"Living Downstream" / Conflict of interest on the part of the New England Journal of Medicine and its book review.

[Bill Ravanesi <ravanesi@bu.edu>]

  December 10, 1997
  
  
  				OLD TRICKS
  
  
  
  Can The New England Journal of Medicine be up to some old and
  long-discredited tricks?
  
  In a review of Sandra Steingraber's book "Living Downstream:
  An Ecologist Looks at Cancer and the Environment," which
  appeared in the Journal (Vol. 337, No. 21, Nov. 20, 1997), Jerry
  H. Berke, who is identified as an M.D., M.P.H. living in Acton,
  Massachusetts, accuses Ms. Steingraber of having produced a
  "biased work" for daring to suggest that (a) we are in the midst
  of a cancer epidemic, and that (b) chemical residues and pesticides in food
  and drinking water are probably more to blame for the recent steep increase
  in the incidence of cancer than AIDS, improved diagnostic techniques, and
  so-called life-style factors, such as fatty diet and cigarette smoking.
  
  To support his argument, Dr. Berke cites the findings of just one study--a
  1995 investigation published in the Journal of the National Cancer
  Institute by Dr. Susan Devesa and some colleagues at the National Cancer
  Institute, who compared cancer incidence in the five-year period from
  1975-1979 with the period 1987-1991, and declared that the increased
  incidence of 18.6% among males and 12.4% among females could be largely
  ascribed to known factors, such as better detection, AIDS, smoking, and
  exposure to sun, and not to environmental causes.
  
  Dr. Berke goes on to cite the conclusions of an accompanying editorial
  co-authored by Dr. Philip Cole, an epidemiologist at the University of
  Alabama (and a long-time paid consultant of the electric utility industry),
  who warns that a casual interpretation of cancer statistics can "lead the
  unwary to see a rise in cancer where none has occurred," and to assume that
  "this rise was due to environmental contamination."
  
  Dr. Berke chooses not to quote Dr. Joseph F. Fraumeni, Jr., one of Devesa's
  co-authors and a former director of the epidemiological and biostatistics
  program at the National Cancer Institute, who told Jane Brody of The New
  York Times that environmental factors might be involved in the increases
  found in cancer of the brain, liver, testicles, kidney, and breast.
  
  Dr. Berke does not mention the fact that only about one-third of the sharp
  increase in Non-Hodgkins lymphoma--the cancer of the immune system that
  killed Jacqueline Kennedy Onassis--can be ascribed to AIDS (as Berke
  asserts) and organ transplantation, for the simple reason that far and away
  the steepest increase in this disease has occurred among people 60 and
  older, which is an age group least affected by AIDS and less likely to
  undergo organ transplant surgery.
  
  Apparently, Dr. Berke is unaware that a 1990 study conducted by Devra Lee
  Davis, then a professor at the Mount Sinai Medical Center in New York, and
  published in the American Journal of Industrial Medicine, found that the
  incidence of brain cancer in people under the age of 45 had increased 2% a
  year from 1973-1988. Another study by Davis published in The Lancet, the
  world-renown British medical journal, found that the incidence of cancer of
  all types has risen sharply during the previous 20 years among people 55 or
  older in the United States, Japan, and four European nations.
  
  Dr. Berke must somehow have missed seeing the story that ran on September
  29, 1997, on the front page of The New York Times and in most of the
  nation's other leading newspapers about a study conducted by the National
  Cancer Institute showing that the rate of increase in the incidence of
  cancer among the nation's children is nearly 1% a year. Acute lymphocytic
  leukemia among boys and girls increased 27% between 1973 and 1990. Brain
  cancer among children increased nearly 40% during the same period.
  
  Apparently, Dr. Berke is unaware that in 1997 the American Cancer Society
  issued a report stating that one out of every two American men will develop
  cancer in his lifetime, and that one out of every three American women will
  develop cancer in her lifetime.
  
  No cancer epidemic? One out of every two American men? One out of every
  three American women? What planet is Dr. Berke living on? Would he use the
  phrase influenza epidemic if one out of every two American men and one out
  of every three American women were developing in his or her lifetime a
  potentially fatal strain of influenza? Does he perhaps believe that the
  dramatic increase in cancer among children has occurred because they've
  suddenly begun to eat badly or are going to the doctor more frequently?
  Can he have succumbed to the quaint notion offered by some members of the
  medical community that the sharp increases in cancer among Americans are
  occurring because people are living longer--in this case, because children
  are living longer?
  
