Flacking for Big Pharma

By Harriet Washington

Drugmakers don’t just compromise doctors; they also undermine top medical journals and skew medical research.

“Drug Makers Cut Out Goodies for Doctors” and “Drugmakers Pulling Plug on Free Pens, Mugs & Pads” read headlines in The New York Times and The Wall Street Journal Health Blog at the end of 2008 after, in a very public act of contrition, 38 members of the pharmaceutical industry vowed to cease bestowing on prescribing physicians goodies such as pens, mugs, and other tchotchkes branded with their names. Some physicians and ethicists had long expressed concern about the “relationship of reciprocity” that even a pizza or cheap mug can establish between doctors and drugmakers, and branded trinkets also send a message to the patient, who might reason that Gardasil must be a good drug if her doctor wields a reflex hammer inscribed with its name. But while the popular press celebrated this sudden attack of nanoconscience and while we still gravely debate whether physicians’ loyalties can really be bought for a disposable pen or a free lunch, the $310 billion pharmaceutical industry quietly buys something far more influential: the contents of medical journals and, all too often, the trajectory of medical research itself.

How can this be? Flimsy plastic pens that scream the virtues of Vioxx and articles published in the pages of The New England Journal of Medicine would seem to mark the two poles of medical influence. Scarcely any doctor admits to being influenced by the former; every doctor boasts of being guided by the latter. In fact, medical-journal articles are widely embraced as irreproachable bastions of disinterested scientific evaluation and as antidotes to the long fiscal arm of pharmaceutical-industry influence.

And yet, “All journals are bought—or at least cleverly used—by the pharmaceutical industry,” says Richard Smith, former editor of the British Medical Journal, who now sits on the board of Public Library of Science (PLoS), a nonprofit open-access group publishing scientific journals that eschew corporate financing and are freely available online to the public.

Big Pharma, as the top tier of the industry is known, starts modestly, inserting the thin edge of its wedge by advertising copiously—and often inaccurately—in medical journals. In 1981, concerned officials at the Food and Drug Administration recognized the educational nature of pharmaceutical advertising by establishing explicit standards for medical-journal ads that mandate “true statements relating to side effects, contraindications, and effectiveness,” and a “fair balance” of statements about medication risks and benefits.

In 1992, the editors of the esteemed Annals of Internal Medicine decided to gauge how well their own advertisements met that standard. They tested 109 advertisements along with the references cited by those ads, sending each ad to three expert reviewers who evaluated them in light of the FDA standards. Fifty-seven percent of the ads were judged to have no educational value, 40 percent failed the fair-balance test, and 44 percent, the reviewers believed, would result in improper prescribing. Overall, reviewers would have recommended against publication of 28 percent of the advertisements, as the Annals revealed in its published report.

The FDA subsequently issued 88 letters accusing drug companies of advertising violations between August 1997 and August 2002.

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