To understand how to find and consume science, particularly on the topic of medicine, one has to understand how it is produced and published, and some of its past.
Science has not always existed, nor has medicine as we know it. In the relatively short time that the ideas of the Enlightenment have prevailed in some areas of our life, and science and medicine have been practiced, it has changed enormously.
Originally shared informally, or in books, journals arose to make the process of sharing discoveries more efficient, and to serve particular groups with an interest in keeping up with the latest developments, amongst which of course are doctors.
Much of what was called science as recently as the middle of the 20th century was actually marketing material, published in organs of the drug companies, and used to promote whatever drugs the companies wanted to sell. Others were published by doctors themselves, like the progenitor of the New England Journal of Medicine. Or by groups of scholars with shared interests.
Of course we are mostly interested in medicine, and in the 20th Century as in no age before, the practice of medicine, and of medical research, came to mean the use of drugs, and their invention respectively.
The market in drugs was effectively unregulated until well into the 20th century. The FDA arose out of the Department of Agriculture, and it traces its roots to a single chemist in the U.S. Department of Agriculture in 1862, who was concerned with detecting adulterated fertilisers. Perhaps no one was paying attention to human drugs in the 19th century in the federal government, but our fertilisers were getting their due attention.
With the passage of the Federal Food and Drugs Act in 1906 what we think of as the FDA started to take shape, but even then most food and drugs were outside it’s remit. Instead most regulation of drugs occurred, with enormous variation, at the State level.
The 1906 Act, a law that took fully 25 years to write and pass, was only concerned with the prohibition of interstate commerce in adulterated and mislabeled food and drugs. Not with their efficacy, or honesty in claims, etc. Nor with intra State commerce in such drugs. All it was concerned with was accurate labels with respect to contents, for drugs shipped between States, and this was a huge advance.
In 1911 the Supreme court ruled that the 1906 law did not apply to false therapeutic claims, despite the arguments of the government. So outright fraud was ok, so long as the ingredients were correctly labelled.
Products legal under the law because of the oversights of it’s authors, and because the Supreme Court was so strictly constitutionalist, included Banbar, a “cure” for diabetes; Lash-Lure, an eyelash dye causing at least one case of permanent blindness; and my favourite Radithor, a radium-containing tonic that one drank, presumably to ensure stomach cancer.
One could do anything, and publish anything, and so being our species that is exactly what they did. With the kind of results you might expect. You can find a lot of information about science, or its history by reading Ways of Regulating Drugs in the 19th and 20th Centuries, or more generally by searching here in Google Books.
In 1938 the Food, Drug, and Cosmetic Act was passed, but only five years after being submitted, and only after public outrage over the effects of a drug marketed for children, Elixir Sulfanilamide. Over 100 died, many of whom were children of course. For the first time proof of efficacy claims, and of safety were required for new drugs prior to being sold.
But many old ones were grandfathered in and remained on the market.
Though it may be hard to believe, even brief periods of consideration show that to some extent this situation prevails to this day.
Efficacy is clearly not required for homeopathic “cures” for instance, which depend on the placebo effect for any benefits they produce. Tobacco, clearly a drug, has avoided regulation. So if you have the money, or the audience, or the ears of the federal government anything goes to this day.
Most of what we consider the duties of the FDA, and its practices and regulations, were developed out of enforcement of the Act, more so following amendments to it and as custom developed, and regulations were promulgated based on this legislation. For most of the period following the 1938 Act things did not resemble current practices.
Modern medicine as we know it did not really exist either. Besides the absence of anything like effective drugs except those derived from herbal cures like digitalis, and a few patent medicines like aspirin, and heroin, they had very few instruments beyond a stethoscope. Germ theory had originated relatively recently, and the rate at which ideas and practices spread and were adopted was very slow in comparison to now. In this vacuum what a doctor was defined as varied, as did the practice of medicine and the production of research.
Into many of theses gaps stepped the American Medical Association, with mixed results, which when it was founded was one of many professional associations of doctors. The various amalgamations of doctors often promoted or had quite different ideas of what a doctor should be, do, how they should be trained, and what the practice of medicine was and should be. Nor was the AMA the largest in the mid 19th Century.
