*DifferenTakes* is an investigative series of issue papers, published by the Population and Development Program at Hampshire College, providing alternative information and analysis on a wide range of reproductive rights, population, environment and social justice issues.
We are pleased to send you our latest issue, *"Colonizing the Future: "Scarcity" as Political Strategy" *by *The Corner House*. In this issue, the authors reveal how in the face of contrary evidence, population control advocates are shifting their focus from claiming that human numbers are the cause of past and present scarcity to asserting that population growth will be the cause of absolute scarcity inthe future..
- Betsy Hartmann and Amy Oliver Co-editors, DifferenTakes * Available soon at: http://popdev.hampshire.edu/projects/dt
Colonizing the Future:"Scarcity" as Political Strategy
by The Corner House
A Publication of the Population and Development Program at Hampshire College . No. 43 . Fall 2006
The past is consumed in the present and the present lives only to bring forth the future. --- James Joyce1
Tomorrow belongs . . . Tomorrow belongs . . . Tomorrow belongs to me!--- Chorus, Nazi drinking song, Cabaret2
A preoccupation with the future not only prevents us from seeing the present as it is but often prompts us to rearrange the past. --- Eric Hoffer3
Whenever global environmental crises, Third World poverty or world hunger are at issue, economists, demographers, planners, corporate financiers, and political pundits (at least in the North) have frequently invoked human numbers, whether gratuitously, cynically or for the most part subliminally. Reports on the economy and politics of Southern countries --- invariably the "problem" of population is deemed a Southern problem --- have begun by citing population figures, even though these may have little or no relevance to what follows. But the figures once cited frame the subsequent discussion, skewing the identification of both problems and solutions. The message remains the same: too many people.
Such Malthusian images and thinking --- too many people outstripping supply --- have not gone unchallenged, however. On the contrary, meticulous political attention to what is actually happening on the ground has invariably located the causes of hunger not in an absolute scarcity --- no food at all --- but in socially-generated scarcity --- not enough food for some people in some places because other people have the power to deny others access to food, land and water.
Such power imbalances lie at the root of the manufactured scarcity that is the hallmark of food poverty, whether yesterday's or today's. An incomplete list of such imbalances might include: the enclosure of commons, lack of access to land, unequal gender relations, ethnic and racial discrimination, sexism, intra-household inequalities, denial of human rights, the political exploitation of famine, agriculturalmodernization, market liberalization, and ecological degradation.
Rooting deprivation firmly and squarely in power relations provides proof --- if proof was needed --- that no matter how much food is produced or water harnessed, how few babies are born or how dramatically human numbers fall, it is the nature of inequity remorselessly to generate "scarcity." Without changes in the social and economic relationships that currently determine the production, distribution and consumption of food and water, there will always be those who are judged "surplus to requirements" and who are thus excluded from the wherewithal to live. The human population could be halved, quartered, decimated even, yet hunger would still remain. So long as one person has the power to deny food to another, even two people may be judged "too many."
One result of detailed sociological studies showing that neither the historical record nor contemporary realities support the view that the numbers of people per se are responsible for scarcity is that fewer and fewer institutions now suggest that today's or yesterday's crises are caused by population growth. Even former bastions of Malthusianism, such as the UN Food and Agriculture Organization or the International Food Policy Research Institute (IFPRI), now acknowledge that politics rather than too many people lies at the heart of continuing famine and malnutrition. As Eugenio Díaz and Sherman Robinson of IFPRI note:
"Providing an adequate aggregate food supply will not eliminate malnutrition and hunger, now or in the future . . . To achieve food security for the entire world population, countries must work to reduce poverty and achieve a more equitable distribution of income."4
But this does not mean that the political use of scarcity has been abandoned---far from it. Neo- Malthusians are increasingly shifting their focus from claiming that human numbers are the cause of past or present scarcity to asserting that population growth will be the cause of absolute scarcity in the future.
The marketing of genetically-modified crops is illustrative, and its messaging resolutely future-oriented. The predicted millions of yet unborn 'extra mouths to feed,' (primarily dark-skinned ones, of course), are used first to establish a foothold for genetically engineered agriculture as a "partial solution" to world hunger --- and then to expand that foothold by smothering discussion of any other alternatives, particularly any redistribution of wealth or power. As a promoter of biotechnology states:
"How do we feed a growing population --- which some estimate will reach 9 billion in the next 30 years --- when most arable land on the planet is already under cultivation? . . . Modern biotechnology is part of the answer. Modern biotechnology is not a panacea, but it can help make a difference in the fight against hunger and poverty. Using this new technology, we can feed hungry children, raise incomes, fight disease and protect the environment."5
The structural causes of hunger are now acknowledged, but they are dealt with solely in the context of the present. The future is used to thrust them into the background, casting them as petty distractions of purely academic interest compared to the overwhelming task of boosting future food production. This persuasive power of the future to depoliticize the debate on food poverty and to channel decision making towards a genetically-engineered future is evident in a report from the UK's influential Nuffield Council on Bioethics, which briefly considers redistribution as an option for addressing hunger --- but then summarily dismisses it as infeasible:
"Political difficulties of redistribution within, let alone among, countries are huge. Logistical problems and costs of food distribution also militate against sole reliance on redistributing income (i.e. demand for food) to meet present, let alone future, needs arising from increasing populations in less developed countries . . . What is required is a major increase in support for GM [genetically-modified] crop research and outreach directed at employment-intensive production of food staples within developing countries."6
In the process, questions over the very real role that genetically-engineered agriculture will play in exacerbating the structural causes of hunger --- not least through the privatization of seeds --- are effectively side-stepped.
Other future threats to environment and society are similarly being used to colonize the future and thereby capture the present. In climate change debates, for example, the talk is of future teeming numbers of Chinese and Indians causing whole cities to be lost to flooding through their greenhouse gas emissions --- unless Northern companies are granted property rights in the atmosphere through carbon-trading schemes to continue their own pollution.7
In regards to water, the World Commission on Water for the 21st Century readily conceded in its 2001 report, Vision 21, that current water scarcities do not lie in absolute shortage --- but it went on to argue that future population growth will lead to generalized water scarcity. What the Commission terms the "gloomy arithmetic"8 of future thirsty slum dwellers will condemn us to water wars, unless market discipline and privatization are brought to water use through water pricing:
"Without full-cost pricing the present vicious cycle of waste, inefficiency, and lack of service for the poor will continue. There will be little investment from the private sector, services will be of poor quality and rationed, and there will be little left for investing in water quality and other environmental improvement."9
The Commission's analysis has since been debunked by a succession of reports, most recently by the United Nations Development Program.10 But the "war-room" mentality generated by such predictions of future scarcity-driven apocalypses diverts attention away from the awkward social and environmental histories of discredited policies and projects such as large-scale dams, nuclear power stations and genetically-modified agriculture. We are now told that these are the only ways to meet globally aggregated predictions of supposedly climate-friendly energy demand or food needs.
Such seems to be the power of "scarcity" to colonize the future that even those who ascribe today's scarcities to political conflict frequently set aside the insights of political economy in favor of human numbers as an explanation for future shortages.
