Paging (and Paying) "Dr Coca-Cola"

A few weeks ago, the Los Angeles Times Booster Shots blog announced that "Dr. Coca-Cola will see you now," noting opposition to the recently revealed alliance between the Coca-Cola Company and the American Academy of Family Physicians:

[in] a sharply worded letter sent Wednesday to Dr. Douglas E. Henley, the academy’s chief executive.

'We urge the AAFP to regain its credibility by rejecting the deal with Coca-Cola,' the letter stated. 'If the AAFP declines to do that, we urge your organization to reassert its support for the public health (and its own independence) by supporting a warning label on caloric sugar-sweetened beverages and a federal tax on soft drinks to support health promotion or health insurance programs.'

The letter was signed by 22 doctors, nutritionists and health advocates,

Dr Henley was not moved:

Henley told Food Navigator-USA.com that the academy was aware of the letter. But he stood by the partnership with Coke.

'We will move forward with this commitment together by providing educational materials on sweeteners and how to maintain a healthy, active lifestyle while still enjoying many of the foods and beverages consumers love,' he said in a statement.

Nonetheless, criticism of the deal has continued. A Kansas City Star editorial said:

the Leawood-based American Academy of Family Physicians has set a poor example when it comes to resisting the lure of the soft drink industry.

The academy has accepted a grant from Coca-Cola, reportedly in the neighborhood of $500,000. It will use the money for educational materials about drinks and sweeteners for its consumer Web site, FamilyDoctor.org. Leftover funds will go into the academy’s general budget.

In return, Coca-Cola gets what? Legitimacy, for one thing. Consumers are less likely to consider a product unhealthy if it’s listed as a partner with a leading physicians’ alliance.

In a more shameful scenario, the soft drink manufacturer would succeed in muting the message that the academy puts out to its consumers.

The editorial did not buy Dr Henley's assurances:

Academy leaders say they won’t allow the hefty corporate grant to compromise the organization’s integrity.

'We have total editorial control, as we always have, of FamilyDoctor.org,' said Executive Vice President Douglas Henley.

Henley added, 'I would hope folks won’t rush to judgment but hold us to the content we’re going to put on FamilyDoctor.org.'

But consumers accessing that information will soon be informed that information about soft drinks is being sponsored in part by Coca-Cola, 'a proud partner of FamilyDoctor.org.'

That’s a mixed message, regardless of the content.

Meanwhile, family physician and AAFP member Dr Howard Brody noted on his Hooked: Ethics, Medicine and Pharma blog how AAFP leaders continued to obfuscate:

AAFP President Dr. Lori Heim: obesity is more complex and that 'there's no one evil out there.'

Why does the question of whether it's a good idea for AAFP to take money from Coke so quickly segue into the question of whether Coke is 'evil'? (For our blogger colleague who likes logical fallacies, Roy Poses, this sounds like "straw man." [It sure does - Editor]) Why does it have to be: either they are evil or else it's just fine for us to take their money? What cannot it simply be that they have different interests--they are trying to make a buck selling beverages (some of which I enjoy drinking myself, I am pleased to report, if they don't have calories in them) while AAFP is trying to protect the public interest through credible health education? What part of conflict of interest don't you understand?

Some AAFP members went beyond criticism, as reported by the AP:

Dr. William Walker, public health officer for Contra Costa County near San Francisco, likened the alliance with ads decades ago in which physicians said mild cigarettes are safe,

Walker has been a member of the academy for 25 years but quit last week. He said 20 other doctors who work with his local medical practice also quit because of the Coke deal.

Nonetheless, as Dr Brody later posted,

Sadly, if the responses to this news report from AAFP leadership are accurate, the AAFP still does not get it. '[AAFP CEO Dr. Douglas] Henley said the academy regrets the resignations and hopes other members will not 'rush to judgment' before seeing the new content." News flash: we don't need to see the content to know there's something rotten in Denmark. The deal itself raises concerns about the credibility of anything AAFP posts about diet and obesity from now on.

So here we have the latest variant on institutional conflicts of interest affecting medical associations. We have noted (e.g., here) how professional societies have blithely accepted substantial funding from corporations which sell products physicians may prescribe for or implant in patients. This raises concerns that professional societies have become drug and device marketers. This conflicts with physicians' prime directive, to put the interests of individual patients ahead of their own, and hence to base decisions on which drugs to prescribe, tests to order, and procedures to do on maximizing benefits and minimizing harms for individual patients, not maximizing financial gain for physicians, or their organizations.

