It's March 25, 1999, and health reporters across the country are hard at work. "Some people can hardly contain their excitement," gushes a front-page article in the Calgary Herald. They "may have an extra bounce in their step today," it adds, "but it's not just because spring arrived this week." The event that floods newspapers across Canada with joyful articles is the arrival of Viagra. The release of Pfizer Inc.'s anti-impotence pill to the Canadian market sparks a deluge of one-liners, from The Toronto Star's "swell of eager customers" to the

Edmonton Journal's "pharmacists are expecting potent sales," as well as the more straightforward description of "the tiny blue pill that can salvage a limp sex life," in Halifax's The Daily News. Clever or crass, journalists are caught up in the hype of the new drug, with articles appearing in almost every Canadian daily.

Almost six years later, the coverage continues to flow. In 2000, the National Post carried 26 articles with the word "Viagra" appearing in either the headline or first paragraph; in 2004, it published 33. The Star's archives show that since the drug's release, it has appeared in more than 500 articles.

While Viagra received unusually high media attention because of its sex appeal, daily newspapers write about prescription drugs all the time - as they should. There has always been high reader interest in medication, and that interest is on the rise. Baby boomers are reaching an age when pharmaceuticals become their best friend. Canadians spent $15.9 billion on prescription drugs in 2003, averaging 11 prescriptions per Canadian - a 7.9 per cent increase over the previous year. Today, the ease of online shopping makes drug reporting all the more important. Anybody with an email account knows that offers for the "cheapest meds you'll find" are not in short supply. Dozens of unsolicited offers per week are not only annoying junk mail, they can be dangerous. If we don't need a prescription to get prescription drugs, we don't need a doctor or medical history either. It is up to journalists to provide accurate, fair, and balanced drug information. Despite some success, there is still a lot of work to do in this area.

Studies that have examined the quality of newspaper drug reporting have found ailments. "Drugs in the News," published in April 2003 by the Canadian Centre for Policy Alternatives (CCPA), set out to determine whether we can rely on daily newspapers to provide us with "the good, the bad and the ugly about new drugs." Researchers found the good, but the "bad and ugly" seem to be missing in action. Of 193 articles examined, every one mentioned the benefits of a particular drug, but 68 per cent did not mention any side effects. Only four per cent of the articles explained the conditions under which it is not safe to take a drug. In addition, they rarely discussed the financial conflicts of interests of drug-study sponsors or spokespeople.

Health journalists got some redemption in a study published last April in the Canadian Medical Association Journal. Looking at reporting on drugs used to treat genetic disorders specifically, it found not only an overemphasis on benefits in newspaper articles, but that scientific journals - often journalists' sources of information - were guilty of positive spin too. The study indicated "journalists may not always be the primary source of exaggerated claims." Rather, it's a combined effort of overenthusiastic scientific journals, researchers looking for recognition, and journalists' desire for attention-grabbing stories.

Scientists are generally pleased with newspaper articles offering glowing reports, but doctors are more critical. A 1999 survey of 250 Canadian general practitioners found that only 34 per cent believe medical news is accurate. Their most common explanation for poor reporting is a journalist's desire to grab the reader's attention, followed by limited scientific knowledge and limited research time. Regardless of who is to blame, health journalists play a crucial role in disseminating drug information to the public. But they are producing too many unbalanced, deceptive articles. It's frustrating because the problems are, for the most part, rectifiable.

Viagra is unusual because of the excessive amount of coverage it has received, but that makes it an exemplar of the kinds of problems facing journalists. Up to three million Canadian men suffer from erectile dysfunction, which is often a side effect of more serious conditions such as diabetes or hypertension. Damage to blood vessels caused by both of these conditions hinders the ability of blood to flow to the penis, so impotence becomes a symptom. Yet Viagra has become the target of countless jokes about enhanced male performance. When it comes to this drug, journalists have to deal with a lot of misconceptions, but it's up to them to set the record straight.

Some problems with drug reporting are easy to spot, like a lack of balance. On the happy day six years ago when the blue pill entered the Canadian market, one of the Herald's front-page headlines read, "Viagra hits Calgary pharmacies today." The majority of this 507-word article is devoted to praising "the hot-selling anti-impotence pill," followed by a mere two sentences - five per cent of the article - warning men that Viagra is not for everyone. No side effects were mentioned. One month later, the Star ran an article about Viagra. The story cited several "minor side effects," but left some out. The article mentioned facial flushing, minor headaches, and stomach upset, but ignored the possibility of temporary blue-tinted vision, prolonged erection, heart attack, stroke, or irregular heartbeat. People have a right to know all risks involved with taking a particular drug and journalists have an obligation to tell them. "If people are not informed about drug benefit and harm," says Alan Cassels, the lead author of the CCPA study, "they will waste their money and the money of our health system for very little result."