In doing so, they grant Malthusianism an explanatory power that they would actively deny to it when applied to the present and the past. Instead of the past being a guide to future action, the future (implausibly) becomes a guide to the present. As the 20th century futurologist Herman Kahn (reputedly the model for Stanley Kubrick's Dr. Strangelove) stated, "Anyone can learn from the past. These days it is more essential to learn from the future."11 The dictum that "those who cannot remember the past are condemned to repeat it"12 is jettisoned in favor of the ungrounded, and thus politically even more malleable, exercise of "learning from the future." In the process, "scarcity" is rehabilitated. Removed from the messy political realities of the present, it regains its authority as an abstract model, redeploying its mesmerizing powers over those who would privilege theory over lived experience.
Yet future crises are likely to be rooted in the same dynamics in which they are rooted today: political conflict, exploitative distributive institutions, sexism, racism, human rights abuses and environmentallydestructive practices. If society wants to prepare for future resource crises (and there surely will be future scarcity of one kind or another), it would be more prudent to look to the present rather than to some theoretical model of the future. As the future will grow out of the present, a better way of dealing with "future crisis" is not imagining a future Malthusian world that bears no relationship to what exists now or ever has existed, and then imagining how to stave off that hypothetical Malthusian destiny, but rather dealing with current scarcities now on the realistic assumption that what causes scarcity today is going to go on causing scarcity in the future.
Denying Malthusianism a refuge in the future is of critical importance if the past is not destined to be repeated and the present forgotten. But it is also important if "scarcity" is to be marginalized as a political strategy for diverting attention from the root causes of hunger, environmental degradation, conflict and the like.
Indeed, "scarcity," as used in modern economics, is best approached as an endlessly malleable means of legitimizing a particular set of social and political relationships, institutions and policies and of blocking inquiry, rather than as a theory that stands or falls on its ability not only to explain but also to predict. Empirical evidence, coupled with political organizing around other explanations for manufactured scarcity, may temporarily deny political space to those who would use scarcity as a strategy in one arena. But it does not, and will not, prevent its proponents from using it in other arenas where its power has not been weakened --- yet. So long as it remains useful as a means of diverting attention from causes of poverty that might implicate the powerful, it will be recast, adapted and re-used whenever and wherever possible, regardless of the empirical evidence that is built up to counter it.
For granting Malthusianism a space in the future is one of the principle everyday actions through which scarcity-terrorized thinking --- and the power relations and activities that it helps to support --- are reproduced, rejuvenated and allowed (even when debunked by practical experience) to return to haunt the present.
*The Corner House* is a research and solidarity group based in the United Kingdom that aims to support democratic and community movements for environmental and social justice. This piece evolved from a collaborative project with the Women's Global Network for Reproductive Rights to analyze the continuing power of Malthusian thinking. www.thecornerhouse.uk.org.
The Population and Development Program CLPP . Hampshire College . Amherst . MA 01002 413.559.5506 . http://popdev.hampshire.edu Opinions expressed in this publication are those of the individual authors unless otherwise specified. *References* 1. J. Joyce, A Portrait of the Artist as a Young Man, 1916. 2. Cabaret, film directed by Bob Fosse, script by Christopher Isherwood and John VanDruten (1972). 3. Eric Hoffer, The Passionate State of Mind (New York: Harper and Row, 1954). 4. Eugenio Díaz and Sherman Robinson, "Biotechnology, Trade and Hunger," Biotechnology and Genetic Resource Policies, Brief 2, IFPRI, (Jan 2003), http://www..ifpri.org/pubs/rag/br1001/biotechbr2.pdf. 5. Testimony of David Sandalow, Assistant Secretary of State for Oceans and International Environmental and Scientific Affairs, to the Subcommittee on International Economic Policy, Export and Trade Promotion of the Senate Committee on Foreign Relations, Washington, DC, (July 12, 2000), http://bogota.usembassy.gov/wwwse507.shtml. 6. Nuffield Council on Bioethics, Genetically Modified Crops: The Ethical and Social Issues, (1999), paras 4.8, 4.10, http://www.nuffieldbioethics.org/go/ourwork/gmcrops/publication_301.html. 7. Larry Lohmann (ed), Carbon Trading: A Critical Conversation on Climate Change, Privatisation and Power, Dag Hammarskjöld Foundation, the Durban Group for Climate Justice, and The Corner House, (2006). 8. World Commission on Water for the 21st Century, A Water Secure World: Vision for Water, Life and the Environment, (2000), 15. 9. Ibid, 35. 10. UNDP, Beyond Scarcity: Power, Poverty and the Global Water Crisis, Human Development Report 2006, available at http://hdr.undp.org/hdr2006/. 11. Herman Kahn, quoted in VaTech Hydro, Annual Report 2001, 33, http://www.vatech.at. 12. George Santayana, The Life of Reason (Amherst, New York: Prometheus Books, 1998).
Visvanathan, Nalini and Rao, Mohan. Women at risk: Quinacrine sterilisation, a practice that defies accepted international norms, continues in India. Frontline Vol. 14 : No. 19 : September 20 - October 3, 1997
Mulay, Shree. Quinacrine non-surgical sterilisation: troubling questions. Indian Journal of Medical Ethics July -September 2000-8(3)
For further updates send blank email, with subscribe in Subject line, to "Quinacrine Alerts": groups.yahoo.com/group/quinacrine_alert/
RE: Change in FHI's research strategy for female non-surgical sterilization
December 18 2006 Dear Colleagues, We would like to inform you of a change in Family Health International (FHI)'s research strategy for female non-surgical sterilization. FHI has sought to develop a product that is safe and has an effectiveness approaching that of current long-term contraceptive options, such as surgical sterilization and intrauterine devices (IUDs). To date, our research has focused on two products: quinacrine and erythromycin. Safety concerns generated by results from a recent animal study of quinacrine, combined with the results of a recent systematic review of quinacrine's effectiveness in women, have led us to cease our development of quinacrine for non-surgical sterilization. FHI will continue working on the development of erythromycin for this purpose.
With regard to quinacrine's safety, FHI has completed a battery of genotoxicity tests (in vitro tests and in animals) as well as two rodent carcinogenicity studies, one in mice and one in rats. Genotoxicity testing in cells (prokaryotic and mammalian) verified earlier results of others that quinacrine is mutagenic in vitro, although quinacrine was not clastogenic in vivo, i.e., did not cause chromosomal breaks.1
In the first of the rodent carcinogenicity studies, mice exposed to quinacrine systemically (i.e., as are humans when given quinacrine orally) did not show an increased risk of cancer at the end of the one-year observation period.2 In the recently completed rat study, quinacrine was administered directly into the rat uterus, mimicking the proposed contraceptive use in humans. The rat study showed a dose-related increase in malignant reproductive tract tumors at the end of the two-year observation period.3 The increase in tumors was only significant at the upper two doses, and not at the lowest dose. The lowest dose was approximately twice the human dose level on a mg/kg basis.
