List of Survey Reports, Studies Conducted, Projects Completed and Publications. PART – III Period 1998 -2011 Policy Support Studies Waiting for the Ninth Five Year Plan – Occasional Paper (1999) Discussion Papers - Developing Andhra Pradesh – Vision and Its Revision - A Brain Storming Session (December 1999) A Study of Small Offices and Home Offices –Women in Information
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Adnc.asso.fr(16-18 June 2011, Eötvös University, Budapest) Paul Scheffer
EXPERICE - Paris 8
Critical thinking and lifelong education of professionals
and adults : citizenship at stake in medecine and nutrition
I am working in my PhD on “the place of critical thinking in the formation of dieticians and doctors in relation to the influence of the food and pharmaceutical industries”. One of the most important result of my research is to illustrate how the formation, initial and continue, of these two important branches of the health system are not preparing the professionals to cope with the different methods employed by the industries to sell their food or pills, when the professionals of health don’t directly contribute to the benefits of the industrials with different logics in mind. Why is it so? And how could these formations be In which extent these two post A-level formations do really prepare future health professionals to make the difference between reliant or biaised medical and nutritional research, to analyze the sources of power in their fields of intervention, to be aware for instance that key opinion-leaders are today very often identified and paid by the industrials to spread pieces of information which will profit to the industries, or to notice that the public regulatory industries in most of the cases are not able to fulfill their mission, undermined by competitive economical interests using different strategies? This paper would like to propose some elements of answer and discribe the impact of the some of the biggest economical and political influences on the field of public health in the occidental world and in France especially, where the affair of Mediator® pill has led to the death of 500 to 2000 people and a consequent crisis of the concerned public regulatory agency (AFSSAPS), which has been very commented by the press till now and shows how actual and relevant this topic is today.
Now, how are really built the initial and continue formations of these professions? How pregnant is the influence of the industries in them? What could be done so that these formations contribute to prepare in a better way the professionals of these branches to fulfill their mission of public health and not serve the profits of big corporations sometimes without knowing it? What are the groups, the researchers who are working in France and elsewhere for the emergence of a better consciousness of the methods of lobbying, the problems of conflicts of interest, the bias in the fundamental research, the problems of the independence of the experts in the commissions of the public agencies? All these questions are crucial to reinforce an effective citizenship among the professionals of health and the whole public, and also among the professionals working in the public agencies. In France, we are the country which consumes the most pills in Europe, without good reasons. With better sources of information, independent and critical, and stronger regulatory agencies, among others, this could change in the direction of a decreasing consumption of pills, and a better pudlic health. It is the same for food, people are lost among all the different speeches they can hear about food in the newspapers, at TV, from the industries or from the government, this confusion leads to the fact that people refuse to try to make their own opinion about food and eat rather what they like, or what is cheap, depending from the persons in question. A real critical education about food, which is a field where the major pieces of advice are rather simple to understand and follow in fact, could allow to give the possibility to people to regain the control about their choices in matter of food. To try to make its own jugement on this kind of big subject is often considered as too hard and a possible source of confusion among the people and even the students in nutrition themselves. For some of them, it is saffier to follow external instructions without questioning it. But we could also observe that leading a critical initiative can also conduct to a better empowerment by the non- expert people in nutrition and medicine, the students, and even the concerned health professionals. As Philippe Breton said it : To thwart manipulation makes grow in stature the one who cultivates it, and makes him feeling a free man. The joy that one can get from it does not only come from the discovery of what the critical reasoning can achieve, it is not a simple cognitive joy, it is also the pleasure to feel oneself as a singular human being, because really in relation to a world which is not anymore a meer spectacle of puppets from the moment where we understand it (1). The place of critical thinking in the lifelong education of adults is a crucial aspect which can delimitate an education giving power to do conscious and science-based choices dealing with food and medicine, compared to the kind of education that we can observe nowadays, which are quite efficient to build professionals with a pack of different competences, but who will not question the orientations and limits of the competences they received and the authorities above them. This kind of banking education, to take a Paolo Freire's expression, is certainly not the way of protecting or gaining new rights if we are listening to the lessons of our history in these sciences but also in others important ones in 1) The place of critical thinking in the formation of dieticians and doctors The first step of my presentation will concern the formation of