SAN FRANCISCO -- It wasn't a deal with the devil. But it was like asking the family doctors to make a deal with the devil's cousin.
The American Academy of Family Physicians, one of organized medicine's antismoking leaders, was getting the chance to go big time in the fight against another health hazard -- high cholesterol. But there was a catch: The cash for a national anticholesterol campaign was being offered by a branch of a tobacco conglomerate.
So the stage was set for a morality play at the 59,000-member academy's Congress of Delegates' annual meeting here early this month. The doctrine urged vigorously by members of a health activist group -- Doctors Ought to Care (DOC) -- was that no health organization should be linked in any way with the tobacco industry, no matter how remote the connection, no matter how innocent and beneficial the apparent goal. Most members of DOC, a 10-year-old health activist group, are also members of the family physicians academy, making DOC in essence an activist element within the academy.
But the leadership of the academy was bent on winning clearance to proceed with the proposed arrangement with Fleischmann's, a unit of Nabisco Brands. Since September 1985, Nabisco has been owned by the R.J. Reynolds tobacco company, now known as RJR/Nabisco.
(And ironically, at this meeting, the academy introduced its Stop Smoking Kit at the meeting, which includes materials to help physicians persuade their patients to quit.)
Dr. Robert Graham, executive vice president of the Kansas City-based academy, said Fleischmann's proposed about a year ago to spend more than $1 million for full-page ads in women's magazines. The message, to be endorsed by the academy: Have your cholesterol checked by your family doctor. It would be signed by Fleischmann's and the academy, but there would be no overt endorsement of a Fleischmann's product.
Fleischmann's makes a margarine and a yolkless egg mix, both cholesterol-free. Caroline Fee, a spokeswoman for Nabisco's East Hanover, N.J., operations, says Fleischmann's has always tried to "position itself as a tool for physicians" to help patients lower cholesterol. Excess cholesterol in the blood is a key risk factor for heart disease. Fleischmann's had an exhibit at the academy's meeting, and it sponsored a "Better Health" breakfast at the Fairmont Hotel for physicians and their spouses.
A similar relationship between Fleischmann's and the American Heart Association -- the nation's foremost foe of high-fat, high-cholesterol diets -- ended after R.J. Reynolds bought Nabisco. Fleischmann's used to have an exhibit at the AHA's annual meetings and sponsor the buses that shuttled physicians between hotels and convention centers. Today, Fleischmann's presence is banned at the AHA meetings, says AHA spokeswoman Brigid McHugh.
Just a few weeks ago, a Nabisco group went to Dallas, home of the AHA's national headquarters, to try to restore the AHA ties not only to Fleischmann's but to other Nabisco brands as well. But, says the AHA's McHugh, the Nabisco delegation went home empty-handed.
The AHA spokeswoman points out that the fight against smoking is as much a part of the AHA's mission as is the struggle to lower blood-cholesterol levels. "There will be no relationship so long as Nabisco is owned by a tobacco firm," said McHugh. "It would be a very clear, direct conflict with who and what we are."
But the American Heart Association, a voluntary health organization supported by donations, is a very different animal than an academy of family doctors, formed 40 years ago as part of an effort to transform general practice into an established medical specialty.
The AHA is devoted entirely to raising funds and to research and education in prevention and treatment of heart disease. The academy, on the other hand, has many priorities, and one of the highest is to enhance the image of family physicians both within medicine and among the public. Within medicine, family physicians compete for patients with internists, surgeons, pediatricians and obstetrician-gynecologists -- all far more established than family doctors in the medical pecking order. Family physicians often have trouble getting permission
from hospitals to do surgery or specialized procedures, and may be reimbursed less for procedures than some specialists by Medicare or insurance carriers.
Family practice has itself been a specialty since 1969. After three years of a family-practice residency program in a teaching hospital, a physician can take an examination to be certified by the American Board of Family Practice. It was the first board in medicine to require recertification, which is mandatory every seven years. But it's the most diffuse of specialties, covering surgery, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry and neurology. So the academy fights a constant struggle within medicine -- by the more targeted specialties -- to be treated as a bona fide specialty.
