Ragnar Rylander’s Geneva study

on children and respiratory diseases

Pascal A. Diethelm

 

Up until the end of February 2002, the web site of the Geneva Institute of Social and Preventive Medecine (IMSP[1]) contained, in its section entitled “Research”[2], the following text: 

Diet and life habits

Objectives
Our goal is primarily to compare populations that exposed or not to a particular factor (magnesium, tobacco) and to put this factor in relation with other environmental factors. Protective factors (magnesium) and associated or confounding factors linked to life habits (smoking). Our investigations aim at issuing recommendations for methodologies that are applicable to environmental studies.
Persons involved
Responsable : Prof. Ragnar Rylander, physician
[…]

Respiratory infections in children and environmental factors
Objectives
To determine the influence of dietary habits and other environmental factors on respiratory diseases in 4-6 years old children.
[…]
Conclusion
No relation between dietary habits and respiratory symptoms. Environmental tobacco smoke does not modify the risk of diseases. However, we found a causality relation between some symptoms and humidity or the presence of mold in the house.[3]

The above conclusion may surprise many readers: “Environmental tobacco smoke does not modify the risk of diseases.” In other terms, the authors of the research state that exposure of children to tobacco smoke has no incidence on their respiratory health.

 

The same conclusion can be found in an article published by Prof. Rylander and a co-author, in the September/October 2000 issue of Archives of Environmental Health (AEH)[4]:

 

The number of cigarettes smoked at home or any other expression of ETS exposure was not related to an increased risk for disease. […] In conclusion, we demonstrated that home conditions (i.e., humidity, presence of molds, and number of years spent at day-care centers) were major risk factors for respiratory infections in children. Dietary items and ETS exposure were not associated with an increased risk for any of the diseases studied.[5]

 

These conclusions go against the established scientific consensus on the subject. For instance, the World Health Organization convened an International Consultation on Environmental Tobacco Smoke and Child Health in Geneva, Switzerland from 11 to 14 January 1999. The Consultation brought together experts from developed and developing countries to examine the effects of ETS on child health. WHO gives the following account of the conclusions reached by these experts:

 

The Consultation concluded that ETS is a real and substantial threat to child health, causing death and suffering throughout the world. ETS exposure causes a wide variety of adverse health effects in children, including lower respiratory tract infections such as pneumonia and bronchitis, coughing and wheezing, worsening of asthma, and middle ear disease. Children’s exposure to environmental tobacco smoke may also contribute to cardiovascular disease in adulthood and to neurobehavioural impairment.[6]

 

The Swiss SCARPOL study has also investigated the impact of ETS on respiratory health and has published its findings in an article entitled “Effects of environmental tobacco smoke exposure on respiratory symptoms in children”[7]. Based on a survey of 4’470 children aged 6-14 years, the study reaches conclusions that are very similar to those of the WHO experts:

 

Almost half of all schoolchildren in Switzerland, especially those from lower socioeconomic classes are exposed to environmental tobacco smoke. […] Children who were exposed to smoke at home had an increased risk of respiratory infections […] The association between environmental tobacco smoke exposure and respiratory symptoms is in agreement with several previous studies which have shown this association mostly among younger children (under age five[8]). […] There was a dose response relationship between the degree of exposure and risk of respiratory illness. […] We conclude that our study provides and confirms evidence that environmental tobacco smoke exposure is a highly prevalent environmental hazard for children, prenatally and after birth. Exposure to environmental tobacco smoke indeed remains air pollutant number one for children.[9]

 

It is difficult to determine by what route the two researchers from the University of Geneva have arrived at conclusions that are so different from those of the SCARPOL study, while both studies were dealing with essentially similar populations of Swiss schoolchildren. The contrast between the results of the University of Geneva scientists and the views held by the WHO experts is intriguing. The article in AEH provides only a sketchy description of its methodology and gives no explicit indication of the hypotheses that were tested. This makes it hard to assess the paper on scientific grounds. However, one fact that significantly distinguishes the Geneva study from other research in the same area is its source of funding. It has been recently discovered that the study was funded by Philip Morris. Although the support from the tobacco transnational is nowhere acknowledged in the article, it is now well established, as will be shown below, that this research was not a product of independent scientists: it was rather a piece of work done for, and paid by, a corporation that has an obvious commercial interest in its outcome.