doctors and dieticians. I have passed through the formation for dieticians during fast two years myself, at the same time where I was doing my master degree. Full participative observation was for me the best way to do my fieldwork and to experiment the formation I was talking about. The conclusions of my master were to show that the students at the end of their formation, had not received a single course of critical sociology of their field of practise, they had learnt some competences to apply without questioning them, and all of the students I interviewed excepted two had no idea was lobbying or conflicts of interest were about, and it is the same for the few professionals with about ten years of practise that I could interview. As Noam Chomsky says : “We ought to preserve kids from indoctrination, but we should also teach them to resist to it later in their life” (2), it is not the case here, the formation does not provide any course of “intellectual self-defense”, to pick up another expression from Chomsky. For the great majority of the students who are there at the beginning of their twenty's, the science is pure, without stains of external influences, of corruption, the industry is doing its job in a quite responsible manner, and the regulatory agencies are there to watch that all is going fine, so it would not come to the idea of the majority of them to think that it could be worth going behind the great façade and see how it works in fact. We have to say here that nothing in the formation encourages this approach, because its main objective remains “to prepare the students for the final exam” as the majority of the professors say, so that the best pourcentage will succeed. In that way, when I suggested to invite in our courses a researcher who had published interesting books and who had other arguments to share that what we were learning in course, I got the answer that it was “too risky” because the students may be confused and put in danger for the final exam, I was told that they were “too young” to hear such controversial discussions. That students over twenty years old can be considered too young to participate to a debate concerning their future profession shows how critical thinking can remain poor and even suspected here to compromise the success in the studies being too detached of the main pedagogy which is to learn by heart all what the students are supposed to know, and that is all. It was on the contrary not a problem for the chief of the formation, to invite an association which came in the class to speak about cereals for the breakfast. A dietician, appointed by the companies which in fact created this association, like Nestle, Kellogg's and others, came and present us during two hours a power point “demonstrating” how great these cereales were for everybody, using for that biased studies I had already heared about, funded by the same industries. When I asked in my interviews the students about this intervention, all of them except one, had been convinced, and had not understood how the industries had succeeded this way to make them believe in opinion more in favor with the interests of the food industry, although, in my view, dieticians ought to be professionals who should on the contrary be able to protect people from such influence of the food industry. When I asked the chief of the formation why she had chosen to invite this association, she told me that they were coming and bringing some documentation for free, so it was practical for the school which had no money.
I will not go so in details for doctors, but it is quite the same, a Senate report of 2006 declares that 98% of the continue formation is paid by the pharmaceutical industries (3), and a public report from the Inspection Générale des Affaires Sociales (IGAS), a public agency whose goal is to investigate the problems raised among the public sphere well-known for its accurate reports (the equivalent of the Government Accountability Office (GAO) in the United States) showed that the doctors at the end of their studies remained unable to clearly distinguish clean and distorted medical research (4). What is at stake is the real ability of the doctors and dieticians to assume their first mission, which is to assure and if possible improve the public health of the population, because their initial and lifelong education is so influenced by the food and pharmaceutical industries which are using great ressources to lobby the regulatory process in their favor, to influence science and crucial scientific debates in agreement with their interests, among other techniques. Better skills in critical thinking could reinforce the relative autonomy of these professions, to take a concept of Pierre Bourdieu which describes the fact that each field has its own logic, here driven normally by public health goals in the case of medecine and nutrition, but which is relatively autonomous in the sense that it is also influenced by other fields with other logics, like economical interests and profits when we deal with the food or pharmaceutical industries. Robert G. Kaiser for the United States (5), or the work of the CEO collective for Europe (6) have showed that the strategies of lobbying have become more and more efficient since the 80's. The problematic of conflicts of interest in the political and scientific spheres have also greatly emerged in Europe in the last decade, to become a priority of concern, also for the OCDE which has devoted many reports on the subject and written for Conflicts of interest are become, these last years, un major stake in the public debate, in the whole world, not only in the private sphere, but overall more and more in the public sector. The end of the barrier between public and private, through the privatization, the public-private partnerships and the careers going in round trips between the public and the private have created grey zones and opportunities for corruption (7).