The relevance of the in vitro and animal study results to humans is unclear. Quinacrine was used widely in the 1940s for malaria treatment and prevention, and an oral toxicology study in rats found no increased risk of cancer.4 However, fewer data exist about intrauterine quinacrine administration. As previously published, FHI conducted a number of early clinical trials of quinacrine involving small numbers of women in the late 1970s and 1980s.5,,67 Since that time, FHI has conducted two long-term epidemiologic studies of women who received intrauterine quinacrine, either as part of the FHI early trials, or as part of other public or private family planning programs not funded by FHI.8,9 Neither long-term study has shown a significant increase in the risk of cancer. Since these studies had limited power to estimate cancer risk because of the relatively small number of study participants, FHI initiated and is currently completing a five-year, case-control study that should provide additional evidence about any potential association between intrauterine quinacrine administration and the risk of gynecologic cancers in women. These results should be available in mid-2007.
We have reported these recent rat study results to the U.S. Food and Drug Administration (FDA). Because women already have a variety of other contraceptive options, we believe that the potential risk of cancer outweighs the potential benefits of quinacrine as a method of contraception, and we anticipate that the FDA would reach a similar conclusion. These considerations have prompted FHI to both cancel its plans for a clinical study of quinacrine in women and to stop working to develop quinacrine as a method of non-surgical sterilization.
Ultimately, a "weight of evidence approach," based on the sum of all findings from available safety studies, will be needed to conclude whether intrauterine administration of quinacrine increases a woman's risk of cancer. While FHI will not be proceeding with quinacrine development, we still plan to convene a scientific panel in late 2007 (after results from the five-year, case-control study are available) to review results of all in vitro, animal toxicology, and human epidemiologic studies. The panel will evaluate the potential risk of cancer based on all available data. This evaluation may be useful to physicians and public health authorities if they need to address women's concerns in countries where quinacrine was used for non-surgical sterilization in the past.
Concerning quinacrine's effectiveness, FHI recently completed a systematic review of data on the effectiveness of quinacrine as used in clinical trials over the past two decades.10 Reported pregnancy rates are as high as 12.6 per 100 women, at five years after two insertions of 252 mg quinacrine, one month apart, according to the standard clinical protocol. This level of effectiveness does not satisfy our goals for a non-surgical sterilization product.
Furthermore, recent results of an FHI-sponsored animal study of a potential adjuvant to increase quinacrine's effectiveness were not promising. FHI's systematic evaluation of quinacrine reflects our dedication to (1) thoroughly studying contraceptive technologies to maximize the availability of safe and effective contraceptive options, and (2) conducting research that respects and values women's welfare. In this respect, an essential component of our non-surgical research program has been an ongoing dialogue with women's health advocates. In 2001, we formed a panel of women's health advocates, and they have regularly provided invaluable advice and input to our program. We still believe that a method of non-surgical sterilization that is safe, effective, inexpensive, and easy to administer would expand the array of contraceptive choices, especially for women who do not have access to surgical sterilization or who prefer a permanent non-surgical method. FHI will continue its efforts to develop such a product, through its current evaluation of erythromycin and consideration of other potential candidates in the future.
A One-Year Neonatal Mouse Carcinogenesis Study of Quinacrine Dihydrochloride
Aida M. Cancel A1, Thomas Smith A2, Ursula Rehkemper A2, John E. Dillberger A3, David Sokal A1, R. Michael McClain A4 A1 Family Health International, Research Triangle Park, North Carolina, USA; A2 Covance Laboratories, Harrogate, North Yorkshire, England; A3 J. Dillberger, LLC, Nashville, Indiana, USA; A4 McClain Associates, Randolph, New Jersey, USA
Quinacrine is an acridine derivative under investigation for its use in nonsurgical female sterilization. Safety issues regarding the carcinogenic potential of quinacrine have been raised because it is mutagenic and clastogenic in vitro. The objective of the study was to evaluate the carcinogenic potential of quinacrine dihydrochloride (quinacrine) in neonatal mice treated with single intraperitoneal doses on postpartum days 8 and 15 and observed for 52 weeks. Neonatal Crl: CD-1 mice of each sex were randomly allocated into four treatment groups (0, 10, 50, and 150 mg/kg), dosed twice with quinacrine suspended in carboxymethylcellulose, observed for 52 weeks post dose, and then euthanized, necropsied, and subjected to a full histopathological examination. In male mice, tumor incidence was not significantly increased at any site at any dose level. In female mice, the incidence of benign uterine endometrial stromal polyps was slightly greater at the mid and high dose (=50 mg/kg), as was the incidence of endometrial hyperplasia. The incidence of polyps in these groups was not significantly greater than in controls by pair-wise comparison but was significantly greater (p= .042) by the linear trend test. The authors conclude that quinacrine administered twice to neonatal mice may have enhanced or accelerated the development of endometrial hyperplasia and uterine stromal polyps at higher doses. Because uterine stromal polyps are a commonly observed benign tumor in older mice, the significance of this finding is unclear and will require a weight of evidence evaluation for a conclusion on the carcinogenic potential of quinacrine.
Keywords: Carcinogenesis, Endometrial Stromal Polyps, Neonatal Mouse, Quinacrine, Uterus ^^^^^^^^^^^^^^^ For additional information about this study, please feel free to contact us.
David Sokal, MD Scientist, Clinical Research Division Family Health International (FHI) PO Box 13950 Research Triangle Park, NC 27709, USA Office - direct: 919-405-1466 FHI gen'l phone: 919-544-7040 ext. 232
Karen E. Haneke, MS Program Manager, Nonsurgical Sterilization Product Development Family Health International (FHI) PO Box 13950 Research Triangle Park, NC 27709, USA Phone: 919-544-7040 ext. 530
1 Clarke JJ, Sokal DC, Cancel AM, et al. Re-evaluation of the mutagenic potential of quinacrine dihydrochloride dehydrate. Mutat Res 2001;494(1-2):41-53. 2 Cancel AM, Smith T, Rehkemper U, et al. A one-year neonatal mouse carcinogenesis study of quinacrine dihydrochloride. Int J Toxicol 2006;25(2):109-118. 3 A manuscript describing the study is being prepared for publication. 4 Fitzhugh OG, Nelson AA, Calvery HO. The chronic toxicity of quinacrine (atabrine). J Pharmacol Exp Ther 1945;85:207-221. 5 Laufe LE, Sokal DC, Cole LP, et al. Phase I prehysterectomy studies of the transcervical administration of quinacrine pellets. Contraception 1996;54:181-186. 6 Zipper J, Cole LP, Rivera M, et al. Efficacy of two insertions of 100-minute releasing quinacrine hydrochloride pellets for non-surgical female sterilization. Adv Contraception 1987;3:255-261. 7 Sokal DC, Zipper J, King T. Transcervical quinacrine sterilization clinical experience. Int J Gynaecol Obstet 1995;51:S57-69. 8 Sokal DC, Dabancens A, Guzman-Serani R, et al. Cancer risk among women sterilized with transcervical quinacrine in Chile—An update through 1996. Fertil Steril 2000;74:169-171. 9 Sokal D, Hieu DT, Weiner DH, et al. Long-term follow-up after quinacrine sterilization in Vietnam. Part II: Interim safety analysis. Fertil Steril 2000;74:1092-1101. 10 A manuscript describing the review is being prepared for publication.
DifferenTakes is an investigative series of issue papers, published by the Population and Development Program at Hampshire College, providing alternative information and analysis on a wide range of reproductive rights, population, environment and social justice issues.
