CAMBRIDGE, England — She’s the editor of a venerable British medical journal. But Fiona Godlee is no ivory-tower academic.
In a decade at the helm of the BMJ, Godlee has launched crusade after crusade, many of them stirring storms of controversy. She’s used the pages of the journal to blast US dietary guidelines as based on poor science and biased by commercial interests. She’s taken on governments, too, for spending billions to stockpile a flu medication that does not work — at least, according to a review published by the journal.
And she’s gone after global pharma giants Roche and GlaxoSmithKline for hiding trial data that cast doubt on the safety or efficacy of their drugs.
“The BMJ is a campaigning journal,” Godlee said.
That approach has drawn in readers. It’s also provoked outrage among some clinicians and researchers. Critics say Godlee risks undermining the credibility of one of the most prestigious medical science journals in the world by such overt campaigning.
The BMJ “should carefully think about what it wants: to remain a top scientific medical journal, or to transition into a public-opinion publication that seeks to attain the highest ratings possible based on one-sided positions that are not carefully researched,” said Rafael Perez-Escamilla, an epidemiologist at Yale University. “They can’t have it both ways.”
‘Doctors are human beings’
Godlee, who cycles through Cambridge on her folding Brompton bicycle, joined the BMJ (then called the British Medical Journal) in 1990.
As a girl, she was educated at Bedales School and Marlborough College, two of the most exclusive — and eye-wateringly expensive — private schools in England. Then she spent eight months in Kenya as a schoolteacher, before returning to England to study medicine. She earned her physician’s degree from Trinity College, Cambridge, in 1985, and moved back to London to continue training as a general physician.
But Godlee, now 54, always had an interest in writing. She took a year, and then a second year, out of her training to intern at the BMJ. “At the end of that second year, I just thought: This is really fun,” she said. “The BMJ has such a broad remit, yet it allows you to feel that you’re still embedded in medicine.”
And she is steeped in medicine. Her father was a doctor; she is the great-great-great-granddaughter of Joseph Jackson Lister, who improved the microscope so that it could be used in medical research; and her family tree includes Dr. Joseph Lister, who pioneered the sterilization of surgical instruments in the 19th century.
When Godlee became editor in chief of the BMJ in 2005, she set her sights on making the journal as pleasurable to read as possible, while maintaining its academic standards. “Doctors are human beings too, and this stuff has to be readable,” she said.
“Some people would say we have gone too far down the magazine route,” Godlee conceded. “But we have no doubt that we’ve increased our influence and increased our readership among clinicians.” The print journal has a global circulation of 122,000 and is widely read by physicians; its website gets 3.6 million hits per month, 22 percent of them from the United States.
And under Godlee, the journal’s reach has broadened beyond doctors: The BMJ’s investigations routinely make headlines in mainstream media.
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In September, for example, it ran a feature article by journalist Nina Teicholz blasting the science behind US dietary guidelines.
Teicholz, who wrote a book last year advocating for higher-fat diets, argued that evidence underpinning the guidelines had been cherry-picked to overstate the risk of saturated fats. Her article, which was framed as a BMJ investigation, also accused the advisory committee that worked on the guidelines of being influenced by commercial interests, such as agricultural lobbies.
There was an immediate backlash. The advisory committee described the article as “woefully misleading and in many cases, factually incorrect.” A petition, signed by more than 150 nutrition scientists, called for the BMJ to retract the piece. It claimed the article was riddled with errors, including misstating the committee’s process for selecting and evaluating evidence about nutrition.
“I believe that the BMJ did cross the line in this instance,” said Perez-Escamilla, who is a member of the advisory committee.
The BMJ published a correction to the article a month later, acknowledging that it had misstated the findings of a nutrition study on saturated fats. The BMJ is now having Teicholz’s article reviewed externally, and Godlee said she’s willing to consider a retraction “if it is necessary” — but added that she does not regret running the piece.
Wasn’t she worried about hiring a journalist who was also an advocate to write about the nutrition debate? Godlee paused. “I think that’s a fair point,” she said. “Our defense would be: peer review, fact-checking, editing. Whether we did a good enough job on that will obviously emerge.”
Faulty flu prevention?
The BMJ is not alone in advocacy campaigns. The Lancet, another British medical journal, has been pressing governments and health systems to do more to treat or prevent cancer and liver disease, for example.
Godlee’s campaigns, though, often take a tougher, more confrontational line.
In 2009, the BMJ published a review of the efficacy of Tamiflu, an antiviral medication that was being stockpiled by governments against the threat of influenza viruses such as H1N1. The review questioned its efficacy, and noted that crucial clinical trial data on the drug were not publicly available.
This marked the beginning of the BMJ’s Open Data campaign, which calls for all patient-level trial data to be published.
Drug maker Roche subsequently released its Tamiflu data. And in 2014, researchers published a second review in the BMJ, with a damning conclusion: Governments had spent billions on stockpiling a drug that did not work. An accompanying BMJ editorial declared “that the entire ecosystem of drug evaluation and regulation is deeply flawed.”