Eminent researchers like David Michaels have illustrated many different strategies that the industries are using to create uncertainty, false debates, in the field of science in order to avoid regulations which could damage their profits. They fund studies whose results will pollute the scientific litterature with conclusions favorable to the industries. Several studies have shown that the studies commanded by private investors are about 4 times more likely to be favorable to the sponsor than indepedent ones (8-9), it is also the case among studies concerning food as a study published in PLoS Medecine, among others, underlined it (10). It is now so well accepted by the scientific community that the source of money which contributes to stimulate the study as an influence on the results that it is called the « funding effect », and has to be taken in consideration to evaluate the quality of the studies, according to David Michaels and other renowned scientists. Industries have also developed strategies to control the diffusion of news which could be a threat for their profits. Through the great amount of money they give to the media, the industries exerce a power on them, being able to take this money back if the media publishes bad news for one or another firm concerned, as John Stauber and Sheldon Rampton have documented it (11). If all that is not enough to avoid the spread of embarrassing studies, industries like the food and pharmaceutical ones also, often try to discredit the responsible researchers or journalists, exerce some pressure on their hierarchical superiors and if it does not convince the « muckrackers» to abandon their pretentions, the industries can choose to suit these persons in most of the case for diffamation, os it happened with the French researcher Pierre Meneton, who publicly declared in 2006 that the salt industry was practising disinformation to abuse the health professional and the public. The French salt industry took him to the court, but the researcher mastered his field so well that he won the trial in 2007 (12).
Even if industries are loosing some trials, it certainly may discourage other potential good scientists to choose sensible subjects of research, or if it is the case, to publish compromising results for such influencial and umbrageous actors. And globally, these techniques which are used by most if not all big industries to defend their profits, succeed in creating confusion among the health professionals and overall the public, it is so true for food, taht the observers are talking since a couple of years of « nutritional cacophony », at least in France, to describe the fact that there is so different lines about food, that the consumers say to be lost in this jungle, although the conclusions available from the best science in nutrition lead on the contrary to simple and coherent pieces of advice which should be not so complicated to take into actions, but we have to discuss here the case of the regulatory agencies which should assure the diffusion of this kind of information.
Regulatory agencies are key-stones of the public health systems in France as it is the case in most of the richest countries, they should normally achieve to make access to the public good vulgarisations of the best science available to allow the consumers to make good choices for their health, give some crucial marks to the health professionals through carefully prepared recommandations, and act in a sense that as less harmful products come to the markets as possible. This should be the ideal, but in fact, it is not the case, because regulatory agencies are facing huge pressures everywhere, because the amount of money only implicated for instance for food and drugs at stake are considerable : it is noticed that the Food and Drug Administration in The United States is supposed to regulate about 25% of the US economy (12), for instance. When these agencies are not discouraged to do their job by the government in charge which can cut in their budget or place at their heads some personal who will follow the instructions from the executive branch before to comply with the scientific results the agency may establish itself, as it has been the case for the Food and Drug Administration under the so devoted to industry interests Bush administration (13). Otherwise, the process of the agencies can also be distorted by many other ways, among them, by recruited experts by the industry who sit in the agency committees in charge to take the resolutions diffused to the public. The conflicts of interests of the experts are so commun for drugs that it is said hardly possible to find good experts without ties with the pharmaceutical industry, it may be not so extreme concerning food products in France, but the exemple of the public recommandations in favor of a great consumption of dairy products in contradiction with the best science available which suggests to reduce this consumption, shows that public agency for food are also subjected to pressure far from the public health ideal. After having read the disclosures of these experts, I could notice that 12 members on 23 in the committee had ties with the diary industry, even the director of the Dannon Institute was sitting there. What is also happening concerning the agencies which regulate drugs in Europe, is that they are put in concurrence : if an agency does not accept the drug of a firm, this firm will simply go to another agency in Europe, what is a strong incitation for the agencies to accept more easily the files given by the firms, particularly in reason of the dependance of the agencies to the pharmaceutical industry which fund them all, at 80% for the French one for instance. The regulatory agencies have under these conditions limited power to have a real impact on the markets, and when the French agency for the safety of food had for instance to take position about salt after the trial of Pierre Meneton, it did not propose any new regulation, but suggested, as it often the case, that the food industry regulate itself alone, what it is exactly what the industry deserves in that What is at stake concerns nearly everybody on the planet, and