By Mark Blaxill
Everybody hates baseball’s new all-time home run king, Barry Bonds, for doing steroids, except of course in San Francisco where he’s a hero. But even in the Bay area, everyone knows that it’s the player’s union that stands in the way of the rigorous drug testing that will take drugs out of baseball. In most national polls, the approval rating for Congress is now down well below 30%, but in local elections voters still re-elect their own Congressman 98% of the time. Lots of people love to criticize lawyers as a group, but when you get into trouble your own lawyer is your best friend. In short, when professional people do their work well, it’s not hard to support the professional you know well even when their official representatives behave badly.
The American Academy of Pediatrics (AAP) is the union of American pediatricians. Their job is to defend the commercial interests and reputations of their constituents regardless of what the larger social interest might be. One activity of the AAP is to lobby the Federal Government to spend more money to help pediatricians to make more money.
Even when they make the case for things like expanded health insurance coverage for children, they’re also making the case for their members. Along the way, they make sure they make a case for things like: “Providing appropriate physician payment within Medicaid and SCHIP to ensure children receive access to care.”
The AAP also has a journal named Pediatrics, a publication that they claim is “intended to encompass the needs of the whole child in his physiologic, mental, emotional, and social structure.” In practice, the journal serves the agenda of the practicing pediatrician, often publishing shoddy science if it furthers the policy interests of the Academy. The stunning failure of Pediatrics to face the facts regarding the autism crisis is one of the sad byproducts of a tragic situation in which so few medical leaders have found a moral compass to guide their choices.
If you want to cut to the chase and find the commercial life blood of the pediatric profession you don’t need to look much further than the pages of the AAP’s web-site where the childhood immunization program is featured under nearly every tab. You can’t underestimate the importance of the childhood immunization program to the business of the practicing pediatrician. The reason goes right to the heart of the economic tension between customers and suppliers in our upside down health care system.
By and large, we’re all better off if we aren’t spending a lot of time in the health care system. If we’re sick we often appreciate the valuable care we receive from skilled professionals, but it’s not like buying new clothes or a car: if we’re using the doctors’ services too much, that doesn’t mean we’re having much fun in the process. By and large, doctors want us to be healthy too. But if we were all healthy all the time, we wouldn’t need to spend much time seeing doctors and there would be less economic need for their services. So doctors have incentives to give us reasons to come visit them. The practice of pediatrics is no different.
The most powerful economic friend that pediatricians have has become enshrined in law and ritual unlike any other medical practice in history. It is a 20th century invention known as the well child visit. While most parents learn to love and appreciate their pediatrician (notwithstanding the occasional sour experience), the main reason they go to see them is the well child visit. It’s a ritual with which eager and conscientious mothers, driven to do the best for their babies, have all learned to comply. And although there are a few side rituals performed during these brief encounters (only 16 minutes is spent on average with the pediatrician), there is little medical reason to conduct them except to perform a single service: the delivery of required childhood immunizations.
Pediatricians like to complain that “we don’t make money on vaccines; in fact we lose money.” If you ever hear that complaint from your doctor, tell them either to stop whining or go back to get their MBA. The hard fact is that a major chunk of a pediatrician’s annual income of about $140,000 comes from the well child visit. I’ve made numerous attempts to estimate the actual percentage, but it’s hard to do without access to private financial data and I’ve been unable to find any published estimates. Suffice it to say, if you hang around a pediatrician’s office on any given day and take a poll of the parents in the waiting room, a large percentage of them are there waiting to get their children vaccinated.
Make no mistake; the driving force behind the economic livelihood of a modern pediatrician is the childhood immunization program. Put another way, if you reduced the size of the childhood vaccine program by half, pediatricians would see a drastic decline in office visits and a lot of pediatricians would go out of business. It’s not hard to imagine then why the AAP is all over immunization policy and Pediatrics is all over the science that surrounds it.
Which brings us to the latest skirmish in the child health wars: the Eli Stone episode. It’s not unlike the recent non-fiction episode on Capitol Hill when congressmen working on behalf of Eli Lilly mysteriously intervened to exempt the manufacturer of thimerosal from liability in an otherwise unrelated Homeland Security bill. In a similar fashion, the AAP’s call for banning the Eli Stone episode steps over the line and has caused even disinterested people to wonder, what do these people think they’re doing? It’s one thing to promote vigorous debate in a democracy and everyone has a right to defend their interests and beliefs. But it’s quite another thing to ask for, no, demand censorship. That’s a demand that insults the intelligence of every American and puts the economic interests of a few over the rights of citizens to participate in the free exchange of ideas.
