IS ACADEMIC MEDICINE FOR SALE?
Posted by bmhegde on 1
Hold on! Before you want to hang me for writing this article, please note that the heading is borrowed from an editorial in the New England Journal of Medicine. (2000; 342: 1516-1518) My lamentations about medicine having gone to the market place, riding piggyback on technology, making it almost impossible to believe any of the short case-control studies published even in the “respectable” journals for years, had only fallen on deaf ears. I have become a laughing stock in the higher echelons of the Indian medical academia! I am told that a group of cardiologists in Bombay, when asked to assess me for the Fellowship of the Academy of Medical Sciences recently, opined that “he is only a quack and has no idea what cardiology is all about!” I did not become the Fellow-rightly so.
I was so happy that at least some of the “great” people could assess me correctly! Now comes the time bomb from America. I am sure our holy cows would now wake up from their sedative induced slumber. They would want things to come from America for them to believe anything in any field. Our western slavish mentality knows no bounds. We could realize that Amarthya Sen is a gem (Bharatha Ratna) only after the Nobel committee identified him! He has been advocating his “poverty economics” for years without getting any recognition from us in the past.
“The ties between clinical research and industry include not only grant support, but also a host of other financial arrangements. Researchers serve as consultants to companies whose products they are studying, join the advisory boards, and the speakers’ bureaus, enter into patent and royalty arrangements, agree to be listed authors of articles ghost written by interested companies, promote drugs and devices at company sponsored symposia, and allow themselves to be plied with expensive gifts and trips to luxurious settings. Many also have equity interest in companies. Academic medical institutions are themselves growing increasingly beholden to industry. Harvard used to be an exception; but they are also softening their stand.” Wrote Marcia Angell. (NEJM 2000; 342:1517)
I could quote some of my bitter experiences, that I had shared with readers from time to time, here to complete the picture. Time was when a symposium on treatment of high blood pressure was held in a five-star hotel in Goa. I was pitted to speak against a star speaker from America. This gentleman is a regular company “employee”, having a very high academic status in addition. The drug in question was a receptor blocker of a particular new variety. While the American went on to describe the drug as the panacea for all hypertensives and should be the first drug of choice, I had to, per force, take the opposite stand as I was convinced that this drug was not the drug of first choice. This great master ridiculed me and the audience, of course, was with him. In March 2000 while I was on a lecture tour of some Universities in the US, early morning wake up alarm in my hotel room was blaring out the news item that this very drug, in the first ever human study, had caused many more heart failures, while it is touted as the drug to prevent heart failure. The study has since been stopped and the newscaster was asking nearly a million Americans who are already on the drug to contact their doctors to get the drug changed immediately. I tried in vain to contact the “great” man but to no avail. This happens again and again.
No one has so far described science in a way that satisfies everyone. “Science, for example, can not give absolute proofs of the laws of nature because, although we can test an idea repeatedly, we can never be sure that an exception does not exist.” Says Michael Cross in the New Scientist 2000 February 19th. Every time something goes wrong and is detected, anyone could take refuge under this clause. This statement of Cross should not be misread to say that science is not good. It only goes to emphasize the fact that scientific methods are but one of the many ways to human wisdom.
Let us examine why there is such a large nexus between the academia and the for-profit industry. For one thing even hospitals have come under the latter umbrella! It is argued that ties between industry and academia are necessary for “technology-transfer”, a word invented after 1980s, when the American Government passed the Bayh-Dole Act. Academic institutions supported by Federal grants could patent and license new products discovered by their faculty in return for royalties. This law is cited when large-scale tie-ups go on between these two institutions. It is needless to say that we follow that rule blindly in our country. The second reason given is that academic institutions needed the money very badly. These are the main reasons why we are where we are today. The business goals of the companies influence the mission of the research institutions and also influence their final results.
One of the reasons why the cost of modern medical treatment, both medical and surgical, has skyrocketed is because the expenses incurred by the industry for its sponsored trips of the medical scientists, meals in top of the range hotels, gifts, honorariums, conference and symposia expenses, consulting fees, and research grants eventually are paid by the consumer! There is no free lunch in this world. Companies try and catch doctors very young when they are still house officers. Rothman records in a report (NEJM 2000; 342:1284) that the companies’ gifts are intended to buy the goodwill of young physicians with long prescribing lives ahead of them. Similar is the situation in many areas where the industry uses the talent of the academia for their research. Ultimately it is a Faustian bargain.
In fact, there are a few “researchers” who would not have seen a single patient all their lives, but profess to the world about the drug treatment of major illnesses. The companies mainly target those diseases that are likely to be life long business for them like diabetes, high blood pressure, coronary artery disease etc. There are many guidelines all over the world for the treatment of these diseases. If one takes care to carefully scrutinize them, one quickly realizes how fallacious they are. To give an example of hypertension, there are six guidelines in all: we in India are trying to have our own guidelines, in addition. If all of them are computed together they cover just about 39% of the patients. For the rest there are no guidelines. Young but enthusiastic doctor gets frustrated looking at these. If any of the guidelines are not convenient to the drug companies the companies get their “great brains” to refute them and have new guidelines. This happened with the American National Guidelines for high blood pressure management some time ago. (JNC V).
One could take any area for scrutiny. Anti-cholesterol drugs, anti-arrhythmic drugs, heart failure drugs, anti-hypertensive drugs, anti-diabetic drugs, pain killers, anti-cancer drugs or, for that matter, many of the procedures for surgical corrections and even some of the untested technologies like coronary care units, terminal care units, flow catheters and many other areas have their load of skeletons in their cupboards. An unbiased audit would get these skeletons out of the cupboards.
When the gulf between the industry and the academia narrows, as has happened now, medical students and house officers, under the constant tutelage of industry representatives, learn to rely very much on drugs and devices more often than they should do. Young doctors learn that there is a pill for every ill and a surgical correction for every anatomic deviation from the normal. Faculty members could get distracted from their teaching commitments. Doctors get used to these company courtesies of receiving gifts and favours to further their continuing medical education. In this generation there is always an overemphasis on drugs and devices that could ultimately work against patient interests. The Hippocratic oath really becomes hypocratic oath.
It is time to do a bit of introspection before it is too late in the day for us do even that. We should see that we are not open to the charge that we are for sale. Academic medical schools should educate their students on the ills of the prevailing scenario and have to inculcate in their students the love for ethics and give them a good idea of pharmaco-economics and the ways of the business world that may be alien to them at that stage in life.
Let us not forget that 80% of the world population even today does not have any touch with modern medicine, 62% of upper middle class Americans can not afford health insurance as the premia are sky high for them, 57% of Britons do wish to have alternative systems of medicine when they are ill, despite the fact that they have the free National Health Service. Let us also remember that patients could very well live without doctors, but doctors could never survive without patients!