 

When scientists are confronted with a situation of conflict of interest where the main financial sponsor of their work has an interest in the results, especially when the subject is sensitive and/or controversial and has an important public impact, ethics normally requires that they declare their sources of funding in all their publications and presentations. This transparency should allow, among other things, others to interpret their results with the necessary degree of caution. It is indeed notorious that industries are very reticent to finance research that produce results that are contrary to their interests. It is rather unfortunate that Rylander and his co-author have omitted to mention the source of funding of their project. Neither the web site of IMSP, nor the article in AEH, contains the slightest hint that the project was financed by Philip Morris.         

 

We will quote extracts from a series of documents obtained from the Philip Morris web site that relate to the study undertaken by Rylander and his assistant on the relation between environmental factors and respiratory diseases in children. These documents, which constitute a very small subset of the whole collection of documents relating to Rylander, make it possible to reconstruct to a large extent the evolution of the project and the framework in which it took place, and to get an idea of the motivations that guided it. We realize that such a reconstruction, based on documents that essentially come from a single source, runs the risk of being incomplete. Thanks to the “quality” of the documents, we think that it nevertheless allows us to apprehend in a sufficient way the initial elaboration, the financing and the development of the study on children and respiratory diseases that lead to the publication in AEH. This is already by itself very instructive.  

 

Before quoting the first document, which dates back to 1990, let us set the stage. In 1990, Dr. Ragnar Rylander is professor of environmental medicine at the University of Gothenburg in Sweden and associate professor at the Institute of Social and Preventive Medicine in Geneva, Switzerland. In parallel, he works as a consultant for Philip Morris, USA, under an agreement that was signed in 1972[10] and that has been renewed by mutual consent each year[11]. For his consulting services, Philip Morris USA pays him about $90'000 annually, while his work for the transnational does not exceed – according to his own declarations – more than 10% of his time. An internal Philip Morris memorandum[12] informs us that the payment of this amount is a “commitment”  and the $90'000 are paid “no matter what we asked him to do for us”. His main contact person at Philip Morris USA is Dr Thomas Osdene, Vice President, Science & Technology, a rather senior person in the Philip Morris hierarchy.   

 

The Documents

 

1.         The first mention of the Geneva children study is found on a fax, dated 6 September 1990, that Ragnar Rylander addresses to Thomas Osdene:

I visited Inbifo[13] yesterday and we had a good discussion on ETS. I have initiated a pilot study in Geneva on respiratory health in children and diet habits to test the hypothesis that this could be important and also related to ETS as outlined in my letter to EPA.[14]

 

In substance, it appears that a good discussion on ETS at INBIFO has prompted Rylander to start his study on children. The hypothesis at this initial stage is rather general, perhaps understandably. 

2.         On 29 January 1991, Ragnar Rylander writes to Thomas Osdene:

As agreed I will keep you informed about the development in the following special projects :
1. Linda Koo group developments particularly risk factors for lung cancer in in-smokers

2. Geneva study on respiratory diseases in children with relation to diet factors and ETS.[15]

This letter refers to an agreement that was passed between Philip Morris and Rylander. We have no information on the exact terms of the agreement. It should be noted that, from the outset, the Geneva study on children is treated as a “special project”.
  

