Marcia Angell documents how drug companies have corrupted the integrity of drug research, medical education and clinical practice.

Anyone who works in clinical medical practice is keenly aware of Big Pharma’s relentless and intrusive marketing practices. You can’t avoid it. The pens, notepads and schwag plastered with the brand-name anti-depressants. The ubiquitous “detail” salespeople who schmooze up doctors and shower them with free samples. The physician junkets to exotic resorts to hear “educational” lectures by esteemed leaders of the field.

I know all this. What I didn’t realize was how thoroughly drug marketers have corrupted academic medicine — the research at medical centers, the education of new doctors at medical schools, and daily clinical practice. In the May-June issue of the Boston Review, Marcia Angell, the former Editor of the New England Journal of Medicine, documents in devastating detail how the drug industry has insinuated itself into every imaginable nook and cranny of academic medicine in order to sell its drugs.

The best indication of its success is the invisibility of the marketing. The sales propaganda has gotten so effective that it is brilliantly disguised as high-minded “education.” Marketing has become a normative part of medical education, research and practice.

In her sober, understated indictment, Angell, Senior Lecturer in Social Medicine at Harvard Medical School and author of The Truth About the Drug Companies, writes:

The boundaries between academic medicine — medical schools, teaching hospitals, and their faculty — and the pharmaceutical industry have been dissolving since the 1980s, and the important differences between their missions are becoming blurred. Medical research, education, and clinical practice have suffered as a result.

Academic medical centers are charged with educating the next generation of doctors, conducting scientifically important research, and taking care of the sickest and neediest patients. That’s what justifies their tax-exempt status. In contrast, drug companies — like other investor-owned businesses — are charged with increasing the value of their shareholders’ stock. That is their fiduciary responsibility, and they would be remiss if they didn’t uphold it. All their other activities are means to that end. The companies are supposed to develop profitable drugs, not necessarily important or innovative ones, and paradoxically enough, the most profitable drugs are the least innovative. Nor do drug companies aim to educate doctors, except as a means to the primary end of selling drugs. Drug companies don’t have education budgets; they have marketing budgets from which their ostensibly educational activities are funded.

This profound difference in missions is often deliberately obscured — by drug companies because it’s good public relations to portray themselves as research and educational institutions, and by academics because it means they don’t have to face up to what’s really going on.

Angell’s essay marshals a considerable amount of empirical research to make her case. And while not all of the charges are new or shocking, the steady accretion of facts makes a powerful case that academic medicine has willingly surrendered its integrity and independence to the drug industry — with troubling consequences for the safety and scientific merit of many drugs and types of medical treatment.

Angell notes how medical centers and med schools have joined hands with the drug industry at numerous points — in striking up research partnerships, in sitting on companies’ boards of directors, in offering up clinical facilities for drug trials, in sitting on advisory boards.

These incestuous relationships not only affect how research is shaped — what questions are asked and how research projects are designed and published; they also affect how medicine is practiced. Academics with paid ties to the industry play influential roles in writing practice guidelines that professional and governmental bodies issue, and they participate in numerous FDA deliberations.

Thanks to the Bayh-Dole Act enacted in 1980, the drug industry no longer has to do its own early-stage drug development research. It can rely upon federally funded university research, which we taxpayers finance. Then, if a promising drug compound is discovered, the drug companies can swoop in late in the game to do the final stages of development and acquire exclusive rights to the drug. Less risk, lower costs. Or drug companies can produce trivial variations on established, top-selling drugs — the “me-too” drugs — which can be highly lucrative but therapeutically trivial.

Like most Boston Review cover stories, this one is part of a forum that solicits reactions from a variety of commentators. One respondent, Adriane Fugh-Berman, elaborates in great detail how continuing medical education courses serve as a prime channel for pharmaceutical marketing:

Industry-paid speakers frequently deny espousing marketing messages. I’ve heard many physicians justify their pharma-funded speaking gigs by saying, “I never emphasize their product” or, triumphantly, “I don’t even mention their drug!” But these comments only highlight their sales skills. Pharma doesn’t hire doctors to sell drugs; that’s a drug rep’s job. Pharma hires physicians to sell diseases.

The process of selling what industry calls a disease state begins many years before a drug is submitted to the FDA for approval. Specific marketing messages for a product may be developed seven to ten years before a drug goes on sale.

Pre-approval marketing messages assigned to opinion leaders might emphasize the under-diagnosis of a targeted condition, stress the serious consequences of delayed treatment, or trumpet the importance of a new receptor or novel mechanism of action.

I am one of the commentators, too, in an essay called Restore Medicine to the Commons. I make the case that we must develop a larger analysis of how academic medicine “creates value” in ways that commercial enterprises cannot. Why is it important that medical research, education, and clinical practice be independent of the marketplace? An excerpt from my essay:

Vast swaths of medical knowledge and practice, too, have been privatized and monetized — patents for common medical procedures, one-fifth of the human genome, artificially created life forms, and much else. It should come as no surprise that professional practices and norms have been similarly warped to serve market ends. Much of this transformation has occurred in incremental, deliberately obscure ways. Angell has performed a great public service in making this transformation more explicit and comprehensible.

In so doing, she has helped us to see the unmet challenge within academic medicine: to name and reclaim its moral sovereignty over the vital functions that it, and only it, can perform. I will not presume to suggest how specific reform should be pursued. But I do believe that, whatever paths are taken, academic medicine must assert the value of its independence from market forces. Otherwise its moral stature and expertise will have no foundation.

Marcia Angell has performed a great public service in showing just how far the trustworthiness and integrity of academic medicine have been compromised. The unanswered question is, From whence will the leadership for reform arise when so many aspects of academic medicine are already profoundly compromised?