Ivory Towers, Dark Towers

PLEASE SCROLL DOWN FOR ARTICLE

This article was downloaded by: [Purdue University]On: 6 August 2009Access details: Access Details: [subscription number 906130191]PublisherInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

Journal Of Pharmaceutical Marketing & ManagementPublication details, including instructions for authors and subscription information:http://www.informaworld.com/smpp/title~content=t792304025

Ivory Towers, Dark TowersMatthew M. Murawski a

a Department of Pharmacy Practice, Purdue University, West Lafayette, IN

Online Publication Date: 28 January 2008

To cite this Article Murawski, Matthew M.(2008)'Ivory Towers, Dark Towers',Journal Of Pharmaceutical Marketing &Management,18:2,35 — 46

To link to this Article: DOI: 10.1300/J058v18n02_04

URL: http://dx.doi.org/10.1300/J058v18n02_04

Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf

This article may be used for research, teaching and private study purposes. Any substantial orsystematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply ordistribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae and drug dosesshould be independently verified with primary sources. The publisher shall not be liable for any loss,actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directlyor indirectly in connection with or arising out of the use of this material.

http://www.informaworld.com/smpp/title~content=t792304025

http://dx.doi.org/10.1300/J058v18n02_04

http://www.informaworld.com/terms-and-conditions-of-access.pdf

Ivory Towers, Dark Towers

Matthew M. Murawski

SUMMARY. This article discusses some of the social and organiza-tional forces acting on pharmacy educators. It argues that these forcesmake the presentation of a balanced, in-depth discussion of the pharma-ceutical industry extremely difficult. Evidence that the popular culturehas demonized pharmaceutical executives to the point of caricature ispresented, and the point is offered that this sort of distortion has found itsway into the academy. Sources of potential bias against the industry arediscussed, as well as the various sins of omission and commission towhich pharmacy faculty may be prone which contribute to the negativeimage of a life-saving industry, as well as suggestions for positive ac-tion. doi:10.1300/J058v18n02_04 [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com>© 2007 by The Haworth Press. All rights reserved.]

KEYWORDS. Pharmacy education, pharmaceutical industry, bias, cor-porate image

Matthew M. Murawski, RPh, PhD, is Associate Professor of Pharmacy Administra-tion, Department of Pharmacy Practice, Purdue University, R. Heine Pharmacy Build-ing, Room 502, 575 Stadium Mall Drive, West Lafayette, IN 47907-2051 (E-mail:[email protected]).

[Haworth co-indexing entry note]: “Ivory Towers, Dark Towers.” Murawski, Matthew M. Co-publishedsimultaneously in Journal of Pharmaceutical Marketing & Management (Pharmaceutical Products Press, animprint of The Haworth Press) Vol. 18, No. 2, 2007, pp. 35-46; and: Pharmacy and the Pharmaceutical In-dustry: Healing the Rift (ed: David A. Holdford) Pharmaceutical Products Press, an imprint of The HaworthPress, 2007, pp. 35-46. Single or multiple copies of this article are available for a fee from The Haworth Doc-ument Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

Available online at http://jppm.haworthpress.com© 2007 by The Haworth Press. All rights reserved.

doi:10.1300/J058v18n02_04 35

Downloaded By: [Purdue University] At: 18:37 6 August 2009

INTRODUCTION

I can remember quite distinctly when I became aware that the Zeit-geist had grown to include a perception of the pharmaceutical industryas unrepentantly evil. It was 1993, and I and my wife were watching TheFugitive with Harrison Ford. I’d seen the industry used as a foil before,but this was the first “A-list” film I could recall with the villainy pro-vided by the dynamics of clinical trials and corporate profits.

Things haven’t improved in the interim. Michael Moore is workingon an anti-pharmaceutical project with a working title of Sicko. Theplot of Mission: Impossible 2 included further drug company skulldug-gery. And it’s not limited to films aimed at adults (well, roughly). Phar-maceutical firms provide the adversarial framework of video games(Resident Evil, City of Heroes, City of Villains) and have even come toguest star as the nasty bad guys in children’s films (The Shaggy Dog).One of these nights I half-expect my son’s night terrors to result in a cryof “Daddy! Daddy! There’s a PSR (i.e., pharmaceutical sales represen-tative) under my bed!”.

