If you don’t read the newspaper, you’re uninformed. If you read the newspaper, you’re misinformed.
Corporate funding has made medical journals wealthy. When I trained 35 years ago, they were everywhere, but with the cash injection you will read about below, they have become a blizzard of paper on every surface of a doctor’s house and office. To scan the primary care articles alone would take hundreds of hours a month. Over 5,000 journal articles get published every day.
Physicians get their information from journals, and the editors are responsible for everything that gets printed. They are the most sophisticated people in healthcare, and they understand what is happening as it occurs. But they only speak up after they retire because they do not want to lose their prestigious, lucrative jobs (I am guilty of this, too).
The following are two of their confessionals. There are similar statements published about NEJM, JAMA, and others.
Journals have devolved into information laundering operations for the pharmaceutical industry. The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.
Richard Horton, Lancet editor
Medical journals are an extension of the marketing arm of pharmaceutical companies.… between two-thirds and three-quarters of the trials published in the major journals—Annals of Internal Medicine, JAMA, Lancet, and New England Journal of Medicine—are funded by the industry.
Richard Smith, editor, British Medical Journal and author, The Trouble with Medical Journals (2006)
About half of journal revenue comes directly from drug companies. Perhaps 90 percent of the articles and research are industry-funded, and the industry’s contractors ghostwrite the majority. Marcia Angell, the NEJM editor for 20 years, told how they do it in The Truth About the Drug Companies (2004), “I saw companies begin to exercise a level of control over the way research is done that was unheard of when I first came to the journal… It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.”
A review of 370 drug studies in 2003 showed that industry-sponsored trials were much more likely to have positive results than when funding was from other sources. A single positive trial may be printed and reprinted in hundreds of different venues and forms. The core of science is unfavorable reports, but these are frequently concealed. For example, during the approval process for the influenza treatment Tamiflu, the drug company withheld the Australian studies that suggested the drug was worthless.
If a journal publishes something their industry sponsors dislike, they will threaten them with loss of advertising or worse. Annals of Internal Medicine (June 1992) made the mistake of publishing Michael Wilkes’ study about drug advertising harms. The NEJM and JAMA had turned down the article.
In punishment, the big corporations withdrew advertising from the Annals, and they lost over a million dollars in revenue. Two respected editors lost their jobs. After this, US journals allowed pharmaceutical companies to print written rebuttals of any study they did not like in the same issue as the study. Neither big tobacco nor big food has ever received a concession like this.
Journals make startling amounts of money. Profit margins at scientific publishing companies average a sensational 35 percent. Other successful publishers worldwide average 10 percent, and industries without subsidies are successful at 10 percent. Reed Elsevier, the largest medical publisher, is stunningly profitable:
YEAR: REVENUE: NET: PROFIT:
2016 3.28 b 1.22 b 37%
2010 2.58 b 933 m 36%
How do they do it? Journals’ expenses are modest. Industry, federal grants, and academia pay for studies, so these are free. Review editors and members of editorial boards are mostly unpaid volunteers. Revenues are huge, however. A single journal subscription may cost several thousand dollars a year. Reprinted articles from a journal often cost $50 each. Comprehensive literature searches can cost tens of thousands of dollars to get the full texts.
Journals were billing Harvard’s library $3.5 million a year for subscriptions. It had to cut some journals from their list because of these ever-increasing costs. In 2019, the University of Southern California ended its subscription to Elsevier’s journals because of the exorbitant prices.
Reprints make money for the journals because they sell them right back to the study sponsors. These companies typically pay for the entire charade, from study design to research grants to ghostwriting. Salespeople gift purchased articles to doctors to prove that the drugs work. This is a page from the corporate sales and influence playbook. Dr. Deepak Malhotra described the way it works in the BMJ: “As a medical director of a pharmaceutical company, I learnt how to get articles published in journals, with one journal promising publication if we purchased 2000 reprints at $10 each.”
The NEJM’s publisher gets 23% of its income from reprints. The Lancet?—?41%. JAMA receives 53%. In a 2012 study, reprint income per article for the Lancet was a median of £287,353 ($363,946), with the most profitable one £1,551,794. Industry funding was ten times more likely in the most reprinted articles. Journal volumes labeled “special editions” are advertising vehicles. They look like the others but usually describe only a single therapy, and the journal editors do not expect them to have high scientific standards. One drug company typically supplies nearly the entire budget.
Occasionally, industry fabricates entire journals, and they look legitimate. Merck created the Australasian Journal of Bone and Joint Medicine to advertise Fosamax. Recall the Disease-Mongering chapter; this drug’s utility is doubtful. The Medline database did not index this journal, and it had no website. Elsevier published the magazine for several months, then it vanished.
The industry pays journal editors directly, and they get their salaries in addition. Jeanne Lenzer describes how the device companies use this power:
A medical journal editor who received millions of dollars from a medical device manufacturer wrote and edited articles favourable to the manufacturer without stating his conflict of interests to readers. Thomas Zdeblick, a University of Wisconsin orthopaedic surgeon… editor-in-chief of the Journal of Spinal Disorders & Techniques in 2002, received more than $20m… in patent royalties, and $2m in consulting fees from Medtronic for spinal implants sold by the company during his tenure as editor.
Jason Fung, a Canadian academic nephrologist, summarizes these payouts in a blog:
Of all journal editors that could be assessed, 50.6% were on the take. The average payment in 2014 was $27,564. Each. This does not include an average $37,330 given for ‘research’ payments… Each editor of the Journal of the American College of Cardiology received, on average, $475,072 personally and another $119,407 for research. With 35 editors, that’s about $15 million in money for editors. No wonder the JACC loves drugs and devices.
The massive advertising revenues, the reprint deals, and the payoffs to the editors create near-complete corporate control of the only physician information source. We support the drugmakers and device manufacturers with insurance and government dollars, and they pay the journals and editors. The “big five” most respected medical journals, Lancet, JAMA, BMJ, NEJM, and Annals of Internal Medicine, are all contaminated with this commercial bias. The BMJ has the most integrity, at least by one measure. Only three percent of its revenues come from reprints.
Business corrupts science when it pays for research. Nortin Hadler wrote in The Citizen Patient (2013): “It turns out that the vast majority of the clinical literature is so lacking in methodological quality as to offer no contribution of substance to clinical decision making. For most clinical questions, one is fortunate to find a dozen studies that can be deemed informative.” Gøtzsche is franker: “The pervasive scientific misconduct has led to a research literature where one has to dig deeply to find the few gems among all the garbage.”
The following is excerpted from Butchered by Healthcare, by Robert Yoho, MD. For more information, see dryohoauthor.com.
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