[Marxism] Crusaders against a profit-oriented medical industry

Louis Proyect lnp3 at panix.com
Tue Mar 20 08:00:31 MDT 2012


NY Times March 19, 2012
A Drumbeat on Profit Takers
By ABIGAIL ZUGER, M.D.

CAMBRIDGE, Mass. — The old crusaders are getting just a little 
creaky: Dr. Arnold S. Relman, 88, has a hearing aid and the hint 
of a tremor; Dr. Marcia Angell, 72, osteoporosis and arthritic 
hands. But their voices are as strong as ever.

Colleagues for decades, late-life romantic partners, the pair has 
occasionally, wistfully, been called American medicine’s royal 
couple — as if that contentious Tower of Babel could ever support 
such a topper. In fact, controversy and some considerably less 
complimentary labels have dogged them as well.

 From 1977 to 2000, one or both of them filled top editorial slots 
at The New England Journal of Medicine as it grew into perhaps the 
most influential medical publication in the world, with a voice 
echoing to Wall Street, Washington and beyond. Many of the urgent 
questions in the accelerating turmoil surrounding health care 
today were first articulated during their tenure.

Or, as Dr. Relman summarized one recent afternoon in their sunny 
condominium here, Dr. Angell nodding in agreement by his side: “I 
told you so.”

“I’ve allowed myself to believe that some of the things I 
predicted a long time ago are happening,” he said. “It’s clear 
that if we go on practicing medicine the way we are now, we’re 
headed for disaster.”

Their joint crusade, stated repeatedly in editorials for the 
journal and since expanded in books and dozens of articles in the 
lay press, is against for-profit medicine, especially its 
ancillary profit centers of commercial insurance and drug 
manufacture — in Dr. Relman’s words, “the people who are making a 
zillion bucks out of the commercial exploitation of medicine.”

Some have dismissed the pair as medical Don Quixotes, comically 
deluded figures tilting at benign features of the landscape. 
Others consider them first responders in what has become a battle 
for the soul of American medicine.

They met almost 50 years ago. He was a star of the academic 
medical scene in Boston, a Brooklyn boy who wanted to be a 
philosopher but had to make a living. She was born in Tennessee 
and raised in Virginia, worked in microbiology labs through 
college and after, then landed in medical school at Boston 
University, an older student and one of 8 women in a class of 80.

In need of a student project, she was referred to Dr. Relman, then 
a kidney expert with some data that needed analysis; that first 
collaboration was published in 1968. “He was a rather forbidding 
person in those days,” Dr. Angell recalled. A classmate once saw 
him greet her on the street and said, impressed, “You talk to him?”

Reader, she married him, but not for four decades: They were wed 
in a City Hall ceremony in 2009, a second marriage for both.

Patients vs. Profits

Their editorial collaboration long predated the romance. In 1980 
Dr. Relman, then three years into his tenure as editor in chief of 
The New England Journal, recruited his bright student to join him. 
That was also the year he launched his first editorial salvo 
against profit-making hospitals and laboratories and other 
investor-owned medical businesses.

“We should not allow the medical-industrial complex to distort our 
health care system to its own entrepreneurial ends,” he wrote; 
medicine must “serve patients first and stockholders second.” 
Revisiting the subject in 1991, he deplored a “market-oriented 
health care system spinning out of control” with commercial forces 
influencing doctors’ judgments and manipulating a credulous public.

He received an outpouring of response, including both hearty 
congratulations and accusations that he misunderstood market 
forces and was immensely naïve to assume that money was not most 
physicians’ prime motivating force.

Many similar articles and a book later, Dr. Relman remains 
unswayed. “I happen to believe that doctors are not saints, but 
not sinners either,” he said. “They are sensible, pragmatic, decent.”

In his ideal health care system, doctors would be salaried and 
organized into large multispecialty group practices similar to the 
Mayo Clinic and other private clinics; care would be delivered by 
a single-payer nonprofit system, financed by the taxpayers. “You’d 
save an enormous amount of money,” he said, much of it by 
eliminating the private insurance industry, “a parasite on the 
health care system.”

Opponents say that he just doesn’t understand how things work. 
“Angell and Relman have a conspiracy theory regarding how industry 
operates,” said their longtime critic Richard A. Epstein, a law 
professor at New York University who has a strong libertarian view 
on health care issues. “All they can talk about is greed.

