Portal de Periódicos da CAPES

A Conversation With Maureen Henderson

2009; Lippincott Williams & Wilkins; Volume: 20; Issue: 5 Linguagem: Inglês

10.1097/ede.0b013e3181aff097

1531-5487

Thomas D. Koepsell,

Global Cancer Incidence and Screening

Maureen McGrath Henderson was born in Tynemouth, England on 11 May 1926. Scottish by heritage, she grew up in northern England and earned her medical degree and Diploma in Public Health at the University of Durham. After training with several noted British epidemiologists, she immigrated in 1960 to the United States into faculty positions at the University of Maryland and Johns Hopkins. She rose to become department chair at Maryland, and then relocated to the University of Washington in 1975 as Professor of Epidemiology and Medicine, and Associate Vice President for Health Affairs, overseeing interdisciplinary research centers. In 1983, she founded the Cancer Prevention Research Program at Fred Hutchinson Cancer Research Center, directing it for 11 years. As a clinical epidemiologist, she has focused on prevention of the most important and most common contemporary diseases, and, during her professional life in Seattle, on prevention of cancer, cardiac disease, adverse pregnancy outcomes, hypertension, strokes, lung, and breast cancer. She co-directed 2 major cancer prevention trials, including the huge Women's Health Initiative. Throughout her career, she served on multiple federal advisory panels, was president of the Society for Epidemiologic Research and of the American Epidemiological Society, and was elected to the Institute of Medicine. Among many other honors, in 1996 she received the Georgianna Jones Lifetime Achievement award in Women's Health Research. She retired and became an Emeritus Professor in 1998.Figure: Maureen HendersonINTERVIEW TK: Maureen, you didn't exactly take a straight path to becoming an epidemiologist. How did you end up being in epidemiology? MH: Being immature, I thought I wanted to be an obstetrician. Luckily, I could not get a residency anywhere because I was female and a Roman Catholic. So I decided to go into family practice residency training, in a practice where the senior partner was responsible for 350 deliveries a year, either at home or in a maternity hospital staffed with midwives. I thought, I can do that and then decide after a couple of years whether I want to try to get back into obstetrics. I enjoyed being a family physician and the opportunities to do research, since the British program insisted that family practitioners keep complete and accurate records on each patient. During my second year of training, I developed a bad and persistent cough, and by the end of the year was found to have active pulmonary tuberculosis from a primary infection that occurred while I was a house officer. They sent me to a sanitarium for 6 months—collapsed my lung and did a thoracotomy. After my pneumothorax was stabilized, I went back to my medical school and said, “My lung is collapsed, and I am on a 2-week program of air replacement which will last for the next 4 years. I'd like to use those 4 years by going into residency training for an appropriate specialty, where I wouldn't be looking after patients—for example, radiology.” “No, you see patients doing radiology.” “How about radiotherapy?” “No, you see patients occasionally in radiotherapy.” So I eventually decided to take a diploma in public health. Which was, actually, very interesting. The pediatricians had just started a population-based longitudinal cohort study of a 1000 families in Newcastle-upon-Tyne. The infants in the cohort were followed for 12 years to determine their illnesses and how those illnesses were treated, and they used these data to identify the actual physician needs of the cohort. Senior professional Medical Research Council staff worked with these investigators and provided the university with their expertise and time in teaching the epidemiological courses. So we had far more expert and intensive instruction in epidemiological techniques than usual. I returned to family practice after I completed the degree in public health, to find that this practice in a depressed part of England—known to have the country's highest rates of heart disease in men—now also had higher rates of heart disease in younger women. I decided to get an expert opinion about my opportunities for more education in investigative clinical epidemiology, and I went to London to consult with Jerry Morris. I was fit and thinking of making a career using epidemiological techniques to find out causes and, therefore, ways to prevent important diseases. Jerry listened to me, and was very courteous, but ended up saying, “Look, you're a very pretty girl, go home and get married. Research is far too difficult for women.” TK: So you followed his advice. MH: [Laughter] I got a fellowship to work in epidemiological research in London at St. Bartholomew's Hospital, and to attend courses in epidemiology in the London School of Hygiene and Tropical Medicine. The fellowship was overseen by an advisory committee chaired by Sir Richard Doll. My thesis subject was the identification of the specific lung cancer histology associated with cigarette smoking. After completion of my fellowship, I was invited to join the Medical Research Council unit working in St. Bartholomew's called the Smog Unit. They invited me to be their clinical epidemiologist. I accepted the job with the agreement that I continue to take courses at the London School of Hygiene. One of my reasons was to work with and learn from Donald Reid, Bradford Hill, and of course my advisor, Richard Doll. TK: Who would you single out as having most strongly influenced your career? MH: Honestly, I think the biggest influence was Richard Doll's wife. TK: Richard Doll's wife? MH: Yes, she was a high administrator in the Medical Research Council. I asked Richard and Joan for advice about whether I should stay with the Medical Research Council or go back to a teaching hospital and get a faculty position. Joan said, “You need to get a fellowship in the United States for a while. We in this country don't have money to do research, and if you want to do your own research, you've