This week on the Mad in America podcast, we are joined by Dr. Jon Jureidini.
Jon is a child psychiatrist who also trained in philosophy, critical appraisal and psychotherapy. He has a continuing appointment as a professor in the School of Medicine at the University of Adelaide. He heads Adelaide University’s Critical and Ethical Mental Health research group, which conducts research, teaching and advocacy to promote safer, more effective and more ethical research and practice in mental health; and the Paediatric Mental Health Training Unit, providing training and support to medical students, GPs, allied health professionals, teachers and counsellors in non-pathologising approaches to primary care mental health.
He has an international reputation for his work on the evidence base for psychiatry and is a strong advocate for addressing the social determinants of mental health.
Jon, together with co-author Leemon B. McHenry, wrote the book The Illusion of Evidence-Based Medicine published in 2020. The book was followed by an opinion piece which appeared in the British Medical Journal in March 2022.
In this interview, we discuss the issues with evidence-based medicine and what led to the debasement of a system originally conceived to challenge extravagant claims and poor science.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
James Moore: Dr. Jureidini, welcome. Thank you so much for joining me today for the Mad in America podcast.
Jon Jureidini: It’s a real pleasure to be here. Thank you.
Moore: We’re here today to talk about your 2020 book, authored with Leemon B. McHenry, entitled The Illusion of Evidence-Based Medicine. I’d like to come on to talk about the book and the paper but first, I was interested to know a little about you.
You’re a professor of psychiatry and pediatrics at the University of Adelaide in Australia and you’ve written extensively on clinical trials, misleading drug promotion and corporate influence in medical education. I just wondered how was it that you came to have this kind of critical focus on these issues.
Jureidini: The first experience I had of thinking this might be an issue was actually something that seems quite trivial. I was at a conference and it was in an exhibition hall of drug companies and I raced around and grabbed all the freebies I could. I sat down in a chair and looked at this crap that I’d accumulated that I didn’t really want and I thought, something strange is going on here. That kind of piqued my interest.
It happened that our professor of pharmacology had put around a series of guidelines about interacting with industry and I kind of laughed at it and thought, how Calvinist. After having had that response, I reflected more and then I ran into Peter Mansfield, who ran an organization called Healthy Skepticism, which was quite influential in its time. He educated me about these issues.
Moore: Before we turn to the book, I wanted to ask about the concept of evidence-based medicine. Is it just an academic concern which should involve journal editors and researchers or should it also be of concern to the average person in the street?
Jureidini: The trouble is the average person is not in a position to appraise the evidence and is therefore reliant on other people to do that. Maybe that’s a bit of an overstatement because there are people outside of medicine who have done a fabulous job of appraising the evidence, Robert Whitaker being one of them. But the average person considering decisions about their own health isn’t well equipped to do that kind of analysis.
I’ve been accused of scaremongering and I say, “It’s not me creating the fear. It’s actually a very scary business, evidence-based medicine, and something we should be very concerned about.”
Moore: Your book tells a story of the many ways in which the profit-driven motive of the pharmaceutical industry undermines the integrity of science and you talk of the corrupting influence of commercial objectives.
There are many players in this process, from pharmaceutical manufacturers and their research and marketing teams, to journal editors, medical education providers and then ultimately prescribers. Mentioned often in the book is the role of what’s called key opinion leaders. Particularly in psychiatry, key opinion leaders seem to be very prominent. Could describe for us what a key opinion leader is and some of the ways in which they interfere with and influence the science?
Jureidini: That term is used by the pharmaceutical industry, primarily. What they are looking for are like-minded individuals who share their views about medicine and who can be used to unwittingly promote their products. A typical situation would be a young clinician with academic aspirations who has some ideas that are broadly sympathetic to the drug company’s agenda. The drug company recognizes that, grooms the young academic and helps them in their career.
One of the things that’s really hard when you’re getting started as a medical academic is to get research funding. The people who’ve already been funded are the people who then get funded, so you’ve got to find a way to jump onto that treadmill. Drug company sponsorship for research is a good way of doing that.
It happens in two ways. One, you get invited to become a chief investigator in a study that’s already been designed by a company. The duties of the chief investigator are not particularly onerous, you just have to contribute patients and your unit gets well rewarded for that and you get to go to chief investigators meetings which are typically held in nice cities around the world, that’s one way.
