This essay puts a different spin on public policies that eventually fall from grace, with a look at the cultures of medical practice, medical science, and American society.

December 18, 2002

HRT, Public Policy, and Medical Traditions

by Deborah E. Moore, PhD

“How could so many doctors get it so wrong for so long?” asked Tom Brokaw, several times, on NBC Nightly News during a series of stories on the recent reversal of medical policy concerning Hormone Replacement Therapy (HRT). The practice of prescribing HRT, long perceived and promoted as a near panacea for menopausal women, was suddenly and stunningly becoming undone. Indeed, how could so many doctors get it so wrong for so long?

In light of the fact that since decades ago, animal and human studies of female hormones used as replacement therapy have consistently indicated the potential for cancers and lethality, perhaps a better question would be: “Why wasn’t this drug taken off the market long ago?” One way to address both questions is to look at the cultures of medical practice, medical science, and American society.

It’s no news to most people that the profit-motive is reflected in just about all aspects of American life. Business interests are now unabashedly represented as integral parts of, among many other things, sports events, charity events – and medical research. While most individual medical research scientists undoubtedly are sincere truth-seekers, their bread-and-butter, these days, most often comes from industrial origins or influences. This fact implies an inherent conflict of interest. “Medical research”, whether sponsored by government grants or industry, carries with it an expectation that pharmaceutical or biomedical industrial interests will be involved.

“Treatment” these days almost exclusively implies pharmaceutical, surgical, or genetic intervention or remediation. It is not usually in the interest of corporate profit-making to promote remedies that are preventive by nature (better diet, avoidance of chemicals, etc.) or various alternative treatments for ailments (acupuncture, homeopathy, etc.), so these approaches are still generally marginalized as legitimate treatment options. The habit of seeking/pushing pharmaceutical, “immediate” relief for all or any of real or perceived ills is typically American, and reflects the capitalism inherent in classic American culture. It is the nature of marketing to create the perception of need, and to obscure the reality of actual need. Of course, it is mainly through corporate advertising of medical products, and superficial, often misleading, media coverage of scientific research, that consumers are informed of medical treatments.

It should be of no surprise to Tom Brokaw or anyone else that so many doctors got it so wrong for so long. HRT is certainly not the first medical practice/medical policy to be discredited, found harmful, or seriously questioned years after intensive promotion by the medical-industrial complex. The record abounds with such stories: thalidomide; over-prescribing of barbiturates; Fen-Phen; Redux; Propulsid; unnecessary Caesareans; thimerosal-containing vaccines; antibiotics overuse; and excessive use of Ritalin for children, not to mention antidepressants for too many adults, and many others we hear about regularly on the evening news. What is wrong with this picture?

Medical Traditions
Profit-driven industry and the marketing habits of a capitalistic society are only part of this complex picture. Other pieces of it can be found in the behaviors of doctors, their patients, in the system of medical science itself, and the culture of policy-making.

Problem #1
Practicing doctors are very busy people. While they may attempt to keep up with new research in their area of expertise, time limits their ability to keep on top of all medical research that might be relevant to their practice, including the oldest research, the newest research, and research from other disciplines. So what do busy doctors do? They often rely on their professional associations and their associations’ journals for information. Because these associations are so intertwined with the rest of medical industry, they are all too often embedded in a status quo that is shaped by vested interests, and are therefore threatened by and resistant to innovative ideas. So, information actually getting to doctors may be narrow, biased, or otherwise limited.

Problem #2
Patients are also busy people, and, by and large, like to leave medical decisions and suggestions up to their doctors. They certainly, for the most part, cannot be expected to read medical literature. So, unwittingly, patients end up in a kind of passive collusion with their doctors to promote the status quo.

Problem #3
In American medical science, the burden of proof rests almost entirely on scientific studies and peer review to determine whether any practice is safe and effective. While this system is excellent in theory, it often breaks down in reality. Studies don’t always measure the right thing, or enough things, or interactions; they are extremely expensive to perform, are fallible, are not fraud-proof, and usually do not measure long-term effects. Clearly, many pharmaceuticals enter the market with premature approval and incomplete information. Too often, it is only in the laboratory of the real world that significant dangers are found. Sometimes, as with HRT, it is only when large-scale, longer-term studies are finally performed that the clearer realities ultimately emerge, even though early studies, conflicting shorter-term studies, and anecdotal evidence should have raised many red flags.

Problem #4
Policy-making itself can become its own status-quo trap. Individuals in powerful positions as science or medical advisors to or within organizations of authority frequently build careers on programs that become entrenched public policy. Having spent a good part of their career pushing a particular policy, changing their position does not come easily, and they predictably will do what they can from their places of power to defend this policy.

When these four problems converge with industrial needs and American culture, what results can be termed, “medical traditions”. Medical traditions are created from treatments that seem to work, are believed to work, are endorsed by the right professional institutions and individuals, are lucrative for those who produce them, and are positively responded to by consumers. These treatments are used for years to the point that they become, explicitly or implicitly, medical/public policies. Once they are entrenched in and accepted by society as an integral part of the culture, it is almost impossible to consider living without them. At this point, they are truly “medical traditions”. People believe in and follow them without questioning.

If one were to view medical traditions in the same light as other human traditions, growing out of use and acceptance more so than from unshakable scientific evidence, one can understand how so many can get it so wrong for so long.

So, with HRT, we are witnessing the fall from grace of a time-honored medical tradition that, in the long run, may have contributed more damage than benefits. Was it accepted prematurely when there was actual evidence early on showing potential damage? Are there lessons we, as a society, should be learning from this, and from all the other practices, drugs, and medical traditions that have ultimately been discarded? At what point does it become irresponsible and unethical to willfully ignore potential dangers? Perhaps common sense can answer these questions.

Is fluoridation a medical tradition?

If one looks at the entire and very long history of fluoridation, and if one understands the complexity of this public policy and practice, with all the societal nuances involved, it is almost impossible not to consider fluoridation a medical tradition. In similarity with HRT, the earliest long-term tests were truncated, and some questionable results from these tests were ignored. There always was and still is a very strong industrial component to the promotion of fluoridation. And, in the memory of most of us now living in this country, we have been told our entire lives, by what we assume are the best sources, that fluoride is unequivocally the best thing for teeth. Why would anyone question such a thing?

On the other hand, why haven’t more professionals been asking questions about the many peer-reviewed studies that should be raising red flags, such as those suggesting hip fractures in long-term fluoridated communities, or disturbing correlations involving arthritis, bone cancers, thyroid disease and other evidence of endocrine disruption, and more recently, increased lead uptake in children? These types of studies, among others, have consistently been ignored or dismissed by the medical establishment.

 It is a troubling aspect of fluoridation-as-a-medical-tradition, that many good and educated health professionals, who only want the best for their patients, presume its safety and efficacy, even while aware of the controversy. That it is a long-term health policy with endorsements from high places, apparently keeps them from seeing the credible scientific questioning of this practice. Appeals to authority that perpetuate medical traditions can result in stagnation of ideas and approaches, not to mention turning a blind eye to possible toxic effects. Obviously, as with HRT, this can ultimately lead to dangerous outcomes.

Whether it’s HRT, fluoridation, or any other widespread medical/public policy or practice for which enough credible doubt exists, but the practice is defended and continued, precaution be damned, then logic and wisdom float out the window, we compromise scientific integrity, and we risk exacerbating the toxification of our selves and our world.

Deborah E. Moore, PhD, Director of Second Look, comes to her position with a background that includes teaching, writing, and organizing, as well as scholarship in the philosophy and sociology of science and medicine.