A Drumbeat on Profit Takers
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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.
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."
First Published March 22, 2012 12:01 am