A Fortress of Medical Research Confronts The Information Age: Part One

New England Journal of Medicine at 200

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NEJM at 200: Part One
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NEJM at 200: Part One

INTRO: As the New England Journal of Medicine celebrates its 200th anniversary, a national debate has been brewing about the close relationship between money and medicine. In the first of a 2-part series, the Connecticut Mirror’s Neena Satija examines how researchers come under fire for taking industry money, yet can’t survive without it.

Arnold Relman is the oldest living editor of the New England Journal of Medicine, having stepped down from his position in 1991.  Back in the 1960s, he coined the term “medical-industrial complex” to point out the increasingly close ties between doctors, researchers, and big companies. Here’s what he has to say about the state of health care today.

RELMAN: “It’s the money that’s entered health care that has corrupted everything.”

Relman was one of the first journal editors to require that researchers disclose any financial conflicts of interest they might have in the work they were doing. But have those rules really managed to stave off the medical-industrial complex?

JEROME KASSIRER: “Unfortunately I think the answer is no. Money is such an important motivator.”

That’s Jerry Kassirer, who was editor of the journal from 1991-1999. A study by the journal PLOS Medicine in 2005 estimated that much of the research published by the New England Journal is funded by industry – a lot more so than other major medical journals. And journals make a lot of money on reprints of studies, which drug companies usually buy and distribute to doctors if they want to promote the research results. How much money, exactly? No one knows, since the New England Journal keeps that information private. Even Kassirer didn’t know when he was editor.

KASSIRER: “It was a lot of money. I was never made aware. I remember so clearly my very first budget meeting. I was given a sheet with the expenses of the journal. And I asked naively, ‘where is the income?’’ And they said, you don’t get that. And I shrugged my shoulders, and began to understand.”

The New England Journal is owned by the not-for-profit Massachusetts Medical Society. In 1999, the society wanted to publish a new set of journals using its current journal’s brand name – journals called “The New England Journal of Cardiology” and “The New England Journal of Oncology,” for instance.

Kassirer vehemently disagreed with their idea. It cost him his job.

KASSIRER: “I thought that the society was exploiting the journal in order to try to bring in more money and said so quite publicly. I think after a while they just simply got tired of my objecting to all these things.”

When Arnold Relman was editor, he says the journal made more than enough money from classified ads and subscriptions. So he made a suggestion. 

RELMAN: “We didn’t need commercial advertising. And I would have been much happier without it, but the society would hear none of it.”

All we know right now from tax documents is that the society made about $90 million in revenue from publishing activities in 2009, including $20 million from “advertising.” Many say the journal should be more transparent by disclosing how much it takes from drug companies in reprint sales and advertising. After all, it expects researchers who submit articles to disclose conflicts of interest.

But Tom Stossel says disclosure would amount to nothing. Stossel teaches at Harvard Medical School. He says he used to be very skeptical of the relationship between research and industry. Then he joined the advisory board of the company Biogen, and he realized something.

STOSSEL: “Medicine was improving incredibly not because doctors got smarter or more ethical, but because of the amazing products we were getting from the medical products industry.”

Stossel says all this talk about financial conflicts is distracting us from trying to develop better drugs and save lives. He thinks journals rail against conflicts of interest not because they’re worried about biased research, but because they’re threatened by drug companies whose employees know more about medicine than they do. Those employees, he says, have good intentions. And so do researchers.

STOSSEL: “Show me an example of somebody who had a financial interest and in a blatantly biased way misrepresented the truth. I’m sure you can find it. But it’s got to be vanishingly rare.”

Some would point to one example that got the New England Journal in trouble. In the year 2000, the journal published a study touting the benefits of the painkiller Vioxx, manufactured by Merck. Merck bought almost $1 million worth of reprints of the study from the journal. But four years later, it removed Vioxx from the market because it hadn’t reported certain serious side effects associated with the drug.

Marcia Angell, who was on the editorial board of the journal until 2000, says it’s getting harder and harder to guard against these kinds of episodes.

ANGELL: “I think the public is in a difficult situation. It’s hard to know what to believe. And you can hardly be too skeptical.”

Angell is also disappointed that the New England Journal has relaxed some of its conflict-of-interest rules since she left. Now, authors of review articles or editorials are allowed to take money from industry, and the journal editors decide whether it’s too much. While she was there, they weren't allowed to take any money.

ANGELL: “We realized that disclosure was not enough, because these were matters of judgment." A judgment, Angell says, that could be swayed.

But it's become more difficult to find reviewers who haven't taken any money from drug companies. And how do you establish a zero-level for conflicts of interest anyway? Jeffrey Drazen is the journal's current editor. 

DRAZEN: “If you’re asking me now to write an editorial about something and I have received no money from the company but I’ve gotten maybe a mousepad and maybe a trip to a meeting…this is no money?”

That’s how Stossel feels. He thinks people who rail against the so-called “medical-industrial complex” have their own agenda.

STOSSEL: “This jihad against industry…it’s become a livelihood. And if your full-time job is beating up on other people, then the more people who believe it, you can get your papers published, you can get your book published…”

Whether it’s justified or not, though, the chorus against ties between drug companies and medicine is getting louder. Included in the federal health care law is a provision requiring pharmaceutical companies to report payments they make to doctors. At the same time, the relationship isn’t going away as doctors get busier and have less time to read medical journals. Bill Summers is a History of Science and Medicine professor at Yale University.

SUMMERS: “I worry that medical journals will become irrelevant. Where do you learn about a new drug? Well, you learn about it from the salesperson.”

That may be one reason scientific publishers are starting to change the way they do business. We’ll talk more about that in the second part of the series. For WNPR, I'm Neena Satija.

Read more at the Connecticut Mirror at http://ctmirror.org/story/16034/nejm.