The AMA’s particular genius, if you can call it that, was that it was run by a very capable organiser, Nathan Davis, a ruthless individual it has to be said, and one with very few scruples.
The AMA, or Nathan Davis, the two can be hard to distinguish, realising that it’s future, and the interest of those running it, lay in cornering the market in doctors, decided that this could in part be assured by eliminating all types of medical practitioners apart from the type it represented. It undertook a campaign against quackery, without oversight or public participation or the involvement of the government. It also set about defining what a doctor is, how they should be trained, paid, what they could and could not do, and most importantly that they pay dues to the AMA throughout their professional lives in order to practice medicine. The AMA is the most effective closed union shop in history, an arrangement that ensures high wage costs, it being the only such arrangement I could find that is required by US law.
Nathan Davis can be considered as a white collar James Hoffa, with the AMA as his Teamsters, and the comparison is more than frivolous. Except Davis was far smarter, and far more effective.
The only significant group of health practitioners to survive this drive in the USA were chiropractors, who to this day are governed by a different professional association, with a great deal of animus remaining between the groups.
Along the way the AMA also acted to gather to itself not just power, and the sole representation of doctors as their professional association, as well as defining what medicine consisted of, but actual ownership of various drugs and cures.
In their efforts to profit from cancer cures for instance Nathan Davis, using the AMA and it’s journal as tools, first tried to buy, then to obtain by force, and finally to suppress when these efforts failed, the Hoxsey Cure.
Patient welfare was clearly not his or their primary concern.
Despite (suppressed) evidence, some of it the result of at least one study by the AMA, that it was safer and more effective than cures promoted by the AMA elsewhere, (admittedly not very high praise at all) Nathan Davis and the AMA, using tactics which would produce a jail sentence today, drove Hoxsey from the field.
Hoxsey sued the editor of the Journal of the American Medical Association for libel and slander, after the journal called him a fraud. Hoxsey won the case, that is the jury found for him. But the judge saw fit to award just one dollar in damages.
Hoxsey struck oil and got out, and who can blame him. His cure, whatever its merits or lack thereof, moved with a nurse to Tijuana to escape the FDA and AMA in 1963.
Ironically the Hoxsey cure is used today in respect of it’s methods, and of the underlying reasoning, in the form of stimulating the tumour to be attacked by the immune system by provoking it in various ways. Such as with chemical burns, caustics, or by causing inflammation, centered on the tumour. In this way it becomes more visible and apparent to the immune system, and is attacked.
Of course the AMA and Nathan Davis were not complete monsters, ok, they were. But his campaign to stamp out fraud, using the Journal of the American Medical Association, was not entirely corrupt or without merit, far from it. But it was itself corrupt even by the standards of the day, and science and medical publishing was bent to this aim, as was the practice of medicine and medical publishing. Today we live in Davis’ world in terms of how medicine is taught, practiced, etc.
This could happen because drug development and promotion was almost completely unregulated. As was the publishing of science, and as a result a lot of very dangerous drugs, often with less than no curative properties, were promoted and sold.
Many of what we would recognise as journals at the time concerned with medicine were house magazines published by drug companies who wanted to market their latest patent cures to doctors. Rigorous standards for papers published was not a consideration.
In the case of Bayer a notable drug they invented and marketed in this manner was Heroin, originally a registered trademark, which they promoted as a less addictive alternative to morphine.
Merck followed a few decades later in one of their “journals” promoting Cocaine for, amongst other things, its power to treat Heroin addiction.
Those papers were published without many of the safeguards that we take for granted now, like peer review, and their methods of review, and standards for publication were enormously varied, and often laughably corrupt were it not for the damage done.
Fortunately for us things are different now, to a degree, but human nature has not changed. Nor has the drive to profit, and if anything the power of the drug companies is greater, there is still fraud, and science is still bent to dishonest means.
Witness the tobacco industry’s ability to find plenty of scientists willing to put their names to the most ridiculous claims in papers and hearings for years. Arguing there was no evidence that smoking tobacco was addictive, or that it was carcinogenic, were ranks of tobacco company scientists willing to publish anything. So ensuring tobacco’s ability to escape regulation as a drug, though it clearly is, to this day.