An academy award winning film of 2005, The Constant Gardener,met with considerable criticism. Astonishingly, the film drew review-ers’ ire not because of its scathing portrayal of a fictional pharmaceuti-cal firm, but because it may not have been critical enough (1, 2). Thefilm’s director noted on National Public Radio that drug companies arethe “perfect bad guys” (3). Without a doubt, when pop culture needs alogo for badness, a quick expression of purulent, amoral evil, a pharma-ceutical executive does the job. Here’s a villain whom one can hiss andboo without reservation or guilt. And this bad guy’s no tyro, or ineffec-tual–no Snidley Whiplash. He is the frighteningly capable, distilled es-sence of darkness: the pharmaceutical industry executive has becomethe new Nazi.

But that’s the innate fickleness of popular culture. Who cares if theindustry provides products that save millions of lives each year or thatimmeasurably enhance the quality of those same lives? The popular cul-ture, almost by definition, is not about reality. It is about perception,about an “image.” And those who labor to improve all our lives, whohave accomplished near miracles of medicine? Well, their image is, ba-sically, “these are bad people.”

One would hope, however, that such distortion would not be found inthe purportedly objective ivory towers of academe, especially when youare talking about pharmaceutical education. And yet, based on admit-tedly anecdotal reports, that does not appear to be the case. As I interact

36 Pharmacy and the Pharmaceutical Industry: Healing the Rift


with pharmacy students from across the country, I have been struck byhow many have a negative image of the pharmaceutical industry, thesame industry I was once taught was part and parcel of the profession it-self. While I have faith that my colleagues try to provide a balanced pre-sentation of that industry, no matter what their personal attitudes mightbe, I believe there is a certain amount of bias built into the system, biasthat contributes to this negativity toward the pharmaceutical industry.What follows is a discussion of the sources of that bias and someconstructive suggestions for change.

SOURCES OF BIAS

Let’s start with pressure. As any pharmacy educator can attest, thereare a lot of things that have to be covered in the pharmacy curriculum.At some point in the process, a certain amount of educational triage ispracticed; some topics must be and are given short shrift. Some are notcovered at all. This is especially true in the social and administrative sci-ences, where the potential content areas are almost infinitely vast. Aconscientious instructor must weigh the relevance of the topic to the stu-dents before her, consider those students’ ability and interest, and takeinto account her own skills and the content areas wherein she has themost expertise. In such circumstances, and with student’s circum-scribed understanding of what will actually impinge on their profes-sional lives, it is no surprise that the tendency is to emphasize thosetopics most directly related to day-to-day professional practice. For in-stance, understanding a patient’s motivation for engaging in health be-haviors will be given a much greater weight than understanding thearcane details of the economics of the drug development process. Notonly does understanding the Health Belief Model and other theories ofhealth behavior impinge directly on practice, but it is knowledge whoserelevancy even first-year students can perceive.

Given such difficult choices, it should not be surprising that rela-tively little time is given to understanding the dynamics of one of themost complex sectors of the economy. If it were not for the ongoing badpress the industry receives in the media and the natural curiosity this en-genders in pharmacy students, one must wonder if the topic would re-ceive coverage in the curriculum at all.

But clearly, when tasked to provide some discussion of the pharma-ceutical industry, our time-poor instructor faces a difficult choice. If shetries to present a balanced perspective, she finds herself between Scylla

Matthew M. Murawski 37


and Charybdis. To convey an accurate, balanced portrayal of the nu-ances of the industry will require the expenditure of a great deal of pre-cious class time. If she selects a brief overview, that approach is likelyto be negatively biased, emphasizing the bad more than the good (whichusually requires far more time and effort to explain). But should sheadopt a succinct perspective, that the pharmaceutical industry = bad(however preposterous that may be), our instructor’s effort likely willnot only be well received (the popular culture has prepared the students,after all), but she will also free up precious time for other topics in theprocess.

Under these conditions, those faculty members who do make theeffort to discuss the up side of the industry in their classes deserve com-mendation, not condemnation. However, a second issue, that of per-spective, may favor the converse result. Academia is, by and large,oriented toward a liberal, progressive perspective (4). Even nominallyconservative faculty may adopt liberal perspectives in response to cul-tural pressure or drift toward a more liberal viewpoint over time (5).And while the actual extent to which liberal viewpoints hold sway in theacademy continues to be a contentious public debate, there’s not muchdoubt that business models like those of the pharmaceutical industry arehardly likely to be looked on positively by most liberally orientedthinkers, who may constitute the majority of faculty.