Not surprisingly, the AAP’s journal has leaped into the fray, rushing into publication yet another bizarre study claiming to show that ethyl mercury is really not the least bit dangerous for children, and it’s far safer for them than methyl mercury. All because it leaves the blood quicker than methyl mercury (where does it go?) and because a few parts per billion of ethyl mercury can be detected in stool and must therefore all be excreted (how could they possibly know?).
Stay tuned for more than you ever wanted to know about mercury levels in baby’s bowel movements. But this whole episode brings me back to an experience some of us had with Pediatrics nearly five years ago. In the immortal words of Yogi Berra, this feels “like déjà vu all over again.”
Back in the summer of 2003, when analysts from the Statens Serum Institut in Denmark (themselves a vaccine manufacturer) published three variants of basically the same study in three different journals within weeks of each other (an unethical scientific practice in itself, technically known as “duplicate publication”), by far the lowest quality study came out in Pediatrics. Sallie Bernard, Lyn Redwood and I were working together on a rebuttal press release and one point we wanted to make was that there was a financial conflict of interest on the part of Pediatrics due to the fact that some of its top advertisers were vaccine manufacturers. This was not a great secret (nor was it a point we featured prominently), since Pediatrics actively promoted the prestige of its advertisers on its web-site and provided a list of top 10 advertisers for all to see.
When we sent out our press release on September 1st, criticizing the study and the journal’s decision to publish it, we included a link to the list of Pediatrics advertisers. Within hours of releasing it, we began to get questions back saying, “where’s the page?” When people clicked on the link we provided, they came up with nothing. “Nonsense”, we thought and went back to correct the url. Much to our amazement, within the short time between finding the link and our press release going out, the entire page had been taken down (and remains down to this day). Unfortunately, neither of us had saved the page itself, only the now-dead link. Sadly, the proof point had vanished, or so we thought.
Three years later, when I told this story to a close friend of mine, he taught me a trick about finding archives of web pages. There’s a thing, he said, called the “Wayback Machine” that preserves copies of old web pages, even dead links, going way back in history. It’s not perfect and it misses many things, but I hoped that I would get lucky and find the missing page. Sure enough, when I searched for it I found that the August 4, 2003 advertiser list was still there in all its glory, while the next version on September 25 had no listings at all. [For a version of the August 4 page, click HERE ] In black and white on the list of Pediatrics’ most active advertisers were:
• Pasteur Merieux Connaught (now part of Sanofi-Aventis) one of the original manufacturers of the thimerosal-containing DPT vaccine;
• North American Vaccine (a subsidiary of Baxter International) manufacturer of a thimerosal-containing DTaP vaccine; and
• Glaxo Wellcome, by then part of GlaxoSmithKline, manufacturer of a thimerosal-containing hepatitis B vaccine.
If you believe that you get the news the advertisers pay for, it’s not a big step to worrying about advertiser influence on science as well. I guess Pediatrics didn’t want people drawing inconvenient inferences about their objectivity and so they decided to cover their tracks. Is it any surprise that, five years later, they’ve asked ABC to censor a story line in a fictional TV show?
So when the AAP takes an official position, don’t be fooled into thinking that they’re doing anything else except defending the economics interests of their members. Don’t expect them to like it when anyone takes shots at the goose that laid the golden egg: the childhood immunization program. And don’t get too upset about it. That’s the way the world works. Unions exist to protect the income of dues-paying members.
But it’s time to start asking some tougher questions, when AAP “calls for the cancellation” of the Eli Stone episode and accuses ABC of “reckless irresponsibility.”
In the midst of an explosion of chronic childhood illness in America: What’s going on?
In the midst of a national emergency in autism: Why are so many children sick?
And when parents and children so desperately need help from the front line of medical care: what has the AAP done beyond serving the narrow interests of its members?
Perhaps its time for the rank-and-file pediatricians to stand up and start taking their union back.