Guest Post: Scholarly Mad Libs and Peer-less Reviews

Health Care Renewal presents a guest post by Marjorie Lazoff, MD, a Board certified internist with a clinical background in academic emergency medicine.  She is currently a full time freelance editor and independent consultant specializing in evidence-based clinical content and medical informatics.

On December 17, 2014, Scientific American published an investigative report by journalist Charles Seife documenting a new and curious form of scholarly publication fraud, For Sale: “Your Name Here” in a Prestigious Science Journal. As an editor and supporter of evidence-based medicine I am both appalled by, and sympathetic to, how such widespread fraud could take place unnoticed.

Seife describes how he discovered the doctored writings:

The dubious papers aren't easy to spot. Taken individually each research article seems legitimate. But in an investigation by Scientific American that analyzed the language used in more than 100 scientific articles we found evidence of some worrisome patterns—signs of what appears to be an attempt to game the peer-review system on an industrial scale…

…This is not a simple case of plagiarism. Many seemingly independent research teams have been plagiarizing the same passage. An article in PLOS ONE may eventually lead to 'our better, comprehensive understanding' of the association between mutations in the XRCC1 gene and thyroid cancer risk. Another in the International Journal of Cancer (published by Wiley) might eventually lead to 'our better, comprehensive understanding' of the association between mutations in the XPA gene and cancer risk—and so on. Sometimes there are minor variations in the wording but in more than a dozen articles we found almost identical language with different genes and diseases seemingly plunked into the paragraph, like an esoteric version of Mad Libs, the parlor game in which participants fill in missing words in a passage.

Another example virtually eliminates the likelihood of coincidence:

There is no such thing as a 'Beggers funnel plot'…the proliferation of 'Begger's' tests [were discovered] by accident. While looking for trends in medical journal articles, papers [were found] that had almost identical titles, similar choices in graphics and the same quirky errors, such as 'Begger's funnel plot.'

Seife’s investigative reporting revealed that China was the source of most of his “fill-in-the-blanks” research. Further,

Much of the funding for these suspect papers comes from the Chinese government. Of the first 100 papers identified by Scientific American [and listed at the close of his article], 24 had received funding from the National Natural Science Foundation of China (NSFC), a governmental funding agency roughly equivalent to the U.S.'s National Science Foundation. Another 17 acknowledged grants from other government sources.

Seife suspects that most research probably began as legitimate work without intent to deceive, but somewhere an author or service was added to help ensure publication through the necessarily arduous manuscript review process.

The culprit?

A quick Internet search uncovers outfits that offer to arrange, for a fee, authorship of papers to be published in peer-reviewed outlets. They seem to cater to researchers looking for a quick and dirty way of getting a publication in a prestigious international scientific journal.

Seife’s investigation goes undercover, 60 Minutes style:

In November Scientific American asked a Chinese-speaking reporter to contact MedChina, which offers dozens of scientific 'topics for sale' and scientific journal 'article transfer' agreements. Posing as a person shopping for a scientific authorship, the reporter spoke with a MedChina representative who explained that the papers were already more or less accepted to peer-reviewed journals; apparently, all that was needed was a little editing and revising. The price depends, in part, on the impact factor of the target journal and whether the paper is experimental or meta-analytic. In this case, the MedChina rep offered authorship of a meta-analysis linking a protein to papillary thyroid cancer slated to be published in a journal with an impact factor of 3.353. The cost: 93,000 RMB—about $15,000.

Finally, the corrosive effect of this particular fraud on scientific and medical publication is real:

Publishers at the moment are fighting an uphill battle. 'Without insider information it's very difficult to police this,' Clinical Endocrinology's Bevan says. CE and its publisher, Wiley, are trying to close loopholes in the editorial process to flag suspicious late changes in authorship and other irregularities. 'You have to accept that people are submitting things in good faith and honesty,' Bevan says.

That is the essential threat. Now that a number of companies have figured out how to make money off of scientific misconduct, that presumption of honesty is in danger of becoming an anachronism.