We are pleased to send you our latest issue, "Too Many Grannies? The Politics of Population Aging" by Sarah Sexton. This issue looks at how in countries with low fertility old people are now being cast as burdens with alarmist images and arguments similar to those used to generate fear of "too many babies" in the Third World.
- Betsy Hartmann and Amy Oliver Co-editors, DifferenTakes
* Available soon at http://popdev.hampshire.edu/projects/dt
Too Many Grannies? The Politics of Population Aging
A Publication of the Population and Development Program at Hampshire College • No. 42 • Fall 2006
Until recently, pensions were primarily of interest to just two minorities: older people and actuaries. But no longer. As The Economist puts it, “for the first time, pensions are as hot as an issue can get.”1 Pensions are now prompting workers to put up the barricades and go on strike across Europe. They are triggering bankruptcies among top-ranking companies. They are filling newspaper pages and television screens.
Surely, headlines of people living longer and healthier lives should be a cause for celebration? Instead, media reports dwell on doom-and-gloom scenarios of masses of desperately poor, gray-haired folk who will be a burden on their families and society alike.
It has been an axiom of international politics for decades that our world is overcrowded with billions of humans or rather poor and brown-skinned youth, largely from the South. Have the poor old of the North now joined these surplus billions? Or is the focus on aging simply a continuation in another guise of age-old Malthusian politics? After all, the apocalyptic language used in media reports is echoingly familiar. This time, however, “demographic time-bombs” refer to aging women, conflict is predicted between generations instead of countries, and the greatest risks are believed to stem from people living longer than they used to.
Too many old people? Demographic studies indicate that the absolute numbers of older people and their proportion in any given population are rising in many countries around the world. In Japan, the proportion of the population over 65 is the highest in the world at 19 percent, even though half a century ago, it was just five percent, well below that in the US, UK, France or Germany. In the UK, the proportion of the population over the age of 60 has been about the same for the past 20 years (21 percent), but this figure is predicted to rise to almost 30 percent by the year 2031. Of OECD (Organization for Economic Co-operation and Development) countries, Italy, Japan and South Korea are likely to be the “worst affected” by population aging. By the year 2050, more than one third of the populations in these countries will be over 65 compared to one fifth in the US, Mexico and Turkey. Although warnings usually focus on a “crisis” in Northern countries, some 60 percent of older people already live in the South, with the figure expected to rise to 80 percent by mid-century.
What actions should be taken based on these projections, however, is open to question. Historical demographic statistics do not show that the proportion of older people in a population has risen constantly: just like birth rates, it rises and falls over time as circumstances change.
Indeed, the increase in the number of older people is, to a certain extent, a temporary phenomenon, reflecting the advancing years of those born during the “baby boom” the sudden leap in births that occurred in many industrialized countries after the Second World War between 1946 and 1964. This “old age bulge” will simply work its way to the top of the age pyramid and deflate by about the middle of the 21st century as the baby boomers die. Rarely mentioned is that societies managed to find the money to feed, clothe, house and educate all these baby boomers for their first dependent 16 to 20 years before they started working; or that the US economy will be three to four times larger when the baby boomers retire than it was when they were young dependents.2
Predictions of what will happen in the future based on current statistics and trends are notoriously problematic, not least because they do not allow for changes occurring between now and then. Population studies certainly do provide indications for future economic development and growth, labor markets, national savings, age structures, health, fertility and mortality, functioning of markets, welfare programs and inequality. But the results are simply projections rather than predictions, and in many cases they are inconclusive.
…living for too long? Besides a higher proportion of older people, another cause of the supposed pensions (and healthcare) crisis is significant increases in longevity. One financial journalist asserted that: “Once upon a time our biggest fear was dying too young. Now it is living too long.”3
Life expectancy in many countries has been lengthening for the past 200 years. In the first half of the 20th century, lower death rates in early life accounted for much of this rise in longevity. But people now tend to be living longer because of changes that affect the rest of their lives: less smoking, less exhausting and dangerous jobs, better education, and medical advances in anesthesia and surgery.
Yet it is hardly a surprise that people are living longer. Governments and actuaries have had at least half a century’s warning of any “crisis,” given that pensioners were born 60 or more years ago.4
Many projections of life expectancy assume that people’s lives will simply carry on lengthening, just as predictions of future population growth are often based on extrapolating birth rates way into the future. But just as population growth and birth rates do not continue ever upwards, so, too, life expectancy will not increase ad infinitum.
Indeed, average life spans in several countries are falling rather than rising. According to US Census projections, life expectancy in more than 40 countries is anticipated to be lower in 2010 than in 1990. In Russia, for instance, life expectancy has dropped significantly since 1985, especially for men, a fall attributed to alcohol-related diseases, accidents and violence. In sub-Saharan Africa, life expectancy has dropped precipitously by 10-20 years in the past two decades largely because of AIDS. If there are proportionally more older people in many African countries than there used to be, it is more because the young are dying than because the old are living longer.
.. . . or too few babies? Rather than “too many old people,” the issue could be presented equally well as one of “too few babies,” implying that a country will have “too few workers” in the future. In the past 50 years, the world’s average birth rate has tumbled from five children per woman to 2.65 children. Most of the 44 countries classified by the UN as “developed” have birth rates below the replacement level of 2.1 children per woman.
In recent years, Italy has had the lowest birth rate in Europe with Spain not far behind. But the most recent figures suggest that Germany now has the lowest: 8.5 births for every 1,000 inhabitants compared with 12.7 and 12 in France and Britain respectively. “Baby Shock: We Germans are Dying Out” headlined one newspaper article in March 2006. In response, some politicians have suggested that people (especially educated women) who do not have children should have their pensions reduced by half.
And it is not just in the developed world that fertility has fallen. In East Asia, Thailand, Burma, Sri Lanka, many Caribbean countries and most South American countries, fertility rates are now below replacement level. Brazil, Iran and Turkey may all be below replacement level within 15 years. In some countries where more boys than girls are being born and raised because of sex selection and son preference, the decline may be compounded.
Yet reducing the birth rate has been a key international policy goal for more than 50 years. Rather than reassessing this goal, however, it has proved easier to target and to blame vulnerable older people.
An October 2005 OECD study projects that, by the year 2050, 10 active workers will be supporting, on average, more than seven older inactive people compared with just four in the year 2000. What is rarely highlighted in such studies is how the previous generation of retirees laid the foundations for economic growth through their own work and taxes.
Statistics, moreover, leave out the reasons why many people of all ages struggle to earn a reasonable living, such as a lack of skills, experience or aptitude, lack of educational opportunities, low wages, the outsourcing of manufacturing and, increasingly, service jobs to even lower-waged countries. Raising the age at which people can retire and draw a pension as a way of reducing the cost of pensions assumes that there are jobs and training available and that older people do not suffer age discrimination. In the UK, some 40 percent of the one million people between the ages of 50 and 65 who want to work are unable to find employment.