Family physicians are a respected source not only of decisions about tests and treatments, but about diet. Having the main family physician organization humming "things go better with Coke" suggests that professional advice could be co-opted by marketing. As Dr Brody noted above, the issue is not whether the product is good or bad, but is whether physicians are giving each patient the best possible advice.

One question implied by the "Dr Coca-Cola" story is why the leadership of the AAFP seems so oblivious to the conflict of interest issues it raises.  As Dr Brody wrote:

What's even more depressing is that with the whole world telling them that they mishandled this affair, the AAFP still seems to think that the problem is someone else's.

I appreciate Dr Brody's depression, but note that this is not the first time that AAFP leadership has seemed tone deaf to the issue of the organization's institutional conflict of interest. In 2005, we posted how the AAFP had banned the "No Free Lunch" organization, which opposes most pharmaceutical marketing to physicians, from appearing in the exhibit hall of its annual meeting. The exhibit hall was otherwise populated by lavish exhibits by pharmaceutical and other health care corporation marketers.

The abstract for a 2006 article in Family Medicine [Standridge JB. Of doctor conventions and drug companies. Fam Med 2006; 38(7):518-20. Link here] began:

Pharmaceutical companies provide the majority of financial support for staging the American Academy of Family Physicians (AAFP) Annual Scientific Assembly. In return they are allowed to dominate the physical and mental environment.

The current web-site for the AAFP Foundation boasts of its corporate partners, which include many of the biggest pharmaceutical and biotechnology companies (at the "Pinnacle" level, Amgen, AstraZeneca, Lilly, Purdue Pharma.

So adding Coca-Cola to the list of corporate sponsors does not seem like such a big step.  In fact, being "Dr Coca-Cola" does not seem intrinsically more questionable than being "Dr Amgen," "Dr AstraZeneca," etc.

Nonetheless, one would think that the latest round of criticism would make the top leaders of this august professional society less comfortable about the organization's financial relationships with pharmaceutical, biotechnology, and now beverage corporations.  I fear, though, that they may live too much in the sort of bubble that now protects top executives of most large health care organizations to really question their corporate ties.  After all, according to the most recent (2007, covering 6/2007-5/2008) US Internal Revenue Service form 990 filed by the AAFP (via Guidestar), its leaders get sufficient compensation to put them into such a bubble.  For example, Dr "Coca-Cola" Hensley received $441,027 regular compensation and $108,930 in benefits and deferred compensation, compared with a median compensation for family physicians in 2008 reported as $159,000 from one survey.  Presumably "voluntary" officers got five- and six-figure "expense accounts and other allowances," maxing out at $195,648 for then President Dr James B King.  It may be hard for leaders who are so comfortably recompensed by the organization to become uncomfortable about the financial relationships that make the largesse they receive seem less of a burden for members who may not be so well-paid.  The leaders' comfort with the current arrangement, however, makes their organization more liable to be viewed as a drug, device, and now beverage marketer rather than a defender of physicians' professionalism.  Maybe the leaders should accept more austere compensation, perhaps similar to what working family doctors get paid, as the price they need to pay to remove questions about their organization's real commitment to professionalism.

The AAFP Opens the Door for No Free Lunch

An email press release by the organization No Free Lunch today reveals that the American Academy of Family Physicians (AAFP) has reversed its previous decision (see post here), and will now allow No Free Lunch to have a booth in the exhibition hall during the AAFP annual meeting in San Francisco.
The email stated,

