On a dreary Monday several months ago, with the fog
blotting out what would otherwise be a splendid view of the Chicago skyline,
Dr. George Lundberg, editor of The Journal of the American Medical
Association, stretched across the clutter in his sprawling corner office to
confide his latest coup. The lead article in next week's issue, "Fish
Consumption and Risk of Sudden Cardiac Death," was, he murmured,
"really hot." A steely-eyed pathologist with a finely honed news
sense, Lundberg is rarely wrong on such matters, in part because he leaves
nothing to chance.
The previous Tuesday, the American Medical Association
press office deluged 2,500 media outlets around the world with press packets,
E-mails, faxes and, for broadcasters, tantalizing chunks of ready-to-air film
footage trumpeting the findings of the study: a link between fish consumption
and a 50-percent reduction in sudden cardiac death. As anticipated, this
effort had the desired effect. The story received prominent play on ABC and
CNN, in Time, The Washington Post, The New York Times, Newsday and in foreign
outlets from Ireland to Asia. The major wire services and radio networks ran
pieces on it. Restaurant Business magazine reported a spike in restaurant fish
sales, and gleeful fish marketers plotted to use the findings as rationale for
a new publicity slogan: Seafood, Take It to Heart.
But a closer look at the fish study reveals that it is of little real
significance. The researchers looked not at a random cross section of
Americans, but at 20,551 white male physicians, fully 90 percent of whom
reported eating fish one or more times each week -- 10 years before the study
was completed. No follow-up diet data were gathered because the study was not
designed to look at diet per se, but at other factors thought to be related to
sudden death. And there was a strong suspicion (mentioned casually in the
study, and hardly at all in news-media accounts of it) that the relatively
small number of doctors who didn't eat fish also had a less healthy life style
than their more robust fish-eating colleagues. In other words, the report may
represent nothing more than a statistical fluke.
In a JAMA editorial accompanying the study, Daan
Kromhout, a public-health researcher with the National Institute of Public
Health and the Environment in the Netherlands, did nothing to dispel these
doubts. He pointed out that earlier investigations had found no association
between sudden cardiac death and fish consumption, and that this study
"does not provide clear-cut answers." Indeed, Kromhout's editorial
mentioned earlier research suggesting that a high intake of fish may even
result in a "detrimental health effect" due to, for example, mercury
poisoning. Thanks largely to the journal's publicity machine, however, more
than 50 million consumers failed to hear Kromhout's cautionary message.
Lundberg does not consider this a problem. "People
are told that eating fish once a week is not a bad thing," he shrugged.
"What harm could it do?"
A thousand miles east of Lundberg's offices, the
editorial offices of The New England Journal of Medicine nest in dignified
obscurity on the sixth floor of the Harvard Medical School library. When I
arrived one day soaked by a late-morning downpour, the journal's editor in
chief, Dr. Jerome Kassirer, opened an umbrella and escorted me firmly to a
near-empty Harvard dining room. Over scallops and pea pods, Kassirer regaled
me with details of the journal's success. It has 245,000 subscribers worldwide
and enlists 6,000 volunteer reviewers, who pour through 3,600 submitted
research articles each year, 90 percent of which are ultimately rejected. When
I asked Kassirer what the journal had in the pipeline, he replied stiffly that
he never discusses upcoming articles -- but hinted that he and his executive
editor, Dr. Marcia Angell, had penned something special for the coming New
Year's edition. Their editorial, titled "Losing Weight -- An Ill-Fated
New Year's Resolution," implored Americans "not to sacrifice one of
the great pleasures of life -- eating." The commentary provoked snide
newspaper columns, television spots and a letter from the former Surgeon
General C. Everett Koop, who accused the New England Journal of trivializing
"the second-leading cause of preventable death in the United
States." When I asked Angell if she finds criticism of this sort
unsettling, she allowed herself a tiny smile. "Given the choice,"
she said, "we prefer not to be boring."
The truth is, neither N.E.J.M. nor JAMA (as the two
journals are commonly referred to) can afford to be. Though no one's idea of a
tabloid war, the competition between these two eminent medical journals for
subscribers, advertising dollars and intellectual primacy is fierce.