The other way is investigator-initiated research. If I’ve got an idea about how to use an existing drug, it won’t matter much to the company about whether there’s any scientific merit in that proposal. They’ll want to support me in doing that. They might get a publication out of it with their name on it but, more importantly, they are grooming me as a budding academic researcher and then are able to trade off my reputation. They will invite me to give talks at conferences, to participate in company-sponsored events at conferences that are disguised to look like they’re part of the legitimate program, and sometimes they are because companies influence the conference organizers.
The key opinion leader is not generally motivated by financial reward although there can be, if not direct financial reward to the key opinion leaders, certainly to their academic research teams. It’s more about career advancement. If you look at heads of department around Australia and I have reasonable confidence in saying around America too, you will struggle to find somebody who has got to a head of department position in psychiatry without having a leg up from industry.
Moore: It comes across in the book that key opinion leaders seem to be amplifying product marketing messages to give a seal of approval and contributing to perhaps the ghostwriting or ghost management really of journal articles, so they’re quite enmeshed in the process, aren’t they?
Jureidini: Absolutely and the other thing that a key opinion leader can do that a drug rep can’t do is promote off-label prescribing. The company itself is prohibited from promoting to doctors that they should use drugs off label. A key opinion leader is not, and so the key opinion leader is the person who promotes off-label prescribing with all of the dangers associated with that.
Now, off-label prescribing in and of itself is not necessarily a bad thing but most off-label prescribing that occurs in psychiatry is poorly thought out and poorly supported by evidence.
Moore: There were some terms in the book that I hadn’t come across before, you talk about astroturfing and evergreening, so could you tell us more about those?
Jureidini: Astroturfing is about fabricating consumer groups. The highest profile parents group for ADHD is actually a drug company-sponsored entity. What you get out of that is a consumer voice which can be more powerful than something that’s coming from industry. It appears to be independent, but it’s not.
Evergreening is about patent extension. A patent is usually 20 years but by the time the drug gets onto the market, there might be only a few years left. If you can come up with a new indication for the drug then you can get an extension of the patent. With blockbuster drugs—ones that turnover at least a billion dollars a year—just 12 months of patent extension is very valuable to a company. So you get these more-or-less fabricated conditions like social anxiety disorder or female sexual dysfunction that are used purely and cynically to extend patents and make profits for industry.
Moore: In the book, it’s mentioned that in the 1800s and early 1900s, the pharmaceutical companies’ extravagant claims for their drugs at the time were labeled the “Great American Fraud.” This created the need to regulate and police their claims and ultimately led to evidence-based medicine as an attempt to bring that into line.
After reading your book, I had to ask myself, are we really any better off now in 2022 than we were in those wild times?
Jureidini: I think we are. I don’t want to denigrate the concept of evidence-based medicine, because evidence-based decision-making is a good thing. Our concern is that true evidence-based medicine isn’t what’s practiced, largely because of the influence of industry but there are other reasons too.
One of the most striking shortcomings in the current approach to evidence in medicine is the absence of rigorously trying to set out to disprove a favorite hypothesis. What happens mostly in medicine is that people get an idea that they like and then try and massage the data to support that point of view rather than having a good idea and thinking “I’d really like that idea to be meaningful but before I go out there and tell people that I’ve got this great idea, I want to do whatever I can to challenge the idea.”
Drug companies in particular do bigger and bigger studies with more and more people in them which makes it more likely that the results are going to reach statistical significance. The general perception is the bigger the study the better. But actually, if you can demonstrate in a very small study that there’s a significant effect, that’s much more meaningful than demonstrating it in a large study.
In our book, we talk about research into scurvy in the 18th century. There were two patients in each group in that study but because lime juice containing vitamin C was actually a straightforward preventative and cure for scurvy, it only took a total study of 14 people to prove a really important medical development.
I think that should stand as a paradigm of good practice, that if you can show something in a small study and if it’s something stands out, then that’s much more likely to be meaningful than something that you need a meta-analysis of 15 different studies to show a fractional benefit, which is the case with antidepressants.
Moore: Talking a little bit about clinical trials, in the book you go into some detail about GlaxoSmithKline’s infamous Study 329 which evaluated the antidepressant paroxetine, and also Forest Laboratory’s citalopram study. In the book, you say, “In a post-truth world we want to restore objectivity to the scientific testing of medicines.”
