Drug companies in pursuit of profit

March 24, 2003

http://www.healthmatters.org.uk/stories/morgan.html

Health Matters issue 43 Winter 2000/01 Buying science, selling drugsSteve

Morgan, Morris Barer and Robert Evans explain how drug companies

systematically manipulate scientific research in pursuit of profit

According to standard economic theory the behaviour of private firms is

driven by the desire to make as much money as possible. For drug companies,

which have extraordinarily high fixed costs and low variable costs of

production, the route to profitability is through sales.

At least part of the selling process in the pharmaceutical industry involves

creating and disseminating scientific evidence about the merits of a

product. In an ideal world, corporate investment in clinical research would

facilitate prescribing decisions based on objective evaluations of

scientific evidence on safety, efficacy and cost-effectiveness. Reality,

alas, intrudes.

Pharmaceutical companies are not educational charities, investing in

disinterested product evaluation. Science and objectivity are of interest to

a private, for-profit corporation only insofar as they further the drive for

profits. In fact, to the discomfort of many economists, economic theory does

not rule out destroying scientific information or producing false

information as a means of pursuing the profit objective, just as it does not

rule out contaminating the environment, using child labour or selling known

carcinogens. Consider, for example, the long and sordid history of the

tobacco industry.

In the pharmaceutical sector, it may be profitable for a firm to promote

bias in the creation, evaluation and dissemination of information so as to

encourage sales - provided that such behaviour is either undetected or

carries penalties that are outweighed by its profit potential.

The picture that has emerged from the clinical sciences overwhelmingly

suggests that such practices are profitable because they routinely occur in

the pharmaceutical industry.1 Despite scientific pretences, drug companies

have injected various forms of bias into virtually every aspect of the

product evaluation process.

They begin at the front line, courting practising physicians - most

notoriously by proffering gifts: complimentary meals, travel, gifts and

entertainment all have a documented impact on prescribing, increasing the

use of the sponsor's products regardless of appropriateness.2,3 If gifts and

other inducements did not affect prescribing behaviour, economic theory (and

common sense) predicts that they would not be offered.

Not every physician accepts gifts and not all of those who accept them are

influenced. Further, even physicians most likely to believe drug

manufacturers' promotional claims will also be influenced by other sources

of information. For, along with other potentially competing interests, the

physician's primary duty of trust is to the patient. This makes it

imperative for drug companies to influence, to whatever extent they

profitably can, the ostensibly non-promotional sources of drug-related

information.

Medical associations have long been a third-party source of drug-related

information for prescribers. Prescribing information, cautions, and

guidelines disseminated under the auspices of medical associations carry the

implicit scientific credibility that such endorsement brings - so drug

companies have invested tremendous resources in marketing activities

channelled through medical associations. In the process, drug-makers have

allied the medical profession as a whole just as they have allied individual

physicians. Through grants, advertising and other sources of financial

support, medical associations are heavily reliant on the pharmaceutical

industry as a source of funding, placing the associations in an obvious

conflict of interest.4-7

Despite the fact that virtually every systematic review of the content and

impact of drug advertising confirms that it is of dubious information

value,3,4 the financial gains from permitting advertising have proved too

strong for associations and their journals to resist. Through medical

associations, drug companies fund continuing medical education programmes,

consensus conferences, scientific meetings and prescribing guideline

development. As economic theory would predict, the result is educational

events that systematically favour the sponsor's products.8,9

Not only do firms influence the process by which evidence is disseminated -

putting their 'spin' on whatever the findings may be - they also influence

how the evidence is created in the first place. If investment in clinical

sciences can be orchestrated in a way that generates favourable findings -

which, in turn, generate more sales - economic theory predicts that firms

will so orchestrate their investments. And indeed, using financial,

contractual and legal means, drug manufacturers retain a degree of control

over clinical research far greater than most people realise.

The most obvious mechanisms through which the evidence can be biased occur

in drug trials sponsored by corporations.10 Trial sponsors commonly control

the research question, selection of patients, and other means to control the

evaluation. Combined, these have documented effects on empirical findings.

