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The Increasing Corruption in the U.S. Medical & Pharmaceutical Sector

The New York Times December 16, 2005

Drugs, Devices and Doctors


Merck, the pharmaceutical giant, is under siege. And one side effect
of that siege is a public relations crisis for the Cleveland Clinic,
a celebrated hospital and health care organization.

But the real story is bigger than either the company or the clinic.
It's the story of how growing conflicts of interest may be distorting
both medical research and health care in general.

Merck stands accused of playing down evidence that Vioxx, a
best-selling painkiller until it was withdrawn last year, increases
the risk of heart attacks. The most recent accusation of obscuring
the evidence came from The New England Journal of Medicine, which
discovered that the authors of a Merck-supported paper published in
the journal had removed data unfavorable to Vioxx. The journal called
on the authors to issue a correction.

Dr. Eric Topol, a famed cardiologist at the Cleveland Clinic, has
been warning about the dangers of Vioxx since 2001. In videotaped
testimony at a recent federal Vioxx trial (which ended in a
mistrial), he accused Merck of scientific misconduct, and also
testified that Merck's former chairman had called the chairman of the
Cleveland Clinic to complain about his work - an action Dr. Topol
called "repulsive."

Two days after that testimony, according to Dr. Topol, he was told
early in the morning not to attend an 8 a.m. meeting of the clinic's
board of governors, because the position of chief academic officer,
which gave him a seat on the board, had been abolished. A clinic
spokeswoman denied that the abrupt elimination of this post had any
link to his Vioxx testimony.

A few days later, The Wall Street Journal reported on a web of
financial connections between the Cleveland Clinic, its chief
executive and AtriCure, a company selling a medical device used in a
surgical procedure promoted by the clinic. Dr. Topol - whose demotion
also cost him his seat on the conflict-of-interest committee - was
"among those who questioned the ties," the newspaper said.

O.K., it's sounding complicated. But the essence is simple: crucial
scientific research and crucial medical decisions have to be
considered suspect because of financial ties among medical companies,
medical researchers and health care providers.

That should come as no surprise. The past quarter-century has seen
the emergence of a vast medical-industrial complex, in which doctors,
hospitals and research institutions have deep financial links with
drug companies and equipment makers. Conflicts of interest aren't the
exception - they're the norm.

The economic logic of the medical-industrial complex is
straightforward. Prescription drugs and high-technology medical
devices account for a growing share of medical spending. Both are
products that are expensive to develop but relatively cheap to make.
So the profit from each additional unit sold is large, giving their
makers a strong incentive to do whatever it takes to persuade doctors
and hospitals to choose their products.

The tools of persuasion go beyond hiring cheerleaders as sales
representatives. There are also financial inducements, sometimes
disguised, sometimes blatant. A few months ago, Reed Abelson of The
New York Times reported on a practice in which device makers give
surgeons who are in a position to choose their products (with others
paying the cost) lucrative consulting contracts, in some cases
running to hundreds of thousands of dollars a year.

Above all, the line between medical researcher and medical
entrepreneur has been blurred. In her book "The Truth About the Drug
Companies," Marcia Angell, a former editor of The New England Journal
of Medicine, writes that small companies founded by university
researchers now "ring the major academic research institutions ...
hoping for lucrative deals with big drug companies." Usually, she
says, "both academic researchers and their institutions own equity"
in these companies, giving them a strong incentive to make the big
drug companies happy.

The point is that the whiff of corruption in our medical system isn't
emanating from a few bad apples. The whole system of incentives
encourages doctors and researchers to serve the interests of the
medical industry.

The good news is that things don't have to be that way. Economic
trends gave rise to the medical-industrial complex, but only because
those trends interacted with bad policies, which can be fixed. In
future columns I'll talk about how serious health reform can reduce
the conflicts of interest that taint our current system.

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