Commentary: Lack of scientific influences on epidemiology

Unethical, anti-scientific, politically motivated attacks on health research and researchers by wealthy organized interests can be a nightmare. I know this from experience. In ‘Corporate Influences on Epidemiology’,1 Neil Pearce recounts a bit of what it is like to have one's scientific contributions attacked because someone does not like the worldly implications of the results, and suggests that the problem is sufficiently pervasive to be a threat to epidemiology. The concerns, and especially the advice, Pearce offers seem to fit my own experience well. I have developed a thick skin, focused on the long run, and avoided imitating those who attack me by overstating or misrepresenting the evidence. I find strength in the fact that, as Pearce notes, most of the time science—not political correctness, not well-funded advocates—wins in the end. The twist on Pearce's message in my case is that he might consider me to be on the wrong side (others who are less tempered and thoughtful than Pearce might go further in their condemnation), since I have done a few critical scientific analyses of epidemiological claims as part of industry consultancies. More significantly, the anti-scientific attacks on epidemiology that I have been a victim of have come not from corporations, or even government, but from those who are thought by most people to be public health advocates. The players and specific areas of research are different, but as with corporate influence, influential organized interests are willing to damage science and even sacrifice people's health to further their goals. As a brief summary, much of my work focuses on the possibility that the health impact of nicotine use might be considerably reduced by encouraging smokers to switch to an alternative source of nicotine, oral smokeless tobacco being the most promising, since ample epidemiological evidence clearly shows that smokeless tobacco causes about 1/100th the total disease risk from smoking.2–4 This approach, known as ‘tobacco harm reduction’5—analogous to other harm reduction strategies such as promoting condom use, needle exchange or seatbelts—is opposed by the wealthy and influential non-profit and governmental organizations that control almost all of the funding and discourse on tobacco and health. Those organizations have effectively misled the public and policy makers about the epidemiology,2,,4,6,7 overstating the health risks from ST use by orders of magnitude. Thus, there is little realization of the potential of harm reduction by smokers or even most health professionals. (Why organizations that claim to be concerned with people's health prefer to let them die from smoking, rather than learn of a very good alternative, is beyond the scope of this commentary.) Tobacco harm reduction involves substantial potential for disease and mortality reduction and several genuine uncertainties (though the underlying epidemiology of comparative health risks is not among them), making it an important area for research. However, the organizations that control most of the agenda and funding for studies of tobacco and health actively block research that might undermine their abstinence-only (a.k.a. ‘quit or die’) activist positions. Those organized interests have used their power to try to de-fund me and my students, terminate my faculty position and censor the presentation of information about tobacco harm reduction by me and others. They have been successful at some of these to a disturbing extent, and may yet succeed at all of them. I provide some detail about the actors (non-corporate entities that include advocacy organizations, the administration of the new University of Alberta School of Public Health, and others) and their actions (sufficiently shocking that I am concerned that mentioning them would distract from the main message of this commentary) in a recent article.8 As outlandish as my situation has been, epidemiologist Jim Enstrom has suffered even more at the hands of anti-tobacco activists for publishing a single result from his research (which has not been challenged on substantive scientific grounds) that they did not like.9,,10 Some of the ad hominem attacks on Enstrom and on me are facilitated by the fact that those of us who do research that the anti-tobacco orthodoxy does not like, and thus will not fund, need to seek grants from industry. (For both Enstrom and me, those grants have been completely hands-off money: no restrictions on its use, no involvement of the funders with research decisions, no pre-publication access to the work.) Those who control the competing funding use this as an excuse to attack us without addressing the scientific merit of our work. But this is clearly just a convenient rationalization for the attacks, given that every researcher I know who dared depart from the anti-tobacco orthodoxy—whether or not they ever accepted grants from the industry—has suffered similar attacks. Pearce and others have implied that an association between funding sources and results means that industry funding causes researchers to reach certain conclusions. Many who invoke this commit the classic epidemiologic error of reversing cause and effect. In controversial areas of public health research, academics who have previously published conclusions or want to do research that might be seen as positive for the industry typically find that they are refused funding from sources other than industry. Pearce, unlike some others, recognizes that cause and effect often flow in this direction, but he fails to carry through that analysis to note that such causation is driven by the behaviour of the non-industry funders, not the industry or the researchers. Moreover, the situation is remarkably symmetrical: a history of conclusions that support the agendas of particular government and advocacy organizations increases the chance of getting funding from them. What is less symmetrical is that it is difficult to imagine any corporate actor attempting (let alone getting away with) anti-scientific attacks on epidemiology remotely like those made by anti-tobacco activists. Some damage done by these attacks is overt and immediate, including misinforming the public and policy makers and directly interfering with research. But less visible damage includes erosion of the overall quality of the science and discouraging researchers from doing innovative or controversial work. My students have noticed that when they do research on harm reduction, they are harassed at every turn (e.g. the human subjects ethics board has yet to approve any of our projects, even when there is no risk to the subjects—when they did not merely sit on our requests for inexcusable periods they imposed literally impossible requirements; other professors demanded that one student withdraw from authorship of her papers to please outside constituents), whereas if they were to adhere to the abstinence-only orthodoxy they could tap into seemingly limitless funding, employment opportunities and uncritical approval. Thus, I concur with Pearce that political interests have influences that pose a threat to