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A Drumbeat on Profit
Takers
The New York Times
March 19, 2012
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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