That’s quite a goal and quite a target, isn’t it? How could we start to move toward a place where we can have confidence that clinical trials are free from corporate influence and conducted for science rather than acting as a marketing tool for a particular drug?
Jureidini: The more or less complete solution to that would be to take pharmaceutical research out of industry. It was put into industry because that seemed to be the most economically feasible way of doing it. It proved to be economically feasible for industry but not beneficial for patients.
It’s not the case that industry generously pays for research. Industry passes on all of the cost of research and more in the way that they market their drugs. So they carry out all this research and still make huge profits and they tell us how expensive research is to do. If that were all true then they should be really happy to relieve themselves of the responsibility of research and a tax could be exacted on them to cover that research or the money instead of going to the cost of drugs could go to government who could then commission properly conducted research, but that’s not going to happen.
Something that could happen and would be feasible would be that people carrying out research could only publish just their data, not their conclusions or any analysis of it. The data would be published on a suitable website with access for properly qualified people who could then analyze the data and report on it. The company could as well, but they would have no more access to the data than an independent person would.
There was an initiative called All Trials, which attracted a lot of attention. It was a step forward in that it required that the protocols of trials be published and the results always being published. In fact, GlaxoSmithKline was a big mover in getting that off the ground and that seems like a virtuous act by the company until you know that in a legal settlement they were ordered by the Attorney General in New York to publish all their trials. Cleverly, they made a virtue out of a necessity and they made themselves look like great corporate citizens and a big supporters of the All Trials initiative. So you need to be a bit skeptical about supposed positive acts by companies.
Who do the data belong to? Drug companies say they belong to them and talk about intellectual property. From our point of view, they belong to the participants who’ve made a sacrifice and a risk in participating in trials. Our obligation to them is to make the best possible use of the information that’s been generated in the interest of patients more generally. I think that patient interest trumps intellectual property considerations.
Moore: It was surprising to read how difficult it was for you to access data behind Study 329 and the Forest Laboratories citalopram study.
Jureidini: We’ve had a more recent episode where we’re just finishing off a reanalysis of a study called TADs, the Treatment of Adolescent Depression, which is probably the most influential trial of antidepressants in adolescents.
By the time we got on to Duke University, we were too late to get hold of the individual patient records and they had already been destroyed. But in existence, and very important, were the serious adverse event reports. There were 60 or so serious adverse events, and Duke still had the original reports that were filled out at the study sites by the people who were carrying out the study.
At high cost, they agreed to make them available to our team and we did some negotiation and got the cost down a little bit. We wrote a contract between our university and Duke University that would enable us to have access. Then, at the last minute, they said, “Actually, we’ve gone to our ethics committee and we can’t give you those documents because they can’t be sufficiently redacted to protect the identity of the patients.” This was clearly untrue because I had already provided the same documents to Columbia University in an earlier analysis of suicide and antidepressant trials.
What was equally interesting was that we went to our university and said, “Please support us in enforcing this contract that Duke has already entered into.” But our university wouldn’t do that. We got an American law firm to support us but again, our university wouldn’t let us pursue a legal means. Then when we wrote the whole thing up, our university wouldn’t let us publish any of the correspondence that we’d had with them about it.
One of the things that we do go on about in our book and in the opinion paper is the way in which academic institutions have sold out to industry more generally, and how concerning that is.
Moore: You said how difficult it was to access the data. When the regulators come to approve a drug, do they get to see the raw data from trials, or is that not part of how the approval is given?
Jureidini: This is not an area of expertise for me but my understanding is that the regulator is often quite accepting of what’s fed to them by industry. I’ve been involved in one case where the judgment by the FDA was in fact a cut and paste from documents submitted to them by industry.
There are famous cases of people in the FDA taking a proper interest in what is being presented to them. Unfortunately, they don’t seem to have been well supported by their agency when they’ve tried to do something about that. They have been treated very poorly and have to be whistleblowers rather than it being resolved within the agency. We know there’s a revolving door with people within the FDA working their careers towards senior positions within industry, and the FDA is funded by pharmaceutical licensing fees, so that relationship is far too close and blurry for patients to feel safe.
Moore: There’s this whole web of interlinked parts of the puzzle in terms of how industry does its influencing. Your book also says that political lobbying by the pharmaceutical industry is the single most important factor in the corruption of the regulatory system. It goes on to say the pharmaceutical industry is the largest lobby in Washington DC.