“They understand medicine pretty well,” he added. “The moment they 
start talking about industry — oy gevalt! They have a deep 
difficulty understanding the issues.”

Dr. Angell has drawn a similar response for her intensely critical 
focus on the pharmaceutical industry. She traces it to the late 
1980s, when manuscripts she edited for The New England Journal 
testified, she says, to the “new power and influence of pharma” 
over studies validating its products. Instead of standing back 
while impartial scientists evaluated drugs, manufacturers were 
suddenly involved in every aspect of the process.

Dr. Angell says she vetted manuscripts that omitted any mention of 
a drug’s side effects, and studies that were weighted to make a 
drug look good; she repeatedly heard about studies never submitted 
for publication because they made a drug look bad.

“You don’t know what was suppressed,” she said. “You don’t know 
what was selected. You don’t know whether the goal posts were 
changed” so that good six-month data was offered for publication 
instead of bad one-year data. “You really don’t know.”

“I think it is genuinely difficult to know what to believe in 
clinical research now,” she added. “There are a lot of grubs 
crawling around under there.”

Both she and Dr. Relman roll their eyes at “those who choose to 
believe” that investor-run companies — including health insurers 
and drug makers — may have a primary goal other than shareholder 
profit, no matter the corporate spin regarding higher motivations.

Industry defenders say that the giant expense of developing new 
drugs and bringing them to market justifies the hard sell. “The 
pharmaceutical industry is operating under unbearable pressures,” 
Mr. Epstein said.

Dr. Angell’s most recent focus has been the microcosm of 
psychoactive drugs. In a two-part series in The New York Review of 
Books last summer, she gave a sympathetic hearing to three books 
arguing that most drugs used to treat mental illness are 
ineffective and unnecessary, creating more problems than they 
solve. She also trained a critical eye on the giant manual that 
governs psychiatric diagnosis, noting that many of the experts who 
define new psychiatric disorders have extensive connections with 
companies that make drugs for the disorders.

Some experts agree with her take. “Something is really going on 
there,” said Dr. Howard Brody, a professor at the University of 
Texas Medical Branch in Galveston who has written extensively 
about the drug industry. “When history ends up writing of this 
era, it will show psychiatry seduced by the commercial model of 
medicine.”

But psychiatrists question what seems to be a uniform disdain for 
some reasonably effective medications.

“Antidepressants work,” wrote the psychiatrist Dr. Peter D. 
Kramer, the author of “Listening to Prozac,” in a rebuttal 
published in The New York Times — “ordinarily well, on a par with 
other medications doctors prescribe.”

“Dr. Angell is now doing pretty much the same thing the industry 
she assails has done, just the converse,” said Dr. Richard A. 
Friedman, director of the psychopharmacology clinic at Weill 
Cornell Medical College in New York and a frequent contributor to 
Science Times. “Pharma withheld the bad news about its drugs and 
touted the positive results; Dr. Angell ignores positive data that 
conflicts with her cherished theory and reports the negative results.”

Dr. Angell says she is “just a believer in following the 
evidence,” and in at least one celebrated case — the controversy 
surrounding silicone breast implants — she found that the evidence 
supported manufacturers’ claims that the implants were safe, 
despite pervasive public opinion that they were not. (They have 
since been quietly reintroduced after additional studies bore out 
the safety claims.)

Raising Ethical Concerns

Dr. Angell presents the atypical figure of an influential 
physician with an encyclopedic knowledge of medicine but virtually 
no experience in its practice. She completed two years of 
hospital-based training in 1969 — “I loved working with patients,” 
she says — but she never cared for a patient again. Instead, newly 
married, she had two daughters (“When I got pregnant I was 
fired”), and finished up in the laboratory specialty of pathology. 
She joined the journal’s staff a short time later.

In a 1981 editorial, she deplored the “grim and highly responsible 
series of trade-offs” most women in medicine were forced to make 
in those days, but the figure she cut was far from grim.

Instead, former colleagues paint a picture of Dr. Angell as slim, 
cool and elegant, as if the office were not The New England 
Journal but Vogue — the only woman in a roomful of men, and firmly 
in control of the show.