If someone is paying then someone else is willing to put their name to almost anything.
But not all efforts to publish scientific research in the 19th and 20th Centuries were corrupt, far from it. Many journals were started by doctors genuinely interested in improving the practice of medicine, like that started by Drs. John Warren and James Jackson. This was the progenitor of the New England Journal of Medicine. Others were founded or picked up by various regional and national medical associations like the Massachusetts Medical Society, and the British Medical Association, often with no requirement that the journals be profitable in themselves.
Over time as the costs of publishing increased, and the need for medical associations and groups of doctors to ensure the flow of reliable science for themselves diminished, they were spun out as independent journals, or sold to publishing companies.
Many have been gathered by specialised publishing groups, which themselves we engulfed by conglomerated publishing companies larger still owning hundreds of titles, like Wiley, or Thomson-Reuters, for whom scientific journals represent one branch of an enormous diversified publishing enterprise.
Now subjected to the laws of the marketplace, they have to make money. The aims of for-profit publishers are quite different from professional associations who have an interest in a well informed and trained audience above all else.
Standards have been put in place in successive waves to deal with the evolving challenges, and today scientists are required to disclose conflicts of interest, sources of funding, and peer review has been adopted, etc.
Most journals now specialise, they focus on one narrow area of knowledge, often a subsection of one scientific discipline. Examples in human health are The Lancet, or BMJ, or the NEJM. Three very old (around 200 years) examples, others being the Annals of Neurology, down to the esoteric Abdominal Imaging, and Acoustical Physics.
This atomisation of science publishing means that today there is an enormous number of journals, all competing to publish unique science to satisfy and attract readers to ensure relevancy and continued sales. With this enormous variety comes enormous variations in quality, and the rigor and standards by which papers are evaluated and published, as well as fierce competition.
Bear this in mind when reading papers, but do not fall into the trap of the conspiracy theorists. Most scientists are sincere and well intentioned, as I continue to hope most people in all walks of life are.
The increased requirements that science pull its weight as governments sought to balance the books, as well as wider changes in competition and technology has resulted in changes in the way articles are submitted, reviewed and published.
There have been waves of consolidation and closures, and some surviving journals have stopped publication of an expensive, and largely unnecessary, print version. Journals have raised prices, for both publishing and access to articles, and with online came the ability to sell individual papers more easily, unbundled from the journal.
With low readerships inherent, and increased competition as with all of publishing, some marginal journals have abandoned all all but the semblance of academic rigour and are strictly pay to play enterprises with little if any real peer review or editorial control. Even the largest and most respected charge for publication, often thousands of dollars, while peer reviewers remain unpaid and subscribers pay to read individual papers, or to subscribe to or purchase the journal.
But the practitioners of science have been affected by changes in society and how science is funded, too. The people who write the articles and submit them for publication find themselves in a very different environment, with very different pressures about what to publish, how frequently, etc.. Not just from the side of the publishers either.
The practice of science because of these trends in the latter half of the 20th century has transformed it into a publish or be damned exercise. A scientist can only keep their often now untenured positions if they publish, if they publish regularly and if their research is cited in other papers and has a high weight. The practice of science has also become enormously competitive, and subjected to powerful interests often in conflict with the fundamental ethos of science, and of the Enlightenment.
These issues are beyond the scope of this article to discuss in detail. However the increase in pressure to publish, along with the increase in the amount of research conducted worldwide, with a relatively fixed quantity of publishing real estate, has resulted in enormous pressure on scientists. The more prominent journals are said to exclude up to 90% of papers submitted for instance.
Of course with increased pressure and commercial considerations comes increased fraud and corruption. When you push someone into a corner and threaten their livelihood it has been shown again and again that people react in whatever ways are available to them to defend their income, reputation, stature and position. That too is beyond the scope of this article.