Clinical trials funded by drug companies are more likely than non-industry

funded trials to generate 'scientific evidence' that favours the funding

company's product, and the data is more favourably interpreted by those with

financial ties to related drug companies.11

Drug companies are also very careful about what aspects of their studies

reach the public domain.12,13 Since the clinical data generated by

industry-funded drug trials is proprietary, it is seldom open to competitive

or public scrutiny. Secrecy, however, is the antithesis of good, transparent

science. It not only undermines the external review processes for studies

that are 'made public', but it also engenders reporting biases because

positive results are more likely to get published and are frequently

published multiple times.13-15 The evidence put before the public is far

rosier than the actual experiences of test subjects would suggest.

Hospitals and universities have too often tacitly acquiesced to such

practices by permitting contract-based research on terms inimical to good

science and patients' interests.16 It should not be surprising, in a time of

declining public funding, that universities and hospitals are willing to

accept research contracts with strict disclosure and confidentiality clauses

and/or methodological flaws. Pharmaceutical companies are a major source of

revenue upon which hospitals and universities increasingly depend.

In addition to fees paid on contract for specific studies, drug companies

give large corporate grants to public institutions. These for-profit firms

do not engage in hand-outs without reasons tied, directly or indirectly,

back to the corporate bottom line. Gifts to public institutions from a drug

company raises that company's image and serves as a means through which it

can influence the decisions of universities and hospitals.

Even when drug companies are not the sponsors of research studies, they use

lawsuits and other means to influence what is studied and what is reported.

Legal threats, regardless of their merit, are increasingly being used as a

means by which the drug industry silences recalcitrant researchers.17-21

Lawsuits significantly raise the anticipated costs of conducting and

publishing clinical research that yield results 'unfriendly' to the

objectives of manufacturers.

Even if individual researchers under legal attack win in the courts, they

lose considerable time, energy and money, and are put at a disadvantage in

research competitions with their peers.17,20 Other researchers note this. It

is hard to gauge how much critical research is 'chilled' as a result, but

such chilling is a plausible company objective - 'punish one to teach a

thousand'.

Evidence-biased medicine

Drug companies have also launched legal actions against those who conduct

independent evaluations and publish clinical guidelines.

In 1997, Bristol-Myers Squibb sought an injunction to prevent the Canadian

Coordinating Office of Health Technology Assessment (CCOHTA) from releasing

a summary report on drugs to lower blood cholesterol.

They were unsuccessful at trial, and on appeal, and received a judicial

rebuke. But they effectively shut down CCOHTA for a year and drained its

budget. Meanwhile they preserved their leading market position, generating

revenues that undoubtedly more than covered their legal expenses.

Increasingly, the industry is simply leaving the academics behind by having

drug trials designed, managed and reported by private, for-profit contract

research organisations. In 1991, academic centres accounted for 80 per cent

of industry-funded clinical trials; in 1998 they accounted for only 40 per

cent.22-24 Private research firms picked up the difference. The ostensible

reason for this change is that private firms can conduct research more

quickly than universities and hospitals. This is clearly of interest to

firms who wish to get the maximum number of market days out of their

fixed-term patents.

But a second advantage of contract research is that the firm can retain

complete control over questions, methods, data and publications, without

hindrance from academic review processes. While academic researchers and

clinicians may still be involved, no individual will have sufficient grasp

of the overall project to be able to question methods or see warning signs

in data coming in from all participating centres.

Professional medical writers frequently write up the results of privately

contracted research. The articles are then published under the names of

prominent researchers or clinicians paid a fee for reviewing the manuscript

and attaching their names. The practice of ghost-written papers published

under 'honorary' authorships has become so pervasive, and the belief that

this reduces accountability for research is so strong, that some medical

journals now require that authors list their contribution to the research.25

Using profit-making organisations to conduct research on behalf of drug

companies, and using public relations firms to put media 'spin' on the

results and coordinate their publication, completes the process by which the

industry has infiltrated every stage of the modern research enterprise.

Faced with this infiltration, patient welfare and scientific process are

simply overwhelmed by the profit objective of the pharmaceutical companies.