Typically, doctors have no more than three hours a week to read the latest
journals, and there are nearly 4,000 of them competing for a physician's
attention. Grabbing a chunk of that reading time requires careful wooing not
only of doctors, but also of the rest of us. In a trend some critics consider
troubling, journals are increasingly gearing their content toward general
consumption, appealing directly to lay readers in a bid to increase their
visibility and make themselves a "must read" for doctors. "It's
kind of a joke among us," says Dr. Anthony Fauci, director of the
National Institute of Allergy and Infectious Diseases. "Your patients
read about some study in the newspaper and if you don't read the journal
yourself, you aren't going to know what they are talking about."
JAMA and in particular N.E.J.M. have long and
illustrious histories of publishing landmark research. But while these sober
studies often set the standards of care for the nation's practicing
physicians, they hold little marquee value. What increasingly get the buzz are
life-style reports -- tantalizing and suggestive research on sex, food,
exercise and health "breakthroughs," studies that tell us, in Dr.
Angell's words, "what to do when we get out of bed in the morning."
That these reports sometimes teeter on the edge of scientific credibility is
easily lost in the fact that they have instant and obvious journalistic
Clearly, there is a voracious public appetite for such
news. A recent survey showed that Americans now rely more on the media than on
their physicians for health information. The rise of managed care and the
shrinkage in time most doctors have available for patients have contributed to
this trend, as has the legion of aging, health-obsessed boomers. And there has
been an unmistakable attempt on the part of N.E.J.M. and in particular JAMA to
cash in on this, by running a steady stream of reports and commentaries that
appeal to the public at large -- surprisingly mundane reports on the health
benefits of walking, for example, or the dangers of making calls on a cell
phone while driving a car.
Medical journals represent scholarship, of course, but
they are also businesses, and most are beholden to drug makers for their
economic viability. N.E.J.M. and JAMA had display advertising revenues last
year of $19 million and $21.4 million respectively, the vast bulk of it from
drug companies. While both journals claim a fire wall between their
advertising and editorial departments, it is clear that the vast majority of
drug-company-sponsored studies that get published are positive, not negative,
and that N.E.J.M. and JAMA rely on the media to make these findings public.
This in turn generates a steady revenue stream, both from advertising and from
reprints of articles that drug makers buy in bulk and distribute to doctors
worldwide. These funds support not only the journals, but also the lobbying
organizations that back the journals, in this case the Massachusetts Medical
Society and the American Medical Association.
This targeting of the lay public also reflects recent
changes in drug advertising. Last summer, modifications in Food and Drug
Administration guidelines cleared the way for pharmaceutical companies to
bypass doctors and broadcast appeals directly to consumers. The resulting gush
of drug ads has bankrolled an explosion of health coverage -- and encouraged
networks, newspapers and magazines to set aside space for health
"news," just as they do for sports or the weather. It's a rare week
that pronouncements emanating from N.E.J.M. or JAMA or both aren't featured in
headlines and on television. "You don't find Peter Jennings quoting
anything else in his newscasts," Koop says. "It's the New England
Journal, JAMA or nothing." As a result, Kassirer and Lundberg, both
brilliant manipulators of the press, are arguably the most influential men in
American medicine. And both are willing to go to extraordinary lengths to
maintain that influence.
Just how far George Lundberg will go is amply
demonstrated in JAMA's April 1 issue, which featured an article debunking
"therapeutic touch," an alternative-medicine technique taught at
many nursing schools. One co-author was Linda Rosa, a nurse and member of the
National Council Against Health Fraud, a lobbying group whose avowed mission
is to discredit alternative health-care practices, in particular therapeutic
touch. The other co-author was Rosa's 11-year-old daughter, Emily, who
"designed" the study two years ago as a fourth-grade school-science
project. Neither mother nor daughter has the academic or scientific
credentials associated with contributors to top-flight scientific journals,
and had this study appeared in a less vaunted publication it would most likely
have been dismissed as an April Fools' stunt. But with the patina of
scientific legitimacy conferred by JAMA, the study received widespread
coverage not only as a human-interest story, but also as an important
scientific one. Emily made guest appearances on "CBS This Morning,"
the "Today" show, CNN and ABC, and was billed as "the youngest
person ever to publish in the prestigious Journal of the American Medical
Association" on "NBC Nightly News." The study also received
front-page coverage in The New York Times, The Los Angeles Times, The Denver
Post and other newspapers.
"That a child's school project should be published
in a major medical journal is very disturbing to me," says Carol Wells-Federman,
a registered nurse and co-director of the Chronic Pain Management Program at
Beth Israel Deaconess Medical Center in Boston. "And she's the child of a
known skeptic. If the daughter of a therapeutic-touch practitioner submitted
an article in support of the therapy, it wouldn't get to first base."
