The Multinational Monitor


July/August 2002 - VOLUME 23 - NUMBER 7&8

T H E    F R O N T

The Great Hormone Hoax

The Women's Health Initiative study on the benefits and risks of hormone replacement therapy (HRT) in July drove a stake into the drug treatment taken by millions of women in the United States.

The Women's Health Initiative, a clinical trial to assess HRT -- a combination of estrogen and progestin -- for use by healthy women, ended the research early because the risks became painfully obvious. After five years of using the drug, women had elevated chances of breast cancer, heart attack, stroke and blood clots. The scientists believed it would be unethical to continue to test the drugs, marketed by Wyeth under the brand-name Prempro.

The study results, published in the Journal of the American Medical Association, show that long-term HRT increases the risks of breast cancer, heart attack, stroke and pulmonary embolism. Those risks outweigh the benefits of long-term use of the drug: reducing the risks of bone fracture and colon cancer.

The study results came as a shock to millions of women who had been sold on the drug by their doctors, many of whom strongly and routinely urged older women to take HRT, and by a decades-long, aggressive marketing campaign from the drug's manufacturer.

HRT was touted as preventing bone loss, heart disease, Alzheimer's disease, cancer and wrinkles; and as a way to improve women's sex life and make them more beautiful.

However, despite the hype around HRT, many of the benefits claimed for it have never been proven in a randomized-control study -- where the effect of a drug is compared to a placebo. The evidence for the benefits of HRT came from "observational studies" -- a review of the reported effects on women taking the drug. The problem with observational studies is that women who chose to take hormones may be healthier than women who chose not to take hormones. Also, observational studies do not include dead people, so would not have picked up women who died from hormone use.

Pill Peddlers
The peddling of hormones began on a mass scale in 1966, with the publication of Dr. Robert Wilson's bestseller, Feminine Forever. The book promoted estrogen as a wonder drug that could counter the changes of menopause and keep women young, attractive, sexually vital and happy.

Wilson set up a foundation and traveled around the country, preaching the gospel of estrogen and describing the experience of menopause in frightening, Gothic terms: warning that "no woman can be sure of escaping the horror of this living decay." Menopausal women, whom Wilson called an "intersex" because they supposedly are no longer truly female, could, however, save themselves by taking estrogen. It would make them "more pleasant to live with" and prevent them from becoming "dull and unattractive."

Estrogen had been in use since the 1930s to treat hot flashes and other menopause symptoms. But Wilson's claims were grander, playing on aging women's desire for longevity and on their fear of losing beauty and health. By 1975, Ayerst-manufactured Premarin, the leading estrogen pill, was one of the top five most-prescribed drugs in the United States.

It was only years after Wilson had gained fame that the Washington Post revealed that Ayerst -- which later merged into Wyeth -- secretly financed Wilson's book and his foundation.

More than 35 years later, drug companies are still selling hormones to menopausal and post-menopausal women. The marketing is more sophisticated today, but the underlying message is the same: There's a pill that will make you healthy, happy and beautiful -- never mind whether it has been scientifically proven.

Although the theories about HRT's benefits were plausible, they were not proven. That did not stop drug companies and doctors from treating the drugs as if they were.

The first big scare about taking estrogen came in December 1975, when two studies linked estrogen to endometrial cancer, in the lining of the uterus. Estrogen prescriptions dropped off until the 1980s, when research showed that the risk of uterine cancer was reduced when estrogen was combined with a second hormone, progestin.

The popularity of hormone therapy exploded as doctors and many women embraced it enthusiastically. Although the drugs are now available together in one pill, many women still take estrogen and progestin in separate dosages. Estrogen pill sales rose from 13.6 million prescriptions in 1982 to 31.7 million in 1992. In 1995, Premarin estrogen pills were the top-selling brand-name pharmaceutical in the United States. Sales of progestin pills rose five-fold in the same period, to 11.3 million.

In 1990, the Nurses Health Study, then the largest U.S. women's health study, showed a strong association between taking estrogen and breast cancer. It did not prove that estrogen caused breast cancer, but there was a strong association.