I don’t want to write a book on this subject, although I am almost there as it is, but you should be aware of these factors and others, and never accept anything uncritically, no matter how prestigious the journal is that you are reading. Having said that one can assume that science published today is more likely to high quality, to not have been produced as a marketing gimmick, and that the authors do not have a hidden agenda affecting their behaviour. Science is more rigorous, subject to greater scrutiny and less likely to be outright fraud than at any time in human history.
Despite economic headwinds, and so many changes in the way science is published, there are thousand of journals covering every conceivable branch of human enquiry. Accompanied by an explosion in research and the quantity of it being published.
However, such a proliferation of journals and papers means that finding research can be very difficult, even using Google. Unless you already know the paper you want, and have it’s title or some other unique identifier, more of those later, searching for a paper using search engines is enormously time consuming.
Fortunately for us this problem predates our interest in the subject by quite some time, and various aggregators and indices of science have been created.
However, as with journals themselves, these search engines may discriminate in some way, and narrow your field of view by excluding some research even from journals they index, whilst simplifying a search. They also often lag behind the publication schedule of the journals they index. It may take six months for instance for a paper to be indexed and available in Pubmed after it has been published in the Annals of Neurology.
You can access my favourite starting point, PubMed, an aggregator of medical research run by the National Institutes for Health (NIMH), who include a helpful guide to using their index and search tool here.
Others exist, like JSTOR, and others I am likely not aware of, and many I am. start looking.
In reaction to the trend of rising prices and harder to access research, as well as to the closed nature, and abuses in the process of acceptance and review there grew a movement for what is called open access journals.
Enabled by the internet, many new journals with much different practices have been founded in the past two decades. These are often dedicated to areas of enquiry neglected by the mainstream journals, or that allow science produced, often necessarily, under less rigorous circumstances than possible for papers published by older journals. They sometimes borrow ideas like open source and apply it in the peer review process, by publishing unedited texts or opening the peer review process to wider comment and participation. Some of this has been a reaction against the barriers to access by readers, some to the barriers to publishing.
An example of an open access journal in the area of medicine is Plos One,
Open access can mean a variety of things, whether open access to readers, or an open peer review process. But it simply means, as its name suggests, that you can read full texts without having to pay for the privilege or by buying a subscription. Articles are still subject to peer review in most cases, and articles may or may not be published conditional on some payment to cover expenses.
This is important to us because access to science is not cheap. Annual subscriptions to one top tier medical journal are £160/€233/$222 per year. Individual papers are usually from £15/€25/$25 to £30/€50/$50 each. That may sound ok, but when you realise you may want to read forty papers just to start with, you also realise the cost adds up fast. I have going on 300 papers on my computer. If those hypothetical forty are published in fifteen different journals, and that is going to cost perhaps five hundred dollars, if you are able to plan in advance and aggregate some of the papers under cheaper subscriptions, suddenly Open Access makes a great deal more sense.
Unfortunately much of what you will want to read is not published by Open Access journals. More aggravatingly, much of what you may want to read was probably produced originally using taxes. Fortunately for us again our coming to this realisation was preceded by some time, though not by long enough to save me much money, by a similar realisation in the US government. They now require that any research produced with government funding be available for free six months after publication. You may have to wait, but it will be free.
In addition if you or a friend are a student at a university membership of the library gives you free access to most if not all journals through programs like JSTOR. Visit the library and ask the librarian, they can often perform searches for you and deliver the papers to you. If you have a friend, or child at university, you can access it through them.
The process of getting a paper published has been affected by the internet, as well as changes in politics and economics, of course, though varying somewhat from journal to journal. In future posts I will deal with that and some of the issues in writing and publishing science affecting the area of review.
I will also discuss the structure of papers, how to read them, and in that post I will also deal with how to follow a thread of research using citations, and things like the DOI, citations and how to manage them, and how to create your own science library.
- What is science (October 18th, 2014)
- Where science is published and how to find it (October 23th, 2014)
- Peer review (October 29th, 2014)
- Evaluating science (November 3rd, 2014)
- Type of scientific paper, their structure and interpretation (November 7th, 2014)
*Changed list of planned posts on October 17 to accommodate increase in number of planned posts and compressed publication schedule, moving dates up.