While admitting that five years ago the article
"wouldn't have made it into peer review," Lundberg makes no
apologies for running it or for his lavish courtship of the press. He sees
JAMA's aggressive marketing of its own medical news as a way to improve
medical journalism. Journalists, however, question Lundberg's motives.
"All journals are increasingly playing the press," says Lawrence K.
Altman, M.D., a veteran medical reporter for The New York Times.
"Lundberg courts the press for the same reasons that everyone does,
because he wants publicity to attract advertising."
Lundberg is not a spontaneous man, and he carefully
prepared a staggering assortment of visual aids, flow charts, tables and
graphs for our meeting. As he talked, he jabbed at these with a swagger stick,
a memento of his years as a lieutenant colonel in the Vietnam War. "It's
a wonderful invention," he sighed, "but illegal now, like so much
fun Army stuff." When I asked him to compare JAMA with N.E.J.M., his eyes
narrowed. "Most American physicians don't see the Boston journal, and
even fewer read it," he said. "It is predictable, elitist and
There is bravado in this, but also truth. Until
recently, N.E.J.M. was in a class by itself in American medical publishing,
but it now feels the nip of a canny and ambitious rival. Under Lundberg's
17-year leadership, JAMA has gradually risen from a house organ serving at the
behest of the American Medical Association to an independent force poised
easily in the top tier of medical publishing. JAMA licenses 15 international
editions and circulates to 750,000 readers in 150 countries. It is considered
more eclectic and daring than N.E.J.M., less dogmatic and more responsive to
the needs of its audience. Lundberg takes pride in his young and largely
female editorial staff and in his own willingness to move with the times -- to
put JAMA on the Web, for instance, and to enter into what he calls a
"proactive" partnership with "our friends in the press."
But that relationship might better be described as
anthropological. Lundberg has studied hundreds of journalists, and integrated
what he has learned into official JAMA policy. Noting eight years ago that
N.E.J.M., which publishes on Thursdays, was getting more than its share of
news coverage, he bumped up JAMA's publication from Friday to Wednesday to
steal his rival's journalistic thunder. At one time, JAMA got fewer weekly
press citations than N.E.J.M., but the gap has closed. And whatever it lacks
in influence, JAMA has a circulation that is by far the largest of any medical
journal in the world, more than triple that of N.E.J.M.
That said, JAMA has yet to shed completely its
poor-cousin status, or its eagerness to please. Thousands of free copies are
mailed to journalists, complete with lavish press packets highlighting the
week's "hot stories." One of these "hot stories" also
forms the basis of "JAMA Report," a two-and-a-half-minute
"video news release" accessible via satellite to every television
network and local station in the country. "JAMA Report" gets
enormous play; an average of 25 million and as many as 110 million viewers see
at least part of it every week, usually on cable health shows or local-news
health segments. Often these reports are broadcast without attribution, as if
the segment had been produced by journalists, not JAMA publicists.
Barry Cohn, broadcast news producer for the A.M.A.'s
Department of Science News, says he makes no attempt to balance these reports,
or to call into question the steady stream of medical
"breakthroughs" they promote. This, not surprisingly, can lead to
controversy. Dr. Timothy Johnson, medical editor for ABC News, says he
considers JAMA Report no better or worse than the piles of video news releases
he gets from other medical institutions "trying to get their products out
to the public." Neal Freeman, a veteran newsman and chairman of the
Blackwell Corporation, which produces the weekly PBS series "Technopolitics,"
describes such reports as "designed to deceive" viewers by making
press puffery look like journalism. "Frankly, I can't think of a more
corrupting influence than the video news release," he says.
Lundberg's efforts to "educate" through
promotion can backfire, as in a study published in JAMA last October touting
the plant extract Ginkgo biloba as a palliative for the symptoms of
Alzheimer's disease. The study was too small to reach any definitive
conclusions, but JAMA's promotion of the results, including one of its news
videos, encouraged patients to seek an unproven herbal treatment that may have
a bigger impact on their weekly budget than on their health. This points out
one of the problems of unmediated press reports: what the scientific community
might read as, at best, suggestive information, the general public regards as
gospel. Preliminary trials of drugs and medical devices can be instructive to
scientists, but they are rarely of relevance to consumers. Yet too often they
are used to ballyhoo small and questionable benefits of treatments with
unknown or unquantified risks. Dr. Robert Myerburg, director of cardiology at
the University of Miami Medical School and an expert on clinical trials, says
that studies of common therapies like estrogen-replacement supplements or
cholesterol-lowering drugs are particularly prone to misinterpretation by
physicians as well as by the public. "Too often, side effects, which the
entire treatment population is exposed to, are overlooked or downplayed, and
the benefits, which affect only some of the treatment group, are
overplayed," he says. "The problem with these studies is the
perspective they create. They make news, but they aren't good science."