Jureidini: It’s interesting because in Australia, being a small jurisdiction, there are two or three psychiatrists who more or less own the public and political discourse. While their entanglement with industry is not huge, they’ve got to the stage where they get all the funding they want from government. Nevertheless, they experience significant career advancement through their engagement with industry and although both speak strongly to social determinants of mental health, they are always sticking up for pharmaceutical intervention.
With the recent publicity about the final putting to rest of the “chemical imbalance,” these key opinion leaders in Australia are wheeled out to say, “Well, yes we knew that all along, but that doesn’t mean that antidepressants aren’t great drugs for anybody who takes them.” So they’re not directly motivated by industry to do that, so you’ve got the voice of apparently well-intentioned, well-qualified public citizens and then you’ve got the direct lobbying. As you rightly pointed out, there are more pharmaceutical lobbyists in Washington than there are Congress members.
The political pressure is not just being applied from one direction, it’s coming from multiple directions. As Leeman pointed out in our book, it is a product and celebration of neoliberalism, and our health is not something that should be prone to that political and economic approach.
Moore: And dramatic creep in terms of identifying things to treat. I seem to remember it was one of the senior people in Merck saying that they wanted Merck products to be more like Wrigley’s chewing gum, something that people just have every day rather than to be seen solely as treating diseases.
Jureidini: Exactly, and that shapes the research agenda as well. Tropical diseases, for example, that kill and disable millions and millions of people get relatively little research from industry because if they do find a treatment it would most likely be something that people take for a couple of weeks and then stop. There’s not the same level of profit in it.
Moore: I’m sure you are aware that there’s been this issue about withdrawal effects from antidepressants and this idea that withdrawal problems are mild and self-limiting over a couple of weeks, We know that this came from the pharmaceutical industry. I was interested to read that the genesis for that might actually have been from a disagreement about the withdrawal effects of paroxetine being a short half-life drug and fluoxetine being a longer half-life drug. Two pharmaceutical companies essentially trying to out-argue each other as to which was the easiest to withdraw from.
Jureidini: Fluoxetine (Prozac) was the first to market and it was losing its market share to paroxetine (Paxil). Part of it was the more energizing effect of Paxil because it’s a shorter-acting drug and quite a nasty drug, but Lilly, the makers of fluoxetine, found a way of getting back at GlaxoSmithKline by saying, “Well your drug is going to have more withdrawal effects because ours is longer acting drug and won’t create the same problems.”
It’s a rare example of vigorous competition between companies though, because most of the time, what’s good for Glaxo is good for Lilly. If you promote fluoxetine, doctors aren’t necessarily going to prescribe fluoxetine. They just recognize that there’s not a lot of difference between different antidepressants. If Lilly is busily doing something that increases the sales of fluoxetine, they’ll also be increasing the market for paroxetine. Market size is probably a bigger issue for companies than market share.
Moore: You end the book with what you call a Radical Proposal and we’ve talked a little bit about that in terms of having trials independently assessed and the data taken out of industry. But, I wondered what else you felt there was anything more we could do to achieve intellectual honesty. I’m thinking of things like the Restoring Invisible and Abandoned Trials (RIAT) initiative that I know you’ve been involved with. Are there other things happening that might start to chip away at this monumental problem?
Jureidini: Yes, I think of the RIAT initiative. We’ve been involved with two of those and I think it’s a great initiative. Maybe half a dozen studies have been done, and one thing that you recognize is how incredibly time expensive it is to do this kind of work and how difficult it is to get it published.
It’s relatively easy for the company to get their shoddily reported study published in the first place, but you wouldn’t believe how hard it was for us to get our BMJ study on reanalyzing Study 329 published. We had 27 pages of reviews on the first submission. There were six months of to-ing and fro-ing between us and the BMJ and people were at each other’s throats.
It was an incredibly demanding, stressful process. In the end, the BMJ were very flattering about it and Fiona Godlee said it was one of the proudest moments of hers as the editor of the BMJ, but they didn’t make us feel like that. We felt like we were having to justify every full stop and capital letter, whereas the people who published the trial initially, albeit not in the BMJ, had just had ghostwriters prepare it. They’d present it to one journal and get rejected. Then present it to another one, do about half of what the reviewer’s asked them to do, and there it was in print.
Moore: At the end of the book, in the appendices, there are a number of letters presented that you or Leemon wrote to senior people in pharmaceutical companies or to journal editors. You get some sense there of how difficult a job this is. You must feel like you’re bashing your head against a brick wall most of the time.