“Old” is, moreover, a relative term. Attitudes toward “old age” are anything but unilinear and unambiguous. Nor are boundaries between “working age” and “old age” completely rigid. Many retired people are part of the “active” economy rather than a dependent expense or a passive burden. This is the case whether they are seen only in the narrow calculus of economics and accountancy or whether they are considered as part of a broader politics of welfare. In financial terms, they spend, save and invest, all of which helps an economy. They may not be net consumers of public money or national wealth, if the broader effects of their activities are taken into account. For instance, many perform social, voluntary, group and family activities, such as (grand)childcare and community and charity work, all of which are not captured by quantitative measures such as GDP and thus are not off-set against public expenditure.
.. . . or too few migrants? Dull, number-crunching arguments about life expectancies, birth and death rates, and the affordability or otherwise of pensions and health care become emotionally charged when they overlap with debates on immigration. Indeed, fears of “too many immigrants” provide much of the subtext for the current debates on population aging. In the process, both migrants and pensioners are being scapegoated.
Supporters of increased immigration, either on a permanent or temporary basis, argue that migrant workers provide much-needed skills and labor, given the declining ratio of younger people to older ones. They thereby boost economic growth and enable pensions and health care to be paid. UN Secretary General Kofi Annan points to Japan, Russia and South Korea as examples of countries facing shrinking economies and “stagnating” societies. “Immigration alone will not solve these problems,” he says, “but it is an essential part of any solution.”5 Opponents contend that immigrants take the jobs of “native workers,” lower the wages of others, and thereby depress the economy for everyone.
While these arguments are ostensibly about economic costs and benefits, racism and nationalism are never far from the surface and other economic and historical realities are selectively left out of the picture. The UK and the United States, for instance, have been countries of migrants for centuries, and their preeminence still relies on the legacy of slavery and colonialism. Columnist Gary Younge of the UK’s Guardian newspaper points out that “economically, without the huge pool of cheap labor emanating from the developing world, documented or not, we simply could not function as we do.”6 Many migrants are filling jobs that British people are unwilling or unable to do.
More and more migrants are going to OECD countries as highly-skilled workers to fill jobs in areas of shortage, such as nursing, teaching and information technology. Without nurses and doctors from overseas, for instance, the UK’s public health service would collapse.
Far from depending on welfare, many migrants are supporting families and communities in the countries from where they came. In 2004, migrant workers formally transferred US $150 billion in total, and informally twice that amount in all, triple the value of official aid to Southern countries and not far behind foreign direct investment.7
An estimated 200 million people now live and work outside their own country, double the number of 25 years ago, but representing just three percent of world population. Europeans migrated in vastly higher numbers in the 19th century to the Americas and Australasia. Nonetheless, migrants are often held responsible for unemployment among old and young alike. Three academic economists point out how easy it is to create a “popular wisdom [that is] simply false”:
“Start by substantially overestimating the number of migrants, as the natives invariably do. They assume the number of jobs is fixed. Evidently any immigrant must be taking the job of a native, so unemployment can be cut only by stopping immigration.”8
Often left out of discussions is an international trade policy that allows capital to roam freely across borders in search of low wages, destroying jobs and livelihoods, but that does not allow people to move in search of better ones. To date, such free market policies have been instrumental in causing the forced movement of people who are simply trying to survive or are fleeing from torture and oppression and in causing the increased racism and hostility they encounter if they manage to migrate. In a similar and related process, pensioners are denigrated as burdens on the young even as footloose capital depends on their savings.
In Whose Interest? A major goal of many of those who emphasize the aging crisis (too many old people will soon cause countries to go bankrupt) is to reduce direct state provision of pensions so as to increase private, for-profit provision, albeit with significant public subsidies. Pension savings are not intended to be stuffed under a mattress or hoarded in a bank vault, but put into private pension funds that buy and sell stocks and shares around the world or gamble on other financial instruments such as derivatives and hedge funds.
The privatization of pension systems over the past decade and more has not led to better pensions for more people, nor to greater economic growth. But the theory persists because formidable commercial, political and social interests support it for their own opportunistic reasons: to expand stock markets, liberalize financial markets and change the role of the state. The “crisis” thus lies not in pensions nor in the numbers and proportions of old people, but in neoliberal aspirations.
Population aging may well be “unprecedented” and “without parallel in the history of humanity,”9 but it does not follow that the challenges it creates are major, nor that proposed solutions are as obvious as they might appear.
If there is a crisis of too many old people, it is one of too many people in poverty in their old age, both now and in the future. Problems of pension financing derive less from demographic changes than from unemployment, low wages, and a shift in income distribution away from wages towards profits. Even if demography were the main problem, a private system based on financial markets would not be the solution, as it is more costly, less equitable and inherently less secure than public alternatives. Worsening financial problems won’t be the result of the existence of more old people, but exaggerating the demographic challenge only makes that grim future more likely. As economist Paul Krugman points out, “The view of demography as destiny is only a half-truth, and in some ways it’s as damaging as a lie.”10 ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ Sarah Sexton is at The Corner House, a research and solidarity group based in the United Kingdom that aims to support democratic and community movements for environmental and social justice. This piece is drawn from a recent Corner House Briefing by Richard Minns with Sarah Sexton entitled, “Too Many Grannies: Private Pensions, Corporate Welfare and Growing Insecurity.” http://www.thecornerhouse.org.uk.
The Population and Development Program CLPP • Hampshire College • Amherst • MA 01002 413.559.5506 • http://popdev.hampshire.edu Opinions expressed in this publication are those of the individual authors unless otherwise specified.
References 1. “Britain’s Pensions Pickle,” The Economist (leader), (December 3, 2005), 11. 2. Dean Baker and Mark Weisbrot, Social Security: The Phony Crisis (University of Chicago Press, Chicago, 1999), 31. 3. Trevor Matthews, “Fewer pension pots, more efficiency,” Financial Times (November 23, 2005), 19. 4. Gordon L. Clark and Noel Whiteside, Pension Security in the 21st Century: Redrawing the Public-Private Debate (Oxford University Press, Oxford, 2003). 5. Kofi Annan, “Migrants can help rejuvenate an ageing Europe,” Financial Times (January 29, 2004). 6. Gary Younge, “Detox this racist culture,” The Guardian (May 16, 2005). 7. “The global workforce: How to realise the benefits of migration, and reduce its risks,” Financial Times (editorial) (October 6, 2005), 18. 8. Tito Boeri, Herbert Brucker and Richard Portes, “It’s economic sense to open borders,” Financial Times (June 10, 2005), 19. 9. United Nations, World Population Ageing: 1950-2050, Department of Economic and Social Affairs: Population Division (New York, 2002), http://www.un.org/esa/population/publications/worldageing19502050/. 10. Paul Krugman, “America’s Senior Moment,” The New York Review of Books (March 10, 2005), 6-11.
Nigel Hawkes, Health Editor Ease of transmission puts thousands at risk
Third transfusion death alarms scientists
Thousands of people are at risk from an outbreak of variant Creut-zfeld-Jakob disease spread by contaminated blood or infected surgical instruments.
An analysis of the death of a third patient after a transfusion of infected blood, published yesterday, shows that the disease is very easily transmitted by blood. Nobody knows how many donors may have given infected blood in the past, or may still be giving it today.
