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Lawmakers say FDA better Clean Up its Act

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For six years, the Bush administration has placed pharmaceutical industry interests ahead of public interest by appointing persons with strong ties to drug companies to high level positions at the FDA.

As a result, Congressional investigations and a recent survey indicate that the health and safety of all Americans is being compromised.

On July 20, 2006, the Union of Concerned Scientists published the results of a survey that showed an insidious political influence of science within the FDA. According to the UCS press release, the survey was co-sponsored by Public Employees for Environmental Responsibility (PEER), and was sent to 5,918 FDA scientists.

The survey found that 61% of the responding scientists knew of cases where the "Department of Health and Human Services or FDA political appointees have inappropriately injected themselves into FDA determinations or actions."

In responding to the survey, one scientist wrote: "Over the last several years I have noticed a significant increase in the number of decisions that have become politicized (e.g., increasing requests to review even simple regulations and changes, both by Congress and the Commissioner's office and to make apparently politically-motivated changes in language and sometimes to alter bottom line results), and I think the integrity of scientific work could be improved by minimising the 'politics' of the process."

Out of the nearly 1000 scientists who responded, close to one-fifth or 18.4%, said they had "been asked, for non-scientific reasons, to inappropriately exclude or alter technical information or their conclusions in a FDA scientific document."

In addition, 40% of the scientists said they fear retaliation for voicing safety concerns in public and more than one-third said they did not feel they can express safety concerns even inside the agency.

The survey also found that only 47% think the "FDA routinely provides complete and accurate information to the public," and 81% agreed that the "public would be better served if the independence and authority of FDA post-market safety systems were strengthened."

In a complaint aimed at the FDA's Office of Regulatory Affairs, one scientist said it should "not ostracise scientists or black ball them because their foresight sees a problem with a drug, device, food, biologics, etc. that possess a potential hazard to health now or in the future."

In response to the concerns raised by FDA scientists, the UCS recommends:
  • Accountability: FDA leadership must face consequences if they side with commercial or political interests and not with the American people.

  • Transparency: Scientific research and reviews should be open so any undue manipulation is immediately apparent.

  • Protection: Safeguards must be put in place for all government scientists who speak out.
"These disturbing survey results make it clear that inappropriate interference is putting people in harm's way," said Dr Francesca Grifo, Senior Scientist and Director of UCS's Scientific Integrity Program, in the press release.

"All federal scientists," he said, "need protections so they can speak out when their science is manipulated, and all federal agencies need fully functioning independent advisory committees."

"FDA leaders," Dr Grifo noted, "should act now to improve transparency and accountability and renew respect for independent science at the agency."

"FDA leadership," he stated, "must understand and support independent science and it is up to Congress to hold them accountable."

But nothing about this survey is news to FDA officials. By use of the FOIA, the UCS and PEER, recently obtained a copy of a previously unpublished survey by the Health and Human Services Office of Inspector General from late 2002, that polled 846 FDA scientists, and with nearly half responding determined that:
Nearly one in five said that they "have been pressured to approve or recommend approval" for a drug "despite reservations about the safety, efficacy or quality of the drug."

Two-thirds lacked confidence that the FDA "adequately monitors the safety of prescription drugs once they are on the market."

Only 12% of the responding scientists were completely confident that FDA "labeling decisions adequately address key safety concerns," and 30% were not at all or only somewhat confident.

More than one-third were not at all or only somewhat confident that "final decisions adequately assess the safety of a drug."
Despite the above results, the report published by the OIG in March 2003, included the conclusion that FDA scientific reviewers "have high confidence in decisions FDA makes."

On August 8, 2006, the UCS briefed acting FDA Commissioner, Andrew von Eschenbach, on the latest survey and discussed the political inference at the FDA. To restore integrity, UCS recommended that Dr von Eschenbach adopt and enforce three basic commitments:
  1. to ensure that data or results are never softened for any audience. Rigorous scientific debate must be valued at the FDA;

  2. to pledge to support scientists who speak out by taking adverse employment action against any manager who retaliates against a reviewer; and

  3. to commit to a culture that supports a collaborative process of testing and challenging scientific hypotheses.
Along with the recommendations, the group's August 8, 2006, press release said, "The FDA must allow an open scientific process and recognize the need for scientists to pose and answer questions without consequences related to their status at the FDA."