3.         On 18 February 1991, Rylander sends Osdene a two-page letter with a paragraph dedicated to the Geneva study :

 

The questionnaire for the child respiratory disease/diet project in Geneva has now been finalized and I had an organization meeting with the group who is going to conduct the interviews. The study should be underway within the next few weeks and we will probably be bale to do a preliminary analysis before the summer. My planning is that the study should run for at least one year, but at some points in between, there will probably be a need to discuss methodology and criteria for symptoms together with someone knowledgeable on respiratory diseases, like Mike Lebowitz.[16]

 

It is worth observing here that Rylander starts the study, does the preliminary analysis and then considers discussing methodology and criteria for symptoms. When looking for advice from someone knowledgeable in respiratory diseases, it is also interesting that Rylander does not envisage any of his colleagues in Switzerland, where expertise in respiratory diseases is not lacking (for example, professor Leuenberger of the neighbor university of Lausanne would have been an obvious choice). He proposes the name of Mike Lebowitz, a consultant for the tobacco industry[17].

4.         On 26 March 1991, Rylander informs Osdene by fax:

The Geneva child infection – diet programme will start shortly after Easter – the questionnaire has now been tested in a pilot experiment.[18]

5.         On 15 April 1991, Rylander writes a letter to Osdene in which he reports on his activities. He refers to the Geneva study as follows:

We also reviewed the Geneva project on child respiratory health ETS exposure and diet habits. The collection of the data will start this week and by June/July we will hopefully have enough material to make a preliminary analysis. If the data looks good, I plan to look for money to run a more extensive study throughout next year.[19]

When Rylander says to Osdene that he will need more money “if the data look good”, he cannot ignore that for Osdene, good data are data that support the industry position, in other words data that either exonerate passive smoking of any serious harmful effect on the health of non-smokers or at least entertain the controversy about such effects.

6.         New fax from Rylander to Osdene on 3 May 1991:

 

The various projects are proceeding nicely – we now have 150 interviews completed in Geneva in the child - respiratory disease – diet study and before the summer we will have enough to make the first evaluation.[20]

 

7.         On 20 May 1991, Rylander sends a fax to Osdene announcing:

The field work for the child-diet-respiratory study in Geneva is now completed and we will analyze the data within the next months.[21]

8.         On 15 July, Rylander sends a fax to Donald Hoel, the lawyer from Shook, Hardy & Bacon, the law firm in Kansas City that assists Philip Morris and the tobacco industry in their litigation and liability issues.

Dear Don,

Has anything come up concerning visit to Europe yet ? At present I am busy writing an editorial on childrens respiratory diseases and ETS exposure. Apparently, I am still accepted in some scientific circles !!!

Please give me a call at home whenever convenient.

With my best regards

Ragnar Rylander[22]

9.         The message is well received and even creates some stir. In a post-scriptum dated 19 July 1991 to Steve Parrish, of PM Management, presumably written by Don Hoel,  one reads :

I am also enclosing for you a copy of a telefax message I recently received from Dr. Rylander. You will see that he is working on an editorial on children’s respiratory diseases and ETS exposure. I am not sure what this is about but in all probability it will be important for us. While I do not have any immediate trips planned for Europe at this time, it may be worth while to visit with Dr. Rylander and see if I can assist him in the “editing” of his report. What do you think?[23]

 

The answer is contained in a handwritten note (which can be attributed to Steve Parrish) on the same document:

I said “no”. They will meet in Richmond when Rylander [is] there next month.[24]

 

Rylander’s project to write an editorial on children and ETS appears as a highly sensitive subject for Philip Morris. Interestingly, the lawyer does not seem too concerned about the eventuality that it could upset Rylander that a lawyer be delegated by Philip Morris to assist him in the “editing” of his report.

10.    In his reports on monthly activities for July 1991, addressed on 5 August to Steve Parrish, R.A. Pages, Principal Scientist in Richmond, states:

1. Discussions with Don Hoel: CIAR budget and bylaws; Rylander—currently working on an editorial re children’s respiratory disease and ETS; OSFA; T. Sterling.[25]

Rylander’s project on children appears to be a matter of importance that is debated at a fairly high level in the PM hierarchy, and is treated on the same level as the CIAR[26] budget and bylaws.

