Beware of the medical-industrial complex

Dr. Arnold Relman, Outspoken Medical Editor, Dies at 91

By DOUGLAS MARTINJUNE 21, 2014

Photo
Dr. Arnold S. Relman in 1979 at The New England Journal of Medicine. He led it for 23 years. Credit Associated Press

Dr. Arnold S. Relman, who abandoned the study of philosophy to rise to the top of the medical profession as a researcher, administrator and longtime editor of The New England Journal of Medicine, which became a platform for his early and influential attacks on the profit-driven health care system, died at his home in Cambridge, Mass., on Tuesday, his 91st birthday.

His wife, Dr. Marcia Angell, said the cause was melanoma.

Dr. Relman and Dr. Angell filled top editorial posts at the journal for almost a quarter-century, becoming “American medicine’s royal couple,” as the physician and journalist Abigail Zuger wrote in The New York Times in 2012.

The couple shared a George Polk Award, one of journalism’s highest prizes, for an article in 2002 in The New Republic that documented how drug companies invest far more in advertising and lobbying than in research and development.

His extended critique of the medical system was just one facet of a long and accomplished career. Dr. Relman was president of the American Federation for Clinical Research, the American Society of Clinical Investigation and the Association of American Physicians — the only person to hold all three positions. He taught and did research at Boston University, the University of Pennsylvania, Oxford and Harvard, where he was professor emeritus of medicine and social medicine.

Early in his career, he did pioneering research on kidney function.

He was also editor of The Journal of Clinical Investigation, a bible in its field, and he wrote hundreds of articles, for both professional journals and general-interest publications. Days before he died, Dr. Relman received the galleys of his final article, a review of a book on health care spending for The New York Review of Books, to which he was a frequent contributor.

In a provocative essay in the New England journal on Oct. 23, 1980, Dr. Relman, the editor in chief, issued the clarion call that would resound through his career, assailing the American health care system as caring more about making money than curing the sick. He called it a “new medical-industrial complex” — a deliberate analogy to President Dwight D. Eisenhower’s warning about a “military-industrial complex.”

His targets were not the old-line drug companies and medical-equipment suppliers, but rather a new generation of health care and medical services — profit-driven hospitals and nursing homes, diagnostic laboratories, home-care services, kidney dialysis centers and other businesses that made up a multibillion-dollar industry.

“The private health care industry is primarily interested in selling services that are profitable, but patients are interested only in services that they need,” he wrote. In an editorial, The Times said he had “raised a timely warning.”

In 2012, asked how his prediction had turned out, Dr. Relman said medical profiteering had become even worse than he could have imagined.

His prescription was a single taxpayer-supported insurance system, like Medicare, to replace hundreds of private, high-overhead insurance companies, which he called “parasites.” To control costs, he advocated that doctors be paid a salary rather than a fee for each service performed.
Continue reading the main story

Dr. Relman recognized that his recommendations for repairing the health care system might be politically impossible, but he insisted that it was imperative to keep trying. Though he said he was glad that the health care law signed by President Obama in 2010 enabled more people to get insurance, he saw the legislation as a partial reform at best.

The health care system, he said, was in need of a more aggressive solution to fundamental problems, which he had discussed, somewhat philosophically, in an interview with Technology Review in 1989.

“Many people think that doctors make their recommendations from a basis of scientific certainty, that the facts are very clear and there’s only one way to diagnose or treat an illness,” he told the review. “In reality, that’s not always the case. Many things are a matter of conjecture, tradition, convenience, habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive.”

Dr. Relman edited The New England Journal of Medicine from 1977 to 2000. Founded in 1812, it is the oldest continuously published medical journal in the world, reaching more than 600,000 readers a week.

When he took the journal’s helm, interest in health news was booming, and newspapers and magazines competed to be first in reporting new developments. One policy he instituted was to ask general-interest publications not to disclose a forthcoming article in advance, a request almost always honored, albeit sometimes grudgingly.

He also began requiring authors to disclose any financial arrangements that could affect their judgment in writing about the medical field, including consultancies and stock ownership.

Dr. Relman and Dr. Angell met when she was a third-year student in one of his classes at Harvard Medical School. They published a paper on kidney disease together in The New England Journal of Medicine, then did not see each other for years.

After he became the journal’s editor, he asked her to come on board as an editor, which she did, abandoning her career as a pathologist. They began living together in 1994 — both were divorced by then — and married in 2009.

They became the ultimate medical power couple, not least because they were gatekeepers for one of the world’s most prestigious medical journals. Their outspoken views further distinguished them.

“Some have dismissed the pair as medical Don Quixotes, comically deluded figures tilting at benign features of the landscape,” Dr. Zuger wrote in The Times. “Others consider them first responders in what has become a battle for the soul of American medicine.”

Arnold Seymour Relman was born on June 17, 1923, in Queens (in an elevator, according to Dr. Angell) and grew up in the Far Rockaway neighborhood. His father was a businessman and avid reader who inspired his son’s love of philosophy. His mother nicknamed him Buddy, and friends called him Bud the rest of his life.
Continue reading the main story Continue reading the main story
Continue reading the main story

He skipped grades in school and graduated at 19 from Cornell with a degree in philosophy, but he chose not to pursue the field because it “seemed sort of too arcane,” his wife said. He earned a medical degree from the Columbia University College of Physicians and Surgeons at 22. His first marriage was to Harriet M. Vitkin.

In addition to Dr. Angell, he is survived by his sons, David and John, and a daughter, Margaret R. Batten, all from his first marriage; his stepdaughters, Dr. Lara Goitein and Elizabeth Goitein; six granddaughters; and four stepgrandsons.

Last June, Dr. Relman fell down a flight of stairs and cracked his skull, broke three vertebrae in his neck and broke more bones in his face. When he reached the emergency room, surgeons cut his neck to connect a breathing tube. His heart stopped three times.

“Technically, I died,” he told The Boston Globe.

He went on to write an article about his experience for The New York Review of Books, offering the unusual perspective of both a patient and a doctor.

“It’s both good and bad to be a doctor and to be old and sick,” he told The Globe.

“You learn to make the most of it,” he added. “Schopenhauer, the German philosopher, said life is slow death. Doctors learn to accept that as part of life. Although we consider death to be our enemy, it’s something we know very well, and that we deal with all the time, and we know that we are no different. My body is just another body.”

A version of this article appears in print on June 22, 2014, on page A23 of the New York edition with the headline: Dr. Arnold Relman, 91, Outspoken Medical Editor, Dies. Order Reprints|Today's Paper|Subscribe