Jerome Kassirer contends that N.E.J.M. has no interest
in making news, and cites as evidence the fact that the journal has turned
down newsworthy submissions that later appeared in JAMA to great fanfare.
Kassirer says his journal has no need for hype, that it does not "and
never will" circulate news releases and that it doesn't support a news
office. The very mention of a video news release makes his upper lip curl.
"We are the acknowledged leader in medical
publishing," he says, so hotly pursued by scientists that public
attention is beside the point. Indeed, while many medical scientists complain
about N.E.J.M.'s "East Coast bias" and "left-wing agenda,"
most are clamoring to get their research into its pages. "I submit my
best work there," says Anthony Fauci. "And so do most scientists I
The Boston journal makes no apologies for its elitism,
but rather revels in it. It sees itself as an unabashed meritocracy. The cabal
of luminous medical minds that gathers in N.E.J.M.'s editorial offices each
Thursday to determine the fate of aspiring contributors is a decidedly Brahmin
bunch, mostly gray and furrowed and, with the exception of the executive
editor, Marcia Angell, entirely male.
As always, the articles under consideration the day I
visited had already passed muster with one or more of N.E.J.M.'s in-house
editors, but by the tone of the arguments that followed you would think they
had just blown in over the transom. Studies were shot down for poor design,
bias and suspicious-sounding statistics. But then a weakly received paper (in
Angell's words, "it doesn't snap my socks") got Kassirer's approval
because it overturns a theory he personally considers ridiculous: that the
bright lights in hospital nurseries can blind infants. "Just because we
can't convince the lunatics doesn't mean we shouldn't run it," he said.
To which Angell responded, "But there are so many lunatics." The
fact that the research has photogenic appeal (it involves newborns wearing
goggles) probably didn't hurt, either. It got thumbs up. The meeting lasted an
hour and a half, with all but four of a dozen studies rejected.
Kassirer is used to getting his own way, but, when
necessary, savors a good fight. When I asked if he gets hate mail, he happily
pulled out a well-tended album of the stuff. He told me that a particularly
harrowing death threat, prompted by an article on an abortion-inducing drug
combination, once led him to hire an armed security guard for two weeks.
But that was clearly the exception: Kassirer has the
look of a man who can take care of himself. The son of an assembly-line worker
who grew up and attended medical school in Buffalo, he has a cocky, defensive
edge. When I questioned whether he, a kidney specialist, feels truly qualified
to pontificate on such fields as gynecology and public health, he pulled his
fleshy six-foot-plus frame out from behind his desk and answered,
"Yes." Who edits his editorials? "My wife, and of course,
Marcia." Who edits Dr. Angell? "Me."
Kassirer's arrogance is so transparent as to seem
affected, calculated to serve his journal's attention-getting needs much as
does Lundberg's less- subtle courtship of the media. Certainly Kassirer's
fiercely independent stance has led N.E.J.M. down some rocky paths and
generated its own form of publicity. Last year an editorial written by Angell
compared the testing of AIDS drugs in the Third World to the infamous Tuskegee
experiment, in which African-American men were deprived of treatment for
syphilis in the name of science. The commentary provoked a particularly strong
response from infectious-disease experts. N.E.J.M.'s chief advisers on AIDS,
Dr. David Ho and Dr. Catherine M. Wilfert, quit the journal's board in
protest. Dr. Harold Varmus, director of the National Institutes of Health, and
Surgeon General David Satcher, then head of the Centers for Disease Control
and Prevention, wrote rebuttals. Varmus will no longer comment on the affair,
but at the time he publicly accused N.E.J.M. of grandstanding.
Kassirer says he regrets the board members' decision to
leave, but not running Angell's commentary. "The editorial page is no
place for a Talmudic discussion," he says. "This was Marcia's
position, and she had a right to voice it."
