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Response to Review of Managing Uncertainty: Women and Cancer in Contemporary History

Yolanda Eraso has provided an excellent account of the importance of historical perspective to current health policy debates. She rightly points out how fully contextualising past medical interventions and debates, as opposed to the selective view of history which policymakers often adopt, would provide a sounder foundation for policy decisions. Viewing past medical decisions in their broader context cautions against accepting all medical interventions as necessarily progressive and uncontested.

As Yolanda explains, in my book Women’s Bodies and Medical Science, I take the reader through the debates about changing understandings and interpretations of carcinoma in situ (CIS or CIN3) and the Pap smear since the latter was discovered and heavily promoted in America in the 1950s, in order to show the significance of the issues at New Zealand’s National Women’s Hospital. As she rightly points out, my focus was primarily on Anglo-Saxon medical literature in analysing that history. Yolanda suggests that had I paid more attention to the promotion of colposcopy by Germany, Austria, Switzerland, Brazil and Argentina, I might have shed more light on the personal and medical disputes between gynaecologist Herb Green and colposcopist Bill McIndoe, and on the role of colposcopy in those disputes.

Personal and territorial disputes within institutions are always hard to disentangle. However, the irony here is that Green himself was an avid supporter of colposcopy as a safeguard for initiating a conservative approach to a positive cervical smear. McIndoe provided colposcopy for him, but was also firmly allied with pathologist Jock McLean in professional disputes with Green, at least from the early 1970s. From 1974 he stopped doing colposcopies and Green, now deprived of this safeguard, reverted to the more interventionist cone biopsies on all cases. Thus Green did not align himself with the American enthusiasm for reliance on the Pap smear as opposed to McIndoe’s promotion of colposcopy; quite the opposite. Yolanda writes that, ‘Follow up using the colposcope alongside a rigorous histopathological analysis of the removed tissue, gave gynaecologists trained in colposcopy (my emphasis) a confidence in the management of CIS that the Pap test alone lacked’. Yet at National Women’s, it was Green, and not the colposcopist, who held that confidence as a result of his reading of international literature, including that emanating from countries such as Germany, Austria, Switzerland, Brazil and Argentina. I did not intend to suggest that this was simply a personal dispute, but colposcopy itself was not at the heart of the dispute.

Yolanda’s plea for current policymakers to take heed of historical context also holds true for the 1987–8 Cartwright Inquiry itself. This inquiry was an investigation into medical history from the 1950s to the 1970s, but took historical evidence selectively and failed to conduct an in-depth study of the contemporary medical literature. Had it done so it would have come to a very different conclusion; that it did not do so reinforces the view that it was driven by a broader political agenda, firmly located in the 1980s.

Yolanda is to be congratulated for her incisive review, and her analysis of the complexities of the history of ‘managing uncertainties’ in gynaecological cancer and pre-cancer.