Critics claim that a major issue that needs to be addressed involves the rampant conflicts of interest among members of the FDA's advisory panels who have financial ties to the pharmaceutical industry. In November 2005, a new law was passed that required members of the committees to disclose all financial ties to drug companies.

The categories for disclosure were broken down into dollar amounts and time frames, such as less than $10,000 a year or between $10,000 and $50,000 a year. After reviewing the financial disclosure forms, the FDA is permitted to grant waivers that allow experts to sit on panels even if they have financial ties to a drug company.

However, on April 21, 2006, the Boston Globe discussed the practical effects of the law since it was enacted and reported that FDA critics "say the new transparency has changed little, and scientists who have conflicts of interest can still guide FDA decision making."

In less than 6 months after the law went into effect, the Globe determined the FDA had granted close to 100 waivers.

One of the current investigations of the FDA involves allegations that the agency approved the antibiotic, Ketek, despite serious questions about the drug's safety and efficacy, and with full knowledge that the clinical study submitted to support Ketek's approval was fraudulent.

Critics say Ketek's side effects of liver damage were known to its maker, Sanofi-Aventis, early in clinical trials but were covered up. The drug has been blamed for the death of four patients and the liver damage or failure in 37 other patients since 2004.

Internal FDA emails that surfaced during the investigation show that at least four FDA safety officials, Dr David Graham, Dr Charles Cooper, Dr David Ross and Dr Rosemary Johann-Liang, had voiced serious concerns about the safety of the drug.

"I tried to argue that given Aventis's track record in which they have proven themselves to be nontrustworthy that we have to consider the possibility that they are intentionally doing a poor job of collecting the postmarketing data to protect their drug sales," Dr Cooper said in an email.

"It's as if every principle governing the review and approval of new drugs was abandoned or suspended where telithromycin is concerned," Dr David Graham wrote in an email that recommended Ketek's "immediate withdrawal."

"We don't really know if the drug works;" he said, "no one is claiming it works better than other, safer drugs; and we're flying blind as far as safety goes, except for our own A.D.R. data that suggests telithromycin is uniquely more toxic than most other drugs."

In May 2006, Dr Johann-Liang called for a halt to tests of Ketek in children with ear infections, arguing that cutting the duration of ear pain by one day was hardly worth risking death.

The FDA's actions in regard to Ketek are being investigated by Senator Charles Grassley's (R-Iowa), Senate Finance Committee, and by Representatives, Edward Markey of Massachusetts, and Henry Waxman of California, ranking Democrats on the House Government Reform Committee.

In May 2006, the lawmakers released a statement that said although "the FDA has consistently assured the public of Ketek's safety and efficacy, public documents obtained and examined by Representatives Markey and Waxman's staff indicate that the approval process for this drug was seriously flawed."

As Chairman of the Senate Committee, Senate Grassley has called for a "major overhaul and a culture change at the highest levels" of the FDA. In a May 1, 2006, press release, he noted concerns over the FDA's complicity with the drug maker and its subsequent failure to ensure the integrity of a study on the benefits and risks of Ketek.

The Senator called it "mystifying" on May 16, 2006, that the FDA would continued to provide information that it knew was fraudulent, and warned that he planned to keep the pressure on the FDA to provide more information about Ketek's approval and post-market surveillance.

According to Dr Graham, Ketek is at least as toxic to the liver as three other drugs that have been pulled off the market and the FDA's original approval of the drug was based on a study that FDA officials knew was fraudulent.

"It's no surprise to learn that the FDA didn't listen to Dr. Graham on the dangers of Ketek," Senator Grassley was quick to point out. "The FDA has made it their business to discredit Dr. Graham and others who aren't willing to cater to the drug companies," he noted.