Experts cite another reason why journalists, and the lay
public, might view some N.E.J.M. offerings with wariness: Kassirer's professed
willingness to overrule reviews of research articles written by experts whose
knowledge in a field eclipses his own. "The reviewers are
consultants," he says. "I get the last word."
To an increasing number of scientists concerned with the
integrity of the peer-review process, the very notion that peer review can be
overruled is a contradiction in terms. Dr. Iain Chalmers, an obstetrician on
the staff of the Cochrane Center in London, an international collaboration
with the National Health Service Research and Development Program aimed at
bettering research practice and scientific publication, says that the medical
publishing industry is a "cutthroat business with all sorts of vested
interests," and that Kassirer's failure to acknowledge this, or to
address the limitations of his position, "shows a shocking lack of
self-awareness." Chalmers is particularly alarmed at Kassirer's
reluctance to reconsider the submission and selection process, which he and
others say is consistently subject to bias. Kassirer has declined to attend
meetings with other scientific-journal editors to hash out this problem,
contending that his review process is in no need of tinkering. "Kassirer's
position, that 'all is well,' shows a complacency that is almost never
justified and is extremely dangerous," Chalmers says.
In the current relationship between the medical journals
and the press, reporters are not always consigned to the role of conduits.
Medical reporting varies in depth and quality from venue to venue, and while
the press tends to be less savvy at understanding methodological weaknesses in
any given study, it is gradually becoming more adept at seizing on clear
financial conflicts of interest. Two years ago, N.E.J.M. published an
editorial saying that the benefits of the anti-obesity drug dexfenfluramine
(brand name Redux) outweighed the risks and heralded it as "an important
new drug in the clinician's arsenal." Almost immediately, however, major
newspapers -- including The Wall Street Journal and The New York Times --
reported that the authors of the N.E.J.M. commentary, though academics, had
also served as consultants to the drug's manufacturer and distributor. The
conflict was especially embarrassing because last September, Redux was linked
to heart valve damage, and the F.D.A. pulled it off the market. While Kassirer
and Angell characterized this episode as "unfortunate," they
insisted that it is atypical. "To our knowledge, this was the first
violation of our policy in the six years it has been in effect," they
wrote later in an editorial. "That is not a bad record."
Even if the press wanted to be more enterprising and
aggressive about keeping the medical journals honest, it works against a
constraint known as the Ingelfinger Rule, which allows the journals to control
the flow of information. Almost 30 years ago, the New England Journal
instituted the policy (named for Franz Ingelfinger, then its editor), which
simply states that the journal will not publish information that has appeared
elsewhere. JAMA has also adopted this policy, albeit selectively, as have
other journals, with the practical effect that the journals enjoy an exclusive
franchise on the medical information they purvey. As a result, many scientists
are loath to speak publicly of their work for fear of jeopardizing their
chances of publication. This means that the public must wait to hear research
results until journals review and publish them, a process that can take many
While Kassirer and Lundberg insist that the rule
represents a sort of quality control, Ingelfinger himself had a different,
more pragmatic view: he described the rule as an economic imperative, a way to
avoid getting scooped by medical weeklies and losing the edge with readers and
advertisers. Whatever economic benefits accrue to the journals, they sometimes
come at the expense of the public. "The Ingelfinger Rule is an attempt to
harass and intimidate researchers so that journals can control their own
public relations," says Dr. Michael S. Wilkes, a medical journalist and
professor of medicine at the University of California at Los Angeles.
"Its purpose is to drum up media interest, and, ultimately, to increase
A recent episode illustrates how this high-minded
editorial policy can undermine daily health practice. In April, the National
Pediculosis Association disclosed the results of an unpublished Harvard study
showing that head lice develop resistance to widely used over-the-counter
shampoo treatments. Deborah Z. Altschuler, president of the association,
expressed delight that parents didn't have to wait anywhere from 6 to 18
months to learn that the expensive and potentially toxic lice shampoo they
routinely pour over their children's heads was, in at least some cases, of
little or no use. But the study's authors were aghast at the disclosure,
fearing that it would kill any chance of publication in the prestige journals.
They are probably right. Under the Ingelfinger Rule,
N.E.J.M. will not publish the article, and JAMA seems less than intrigued.
"I don't know whether we would publish it," Lundberg says. "But
I hardly consider head lice a public health emergency." Millions of
American parents might beg to differ. Most school nurses, pediatricians and
health maintenance organizations still recommend the shampoo.
© 1998 New York Times Magazine
June 28, 1998