Next, we must consider the kind of source materials available to theeducator. Pharmacy students, while intelligent and quite capable, aren’teconomists nor MBAs. The kind of material appropriate for the discus-sion of the industry for such students requires a level of sophisticationapproximately appropriate for that of a well-read average citizen. Muchof the accumulated material that I have reviewed over the years that hashelped me understand (to the extent that I may) the nuances of the in-dustry has been quite complex and often presumes a substantial masteryof prerequisite content. This compares dramatically with the tremen-dous amount of material available almost everywhere, generated by anynumber of media outlets, that is readily accessible, written or producedat an appropriate level, and that happens to be highly critical of the phar-maceutical industry. This is not to say that the material required to cre-ate a fair and balanced review of the industry does not exist, but tosuggest that useable content critical of the industry is far easier to comeby than material that would be considered supportive.

As an example, I have a DVD on my desk entitled Side Effects, theMovie. Its story is stridently anti-pharmaceutical, although I must saymy students tell me it is mostly a “chick flick,” and not a very good one



of those. But I cannot find anything similar that is supportive of the in-dustry. Honestly, when is the last time you saw something positiveabout the industry in any newspaper, news magazine, Internet site, orTV coverage? How odd is that, when you consider the number of peoplewhose continued existence can be attributed to that same industry.

SINS OF OMISSION

All these factors lead to certain cardinal sins we academics may beprone to when discussing the industry and its role in the profession.First, let’s consider the sins of omission. These are the kinds of thingswe should do, but often don’t, for many of the reasons listed above. Wemay, for example, fail to adequately explain the role of the industry inthe evolution of pharmaceutical therapy.

When working with my own students, I try to contrast and comparethe means available to treat hypertension when I began practice (meth-yldopa was the main drug of choice) with the alternatives in their thera-peutic toolboxes today. It is not hard to show that tremendous progresshas been made in how effective pharmaceuticals have become in treat-ing disease. What is more difficult to convey is some sense of the diffi-culties involved in that progress to give students some appreciation ofthe challenge that is drug development. Creating a new and therapeuti-cally beneficial compound that does not produce noxious or harmfulside effects or adverse reactions may require less effort and expertisethan, say, putting a man on the moon, but the difference in effort re-quired falls only an order of magnitude or so shy of that enormousaccomplishment.

And yet, I find that students seem to think new drug discovery ismore or less a walk in the park, almost as if there’s some master listsomewhere, and companies just go look a promising molecule up andstart making it. More than anything, this is something of which our stu-dents need a real appreciation. Whatever else may be said about thepharmaceutical industry, the job of drug discovery and development is,in fact, incredibly complex and difficult. And that’s just the clinical as-pect of drug discovery; the regulatory and economic complexitiesrepresent an almost equal challenge.

Which brings us to another sin of omission, that we do not adequatelyconvey the economic realities of research and development–the costs ofdiscovery, the probabilities of payoff, and the comparative economicchoices inherent between the pursuit of incremental improvements ver-



sus the search for blockbuster innovations. It is difficult to explain theniceties of cost accounting that are relevant to the industry’s often re-ported high levels of profitability. Suffice it to say that, depending onhow you treat the costs of research and development, the pharmaceuti-cal industry’s purportedly excessive levels of profitability are actuallynot only not excessive, but perhaps arguably not all that good. This is asubtle and complex argument, and the truth most likely lies somewherebetween those two viewpoints; however, an evenhanded discussion ofthe costs of research and development and industry profitability re-quires a financial background in students and teachers that is typicallymissing and would be too time-consuming to provide.

And finally, perhaps the most glaring sin of omission of all is the fail-ure by many academics to acknowledge, as publicly as they might, thesupport their own research and careers have enjoyed from the pharma-ceutical industry. I think of it as the “prostitute syndrome.” No onewants to be perceived as having sold themselves to the evil empire, butthe reality is that most pharmacy academics owe credit for at least someof their success to direct or indirect pharmaceutical support. New fac-ulty development awards from our key organizations are usually spon-sored by the industry, and many of us have grants from the industry onour CVs. That is fine. The question is, are the students we instruct awareof this?

SINS OF COMMISSION

Failure to make statements that, perhaps, should be made is onething. Failing to act is an essentially passive behavior, and it may occurwithout prejudice or animosity toward the industry. But there are alsosins of commission, behaviors which require direct action and so reflectunderlying beliefs or philosophical stances. The problem with thesesins of commission is not that they occur. Rather, the issue is that manyof these sins of commission are based upon perspectives that are sim-plistic and unsophisticated, thereby reducing complex issues intogood-versus-evil, black-and-white editorial cartoons aimed at demon-izing pharmaceutical companies. It is one thing to determine, via aneconometric analysis, that some corporation’s policies result in sub-optimal outcomes for society as a whole. Such observations are a ratio-nal part of the public discussion about how we should best allocate ourcollective effort and resources. It is quite entirely another thing to im-ply, explicitly or implicitly, that the corporation’s actions are the result



of moral turpitude or degeneracy. In academia, the process of analysisis just as important as the conclusions. If faculty members engage incrude, sloppy analysis and critique of the industry due to personalconviction instead of objective observation, they embarrass the educa-tional process and do a disservice to students.