Private practitioners have become more-than-willing pawns in this process,

often putting their own financial and academic interests ahead of their

patients' interests. In the private, contract-based research setting, data

gathering is conducted by ordinary practising physicians.22-24 The fees paid

for enlisting patients in these studies, together with bonuses for meeting

recruitment targets and deadlines, can amount to hundreds of thousands of

dollars a year.24 In this context the notion of supplier-induced demand

takes on a whole new complexion. Inappropriate treatment occurring under

heavy financial incentives appears to be a form of 'collateral damage'

acceptable to the doctors, contract research organisations and funding drug

companies.

Contract research for profit is a recent development, but all the other

marketing practices described above are decades old. Documentation of

attempts to generate biased clinical evidence for marketing purposes dates

back decades. As early as the mid-1950s, public commissions of inquiry in

Canada, the US and the UK all received testimonies of industry efforts to

introduce bias into the prescribing process, not only by the ubiquitous

practice of giving gifts and other benefits to prescribing physicians, but

through financing articles in journals intended for prescribing doctors, and

influencing their content.26-28

Then, as now, drug companies: sponsored drug trials; hand-picked

investigators depending on the degree of quality needed (for example,

picking young investigators of little or no reputation to study the more

dubious drugs); discouraged the publication of unfavourable results; used

multiple trials at different centres to raise awareness of a drug before its

market launch; and published results multiple times (both before and after

the drug's launch) so as to hamper those searching for scientific evidence.

As Yale political scientist Ted Marmor has noted, 'Nothing that is regular

is stupid.' These practices are profitable.

References

1. Barer ML, McGrail KM et al (eds) (2000) Tales From the Other Drug Wars:

Proceedings from the 12th Annual Health Policy Conference. Centre for Health

Services and Policy Research, UBC. www.chspr.ubc.ca [26 September 2000]

2. Wazana A. (2000) Physicians and the pharmaceutical industry: Is a gift

ever just a gift? JAMA; 283 (3): 373-280.

3. Lexchin J. (1993) Interactions between physicians and the pharmaceutical

industry: what does the literature say? Can Med Assoc J; 149 (10):

1401-1407.

4. Guyatt G. (1994) Academic medicine and the pharmaceutical industry: a

cautionary tale. Can Med Assoc J; 150(6): 951-953.

5. Glassman PA et al (1999) Pharmaceutical advertising revenue and physician

organizations: how much is too much? Est J Med; 171 (4): 234-238.

6. Mabin DC. (1995) BMJ should declare its own conflict of interest. BMJ;

311: 878.

7. Ubel PA, et al (1995) Acceptance of external funds by physician

organizations: issues and policy options. J Gen Intern Med; 10: 624-630.

8. Sheldon TA, Smith GD. (1993) Consensus conferences as drug promotion. The

Lancet; 341 (8837): 100-103.

9. Spingarn RW, Berlin JA, Strom BL. (1996) When pharmaceutical

manufacturers' employees present grand rounds, what do residents remember?

Acad Med; 71: 86-88.

10. Bero LA, Rennie D. (1996) Influences on the Quality of Public Drug

Studies. Int J Technol Assess Health Care; 12 (2): 209-237.

11. Brill-Edwards M. (2000) Canada's Health Protection Branch: Whose Health,

What Protection? In Tales From the Other Drug Wars: Proceedings from the

12th Annual Health Policy Conference, Barer ML, McGrail KM et al. (eds.)

Centre for Health Services and Policy Research, UBC 2000; www.chspr.ubc.ca

[26 September 2000]

12. Wahlbeck K, Adams C. (1999) Beyond conflict of interest: Sponsored drug

trials show more-favourable outcomes. BMJ; 318 (7181): 465.

13. Rosenberg SA. (1996) Secrecy in medical research. N Engl J Med; 334 (6):

392-4.

14. Rennie D. (1999) Fair conduct and fair reporting of clinical trials.

JAMA; 282 (18): 1766-1768.

15. Johansen HK, Gotxche PC. (1999) Problems in the design and reporting of

trials of antifungal agents encountered during meta-analysis. JAMA; 282

(18): 1752-1759.

16. Angell M. (2000) Is academic medicine for sale? N Engl J Med; 342 (20):

1516-1518.

17. Shuchman M. (2000) Consequences of blowing the whistle in medical

research. Ann Intern Med; 132 (12): 1013-1014

18. Hemminiki E, Hailey D, Koivusalo M. (1999) The courts - a challenge to

health technology assessment. Science; 285 (5425): 203-204.