Hormone proponents responded by assuring women the combination HRT drug was not associated with increased risk of breast cancer, and by asserting that hormones offered benefits that far offset the small increased risk of breast cancer. Both of these arguments have now been proven false.

Age and Beauty
U.S. negative attitudes about aging -- particularly in women -- created a ready market for these hormones. Women wanted to believe ads suggesting that HRT prevents wrinkles. And it wasn't always ads that did the convincing. Parade magazine put model Lauren Hutton on its cover for a piece on celebrity beauty tips, and quoted her saying her "No. 1 secret is estrogen. It's good for your moods, it's good for your skin." The article didn't mention that Hutton was a paid spokesperson for Wyeth, and appeared in the company's ads.

Doctors also were misled by sales pitches crafted to look like scientific information.

In 1998, Wyeth ran ads in Women's Health in Primary Care, a publication for physicians. They contained a drawing of a woman's body with lines pointing to the parts that HRT purportedly helped. Its headline conjured up the incorrect notion that all these claims had been proven scientifically: "If your menopausal patients have new questions about menopause ... consider the entire body of evidence.''

Manufacturers of HRT drugs also paid for favorable research about the drug and to disseminate the results to doctors. They footed the bill for medical-journal supplements that resembled peer-reviewed studies.

The "Bombshell"
In 1993, the National Institutes of Health launched the Women's Health Initiative to get definitive answers to questions about HRT.

That led to June's announcement warning women off HRT for long-term use and prevention of disease, a culmination that Dr. Wulf Utian, an advocate of HRT, called "the biggest bombshell that ever hit in the menopause area."

For those who had tracked the science, rather than the marketing propaganda, the results from the Women's Health Initiative were much less of a surprise. They knew that clinical trials had never demonstrated the purported benefits of HRT.

Following the Women's Health Initiative, Wyeth's stock value plummeted, losing approximately one-third of its value.

The company continues to market HRT for short-term use in women suffering severe effects of menopause, and for use for osteoporosis, trying to salvage something from its one-time golden goose.

-- Amy Allina and Cynthia Pearson

Amy Allina and Cynthia Pearson are program and policy director, and executive director of the National Women's Health Network.

Fish and Empire

For ages, fisherfolk have cast their nets into the waters of the Atlantic coast, stretching for 2,000 kilometers from Morocco to Guinea-Bissau, one of the world's last remaining great fisheries. Their catches have been abundant, but the increasing presence of foreign trawlers, particularly from Asia and Europe, has brought the depletion of some key fish stocks. This has raised concern that the livelihoods of small-scale fisherfolk and the sustainable development of a major economic sector are now under threat.

"If there had been enough fish in our waters, would we have to use up our fuel to go as far away as Freetown [Sierra Leone] to fish?" asks Abdourahmane Ndir, a Senegalese fisher. He warns that if European boats continue to overfish, "they will kill Senegalese waters, just as they have done with their own."

Partly in response to such concerns, Senegal halted European fishing in its offshore waters in January, following a breakdown in negotiations over renewal of fishing concessions the European Union (EU) has enjoyed for more than two decades. The agreement with Senegal is one of many the EU has signed with African countries allowing vessels, mainly from Spain, Portugal, Greece, Italy, the Netherlands and the UK, to take home hundreds of thousands of tons of tuna, shrimp, sardines, salmon, anchovies, hake and other types of fish in demand in Europe.

Since the 1950s, industrial fishing in the northern seas has expanded rapidly, depleting stocks in the most productive areas to levels at which recuperation has become almost impossible. The EU headed south during the 1970s and signed agreements with African and Indian Ocean countries, permitting more than 300 ships to work in African waters.

While the EU also has treaties with nations in the North Atlantic and Latin America, its most important source of imported fish is Africa. The EU bought 540,000 tons annually between 1993 and 1997. Nearly half of this haul -- 240,000 tons per year -- came from Africa. Morocco provided 74 percent of Africa's share, while Angola, Guinea-Bissau, Mauritania and Senegal together accounted for 25 percent of the catch.