11.    On 9 August 1991, Rylander writes to Osdene:

Back from vacation and overload already; several points to discuss. Enclosed please find the invoice for project funds September/October. It would facilitate very much if it was possible to have a first $6000 from the NovDec funds – the child diet project in Geneva has advanced more rapidly than anticipated and we need to analyze the data quickly before the next step. If it is easier, we could also term this special project, focusing on work done for Linda [Koo] and send separete [sic] invoice. Please advise.

Data from Geneva study are now in computer and will be analyzed late next week. It should be very interesting to see if this approach works.

For September I am still planning to come to Richmond arrival Sept 29 departure Oct 1 in the afternoon. Please let me know if this is convenient or if you want me to come at other time period.[27]

 

This letter confirms that the Geneva project is financed by Philip Morris from its early stages. The sentence “It should be very interesting to see if this approach works” is disturbing, especially when one thinks of what Philip Morris might consider as an approach that “works”.

12.    On 31 August 1991, Rylander writes another letter to Osdene:

Through contacts with Bob [Robert Pages] and Don [Donald Hoel], I understand we are all going to meet in Richmond towards the end of September. My travel planning is to arrive on Sunday, September 29 with departure in the afternoon of Tuesday, October 1.

 

Enclosed please find a summary of the different projects which I think would be of interest for this meeting. I have not yet sent copies to Bob or Don as I would like your approval first concerning content and scope. Please let me know and I will make the necessary adjustments and additions and correspond directly with Bob and Don.[28]

 

Rylander subjects his work – content and scope - to the double control of Philip Morris and the lawyers of Kansas City.

 

13.    The summary of the different projects that is attached to the previous letter is a two page document that lists six different activities, among which the Geneva project appears in good place:

The Geneva Child/Diet/Respiratory Infection/ETS Exposure study has been completed in its first phase and the results are being evaluated. Correlations have been found between the number of cigarettes smoked by the mother and the incidence of bronchitis, but a stronger relationship was found between the same disease and consumption of certain vegetables. […] There is now a second planning phase in the study and a complete research protocol will be established towards the end of 1991. The project looks very promising as the first data suggest that diet factors may be of equal or even larger importance for children’s respiratory disease than ETS.[29] (emphasis by the author)

 

14.    It’s interesting to observe that the project looks “promising” because diet factors reduce the importance of ETS exposure. Rylander makes a posteriori hypotheses on the observed correlation between diet factors and infections. In all likelihood, the questionnaire applied by Rylander to his subjects listed a great number of nutriment categories. Owing to the small size of the population sample used in the study, the occurrence of associations between some nutriments and the diseases under consideration is not surprising, as there is a large probability that some associations be observed simply by chance, without necessarily reflecting any underlying phenomenon.  

15.    Rylander visits the Philip Morris research center in Richmond on 30 September and 1st October 1991. When he gets back to Sweden, he sends a fax to Osdene on 8 October in which he says:

Thank you for a delightful visit last week. I also had a very good session with Don [Hoel] and we covered a variety of ETS related topics. In two weeks time I am off to Geneva for the final evaluation of the pilot child – diet infection study. I will send you a report shortly afterwards. […] I am also enclosing an invoice for project costs for November-December on $7000 with an additional $7000 coming mid-November. I am very grateful for the increase we discussed over the telephone – the major part of that money will as before go to the Geneva ETS related activities as discussed previously. I hope the above meet with your approval.[30]

 

Rylander has obtained more money, of which he will assign the major part to the Geneva study. We observe that he enjoys a great deal of freedom for the allocation of the funds he gets from Philip Morris.

16.    On 22 October 1991, Donald Hoel sends a letter to Rylander:

As promised, I am enclosing herewith some articles relating to children’s health and nutrition. I hope you will find these of interest.[31]

 

Philip Morris lawyers seem to be very versatile, acting as scientific librarian. Rylander could have obtained all the references he needed in Geneva, where the WHO library offers one of the largest collections of medical references plus the service of qualified librarians and access to state-of-the-art computer systems. We have not found the articles sent by Howl. They seem to have triggered a major change in his approach to the children study.

