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The Hippocratic Wars

By Ellen Ruppel Shell


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 appeal.

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 stultifyingly dull."

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 know."

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 months.

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 journal revenues."

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



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