Were this the only threat currently facing research journals today! Last month, Retraction Watch published an article describing a known and partially-related problem: fake peer reviews, in this case involving 50 BioMed Central papers. In the above-described article, Seife referred to this BioMed Central discovery; he was able to examine 6 of these titles and found that all were from Chinese authors, and shared style and subject matter to other “paper mill-written” meta-analyses.

Retraction Watch agrees:

It would seem that a third party, perhaps marketing services helping authors have papers accepted, was involved.

Problems with peer review are longstanding editorial fodder. For a description of another recent peer review scam, this one involving authors hijacking researchers’ identities, see the article also written by Retraction Watch editors and published last month in Nature.

On Friday, in response to requests by several publishers, The Committee on Publication Ethics (COPE) posted a statement on inappropriate manipulation of peer review processes 

While there are a number of well-established reputable agencies offering manuscript-preparation services to authors, investigations at several journals suggests that some agencies are selling services, ranging from authorship of pre-written manuscripts to providing fabricated contact details for peer reviewers during the submission process and then supplying reviews from these fabricated addresses. Some of these peer reviewer accounts have the names of seemingly real researchers but with email addresses that differ from those from their institutions or associated with their previous publications, others appear to be completely fictitious.

COPE recommends, among other things, the retraction of articles based solely on fraudulent reviews. Retraction Watch’s announcement earlier today of a MacArthur Foundation grant to help fund a comprehensive and freely available database of retractions could not have come at a better time!

Seife and Retraction Watch have documented new forms of published research fraud among third world researchers. Certainly the solution is not for editors and readers to suspect all papers from specific countries; there are ample instances of research fraud emanating from English-speaking researchers and top U.S. institutions. Research from around the world is critically important, particularly although not exclusively in the basic sciences, emerging infectious disease, and public health/epidemiology. Now that it has been identified, a common screening procedure for manuscripts at a journal can be adjusted to filter out this new form of plagiarism.

Sadly, it seems to me that fraudulent research of all types can flourish within a perfect storm of circumstances and factors: the globalization of science and medicine encourages non-or-limited English-speaking researchers to publish (or perish) in the highest impact English language journals; the proliferation of open-access wannabes, hybrids of every color and degree of sincerity, and other money-over-science journals and companies that rip off desperate and naïve researchers; a complicated, time-consuming and often author-unfriendly manuscript submission process; and journal editors who struggle with limited staffing and resources, necessarily arduous editorial processes, and the pressure of increasing numbers of worthy manuscripts deserving to reach the scientific and medical communities in near-real time. Research fraud is particularly destructive given traditional publishing’s ongoing struggle to survive the transformational Electronic Age; the pervasive if not perverse marketing of pharma, medical device companies, and self-promoting individuals and institutions using “unbiased” research; and today’s bizarrely anti-science culture.

Health Care Renewal is wonderful at calling out intentionally perpetrated health care events whose importance and implications can be debated, depending on one’s perspective and personal values. Here, I think, we have the reverse: there is near unanimity over the need to prevent fraudulent papers of any type from contaminating our research databases, as best as is humanly and technologically possible. There is also near unanimity among quality medical journals throughout the world, and internationally respected editor and publisher groups, to confront and solve these problems. The enemy identified by HCR is not always unrestrained greed or maliciousness. Sometimes, as in this case, the enemy is a cacophony of small circumstances and extraneous factors that could, if left unattended, invisibly erode something we all hold dear.

Without ongoing attention and support from the entire medical and science communities, we risk the progressive erosion of our essential, venerable research database, until it finally becomes too contaminated for even our most talented editors to heal.

Dr Marjorie Lazoff

ADDENDUM (30 December, 2014) - This post was reposted on the Naked Capitalism blog on 24 December, 2014.

ADDENDUM (7 January, 2015) - See also comments on DSHR's Blog.  

ADDENDUM (19 January, 2015) - This post was reposted by TruthOut on 10 January, 2015.

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Who Really Makes Brand-Name Pharmaceuticals?

A striking illustration of the hazards to patients' and the public's health from health care organizational leaders using fashionable management techniques to maximize short-term revenue appeared in Reuters. 

