Offline: A story of discrimination against women

Abstract

Utako Okamoto (1918–2016) is not a name widely known, let alone celebrated, in medicine and global health. Yet this remarkable Japanese scientist deserves international recognition for her heroic struggle to advance women's and children's health. She discovered the drug tranexamic acid in the 1950s and believed that its powerful haemostatic properties might offer decisive benefits for women who suffered post-partum haemorrhage. Ian Roberts, in his inaugural UK Faculty of Public Health Bazalgette Lecture delivered last week in London, described the story of a medical scientist with an astonishing vision. But it was a vision that was repeatedly crushed by endemic discrimination. The credit for rediscovering the work of Utako Okamoto lies with Ian Roberts and Ayumi Naito. The story he uncovered is emblematic of the difficulties faced today by scientists seeking to translate their discoveries into practice. On March 10, 2010, Ian had a rare life-changing moment. Leading a randomised trial of over 20 000 adult trauma patients (CRASH-2), he and his collaborators found that intravenous tranexamic acid reduced the risk of death from bleeding by 15%. The effect was greatest if tranexamic acid was given within 3 h of the trauma. Calculations showed that the widespread use of this cheap generic medicine could save 130 000 lives annually. The trial cost £2·5 million. With such a stunning result, Ian asked England's Department of Health for £500 000 to help implement the findings. He received a paltry £15 000. Implementation of research results was not a priority for the UK Government. Still, he was able to get tranexamic acid onto WHO's list of essential medicines. And he devised innovative ways—eg, animated videos—to spread the message that this neglected drug had life-saving properties. But the obstacles proved formidable. The pharmaceutical company that made tranexamic acid, Pfizer, was not interested in promoting it since they saw no likely profit accruing, despite the medicine's cost-effectiveness. Civil society organisations and the British military proved more helpful. Eventually, dogged persistence, combined with powerful imagery (showing the number of graves that could have been eliminated from Arlington National Cemetery if tranexamic acid had been used by US armed forces), enabled the drug to gain wide acceptance. But this success was only the beginning of a larger and more revealing narrative. Ian became intrigued about the origins of tranexamic acid. Although Pfizer held the licence for the drug, the company was not responsible for its discovery. Utako Okamoto, working with her husband Shosuke near Kobe, Japan, deserved that accolade. Ian travelled to Japan with his partner, Ayumi Naito, a Japanese paediatrician, and found Utako's home, which doubled as a laboratory where she continued her research. She had a clear vision for her work. She wanted to deliver results that outperformed global standards. She sought to be truly innovative by avoiding the currently fashionable trends in research. And she was driven by wanting to find an effective treatment for post-partum haemorrhage. Ian saw Utako's journey as a story of perseverance. Together with his colleague, Haleema Shakur, he embarked on the second phase of his research—this time to fulfil the hopes of Utako by launching a trial (WOMAN; World Maternal Antifibrinolytic trial) to test if tranexamic acid could indeed reduce deaths from post-partum bleeding. Haemorrhage is the commonest cause of maternal mortality. If WOMAN could repeat the success of CRASH-2, Haleema and Ian's team would have discovered one of the most important interventions to save the lives of women during pregnancy. The result beat all expectations. Deaths due to bleeding when tranexamic acid was given within 3 h were reduced by 31%. The result was little short of a global sensation—over 800 separate news reports, cited on over 2500 radio stations, and reaching 80 million people via social media. Utako died just 2 weeks before the WOMAN trial ended. And it was this result that changed the way Ian thought about Utako's story. It was not a story of perseverance. It was a story of discrimination against women. Discrimination that Utako had endured her entire life. And discrimination that continues today as governments, development agencies, and international organisations continue to fail to implement one of the most safe and cost-effective tools ever discovered to save women's lives.