That it can be transmitted by infected blood means that there is a serious risk of a self-sustaining secondary epidemic of vCJD. Transmission is much easier than by eating contaminated meat, where a species barrier must be overcome.
The evidence of the three cases is that vCJD can develop in as little as six to seven years if transmitted by blood. The incubation period for vCJD caught from infected beef is significantly longer. The National Blood Service said that it had taken all the precautionary measures it could. “The trouble is that there is no test we can use,” a spokesman said.
At greatest risk are a handful of people known to have had blood transfusions from healthy donors who went on to develop vCJD. There are 24 such recipients still alive, and their risk is substantial, Professor John Collinge, Britain’s leading expert on the disease, said.
The unnamed third patient to catch vCJD from contaminated blood had a transfusion when he was 23. Seven years later he developed symptoms. He opted to join an experimental treatment trial organised by the Medical Research Council in which patients are given the drug quinacrine. He died a year later, aged 32.
He was one of 66 people identified by the National Blood Service as having received blood from a donor who later developed vCJD. Of these, 34 died of other causes within five years of the transfusions. Of the remaining 32, eight have now died, three from vCJD.
Professor Collinge, who reports on the case in The Lancet, said: “That three individuals from this small group of people that we know to have been exposed through blood transfusion have already developed vCJD infection suggests that the infection may be efficiently passed by this route, so the risk to remaining individuals is likely to be substantial.”
So far, about 160 people, mostly young, are known to have died of the disease by eating contaminated beef. The numbers were relatively low because of the “species barrier” between cows and humans.
Measures taken so far to prevent transmission by blood include importing blood plasma from the US, excluding as donors all those who have themselves had a transfusion as well as those whose blood has gone to recipients who have later developed vCJD, and removing white blood cells from all blood components in the belief that they are the most likely carriers of the rogue prions that cause the disease.
But without a test it is impossible to screen all blood donations, as is done for HIV and other diseases. Nor is it yet known how many potentially contaminated donors there are. The incubation period for vCJD acquired from beef is so long that there is ample opportunity for a blood donor to be carrying the rogue prions for years without any knowledge.
Experiments in mice show that such subclinical infections can still act as a source of full-blown infection if transmitted to other mice.
Studies of tonsils removed in routine operations suggest, the Spongiform Encephalopathy Advisory Committee (SEAC) says, that there could be several thousand subclinical carriers of the disease.
They might infect others in two ways: either through blood transfusions, if the precautions prove inadequate, or more likely in SEAC’s view through contaminated surgical instruments.
A big potential danger is in dental surgery. “The large number of dental procedures coupled with good patient survival implies that any significant risk via this route could have a major impact on the dynamics of secondary infection,” the committee said.
But nobody yet knows how infective the mouth and gum tissues of vCJD victims are. Dental instruments are sterilised between patients, but routine sterilisation is not enough to destroy the prions that cause the disease.
The Lancet paper says that tests on the tonsils of the patient who died showed that they were infected with prions. Testing tonsil tissue is a way of determining early if there is reason to suspect prion disease, Professr Collinge said. ^^^^^^^^^^^^^^^^^
Refer Feminist Research: Dumble, Lynette J. and Klein, Renate. Hormone Replacement Therapy: Hazards, Risks and Tricks. In: Menopause: the Alternative Way The Australian Women's Research Centre Monograph Series No. 1, 1994, pages 38-55.
and: Renate Klein and Lynette Dumble. Disempowering midlife women: The science and politics of hormone replacement therapy (HRT). Women's Studies International Forum 1994; 17: 327-43.
US breast cancer decrease tied to drop in hormone replacement therapy use
By Joanne Laurier
A startling decrease in US breast cancer rates in 2003 may be attributable to the fact that millions of older women stopped using hormone replacement therapy (HRT) in 2002, according to researchers at the University of Texas M.D. Anderson Cancer Center.
Investigators reported a remarkable 7 percent relative decline in breast cancer incidence between 2002 and 2003, with a steeper decline of 12 percent in women between the ages of 50 and 69 diagnosed with estrogen receptor positive breast cancer, that is, breast cancer that is hormone-dependent for tumor growth. The findings were presented at the 29th annual San Antonio Breast Cancer Symposium.
“It is the largest single drop in breast cancer incidence within a single year I am aware of,” said Dr. Peter Ravdin, a research professor at M.D. Anderson, in a press release. Ravdin added that the study can only indirectly infer the connection between the decline in breast cancer and stopping the use of HRT.
“But if it is true, the tumor growth effect of stopping use of HRT is very dramatic over a short period of time, making the difference between whether a tumor is detected on a mammogram in 2003 or not,” asserted Ravdin. He added, however, that what it is not known is whether these tumors will regress and never become a problem or just take longer to show up.
The overall 7 percent decline represented, according to the researchers, some 14,000 fewer women who were diagnosed with breast cancer in 2003 than in 2002, a year in which some 203,500 new cases were diagnosed.
According to the M.D. Anderson analysis, the rate of breast cancer diagnoses increased steadily at 1.7 percent annually from 1990 to 1998, before decreasing to 1 percent a year from 1998 to 2002. By the end of 2003, the rate had dropped 7 percent when age adjustments were made.
“Incidence of breast cancer had been increasing in the 20 or so years prior to July 2002, and this increase was over and above the known role of screening mammography,” said the study’s senior investigator, Dr. Donald Berry of M.D. Anderson. “HRT had been proposed as a possible factor, although the magnitude of any HRT effect was not known. Now the possibility that the effect is much greater than originally thought all along is plausible, and that is a remarkable finding.”
Consumption of hormone replacement drugs drastically fell after a groundbreaking study in 2002 by the Women’s Health Initiative (WHI), which found that HRTa combination of estrogen and sometimes progestin hormonessignificantly increased the risk of developing invasive breast cancer.
Prescriptions for the estrogen-progestin pills plummeted from 22 million per quarter before the WHI study to 12.7 million in the last quarter of 2003. Millions of women were taking the pills in hope of relieving menopausal symptoms such as hot flashes and night sweats, believing them to be a protection as well against heart disease, osteoporosis and aging.
As a result, the menopausal drugs, particularly Prempro, manufactured by Wyeth, had become some of the most popular in history. Responding to the M.D. Anderson study, Wyeth issued a statement claiming that “the potential impact of hormone therapy on breast cancer has long been warned on product labels.”
Dr. Ravdin said that some 30 percent of women older than 50 had been taking HRT in the early part of the decade, but that half of that group had stopped in late 2002 after the WHI findings were released. “Research has shown that ER-positive [estrogen receptor positive] tumors will stop growing if they are deprived of the hormones, so it is possible that a significant decrease can be seen if so many women stopped using HRT.”
Added Berry: “It takes breast cancer a long time to develop, but here we are primarily talking about existing cancers that are fueled by hormones and that slow or stop their growing when a source of fuel is cut. These existing cancers are then more likely to make it under mammography’s radar.”
To conduct the study, Ravdin and Berry teamed up with researchers at the National Cancer Institute (NCI) and Harbor-UCLA Medical Center in Los Angeles. They analyzed data from nine regions across the US that contribute data to NCI’s database, from which national cancer incidence statistics are derived.