The agreements last an average of three years and stipulate the royalties to be paid, the number of observers on each ship and the number of local workers foreign boats must hire. The costs of fishing rights are calculated differently for each agreement -- based on the number of vessels, the amount of fish caught or both. Often the EU pays a flat fee for access rights to a fixed quota of fish and individual shipowners then pay for licenses. Such fees account for an estimated 15 percent of Mauritania's national budget and 30 percent of Guinea-Bissau's.

However, a study by the UN Environment Program (UNEP) warns that the long-term costs of these agreements -- through the loss of income for local fishers, environmental damage and depletion of native fish stocks -- far outweigh the short-term financial gains. The hard currency developing countries earn from these agreements may help them pay off external debts and stimulate economic growth, but, says UNEP Executive Director Klaus Tvpfer, "unless strict safeguards are in place, this can be a costly mistake."

Over-fishing in Senegal
Senegal is one of six countries highlighted in the ongoing UNEP study, "Economic Reforms, Trade Liberalization and the Environment," parts of which were released in November. Over-fishing in Senegal has had a devastating impact, depleting some of the deep-living coastal species favored by European consumers, the report states.

By the late 1990s, fishing in Senegalese waters exceeded the estimated annual sustainable catch of 420,000 tons by an average of 30,000 tons. In 2000, about 30 percent of export earnings were derived from fishing, a sector that employs about 600,000 of the country's 3.5 million economically active people.

But this rapid growth was not without cost, notes UNEP. The report warns that there is risk of shortages on the local market in the future, due to a shift by small-scale fisherfolk in favor of exports rather than domestic markets -- drawn by higher profit margins in the export sector. There has also been a decline in certain species. Yields of conch, an important part of the Senegalese diet, dropped from 20,000 tons in 1989 to 5,000 tons in 1998 due to the depletion of stocks.

In addition, the country has not benefited substantially from transfers of technology promised through its fishing agreements with industrial nations, UNEP reports. Instead of developing new, modern fish-processing plants, emphasis was placed on expanding existing outdated facilities, denying the country an opportunity to process and thus add value to its product before export.

Deadlocked Increasingly concerned about such problems, Senegal is currently deadlocked in negotiations with the EU. The talks reportedly broke down partly due to EU demands for an increase in its catch by 60 percent -- from an annual quota of 10,000 to 16,000 tons.

Senegal, on the other hand, is demanding that the EU pay more for access to its fish. Under the last agreement, the EU paid 48 million over four years. Also, rather than maintaining a simple commercial relationship, Senegal is seeking a more cooperative arrangement to safeguard the sector's sustainability.

But officials are all too aware of the risks of taking a hard negotiating position with their most important trading partner. Amadou Wade of Fenagie, Senegal's fisheries federation, says negotiators are wary of the danger that the EU "could refuse to let us have access to its markets for trade if we don't comply."

Scale and Scales
Through pressure from local associations of fisherfolk, some EU agreements increasingly involve Africans in industrial fishing and contain clauses that support the development of the local industry. The new generation of agreements include measures to avoid over-fishing, give priority to national fleets over foreign vessels and demand greater local involvement in fish processing in order to increase the value of the exported product.

However, critics charge that what makes EU fishing agreements with African countries particularly harmful is that they bring in commercial fleets with bigger boats and superior technology to compete with poor, local artisan fisherfolk.

In Senegal, small-scale fishers rely on a low-technology approach marked by low financial investments and a large workforce. There are 60,000 small-scale fishers who bring in more than 70 percent of the total volume of fish consumed locally. As fish become scarcer, the fishers are travelling farther out to sea. Those unable to keep up with the competition from the larger boats resort to supplying the European and Asian boats instead, notes the Africa-Europe Faith and Justice Network (AEFJN) In some cases, the AEFJN charges, foreign vessels use local fisherfolk to gain access to coastal areas they are prohibited from under the fishing agreements.

-- Gumisai Mutume, Africa Recovery/Third World Network Features.