How reliable are articles in peer-reviewed medical journals?

review of Sickening: How Big Pharma Broke American Healthcare. By John Abramson. Sailor’s books.

The United States spends far more money on health care than other wealthy countries and has fallen to 68th in the world in terms of “healthy life expectancy”.

According to Harvard Medical School faculty member Dr. John Abramson, author of America overdosedand expert witness in litigation involving pharmaceutical companies, pharmaceutical companies bear considerable responsibility for the disparity.

In Disgusting, Abramson reveals, Americans spent almost as much per person on prescription drugs as citizens of other wealthy countries. These days, they’re spending twice as much, largely because of the volume of prescriptions for expensive brand name products. Driven in large part by massive spending on marketing (about twice as much as spending on research and development of the drugs themselves), retail sales of prescription drugs in the United States, he points out, have been multiplied by thirty since 1980. Recently, the cost of brand name drugs has increased 14 times faster than the consumer price index.

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Abramson provides a detailed and accessible cost-benefit analysis of more than a dozen of them, used to prevent or treat pain, heartburn, influenza, rheumatoid arthritis, diabetes, cardiovascular disease and, more recently, Alzheimer’s disease, to make a compelling case that drug companies have created a chasm between “their claimed or implied value and their true value”.

To monetize their control over the information they disseminate about the health benefits of their products, Abramson argues, pharmaceutical companies have managed to gain control of the research agenda (from academic medical centers and government agencies); own clinical trial data (and retain as proprietary secrets); and publish trial results non-transparently in peer-reviewed journals.

Because manufacturers buy reprints in bulk to distribute to doctors, medical journals, Abramson reveals, have a vested interest in publishing articles favorable to brand name drugs. In 2005, for example, sales of reprints accounted for 41% of the total revenue of The Lancet. Unsurprisingly, the New England Journal of Medicine (which, with the Journal of the American Medical Association and Annals of Internal Medicine, does not disclose such information) topped the top five journals in the field for the percentage of published trials that were manufacturer-supported. While authors of articles are required to report conflicts of interest, Abramson points out, no such requirement exists for journals themselves.

Abramson acknowledges that it won’t be easy to reign in the “largely unbridled power” of drug companies, backed by legions of lobbyists in Washington DC and substantial campaign contributions to politicians. That said, his recommendations should hold the attention of every American:

Require that all authors, peer reviewers and editors of medical journals have access to underlying clinical trial data before deciding whether or not to publish articles. And include reviewers trained in statistical methods in the verification process.

Allow the FDA to not only ensure that claims in direct-to-consumer advertisements are consistent with information on agency-approved product labels, but that they contain accurate and relevant summaries of benefits, risks and costs (not just co-payment) compared to other drugs or non-drug therapies. Create a formal Health Technology Assessment (HTA) mechanism within the FDA, similar to the UK government-funded National Institute for Health and Care Excellence (NICE), with full access to trial data clinics, to formulate guidelines for benefits and costs .

Congress should allow Medicare and Medicaid to negotiate prices with companies and establish “a public option” for health insurance buyers.

Most fundamental, according to Abramson, is the urgent need for cultural change in the United States, from addiction to new drugs and deviances to promote and preserve health, driven by profit maximization, to lifestyle changes in diet, exercise and stress reduction. (addressed in only 4% of medical research). Affected, of course, by socioeconomic disparities, more than 80% of heart disease and diabetes, Abramson points out, can be prevented by adopting healthier habits.

In many ways, Dr. Abramson concludes, health care “has become another test of our democracy.” Recognizing that success “is by no means predetermined,” he chooses to believe that American citizens can rise to the challenge.

Amanda J. Marsh