19. Hailey D. (2000) Scientific harassment by pharmaceutical companies: time

to stop. Can Med Assoc J; 162 (2): 212-213.

20. Evans RG. (2000) Uses and abuses of research and the research process.

In Barer ML, McGrail KM et al. (eds) Tales From the Other Drug Wars:

Proceedings from the 12th Annual Health Policy Conference. Centre for Health

Services and Policy Research, UBC 2000; www.chspr.ubc.ca [26 September 2000]

21. Rich P. (1999) Re-evaluating guidelines: clash between researcher and

drug company shows need for further clarification of the process. Medical

Post; 25 (41): cover, 64.

22. Rettig R. (2000) The industrialization of clinical research. Health

Affairs; 19 (2): 129-146.

23. Bodenheimer T. (2000) Uneasy alliance - clinical investigators and the

pharmaceutical industry. N Engl J Med; 342 (29): 1539.

24. Eichenwald K, Kolata G. (1999) Drug trials hide conflicts for doctors.

New York Times; May 16, 1999.

25. Rennie D, Flanagin A, Yank V. (2000) The contribution of authors. JAMA;

284 (1): 89-91.

26. Lang RW. (1974) The Politics of Drugs: A comparative pressure-group

study of the Canadian Pharmaceutical Manufacturers Association and the

Association of the British Pharmaceutical Industry. England: Saxon House.

27. Temin P. (1980) Taking Your Medicine: Drug Regulation in the United

States. Cambridge: Harvard University Press.

28. Restrictive Trade Practices Commission (1963) Report Concerning the

Manufacture, Distribution and Sale of Drugs. Ottawa: Queen's Printer.

Steve Morgan, Morris Barer and Robert Evans are academics at the Centre for

Health Services and Policy Research, University of British Columbia.

April 14, 2003

Elaine,

You're providing a fine service!