Being overly positive is one thing, but not mentioning the dangers of a drug is quite another. The potentially lethal combination of Viagra and drugs containing nitrates, commonly found in heart medications, is clearly explained in all Viagra patient information. The combination can cause blood pressure to drop to an unsafe level, leading to heart attack, stroke, or even death. But most Viagra articles minimize this danger, often mentioning it in the last quarter of the piece, when many people have stopped reading. In fact, two articles ran last March, one in The Vancouver Sun and one in the Herald, based on a study telling readers that Viagra is safe for men with congestive heart failure. While the opening paragraph of the study's abstract explains that the men studied were carefully selected to ensure that they were not taking nitrates, the article in the Sun downplays this danger. After explaining that "many men with congestive heart failure can safely take Viagra," the last line admits half of men with congestive heart failure still can't take Viagra because their heart medications contain nitrates. The article in the Herald does not mention nitrate danger at all. A man taking medicine containing nitrates might read this article and order some Viagra online.

Other drug reporting issues aren't as easy to spot - and may not be dangerous to readers - but certainly are misleading. When reporters base articles on studies funded by profit-driven pharmaceutical companies or rely on statements made by doctors being paid by these companies, readers ought to know. The studies may be accurate and the doctors sincere, but financial incentives can also colour results. Too often, journalists fail to inform readers of these conflicts.

Such was the case with Dr. Jack Barkin, who was quoted in four Star articles between 1998 and 2000, and one each in the Post, the Ottawa Citizen, the Charlottetown Guardian, and the Herald, among others. Barkin, identified as chief of urology at Humber River Regional Hospital in Ontario, praises Viagra in the articles, saying things like, "It's a revolutionary drug," and, "People have called it the Prozac for the penis." It turns out that while Barkin is, in fact, the chief of urology, he also happens to be a consultant for Pfizer. Only the Herald informed readers of his financial tie to the drug company. Barkin might have been genuine, but if there is a potential conflict of interest, the reader ought to know about it.

Health journalists recognize the importance of finding independent sources, but it's not always easy. "The difficulty," says Rita Daly, who covered the health beat at the Star for five years and still writes numerous health-related articles as a feature writer, "is trying to determine who is independent, since so many medical researchers have financial ties to the industry." Karen Palmer, a former health reporter at the same paper, agrees. "Sometimes I'll phone an organization like Cancer Care Ontario and they'll provide experts who are actually linked to similar research," she says, "so it's questionable whether they're actually independent." While readers don't question the validity of doctors' claims, journalists certainly should.

They should also question the validity of scientific studies that might be biased. On September 10, 2004, the Star published an article about a potential new use for Viagra. In a study published in the peer-reviewed medical journal Annals of Internal Medicine, researchers reported that mountain climbers who take Viagra are better able to tolerate hypoxia - a lack of oxygen - at high altitudes. The Star's article suggested the findings may have implications for patients with lung disease and pulmonary hypertension. As a person with chronic breathing problems, I read this article and considered popping a few of the little blue pills myself. But before everybody with lung problems goes filling up on Viagra, there is something people ought to know - the study was partially funded by a research grant from Pfizer. In the journal, the grant is clearly identified as a potential financial conflict of interest, but not in the Star.

Most journalists are wary of studies like this. Elaine Carey, medical reporter for the Star, says, "I always ask the researchers whether they have been funded by the drug company, and I think most good reporters do." The article in question, though, came without a byline and was attributed to the Los Angeles Times. In this case, the blame must fall to the editors who, likely pressed for time, let the article through. "We do occasionally run less objective stuff from the AP wire," says Carey, "and we're constantly trying to educate the foreign desk about how to assess it." While the findings of the study may still be valid, people should be able to consider the company's influence before taking Viagra to perk up their lungs.

