Medicine and Women: 1950-present

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Medicine and Women: 1950-present

Overview

Since the 1950s, women's preventative medicine and health care have greatly improved in the developed world, particularly through the availability of new diagnostic techniques. The use of Pap tests and mammography has become standard methods for the early detection of potentially life-threatening diseases in women. In addition, the increasing participation of women in clinical studies and the greater number of women in the medical field have served to promote women's health, directing attention to medical ailments and issues specific to women.

Background

The Pap test, developed by G. N. Papanicolau in 1943, would prove one of the most important diagnostic techniques for women. This test was designed to enable small tissue samples to be scraped from the cervix for analysis. Any abnormal cells that indicate the possibility of cervical cancer or other uterine problems alert the doctor and patient to the need for careful monitoring and perhaps intervention.

Another major breakthrough for screening was the development of mammography. Albert Salomon studied breast cancer with x-rays in 1913 in Berlin, and in the 1930s Jacob Gershon-Cohen extended these studies at Jefferson Medical College in Philadelphia. These techniques were further developed in studies at the UCLA School of Medicine during the 1940s. In 1949 Raul Leborgne, working in Uruguay, introduced the idea of compressing the breast in order to enhance the image obtained from the x-rays. In 1951 Charles Gros developed the first radiological unit specifically for mammograms. The Compagnie Generale de Radiographie introduced Gros's Senograph machine to the meeting of the Radiological Society of North America in Chicago in 1967, and since then they have been marketed widely round the world.

Medical experimentation prior to 1950 typically excluded female participants. Such testing, during which drugs and other therapies are tried on samples of animals and humans to test their effectiveness and safety, was made complicated by ethical issues of informed consent and willing participation. Some medical researchers did not explain the research to the people they wanted to carry it out on. Some of the subjects were so young, or old, or ill, or mentally incapacitated that they would not have been able to give their consent based on full understanding.

These practices took place all over the world, including Europe and the United States. They reached their worst levels of abuse in the experiments carried out by Nazi doctors on Jewish and other concentration camp prisoners. These experiments were uncovered and many of their perpetrators were punished in the Nuremberg Trials after the Second World War. The Nuremberg Code was subsequently drawn up to establish ethical principles to prevent such abuses from happening again. This code was followed by other regulatory statements in the United States and elsewhere during the 1950s and 1960s. But dubious experimental practices still continued, and many important medical discoveries were made at the expense of mentally incapacitated children or prison inmates.

Impact

More than five decades after its development, the Pap test is now offered routinely to most women beginning in their late teen years, especially in countries that can afford it. This screening program has reduced the numbers of deaths from these conditions. In addition, mammogram technology has also improved. Better x-ray film has reduced the amount of radiation needed to "see through" the skin to the breast tissue to detect abnormalities. In the United States the major medical insurance companies and cancer prevention organizations have long supported universal mammogram screening for women over the age of 50 in order to reduce the numbers of deaths from this cancer.

There has been some debate about whether this screening program detects enough early cancers that can be cured to justify its costs. Some critics even suggest that the mammograms can themselves cause cancer because they use radiation. By the end of the century, ultrasound—which does not rely on radiation—was being used more widely for mammography. One unresolved problem with mammography is that it still requires health professionals to read or interpret the results, and the human eye doesn't always see or understand the information available on the x-ray, leading occasionally to failure to diagnose the disease in time for it to be effectively treated. The American Board of Radiology has only had a specific examination section on reading mammograms since 1990.

Over the last 50 years women have also insisted on participating more fully in clinical trials. It had long been thought important to protect women from becoming involved in such clinical trials, especially when they were still of child-bearing age or actually pregnant. This was to protect them and their children from unknown and unanticipated side effects of the drugs or other procedures that they might be subjected to. However, one consequence of this protectiveness was that medicines were developed based on experiments on men only. Even where the illnesses are the same, men and women can often react differently.

Yet, the drugs and dosages prescribed, as well as other aspects of new treatments, were developed and tailored according to the needs of men rather than both men and women. Even if women are not pregnant or breast-feeding, their body chemistry is different from that of men, especially in the field of hormones and menstruation. Many researchers found it too complicated to allow for the fluctuations of women's body chemistry and simpler to work with males. Similarly, women age differently than men and the role of menopause in their health was not properly considered in much of this medical research.

In the 1970s there began to be a reaction to this protectiveness, which was often an excuse for not addressing the separate issues involving women, and some women argued that men's health was receiving more research attention than women's. The issue came to the fore with the emergence of AIDS in the 1980s. Researchers have since attempted to find a cure or prevention for this disease, and many sufferers have been desperate to be involved in clinical trials that might lengthen their lives.

Women too suffer from AIDS, and they did not appreciate being excluded from these experiments, despite the risks. Many of the same problems of exclusion from clinical trials were felt by ethnic minorities in the United States and other countries. Together, with the women who were concerned about access to clinical trials, they fought some important legal cases to ensure their inclusion. In addition to legal victories, in 1991 the first woman director of the National Institutes of Health in the United States initiated a major long-term study of women's health, including research on the effects of smoking, exercise, hormone therapy, diet, and other factors on the incidence of osteoporosis (brittle bones), heart diseases, cancers, and other illnesses.

Another major area of change in women's health and medicine over the past 50 years has been the growing presence of women in the workforce. Women have entered into all professions, including medicine and health care. Previously relegated to auxiliary roles as nurses and paraprofessionals, women have since gained full entry to medical schools in the United States and Britain, where enrollments are commonly now at least half female.

As well as influencing the work patterns of medical doctors at the end of the twentieth century, the presence of women as physicians is changing the practice of medicine. There has been research to show that women behave differently as doctors than their male colleagues, and have different priorities in treating their patients. Certainly within medical schools in America and Europe there is a growing realization that the way doctors are examined for competence is changing because of the high numbers of women students. These changes are paralleled in the world of medical and scientific research, which are also seeing more women workers, though many still feel that there is a "glass ceiling" limiting their opportunities for promotion.

With the development of hormone replacement therapies many Western women are enjoying longer working lives, with some even beginning to work only after their children are old enough to work. The availability of more effective forms of contraception, even in less developed countries, has enabled women to exercise more control over the timing and frequency of their pregnancies.

Certainly, old paternalistic attitudes among doctors are less readily accepted in countries where patient charters and patient education have reached new levels of awareness and understanding through media exposure. The challenge of the next millennium is to ensure that these advances in women's health are shared equitably around the world, not least because healthy women produce healthy children.

SUE RABBITT ROFF