Jerry Mittelman, DDS, FAPM

-

Elaine

*§ @y

Monday, March 24, 2003 12:06 AM

Drug companies in pursuit of profit

http://www.healthmatters.org.uk/stories/morgan.htmlHealth Matters issue 43 Winter 2000/01 Buying science, selling drugsSteveMorgan, Morris Barer and Robert Evans explain how drug companiessystematically manipulate scientific research in pursuit of profitAccording to standard economic theory the behaviour of private firms isdriven by the desire to make as much money as possible. For drug companies,which have extraordinarily high fixed costs and low variable costs ofproduction, the route to profitability is through sales.At least part of the selling process in the pharmaceutical industry involvescreating and disseminating scientific evidence about the merits of aproduct. In an ideal world, corporate investment in clinical research wouldfacilitate prescribing decisions based on objective evaluations ofscientific evidence on safety, efficacy and cost-effectiveness. Reality,alas, intrudes.Pharmaceutical companies are not educational charities, investing indisinterested product evaluation. Science and objectivity are of interest toa private, for-profit corporation only insofar as they further the drive forprofits. In fact, to the discomfort of many economists, economic theory doesnot rule out destroying scientific information or producing falseinformation as a means of pursuing the profit objective, just as it does notrule out contaminating the environment, using child labour or selling knowncarcinogens. Consider, for example, the long and sordid history of thetobacco industry.In the pharmaceutical sector, it may be profitable for a firm to promotebias in the creation, evaluation and dissemination of information so as toencourage sales - provided that such behaviour is either undetected orcarries penalties that are outweighed by its profit potential.The picture that has emerged from the clinical sciences overwhelminglysuggests that such practices are profitable because they routinely occur inthe pharmaceutical industry.1 Despite scientific pretences, drug companieshave injected various forms of bias into virtually every aspect of theproduct evaluation process.They begin at the front line, courting practising physicians - mostnotoriously by proffering gifts: complimentary meals, travel, gifts andentertainment all have a documented impact on prescribing, increasing theuse of the sponsor's products regardless of appropriateness.2,3 If gifts andother inducements did not affect prescribing behaviour, economic theory (andcommon sense) predicts that they would not be offered.Not every physician accepts gifts and not all of those who accept them areinfluenced. Further, even physicians most likely to believe drugmanufacturers' promotional claims will also be influenced by other sourcesof information. For, along with other potentially competing interests, thephysician's primary duty of trust is to the patient. This makes itimperative for drug companies to influence, to whatever extent theyprofitably can, the ostensibly non-promotional sources of drug-relatedinformation.Medical associations have long been a third-party source of drug-relatedinformation for prescribers. Prescribing information, cautions, andguidelines disseminated under the auspices of medical associations carry theimplicit scientific credibility that such endorsement brings - so drugcompanies have invested tremendous resources in marketing activitieschannelled through medical associations. In the process, drug-makers haveallied the medical profession as a whole just as they have allied individualphysicians. Through grants, advertising and other sources of financialsupport, medical associations are heavily reliant on the pharmaceuticalindustry as a source of funding, placing the associations in an obviousconflict of interest.4-7Despite the fact that virtually every systematic review of the content andimpact of drug advertising confirms that it is of dubious informationvalue,3,4 the financial gains from permitting advertising have proved toostrong for associations and their journals to resist. Through medicalassociations, drug companies fund continuing medical education programmes,consensus conferences, scientific meetings and prescribing guidelinedevelopment. As economic theory would predict, the result is educationalevents that systematically favour the sponsor's products.8,9Not only do firms influence the process by which evidence is disseminated -putting their 'spin' on whatever the findings may be - they also influencehow the evidence is created in the first place. If investment in clinicalsciences can be orchestrated in a way that generates favourable findings -which, in turn, generate more sales - economic theory predicts that firmswill so orchestrate their investments. And indeed, using financial,contractual and legal means, drug manufacturers retain a degree of controlover clinical research far greater than most people realise.The most obvious mechanisms through which the evidence can be biased occurin drug trials sponsored by corporations.10 Trial sponsors commonly controlthe research question, selection of patients, and other means to control theevaluation. Combined, these have documented effects on empirical findings.Clinical trials funded by drug companies are more likely than non-industryfunded trials to generate 'scientific evidence' that favours the fundingcompany's product, and the data is more favourably interpreted by those withfinancial ties to related drug companies.11Drug companies are also very careful about what aspects of their studiesreach the public domain.12,13 Since the clinical data generated byindustry-funded drug trials