And so a national advertising campaign suggesting a cholesterol test by "your family doctor" might represent no small potatoes for the academy. As the Nabisco spokeswomen pointed out, the campaign would offer an important health message, Fleischmann's would get the cachet of physician endorsement, and the academy would get something for itself -- exposure -- in return.
But Dr. Rick Richards of the Medical College of Georgia, the president of 10-year-old DOC, said Fleischmann's and the tobacco industry stood to gain the most. "We don't need them," Richards said. "They need us."
The effort by the DOC forces to keep the
academy from straying from its "pro-health" course, as alternate delegate Dr. Marc Rivo of Washington termed it, took the form of a resolution submitted to the Congress of Delegates, the academy's policy-making body. It asked that the academy "not associate, enter into agreements with, patronize, or utilize the services of any corporation, its parent or subsidiaries, if any of their components produce tobacco products."
Dr. Brent Blue of Jackson, Wyo., who introduced the resolution, argued that in affiliating with Fleischmann's, the academy would be supporting the non-tobacco diversification of the tobacco industry, a stance he considered "utterly misguided." He said the academy risked a public relations disaster by linking with the tobacco industry, and reminded delegates of the black eye suffered by the American Medical Association two years ago when its new president was revealed by the Chicago Sun-Times to own tobacco-growing land. The land was later sold.
Blue also pointed out that since it was bought by R.J. Reynolds, Nabisco no longer takes part in the American Cancer Society's annual Great American Smokeout -- an assertion later confirmed by the cancer society.
Dr. John Beasley of Madison, Wis., called on delegates to "take the lead position and say we aren't going to do business with these guys who are killing 300,000 Americans a year." Smoking is the leading cause of lung cancer and plays a major role in heart disease and emphysema, many studies have shown.
Richards said the Fleischmann's deal was
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-- Dr. George Hess Carson City, Nev.
part of an "insidious campaign" to help the tobacco industry, carried out by subsidiaries in sheep's clothing. As to the argument by Dr. George Hess of Carson City, Nev., that few among the public know of the Fleischmann's-R.J. Reynolds link, Richards noted, "Just because our neighbors don't know we physicians are in the mud doesn't make us less dirty."
But Dr. Harry Metcalf of Williamsville, N.Y., the incoming academy president, insisted that Fleischmann's had agreed to key stipulations that made the agreement palatable. He said the academy would have full editorial control of the ads, and Fleischmann's had agreed that the ads would point out that smoking is a coronary-artery-disease risk, just like high cholesterol. "We will evaluate Fleischmann's to the nth degree," said Metcalf.
"If the cigarette industry is willing to pay us to say cigarette smoking is dangerous, I don't know why we shouldn't accept that," said Hess.
Nabisco's spokeswomen declined to confirm or deny that Fleischmann's had agreed the ads would acknowledge the hazards of smoking, in addition to those of high cholesterol.
Dr. Robert Taylor of Spartanburg, S.C., the academy's outgoing president, agreed that careful scrutiny of the deal was needed. "What R.J. Reynolds says and does are two different things," he said. "We would not trust R.J. Reynolds to determine the editorial content of anything to do with the academy." But he felt the deal was a good one. The debate was "more emotional than substantive," he said.
"Public good must be the measure of any marketing and information campaign," said Dr. Hugh Upton of Los Altos, Calif., chairman of the academy's public relations and marketing committee. His committee originally opposed the deal but accepted it after "Fleischmann's accepted our stipulation that smoking be highly publicized as a risk factor along with cholesterol."And in the end, the Congress of Delegates agreed. It passed a resolution barring any direct contact between the academy and parent tobacco firms. But it rejected the DOC-backed resolution that would have barred any association with any link of a tobacco-based conglomerate.
Graham, the academy's executive vice president, said he felt the DOC-backed resolution would have put the academy "hostage to events." He asked how the academy would be able to blacklist a major pharmaceutical firm if one were purchased by a tobacco-based conglomerate.
And he felt the risk of an academy public relations disaster was worth the potential benefit to public health. "You can make a pretty good hit with a million dollars," says Graham. "There's no such thing as a decision that's risk-free." Mark Bloom is managing editor of Physician's Weekly, in New York.