Whole (37 page)

I know intimately how funding determines research priorities, both as a longtime applicant for research funding and as a peer reviewer for several research-funding agencies that determine which research grant applications receive funding and which do not. I know well both the frustration of having to force research questions into a form that research evaluation panels will find acceptable, and the pressure to find reductionist answers.

Over the years, my growing awareness of the limitations of reductionist research began to trouble me. I found it more and more difficult and disturbing to continue to teach the traditional (and reductionist) views of nutrition—the way I was taught—when my own views were changing. Even as I was chugging away in the reductionist paradigm, something within me knew there was something missing.

Then I began getting ominous warnings, such as the one I privately received from a former colleague, a member of an NIH research application review group (or “study section” in the jargon of NIHers) that was reviewing our latest (and in the end successful) grant application for renewed funding of our project in China. In the application, I had expressed enthusiasm for the biologically complex relationship of diet with cancer, and how our work in China might provide some unique opportunities to develop more complex disease causation models, perhaps reflecting the more wholistic nature of disease occurrence, instead of the
linear mechanistic model. This apparently was a cause for deep concern on the peer-review panel. According to my colleague—who, by telling me this, ignored the code of silence generally imposed on reviewers—I had come perilously close in my proposal to a description of a wholistic research strategy, and he advised me that I should never again defend my research in reference to wholistic interpretation. I was being reminded that I was challenging a fundamental tenet of biomedical research and that, in doing so, I almost cost us the much-needed funding for the third and final three-year phase of this research project. I chose shortly thereafter to discontinue my very active experimental research program of thirty-plus years—a personally agonizing decision at the time because experimental research had long been my life’s work, and I loved working with students. I could no longer bring myself to write research grant applications for funding to investigate only highly focused hypotheses on minute details out of context.
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But that choice—to opt out of the system, or even just to challenge it—is one that not every researcher has. Our program was, at that time, the largest, best-funded research group in a large nutritional science department long regarded as the best in the country, which gave me the freedom to explore questions that, in subtle ways, defied the prevailing paradigm. Others, especially those just starting out in their career and seeking tenure, are under much more pressure to adhere to the research community’s industry-friendly expectations.

There is pressure on the other side of the table as well. From the late 1970s to the late 1980s, I was a member of a research grant review panel for the NIH’s National Cancer Institute (among other cancer research agencies), and there were several occasions when an enthusiastic applicant proposed an investigation of a biological effect by considering a relatively broad array of causal factors—in other words, to look at a problem wholistically. Without fail, such “shotgun approaches” and “fishing expeditions” were summarily rejected without further review for funding priority. I generally went along with these rejections because, too often, the applicants did indeed lack any sense of focus or purpose. But not always. Our panel’s knee-jerk rejections reflected something more, something that I find especially revealing, and troubling, in science: the belief that highly focused hypotheses—not fishing expeditions—were the only type that deserved to get funding.

Occasionally, I learn of more recent research that is being funded under a systems analysis model similar to our project in China. In earlier years, however, our work was the only such project that interpreted data in this way. What we learned in China, coupled with our laboratory work, has completely changed my understanding of nutrition; imagine what else we could learn if we funded a few more non-reductionist studies!

I know firsthand the personal passion and honest sincerity that the vast majority of biomedical researchers and practitioners bring to their work. But they are working in a system that, due to the pressure it puts on them to perform only reductionist research, makes it very difficult for that passion and sincerity to result in good, effective science.

As we discussed in Part II, reductionist research on its own is fundamentally inadequate. By definition, it lacks the understanding of the whole that is required to give meaning to its insights. Its solutions—as with a solution that works only for a spherical cow in a vacuum—do not hold up in the context of real life. But the profit motive doesn’t just limit researchers’ ability to do rigorous science through industry’s funding priorities; it also leads to serious negative consequences, such as industry’s push to translate questionable research findings into profit as quickly as possible.

Health products and services that arise from reductionist research are mostly delivered via syringes, pills, and potions, and their funders (or should I say “investors”?) rush these products and services to market very quickly, usually before the implications of the research on which they’re based can be fully explored and integrated. Of course, companies test new products and services; in fact they run up big bills doing so, betting on their randomized control trials to show positive health benefits. Sometimes they do. However, calling those positive results truly promising requires assuming that narrowly focused, short-term results actually bring longterm health. That’s a risky and generally unfounded assumption.

In short, the pressures of the market result in products that are based on unripe research insights and unpredictable in their long-term effects.
It shouldn’t be much of a surprise that these products end up being of limited utility at best and actually harmful at worst.

Vitamin E, which we discussed in
chapter eleven
, is a good example. A prominent study suggested a correlation between vitamin E levels in the body and healthier hearts.
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Industry began marketing vitamin E as a heart healthy supplement and rushed it to market. Then evidence started mounting that vitamin E supplementation actually increased overall mortality through, among other things, more prostate cancer and secondary heart disease
⁵
—evidence that industry has ignored for as long as possible. Researchers’ responses to learning this new but damning information about vitamin E resulted in a consensus that the party must go on.
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Everyone wants to find a way to save the market for vitamin E, or to find a replacement if vitamin E is beyond salvation. There is clearly great incentive to produce evidence that will justify the continued marketing of such products.

