AN INTERDISCIPLINARY ANALYSIS OF THE HORMONE REPLACEMENT THERAPY SAGA

In this issue we publish an unusual, albeit very much needed, approach to the HRT debate. An international and interdisciplinary team have put together their expertise from the historical, epidemiological, biological, clinical, and advocacy perspectives. Nancy Krieger and her colleagues ask in their paper an undoubtedly crucial question: why, since the mid-1960s, were millions of women prescribed powerful pharmacological agents that had already been shown, three decades earlier, to be carcinogenic?

To understand the eventual answer to this question, they identify in the HRT process a series of missing elements, like for example the invisible industrialist, regulatory agencies and public compared with private interests, beliefs regarding individual compared with collective risk, the irresistible growth of individualised ‘‘preventive medicine”, and the gendering of hormones and regulation of women’s sexuality.

To avoid the occurrence of similar iatrogenic disasters in the future, Krieger and colleagues call for greater transparency with regard to the funding of scientific and medical training, research, and publications, especially to expose potential conflicts of interest arising when funders stand to gain economically from the issues, activities, and products they are either: (a) underwriting, or (b) attempting to obfuscate.
 See page 740

In those years dominated by the Washington consensus on deregulation and structural adjustments, it is important to learn how even in US states—the most powerful advocates of such policies—public service expenditures by state and local governments are strongly related to all cause mortality. The report from James R Dunn, written from Canada, concludes that, “From our analysis, the most promising sectors for public investment to improve health are higher education and primary and secondary education. So long as such expenditures are able to produce high levels of equitably distributed services, our findings suggest one would expect an impact on population health”.
 See page 768

George Knox has produced a convincing ecological analysis from the UK on childhood cancers and oil combustion, showing how these cancers are strongly determined by prenatal exposures to oil based combustion gases, especially from engine exhausts. One component, 1,3-butadiene, a known carcinogen, may be directly causal.
 See page 755

In their Editorial on Knox’s paper, Manolis Kogevinas and Neil Pearce highlight the impressive effort of environmental epidemiology behind this piece, stating that, “More than these specific associations, which may or may not be supported by further research, what makes this paper unique is its capacity to combine in a meaningful way a series of routinely collected data on births, deaths, residences, sources of exposures and specific exposures.”
 See page 717

And last, but not least, we as activists and members of the Health for All generation in public health strongly recommend to our readers the Editorial from our board member, Fran Baum. She describes how, after creating a true international movement for public health in the 1980s, WHO lost its ability to inspire and appeared to give up its leadership in global health to the World Bank. Fran perceives two signs of hope: the existence of the People’s Health Assembly and the recent creation of the WHO Commission on the Social Determinants of Health. If Fran has hope, so do we.
 See page 714