Tuesday, December 8, 2009

The AAFP-Coca-Cola Deal: A Letter to a Member

I have now posted several times regarding the deal struck between my own medical specialty society, the American Academy of Family Physicians (AAFP), and Coca-Cola to fund patient education materials on obesity, most recently: http://brodyhooked.blogspot.com/2009/11/health-care-renewal-on-aafps-tone-deaf.html

As a dutiful AAFP member I sent a letter to the President, Dr. Lori Heim, and the Executive Vice-President, Dr. Douglas Henley, raising the same concerns about conflict of interest and public trust in organized medicine that I did in my blog postings.

I have now received their reply. I have not yet formally resigned but the chances of my remaining an AAFP member do not look good.

There is no hint of any retreat from the stance taken by AAFP at the start, that this relationship is to be commended and not condemned--despite the fact that in the interim, the editor of one of the major family medicine journals, Dr. Jeff Susman of the Journal of Family Practice, wrote an editorial sharply critical of the AAFP's position (Susman J. Do things really go better with Coke? http://www.jfponline.com/Pages.asp?AID=8183&issue=December_2009&UID=).

Some samplings from the AAFP letter (which I assume was mostly a form letter sent to all members who complained): "As a long-time member..., you certainly must appreciate the fact that the AAFP has been managing relationships with outside funders successfully for many years. The Academy has then highest standards and rigorous rules...and rigorous firewalls are in place to assure the separation of editorial and policy decisions from funding considerations."

Comment: It is true that people like me have been very lax in the past. It seems the AAFP has been happily taking funds from a variety of commercial interests, and that Coke is only the latest in the series. Shame on us family docs for not objecting loudly before this. But past actions of a questionable nature certainly don't justify future actions even more discreditable.

"Your comparison with the AMA's Sunbeam situation is a false one...no product endorsements are expressed or implied...our board of directos has been kept fully informed at every stage of development...Our Board took the lessons of Sunbeam very seriously in our deliberations and took pains to avoid all those traps."

Comment--points well taken. In the various ways listed, the AAFP did not act exactly like the AMA. They do indeed seem to have learned all the lessons of Sunbeam except the final, and most important one: don't let the dollar signs blind you to how bad you're going to look when the deal becomes known to the wider public.

"The argument voiced by many is that even the appearance of a confliict means that a conflict exists and that it is irresolvable. The AAFP has never accepted this line of thinking. Conflicts need to be disclosed and then dealt with. Again, the AAFP has been very successful in disclosing and managing any potential conflicts..."

Comment: This is indeed a possible ethical position. It is, for reasons I discuss at length in HOOKED, a highly unsatisfactory one. It is also not the dominant position taken in the medical literature with regard to professional societies and their responsibilities to set the highest professional tone for their members. (For just one recent example see Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA 301:1367-1372, April 1, 2009.)

"In a world of complex relationships, when tensions are high and society is so polarized, there are two approaches an organization such as ours can take. One is a strategy of engagement, whereby we choose to work together with organizations different from the AAFP in areas of mutual interest to advance the greater good and build trust and influence to help change behavior. One example of this...involved the Coca-Cola Company a few years ago, when the Robert Wood Johnson Foundation, the William J. Clinton Foundation, and the American Beverage Association worked together to address the issue of suragy soft drinks sold in school vending machines. ... The other strategy is not to collaborate at all with such organizations..."

It was Arthur Schafer at Manitoba who first noted how quickly, in the minds of industry apologists today, "engagement" and "collaboration" somehow automatically segue into "taking a lot of money from." The AAFP leadership here poses an utterly false dichotomy. None of the AAFP members who are up in arms over the Coke deal are complaining because AAFP saw fit to engage with Coca-Cola.

Summary: The leadership of the AAFP appears to have elected to turn a blind eye toward the controversy sparked by the Coca-Cola deal and has apparently wrapped itself smugly in its assurance that it can do no wrong. This certainly leaves members like me in a bind, which sadly appears resolvable only by us parting company. If the AAFP decides that this means I am no longer willing to engage with them, I guess they will have to be of that mind.