epidemiology, though he was overly narrow in focusing on corporations. A few of the many other non-corporate distortions of epidemiology include: Advocates of cancer screening have often overstated the scientific evidence of its benefits and successfully established apparently inefficient standards of care. Officials working on HIV/AIDS have been convincingly accused of intentionally overstating disease prevalence.11 The US government has been repeatedly cited for making epidemiologic claims that are based only on puritanical religious doctrine.12 Of course, some of the behaviour Pearce cites represents inexcusable violation of scientific and academic ethics. Putting your name on a paper that someone else wrote without your involvement is indefensible. Perhaps, it is even worse when it is ghostwritten by an organized interest, compared with the more common variant, wherein a senior researcher ‘authors’ numerous papers thanks to his students and employees. When someone (corporation or otherwise) suggests the idea of doing a particular analysis (whether they pay for it or not), this should be acknowledged, to give due credit for the idea and to make clear that the work may have been done in pursuit of someone else's worldly agenda. And, of course, if that suggestion came with an attempt to dictate the outcome of the analysis, then it is no longer a suggestion, but is again indefensible ghostwriting. Enforcement of these simple rules might be aided by clearer codes of conduct. But Pearce's sketches of solutions that involve codes, professional organizations and getting the ‘right’ people on influential committees offer little hope of addressing the fundamental challenges. Trying to thwart powerful interests by creating more power elsewhere has a very unfortunate history. The influence of powerful organized interests on government public health policy that Pearce alludes to is not some anomaly that can just be fixed once it is recognized. It is an example of the political tendencies toward agency ‘capture’13,,14 and ‘iron triangles’ (e.g. the military-industrial complex)15 that are always present in government and that offer strong cases for maintaining pluralism as a counter to centralization. It is easy to fall into a utopian belief that if some right-thinking individuals are put in a position of sufficient power, that a problem would be solved. But the annoying thing about positions of sufficient power (whether they be government offices or the Committee of the Grand Arbiters of Epidemiology) is that once they exist, we honest brokers seldom fill them. Usually the power ends up in the hands of an organized interest (often industry, though sometimes their antagonists). My phrase ‘we honest brokers’ is, of course, a sarcastic allusion to the fact that most of us who seek to influence public policy believe we are doing the right thing in the right way. This is true for those who advocate distributing condoms or banning them, eliminating hydrogenated oils or giving consumers a choice, free HPV vaccines or none, more screening mammograms or fewer, etc. Or to phrase it in terms of the central question of pluralistic society, what should we do when there is disagreement about what constitutes the public interest? A less fundamental but more immediate question is how can there be useful rules about disclosing conflicts of interest when there is disagreement about what constitutes a conflict of interest? My copy of Pearce's manuscript explicitly declares that he has no conflicts of interest. Yet his paper recounts fights that involved him personally, which surely must affect his motives. He offers thoughts about who should serve on advisory committees when his career has benefited from being chosen to serve on several such committees. These omissions probably reflect the widespread misperception that conflicts of interest result only from finance, which is only one of many possible influences facing a researcher, and usually not even the greatest. Even what seem to be clear financial conflicts are often unacknowledged. Pearce's failure to note that he will profit from sales of the book he plugs in his second paragraph is of little consequence, since it goes without saying that self-promotion is part of the motive of most authors. But other common omissions likely affect the interpretation of research. For example, most of the articles that are highlighted as arguments against tobacco harm reduction were written by employees of politically active organizations that are committed to abstinence-only tobacco policies, but the authors never identify this as a conflict of interest. In several recent articles, such authors have included vehement anti-harm-reduction editorializing and policy conclusions (that in no way followed from their research results) without disclosing their employer's position. You can almost hear them saying, ‘but we are employed as activists on the right side of the issue, so we do not have a conflict! Only those on the other side have a conflict!’ Possibly worse than the challenge of competing visions about what is right for society is that people who actually secure power, for various reasons, come disproportionately from those whose primary goals do not include what is right for society. Some of the greatest thinkers in human history have struggled with these conundrums, which one summed up with the passage that begins, ‘But what is government itself, but the greatest of all reflections on human nature?’, and goes on to point out that both the governed and those granted the power of governing will be people, not angels.16 That author, James Madison, went on to design a pluralistic, multi-voiced, hypercritical process that addressed the conundrum in that passage. Those of us who study the history of the United States and the creation of modern governments-of-the-people—and who are watching the worst nightmares of America's Founding Fathers play out in our lifetimes—are very skeptical about trying to solve problems by giving the ‘right’ people the power to make sure things are done right. Remember that fascism was originally a utopian intellectual movement, backed by people like us, and we idealists who are tempted by its theoretical potential must remember what often happens when authority is proposed as a solution to pluralistic disagreements. Less dramatically, it is well known that discussions of governance process are almost always stalking horses for discussions of policy. That is, particular individuals are always going to control those ‘neutral’ committees, write the codes of conduct, etc., and those individuals are going to have worldly agendas. My own story (and many others) show that anti-corporate activists can be every bit as narrow-minded, anti-scientific and anti-free-speech as the worst corporate actors. When those individuals influence epidemiological codes of conduct, serve on committees or write IARC or Surgeon General reports (and they do!), science suffers because the process is used to score points for one side of a worldly political battle, as would be the case if corporations had that control. 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