In Part II of this series, we discussed how intents and biases, while occasionally desirable, can contaminate the medical system in terms of research, policies and practices. We also counted methodological “tampering”, reporting bias, publication bias, censorship and resistance among the possible sources of such contamination.
In the ensuing Part III of this series, we will continue to explore our medical system through the lens of human error — this time by delving into some specifics of our human nature.
One of the most prominent theory in behavioural psychology, operant conditioning, explains an organism’s future behaviours in terms of the cumulative effects of reinforcement and punishment. While the theory of operant conditioning falls short in explaining or predicting certain human behaviours, it has in effect established itself as basic research in behavioural psychology — with countless applications and corroborating evidence originating from several animal and human studies.
Perhaps what’s more interesting — for us at least — is that for centuries, human already possesses some implicit knowledge about operant conditioning before they ever encounter that term! For one, the history of medicine is itself saturated with stories of human applying operant conditioning onto themselves — or sometimes onto oneself — to achieve certain short-term, personal goals that would have devastating health impacts for the future generations.
To explore further, let’s look some of the most recent examples on how rewards and punishments play out and influence the practices of medicine, subsequently altering the quality of services that the patients would receive.
Questionable Institutional Ties
Ties Between Medical Publishers and Pharmaceutical Companies
While not necessarily well known to the public, the medical journals are generally cognizant of the potentially conspiratory role they play by disseminating studies funded by the industries. To illustrate, in the early 2014, there has been a heated debate in the British Medical Journal (BMJ) on whether they have made the right decision by banning all researches funded by the tabacco industry.
(for the record, there is no debate on the scientific frauds perpetrated by the pharmaceuticals. Rather, the issue is whether banning industry research constitutes the right way to proceed.)
In fact, in a January 2014 head-to-head article, Richard Smith and Peter Gøtzsche, who took the position that the banning was the right decision, raised the issue of conspiracy between medical journals and pharmaceutical companies:
“In contrast to tobacco funded research, which is comparatively rare, two thirds of the clinical trials published in major journals such as the Lancet or New England Journal of Medicine are funded by the drug industry. In addition, companies use ghost writers to promote misleading trials in scores of secondary publications and reviews in major journals. These, just like the original research, often carry the names of opinion leaders, which seems to give the articles credibility. This common practice is scientific fraud.
Readers of these journals are thus given a seriously corrupted view on the benefits and harms of drugs that they will be heavily persuaded to prescribe. The companies spend millions of dollars buying reprints of the studies they have sponsored, using the brand of the journal to promote their drugs. The journals make huge profits on these sales, a gigantic conflict of interest.”
(while this article uncovers a plethora of misconducts perpetrated by the pharmaceuticals, it is unfortunately inaccessible to the general public — another gigantic conflict of interest? 😉 )
In response to the article, Dr. Ben Goldacre, a strong advocate against bad science, took a different approach and argued that if practitioners don’t inform themselves about the malicious tactics the industry has at its disposal, they might just end up acting as the industry’s associates themselves:
“Our current model is to give trainees some pointers on basic study design and critiquing an individual academic manuscript. This is plainly not enough, given what we now know about the extent of withheld trial information, misleading trial reports, manipulation of the academic literature, and the biased dissemination of evidence through marketing.
Depending on specialty, doctors who qualified in the 1970s could easily find themselves almost exclusively using drugs that came on the market long after they left formal training. Such doctors will be essentially self taught about these drugs and barraged with information of variable quality, from an industry with global revenues of $900bn (£552bn; €666bn), which is incentivised to keep sales of individual drugs high.”
Ties Between Governments and Food Corporations
Let’s take a look at some food guides issued by certain federal governments. In 2011, U. S. Department of Agriculture (USDA) released MyPlate, a national-wide food guide which would then replace the existing food pyramid. In the MyPlate pie chart, we notice an unusual emphasis on the consumption of diary and grain — A possible sign of food-guide meddling by certain lobbyists to promote the country’s agricultural industry. To inquire further, we dug out the amount of money spent by the agricultural industry on lobbying in 2011, and here is Isaac Weiner, a holistic health counsellor, commenting on the merit of MyPlate in terms of the promotion of public health:
“Instead of trying to give people advice that is skewed by vested interests, the government should eliminate the subsidies that make processed food artificially cheap, so that it’s easier for us to make our own choices to eat healthier. While MyPlate is better than previous guides, it’s inherently insincere, as it is committed to the status quo rather than allowing a new food economy that actually supports our health.”
It seems that when designing a national-wide food guide, economic interests of a country needs to be taken into account as well.