In October 2001, doctors began enrolling subjects for the Ketek clinical trial known as Study 3014, and were paid $100 for each patient that signed up. The participating doctors would also receive another $150 when the study results were submitted, and a final $150 when all questions related to the study were resolved, according to the May 1, 2006, Wall Street Journal.

On July 24, 2002, drug maker Aventis submitted the results of the study to the FDA, but when FDA officials submitted the study to the advisory committee for review, they did not disclose that the Division of Scientific Investigation and Office of Criminal Investigation was investigating the integrity of the study.

The misconduct that took place during the clinical trials is so serious that critics say it calls the validity of the entire study into question. For instance, the doctor who signed up the 3rd highest number of patients, was in a chronic state of cocaine addiction while conducting the clinical trial, and was arrested and found to have cocaine hidden in his underwear, while holding his wife hostage with a gun, the same month the study results were submitted to the FDA.

Another doctor who participated in the study was totally disqualified as an investigator and prohibited from conducting any clinical trials in the future, and another who signed up 150 patients was cited for 20 violations of the study's instructions.

Dr Anne Campbell, the doctor with the highest number of subjects in the study, was sentenced to nearly 5 years in prison in March 2004, after being charged in a 21-count indictment over her misconduct.

Senator Grassley is demanding a face-to-face interview with the FDA investigator who discovered the fraud and misconduct in the trials, who he contends "is key to understanding what the FDA did when it became clear that the safety study required by the FDA in order to approve the drug was fraudulent and faulty."

This investigator authored a March 25, 2004, memorandum from the Division of Scientific Investigations titled, "DSI Recommendations on Data Integrity," that states in part, that Study 3014 involved "multiple instances of fraud" and that "the integrity of data from all sites involved in [the] study ... cannot be assured with any degree of confidence."

After months of trying unsuccessfully to get an interview, Senator Grassley finally marched right over to the Department of Health and Human Services headquarters and asserted a congressional right to speak to the investigator.

After a brief conversation with senior officials, he left mad as a hornet. "This is extraordinary to me," he said outside HHS headquarters. "I haven't had to go to an agency like this since 1983 to get information I requested.

"I smell a cover-up," he stated.

On June 22, 2006, Senator Grassley publicly announced a not too subtle warning to officials at the agency. "Two years ago I called a congressional hearing to probe the FDA's handling of the withdrawn painkiller Vioxx," he said in a statement.

"It might be time," he warned, "to round up another oversight hearing after the runaround I got recently at the FDA."

"The FDA," he wrote, "refused to allow me to question an internal investigator who is leading an inquiry into alleged fraud involved with clinical trials for the antibiotic Ketek."

"So for only the second time in 23 years," he said, "I resurrected in June my unconventional means to fulfill my Constitutional oversight responsibilities."

He said, "I appeared at the FDA's doorstep," and noted that agency officials refused to let the investigator speak to him.

However, he warned, "Bureaucratic stonewalling won't deter this U.S. Senator."

"I won't rest," Senator Grassley said, "until the light of day exposes what ought to be available for public consumption."

"It all boils down to keeping the government accountable," he wrote, "to the people and strengthening the public trust in government."

In another statement released on June 29, 2006, he stated, "Ketek is another example where the F.D.A. accommodated a drug maker and turned a blind eye to serious safety concerns."

Over the past couple of years, the suppression of the scientific process and the muzzling of scientific dissent at the FDA became evident first when officials forced Dr Andrew Mosholder to suppress a link he found between SSRI antidepressants and suicide in children, and Dr Graham went public with allegations about the FDA's mishandling of the Vioxx matter.

On March 10, 2005, Senator Grassley gave a speech to the Consumer Federation of America and said these two whistleblowers had done more to shake up a complacent FDA than probably anybody in recent history and relayed parts of the story saying:

"Early last year I heard that the FDA was muzzling one of its own scientists. In February 2004 the FDA held a meeting to decide whether there was a link between some antidepressant drugs and suicidal behavior in kids.

