The Woman Who Knew Too Much
Author: Gayle Green
The radical theme of the title of this biography is a reflection of the non-conformist streak that runs through the life of its subject, an epidemiologist who was resolute in her mission to eliminate the health hazards that her research revealed. The book describes Alice Stewart as ‘a kind of medical detective‘ who practiced ‘a Sherlock Holmes type of medicine’, and it characterises her research as one in which she applied such qualities as ‘her gift for including the noise‘, and her ‘ability to keep questions open and tolerate uncertainty‘. At the heart of the biography lies the saga of how she repeatedly uncovered life-threatening facts that go against the prevailing orthodoxy, and how she doggedly fought to reverse the dangerous status quo. On one hand, the story is of Stewart regularly stoking the ire of her colleagues with her discoveries, and on the other, of how she was ‘blackballed‘, ‘blacklisted‘, and ‘cold-shouldered‘ by the medical research establishment. What stood out throughout the book was her steadfast advocacy for truth, the reason the author portrayed her as ‘a woman who is courageous (and stubborn) enough to stick to her positions against the attempts of powerful authorities…to discredit her’, and as ‘that rare thing in radiation research, an independent scientist who has found ways of surviving without institutional support’. Perhaps most significantly, the book also depicted her as a campaigner who ‘made her expertise available to activists and put her science to the service of society‘ (pages 1 -3, 213, 229, 249 and 257).
The book’s biographical portrait of Stewart charted her life from childhood to old age activism. The early account particularly highlighted the influence that her physician parents, both ‘pioneers in paediatrics‘, had on her career choice. Her mother’s story was particularly fascinating on its own merit, and for undoubtedly influencing the independent-mindedness that characterised Stewart’s career. For example, the author recounted how Stewart’s mother overcome both the professional challenge of studying medicine as a woman, and the societal prejudice that existed against female doctors. The book also traced Stewart’s educational progress through to medical school where the male medical students ‘managed to segregate‘ their female colleagues, and to clinical training at the Royal Free Hospital where she ‘hit her stride’ and ‘found to her surprise that she loved clinical work‘. The book also recounted her specialist training at the same hospital, and her later appointment as consultant physician to the Elizabeth Garrett Anderson Hospital in 1939 (pages 19-25 and 40-46).
In narrating Stewart’s epidemiological career, the book referred to the second World War as the serendipitous event that disrupted her first consultant job and fortuitously redirected her course away from clinical to social medicine. It is remarkable that she not only commenced her career at the Nuffield Hospital in Oxford without any prior epidemiological training, but the book described how she made her mark with her very first research in which she studied the effects of TNT on shell-filling factory workers; this study, the author enthused, was a ‘landmark and career-defining work that brought her recognition and election as only the ninth female Fellow of the Royal College of Physicians. The book then went on to outline an ill-fated turn-around in her professional fortunes after she assumed headship of the epidemiological unit in 1945. Whilst the author partly attributed this to gender prejudice, she also pointed a blaming finger at Stewart’s own personality; for example, the author referred to her failure to assert her clout, her withdrawal from ‘the corridors of power‘, and her non-participation in decision-making processes. Her refusal to seek out the ‘male mentoring‘ that would have helped her, and a tendency to ‘cut herself off from scientists who might have been supportive’, also fed into the author’s conclusion that self-sufficiency was both Stewart’s ‘strength and weakness as a woman working her way in a man’s world‘ (pages 51-59, 70-77, 255-257 and 228).
