Sunday, April 17, 2005

"It is a bit like farming . . . . "

Many years ago (20?) I was asked by some folks making a show about contaminated water to come to Beverly Hills and be filmed in an informal setting with some other people I knew (the only one of which I can remember at this long remove is Lois Gibbs, the hero of Love Canal). Why not? I knew and respected Lois and it sounded like it might be fun.

And it was. With Mrs. R. and the two little reveres, off we went. Picked up by a limo, a nice hotel and then the show, with Lindsay Wagner (The Bionic Woman, now hawking beds on late night cable) and Henry Morgan (Colonel Potter from M*A*S*H). We chatted away, were asked a bunch of questions by the moderator about various "things people could do personally" if their water were contaminated, none of which we said were of much use. And that was that. We each got our pictures taken with the TV stars. As I said, it was fun.

Then I saw the show (which played over and over in the middle of the night around the country). It was an infomercial from a water filter company. Water filters were never talked about on the show. Just all the other things--the ones that didn't work.

I was reminded of all this when I saw a Commentary by Georgetown Medical School's Dr. Adriane Fugh-Berman in the Journal of General Internal Medicine (available here). Fugh-Berman is an authority on complementary and alternative medicine. She describes how she was approached by a Medical Education Company (MEC) hired by a pharmaceutical firm to put her name on a "draft" of a medical article on herb-warfarin interactions to be submitted to a scientific journal.

Warfarin is a standard blood thinner used in clinical medicine. For fifty years it has had almost no competitor. Interestingly, the "sponsoring" pharmaceutical company made neither warfarin or herbal remedies. Curious as to why they would be interested in publishing such a paper, Fugh-Berman received this reply:
This paper is a series of communications concerning the importance of anticoagulation therapy with warfarin for stroke prophylaxis, whilst simultaneously highlighting the difficulties and burden that such therapy places on the patient, clinician, and society. One such problem concerns warfarin’s high interaction potential, which can give rise to problems with anticoagulation control. Whilst there is no promotion of any drug within this paper, ABC Drugs is keen to set the scene for new anticoagulants that are not subject to the numerous limitations of warfarin.
Aha. The water filter gambit.

And it turns out that this whole scenario is quite common, although the true frequency of "corporate ghost authorship or coauthorship is unknown":
Some conflicts of interest are invisible. Pharmaceutical companies routinely seed medical literature with reviews or commentaries that advantageously frame a marketed drug, but some sponsored articles never mention the targeted drug. Both types of articles are usually written by a medical education company (MEC) that receives funding from a pharmaceutical company. Academic physicians are recruited to sign these articles.

The division of labor for such a corporate-sponsored article is rarely equal; although the signer is invited to make changes, the primary obligation of the academic coauthor is to claim authorship. The primary author from the MEC remains anonymous, and any instructions given to the primary author regarding tone or emphasis are not shared with the named author, who is usually paid by either the MEC or the sponsoring pharmaceutical company.


While a suspicious audience member may discount the objectivity of a speaker who talks about a product manufactured by a company for whom that speaker consults, some conflicts of interest are difficult to discern. Companies regularly fund articles and talks that never mention the targeted drug, but are meant to disadvantage the competition. One of my colleagues was paid handsomely by a drug company to give a hundred talks a year presenting negative data on alternative therapies, a competitor for an infinitesimal share of the market dominated by the company’s blockbuster drug. My colleague did not misrepresent the data, and there would be no reason for the audience to suspect that a talk that mentioned no pharmaceuticals was funded by a pharmaceutical company.
The big medical journals (Lancet, BMJ, JAMA, New England Journal of Medicine) also benefit by selling the drug companies reprints which are then distributed by mail to doctors. This is one of the reasons these journals oppose Open Access and require copyright from authors.

This is a fascinating Commentary about a technique most scientists and doctors little suspect and never think about, but who are its main targets:
These efforts may begin years before a pharmaceutical is approved for sale. It is a bit like farming; weeds are removed, the soil prepared, perhaps a cover crop planted, to be tilled under before seeds are sown in the receptive soil. Some MECs organize continuing medical education conferences, other specialize in writing articles, and some do both. [my emphasis]
Yes, it is "a bit like farming." Complete with manure.