"Dr. Andrew Mosholder - the FDA's expert in this area -- concluded there was a link. However, FDA management disagreed. So, when Dr. Mosholder stuck by his findings, his supervisors canceled his presentation to an advisory committee.

"Instead of allowing Dr. Mosholder to present his findings publicly and subject them to committee scrutiny, the scientific process and his peers, the FDA effectively muzzled him."

But despite the FDA's best efforts, Senator Grassley said, Dr Mosholder wouldn't be silenced and months later he was proven right.

Citing information from the Department of Justice, he told the audience that there are currently under seal in the neighborhood of 100 whistleblower cases involving allegations against over 200 drug companies.

"During the past four years," he stated, "the department recovered nearly 2 and a half billion dollars from whistleblower cases against drug companies."

Senator Grassley called Dr Mosholder and Dr Graham great patriots. "Think about the guts it takes to undermine your career, and to go against your supervisors at a huge federal agency," he said, "and in this case, the multi-billion-dollar drug companies."

In an August 30, 2005, interview with Manette Loudon, the lead investigator for Dr Gary Null, Dr Graham discussed how FDA officials attempted to suppress the results of his study on Vioxx a year earlier. According to Dr Graham, prior to his Senate testimony in mid-November of 2004, there was an orchestrated campaign by senior FDA managers to intimidate him so that he would not testify about the adverse affects of Vioxx to Congress.

One attack he says, came when the acting FDA Commissioner, Lester Crawford, contacted the editor of the Lancet, a UK medical journal, and told him that Dr Graham had committed scientific misconduct and that the journal should not publish the paper that he had written showing that Vioxx increased the risks of heart attack.

The second attack came from other high level officials, he said, who contacted Senator Grassley's office in attempt to prevent Senator Grassley from calling him as a witness.

And the third he says came from senior FDA officials who contacted Tom Devine, Dr Graham's attorney at the Government Accountability Project, and attempted to convince him that the GAP should not represent Dr Graham because he was guilty of scientific misconduct.

According to Dr Graham, these officials posed as whistleblowers themselves, and told Mr Devine that Dr Graham was a "bully," a "demigod," and a "terrible person" that could not be trusted.

In one more last ditch effort to thwart Dr Graham's testimony the week before he testified, he says, the acting Commissioner offered him a job in the Commissioner's Office to oversee the revitalization of drug safety if he would just leave the Office of Drug Safety.

"Obviously he had been tipped off," Dr Graham said in the interview, "by people in the Senate Finance Committee who are sympathetic to the FDA's status quo that I was going to be called as a witness."

To preempt his testimony, he told Ms Loudon, he was offered a job "which basically would have been exile to a fancy title with no real ability to have an impact."

According to Dr Graham, by allowing Vioxx to stay on the market, the FDA is responsible for 140,000 heart attacks and 60,000 dead Americans. "That's as many people as were killed in the Vietnam War," he points out.

He says the FDA could have prevented many of the heart attacks and deaths simply by banning the high dose Vioxx back in 2000 when the agency learned about the results of the VIGOR Study. "But the FDA did nothing for almost two years," he states. "They were "negotiating" with the company over a label."

"The FDA made bad decisions," Dr Graham said, "based of its culture and its institutionalized biases that favor industry, and as a result thousands of Americans died."

During a July 18, 2005, speech on the Senate floor, Senator Grassley proclaimed, "this country's confidence in the FDA has been shaken."

It has not been shaken, he said, by one isolated incident or whistleblower. "It has been shaken because multiple drug safety concerns have been exposed by more than one courageous whistleblower."

"Dr. Graham's testimony before the Finance Committee," he told members of Congress, "suggests that the problems are systemic."

"Oversight of the FDA," Senator Grassley advised, "exposed the cozy relationship that exists between the FDA and the drug industry."

"It revealed that the FDA negotiated for almost two years with Merck," he said, "about how to change the Vioxx label so people would know about the risk of heart attacks."

According to Dr Graham, the Vioxx disaster would not have been as severe in the absence of direct-to-consumer advertising. "I submit," he told Ms Loudon, "that the numbers would have been far lower than what they were."