especially the millions of people suffering from diseases linked to food (obesity, cancers, cardiovascular diseases, diabetes.) or to the drugs itself, which is the fifth cause of death in the United States, killing more than accidents there, according to a study published in the JAMA, one of the most famous medical journal, in 2002 (14). The costs of a few diseases are already enormous, in France, 8 billion euros a year for cancer, 5 for cardiovascular diseases, and 2 for obesity (15). Nothing seems enough to stop the eager for profit of the industries, which want always that we eat more for the food industry, and that we take some pills for the pharmaceutical industry, even for no good reason, as the apparition of the disease mongering process describes it (16) : as the pharmaceutical industry does not succeed anymore in creating real new medical progress with its pills, it decided to create new markets by creating new diseases to sell pills they are manufacturing. The industry stimulates a demand among the public using its fears or believes, and proposes its treatment when the market is mature. One exemple is the pretended dysfunction of the female desire for sex, invented by the industry, which wanted to reproduce the success linked to the Viagra for men, but which certainly does not exist, or at least not to the extent told by the industry for which 43% of the women would be sufferig under this lack 3) Ways of empowerment for the health professionals and the public In that context, it seems clear that a great pressure is put on the health professionals and the public to follow the interests of the sellers of food and pills, but it exists fortunately some ways to build independent and critical knowledge in order to do better choices concerning theses acts of everyday, and also maybe to enact a better health system.
To begin with, I was surprised in doing my research to discover that there were some top researchers, considered worldwide as inescapable references, who had developed compelling critical analyses of the medical and food systems. I am thinking for instance about Richard Smith, former chief editor of the British Medical Journal, Marcia Angell and Jerome P. Kassirer, both former chief editor of the New England Journal of Medecine. These two journals belong to the very best medical journals in the entire world, and the post of chief editor is the most important one for these publications. About the food industry, the works of Marion Nestle, professor of Nutrition, Food Studies, and Public Health and professor of Sociology at New York University, and Walter Willett, Professor of Epidemiology and Nutrition, and Chair of the Department of Nutrition at Harvard School of Public Health, also Professor of Medicine at Harvard Medical School, are very impressive. Their critics can not be discredited, as it is often the case, by saying simply that they come from extremists or incompetent persons, they have to be taken in consideration by honest scientists, and have a relative but certain impact among their community and the decisions related to their fields. The emergence since a couple of decades of courageous « whistleblowers » is also to notice, they are scientists or members of an institution who decide to declare to the public for its own good pieces of information in their detention, even if they do not have the right to do so in term of professional contracts. One of the most famous one was Jeffrey Wigand who released crucial pieces of information about the the toxicity of cigarettes in the 90's to the detriment of his career and even of his personal life, his story reached the public attention through the film Revelation realised by Michael Mann in 1999. The health professionals respond to different manners to this phenomena, they often remain attached to the credit they give to the authorities they are used to follow, the public on the contrary is more curious about these stories, that they may assimile more easily with modern heroes fighting again big corporate industries, like in the film Erin Brockovich based on a true story for instance which had a good success. Several associations in France like Sciences citoyennes (Citizen Sciences), demand that the whistleblowers are better recognized and protected by a real status, but it is still not the case in France, in spite of the risks these persons are taking in these situations. I would like to focus on certain associations or groups which are also doing a considerable and crucial job of independent and critical expertise especially in the medical field in France. The revue Prescrire exists since the 80's, and had warned about several problematic drugs which created some years later different health scandales. The revue is now translated in many other languages, and consulted in France by at least one sixth of the generalist doctors, so about 10 000 for each parution and about 30 000 health professionals. The association Formindep has been created seven years ago, and acts for a better independence of the doctors related to the pharmaceutical industry, especially during their initial and continue education. With very few ressources, this association has produced very significant analyses, and has also for instance suited the Haute Autorité de Santé (HAS : the High Autority of Health), which is the most important autority for health in France, about recommandations delivered for diabetes and Alzheimer, because they had not even been prepared in compliance with the own code of deontology of the HAS, which is not the most restricting however. The former director of the HAS recognized at senatory hearings, that the critics of the Formindep were right (19), and the recommandation for the diabete has been abrogated some weeks ago by the Conseil d'Etat (the State Council) (20). The actions of the revue Prescrire and the Formindep demonstrate that even with scarce ressources, it is possible to do a precious critical work to improve the independence of a professional branch. Some members of these two groups which have gained a great and fully justified reputation are now demanded for interviews for the radio, newspapers, or a few documentaries for