17.    Indeed, on 2 November 1991, Rylander sends a fax to Don Hoel, in which he says:

Thank you very much for the references to child health and diet. This was most helpful. We are now reanalyzing data from Geneva and there are some extraordinary things coming out. I will get in touch with you as soon as we have completed the work.[32] (emphasis by the author)

 

18.    On the same day, Rylander sends a fax to Osdene:

Week before last I took five working days in Geneva, analyzing the data from the child/respiratory disease study and writing a textbook on environmental medicine in French. The data from the child study now start to look extremely interesting. After corrections in the data base, there is now no correlation between ETS exposure and the frequency of upper respiratory infections.[33] (emphasis by the author)

 

Rylander says in other words that the data, which initially exhibited a correlation between respiratory disease and exposure to ETS, have been corrected directly in the database and now the correlation has vanished!

19.    Don Hoel appears to be satisfied by this turn of events. On 4 November 1991, he writes to Helmut Gaisch, of Fabriques de Tabac Réunis, the Swiss Philip Morris subsidiary in Neuchâtel:

I am attaching a copy of a telefax message from Dr. Rylander.  As we discussed, Dr. Rylander is working on some very interesting data from a study in Geneva involving young school children registering for school. The study includes data from physical examination of each child and questionnaire survey of the child’s parents. As soon as I hear further from Dr. Rylander, I will be in touch with you for a possible meeting with him.[34]

 

We note that for Hoel also, the data has now become “very interesting”.

20.    On 7 November 1991, Rylander communicates to Osdene an abstract summarizing the presentation that he intends to give at the annual meeting of the American Thoracic Society (ATS) in May 1992. The conclusion that must draw the maximum interest from Osdene is the following:

There were no significant relationships between ETS exposure and any of the respiratory diseases.[35] (emphasis by the author)

From that point on, this conclusion will remain an invariant assertion throughout the various stages of the project until it will appear in the article in Archives of Environmental Health and on the IMSP Internet site.

 

Contrary to what had been announced in his report of 30 August, there is no correlation anymore with “certain vegetables”. Now it is eggs, chicken, yoghurt and milk desserts that are at stake:
 

For diet factors, the strongest correlations were found between the consumption of eggs and cold (p=0.002), cough (p=0.017 and bronchitis (p=0.003). There was also significant relationship between these diseases and the consumption of chicken, yoghurt and milk desserts. No correlations were found between the diseases and consumption of vegetables.[36]

 

We see that the questionnaire was going quite deep in the level of details, being able to distinguish milk desserts from yoghurts. Given the size of the sample (90 children), we could imagine that the number of variables was not far from the number of subjects in the study. Rylander therefore rightly warns his readers that “the results are based on a food frequency questionnaire and the results must be interpreted with caution”[37] However, in the next sentence, he himself seems to forget his own advice:

The data suggests, however, that there is a relation between consumption of certain proteins and the risk for respiratory infectious disease in children. Diet factors must be taken into consideration in studies on the relation between environmental agents and respiratory infectious disease in children.[38] (emphasis by the author)

 

Given the high likelihood that the observed correlations were random effects[39], it seems premature to conclude that dietary factors “must” be taken into account,  considering  that this requirement puts a heavy burden on future studies.    