Due to heavy marketing of new drugs, Dr Graham says, lots of patients and doctors will use a new drug that is no better than another drug already on the market, even though the FDA does not require that new drugs be at least equivalent to, or better than, the drugs that are already there. All the drug maker has to prove is that a drug works better than a sugar pill, he says.

Silencing scientists to protect the industry has become habitual under the current politically appointed rulers of the FDA. According to Shane Ellison, author of "Health Myths Exposed," pharmaceutically compliant politicians have "democratized" the drug industry. "This means that drug approval is a matter of 51% telling the other 49% that deadly drugs are safe and necessary," he reports.

"Science and choice," he warns, "no longer prevail at the FDA or at pharmaceutical companies."

Mr Ellison is a former pharmaceutical industry chemist who says he felt a responsibility to reveal the truth about the industry's sordid tactics after he witnessed first-hand how they deceive the public, according to a September 3, 2005, interview with Crusador Editor, Greg Ciola.

"To go against the 51% means losing your career," Ellison said. "Therefore, the majority of scientists choose to please drug companies, not the general public."

As an example, Mr Ellison discussed Dr Curt Furberg, a member of the FDA's drug safety advisory committee. Dr Furberg, he says, came forward to reveal that Bextra also caused heart attack and stroke. In the British Medical Journal, Dr Furberg said that his studies showed Bextra to be no different than Vioxx, and warned that Pfizer was trying to suppress that information.

"Immediately thereafter," Mr Ellison said, "Dr. Furberg was barred from serving on the panel that is responsible for considering the safety of cyclo-oxygenase-2 (COX 2) inhibitors."

"The end result being more votes in favor of COX 2 inhibitors, the drug company wins by votes - not science," Mr Ellison told Crusador.

In the case of the pain relieving Cox-2 inhibitors, the FDA's advisory committee was stacked with experts with ties to the drug makers. Of the 32 advisers who would vote on the drugs, it has since become known that 10 of the panel members had consulted in recent years for Vioxx maker, Merck, or Pfizer, who made Celebrex and Bextra.

While the committee voted unanimously that all of the drugs significantly increased the risk of heart attack and stroke, in a 17-15 vote the panel said the FDA should allow Vioxx to remain on the market. A tally of the votes showed that without the 9 votes of the 10 members who consulted for the drug makers, the committee would have voted 14 to 8 to ban Vioxx.

However, the panel's recommendation was met with scorn and outrage by medical experts and researchers alike in the media, and in a rare occurrence, the FDA went against the recommendation of its advisory panel and refused to allow Vioxx to remain on the market.

Critics also accuse the FDA of not properly monitoring the marketing activities of the pharmaceutical industry. An investigation by the House Committee on Government Reform found that since December 2001, there has been a sharp decline in enforcement actions taken against drug companies for illegally promoting their products.

The investigation determined that from 1999 to 2001, the FDA sent out 250 "Notice of Violation" or "Warning" letters to drug companies; but for the time period of 2002 through 2004, the agency sent out only 70 letters, which amounts to a reduction of more than two-thirds.

Since the Vioxx and SSRI debacles, Senator Grassley has jumped on the FDA every time there has been any indication that officials might be putting the industry's interest over public safety. Earlier this year, he wrote a letter to the FDA saying he was concerned that it might be "dropping the regulatory ball" on stimulant drugs, prescribed to treat ADHD.

Specifically, he wrote, "I'm concerned FDA's regulatory responsibilities haven't kept pace with the explosion of prescriptions written to treat 2.5 million children with these drugs."

Despite psychiatric and cardiovascular risk signals associated with the drugs, he noted, it appears the FDA has failed to promptly respond to their possible adverse effects. "Such events," he wrote, "may include sudden unexplained deaths, strokes, cardiovascular irregularities or aggression, anxiety and depression."

Sales of drugs, he said, "have zoomed to the moon, jumping from $759 million to $3.1 billion between 2000 and 2004."

"And yet," he wrote, "the FDA seems to have adopted a wait-and-see approach before charting a course of action to study these risks."