Background: The Contaminated Heparin from China

The particular issue got public notice after US patients started to get sick and die after being infused with heparin, the common anti-coagulant drug. As we have discussed repeatedly starting in 2008 (look here, and see the summary at the end of the post), Baxter International was selling contaminated heparin under its label which was made in unregulated workshops in China, and then transmitted through a complex chain of Chinese and US companies.  What helped to further obscure the problem was what Baxter was buying was called the active pharmaceutical ingredient (API), which actualy means it was buying the active drug from poorly documented foreign sources.  In other words, it had entirely outsourced the manufacturing of a drug it sold as if it had been made by Baxter in the US.

Continued Outsourcing to Questionable Drug Manufacturers

Reuters reported on a new investigation of outsourcing of drug manufacturing to China.  The main point was:

Four years ago, Beijing promised to clean up its act following the deaths of at least 149 Americans who received contaminated Chinese supplies of the blood-thinner heparin. But an examination by Reuters has found that unregulated Chinese chemical companies making active pharmaceutical ingredients (API) are still selling their products on the open market with few or no checks.

Interviews with more than a dozen API producers and brokers indicate drug ingredients are entering the global supply chain after being made with no oversight from China's State Food and Drug Administration (SFDA), and with no Good Manufacturing Practice (GMP) certification, an internationally recognized standard of quality assurance.

'There is falsification of APIs going on, we know it,' said Lembit Rago, coordinator for Quality Assurance and Safety in Medicines with the World Health Organisation (WHO).

In fact, the article made the point that the majority of drugs sold worldwide are the product of outsourced, often unregulated, and potentially contaminated and adulterated manufacturing:

'Illegal ingredients in bulk are a big problem, but nobody talks about it,' said Guy Villax, chief executive of Hovione, an API supplier based in Portugal with factories there and in China, the United States and Ireland.

About 70 to 80 percent of all active drug ingredients - the biologically active component in medicines - originate in China and India, estimate industry experts, with China accounting for the lion's share. Its export market in these products is worth $22 billion in annual sales, according to the China Chamber of Commerce for Import and Export of Medicines and Health Products.

'If China for some reason decided to stop exporting APIs, within three months all our pharmacies would be empty,' said Villax.

How Dodgy Manufacturers Continue to Operate

Apparently, a particular problem in China is that APIs, that is, the particular drugs in question, can be made by chemical as opposed to officially designated "pharmaceutical" companies, and these chemical companies are not regulated,

A key regulatory weakness in China is the distinction between pharmaceutical and chemical companies. While the former are regulated by the SFDA, the latter, making everything from sweeteners to solvents, are not. Yet many chemical companies also churn out drug ingredients, exploiting a loophole by describing the products as chemicals, which they are, rather than the more specific designation of APIs.

For example, the article recounted how an unregulated chemical company was apparently a source for a well-known branded pharmaceutical sold by two big pharmaceutical companies headquartered in developed countries,

[A]company, Jinan Hongfangde Pharmatech (JHP), of Jinan city in Shandong province, had a product list showing at least five patented products for sale. They included tiotropium bromide, a blockbuster lung drug co-promoted by Boehringer-Ingelheim and Pfizer Inc and sold under the name Spiriva,...

Both Boehringer-Ingelheim and Pfizer spokespeople claimed that they only bought drugs from known sources, but then it would be pointless for Jinan Hongfangde Pharmatech to manufacture tiotropium bromide.

The Use of Brokers

More questions were raised by the pharmaceutical company's apparently common practice of buying drugs through brokers,

The rise of the Internet has facilitated exports of drug ingredients. An online search brings up websites offering hundreds of Chinese API sellers. Those not GMP-certified or SFDA-registered are not necessarily substandard, but buyers lack independent quality assurance.

The pervasive presence of brokers in the supply line is another risk. Pharmaceutical companies looking to source APIs in China typically hire middlemen to help them navigate the language, red tape and protocol. That system helps Chinese companies making substandard APIs avoid detection.

The reason corporate executives choose to buy drugs in China rather than having their companies manufacture them themselves seems to be to reduce costs. A post on the In-Pharma blog quoted Lembit Rago, the same WHO official quoted by Reuters, thus,

There are Chinese manufacturers supplying APIs of high quality to multinational companies, but there are also companies producing APIs of poor or not defined quality.