The first and most common sin of commission seen in academia hasto do with the pricing practices of the industry. “Drug prices are toohigh!” is certainly easy to say, and there isn’t likely to be a lot of opposi-tion to such a statement. But the question of drug pricing isn’t that sim-ple. Today’s prices reflect a certain level of incentive for innovation.The more appropriate question to ask is whether the current level ofdrug pricing provides optimal levels of incentive for innovation to pro-vide the maximum value to society. This question provides a more pro-ductive debate. If the current drug prices do not provide an appropriaterate of innovation (up or down) then how can the incentive system bechanged to improve things? Or perhaps society’s optimal return on in-vestment would be realized by raising drug prices to encourage a higherrate of discovery and development. Or the framing of the question mayneed to be broadened to a global perspective where the question of pric-ing examines not only “how much?” but “whom?” Because the discov-eries of the pharmaceutical industry provide global benefits, perhapsinstead of focusing on price levels in the United States the larger ques-tion to ask might be whether high drug prices in the United States are an“innovation tax” imposed by the rest of the world. Instead of blaminghigh drug prices on the industry, maybe it would be better to challengeour assumptions within the framework of social, economic, and globalenvironments. Doing so would be fairer to the industry and result inbetter educational outcomes for our students.

The response to these points usually becomes a discussion of theprofit margin of the pharmaceutical industry, profits that apparently aresomehow prurient, even pornographic in nature, because when de-scribed in this context they are almost universally referred to as the “ob-scene” profits of the industry. This discussion could go on for sometime. Mention has already been made of cost accounting. What neverseems to be considered is whether the profit margins so many findsomehow objectionable take into account the costs of failure? You haveto be a certain age to remember how big a player A.H. Robins once was,but consider how Merck fairs today. Yes, there is money to be had whenthe right choices are made in the industry. But the downside, the factthat this is a very risky business, seems somehow to be forgotten. In-deed, not every story is a success story. Fortunes are lost, and billions in



capitalization disappear. That may be an acceptable consequence, but ifsociety wishes for individuals and corporations to continue to take suchlarge-scale risks, a certain premium for such chancy wagering must bepaid.

Ah, but then we usually come to the horrendous sin of “me-too”drugs. One particular editorial comes to mind, wherein the develop-ment of essentially all statin drugs beyond the first was considered awaste of time and money. Apparently, as soon as one successful com-pound entered the market, the corporations that had already investedhundreds of millions of dollars in their own compounds should haveceased development. Stranger still, the initial commitment to develop adrug should apparently never have been made in the first place, as it wasclear the parent company should have somehow known the drug wouldeventually come to market as a “me-too” drug. If six different compa-nies begin development in a promising new area of therapy on the sameday, they should know which compound will make it through the regu-latory maze most expediently, have the least objectionable side-effectprofile, provide the greatest therapeutic effectiveness, and offer thehighest benefit to society by approximately day two. At that point, so-cially responsible organizations would be expected to immediatelycease development of any second-best compounds, and the worldwould be a better place.

Seriously, it is clear that, if we think of a firm’s pipeline of new drugsas an investment portfolio, then prudent investment requires a certaindegree of resources allocated to (relatively) sure things, while only asustainable fraction of effort is committed to what might be consideredaggressive investing–the quest for truly innovative, blockbuster com-pounds. And this might be a good place to point out that if profits de-crease or the environment becomes less stable (riskier), the best strategywould be to move more resources to product development lines withmore predictable returns on investment and away from riskier, less cer-tain, but higher payoff development options. Incremental improve-ments in pharmaceuticals are the tax-free municipal bonds of theindustry, and that serves a definite function for the company andtherefore society as well.

The point regarding these sins of omission is that, while many as-pects of the industry may prove objectionable to some, the reasons be-hind those circumstances usually do not receive thorough discussion.There are many issues and aspects of the industry that bear close watch-ing and do require extensive discussion and debate. Obviously, in somecases, forces and circumstances have led to outcomes that are not in the



best interests of society as a whole. That is not the issue here. No oneshould consider the industry pure as the wind-driven snow, any morethan it should be considered the cartoon evil it has become in the popu-lar culture. What is unfortunate is the use of a certain kind of conceptualshorthand, one that portrays these outcomes as the natural result of deal-ing with them–with that evil empire. And the problem with such type-casting is not that it offends those who labor in the pharmaceuticalindustry. No, the reason such demonizing is so objectionable is that itobscures the real questions, misleads many as to the forces at work, andcreates significant barriers to finding real causes and, therefore, realsolutions.