television, reaching that way more people. In the field of nutrition, I was astonished to notice that no such groups were existing in France. When I finished my research for my master, I decided to create with four other dieticians the Association de Diététique et Nutrition Critiques (ADNC : Critical association of Dietetics and Nutrition), whose goal was to replace nutrition among the different forces which are determinating it, namely economical and political interests above all, taking inspiration from the revue Prescrire and the Formindep quoted above. The association has just organized its first conference about « Nutrition, economical interests, and political power : what critical education? » in Paris during two days in May, available on its website (21) . We have also already given several interviews to newspapers and radio, and we have given pieces of advice to journalists who are working on documentaries about the food industry in France, and where we may be demanded to participate more directly for production. We also received many supports per e-mail especially among the community of dieticians, what strengthens the idea that something was missing in that field, and encourages us to go further in our direction. I learned a few months ago by the president of the biggest association of dieticians in France that my research of master concerning the influence of food industry in the field in nutrition in France had been well read in the profession, far more than what I estimated, and the president told me that some dieticians had already changed some of their practices after reading it, which is also a great encouragement to continue to produce critical materials to improve critical thinking of these professionals and the public, in the hope that it contributes to the improvement of the practices linked with food and public health.
This initiative to create the ADNC implicates several things concerning the way of doing research and its impact on the empowerment of the public and the concerned professionals. This association directly acts on the subject of my PhD, in a sense I am far away of the position of the scientific who has to be apart from his subject to remain perfectly objective. In my view and experience it is possible to aim at the standards of rigour declined under the idea of objectivity by being fully implicated at the same time in his subject. It demands without any doubt to be as clear as possible with oneself, to have spent much time to do its own « socioanalyze » as Pierre Bourdieu said, and for him it was the first duty of each sociologist to make appear one's own prenotions, desires, and values. It has otherwise the advantage to make arise crucial questions and positions of the actors of the concerned field, as my research of master and the recent conference we have conducted with the ADNC have shown it. My research is in fact also a research-action as it as been theorized by René Barbier among others (22). Briefly said, the research-action is a research whose goal and methodolgy are not only speculative but which aims at the transformation of the subject analyzed. Max Weber's epistemological tradition and its « axiologic neutrality » required for the scientist quality of research, that it would not be acceptable, and it is still often difficult to deal with sensible subjects for PhD students or even for well-established researchers I would say. On the contrary, I hope that this kind of research could develop in the futur, and respond to the call of Pierre Bourdieu who wrote in 1999 an important paper on the subject called « A scholarship with commitment » (23) where he took position by saying that the two attitudes were not irreparably opposed, but could on the contrary lead to a better work of the intellectuals and significant social improvements. More recently different sociologists in a collective book reinforced this idea by describing how significant in the construction and results of their research their implication or even involvement in the field of their subject had been (24). I find that Edward W. Said expressed it that way : The intellectual nowadays has to be, in my views, (.) someone who considers that being a thinking and engaged in a society member allows him to rise questions of moral level, including about the activities the most technical and professionals, in the extent where these ones directly implicate his country and hos power of interaction on its citizens and on other societies. Over and above the fact that this state of mind can also transform the purely professional routine which concerns everybody or almost, in something of far more radical and vivid; rather than to be satisfied to do what we are supposed to do, by questioning the profit and the raison d'être, think about the manner to put this work in relation to a personal project and original reflections (25).
That is exactly what are doing the academics whose works are crucial for my actual research and that I have already mentioned above, namely Marion Nestle, Walter Willet, Marcia Angell, Jerome P. Kassirer, Richard Smith, David Michaels, among others. To conclude, I would like to quote this remarkable extract which resumes what I am experiencing myself in my research about the link between critical thinking and citizenship, in the hope that this research can also bring some improvements in public health for the greatest number of If the habits of thinking critically spread among society, it would prevail everywhere, because it is a manner de cope with the problems of life. The eulogistic speeches from some speaker could not bring into panic such educated people. Those ones take their time before believing and are able, without difficulty and need of certainty, to hold things for probable to different degrees. They can wait for facts, and then weigh them up without never let them influence by the emphasis or the trust with which proposals are advanced by one part or another. Those people know how to resist to the ones who are using their most deep-rooted prejudices or flattery. The education of this ability of critic is the only education to which one can say that it makes good citizens (26).
