Advertisements in medical journals

I remember a very popular health column writer of a newspaper when asked, "What should one eat?′ had advised, "Do not eat anything that is advertised!"

Long time back, I remember seeing advertisements of an antiscabietic drug inserted in every issue of the Journal of American Academy of Dermatology. It used to be in the form of a photo quiz. A full page photograph would ask a question: What is your diagnosis? The diagnosis was always the same: scabies. That would teach us that scabies can mimic anything. But not necessarily every advertisement could catch the reader′s attention like that. It used to do so also as the advertisement was inserted in between the articles and not clubbed together at the end or in the beginning of the scientific content. There would be many who generally would skip the advertisement section if clubbed like that. If the section is not to be read, read, why is it there at all?

Advertising in business is defined as a form of marketing communication used to encourage, persuade, or manipulate an audience (viewers, readers, or listeners; sometimes a specific group) to take or continue to take some action. ^[1]

However, general advertising and advertising in medical journals are substantively different. Someone walking into a supermarket and purchasing a blanket laced with tiny magnets promising relief from all musculoskeletal ailments is different from a physician prescribing an antidiabetic drug after reading an advertisement in a medical journal which is suppressing the fact that the drug might increase, say serious cardiac events.

There is an interesting anecdote related to this. In 1992 Michael Wilkes, a Robert Wood Johnson Clinical Scholar at the University of California-Los Angeles (UCLA), along with his colleagues Bruce Doblin and Martin Shapiro, published a study on the quality, accuracy, and usefulness of pharmaceutical advertisements in medical journals. ^[2] Robert and Suzanne Fletcher, as co-editors of the Annals of Internal Medicine, accepted the paper for publication. The Fletchers were not unaware of the controversy that the UCLA study might generate. The findings from this undertaking were potentially threatening to what had previously been described as a "marriage of convenience" ^[3] between medical journals and the pharmaceutical industry. In an article, ^[4] Fugh-Berman et al., conclude that clinicians rely on medical journals for scholarly articles and the latest information on drugs and devices. Advertisements in these journals are unreliable sources of information, since they "educate" physicians to prescribe the newest, most expensive drugs (which may not be any superior to existing, less expensive alternatives). The scholarly nature of journals confers credibility on both articles and advertisements within their pages. By exclusively featuring advertisements for drugs and devices, medical journals implicitly endorse corporate promotion of the most profitable products.

The advertisers definitely must be recovering their investment; that is why they continue to advertise. On the other hand medical journals have increasingly become major sources of revenue ("cash cows") ^[5] for medical societies. Financial support for activities of the societies publishing the journals depends substantially on the advertising revenue in journals as well as at conference venues. Extreme care needs to be taken so that the integrity and objectivity of the scientific content in the journal is not compromised.

Ironically, even as the main argument against advertising in medical journals is independence, the counter-argument too is independence. Richard Smith ^[6] argues that you can place greater trust in a journal that carries advertising than one that does not, as the former would have more financial independence. He says, "The beauty of drug advertising is that there are many companies who want to advertise in a journal that has a wide circulation. This means that none of them alone has the power to influence the journal".

Taking into account the possibility of development of an unholy nexus between the pharmaceutical industry and the various societies, attempts have been made to formulate code of ethics for medical advertising. As an example, the principles developed jointly by editorial and publishing staff are applied by the American Medical Association (AMA) to ensure adherence to the highest ethical standards of advertising and to determine the eligibility of products and services for advertising in the AMA′s print and digital publications. ^[7]

One is not sure whether such stringent checks and balances exist in journals published from India. The field of scientific publications in India is only just maturing. In 1997, in British Medical Journal, the editors had commented, ^[8] ′In a country such as India, where there are no legal constraints to medical advertising, the scope of misuse extends beyond journals to package inserts, pamphlets handed out by medical representatives, "scientific" newsletters published by drug companies, promotional videos, exhibits at medical conferences, and pre-printed prescription pads and other complimentary items′.

In such a scenario what could be done? As a standard operating procedure, the World Health Organization′s monograph "Ethical criteria for medicinal drug promotion", ^[9] and a checklist against which all future advertisements would be screened may be provided to all the potential advertisers and all advertisements checked against that. Any violations should be strictly dealt with. There remains the question, whose responsibility would it be to ensure compliance? There are hardly ever professional editors for most journals. The editors are preoccupied and probably (over) burdened with ensuring the quality of the scientific content. In my view, the compliance should be ensured by the advertisers and certified each time with a signed copy of the checklist. Pointing out any discrepancies should be the responsibility of vigilant readers.

Ten years down the line after publishing their article, Wilkes et al., affirms, "I haven′t seen anything in the journals that would make me suppose things are any different now compared to 10 years ago. Nothing has really changed." If that is the state of affairs in countries where the conventions of scientific publication are an old tradition, one can imagine the challenges in the path of our own journals.