The researchers warned that because the new study is based solely on population statistics, they cannot know for certain the reasons why incidence declines. “We have to sound a cautionary note because epidemiology can never prove causation,” said Berry. While other effects, such as decreased use of screening mammography and changes in the use of anti-inflammatory agents, SERM or statins, were considered, “only the potential impact of HRT was strong enough to explain the effect,” according to Berry.
Besides the fact that the drop in breast cancer rates was seen in every cancer registry that reports information to the federal government, no big change occurred with any other major type of cancer, indicating that the breast cancer decline is not an error.
“It’s a big deal,” said another of the researchers, Dr. Rowan Chlebowski of Harbor-UCLA Medical Center. “It’s better than a cure,” he said, because these are cases that never occurred. Significantly, when researchers tracked month-to-month figures, they noticed an even stronger trend: cases dropped 6 percent in the first half of 2003 and 9 percent in the second half.
A separate study by the American Cancer Society also documented the plunge. In addition, presented to the San Antonio symposium were data through 2004 from the Northern California Cancer Center and Kaiser Permanente’s Division of Research, showing reductions statewide in both the use of HRT and the incidence of breast cancer since the WHI 2002 study.
“Hormone therapy use dropped 68 percent between 2001 and 2003, and shortly thereafter, we saw breast cancer rates drop by 10 to 11 percent,” said Dr. Christina A. Clarke of the Northern California Cancer Center. “This drop was sustained in 2004, which tells us that the decline wasn’t a fluke.”
Women in northern California’s affluent Marin County were especially heavy users of hormone therapy before the 2002 WHI report and were being diagnosed with invasive breast cancer at a significantly higher rate than the officially recorded national average. Investigators found that California’s overall drop of 11 percent in breast cancer rates in 2003, versus 7 percent nationally, was believed to be due to the fact that more women in California had been using HRT than in other states.
Dr. Marcia Stefanick of Stanford University, chairwoman of the steering committee for the Women’s Health Initiative, said the cancer-hormone link helped clear up the mystery about Marin County’s high cancer rates.
Renowned breast cancer specialist Dr. Susan Love, when asked during an interview on cable network CNN, December 18, if she believed that the significant drop in breast cancer rates was due to the fact that women had stopped taking hormone therapy, replied: “Absolutely. It’s really the mirror image to the [WHI] study in 2002...so when women stopped, we now see the second half, which is the drop in breast cancer...there’s a growing suggestion that having a dense mammogram, having a lot of density on your mammogram is a sign of a higher risk of breast cancer. And many women who go on HRT find their mammograms get more dense.”
A spokeswoman for the National Breast Cancer Coalition, the nation’s largest breast cancer advocacy group, urged caution about the M.D. Anderson study. Fran Visco, NBCC president, commented in a statement, “This report of a significant one-year decline in breast cancer incidence, particularly for post-menopausal women diagnosed with estrogen receptor positive breast cancer, is telling. However, one study of one-year data may not be enough to draw definitive conclusions on whether the decline is a trend or an anomaly. The next set of data, to be released by this research team in April, should help provide answers to that question.”
Visco continued, “The analysis also suggests that during that year, this same demographic was also less likely to have taken hormone replacement therapy (HRT). The researchers involved with this study infer there may be a direct connection between a reduction in use of HRT and decreased incidence of breast cancer. We question whether enough time has passed to know if any decrease in incidence is related to HRT use.”
The NBCC president noted that the findings underscored the importance of thoroughly testing all drug use to ensure that anticipated benefits were real and there were no unintended side effects. She observed that even if the relationship between the decline in HRT use and the decline in cancer was as the researchers described, the onset of breast cancers might simply be delayed. She pointed out that it also remained unclear whether the decrease would result in a decrease in breast cancer deaths.
Breast cancer is the leading major cancer and second major cause of death in American women. Some 275,000 new cases are expected to be discovered in the US in 2006 and more than 1 million worldwide. The American Cancer Society estimates that a woman in the US has a 1 in 8 chance of developing invasive breast cancer during her lifetime; the risk was about 1 in 11 in 1975.
Reversing Trend, Big Drop Is Seen in Breast Cancer
By GINA KOLATA
Rates of the most common form of breast cancer dropped a startling 15 percent from August 2002 to December 2003, researchers reported yesterday.
The reason, they believe, may be because during that time, millions of women abandoned hormone treatment for the symptoms of menopause after a large national study concluded that the hormones slightly increased breast cancer risk.
The new analysis of breast cancer rates, by researchers from the M. D. Anderson Cancer Center in Houston and presented at a breast cancer conference in San Antonio, was based on a recent report by the National Cancer Institute on the cancer’s incidence.
Investigators cautioned that they would like to see the findings confirmed in other studies, including, perhaps, in data from Canada and Europe, and they would like to see what happens in the next few years.
“Epidemiology can never prove causality,” said Dr. Peter Ravdin, a medical oncologist at the M.D. Anderson center and one of the authors of the analysis.
But, he said, the hormone hypothesis seemed to perfectly explain the data and he and his colleagues could find no other explanation.
Donald Berry, head of the division of quantitative science at the cancer center and the senior investigator for the analysis, called the connection between the drop in rates and hormone use “astounding.”
Over all, for women of all ages and all breast cancer types, the incidence of the cancer, the second leading killer of women, dropped by 7 percent in 2003, or about 14,000 cases, the researchers said. It was the first time that breast cancer rates had fallen significantly, something experts said was especially remarkable because the rates had slowly inched up, year by year, since 1945.
But the decrease was most striking for women with so-called estrogen-positive tumors, which account for 70 percent of all breast cancers.
In July 2002, the Women’s Health Initiative, a large clinical trial looking at the use of one menopause drug, Prempro, made by Wyeth, found that women taking the drug had slightly higher breast cancer rates. The study’s findings were a shock to many women and their doctors. Until then, many had assumed that Prempro simply replaced the lost hormones of youth. Within six months, the drug’s sales had fallen by 50 percent.
Scientists knew that hormones could fuel the growth of estrogen-positive tumors, which carry receptors for estrogen on their cell surfaces. The hypothesis is that when women stopped taking menopausal hormones, tiny cancers already in their breasts were deprived of estrogen and stopped growing, never reaching a stage where they could have been seen on mammograms.
Other cancers may have regressed, making them undetectable. And, possibly, without hormones, cancers that would have gotten started may never have grown at all.
“This could well be the study of the year in cancer,” said Dr. Otis Brawley, director of the Georgia Cancer Center at Emory University. He added that it also might help explain why breast cancer rates were lower for black women than for white women blacks, he said, were less likely to use hormones for menopause.
Dr. Brawley also said the findings might explain why cancer in black women was more lethal. Hormone-initiated cancers, he said, might be less deadly than those that arise on their own.
Candace Steele, a Wyeth spokeswoman, said in an e-mail message that “breast cancer is a complex disease and the causes are not known.
At this point, she said, “it is simply inappropriate to make any speculative statements” based on the analysis.
And, she added, “clearly, more studies are warranted.”
Dr. Berry said that the biggest effect overall was seen in women ages 50 to 69. That, he added, is the group most likely to have been taking menopausal hormones. In them, the incidence of breast cancer, including the type that grows in response to estrogen and the one that does not, fell by 12 percent in 2003, the latest year for which data is available.