In early February 2006, he noted, that an advisory panel had recommended adding the strongest black box warning to ADHD drugs to alert patients about the possible cardiovascular side effects.

"The recommendation," Senator Grassley wrote, "brings even more urgency to the controversy surrounding the explosion of prescriptions being filled with these medicines."

"As the debate unfolds," he warned agency officials, "I will continue to closely track the FDA and urge its timely, thorough review of these drugs."

"With millions of Americans, mostly children, regularly taking these medications," he added, "it is essential the FDA leaves no stone unturned to investigate and review this class of drugs."

No doubt in response to all the intense scrutiny from members of Congress, in late July 2006, the FDA outlined a series of changes it plans to make in the methods used to evaluate clinical trials. One of the proposed changes would require a drug company to notify the FDA immediately if it believes a researcher has committed fraud during a clinical trial.

As it is now, drugs companies are trusted to remove unreliable data and are not required to report any fraudulent activity to the FDA until they actually submit the application.

The agency also says it plans to clarify which adverse events in clinical trials must be reported to the review boards that monitor the studies. Other proposed change includes the standardization of forms used to collect information and a revision of the rules on how patients may qualify to participate in clinical trials.

However, people who are tempted to think that the FDA is capable of changing under the agency's current team of politically appointed officials, had better think again.

According to an article by Russell Mokhiber and Robert Weissman, for Common Dreams on August 2, 2006, Dr Steven Nissen, chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic, was recently a member of a panel debating the topic of: "Government Science Panels: Fair and Balanced?" which was moderated by National Public Radio's Snigdha Prakash, and sponsored the Center for Science in the Public Interest.

Dr Nissen spoke about the conflict-of-interest problems "evident at the highest levels of the FDA," the article says.

"For years," Dr Nissen said in describing FDA leadership, "we had an interim FDA Commissioner, Lester Crawford, who shortly after confirmation, abruptly resigns, apparently because he and his wife owned stock in regulated companies."

"Then the administration appointed Andrew Von Eschenbach as interim commissioner, creating another conflict," he noted.

"In his role as director of the National Cancer Institute," Dr Nissen said, "Von Eschenbach must seek FDA approval for human testing or approval of new cancer drugs, an obvious conflict."

But even worse, he said, "the administration appointed Scott Gottlieb as deputy commissioner."

"He came to this job with no regulatory experience, directly from Wall Street, where he served as a biotech analyst and stock promoter," Dr Nissen stated.

"Between them," he said, "Drs. Von Eschenbach and Gottlieb have whined incessantly about the need to speed drug development."

"So while the American people worry about the safety of drugs," he continued, "the top FDA leadership tells us we need faster drug approval."

On November 12, 2005, the Boston Globe reported that prior to his job at the FDA, Dr Gottlieb worked for the PR firm of Manning Selvage & Lee and that his clients included Roche, the manufacturer of Tamiflu, and Sanofi-Aventis, the maker of Ketek, and the parent company to the nation's sole flu vaccine maker.

According to the Globe, the Manning PR firm paid Dr Gottlieb a monthly retainer of $12,500 for nine months, for working on projects that involved eight companies. Other firms regulated by the FDA that he was involved with include Inamed Corp, a company seeking the return of silicone gel implants to the market.

Between May and July 2005, Dr Gottlieb also was paid $9,000 for consultant work performed for VaxGen, a company that won an $878 million government contract to supply the US with 75 million doses of anthrax vaccine.

In any event, no matter who's in charge, the Senator from Iowa is keeping the heat on. In July 2006, he wrote a letter to the Daniel Levinson, the Inspector General at the Department of Health and Human Services, asking for an investigation into whether Dr Brian Harvey of the FDA, conspired against Dr Graham by providing Merck with details about Dr Graham's presentation on Vioxx, prior to the hearing in 2004 to help the company refute his testimony.

"It is no secret that Dr. Graham was and is a critic of the FDA," he wrote to Inspector. "However," he said, "that does not mean the FDA should scheme with drug sponsors to discredit its own employees."


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