But journalists are not scientists. When the information upon which they base their stories is simply false, it's not always their fault. "It's important to double-check anything contained in a press release, because sometimes they're wrong or just subtly incorrect," says Palmer. She once received a news release bragging about findings that would have implications for Alzheimer's patients. Wisely, she spoke to the researcher, who told her the findings had no bearing on Alzheimer's at all. Sharon Kirkey, health reporter for CanWest News Service, has also had a bad experience with inaccurate information. For her, it resulted in published articles containing false news. In October, Kirkey (and many other journalists) wrote about research conducted by a team of scientists at Wayne State University and presented at the annual meeting of the respected American Society for Reproductive Medicine. Based on data from the Women's Health Initiative, the scientists found that women who take birth control pills are significantly less likely to develop cardiovascular disease. Naturally, it was big news. Two months later, WHI released a statement saying that both the study design and data interpretation were flawed. There was no evidence to suggest that using the pill lowers the risk of cardiovascular disease. Kirkey wrote another story to explain the mistake. "I'm not a scientist," she says. "I couldn't review their data for accuracy." Although there isn't much Kirkey could have done to avoid the error, she admits: "One thing I would have done differently was to note the 'recall bias,' meaning the study relied on women to remember what they had done years earlier." The researchers should have recognized that too.

On the surface, it's hard to comprehend why reporters have such difficulty covering health. But taking a closer look into the world of studies, statistics, and scientific method, the pitfalls become understandable. Health reporters need a special set of scientific skills that are not taught at most journalism schools. It's important for journalists to be able to assess the quality of drug studies before deciding to report on them. A study that looks at 100 people, for example, holds much less water than one that examines 1,000. And it is easy to get lost in technical jargon. There's a big difference between a double-blind, placebo-controlled study and a study with no blinding. In the first, neither the researchers nor the patients know which group is on the drug and which is on the placebo, limiting biases; in the second, everybody knows who is taking what, which leads to expectations.

Numbers can be confusing too. Let's say a study looks at the effect of a certain drug on the risk of having a heart attack. Out of 100 patients studied, two people on a placebo (two per cent) had heart attacks and one person on the drug (one per cent) had a heart attack. There are two ways to interpret these findings. In absolute terms, there is a one per cent reduction in the risk (two minus one). But in relative terms, the risk is cut in half (one person versus two people). A press release is likely to report the latter. A 50 per cent reduction in risk is a far more impressive statistic, but it's misleading. It is a reporter's responsibility to understand whether it's a relative or absolute risk being reported and, in turn, explain the numbers to readers.

Understanding the information is only half the battle. Fighting corporate influences is the other half. Newsrooms are inundated with press releases from drug companies every day. These companies - and the public relations firms that represent them - are profit-driven organizations. They do everything they can to promote the sale of their drugs, including obscuring negative study results. "Drug company research is proprietary, and they actively prevent researchers from releasing information about their drugs," says James Winter, professor of communication studies at the University of Windsor and author of Lies the Media Tell Us, a book about misinformation in the media. "We read the good news and the bad news is kept from us." Unbiased information is hard to find, and the urge to use the prepackaged information provided by drug companies can be strong, particularly when a deadline looms. With financial interests at play, press releases are usually upbeat and exciting- an appealing prospect for journalists looking for a quick story. Journalists must be vigilant to avoid being spun by PR. When asked what is the main problem with health reporting today, Palmer says it's sensationalism. "Everyone wants a cure, including our editors," she says. "Sometimes it's easy - but not technically accurate - to see a small step in science as a big, big headline."

The big buzz these days is not Viagra, but the tale of two widely prescribed arthritis drugs. Merck & Co, Inc. yanked Vioxx - Canada's 10^th most-prescribed drug in 2003 - off the market in September 2004 after researchers found it greatly increased the risk of cardiovascular problems. Pfizer's blockbuster seller, Celebrex, remains in limbo after similar results were found. It has outsold Viagra to become Canada's top-selling new drug, and hasn't been withdrawn. However, the safety of Celebrex is under review. Both drugs fall into the category of a COX-2 inhibitor - a relatively new class of drug that is said to target pain and inflammation without producing the stomach problems associated with other forms of treatment.

In retrospect, following the worldwide withdrawal of Vioxx, it would be easy to go back and criticize the news coverage. After all, this widely used drug turns out to have been controversial all along, with numerous studies expressing concern about increased cardiovascular risk. But there isn't much to criticize - and that's part of the problem. The Vioxx fiasco is a perfect example of what happens when a drug isn't covered sufficiently or critically enough. Unlike erectile dysfunction, arthritic pain isn't as entertaining for journalists, so they don't rush to cover it. In each of the six years it was on the market, Vioxx was featured in fewer articles than Viagra - despite the troubling studies about the drug's safety.

On the upside, most of the Vioxx articles that were published drew attention to the scattered reports of dangers. But it wasn't until the actual recall - a dramatic event - that it repeatedly made the front page. Just four months before the recall, a Canadian study showed that people taking Vioxx were 80 per cent more likely to be put in hospital for heart failure than those not on the drug. This surprising statistic was only mentioned in the Star, the Post, The Windsor Star, and the Herald. The massive recall, however, attracted the attention of almost every Canadian newspaper. Vioxx has taught us a lesson: it isn't only the quality of drug stories that matters, but also the quantity.