So,

As long as there are customers for substandard APIs they will be produced and sold.

The cheapest Chinese drugs, of course, come from the most questionable manufacturers, and that may not be apparent to companies who use brokers to facilitate purchases.

'Any number of foreign pharmaceutical companies go no further than looking for API suppliers at CPhI (an international pharmaceutical fair) based only on price,' [manaing director of Samsara Biopharma Consulting Robert] Walsh said.

Reuters spoke to brokers who said an API made by an unregulated chemical company would cost less than one from a company that had a GMP certificate.

'Different (API) grades have different prices. Sometimes we accept an order sheet and we happen to find a factory that can do it cheaper than our factory, we will outsource to them and make a bigger margin,' said one broker based in China who sources for a South African outsourcing firm.

In China there are few legal repercussions for broker firms who relabel or misrepresent products, and tracing counterfeit and substandard APIs is extremely difficult.

'There are a lot of brokers who are relabeling (APIs) which means you can't trace where the API comes from and that adds to the risk,' said the WHO's quality assurance expert Rago.

Andre, the Belgian drug detective, estimates he has uncovered fraud or misrepresentations in as many as 25 percent of cases where he has been hired to audit factories all over China. 'If you can substitute an API that is expensive to make and manufactured at a high level with something that costs much less, then that can happen,' Andre said. 'It's impossible to give an exact number, but it's not rare. It's a minority, but not tiny minority.'

Use of Substandard Raw Materials

Meanwhile, a post on PharmaLot suggested that the supposedly regulated Chinese "pharmaceutical" companies may implement questionable manufacturing practices,

A subsidiary of the Joincare Pharmaceutical Group reportedly used reprocessed cooking oil – otherwise known as ‘gutter’ oil – to make a widely used antibiotic in China. If the term gutter oil is unfamiliar, this refers to reprocessed oil made from kitchen waste dredged from gutters behind restaurants. The State Food and Drug Administration is now investigating the charge after media reports over the past several days, China Daily reports.

Why might gutter oil be purchased to produce antibiotics? The oil is cheaper than the more expensive soybean oil used to make 7-aminocephalosporinic acid, or 7-ACA, a chemical for produce cephalosporins. Joincare produces 25 percent of the total amount of the chemical, although up to a dozen other drugmakers may have purchased gutter oil from various suppliers, according to various Chinese media reports. For its part, Joincare reportedly denied using gutter oil.

The companies reportedly bought the recycled cooking oil from a company called Huikang Grease Co., which is facing prosecution over its alleged processing and selling of thousands of tons of gutter oil in 2010 and 2011. The Shanghai Daily reported that Huikang received around $22.5 million for roughly 14,700 tons of gutter oil sold to Jiaozuo Joincare Biological Product, a unit of Joincare.

Summary

There is increasing evidence that a substantial proportion, probably the majority of drugs sold by big pharmaceutical companies based in developed countries were actually made by often poorly regulated firms based elsewhere, often China or India. To put it more directly, most so called pharmaceutical companies in the US and other developed countries have outsourced the actual manufacturing of drugs. Thus, most companies that appear to be pharmaceutical manufacturing companies are really just pharmaceutical marketing and development companies. (And not so much the latter, look here:  Light DW, Lexchin JR. Pharmaceutical R&D; what do we get for all that money? Brit Med J 2012; 345: 22-25.  Link here.) Pharmaceutical companies appear to be abandoning their core essence, but are content to market drugs  under their logos without telling the patients who take them the real source of these products.  This would appear to be a big scandal, but one that stays curiously anechoic.

I have yet to see any discussion with pharmaceutical executives about why their companies hardly make drugs anymore. In the absence of such discussion, I can only speculate that most likely, this is first a product of financialization. Drug company executives, like most organizational leaders, have fallen under the spell that says their only goal should be to increase short-term revenues. It may be cheaper to buy drugs from perhaps dodgy outsourced suppliers rather than manufacturing them them themselves. Continuing stories like those above, and that of the contaminated Chinese heparin suggest that these outsourced drugs are cheap for a reason. It appears that to save money short-term, pharmaceutical executives may be abandoning their most central mission, to provide pure, unadulterated drugs.