21.    In a fax that he sends on 3 December 1991 to Osdene, Rylander indicates that he considers publishing his results:

The data analysis of the Geneva child respiratory disease project is continuing and I plan to submit a full manuscript to the American Review of Respiratory Disease as soon as we have the values for different nutrients.[40]

22.    One month later, we note a change in the choice of publication: it is no longer the American Review of Respiratory Diseases, it is now the European Journal of Respiratory Diseases. Was the submission rejected? We do not know. On 7 January 1992, Rylander writes a letter to Donald Hoel, of SH&B, saying:

I intend to submit the article on childrens’ respiratory health for publication in the European J Respiratory Diseases. Unfortunately we have not yet been funded for the continuation of that study. When we last met, you indicated that there might be funding possibilities in the States. Do you have more information on this – I think that it is very desirable to expand the study to test the hypothesis developed from this first pilot test.[41] 

 

Internally, and in contrast to the way he presented it in the ATS abstract, Rylander acknowledges that his first study is no more than a pilot test aimed at developing hypotheses. This description is also opportune, because he now wants more money to continue the study.

23.    At the beginning of 1992, Rylander goes to Australia. On 5 March 1992, he sends a fax to Osdene. We note in particular the following extract:

 

You will recall that questions on the number of siblings and attendance to day care centers were included in our Geneva pilot study and correlated to the incidence of infection. We have now expanded on this and I have assembled a series of articles describing this particular environmental risk factor. By and large attending day care centers increases the risk for respiratory infection 5-10 times whereas ETS carries a risk of 1.5-2.5.[42] (emphasis by the author)

 

Rylander acknowledges internally that exposure to ETS increases the risk of respiratory infection. In the same fax, he informs Osdene that:

 

The Geneva study on childrens respiratory disease and diet was accepted for presentation at the American Thoracic Society annual meeting where I will also give a meet-professor-seminar on endotoxins in the environment.[43]

 

24.    Back to Europe, and following a conversation with Donald Hoel, Rylander sends him a fax on 16 April 1992, in which he describes the status of three projects, among which the one on children in Geneva:

2. Children and nutrition.  A pilot study performed among a sample of school children in Geneva demonstrated a surprisingly close relationship between the risk of respiratory infections and the consumption of proteins, particularly eggs (negative correlation = protective factor). Other risk factors, although far less important, were attending day care centers and the number of siblings. No association was found between ETS exposure and the risk for infection. A second pilot study is underway and will be completed early summer. If the preliminary findings can be verified, the results are of great importance for public health and prevention of disease in children.[44]

 

25.    On 9 June 1992, Rylander writes to Don Hoel, communicating him a copy of an editorial that he just completed for Archives of Environmental Health. He says:

Luckily enough our study on childrens’ respiratory infections nutrition [sic] was ready a few weeks after I had written the editorial. The manuscript has been mailed to the European Journal of Respiratory Disease for publication. We are now doing a repeat of the latter study and the results will be available early July. Keep your fingers crossed.[45] 

 

The “keep your fingers crossed” is quite revealing.

 

Hoel now becomes, for a while, Rylander’s privileged counterpart at Philip Morris, since Thomas Osdene, with whom Rylander had been in contact since the end of the sixties and with whom he had a close and apparently very friendly relationship, retired from Philip Morris at the end of May 1992. This may perhaps explain that from that point in time on, the correspondence between Rylander and Philip Morris is sparse.

26.    One year later, Rylander still reports to Don Hoel, as is shown in a fax that he sends him on 24 June 1993, in which he proposes to organize an international workshop, which he motivates as follows:

Studies on smoking and health, particularly cardiovascular disease and ETS related effects are plagued by the presence of confounding factors. There is particularly strong evidence that diet factors are important and that they covary with smoking making conclusions on causal relationships with smoking very difficult. Many studies have not controlled for all possible confounders.

A tradition down the workshop trail would be to organize a meeting with the title “Smokers and non-smokers – confounders I epidemiological studies” and systematically evaluate these factors with recommendations to control them in future studies.

