Thursday, January 19, 2006

Caught in the Cross Fire: The Wall Street Journal vs the New England Journal of Medicine

This week, the Wall Street Journal ran an editorial attacking the New England Journal of Medicine. [Anonymous. New England journal of politics. Wall Street Journal, January 16, 2006. Not yet available online.]

The editorialist was bothered that the New England Journal of Medicine published an unusual editorial "Expression of Concern." (Curfman GD, Morrisey S, Drazen JM. Expression of concern: Bombardier et al., "comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis," N Engl J Med 2000; 343: 1520-8. N Engl J Med 2005; 353: 26.) about a study it had previously published of rofecoxib (Vioxx). (See our post here.)

Here is what the Wall Street Journal said:
The New England Journal is joining the ranks of academic publications risking their reputations as non-partisan arbiters of good science in order to rumble in the political tarpits.
The facts and timing of the Merck ambush certainly suggest as much. Late last year the New England Journal published an 'Expression of Concern' about a Vioxx study it carried in 2000, baldly accusing researchers of omittin key data to make the painkiller appear more safe.
What has Dr. Curfman [Executive Editor of the New England Journal] in a dither is the fact that three more participants [in the group treated with Vioxx] also suffered heart attacks - although only after the cutoff date that had been determined by an outside safety panel for the study.
In fact, as prominent scientists have since attested, the authors were simply following the rules of science. 'If the outcomes truly occurred after the close of the study, then they don't belong in the study,' Brian Strom, an epidemiologist at the University of Pennsylvania, told Nature magazine. [See link here.]
The New England Journal clearly knew all this, and as an esteemed professional body presumably understood the scientific rationale behind the omission. Yet it nonetheless chose to use the Vioxx trial as an opportunity to join in the latest political and legal tarring of Big Pharma as greedy profiteers.
Unfortunately, the attack on Merck isn't isolated, but is part of a growing trend among scientific journals that have joined business-bashing and other liberal campaigns.

Here we go again.

Now that discussion of health care reform is in the air again, maybe it's not surprising that health care issues will be caught in the country's usual right-left cross-fire.

However, framing the debate with political slogans often precludes hearing about a lot of good ideas.

By the way, although I can think of instances in which the New England Journal may have made editorial decisions consistent with thinking currently fashionable on the academic left (for example, see this post), it is not obvious that the Expression of Concern was published for political reasons, or to bash business.

There is also a reasonable argument that Merck should not have withheld data on the three patients who died after treatment with Vioxx. Although a cut-off date for the trial was pre-specified, it resulted in different durations of follow-up for different patients. There is an argument to include adverse events that occurred after the pre-specified trial cut-off date, but not as long after trial enrollment as the period of follow-up used for patients enrolled earlier in the course of the trial.

In my humble opinion, one reason that we have made so little progress in solving the classic problems with costs, access, and quality is that the solution often get caught in these sorts of debate.

If one goes back to the early 1990s, before the abortive attempt by the Clinton administration to reform health care, such debates were common. At that time, many of the chief proponents of managed care were from the Jackson Hole group, which was heavily backed by the pharmaceutical and commercial insurance industries.[1,2] On the other side, promoted national health insurance, were groups such as Physicians for a National Health Plan, some of whose leaders had advocated Marxism.[3]

After the failure of the Clinton plan, there was a surprising reprise of this debate in the pages of the American Journal of Public Health. On one side was was Howard Waitzman MD, who had written "A Marxist view of health care,",[4] and on the other side, Professor Alain C Enthoven, one of the foremost figures in the Jackson Hole group.

Waitzman started by noting Enthoven's past work for the Defense Department during the Vietnam War.[5] Enthoven fired back by decrying "Waitzkin's Marxist vision of a socialist America that would produce a socialist health care system...." [6] Waitzkin then responded by charging Enthoven with being responsible for the "rapid deployment of Minuteman and Polaris nuclear missiles during the 1960s and 1970s. Many have argued that such weapons increased, rather than decreased the risk of nuclear war." [7]
You Marxist. You war-monger. Just like that old comedy routine on TV.

I respectfully submit that slugging matches of this sort did not and will not advance the renewal of health care.


1. Priest D. Health care theorists of Jackson Hole: policy heroes or special interests? - "Managed competition" group says industry’s role is only natural. Washington Post, March 12, 1993. P. A15.
2. Toner R. Hillary Clinton’s potent brain trust on health reform. New York Times, February 28, 1993. P. 3.1.
3. Himmelstein DU, Woolhandler S. The corporate compromise: a Marxist view of health maintenance organizations and prospective payment. Ann Intern Med 1988; 109: 494-501.
4. Waitzkin H. A Marxist view of health care. Ann Intern Med 1978; 89: 264-278.
5. Waitzkin H. The strange career of managed competition: from military failure to medical success? Am J Pub Health 1994; 84: 482-489. [Abstract here.]
6. Enthoven AC. Commentary: setting the record straight - a reply to Howard Waitzkin. Am J Pub Health 1994; 84: 490-493.
7. Waitzkin H. A rejoinder from Waitzkin. Am J Pub Health 1994; 84: 493-494.

1 comment:

Philip R. Alper, M.D. said...

Don't lose sight of the fact that if there is systematic publication bias in scientific journals, physicians do not have equal access to differing points of view .
The Wall Street Journal made explicit a well-known left-leaning bias that affects most of academia and scholarly publications, medicine included.
When I submitted a satire on managed care to the NEJM ("Learning to Accentuate the Positive in Managed Care," Marcia Angell, the Editor, fast-tracked it to publication in six weeks. I wasn't surprised because it was consistent with the published editorial position of the Journal.
Yet when I did a later study on managed care with the support of Stanford Medical School, my academic colleagues refused to allow me to include my credential as a Visiting Scholar at Stanford's Hoover Insitution in the manuscript. They claimed that Hoover's reputation as a right-wing institution would mean "certain death" to our chances of acceptance in all the leading medical journals.