But not everyone agreed. Dr. Peter Openshaw, professor of experimental medicine at Imperial College London, said he believes the review looked only at a select subset of studies on Tamiflu and ignored evidence of the drug’s effectiveness.
“I’m absolutely with Fi Godlee in wanting to ensure that expert advice is independent and free from commercial influence. I’m completely in support of that,” Openshaw said. “But it’s not enough to mount a campaign based on emotion and opinion. If you’re out on a limb, it should be based on facts.”
Godlee points out that in medicine, facts are sometimes in short supply. She is determined to remedy that. She helped set up a campaign, known as AllTrials, to urge all clinical trial data to be publicly reported; she remains on the group’s board. And in 2013, the BMJ helped launch the RIAT initiative — which stands for Restoring Invisible and Abandoned Trials — to unearth and analyze clinical trial data that had been consigned to the desk drawer without being published.
“The bottom line with Fi is that she’s clever, she’s lovely, and she’s charming, and she has a very good strategic overview of evidence-based medicine, including its flaws,” said Dr. Ben Goldacre, a British physician, author, and an ally who has worked with Godlee on AllTrials.
The BMJ’s big target with its RIAT initiative was Study 329, which laid the groundwork for the claim that paroxetine (sold as Paxil in North America) was a safe and effective treatment for major depression in adolescents. This conclusion was soon disputed; Paxil manufacturer GlaxoSmithKline ended up paying out $3 billion in 2012 to resolve allegations of fraud and failure to report safety data relating to Paxil and other drugs.
The company released its paroxetine data as part of the settlement. A re-analysis published in the BMJ this fall showed that the drug was not effective in adolescents — indeed, that it increased harmful outcomes, such as suicidal thoughts.
The analysis “shows the extent to which drug regulation is failing us,” Godlee said at the time.
One of the corollaries of re-analyzing data from clinical trials is that it might lead to the original studies being retracted. That doesn’t concern Godlee, a former chair of the Committee on Publication Ethics, which advises journals on such issues. “Retraction shouldn’t be seen as a terrible thing,” she says. “It’s part of correcting the scientific record.”
Setting the record straight
Godlee is not afraid of correcting politicians, either.
In September, the BMJ published an article that reported a rise in mortality among patients admitted to public hospitals in England during the weekend.
The paper’s publication coincided with a battle over contract negotiations between Jeremy Hunt, the UK government’s health minister, and National Health Service doctors. Hunt seized on the paper to justify his argument that more doctors should work on weekends to prevent these deaths. “Which of course the study can’t show, and nor does it show,” said Godlee.
Many editors might have merely grumbled to their colleagues about it, but Godlee took it further. “I just suddenly got cross — he’s calling this a BMJ report, but the BMJ has not said what he was telling us,” she said. So she wrote to Hunt, accusing him of misrepresenting the research.
This was political dynamite, and the row has smoldered ever since. Thousands of doctors agreed with Godlee, and their fury intensified their dispute with the government.
“Health care is political,” Godlee said with a shrug. “We strive to not be party political, but you couldn’t fail to call the editorial team liberal. We are in favor of social justice and equity, because those things seem to us to promote better health.”
Godlee is unrepentant about the direction she has taken the BMJ. “Our broader remit is to create a healthier world,” she said. “When you see things that aren’t right, we’ve got this opportunity to be a forum to push for change. It seems to me it’s a good use of the journal.”
She traces this philosophy back to one of her 19th-century predecessors, Dr. Ernest Hart, who campaigned against practices that doomed many of London’s poor and unwanted children to death. Several of these campaigns led to important reformist legislation in the Victorian era.
Hart was editor of the journal for more than 30 years. So does Godlee think she will still be at the helm in another decade?
“I hope not. I think it would be a bad thing for the journal, and possibly a bad thing for me,” she said. Then, a possible retraction: “My husband says I’ll never give it up,” she laughed.
There is the possibility that Dr. Godlee published Nina Teicholz’s piece precisely because she is a journalist (although no more of an advocate than Frank Hu) and subject to easy objections. The same criticism of the Dietary Guidelines by researchers or clinicians (among whom there are many equally embarrassed by the poor science) might not find publication in BMJ so easy. (Nor would retraction be so easily considered).
It is admittedly ten years since she rejected a MS by me and my colleagues including major researchers and clinicians arguing for low-carbohydrate diets for diabetes and metabolic syndrome. Her reasons were that the subject was too specialized and she had a number of other minor excuses. Our paper was published elsewhere and was updated in 2015 (Nutrition, 31, 1). It would, of course, be great if Dr. Godlee has become more open-minded than before. Dietary carbohydrate restriction is still a highly controversial but very active field (and one of the major sticking points in the critique of the Dietary Guidelines) and the BMJ might well get the point of view of people in the field.
Controversy on carbohydrate restriction, in fact, has very recently assumed a bizarre political state of affairs. The petition to retract Nina Teicholz’s paper is but one of many events. A trial of Dr. Tim Noakes in South Africa for recommending a low-carbohydrate diet starts tomorrow. I described two other cases in my blog post http://bit.ly/2m5TqZy.