I would be very interested in your comments and also information on where funding could be applied. If the need arise we could meet in New York or Kansas City for further discussions.[46]

 

To Hoel’s ears, a proposal aimed at “making conclusions on causal relationship with smoking very difficult” must sound like music. Rylander’s offer is indeed attractive. The symposium he proposes to organize would, in its conclusions, achieve two things in one go: on the one hand, it would essentially invalidate all previous studies on ETS on the ground that they did not take into account the multitude of confounding factors that “plague” ETS related effects, and, on the other hand, it would make all future studies much more difficult to conduct, since the burden of data collection of all these confounding factors would become almost prohibitive. This proposal provides an interesting clue on the context in which the study on children and respiratory diseases takes place.

 

27.    The previous fax is accompanied with a “Summary of joint research activities”, in which one can read, notably:

The project on nutrition in children and respiratory infections is discussed within the institute in Geneva and the aim is to start a new prospective field study hopefully within the coming year. A questionnaire has to be developed and a scheme to follow the prevalence of infectious disease in children designed. There is a collaboration with a similar project in Perth, Western Australia, launched during my last visit there.[47]

In spite of Osdene’s retirement, the study on children and respiratory diseases continues to be treated as a “joint project” between Philip Morris and Rylander.

28.    However, the study seems to enter a dormant phase for a year and a half. We have to jump to 17 February 1995 to find it mentioned again in a fax that Rylander sends to Richard Carchman[48], Director, Scientific Affairs, at Philip Morris USA in Richmond:

The study on infection in children and diet is under way again and we should have results by early summer.[49]

 

29.    One year later, on 6 September 1996, Rylander submits his budget for 1997 to Philip Morris USA. The budget comprises $65’000 for the Geneva projects and $85'000 for his consulting services, including travel costs.[50] Replying to a request from Philip Morris USA, Rylander provides a description of their joint projects, including the Geneva study on “environmental agents and infection in children”, which is the first listed:

The goal is to evaluate the role of different environmental factors and the risk for respiratory infections in children. One phase of the study has been completed and demonstrates that breast feeding and mold/dampness in homes are the main factors. Exposure to ETS, number of siblings and dietary factors were not associated with a risk. The study continues in a prospective design with monthly follow up of the presence of symptoms, controlling for the environmental agents.[51]

We still have the invariant assertion that seems to characterize the project throughout its life cycle: “Exposure to ETS is not associated with a risk”. We find the same description in an internal Philip Morris memorandum of 15 October 1996 by Loren McAlpin, of Philip Morris USA, under the heading “DR. RAGNAR RYLANDER RESEARCH”.[52]

30.    On 5 February 1997, Rylander communicates to Loren Mc Alpin an overview of his research work in Geneva since 1974, including the study on children:

1987-1996

Environmental factors and respiratory infections in children. Elaboration of questionnaires with particular focus on dietary factors. Three field studies during the winter months with subsequent modifications of the epidemiological technique. Planning of extensive study to be initiated in the fall of 1997.[53]

31.    An internal note dated 13 May 1997 of Philip Morris USA describes the activities included in the “1997 2^nd Revised Budget in cost center 2R1, expense elements 455 and 470”. Under the heading Research Funds – Group of Environmental Medicine, Institute of Social and Preventive Medicine, Geneva University, the first project listed is the study on environmental agents and infection in children. Further down we have the mention: “Granting period: ongoing  Funding: 1997 –$80’000”[54].

32.    Although Rylander has been associated with Philip Morris for over 25 years, as a consultant, as a scientist in charge of extra-mural research of the transnational, in 1997 he still  makes notable efforts to preserve the appearance of independence, as transpires in a candid letter that he sends on 23 June 1997 to Richard Carchman:

Throughout the years I have always been very strict to report to Richmond only and particularly not get engaged in the activities of the Neuchâtel group. Also regarding specific projects, I have also adhered uniquely to Richmond and to CIAR. Finally, I have never been involved with any Philip Morris executive in meetings or contacts with outside persons, to retain as far as possible the image of an independent scientist.[55] (emphasis by the author)

33.    Another internal note of Philip Morris USA dated 10 July 1997 from T. Banty to R. Carchman informs us that “Dr. Ragnar Rylander signed a consultant agreement with Philip Morris in 1972 […] as ‘our representative to INBIFO’”, and then lists his current activities, which again include, for the period 1987-1996, “Environmental factors and respiratory infections in children”[56].