  "The increases [in the incidence of childhood cancer] are too rapid
  to reflect genetic changes, and better diagnostic detection is not
  a likely explanation," Dr. Philip J. Landrigan, a pediatrician who directs
  the division of environmental medicine at the Mount Sinai School of
  Medicine, told the Times in September. (Dr. Landrigan is also senior
  adviser to the new office of children's health at the E.P.A.) "The strong
  probability exists that environmental factors are playing a role," Dr.
  Landrigan added.
  
  According to the report in the Times, Landrigan and other experts "are
  inclined to examine the estimated 75,000 new synthetic chemicals introduced
  in the last half century, the emissions from cars, the pesticides in foods
  and in neighbor	hoods, the runoff in drinking water--the whole collection
  of chemicals out there, mostly untested for toxicity to humans, let alone
  for possible cancerous effects in children."
  
  As a result of the recent data on childhood cancer, Carol M. Browner, the
  administrator of the E.P.A., is undertaking a new research program that
  will move beyond the chemical-by-chemical approach of the past and instead
  investigate a child's total cumulative risk from all exposure to toxic
  chemicals.
  
  Dr. Lynn R. Goldman, the assistant administrator of the E.P.A. for
  pesticides and toxic substances, said that scientists lack even basic
  toxicity data for most of the Agency's list of 3,000 industrial chemicals
  produced in the highest volumes each year--many of them found in consumer
  products and in the workplace.
  
  So who is Jerry H. Berke and why is he so anxious to convince the readers
  of The New England Journal of Medicine that (a) there is no cancer
  epidemic, and (b) it can't possibly be related to exposure to toxic
  chemicals and pesticides in the environment?
  
  Dr. Berke is the Director of Medicine and Toxicology for W. R. Grace &
  Company, of New York City, one of the nation's largest chemical
  manufacturers.
  
  W. R. Grace is the company whose renegade conduct is so powerfully
  described in the best-selling book "A Civil Action," which is now being
  made into a major motion picture starring John Travolta.
  
  W. R. Grace is the company that was found responsible in a 1986 jury trial
  of contaminating drinking water supplies in Woburn, Massachusetts, by
  pouring trichloroethylene--a known chemical carcinogeninto an open ditch
  on company property that led directly to a brook.
  
  W. R. Grace is the company that subsequently paid $8 million to settle
  claims brought by the families of seven Woburn children and one adult who
  developed leukemia after drinking water that was shown to be contaminated
  with the chemicals dumped by the company.
  
  W. R. Grace is the company that pleaded guilty to two felony counts of
  lying to the EPA about the chemicals it had dumped into the ground in
  Woburn, and paid the maximum fine of $10,000 for having done so.
  
  W. R. Grace, also a leading manufacturer of asbestos-containing building
  products, has been a defendant in several thousand asbestos property-damage
  lawsuits brought by municipalities and building owners.
  
  W. R. Grace is a founder of the Safe Buildings Alliance, which was
  organized to help defend Grace and co-defendant asbestos-products
  manufacturers in such litigation. In 1987, the United States District Court
  of Pennsylvania ruled that information disseminated by the Safe Buildings
  Alliance was "misleading as to its objectivity and neutrality" and that
  this information was used in an attempt to convince as many [building
  owners] as possible to "forgo the removal of asbestos from their buildings."
  The court further found that the Safe Buildings Alliance was formed with
  the intent of reducing the sponsors' liability for the hazards created by
  asbestos in buildings."
  
  In a noteworthy trial conducted in Greenville, South Carolina, in 1986, a
  court fined W.R. Grace $4.8 million in compensatory damages and $2 million
  punitive damages for selling the City of Greenville asbestos-containing
  fireproofing material to be used in the construction of its city hall even
  after Grace had removed asbestos from the same product for sale elsewhere
  in the country as a result of pressure from public health authorities who
  told Grace that the asbestos posed a major health hazard.
  
  So much for W. R. Grace. Now, how about The New England Journal of Medicine?
  
  On July 29, 1989, the Journal  published an article (Vol. 320, No. 26) that
  was co-written by Brooke T. Mossman, an associate professor of pathology at
  the University of Vermont, and Dr. J. Bernard L. Gee, a professor of
  pulmonary medicine at the Yale University School of Medicine. In their
  article, Mossman and Gee claimed incorrectly that chrysotile asbestos--a
  type of the mineral widely used in buildings in the United States--was less
  harmful to inhale than other types of asbestos, and that there was no need
  to spend public money to remove the huge quantities of asbestos (some 30
  million tons)that had been installed in buildings throughout the nation.
  