got to go over there.” Then, later, after I had arranged to go, she said, “I'm glad you're going. When you get there, consider staying, because you'll never be a Professor in this country. They will not promote a woman to be a Professor,” which was honest. So at least it led me explore opportunities in the United States. I think I never would have if she hadn't told me. Richard Doll helped me to get a fellowship at Harvard. But before I left England, I was offered a job at the University of Maryland to work in the Department of Preventive Medicine, and with the agreement that a relatively high proportion of my time would be spent working with faculty and students at Hopkins in the Department of Epidemiology, so I could continue my interests in epidemiological research. I already had some very good friends who were associated with the University of Maryland in Baltimore, so I decided to go to Baltimore instead of Harvard. TK: What would you say is the biggest difference between epidemiology as it was practiced when you started your career and epidemiology today? MH: Epidemiology here today is becoming the medical specialty it was in England before I came here. Epidemiology was written into the National Health Service from the very beginning. TK: How do you mean? MH: The National Health Service wrote population-based clinical trials into its practice from the beginning, so that no therapeutic advances or changes would be made without hard data. All new therapies or all diagnostic procedures would be introduced in a randomized context—in both family practice and in hospitals, using all patients, not selected patients. No new treatment would be given to the general public except through randomized trials. They were all being done by physicians and focused on the most common problems. The system was focused a lot more about prevention than I think a lot of epidemiologists do here. TK: What other special challenges confronted you as a woman in epidemiology, and how did you deal with them? MH: When I came, they were very noticeable. The University of Maryland nominated me for a Markle Scholarship, which was to develop medical school faculty to become academic leaders. In each of 4 segments of the country, 25 candidates were interviewed. In my area, the others were all men, of course. And I ended up actually getting the Markle Scholarship. So I went up to New York to this celebration dinner at the Racket and Tennis Club. They didn't let women in! So I walked around and around the block. Eventually they realized I wasn't there. I had to go in through the kitchen! And of course there wasn't a restroom for women, so this great hero from Philadelphia said after lunch, “Now, come along with me and I'll stand guard.” I was telling this story one day at the Annual Meeting of the American Epidemiological Society and there was a black woman nutritionist sitting beside me. She said, “Huh, you shouldn't worry. I had to go in the bushes.” [Laughter] But it's like everything else. If you feel badly about it, you don't get anywhere. TK: You took on major administrative roles during your career, both in academia and in a large cancer research center. What led you to that choice, and did you find it satisfying? MH: I used my administrative role to develop and promote interdisciplinary research. At Maryland, I brought together and integrated scientists from the School of Nursing, the School of Pharmacy, and the social sciences with medical scientists because we were all dealing with changing behavior. And as a result, we got grants from NIH so that residents and interns in pediatrics or pathology could do training in preventive medicine. For a pathologist to do some training in epidemiology was terrific. TK: Collaboration is essential to successful epidemiologic studies. What have you found to be the most important ingredients of a good collaboration? MH: When we set up the Cancer Prevention Research Program at the Fred Hutchinson Cancer Research Center, we decided that the way to make an interdisciplinary program work well in our setting was to have the best people on the faculties of our departments as leaders and to bring in young faculty who would grow into it. First, everybody had to learn about everybody else's area of science. As we brought in more and more people from other parts of the university, they all had to understand the disciplines of other scientists. So when anybody had even a small research proposal, we all met, they explained it to us, and we asked questions from the perspective of our own disciplines. Then when they got a draft we all discussed it together. It was a tremendous use of the senior faculty, and it really worked because everybody understood what the research question was. We also all learned that everyone had independent and important input, and we respected it. Everyone's voice was as important as anybody else's. We were an interdisciplinary group with one goal—to prevent cancer, or deaths from cancer. We had to respect each other and understand each others’ disciplines enough to listen and accept what they said. TK: Which do you think has been your most inuential paper and your most under-appreciated paper? MH: The most under-appreciated, I think, is one I did with Ed Kass.1 Ed had suggested that bacteriuria was a cause of prematurity and small babies. We took 1000 women in our welfare clinics in Baltimore, black and white women, and we got clean-caught urine samples and then followed the women through their pregnancies. The black women had urine of a totally different acidity than the white women, because they consume fewer dairy products due to lactose intolerance. These women also had higher rates of prematurity. But, actually, careful analysis showed these 2 variables to be totally independent. We asked Olli Miettinen in the Department of Biostatistics at Harvard to do an independent analysis of our data, and he confirmed our conclusions. Ed Kass was disappointed that his theory wasn't confirmed. As a result, the paper was published very quietly, so I don't think it was sufficiently noticed, but I think it was a very important paper. TK: And the most influential? MH: I suspect the most important thing we