is proprietary, it is seldom open to competitiveor public scrutiny. Secrecy, however, is the antithesis of good, transparentscience. It not only undermines the external review processes for studiesthat are 'made public', but it also engenders reporting biases becausepositive results are more likely to get published and are frequentlypublished multiple times.13-15 The evidence put before the public is farrosier than the actual experiences of test subjects would suggest.Hospitals and universities have too often tacitly acquiesced to suchpractices by permitting contract-based research on terms inimical to goodscience and patients' interests.16 It should not be surprising, in a time ofdeclining public funding, that universities and hospitals are willing toaccept research contracts with strict disclosure and confidentiality clausesand/or methodological flaws. Pharmaceutical companies are a major source ofrevenue upon which hospitals and universities increasingly depend.In addition to fees paid on contract for specific studies, drug companiesgive large corporate grants to public institutions. These for-profit firmsdo not engage in hand-outs without reasons tied, directly or indirectly,back to the corporate bottom line. Gifts to public institutions from a drugcompany raises that company's image and serves as a means through which itcan influence the decisions of universities and hospitals.Even when drug companies are not the sponsors of research studies, they uselawsuits and other means to influence what is studied and what is reported.Legal threats, regardless of their merit, are increasingly being used as ameans by which the drug industry silences recalcitrant researchers.17-21Lawsuits significantly raise the anticipated costs of conducting andpublishing clinical research that yield results 'unfriendly' to theobjectives of manufacturers.Even if individual researchers under legal attack win in the courts, theylose considerable time, energy and money, and are put at a disadvantage inresearch competitions with their peers.17,20 Other researchers note this. Itis hard to gauge how much critical research is 'chilled' as a result, butsuch chilling is a plausible company objective - 'punish one to teach athousand'.Evidence-biased medicineDrug companies have also launched legal actions against those who conductindependent evaluations and publish clinical guidelines.In 1997, Bristol-Myers Squibb sought an injunction to prevent the CanadianCoordinating Office of Health Technology Assessment (CCOHTA) from releasinga summary report on drugs to lower blood cholesterol.They were unsuccessful at trial, and on appeal, and received a judicialrebuke. But they effectively shut down CCOHTA for a year and drained itsbudget. Meanwhile they preserved their leading market position, generatingrevenues that undoubtedly more than covered their legal expenses.Increasingly, the industry is simply leaving the academics behind by havingdrug trials designed, managed and reported by private, for-profit contractresearch organisations. In 1991, academic centres accounted for 80 per centof industry-funded clinical trials; in 1998 they accounted for only 40 percent.22-24 Private research firms picked up the difference. The ostensiblereason for this change is that private firms can conduct research morequickly than universities and hospitals. This is clearly of interest tofirms who wish to get the maximum number of market days out of theirfixed-term patents.But a second advantage of contract research is that the firm can retaincomplete control over questions, methods, data and publications, withouthindrance from academic review processes. While academic researchers andclinicians may still be involved, no individual will have sufficient graspof the overall project to be able to question methods or see warning signsin data coming in from all participating centres.Professional medical writers frequently write up the results of privatelycontracted research. The articles are then published under the names ofprominent researchers or clinicians paid a fee for reviewing the manuscriptand attaching their names. The practice of ghost-written papers publishedunder 'honorary' authorships has become so pervasive, and the belief thatthis reduces accountability for research is so strong, that some medicaljournals now require that authors list their contribution to the research.25Using profit-making organisations to conduct research on behalf of drugcompanies, and using public relations firms to put media 'spin' on theresults and coordinate their publication, completes the process by which theindustry has infiltrated every stage of the modern research enterprise.Faced with this infiltration, patient welfare and scientific process aresimply overwhelmed by the profit objective of the pharmaceutical companies.Private practitioners have become more-than-willing pawns in this process,often putting their own financial and academic interests ahead of theirpatients' interests. In the private, contract-based research setting, datagathering is conducted by ordinary practising physicians.22-24 The fees paidfor enlisting patients in these studies, together with bonuses for meetingrecruitment targets and deadlines, can amount to hundreds of thousands ofdollars a year.24 In this context the notion of supplier-induced demandtakes on a whole new complexion. Inappropriate treatment occurring underheavy financial incentives appears to be a form of 'collateral damage'acceptable to the doctors, contract research organisations and funding drugcompanies.Contract research for profit is a recent development, but all the othermarketing practices described above are decades old. Documentation ofattempts