Monday, September 21, 2015
Industry-funded research: conflict or confluence?
The great public health imbroglio disclosed over recent weeks, in which widely, highly-regarded scientists were found to be running on Coca-Cola funding to enlighten the world about calories and energy balance, continues to reverberate through all forms of media. You have no doubt encountered a bounty of commentary, perhaps including my initial reaction, and more recently, the mea culpa and pledge of better methods ahead in the Wall Street Journal by Coke's CEO, Muhtar Kent. I've encountered it, too, and in addition, have heard directly from some of those most intimately involved, on both sides of the divide.
As the allegations, apologies, rebuttals, sanctimony, and snark have all propagated themselves through the Twitterverse, I have come to the conclusion that this particular crisis of trust in public health nutrition is part of a much larger crisis of trust in public health nutrition, which in turn is part of a far larger, sociocultural crisis, never better expressed than in Cool Hand Luke: What we have here is failure to communicate.
We don't, in general, communicate anymore; we vituperate. We adopt some opinion to which we are natively inclined, and propound it into the ether. Somewhere out there in cyberspace, a kindred spirit, who for all we know may be a delusional sociopath, corroborates our world view. A few other voices of unknown pedigree join the chorus, and we have established the absolute truth and correctness of our view. Of course, others with opposing views have done just the same. Welcome to the world of cyberspatial echo chambers, in which everyone seeks and finds only those opinions they already own, and no one listens to any arguments in favor of what they already know to be wrong.
In public health nutrition, this is costing us all dearly, and playing only into the hands of those who profit from din, discord, and perennially benighted procrastination. We have had opportunity for decades to apply a set of fundamental nutrition priorities, time honored, evidence-based, to the addition of years to lives, and life to years. Instead of rallying around this common ground, however, we have carved it all up into diverse nutrient fixations, dug in, hunkered down, and commenced to hurl epithets and disdain.
This devolution of constructive dialogue into competing monologues is culture-wide, and perhaps nowhere better illustrated than in the U.S. Congress. Even as we, the people, are all frustrated by partisan antipathy so intense that a given party will renounce its own core values and favored policies if required to obstruct and stymie the opposition, we propagate the same tendency. We repudiate it, but as far as I can tell, ever more of us practice it, from the sets of television studios to living rooms, from the halls of science to schoolyards; on topics ranging from climate to guns, civil rights to nuclear containment. We are masters of the failure to communicate.
And that, in turn, underlies the debacle, and debacle it is, of Coca-Cola's salient involvement in our education about calories. We have approached the topic of industry-funded research with the customary subtlety of a sledgehammer, allowing for only two positions: It is all good, or all bad. That encourages proponents to invite us to follow where research should never have gone in the first place, as in the current case. It encourages detractors to propound a brand of piety at odds with practical advance in the real world. The tendency fabricates opposing corners, and fails to draw a line. In the absence of a line, signifying propriety, there is no way to say on which side of that line a given venture resides. So here we are, with proponents running amok, and opponents raving mad.
Were we more adept at communication, and the nuance it requires, we might readily draw that missing line. It would differentiate conflict of interest, from confluence.
Before concluding with that distinction and its implications, I humbly offer a reality check to the purists among my colleagues who renounce industry-funded research wholesale in the ostensible service of public health. Well-intended though such protestations may be, they are devoid of nuance, and misguided.
A blithe, dismissive, and undifferentiating contempt for industry funded research is contempt for virtually all advancement in modern pharmacotherapy, immunization, and medical technology, all of which are applied daily to the relief of miseries, and the extension of countless lives. It is contempt for the next, new chemotherapeutic agent that treats a cancer nothing else can. It is contempt for the new antibiotic that works despite multidrug resistance. It is contempt for the incipient vaccine that will prevent HIV, or Ebola, or chikungaya, or Powassan.
We may, in our want of subtlety, be emulating the drama of our policy makers who hone the craft of castigation, and refine the art of disparaging sanctimony. Among the many illustrations of this is the high-profile case of Al Gore. Back in 2009, he was excoriated by critics, climate change deniers salient among them, for deriving profits from his “green economy” investments. The accusation was that Gore was advocating for the work of companies most likely to prove personally profitable. Gore's rebuttal was the obvious one: he had advocated first, invested after. He had done what we have all been advised to do in proverb, as an expression of consistency, commitment, and integrity: put our money where our mouths are. Do more than talk about what matters to us; act on it. If that is wrong, then much of the lore on which we were all raised is wrong, and our parents are a pack of story-telling hypocrites.
Let us, then, give our parents the benefit of the doubt, and allow for the possibility that funds and faithfulness to a cause may genuinely align. And let us return to the case of calories and Coca-Cola, and the opportunity for opposing factions to come together, and draw a line.
I propose that industry-funded research is not the problem; conflict of interest is the problem. And I would propose that confluence of interest is very different from conflict, but the two are routinely conflated.
If there are generally understood or expected health effects of any given product, and an entity with a vested interest, be it a pharmaceutical company, a technology company, or a food company, funds research to explore the particulars of those effects, i.e., how much, how often, for whom, and by what mechanisms, that is a potential confluence, rather than conflict, of interest. To ensure it is so, rules of research engagement must apply. The researchers must be authorized to publish results be they favorable or unfavorable to the company's interests. The researchers must be autonomous; methods must defend against bias; and there can be no quid pro quo. Given suitable, contractual terms, private entities can, and do, participate in advancing our understanding.
If, however, the marketing, messages, and aspirations by any given private entity for its product or service are at odds with the generally understood or expected health effects, then that company is, ipso facto, conflicted with regard to the unvarnished truth. That entity is an unsuitable funder of research, the goal of which must be true understanding, however stuttering the course to that ideal may prove to be.
Examples are rather self-evident. Given the widely recognized health benefits of vegetables and fruits, produce companies or trade groups funding research to explore such effects would be confluent, not conflicting, with the interests of public health. Vested interest, and public interest, could readily commingle. Given the widely recognized health (and weight) detriments of sodas, a soda company cannot possibly approach research on the topic of energy balance without conflict. Coca-Cola's role with the Global Energy Balance Network is the very prototype of conflict.
I humbly suggest that replication of such perilous folly becomes less likely in a world that supplants sequential monologue with actual dialogue, in which nuance is permissible, and in which a failure to communicate is not the national pastime. We will, I think, more reliably identify, and renounce, conflict of interest, when we allow for the occurrence of confluence.
The intersection of interest, and investment, is not invariably conflict, although it certainly can be exactly that. Sometimes, it is a confluence that serves the interest of investor, investigator, and public alike. Differentiating between the 2, just like distinguishing baby from bathwater, is in the interests of us all.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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