did was the Women's Health Initiative.2 I don't yet know which of its papers will be the most important paper—there is new information being added every year. But I'll tell you why the Women's Health Initiative is most effective. It isn't the papers we've published; it's the fact that we told the participants about the results as they became sound and available. Usually it takes 4 years for research results to be adopted by physicians. We told these women the results, and they went to their doctors and said “I want to change these pills.” And remember, there were 680,000 of them. So their physicians changed their practice within 2 years. TK: How have you chosen the research questions you wanted to address? MH: By what I thought was the most important problem. I've never done research simply because money was available. I mean, it didn't seem sensible to me just to do it because there was money. TK: What's your assessment of the current state of health of epidemiology? What are the biggest risks and the biggest opportunities? MH: If you're looking at it broadly I think the biggest risk for epidemiology is that money is too easy to get. TK: Too easy? MH: Yes, I think people can get money just to do the things they're interested in, and it has not necessarily led to top-flight work. I think maybe we need higher standards of competition rather than more money. I don't think every institution is equally capable of providing the resources and expertise that it takes. TK: I bet if you asked many working epidemiologists now what the biggest risks are, they would say too little money. MH: Maybe too little overall, but some of the stuff that people spend the money on is just ridiculous. I think you need to have a pretty good education about what you're studying. You need to know something about biology, and you need to have good analytic skills. Everybody can get technical assistance from the machines. But you're really dealing with a sense of dimension and of importance, and you need to be able to put it in perspective. Right now the question of identifying genes and the smaller pieces and so on is not going to have major effects. It's probably going to lead to being able to screen with biomarkers, so you can do a lot more screening. When I was a medical student, we spent hours assisting the surgeons in removing stomachs for stomach cancer. After the Second World War, we got home refrigerators and refrigerated transport, and for the first time we got fresh fruit in the winter. In 30 years the stomach cancer rates had virtually gone to nothing. Now, in this case, why worry about the genes? TK: What would be the single most important piece of advice you could give to a new epidemiologist starting a career? MH: I think I would say what Abe Lilienfeld said. Think about it as a way of life you'd enjoy, and expect to live comfortably, but don't think of it as a way of making a lot of money. It's got to really excite you—something you really think you'll enjoy and feel good about having done. TK: What have been your major interests outside your epidemiologic activities? MH: When I was in Baltimore I sailed all the time. I shared a boat with a pediatric surgeon before she moved to Philadelphia. We sailed and raced. Out here in Seattle, I play golf, swim, and enjoy the friendship of the people around. And I play bridge. TK: Maureen, after your name are the letters O.B.E. MH: Order of the British Empire. TK: Can you say a little bit about how that came about? MH: Oh, the experience was marvelous. The Order of the British Empire was established by King George V, just before the end of the First World War. For the first time ever, ordinary people had been drafted into the armed services. To recognize the contributions to the war, members of the general public were eligible for the first time. The nomination process is secret, and it goes through a year of evaluation. For me it had to go through the US Ambassador because I'm an American citizen. I knew nothing about it till my nephew called me from Germany to say, “Maureen! What is your middle name?” I said, “McGrath.” He said, “Then you are in the Queen's Honor List!” And of course I went, because it's an honor. I took my brother and sister-in-law. We went into Buckingham Palace and through the gates and up the main staircase, with red carpets, and through all of these massive halls with one of the best collection of paintings in the world. They put the guests in a beautiful golden white ballroom with the Grenadier Guards, I think, and an orchestra playing, and we were served refreshments. There were all kinds of interesting people, from all over the world. One woman wasn't wearing a hat. I was wearing a hat, but I hate wearing hats, so I went over to her and said: “You're not wearing a hat.” She said: “I'm making a statement. I'm from Northern Ireland.” I thought, oh, well, okay. I'll leave my hat on. [Laughter]. Then they took us in little groups of 15, and we waited to go in one at a time. You go in, and the Queen is on the dais, and you curtsey as you get up there. The Queen to me was absolutely amazing. She was, as she always is, with her purse on the dais in front of her. She said, “I thank you for coming so far.” I said, “Thank you, Ma'am.” She said, “There are 3 people who are being honored today for work in cancer.” I said I had met them and that we'd all done very different things. She said, “I know that, and I want to know if you're having any success with prevention.” So I said, “Well, if you talk in terms of years, no; but if you think about decades, I think we're getting somewhere.” She chatted about 2 or 3 other things to do with cancer and asked my opinion, and I thought: “This woman's done her homework!” Amazing! There were a 100 people that day, and she chatted to each one. It was marvelous. ABOUT THE INTERVIEWER THOMAS KOEPSELL is Professor and former Chairman of the Department of Epidemiology at the University of Washington in Seattle. He has conducted research to identify preventable causes of many noninfectious diseases and injury types. Maureen Henderson was one of his early mentors and, following her example, his career has bridged epidemiology and health services research.