Union Station in Washington, D.C., was somehow the perfect place to launch the world's first new major medical journal in seventy years. Just a stroll down the hill from the U.S. Congress, the station's grand architecture and quiet palatial rooms conjure a sense of stately history and high hopes. At the time it was built, in 1908, this train station was one of the largest in the world.
The journal launched here in the fall of 2004, PLoS Medicine, (http://www.plos.org) also has big aspirations, as it plans to "challenge the status quo" by providing free web access to all of its scientific articles. What's more, unlike virtually every other leading medical journal in the world today, this journal will not accept any drug company advertisements. Nor will it publish company-funded studies that are considered to be marketing dressed up as science. The aim, say its editors, is to break "the cycle of dependency" that has formed between medical journals and the pharmaceutical industry.
Run by the San Francisco-based not-for-profit Public Library of Science, the new journal's editorial board boosts some of the biggest names in global health care. By challenging the status quo, disentangling from drug company influence, and promoting more independent medical information, this journal is helping show the way forward for all of us.
Challenging and questioning the status quo is the first step for anyone concerned about the selling of sickness. Working out where the boundaries lie between health and disease is not easy, and as we've seen the there are huge promotional forces at work trying to blur them. With many conditions, like high cholesterol or ADD, those boundaries just keep getting wider. These days when a doctor diagnoses a condition and gives it a medical label, that diagnosis may no longer be able to be taken at face value. Though it might seem like common sense, there can be great value talking with family and friends about the appropriateness of a particular medical label, and debating whether the problem at hand is really a sign of disease or simply one of the ups and downs of ordinary life.
Sometimes, of course, disease are real, painful, and deadly, and treatment with the latest and most expensive drugs or other medical technology or procedure is highly desirable. Yet there are many cases where a person's health problems are so mild or temporary that doing nothing is the best option. Irritable bower syndrome, for example, will only be severe and disabling for a tiny fraction of the 20 percent of the entire population said to be afflicted by it. The value of a healthy skepticism towards the hype about the latest disorders, and the numbers allegedly affected by them, cannot be overstated.
The obvious problem for all of us right now is finding good sources of information about human illness that are truly independent of drug company influence. Many doctors still see drug representatives; many patient groups and medical societies still accept generous grants; most medical journals still rely heavily on the industry's advertising and its sponsored studies. Finding quality materials about the risks and benefits of drugs and other therapies is becoming easier, but finding good and accessible, up-to-date, and independent information about disease is, as yet, near impossible.
New ways of defining diseases, and educating people about the options for dealing with them, are urgently needed. To continue to rely on drug company -- funded thought-leaders to write the definitions, and drug company--funded marketing to educate us about them, is dangerous, and really rather absurd. A major renovation of how we understand sickness needs fresh ideas and radical experiments, but there are existing models that may be helpful. Around the world there are many public institutions, and some private bodies, that have found ways to rigorously review all of the available scientific studies about a particular treatment, and come up with an unbiased summary of how well it works. In the United Kingdom, the publicly funded National Institute for Clinical Excellence undertakes such reviews, as do many groups in the U.S., including the innovative private organization ECRI. Sometimes short summaries of this evidence are made available on the web to doctors and the public, like those provided by the international Cochrane Collaboration.
The hallmark of systematically reviewing and summarizing the evidence about treatments is that it is carried out by organizations and individuals who don't profit from selling those treatments. It is now time for similar reviews of the evidence about diseases and disorders that will produce unbiased and easy-to-read information for ordinary people. Rather than simplistic marketing messages that play on fear and use grossly inflated figures to try to scare people into drug therapy, such information would spell out the uncertainty and controversy that surrounds many disease definitions. Without such complete information about the pros and cons of accepting a medical label, an informed choice is impossible.
Yet, more than being Independent, the new bodies that will help to draw the line between health and disease must be more inclusive than the current panels, many of which are dominated by medical doctors. There is an old saying that when you give someone a hammer, everything looks like a nail. Sometimes it is a nail and hammering it helps get the house bill. On other occasions a carpenter's skills may not be the only ones called for. Changing city planning laws to encourage more physical activity may do more to prevent disease than prescribing increasing doses of drugs. Somehow a much broader group of people, both lay and professional, must be involved in defining diseases and disorders, and producing unbiased information about the risks and benefits of various options for treating and preventing them. Health advocacy groups, university departments, and public institutions with reputations for independence, good science, and healthy skepticism are obvious places to start that ball rolling.
In the meantime, most people are left with little choice but to "talk to your doctor," as the slick advertisements and the well-paid celebrities keep telling us to do. But as we've seen, many of our doctors, no matter how committed and hardworking, are still prescribing under the influence of marketing campaigns designed to sell us sickness in order to sell us pills. However, it may be that a fundamental change is coming.
With a membership of fifty thousand, the American Medical Student Association is literally the face of tomorrow's physician. As part of its charter, the association takes no sponsorship from the pharmaceutical industry. It's "PharmFree" campaign urges medical students to simply say no to the free lunches, the gifts, the paid speaking engagements, and the lucrative consultancies. As it happens, their association's, national president, Brian Palmer, was there at the historic launch of the new pharm-free medical journal at Union Station in the U.S. capitol, beaming broadly as he joked with the journal's smart young editors, all of them with wide smiles, firmly fixed on the future more about promoting health and selling sickness.