The continuing story of outsourced pharmaceutical manufacturing provides yet more evidence that current management dogma may be literally toxic. Once again, I suggest that true health care reform requires leadership of health care organization who put patients' and the public's health ahead of short-term revenue (and the personal enrichment that may result).

It is likely that a number of policy changes will be needed to reduce the threats posed by contaminated or adulterated outsourced pharmaceuticals.  There is one simple step that ought to be taken quickly to at least make the problem more transparent.  In the US, most manufactured products have a label disclosing the country of origin.  In parallel with that, all pharmaceutical containers, and all pharmaceutical labels and marketing materials ought to disclose the country in which the active pharmaceutical ingredient was manufactured, and the name and location of the company responsible for that manufacture. 


Appendix - Heparin Case Summary

- We have posted several times, recently here about the tragic case of suddenly allergenic heparin. Although heparin, an intravenous biologic anti-coagulant, has been in use for over 70 years, serious allergic reactions to it had heretofore been rare. Starting late in 2007, hundreds of such reactions, and 21 deaths were reported in the US after intravenous heparin infusions.All the heparin related to these events in the US was made by Baxter International.

- We then learned that although the heparin carried the Baxter label, it was not really made by Baxter. The company had outsourced production of the active ingredient to a long, and ultimately mysterious supply chain. Baxter got the active ingredient from a US company, Scientific Protein Laboratories LLC, which in turn obtained it from a factory in China operated by Changzhou SPL, which in turn was owned by Scientific Protein Laboratories and by Changzhou Techpool Pharmaceutical Co. Changzhou SPL, in turn, got it from several consolidators or wholesalers, who in turn got it from numerous small, unidentified "workshops," which seemed to produce the product in often primitive and unsanitary conditions. None of the stops in the Chinese supply chain had apparently been inspected by the US Food and Drug Administration nor its Chinese counterpart. (See posts here and here.)

- We found out that the Baxter International labelled heparin was contaminated with over-sulfated chondroitin sulfate, a substance not found in nature, but which mimics heparin according to the simple laboratory tests used in the Chinese facilities to check incoming heparin. (See post here.) Further testing revealed that the contamination seemed to have taken place in China prior to the provision of the heparin to Changzhou SPL. (See post here.) It is not clear whether Baxter International or Scientific Protein Laboratories had inspected most of the steps in the supply chain, or even knew what went on there.

- The Baxter and Scientific Protein Laboratories CEOs did not seem aware of where they got the heparin on which the Baxter International label was eventually affixed. But one report in the New York Times alleged that Scientific Protein Laboratories would not pay enough for heparin to satisfy any sources other than the small "workshops."

- Leaders of all organizations involved, Baxter International, Scientific Protein Laboratories, Changzhou SPL, the Chinese government, and the US Food and Drug Administration, and the US Congress assigned blame to each other, but none took individual or organizational responsibility. (See post here.)  Note that SPL was recently bought out and taken private, making its current leadership even less transparent (see post here).  A 2010 inspection of an SPL facility by the FDA revealed ongoing manufacturing problems (see post here).

- Researchers (who turned out to have financial ties to a company which is developing an anti-coagulant drug that could compete with the heparin made by Baxter International) investigated the biological mechanisms by which the contamination of the heparin lead to adverse effects, but no one investigated further how the contamination occurred, or who was responsible. (See post here.)

- Hundreds of lawsuits against Baxter have now been filed, so far without resolution. (See post here.)  Efforts to make documents to be used in these cases public so far have not succeeded (see post here).

- A government report which attracted little attention warned of the dangers of pharmaceutical ingredients made in China and subject to virtually no oversight. (See post here.)

-  Despite requests from the US, the Chinese government did not investigate the production of the heparin that lead to the deaths (see post here.)

-  In February, 2011, a congressional investigation of the case was announced, but results are so far unavailable (see post here.)

-  In June, 2011, a jury returned the first verdict in a civil case about the contaminated heparin, awarding money from Baxter International and Scientific Protein Laboratories to the estate of a man who apparently died due to tainted heparin (see post here).

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