who did talk will be condemned by some of their brethren for breaking ranks.

Ruth’s lawyer encountered that same silence when he tried to find a doctor who would testify to normal handling of a case like hers. He was refused by several doctors.

Professional solidarity is always a priority for the medical profession because it is basic to their power. There are many penalties for those who violate the code. Such doctors are marginalised and their careers stalled.

Covered by his medical insurance, Ruth’s doctor only suffered a day’s embarrassment for his life-threatening negligence. Had his crime been against the profession and not the patient, he might well have suffered a more severe outcome.

The right of the doctor to treat his patient as he wishes is absolute. For over 20 years, no one interfered in Professor Green’s treatment of patients. Eventually, new cases were not referred to him, but no one intervened on behalf of the women he was already handling. In the medical system, there is no voice for the public interest.

With no public scrutiny, regulation is supposed to come from peer review, that is, evaluation by others in the trade.

Some doctors say that such a situation as happened at National Women’s could not recur because peer review is now so widely practised. “The bad old days of the consultant as a tyrant are gone,” Dr Collison told us. Most hospitals now have ethics committees to monitor practices.

But ethics committees are invariably dominated by doctors, and all members are appointed by the hospital with Hospital Board approval. They are not publicly elected. At National Women’s Hospital the ethics committee consists of doctors, one nursing and one lay member. It is chaired by Professor Bonham. Although the committee was instituted in 1977, it appears it failed to investigate or definitively terminate the experiment begun in 1966.

Autonomy is crucial to the power of the profession. Doctors are fanatically jealous of any encroachment on this autonomy. The profession is entirely self-regulating and beyond scrutiny. Doctors are accountable to no one but each other. To preserve this autonomy, the public must learn as little as possible about medical bungles. Left to them the story of the “unfortunate experiment” would have been buried with the victims.