The findings of the new analysis were supported by a separate study in California. That study, published in the Nov. 20 issue of the Journal of Clinical Oncology, found an even bigger drop in rates in that state and a correspondingly bigger drop in hormone use starting in July 2002.
Other researchers, who saw Dr. Berry’s analysis in advance of its presentation yesterday, said they found the hypothesis convincing.
Susan Ellenberg, a professor of biostatistics at the University of Pennsylvania, said the work was provocative. And, she added, “I certainly don’t see any obvious thing that says, ‘Oh, this can’t be right,’ or any obvious flaws.”
Until 2002, as many as a third of American women over age 50 were taking menopausal hormones. The drugs could relieve symptoms like hot flashes, and were thought to protect against heart disease. Because the pills were known to slow bone loss, some women used them to prevent osteoporosis. Some women and doctors also believed, without any good evidence, that the pills could keep skin youthful, preserve memory and make women energetic.
The use of estrogen to treat menopause took off in 1966, when a doctor, Robert Wilson, wrote the best-selling book “Feminine Forever” and flew across the country promoting it. He insisted that estrogen could keep women young, healthy and attractive. Women would be replacing a hormone they had lost at menopause just as diabetics replace the insulin their pancreas fails to make.
Before long, the menopause drugs, and in particular Prempro, from Wyeth, a combination of estrogen and progestins, became one of the most popular drugs in history.
The reversal of fortune came in July 2002 when the Women’s Health Initiative was halted. Its accumulating data indicated that Prempro was associated with a slight increase in breast cancer and in heart attacks, strokes and blood clots. The drug slightly decreased the risk of hip fractures and colon cancer, but those benefits were not enough to overcome its risks, the researchers said. Health authorities cautioned that similar pills must be regarded as having the same risks as Prempro until proven otherwise.
The very next year, 2003, the National Cancer Institute reported recently, there was a huge decline in breast cancer incidence. It was, Dr. Ravdin said, the largest decline for a single cancer in a single year that he was aware of. He and his colleagues wondered what was going on. The cancer kills an estimated 40,000 women a year and any decline in incidence can be important.
“We looked at all the possible explanations,” Dr. Berry said. He ticked them off: less mammography screening. But there was no sign of that. Increased use of drugs like tamoxifen that can prevent breast cancer; no evidence of that.
“There was some notion that it might be statins, but that was essentially debunked,” Dr. Berry said.
After July 2002, Dr. Berry said, the rate “dropped each month and it is exactly where you would expect it to be” if the declining use of menopausal hormones were the reason.
Dr. Barnett Kramer, the associate director for disease prevention at the National Institutes of Health, said that hormones were certainly the most plausible explanation for such an immediate effect on incidence. Most breast cancer is fueled by estrogen and studies have found that removing estrogen, with drugs like tamoxifen that block the hormone, sharply reduces breast cancer rates within a year.
That was also the conclusion of Christina Clarke, an epidemiologist at the Northern California Cancer Center, and her colleagues, when they analyzed the cancer’s rates in California. The investigators used data they had collected for a National Cancer Institute’s program and data from Kaiser Permanente, the health insurer.
Dr. Clarke said that they had data through 2004 and so could ask whether the decrease in cancer incidence in 2003 continued the next year. It did, she said, although it slowed somewhat, as might be expected.
The investigators found that the breast cancer incidence fell even more in California than in the rest of the country the overall drop was 11 percent in 2003, compared with 7 percent nationally. And, Dr. Clarke said, more women in California also had been using hormone therapy than women in other states.
Kaiser Permanente’s prescriptions for hormone combinations like Prempro fell by two-thirds in 2003 and prescriptions for estrogen alone dropped by one-third, Dr. Clarke and her colleagues reported. (Estrogen without progestin can cause cancer of the uterine lining so should only be used by women whose uteruses have been removed. While there is some question about whether estrogen alone increases breast cancer risk, the Women’s Health Initiative did not find such an effect.)
The heaviest users of hormone therapy were women in affluent places like Marin County, where high breast cancer rates had long troubled women and researchers. Women in those areas also largely abandoned the treatments after the 2002 report and their cancer rates declined accordingly, Dr. Clarke said.
Dr. Marcia Stefanick, a professor of medicine at Stanford University and chairwoman of the steering committee for the Women’s Health Initiative, said she found the hormone argument persuasive and felt it helped clear up the mystery in Marin County.
“Everyone kept saying, What is it? What’s in the environment?” she said. Now, she said, it is becoming clear. “The best explanation is hormone therapy.” ^^^^^^^^^^^^^^^^^^^
The sharp drop in breast cancer rates reported this week is astonishingly good news. It is the first major reduction in the incidence of a malignancy that strikes more than 200,000 American women every year and kills some 40,000 annually.
Researchers from the M. D. Anderson Cancer Center in Houston and other institutions reported that the incidence of all types of breast cancer fell a stunning 7 percent in 2003 the latest year for which statistics are available from the year before. This was the first such decline after persistent rises for several decades and a leveling off from 1998 to 2002. The researchers estimate that 14,000 fewer women were diagnosed with breast cancer in 2003 than in the year before.
The most plausible explanation is that women by the millions abandoned or sharply cut back their use of hormone therapy. For many years hormones which have been widely used to treat the symptoms of menopause had also been hyped by the pharmaceutical industry as an elixir to ward off the ravages of aging. Overly enthusiastic doctors also championed hormone therapy as a way to prevent or mitigate heart disease, Alzheimer’s, severe depression and urinary incontinence none of which turned out to be true.
But in mid-2002, a study of the effects of hormones on thousands of women had to be halted after it became clear that prolonged use of a popular hormone combination caused an increase in breast cancer, heart attacks, strokes and blood clots.
Women abandoned the hormone pills in droves, and almost immediately, the incidence of breast cancer began to fall. As Gina Kolata reported in yesterday’s Times, rates of the most common form of breast cancer tumors that are fueled by estrogen dropped a startling 15 percent from August 2002 to December 2003.
The researchers hypothesize that tiny tumors in the breast, when deprived of the hormones that fueled them, stopped growing or at least grew more slowly, leaving them too small to be detected on mammograms. It is also possible that, with their hormones cut off, some tumors shrank or even disappeared. Other factors, like a slight dip in mammography screening to detect tumors and use of drugs that are known or thought to slow breast cancer, might have played a small role in reducing the numbers, but they were deemed too inconsequential to explain the results.
The great unknown is what will happen in the future. If tumor growth was simply slowed, not stopped, the tumors may become detectable as time goes on. But hormone therapy has continued to decline, so the drop in breast cancer is apt to continue. A study in California found that a sharp decrease in breast cancer incidence in 2003 was followed by a slower but continued drop in 2004, a harbinger, perhaps. of what national statistics will show next year.
Further analyses will be needed to identify all possible reasons for the decline of breast cancer incidences. If the hypothesis holds up that the drop in hormone use is the main cause, as seems likely, it should persuade even more women to curb their use except when absolutely necessary. Meanwhile, breast cancer incidence will remain high, underscoring the need for more ways to prevent this dreaded disease.