I commend Harriet Washington for drawing attention to the ways pharmaceutical companies attempt to influence physicians’ prescribing habits [“Flacking for Big Pharma,” Summer 2011]. By sponsoring and funding research that exaggerates clinical efficacy and underreports side effects in favor of their drugs, drug companies unduly bias the conduct and reporting of clinical trials. Washington could also mention that the manufacturers of expensive biomedical products, such as implantable pacemakers and joint replacements, use similar strategies.
Joseph King, MD
South Brisbane, Australia
As a family physician for 33 years whose prescriptions are 90 percent generics, count me as a cobelligerent with Harriet Washington. Still, she needs to temper her enthusiasm with caution. The Women’s Health Initiative study on hormone replacement [which the article cited] was poorly designed and maliciously interpreted. I never use Prempro (estradiol and medroxyprogesterone are inexpensive alternatives), so I don’t have a dog in this fight. But to recruit 16,000 post-menopausal women with an average age in the 60s is hopelessly poor sampling; it bears no relationship to my patients considering HRT, who are younger by 15 years.
Doug Iliff, MD
Harriet Washington shows a lack of understanding of drug development when she laments the comparing of a new drug to a placebo. In many cases (such as drugs for pain relief, insomnia, anxiety), there is a significant placebo effect. Without a placebo group, it is impossible to know the true effect of the active agent; the placebo makes the results more robust.
Also, Washington accuses the industry of truncating a trial “when they (the industry) have reason to believe that it is about to reveal widespread side effects or a lack of effectiveness.” Well, yes, pharmaceutical sponsors do truncate such trials, because it is the right thing to do. Why continue to administer a drug that is ineffective? Why continue to subject trial subjects to unwarranted side effects?
Michael Kurman, MD
Upper Saddle River, New Jersey
The writer is an adviser to healthcare, pharmaceutical, and biotech companies.
Harriet Washington replies: Actually, the Women’s Health Initiative study was the largest trial of (approximately 5,700) women in their 50s ever conducted, and their ages necessarily ranged from 50 to 79 because information about all adverse events, including heart attacks, was sought. Adriane Fugh-Berman, MD, reports in PLoS Medicine that 64 percent of the WHI criticisms trivialize the risks of hormone replacement therapy (HRT) by spinning the science and using “promotional language,” sometimes using identical phraseology. Eight of the 10 most frequently published WHI critics received payments from HRT manufacturers. I don’t claim that the WHI study is perfect, but the transparently conducted, randomized clinical trial generated the best contemporary evidence available on HRT. It contrasts favorably with the industry’s dissemination of duplicitous HRT marketing messages thinly cloaked in data.
Concerning placebos, at issue is the ethics of deploying them instead of using existing approved treatments in medical studies of ill or at-risk subjects. This deprives some subjects of treatment—an often-indefensible act, however useful the generated data may be to drug firms. The problem with sub rosa trial truncation is, once again, the deliberate lack of transparency. Hiding the deleterious results of a trial harms subjects and patients rather than helps them.
Mike Rose’s “Making Sparks Fly” [Summer] focuses on community college students in occupational/vocational programs, but the points that he makes are also relevant to high school students.
During my career in vocational education, I continually encountered upper-level managers who had entered the field straight from universities. They had no first-hand knowledge of the hard realities many vocational students face when they leave high school, and they found it expedient to focus their energy and direct funds toward what they knew best: preparing students for college.
Meanwhile, as vocational education teachers retired and were not replaced, the courses they taught died off and the emphasis they placed on creating new certification programs and career paths for students went by the wayside.
Morro Bay, California
Thanks to Mike Rose for elevating the conversation about seeking a college education. For too long we educators have used economic arguments (which have led to purely selfish arguments) about the cost of education and its worth in realized income to the individual. We are neglecting outcomes such as social good, problem-solving, civic engagement, richness of experience, and habits of the mind.
I’ve long felt that questions were left unanswered about Narcissa Whitman. Debra Gwartney answered many in “Plucked From the Grave” [Summer]. But I can’t get over Whitman’s unconventional choice of wedding apparel: a black bombazine dress. Was she being defiant, like Bette Davis at the Olympus ball in Jezebel, or was she expressing some sort of gloom and foreboding about embarking on such a long, potentially perilous journey?
Debra Gwartney replies: I was also curious why Narcissa Prentiss would choose this outfit for her wedding. It’s not as if the ceremony were rushed; she had about a year’s time, when Marcus Whitman was on a “trial trip” to the frontier west, to plan her wedding day. Years after Narcissa’s death her adopted daughter Matilda Sager wrote that “her best dress was the black bombazine–it was her wedding dress and her whole family wore black at her wedding.” Researcher Nard Jones in his book The Great Command writes that though she settled on black for the day’s service (not unusual in those days, apparently), she packed many “bright print dresses she thought might please the ‘savages’ across the mountains.”
Richard Ellis, in his review of Juliet Eilperin’s Demon Fish: Travels Through the Hidden World of Sharks [Summer], was correct in asserting that the practice of massacring sharks for their fins in order to create a largely flavorless but socially symbolic soup is barbaric and ecologically unconscionable. However, Ellis crossed a line with his incredibly insensitive suggestion that the destruction of Kesennuma, Japan, during the tragic March earthquake and tsunami was somehow justified because “at least for the moment, . . . some sharks have been saved from the slaughter.”
Protecting sharks is a worthy goal, but the implication that loss of human life is acceptable, even desirable, in pursuit of that goal made me livid. As someone with a loved one who lost a close friend in Kesennuma, I would like to remind Ellis that it was not just the town’s fishing industry that was destroyed.
Brooklyn, New York
Your [Summer] Tuning Up subhead, “How lonely my world would be without the second-person pronoun,” is clever. But I would suggest a different one after having read the piece: “How void a poet’s world would be without a license to roam in it.”
It’s a license your writer, poet David Lehman, uses freely, as in “life needs to end in death,” “without you there would be no sex–no chance for immortality,” and “the momentary unity of the sexes combined into a higher entity.” My rigorous PhD training half a century ago caged my flights of fancy by demanding the empirical testing of propositions. I’m envious now of the un-caged Lehman and by writing this letter I hope to start flying with him, he and I/in the sky.
Palm Coast, Florida
Your Summer Letters column included one headed “Cheap Shots” from a “subscriber for approximately 12 months” who complained that the Spring issue Editor’s Note was “too cheaply partisan” and that it “unfairly ridiculed a certain constituency.” I don’t know whether the writer belongs to that certain constituency, but as a subscriber for more than 12 years, I believe that if the editor sees fit to ridicule a certain constituency, that constituency most certainly merits such ridicule.
Rohnert Park, California
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