The book’s dominant theme is Stewart’s consequential discovery ‘that a single exposure to a diagnostic X-ray shortly before birth will double the risk of an early cancer death‘. Describing this as an insight that ‘made a revolution in medical practice’, the book traced its genesis to Stewart’s decision to study leukaemia, a cancer which ‘leant itself to epidemiological study’ because its prevalence ‘was on the increase for reasons unknown’, and its epidemiological pattern was changing from being a predominantly lymphatic type common in older people, to a dominantly myeloid form with a rising incidence in children. The author described in grainy detail the comprehensive questionnaire Stewart developed and administered to mothers of children with leukaemia in 203 public health departments, visiting each one personally although limited by major funding obstacles. The study’s unexpected finding, which Stewart described as ‘a shocker‘ that ‘has determined the course of my life ever since’, was that children who had died of leukaemia and other cancers ‘had been X-rayed before birth twice as often as the live children’ (pages 1 and 78-83).
As is typical of many major medical breakthroughs, the reaction from the medical fraternity to Stewart’s crucial research finding was dismissive. In a detailed and disturbing narrative, the author captured the predictable attitude of the medical establishment to discoveries that threaten the status quo, and it recounted how the medical institutions just ‘went right on X-raying’. The book also conveyed the determination with which Stewart responded to this resistance, noting that she persevered with her studies, and ‘gradually, over the years, made the profession and the public uncomfortable about medical X-rays’. It was perhaps inevitable that this episode evolved into a rivalry between Stewart and Richard Doll, the foremost epidemiologist at the time whose more influential but ‘small and truncated‘ study (which he himself later acknowledged ‘was not very good‘) contradicted Stewart’s findings. The book explored this regrettable discord which manifested in Doll’s refusal to ‘endorse‘ funding for her long-term research survey, and his refusal, as Regius Professor of Medicine at Oxford, to ‘encourage’ her appointment as professor. So influential was Doll’s research in England that the author said the country became ‘the place that held out the longest‘ in making changes to its X-ray practice (pages 84-91 and 98-103).
Beyond her medical epidemiological work, Stewart became involved later in her life in researching the effects of radiation from nuclear weapons and the nuclear power industry. In its exhaustive exploration of this phase of her life, what the author termed ‘the most dramatic chapter of her career’, the book detailed how her investigations revealed ‘a definite relationship between low levels of radiation and the development of certain types of cancer‘. The narrative particularly showed how her studies discredited the results of the A-Bomb studies of the survivors of the atomic bombs at Hiroshima and Nagasaki, studies which had given rise to the erroneous ‘threshold hypothesis‘ which posited that ‘there was a threshold below which radiation was safe’. The book also documented the predictable intrigues, threats, obfuscations, whitewash, rogue science, politics, and conflicts that Stewart’s research evoked within the nuclear industry and nuclear regulatory agencies. However, believing that ‘she felt it was her responsibility to speak out’, the book described how Stewart responded by taking up public activism against the hazards her research exposed, and by promoting her cause as an expert witness in different legal cases across the world (pages 90, 116, 122-123, 130-146 and 154).
This biographical account is of a doctor who made worthy achievements and who defended them against the tide of prevailing medical and societal dogma. The book highlights the value of pursuing scientific truth even when it goes against the orthodoxy, and the moral requirement to take action when it is evident that prevailing practices are harmful to the population. Although the narrative was almost hagiographic, the author nevertheless managed to shine a light on her subject’s shortcomings. The narrative is lucid and focussed, and although it dwelled excessively on the details of every legal case that Stewart participated in, this successfully captured the overall mood that prevailed during the events she depicted.
This is a thorough even if rather one-sided perspective of a subject that has major epidemiological and clinical ramifications. In its portrayal of the well-recognised pattern of the prejudice and biases that blind the medical establishment from accepting critically important discoveries, the book serves as an uncomplimentary mirror to the whole of healthcare. And in its characterisation of the nature of epidemiological work, it highlights the requisite ingredients of carrying out effective public health research. The book particularly teaches the lessons of how single-mindedness and perseverance eventually win out against narrow-minded opposition based on prejudice and self-interest. The themes the book addresses are fundamental to medicine, and I recommend it to all doctors.
Publisher, Place, Year: The University of Michigan Press, Ann Arbor, 1999
Number of chapters: 17
Number of pages: 321
Star rating: 4