(1) Breton Philippe (2000) La parole manipulée, Paris: La Découverte, p.197 (2) Chomsky Noam (2010), Réflexions sur l’université, Paris: Raisons d'agir, p.30 (3) Formindep (2010), Il y aura d'autres Mediator, retrieved from December 11, from http://www.formindep.org/Il-y-aura-d-autres-Mediator.html (4) Foucras Philippe (2007), Le rapport de l’IGAS sur l’information des médecins généralistes sur le médicament, Retrieved November 8, 2007, from http://www.formindep.org/Le-rapport-de-l-IGAS-sur-l?var_recherche=igas (5) Kaiser Robert G. (2010), So damn much money, New York: Vintage books (6) Balanya Belén, Doherty Ann, Hoedeman Olivier, Ma'anit Adam, Wesselius Erik (2005) Europe Inc., Marseille: Agone (7) Hirsch Martin (2010), Pour en finir avec les conflits d'intérêts, Paris: Stock, p.115 (8) Bekelman J.E. (2003), Scope and impact of financial conflicts of interest in biomedical research : a systematic review, Journal of the American Medical Association, 289(4):454-465.
(9) Lexchin Joel, Bero Lisa A, Djulbegovic Benjamin, Clark Otavio (2003) Pharmaceutical industry sponsorship and research outcome and quality: systematic review, BMJ 326 : 1167 doi: 10.1136/bmj.326.7400.1167 (10) Lesser LI, Ebbeling CB, Goozner M, Wypij D, Ludwig DS (2007) Relationship between Funding Source and Conclusion among Nutrition-Related Scientific Articles. PLoS Med 4(1): e5. doi:10.1371/journal.pmed.0040005 (11) Stauber John, Rampton Sheldon (2004), L'industrie du mensonge : lobbying, communication, publicité et médias, Marseille: Agone (12) Liberation, « Le lobby du sel perd son procès contre un chercheur de l'Inserm », Retrieved March 13, 2008, fromdu-sel-perd-son-proces-contre-un-chercheur-de-l-inserm (13) Michaels David (2008), Doubt is their product, New York: Oxford University Press, p.209 (14) Michaels David (2008), Doubt is their product, New York: Oxford University Press (15) Anderson RN (2002), Deaths : leading causes for 2000, National Vital Statistics Reports 50(16) (16) Fassin Didier, Hauray Boris (under dir.) (2010), Santé publique, Paris: La Découverte, p.185 (17) Blech Jörg (2005), Les inventeurs de maladies, Paris: Actes Sud (18) Moynihan Ray, Cassels Alan (2005) Selling sickness, Crows Nest: Allen & Unwin (19) Formindep (2010), La HAS, Le Formindep et ses verges. Retrieved September 4, 2010, from http://www.formindep.org/LA-HAS-le-Formindep-et-ses-verges.html (20) Formindep (2011), Le Conseil d’Etat abroge la recommandation de la HAS sur le diabète de type 2. Retrieved April 30, 2011, from Conseil-d-Etat-abroge-la.html (22) Barbier René (1996), La Recherche Action, Paris: Economica (23) Bourdieu Pierre (2001), « Pour un savoir engagé », in Contre-feux 2, Paris: Raisons d'agir (24) Naudier D., Simonet M. (2011), Des sociologues sans qualités? Pratiques de recherche et engagements, Paris: La Découverte (25) Said, Edward W. (1996), Des intellectuels et du Pouvoir, Paris: Le Seuil, p.98-99 (26) William Graham Sumner, in Baillargeon Normand (2010), Petit cours d’autodéfense intellectuelle, Montreal: Lux, p.269
What is a Stress ECG? The Stress ECG is a sophisticated cardiac investigation that takes approximately 30 minutes to perform. The patient is attached to multiple ECG electrodes and is then asked to walk on treadmil - with increasing degrees of effort and gradient over roughly 20 The stress ECG is predominantly used to detect coronary narrowing that could explain symptoms on effort- or compr