Following an outcry from among its members, the American Academy of Family Physicians has reversed its earlier decision to deny a booth to No Free Lunch and has invited the organization to exhibit at its meeting next week in San Francisco.
In August, The AAFP rejected No Free Lunch’s application to exhibit at its annual meeting—which will be attended by some 5,000 family physicians and slightly fewer exhibitors—stating that No Free Lunch’s position was “not within the character and purpose of the Scientific Assembly.” This despite the fact that the Coca-Cola Company, The McDonald’s Corporation, and The Distilled Spirits Council of the U.S. were all allotted space in the hall, as were countless pharmaceutical companies.
Many members were upset and even outraged that a society which they had supported for many years, and which gives industry almost unlimited access to physicians at its meetings, would not allow a small organization of health professionals to voice an opposing view. Allen Pelletier, for example, a family physician from Memphis, Tennessee, a long time AAFP member and newly elected fellow of the Academy, in an e-mail to AAFP CEO Dr. Douglas Henley, wrote “To my embarrassment, the organization that represents me as a practitioner and teacher of family medicine has shut down the possibility of open (and yes, critical) dialogue about how our practices are influenced by the pharmaceutical industry.” A family physician and AAFP member for 25 years from East Lansing, Michigan, wrote “. . . if an organization like No Free Lunch, well known for the role that it has played in encouraging awareness among physicians of the negative impact of pharmaceutical marketing, is denied the opportunity to set up a booth at the meeting, while commercial sponsors are encouraged to pay extra for more access to members and attendees, then the professional values of our specialty society have truly reached a new low.”

Good for AAFP for reversing course here. The issue, as the above AAFP members' emails made clear, was not whether AAFP should adopt No Free Luncrecommendationsomendations. The issue was a free speech issue, whether AAFP was willing to give No Free Lunch the opportunity to speak out about recommendationsomendations, even if their mode of expression is not as gentile as the AAFP might prefer, and everecommendationsomendations may upset some people. The AAFP already allows commercial interests to speak out about their wares. Their mode of expression may be polished, but is backed by plenty of money and marketing muscle.
Finally, the reasons the American College of Physicians (ACP) banned No Free Lunch from their last meeting remain murky. The public documentation about this decision only includes press releases by No Free Lunch and the ACP, and an article in the Wall Street Journal (available here). The ACP contended that No Free Lunch "caused trouble at its 2001 meeting, even sneaking in an undercover TV crew. Dr. Goodman [the leader of No Free Lunch] says that even if there were some problems, which he isn't sure is[sic] the case, that they weren't orchestrated by the organization" (per the Wall Street Journal). Again, in my humble opinion, an organization with an ethical and academic mission (like the ACP) ought to bend over backwards to ensure free expression and open communication , especially when one side of the argument is made by large, rich, and powerful organizations like big pharma corporations.

AAFP: No Entry to No Free Lunch

The organization called No Free Lunch has been campaigning against a variety of pharmaceutical marketing techniques, particularly giving gifts to physicians, from pens to the "free lunch" in the organization's title.
A report in the trade journal Brandweek.com, and a press release by No Free Lunch, describe how the American Academy of Family Physicians (AAFP) has barred No Free Lunch from exhibiting in the Exposition Hall at the annual AAFP Scientific Assembly.
AAFP Manager of Sales and Services Sharon Hutinett stated that the No Free Lunch exhibit was "not within the character and purpose of the Scientific Assembly." Moreover, AAFP Executive Vice President Douglas Henley stated, "while the AAFP respects the mission of No Free Lunch, their desire to eliminate information-sharing by exhibitors with our members clearly negates the purpose of the Exposition Hall. Therefore, No Free Lunch is not in keeping with the character and purpose of the Scientific Assembly Exposition Hall and it would not be appropriate for AAFP to accept their exhibit application."
The character and purpose of the meeting may be indicated by the large number of exhibits sponsored by pharamaceutical companies in the Exposition Hall. Furthermore, No Free Lunch noted that even corporations such as Coca-Cola and McDonalds were allowed to exhibit. Brandweek.com characterized the character and purpose of the AAFP meeting as "a truly massive marketing event: 5,000 of the top-prescribing physicians in the country are expected to attend the San Francisco shindig."
An AAFP prospectus listed the variety of marketing opportunities for sale, from a "freebie" in every doctor's "gift bags" for $7500 "per piece per day," to, of course, free lunch, "$60,500 pays for the food vouchers that physician-attendees will use for lunch each day at the conference."
So although the AAFP is happy to expose their physician members to a "truly massive marketing event," AAFP leadership apparently cannot tolerate the dissent provided by a single No Free Lunch exhibit.
How such suppression of honest difference of opinions serves the AAFP's mission, "to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity," is beyond me. Whether the AAFP's membership condone such censorship, or even know that it is going on, are also open questions.