  Nowhere in the article was there any mention of the fact that Mossman had
  served as a paid consultant on matters relating to asbestos to a major
  asbestos-products manufacturer, the Owens Corning Fiberglas Company, of
  Toledo, Ohio, or that Gee had not only been a paid consultant of
  Raybestos-Manhattan, Inc., of Bridgeport, Connecticut--a major asbestos
  manufacturer and defendant in asbestos lawsuits--but had also testified in
  behalf of asbestos companies in lawsuits brought by disabled workers
  suffering from asbestos disease.
  
  This omission seemed curious in light of the Journal's own publicly stated
  rules, which not only required authors to "disclose any commercial
  association that might pose a conflict of interest in connection with the
  submitted article," but also declared that "if the manuscript is accepted,
  the Editor will discuss with the authors how best to disclose the relevant
  information."
  
  Six months later, in response to a letter to the editor from a physician
  who raised the question of their conflict of interest, Mossman and Gee
  revealed that they had, indeed, disclosed their outside activities to the
  Journal's editors. This revelation was followed by a two-sentence editor's
  note that spoke volumes about the Journal's attitude at that time toward
  conflict of interest. It read as follows: "Drs. Mossman and Gee did
  disclose to us their public, governmental, and legal activities before
  publication of their article. We kept their disclosure on file but chose
  not to publish it."
  
  On January 17, 1991, The New England Journal of Medicine published a letter
  that was highly critical of the conclusions of Mossman and Gee regarding
  the hazard of inhaling chrysotile asbestos. This letter was signed by
  sixteen medical doctors (including three physicians from the Harvard School
  of Public Health), who represented  7 occupational health clinics across
  the nation, as well as by representatives of 22 other occupational health
  clinics in the Association of Occupational and Environmental Clinics.
  
  As a result of the criticism leveled against the obvious conflict of
  interest on the part of Mossman and Gee, the Journal announced a
  significant change in policy: in the future, it would publish articles only
  by authors who had no financial stake in the subjects they wrote about.
  
  Apparently, Dr. Marcia Angell, the executive editor of the Journal,
  together with her colleagues there, have decided to ignore this pledge. In
  1996, they published an editorial endorsing an anti-obesity drug that was
  written by two researchers with obvious conflicts of interest. One of them
  was a paid consultant of the firm that manufactured the drug; the other was
  a paid consultant of companies that were marketing it.
  
  An editorial in the Boston Sunday Globe on September 1, 1996, which ran
  under the headline "Malpractice at a medical journal?", declared that
  Angell and her staff "clearly should have known" about the conflict of
  interest of at least one of the researchers, who had disclosed in writing
  in an earlier article in the Journal that she was a consultant for the
  pharmaceutical company that manufactured the drug.
  
  Now, coming full circle, we return to the review of Sandra Steingraber's
  book by Jerry H. Berke, M.D., M.P.H., who is allowed to describe himself in
  the Journal as living in Acton, Massachusetts, but not as being employed as
  Director of Medicine and Toxicology by W. R. Grace & Company.
  
  Members of the Massachusetts Medical Society, who are the publishers of The
  New England Journal of Medicine, not to mention the Journal's 230,000
  readers, may not only wish to inquire why Angell and her colleagues have
  chosen to keep editorial company with a writer who so ostentatiously
  carries the chemical industry's polluted water, but also why they have
  chosen to allow him to remain anonymous in their prestigious pages.
  
  *********************************************************************
  No editorial changes can be made without the permission of the authors.
  
  
                   Paul Brodeur
                   North Truro, Massachusetts
  
  (In the interest of disclosure, the writer wishes to declare that he was a
  staff writer at The New Yorker  between 1958 and 1996, and that he is the
  author of three books about the occupational and environmental hazards of
  exposure to asbestos, the contents of which appeared originally as articles
  in The New Yorker.)
  
  		  Bill Ravanesi,MA, MPH
                    Newton, Massachusetts,
  
  (Photojournalist, producer & editor of the documentary "Breath Taken:
  The Landscape & Biography of Asbestos".)
                    © 1997 Paul Brodeur/ Bill Ravanesi