Of course, America is not the only place on Earth where the food guide has been shaped by special interest groups. In 2003, Health Canada began revising what is known now as the current Canada’s Food Guide. To do so, they appointed a Food Guide Advisory Committee, where 4 out of the 12 members are from the food industry. In response, Dr. Yoni Freedhoff, medical director of Ottawa’s Bariatric Medical Institute, posted a rather humorous critique of the Food Guide, stating that the real dangers of the Guide is in what it doesn’t say:
- No words on junk food
- No attempt to deconstruct the saturated fat myth
- No attempt to discourage the consumption of processed food
- No distinction on the different kinds of meat
For another case of how food lobbying can impact our food policies, let’s shift our focus to the United Kingdom. In March 2012, in an attempt to reduce the health impact and crimes associated with alcohol consumption, the British government, under the support of Prime Minister Cameron, decided to roll out a plan which would establish a minimum unit price for alcohol.
However, it quickly became clear after this pledge that the alcohol industry simply would not let go this easily. In fact, the pledge was left hanging for months, until it was finally announced in July 2013 — in the House of Commons — that the pledge has been withdrawn altogether.
In the subsequent investigative reports published by British Medical Journal, the freelance journalist Jonathan Gornall — who sought to understand this U-turn in alcohol policy — made several stark revelations about the inner working between public servants and lobbyists associated with the alcohol industry.
In particular, it was documented in one of Gornall’s article that the alcohol industry would approach the MPs and secretaries with an intention of building long-term relationship — a tactic which would help them gain access to government information and meetings with policy makers. In fact, Jim McCambridge, a research fellow at London School of Hygiene and Tropical Medicine, interviewed several senior members of the alcohol industry while researching the effect of lobbying on health policy, and remarked that:
“It is really about building long term relationships with key policy actors so influence can be exerted in very subtle ways . . . and within these long term relationships what you see is quite astonishing levels of contact.”
And here is John Holmes, a research fellow at the Sheffield Alcohol Research Group, expressing the frustration of public health researchers when it comes to influencing alcohol policies:
“We can’t really change the narrative in any way—we don’t have that power—but bodies such as the Adam Smith Institute have this public megaphone which is disproportionate to the scientific merits of what they’re saying.”
As yet another clever social engineering tactic, the alcohol lobbyists would also reward policy makers, or high-profile public servants, by endowing them with additional titles and awards. For example, due to their respective efforts in scrapping the beer duty, Sajid Javid, the economic secretary of the Treasury, has a wine (Sajid’s Choice) named after him, while George Osbourne, the Chancellor of Exchequer, was named the Beer Drinker of the Year during an annual dinner of the Beer Group.
Around the time the British government unveiled its pledge to implement minimum alcohol pricing in 2012, we witness the publication of several reports denouncing the minimum pricing policy and Sheffield alcohol model — a government-commissioned study which reports optimistic projections about the long-term impacts of minimum pricing policy. As it turned out, some of these reports, including those issued by certain right-winged think tanks (e.g., Institute of Economic Affairs, Adam Smith Institute, Demos, Centre for Economics and Business Research), were either commissioned by the giant brewing company SABMiller, or indirectly funded by the alcohol industry.
And as if the lobbying effort was not great enough, SABMiller would continue to sponsor several seminars and panel events, aiming to persuade policy makers that minimal alcohol pricing constitutes a poor piece of policy — with little evidence to support its effectiveness.
Ties Between Research Communities / Non-Profit Organisations and Food Corporations
With the advances in flavour engineering, the food and beverage industries are becoming increasingly notorious in creating unnaturally-palatable food which induces strong dopamine responses in its consumers – a clever tactic which would secure the profitability of these companies. And with the then-acquired enormous wealth, the food and drink industries can now exert great influences on the perception of food — and doing so usually with little regard to the interests of the general public.
For example, the industries could begin to provide funding to the research communities, and this would then have subtle impacts in the finding of these studies. To illustrate, in a 2013 systematic review published by PLOS Medicine, the authors, in an attempt to study the relationship between reporting bias and financial interest in obesity research, gathered 17 systematic reviews on sugar-sweetened beverages, which added up to 18 conclusions in total.
Interestingly, among the 12 conclusions which did not disclose any tie to food industry, 10 of them concluded that sugar-sweetened beverages could lead to obesity. On the other hand, among the 6 conclusions which did disclose some ties to the food industry, 5 of them concluded that associations between weight gain and the consumption of sugar-sweetened beverages are lacking.
While such kind of study does not rule out the possibility of publication and sampling biases. it does give us a glimpse into how corporate funding can contaminate medical research, as Jacques Peretti put in The Guardian on June 11, 2012:
“The relationship between the food industry and the scientists conducting research into obesity is also complicated by the issue of funding. There is not a great deal of money set aside for this work and so the food industry has become a vital source of income. But this means that the very same science going into combating obesity could also be used to hone the products that are making us obese. Many of the scientists I spoke to are wary about going on the record because they fear their funding will be taken away if they speak out.”