Jureidini: I was at a conference in Sydney a while ago the title of which was “Truth Decay.” It was about the range of things affecting health where post-truth politics were having a negative impact. One of the presentations, by a lovely and very smart man, was about conspiracy theories in health. Interestingly, his chosen topic was people who criticize antidepressants. Here was an academic who thought that our criticism of antidepressants was actually manifesting a conspiracy theory rather than good science. So you can see that the odds are against us in trying to have an impact.
Moore: The book goes into some detail about ghostwriting and the ghost management of clinical trial reports. Could you share with us some of what you found about that during your research?
Jureidini: The most egregious example of ghostwriting and ghost management that I have come across was in the Forest citalopram study. Through legal action, there has been access to company documents.
One of them has a person from the ghostwriting agency writing to a person from marketing in Forest Pharmaceuticals saying, “It’s not clear yet who’s going to write this paper” (as opposed to who’s going to be the author). What they’re saying is they haven’t quite decided who in their team is going to prepare the manuscript, much less who they’re going to claim to have written the paper and who’s going to be listed as the author on the manuscript.
We see drafts of the manuscript prepared by the medical writing agency, as they call themselves and passed over to Forest marketing backwards and forwards. At a very advanced stage of development, out of courtesy more or less, the manuscript is sent to Karen Wagner, who’s the named first author, for her to make a few editorial comments before the medical writer then submits it to a journal. Then they choose a journal that would prefer a brief report so they can get away with not reporting some of the negative findings that would be required in a more extensive report of their paper.
Ghostwriting is a problem academically. It shouldn’t be the case that somebody claims scientific credit for writing a paper that they haven’t written. But from a patient’s point of view, that doesn’t really matter as long as the science is accurately represented. A patient doesn’t really care whether Karen Wagner really wrote that paper or not.
But what a patient does care about is whether the science is accurately represented. The bigger problem than ghostwriting is ghost management, where the whole process of what’s put into the paper and how the science is distorted is controlled by the company through their medical writing agencies. That does matter to patients because it means that false information or potentially fatal information is included in published articles.
Moore: There are some chilling examples in the book where you see the interface between the science and marketing messages and where the two don’t line up. There’s some real sleight of hand to finesse the wording such that, in some cases, goes as far as turning a negative result into a positive result.
Jureidini: Where it’s most dodgy is in the reporting of adverse events. The RIAT reanalysis that we’ve done has not turned out to be dramatically different in the efficacy findings. It’s the way it’s reported that’s the problem there, the spin that’s put on it. But what’s really bad is the way in which adverse events are hidden quite deliberately and cynically.
I think probably the most important thing in our Study 329 reanalysis that was published in the BMJ is a table where we describe 10 ways in which adverse events can be hidden or misrepresented in publications and they’re all incredibly common and used very widely.
Moore: Could you give us some examples of those? One that I do recall was clumping together adverse events to make them look as if they’re more general and not so serious.
Jureidini: If you’ve got some severe psychiatric adverse events you create a category called “neurological event” and you make psychiatric events a subsection of that, then you compare the overall figures. Headaches go into that category and they’re incredibly common, so the noise drowns out the signal.
Alternatively, if you’ve got a drug that has an activating effect that can cause nasty side effects like akathisia, you give different patients different labels. Then you say it’s got to occur 5% of the time or in 5% of patients to be reportable. So by dividing it up, you don’t reach the threshold of 5%.
Or you can rename something. In Study 329, they placed kids who had made suicide attempts under the category of “emotional lability.” Any clinician seeing the label of emotional lability would think, well, the drug made them laugh a bit outlandishly or cry a bit inappropriately, but no, that’s actually code for suicide attempts.
Moore: Study 329 is perhaps one of the more well-known examples of this, has it ever been retracted?
Jureidini: No. I mean, it’s quite amusing looking back on it now, though it wasn’t very amusing at the time. We wrote to the journal; when the journal editor changed we wrote to the new editor. We wrote to Brown University where the named author came from and we wrote to GlaxoSmithKline. We occasionally got replies, but no action.
Moore: So theoretically there are prescribers out there who could still look on that study as a basis for the safety and efficacy of prescribing that particular product and yet, it’s been comprehensively debunked.
