[Marxism] Crusaders against a profit-oriented medical industry
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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
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
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
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.
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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