It is truly not the individuals within my community that I decry (although some could show more creativity and courage!), but rather our world of research, greatly influenced by market forces that define what is expected of us. Most of us know that money talks, as the old saying goes. But few of my fellow researchers and medical practitioner allies really know how corrupting money has been and continues to be. It is so pervasive that it is difficult to see from the inside. When we’re in the belly of the beast, how can we know which beast our host is, or even that our host is a beast at all?

Too often, our research priorities are driven more by personal rewards than community good. But the public pays for this research and depends on its findings, and, in the current system, they are being penalized for it. Individuals within the research community may find personal success by adhering to the reductionist company line, but as a group, we are getting no closer to the goal of health.

Unthinking respect for authority is the greatest enemy of truth.

—
ALBERT EINSTEIN

S
cientific data underpin our decisions about health. They’re used by the public to make lifestyle and buying choices; by doctors to diagnose and treat patients; by government officials to formulate policy; by industry to create and refine services, and to make health claims about those services; and by insurers to decide what diseases and treatments are covered. And that’s only a portion of the ways the results of scientific research touch and affect our everyday lives.

The key link between research and these consumers is the media. Professional journals evaluate and publish research papers based on the editors’ perceptions of the validity and importance of the findings. The mainstream media reports these results, making them accessible to lay readers and offering commentary and lifestyle advice based on the evidence. Without the media, scientific discoveries would languish, unacknowledged and unapplied, in the minds and lab notebooks of the scientists who made them. So the media plays an indispensable role in
transporting information from the realm of its creation to that of its application.

Ideally, media is not just a conduit, unquestioningly conveying information from its creators to the social sphere. Media has traditionally served as a counterbalance to power, whether that power is governmental or scientific (the ability to peer deeply into nature and tell us its secrets is most certainly a form of power). This watchdog function of the media requires critical thought about data and their reliability. It requires that tough questions be asked. It requires journalistic independence. And it requires transparency of motive, so that the ultimate consumers of information can make informed decisions about how to evaluate the ways different media outlets interpret scientific evidence.

Unfortunately, this kind of independent, intelligent health journalism is rare. Neither professional journals like the
Journal of the American Medical Association (JAMA)
nor mainstream media outlets like the Corporation for Public Broadcasting can be relied upon for informed, courageous, and unbiased health coverage. I give those examples in particular because they are seen as the pinnacles of their type of media; the ones you’d least expect to fiddle with the truth. I don’t mean to pick on them for being worse than other media; indeed, you don’t have to look hard to find much less intelligent and honest health reporting in your newspaper and on the evening news. I just want you to understand that the problem isn’t “a few bad apples,” but rather the system in which the media is embedded, and the profit-seeking entities to which the media is beholden.

Research findings’ first stop on the way to public consumption is one of the professional journals, which vary in influence and prestige. Articles in
Nature, JAMA,
and the
New England Journal of Medicine (NEJM)
often make the evening news if they seem interesting and relevant. Other prestigious journals are more obscure, known only to practitioners in the field the journal covers. Examples include
Cancer Research, The American Journal of Cardiology,
and hundreds of others that focus on specific disciplines and subdisciplines. Still other journals are known in the field
as second tier, surviving on contributions that are considered “not up to snuff” by the top-tier publications.

The most important safeguard journals use against bad research is called peer review. This means that the editorial board sends manuscripts submitted to journals for publication to two, perhaps three, qualified reviewers (experienced scientists in that same field) to assess the quality of the research and the significance of the findings. The reviewers remain anonymous to the manuscript authors. This system is designed to filter out poorly done and unreliable research. When it is performed honorably, it is one of the most important guarantors of scientific integrity. Any supposedly authoritative article that has not passed through peer review should not, in my opinion, be invoked as proof of anything.

Peer review falters, however, when the reviewers bring their own biases to their decisions. When they decide in advance that certain research topics are out of bounds. That particular study designs (such as wholistic ones) are illegitimate. That certain conclusions just can’t be right. In other words, when they cling dogmatically to their paradigm rather than seeking to expand or transcend it. Peer review can easily become an iron cage that stifles curiosity and creativity, discouraging many promising lines of research by all but assuring that they won’t be published. This happens far too often. And it’s no coincidence that a substantial reductionist bias permeates peer review, since that bias may serve the financial interests of the journals themselves—by attracting or keeping advertisers.

You may recall, from when we talked about reductionist versus wholistic study designs, that testing the effects of drugs was the subject most amenable to reductionist study design. It makes sense to study a reductionist phenomenon—for example, a single-function pill—via a reductionist lens. And, not surprisingly, medical journals make a lot of money when they please Big Pharma. Professional journals, like mainstream newspapers and magazines, are funded in large part by advertising. Marcia Angell, former editor of
NEJM,
reports that in 2001 the pharmaceutical industry spent $380 million on medical journal advertising. Without this income, the journals could not exist. So it’s no surprise that the peer review process doesn’t bite the hand that feeds those journals.