34.    On 25 September 1997, Rylander submits his 1998 budget proposal to Philip Morris USA. He asks $119’999 for Geneva. Concerning the study on children, he says:

The material from the original study is in manuscript form and additional data analysis are undertaken, following the suggestion of reviewers. It will be submitted for publication early 1998. The plans for an extended study were presented to the Swiss National Foundation for Medical Research but was [sic] not supported. Information is collected for a possible renewal of the request. The project is to [sic] large to be entirely funded by the present support from PMRD.[57]

35.    One year later, on 5 October 1998, Rylander sends to Philip Morris USA his budget proposal for 1999. This budget covers the continuation of the study on children’s infection and environmental agents, for which he asks about $30’000.[58] The request is reviewed internally by Philip Morris USA, and the recommendations are generally favorable, even if the proposal lacks specific details. One reviewer (Helmut Reif, Director, Philip Morris Europe) indicates that the project is relevant to ETS because:

The children & ETS related topics are gaining ground in the public discussion and thorough papers are needed. [59]

36.    On 15 February 1999, Rylander sends to Philip Morris USA a revised version of his research program for the Geneva Institute of Social and Preventive Medicine. The project on children appears in a more elaborate form than on the initial proposal. The budget is also substantially higher: it amounts now to $79’000.[60] The next day, Rylander sends an invoice of $57’300 to Philip Morris for “research project funds for Institute for Social and Preventive Medicine Geneva University as per submitted research proposal, revision 1.”, with the following instructions:

Please pay to World Wide Consumer Bank, PO Box 92965, Rochester, New York 14692-9065, account 019-2493 30.[61]

 

Rylander has himself admitted in declarations to the press that this was his personal bank account.[62] Such mode of payment breaches the legislation of the University of Geneva, which forbids university researchers to financially manage their research activities using private bank accounts, whether in Switzerland or in other countries.[63]  

37.    In a letter dated 10 March 1999, Cathy L. Ellis, Senior Vice President, Philip Morris USA, informs officially Rylander that:

Philip Morris is pleased to inform you that you grant entitled Childrens’ infections and Environmental Agents has been recommended for the continuation of funding by our Scientific Research Review Committee. We have also approved the final year of funding for your grant entitled Magnesium and Cardiovascular Disease. A check in the amount of USD $81'000 has been sent to the World Wide Consumer Bank in Rochester, New York per your request (copy of check attached).

We want to fund quality scientific research and to promote the independent investigation of the issues described in the grant.[64]

 

Readers will appreciate the statement concerning the desire to promote “independent” investigation.     

38.    On 13 August 1999, Ragnar Rylander and his co-author submit their paper on children and respiratory diseases to Archives of Environmental Health. After one revision, the article is accepted for publication on 10 January 2000, to finally appear in the September/October 2000 issue of the journal.

39.    Among the references cited in the paper, one observes a notable omission. No mention is made of the SCARPOL study, which is the reference study on the subject in Switzerland and is considered a very important one in the world. SCARPOL studied a sample of 4’470 Swiss schoolchildren, more than 12 times larger than the sample studied by Rylander and his co-author. Rylander could not ignore the existence of the SCARPOL study and its conclusions, since he was sitting in the same governmental commission in Geneva as one of the authors of SCARPOL, who presented the conclusions of the study to the commission.

 

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This research has been conducted at the request of CIPRET-Genève and OxyGenève, two Swiss associations located in Geneva dealing with smoking prevention and non-smokers’ rights. The author wishes to thank Dr Jean-Charles Rielle, doctor-in-charge of CIPRET-Genève for his help in the research work that lead to this report. The author received no funding or any other external material support, with the exception that CIPRET-Genève has partially reimbursed his Internet connection charges to cover the access to internal tobacco industry documents.