Occasionally, the food industry would choose to direct their funding into certain health charities as they see fit, and among the institutions vulnerable to such kind of infiltration, we find the heart associations around the world.
For example, the Heart and Stroke Foundation, a Canadian non-profit organisation with a primary mandate in promoting cardiovascular health, has, since 1999, held an industry-partnership, nutrition-labelling program known as Health Check. While the conception of the Health Check program might have been well-intentioned, it also became increasing clear over the years that the program was turning into a checkmark-selling mechanism — a means of generating quick-and-dirty cash for the Foundation . In fact, last time we checked (September 2014), there were 1367 products endowed with the Health Check label. These includes, among others:
- Astro Original 0% Plain Yogurt
- Western Family 100% Canola Oil
- Dole 100% Juice Blend Orange Peach Mango
- Boulangerie St-Méthode 100% Multi-Cereal Bread
- Minute Rice 100% Premium Long Grain Rice
- Campbell 100% Vegetable and Fruit Blend – Acai Mixed Berry
- Dempster’s Smart 100% Whole Grain Wheat Bread
- Sonora 12″ White Flour Tortillas
- Becel 64% less Non Hydrogenated Margarine
- Eating Right Beef and Vegetable Ready to Serve Soup
While we wouldn’t exactly consider these food as healthy, it was ultimately the fruit gummies that got the Heart and Stroke Foundation under hot water. In October 2013, Dr. Yoni Freedhoff, medical director of Ottawa’s Bariatric Medical Institute, released the following video accusing the Foundation of promoting the consumption of a certain fruit-like sugary candy named SunRype Fruitsource:
However, the Heart and Stroke Foundation did come out of this stronger after all. In June 2014, the Health Check program was disbanded, with the checkmark logos destined to phase out over the course of the next several months. In September 2014, the Foundation issued a statement cautioning the consumption of free sugar — a stance that it wouldn’t have felt comfortable taking just a year ago, while it was still under corporate influence.
Ties Between Medical Associations / Non-Profit Organisations and Pharmaceutical Companies
Who gets a hand on the guidelines concerning normal level of biometrics? In November 2013, American Heart Association (AHA) and American College of Cardiology (ACC) jointly published a new guideline on the treatment of blood cholesterol — a guideline authored by a panel of 15 members, 8 of which were found — by British Medical Journal — to have ties to the pharmaceutical industry, including the chairman and one of the two co-chairs.
More importantly, however, the guideline was specifically designed to encourage the prescription of the cholesterol-lowering class of drugs Statin, by lowering the cholesterol thresholds for prescription and by setting up an online heart-attack risk calculator which was found by two Harvard Medical School professors to have greatly overestimated the risk:
“it is possible that as many as 40–50% of the 33 million middle-aged Americans targeted by the new ACC/AHA guidelines for statin therapy do not actually have risk thresholds that exceed the 7·5% threshold suggested for treatment.”
Given all these concerns, one can only suspect the influences industry ties can exert on an individual behind the scenes:
“When individuals have commercial ties, they are vulnerable to developing subtle, but sometimes powerful, pro-industry ways of thinking.”
— Lisa Cosgrove, associate professor at the University of Massachusett, November 2013
Incidentally, the United Kingdom, being a country rich in pharmaceuticals, finds itself playing the same cholesterol-lowering game as its American counterpart. Near the end of 2012, the British Heart Foundation, a UK charity with the principal mandate of promoting cardiovascular health, teamed up with the company Flora Pro.Activ to promote their cholesterol-lowering plant sterols. By working together with Flora Pro.Activ, the British Heart Foundation would go on to receive a £750,000 donation as part of the campaign to “raise awareness of heart disease among women”.
And is there more to this? You bet! In the final Part IV of this series, we will continue to explore around the theme of vested interests, and how rewards and punishments can alter the direction and practices of medicine. Once that’s over, we will finish off with some motivational conclusions, along with some practical recommendations to smoothen the atmosphere. But for now, we want to leave you with a provocative quote that’s meant to be taken as it is:
We can no longer trust much research, because it’s been funded by industry. We can’t trust many of our leading experts in medicine, because they are on the drug company payroll. We can’t even trust some of the definitions of disease, because of their links with pharmaceutical companies, and sadly we can’t trust a lot of patient groups, because of their sponsorship by industry as well.
— Ray Moynlhan, Senior Research Fellow at Australia’s Bond University, August 2014 (3:11)
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