to generate biased clinical evidence for marketing purposes datesback decades. As early as the mid-1950s, public commissions of inquiry inCanada, the US and the UK all received testimonies of industry efforts tointroduce bias into the prescribing process, not only by the ubiquitouspractice of giving gifts and other benefits to prescribing physicians, butthrough financing articles in journals intended for prescribing doctors, andinfluencing their content.26-28Then, as now, drug companies: sponsored drug trials; hand-pickedinvestigators depending on the degree of quality needed (for example,picking young investigators of little or no reputation to study the moredubious drugs); discouraged the publication of unfavourable results; usedmultiple trials at different centres to raise awareness of a drug before itsmarket launch; and published results multiple times (both before and afterthe drug's launch) so as to hamper those searching for scientific evidence.As Yale political scientist Ted Marmor has noted, 'Nothing that is regularis stupid.' These practices are profitable.References1. Barer ML, McGrail KM et al (eds) (2000) Tales From the Other Drug Wars:Proceedings from the 12th Annual Health Policy Conference. Centre for HealthServices and Policy Research, UBC. www.chspr.ubc.ca [26 September 2000]2. Wazana A. (2000) Physicians and the pharmaceutical industry: Is a giftever just a gift? JAMA; 283 (3): 373-280.3. Lexchin J. (1993) Interactions between physicians and the pharmaceuticalindustry: what does the literature say? Can Med Assoc J; 149 (10):1401-1407.4. Guyatt G. (1994) Academic medicine and the pharmaceutical industry: acautionary tale. Can Med Assoc J; 150(6): 951-953.5. Glassman PA et al (1999) Pharmaceutical advertising revenue and physicianorganizations: how much is too much? Est J Med; 171 (4): 234-238.6. Mabin DC. (1995) BMJ should declare its own conflict of interest. BMJ;311: 878.7. Ubel PA, et al (1995) Acceptance of external funds by physicianorganizations: issues and policy options. J Gen Intern Med; 10: 624-630.8. Sheldon TA, Smith GD. (1993) Consensus conferences as drug promotion. TheLancet; 341 (8837): 100-103.9. Spingarn RW, Berlin JA, Strom BL. (1996) When pharmaceuticalmanufacturers' employees present grand rounds, what do residents remember?Acad Med; 71: 86-88.10. Bero LA, Rennie D. (1996) Influences on the Quality of Public DrugStudies. Int J Technol Assess Health Care; 12 (2): 209-237.11. Brill-Edwards M. (2000) Canada's Health Protection Branch: Whose Health,What Protection? In Tales From the Other Drug Wars: Proceedings from the12th Annual Health Policy Conference, Barer ML, McGrail KM et al. (eds.)Centre for Health Services and Policy Research, UBC 2000; www.chspr.ubc.ca[26 September 2000]12. Wahlbeck K, Adams C. (1999) Beyond conflict of interest: Sponsored drugtrials show more-favourable outcomes. BMJ; 318 (7181): 465.13. Rosenberg SA. (1996) Secrecy in medical research. N Engl J Med; 334 (6):392-4.14. Rennie D. (1999) Fair conduct and fair reporting of clinical trials.JAMA; 282 (18): 1766-1768.15. Johansen HK, Gotxche PC. (1999) Problems in the design and reporting oftrials of antifungal agents encountered during meta-analysis. JAMA; 282(18): 1752-1759.16. Angell M. (2000) Is academic medicine for sale? N Engl J Med; 342 (20):1516-1518.17. Shuchman M. (2000) Consequences of blowing the whistle in medicalresearch. Ann Intern Med; 132 (12): 1013-101418. Hemminiki E, Hailey D, Koivusalo M. (1999) The courts - a challenge tohealth technology assessment. Science; 285 (5425): 203-204.19. Hailey D. (2000) Scientific harassment by pharmaceutical companies: timeto stop. Can Med Assoc J; 162 (2): 212-213.20. Evans RG. (2000) Uses and abuses of research and the research process.In Barer ML, McGrail KM et al. (eds) Tales From the Other Drug Wars:Proceedings from the 12th Annual Health Policy Conference. Centre for HealthServices and Policy Research, UBC 2000; www.chspr.ubc.ca [26 September 2000]21. Rich P. (1999) Re-evaluating guidelines: clash between researcher anddrug company shows need for further clarification of the process. MedicalPost; 25 (41): cover, 64.22. Rettig R. (2000) The industrialization of clinical research. HealthAffairs; 19 (2): 129-146.23. Bodenheimer T. (2000) Uneasy alliance - clinical investigators and thepharmaceutical industry. N Engl J Med; 342 (29): 1539.24. Eichenwald K, Kolata G. (1999) Drug trials hide conflicts for doctors.New York Times; May 16, 1999.25. Rennie D, Flanagin A, Yank V. (2000) The contribution of authors. JAMA;284 (1): 89-91.26. Lang RW. (1974) The Politics of Drugs: A comparative pressure-groupstudy of the Canadian Pharmaceutical Manufacturers Association and theAssociation of the British Pharmaceutical Industry. England: Saxon House.27. Temin P. (1980) Taking Your Medicine: Drug Regulation in the UnitedStates. Cambridge: Harvard University Press.28. Restrictive Trade Practices Commission (1963) Report Concerning theManufacture, Distribution and Sale of Drugs. Ottawa: Queen's Printer.Steve Morgan, Morris Barer and Robert Evans are academics at the Centre forHealth Services and Policy Research, University of British Columbia.§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§*§§ - PULSE ON WORLD HEALTH CONSPIRACIES! §Subscribe:......... - To Post:........... To :.... - Any information here in is for educational purpose only, it may be news related, purely speculation or someone's opinion. Always consult with a qualified health practitioner before deciding on any course of treatment, especially for serious or life-threatening illnesses.**COPYRIGHT NOTICE**In accordance with Title 17 U.S.C. 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