Interview with Harriet Washington (Part II): The Many Tentacles of Corporate Funding

The Many Tentacles of Corporate Funding: FDA and Medical Journals

With regard to the broad reach of pharmaceutical and medical device company funding, how much of the FDA’s budget is paid for by the corporations themselves? And do you see any danger in that arrangement?

It’s 40 percent. That arrangement is very dangerous because it constitutes a very dramatic conflict of interest. We depend on the FDA to make a dispassionate, scientific evaluation of whether a medication is a good one and a safe one. How are they going to do that when they’re being paid by the people whose medication is being evaluated? It’s a very dangerous precedent that is being set.

How much of the funding of major medical journals comes from drug or medical device company ads?

Not every journal budget has been looked at, but at the largest, most influential journals (outside of the open access model journals) such as the New England Journal of Medicine, Lancet, JAMA, the figure remains between 95 and 99 percent. I am sure this also applies to the vast majority of the less influential journals. Influential medical journals are completely dependent on pharmaceutical company advertising. And it’s not just pharmaceutical companies. You did the right thing to mention medical device companies in your question as well.

Does this influence involve corporations giving direct orders to the editor-in-chief of the journal or is it more subtle than that?

Influence ranges all over the spectrum. There are sometimes direct orders clearly emanating from the journals’ bean counters. I wrote an article this summer for an American Scholar cover story that focused on this. In it, I detailed how Transplantation and Dialysis accepted an article that was questioning the usefulness of epoetin, a commonly used treatment for organ transplant patients. The journal was going to run it, but then the editor-in-chief wrote to the author said, “Unfortunately, I have been overruled by our marketing department with regard to publishing your editorial …” The marketing department wouldn’t allow it because the ads for that drug constituted a large percentage of their operating budget.

There’s also the infamous 1992 case involving Annals of Internal Medicine. They decided to evaluate the ads that ran in their own journal, according to the FDA’s guidelines for such ads. When they evaluated the claims that the medication makers made in their ads, their expert consultants found that many of the ads did not come up to snuff, that they failed to meet the FDA requirements for accuracy. They ran the article and I thought, “That’s wonderful, that’s very courageous.” However, drug makers responded by pulling all of their advertising and the journal almost went out of business.

From your book, I recall the figure being $1.5 million worth of ads that were pulled in one fell swoop. It was strikingly large.

This is a very direct example of this kind of pressure. But a lot of the pressure is more subtle. There’s simply the knowledge that your journal is dependent on the money, and therefore the good will, of the drug companies. And advertisers will often do things like offer to run a hundred thousand dollars of ads in the journal, but only if the discussion of their product is a favorable one.

When I worked at a newspaper, I remember that at first, as an editor, I had almost no contact with the people in the composing room who physically put the newspaper together. But at one point, I was told that I had to go to the composing room every night and check the entire paper after it was assembled but before it was printed, to ensure that that no airline ads ran on the same page with a plane crash. I asked why, and they explained to me that our contract with airlines stipulated that they would not pay for any ads that appeared on the same page as an airplane crash. So I now had to check the paper every day to avoid this.

It’s very similar to what happens with medical journals. They are well aware that if they run negative stories, they can lose ads. And there are more insidious ways that these corporations affect medical journals. They’re not content to deal with advertising; corporations also have become very, very good at manipulating the journals by running clinical trials and having them published in reputable journals.

What they submit for publication can be very misleading. For example, when discussing one of their very expensive COX-2 medications [anti-inflammatory drugs], a company ran articles in the New England Journal of Medicine in which they intentionally withheld the fact that some of the people in the trial suffered heart attacks and strokes and died.

That would qualify as a very significant omission.

They talk about all the people that were helped and simply delete mention of the people that died. This sort of thing is done frequently and the medical journals don’t have much recourse because they do not see all the original data. They only see what the authors choose to share with them. And who is the author? The author is a researcher at a medical school or university who is deriving money for a study from a corporation, which may tell him that he cannot, for example, discuss side effects, or that he cannot discuss the deaths that occurred in this trial. Researchers often comply.  

Ghostwriting is also common. Ghostwriting entails having a writer translate the drug company’s marketing messages into a medical journal article to which a physician appends his or her name. The article is then published without acknowledgement of the ghostwriter’s role and readers are duped into thinking this is the original work of a physician. 

This level of disinformation is profoundly disturbing.

The journal will run the articles and in some cases will never learn that they have published fictitious information. Or, sometimes, they do find out but only after the fact. This is a very serious problem — corporations are actually duping medical journals into running false or at the very least dramatically unbalanced information about products..