With Celebrex, on the other hand, there was plenty of coverage to criticize. Although there were exceptions, the media generally overlooked numerous reported safety concerns and printed a large number of positive articles endorsing the drug. After a study found increased risk of developing stomach ulcers associated with Celebrex, Health Canada issued a warning in May 2002, stating that the drug offered no gastrointestinal advantages over other medications. Newspapers barely covered this warning.

On December 17, 2004, however, another warning issued by Pfizer - about a significant increase in cardiovascular risk - was not overlooked. Although the recent warning was arguably not more serious than earlier concerns, it snared journalists' attention. Why? With the withdrawal of Vioxx fresh in the minds of readers, this warning became more than a warning - it became news. Journalists paid attention. Had it happened several months earlier, Celebrex likely wouldn't have made headlines.

There are two schools of thought on how to fix what ails drug reporting. One says good old-fashioned hard work will do the trick, while the other says specialized training is the ticket. Some firmly believe that journalists covering health cannot do a good job without training. Melinda Voss is the co-founder of the Association of Health Care Journalists, an American organization dedicated to improving the quality of health reporting. In an article published in the spring 2003 issue of Nieman Reports, a quarterly journalism review magazine from Harvard University, Voss explains that health journalists require scientific knowledge and skills that aren't easily acquired on the job. She says the solution for sloppy reporting includes improving the training process for health reporters through systematic health education. The medical/science journalism course offered at the University of Western Ontario teaches students which sources to approach and how to interpret study results.

Most of the journalists interviewed for this article have not had any special training. Generally, they learn from experience. "You might say I've been training on the job," says Daly. "I had no medical training, but the learning curve is steep," says Dan Arsenault, health reporter for Halifax's The Chronicle-Herald until May 2004. "Trust me, if you put your name on a story day after day, you quickly pick up on things."

Even without training, it's easy to see there are problems with drug coverage. Sure, some background knowledge would help, but it doesn't take a scientist to ask the right questions. Healthy skepticism is one tool many reporters and health experts say is needed. Journalists must work hard to fight the urge to write dramatic "breakthrough" stories that bury negatives. They must find sources with no financial interests. And they must let readers know when information might be biased.

Another essential tool is having good interview skills. Many health journalists identify good questioning as a crucial part of the job. Who funded this study? How many patients were in the trial? Are these relative or absolute risks? When Palmer was on the health beat, she kept a list taped to her computer of seven questions to consider when writing a medical story.

Health journalists seem to know the ropes, though they don't always use them to tie up the loose ends in their stories. General reporters, however, lack the necessary skills. For them, there are resources newsrooms should supply. The AHCJ, for example, offers a 220-page resource guide for journalists covering health. It also runs conferences on health reporting, as does the Canadian Science Writers' Association.

Recent developments should help health reporters produce unbiased drug articles. In September, members of the International Committee of Medical Journal Editors announced a new policy to foster openness in study results. As of July 1, 2005, in order for studies to be considered for publication in any of the 11 members' journals, including the Canadian Medical Association Journal, studies must be publicly registered before they begin. That way, a company can't decide not to register and publish studies with negative findings. An editorial published online by all members of the committee says, "Honest reporting begins with revealing the existence of all clinical studies, even those that reflect unfavourably on a research sponsor's product." With this change, journalists will have access to all drug trial results, both good and bad. Similarly, the Canadian Institutes of Health Research, Canada's primary funding agency, announced this past summer that it, too, will require all CIHR-funded clinical trials to be publicly registered.

"Drugs in the News" co-author Alan Cassels is confident that journalists can do a better job. "There are some great drug stories out there, and people need to hear about them," he says. "Journalists must do their work: dig for the details and talk to people who have no conflicts of interest - people who can give real perspective on a drug."

Almost six years after its Canadian debut, Viagra is back in the headlines. On January 24, 2005, journalists describe a new potential benefit of the pill in treating enlarged hearts. As many as nine newspapers across the country run versions of a CanWest reporter's article, all beginning the same way: "After propping up the flagging morale of millions of men in the bedroom, Viagra could tackle a fatal problem above the belt."

Sure, the drug's effect on enlarged hearts has only been tested on mice and has no known effect on humans, but the fact is, a lead like this is too hard for editors to resist. The Montreal Gazette put it on the front page.