Jureidini: Every few years we do a literature search on citations of that study. We found up until quite recently that up to 30 or 40% of the citations of it were either positive or at least uncritical. In fact, I think only a small minority were actually critical, citing it in a way that acknowledged its shortcomings.
Moore: Is there an answer to ghostwriting? I guess going back to your earlier suggestion of it if we could take the whole business of clinical trials out of industry and making independent, presumably that would also deal with issues of ghostwriting because it would then become about the science, not about the marketing message that is applied post-hoc to the science.
Jureidini: Exactly, and the closest I can get to that in advising young doctors is to tell them to only read the methods and results of the paper. In the original publication of Study 329, what was written in the methods and results about efficacy was accurate if you knew how to look at it, but what was written in the abstract and conclusions was entirely misleading.
Now, that didn’t provide any protection against the misleading nature of the way adverse events were reported but it did provide some protection against being led to draw incorrect conclusions as people were doing with that study.
Moore: It must be quite a challenge for prescribers to look at trials and read anything more than the abstract because they’re under so much time pressure. They probably don’t have the time or resources to go and look at the data analysis and the statistics. They’re probably just going by some very high-level messages and the abstract, aren’t they?
Jureidini: Yes, but it only becomes an issue if that paper is going to change your practice. There are a couple of ways in which you can protect yourself from making bad decisions about prescribing drugs that have been misrepresented.
The first is to favor old drugs over new drugs because if a drug has been around for a long time, it’s likely that any adverse effects of it have become more apparent. If it’s survived, that’s probably a good thing. The second thing is to restrict yourself to one or two drugs from any class and get to know those drugs well and only be motivated to change those drugs if you’ve got strong grounds to think that there’s a dramatic benefit to be gained from a new drug.
There are drug bulletins around that doctors can use that provide a kind of screening for that. Prescrire, the French drug bulletin, will tell you if a new drug that comes on the market is worthy of consideration.
Then if you are thinking of using a new drug or treatment, you do need to spend a lot of time looking in detail at the data. You can’t rely on guidelines, and my advice is to form a critical appraisal group, kind of like a journal club, but to find somebody who can mentor a group of physicians in strongly critically appraising literature. But you don’t have to do it very often, because new drugs or new treatments that are going to change your practice don’t actually come along that often.
It looks like they do because new drugs come onto the market but most of them are “Me-too” drugs like all of the antidepressants that came along after fluoxetine and don’t require your attention.
One more thing is about surrogate measures. The idea is that a lot of misleading information comes from placing too much credence on things like changes in blood pressure or lipid levels or, in the case of psychiatry, symptom measures, without looking at mortality or hospitalization or even quality of life measures that measure more substantial outcomes.
The hierarchy of evidence in the conventional pursuit of evidence-based medicine is based on the methodology that’s been used to gather the data. You have a meta-analysis at the top and then a big randomized controlled trial and then cohort studies and then single case studies. What that doesn’t take into account is the importance of what’s being measured, so that hierarchy needs to be respected as well.
Vioxx is probably the best example of something that, at the level of symptomatic improvement, looks like a really good drug but once you started to measure important outcomes like hospitalization and mortality, we discovered that it was a really bad drug.
There’s a long list of drugs that have looked really good when they’ve first been developed because all that has been measured are the surrogates. Once the more important measures like hospitalization and mortality have been investigated, it turns out this drug does more harm than good.
Moore: And as you said earlier, it might be decades before there’s enough data available on the effects of that drug in the clinical setting.
Jureidini: Yes, but with Vioxx, it was years rather than decades. If people had stuck with the old drug for just a while, it would have been long enough for them to avoid the new drugs. It’s great to be an early adopter if you’re buying a new computer or something like that, but it’s not a good idea to be an early adopter with medical treatments.
Moore: Jon, thank you so much for spending some time with me today to talk about your book. It’s very accessible but very sobering reading. It makes clear how evidence-based medicine has been corrupted by corporate interests, failed regulation and the commercialization of academia.
I hope that initiatives like Restoring Invisible and Abandoned Trials and the setting up of journals free from industry influence help to restore some balance.
I can’t imagine how difficult it is to set yourselves up in opposition to people in some of the most profitable businesses on earth who seem to have an endless supply of money to invest in marketing, legal protection and in influencing and all the rest of it. I think it’s an incredibly brave thing to do, so thank you for your work, Jon.
Jureidini: Thank you very much for having me.