It can be seen only as a small cosmic joke that the journal should 
turn into one of medicine’s great cash cows, generating giant 
advertising profits for its owner, the Massachusetts Medical 
Society. The two bitter opponents of medical profit-making found 
themselves leading an increasingly profitable venture.

“They were in the right place at the right time,” said Dr. Thomas 
H. Lee, a Boston cardiologist and an associate editor at the 
journal. “Research was getting into gear, the amount of research 
and the money involved were getting bigger and bigger. Ethical 
issues and difficult, painful policy issues were coming up. They 
rode the wave. They did a lot of good things. The journal became 
hugely prominent in their time, the greatest bully pulpit.”

And not unexpectedly, perhaps, the money issue ultimately came to 
a boil. A long-simmering disagreement between the editors and the 
medical society exploded in 1999; Dr. Relman had left the journal 
by then — he retired at 68 to teach and write — but Dr. Angell was 
still a top editor.

The narrow issue was whether the journal’s “brand name” could be 
used as a kind of seal of approval for other profitable but 
possibly less worthy medical ventures, like newsletters and 
conferences. Dr. Angell and Dr. Jerome P. Kassirer, Dr. Relman’s 
successor, were adamantly opposed, and by 2001 both were out of 
the organization.

But as commentators noted in the considerable news coverage, there 
was a larger issue: how “clean” any medical journal should keep 
itself from the contaminating influence of money, especially 
industry money. Many physicians believed that the degree of 
separation the top editors demanded for the journal, and for its 
expert authors, was unrealistic and counterproductive.

In 1984, Dr. Relman became the first editor of a medical journal 
to require authors to disclose financial ties to their subject 
matter and to publish those disclosures. He later came to suspect 
that simple disclosure was not enough, and his policy evolved to 
excluding all authors with financial interests from writing large 
educational reviews.

That rule was reversed in 2002, after the journal’s current editor 
in chief, Dr. Jeffrey M. Drazen, took the job. Dr. Drazen and his 
colleagues reported that for some subjects, so few experts without 
financial ties could be found that the journal’s scope was 
becoming artificially curtailed.

Unrepentant ‘Pharmascolds’

The journal, now in its bicentennial year, has little internal 
conflict, Dr. Drazen said in an interview. Among its additions in 
the years since Dr. Relman and Dr. Angell left are a media office 
and a substantial Internet presence, complete with Facebook and 
Twitter accounts. Financial conflicts of interest no longer figure 
as a divisive issue.

But the matter continues to rage elsewhere, particularly as the 
Obama administration’s health care act goes into effect. The law 
will require disclosure of almost all payments and gifts that 
device makers and pharmaceutical firms make to individual physicians.

The provisions will shed unprecedented light on what Dr. Angell 
described as a “tsunami” of drug company money, inundating doctors 
and influencing prescribing habits. Patients will be able to check 
out their doctors, and more important, Dr. Brody of Galveston 
said, journalists and other watchdogs will be able to examine 
patterns of compensation on a national level.

“The issues of conflict of interest and integrity in medical 
research are vitally important for journalists and the public,” 
said Charles Ornstein, president of the Association of Health Care 
Journalists. An investigative reporter for ProPublica, Mr. 
Ornstein has collaborated on a searchable “Dollars for Docs” 
database that compiles the limited payment data currently publicly 
available. Other experts disagree on the importance of these 
dollars. Several years ago, two Harvard physicians coined the 
label “pharmascold” to describe, among others, “self-righteous 
medical journal editors” who they say compulsively criticize the 
industry and physicians who work with it, creating needless hubbub 
and erecting barriers that slow medical breakthroughs.

The two prime pharmascolds remain unmoved. Although Dr. Angell and 
Dr. Relman are slowly detaching themselves from academia (she 
retains a teaching appointment at Harvard Medical School, while he 
is now entirely home-based) both still juggle speaking and writing 
invitations and obsessively monitor the health policy winds. A 
shared passion for classical music has always occupied much of 
their leisure time, but only a list of grandchild-focused 
activities hints at advancing age.

“The only reason I’m not happy about not still being young,” Dr. 
Relman said, “is that I would like to hang around longer because 
I’m curious about what happens. I won’t live long enough to see 
it. I hope Marcia will. So I’ve told her that if there’s any way 
to keep me posted, she should.”

Dr. Angell said, “There are going to be a lot of conversations 
featuring lightning bolts from above.”




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