DISCUSSION AND SUGGESTIONS FOR ACTION

So, some pharmacy educators are wont to provide a less than positiveperspective on the pharmaceutical industry. Let’s face it. It is easy to do.It is quicker than the alternative of a thoughtful, balanced discussion,and it is, generally, likely to be well received. Plus, there’s no realdownside in the short term. Certainly, as the public image of the multi-national pharmaceutical firm continues to deteriorate, there’s more thana little tendency to want to distance one’s self and one’s profession fromentities that are and continue to take so many hits. Why take one for theteam when it is not at all clear we all wear the same uniform?

Well, there are some direct consequences. The industry is a majorsource of support for many aspects of pharmaceutical education, facultydevelopment, and continued research. The illogic of biting the handthat feeds you seems so self-evident as to require no further discussion.And, while other sources of funding for all these efforts do exist, phar-macy and pharmaceutical education find themselves struggling for re-sources in a time of belt-tightening at almost every level. Findingfederal or foundation dollars to support education becomes more diffi-cult each year, while pharmacy practice faces its own struggles to main-tain relevancy and to provide evidence of its own cost-effectiveness inan ever-more overburdened health care system. In such dire times, thepossible loss of support from the industry is not something to beconsidered lightly.

Even if the collective decision were to be made that there should begreater separation between the industry and what were once consideredcomplimentary components of the same profession–practice and educa-tion–what would happen? What if we did decide to distance ourselves



from the pharmaceutical industry? Ignore for the moment whether sucha course would be prudent or desirable. The fact is, such an alternativemay not be possible. Some time ago, I and my colleague Dr. Mychaskiwapplied Benjamin Franklin’s point that, in regard to the pharmaceuticalindustry, pharmaceutical education, and pharmacy practice, “we mustneed hang together, or we will most certainly hang separately” (6) .

Given the training and experience of pharmacists and pharmacy edu-cators, it is no surprise that, conceptually, we differentiate ourselvesfrom those individuals who function within the sphere of the pharma-ceutical industry. Our expertise allows us to make these distinctions–distinctions we consider as evident as night and day, black and white.The dangerous error is to assume such differences, so obvious to us, areas evident to Jane and John Q. Public. Consider the words of the firstcitizen, President George W. Bush, when discussing Medicaid: “Peo-ple talked about how the decision to reform Medicaid was immoral.Well, it’s not immoral to make sure that prescription drug pharmacistsdon’t overcharge the system.”

Well, perhaps you do consider yourself professionally superior, ormorally elevated, or just plain better than the minions of the evil empireof the pharmaceutical industry. Perhaps, in fact, you are even correct.That will be a cold comfort indeed if the brush of public opinion tars usall.

What, then, can be done to reach out across this widening gap, to“heal the rift” lest it become schism? The role of individual educatorsseems obvious: to strive to present a balanced, in-depth discussion ofthe industry and its role in advancing health care and the profession.However, as noted above, there are a number of barriers that interferewith such efforts, even if a professor were well intentioned in this mat-ter. So, at the individual level, realistic responses to the “rift” are some-what limited. At the level of the academy, however, a significantcontribution seems possible. Academics respond to their own set of in-centives. A quick review of the American Association of Colleges ofPharmacy’s 2004 CAPE educational outcomes reveals no direct men-tion of the industry whatsoever. The closest we come to a reference oc-curs in Outcomes 3(A) IV, under Public Health, “Maintain professionalcompetence by identifying and analyzing emerging issues, products,and services that may affect public health policy, to amend existing ordevelop additional policies” (8). Given the extent to which the pharma-ceutical industry has been supportive of pharmaceutical education andthe extent to which public perception of pharmacists, pharmacy educa-tion, and that profession is apparently inexorably linked, perhaps the



next iteration of CAPE educational outcomes should address theindustry specifically.

The pharmaceutical industry is in a position to address some of thebarriers discussed above. The paucity of good source materials for theeducator must be resolved and done so in a manner that does not provideunrelentingly positive propaganda, but well-balanced, thoughtful mate-rial developed in a concise presentation of the issues involved. Slidesets, print materials, perhaps even videos, would all be helpful. Morein-depth, supportive material would also be useful, both for coursesaimed at pharmacy students, as well as for graduate programs. A verynice example of this has been developed by the Pharmaceutical Eco-nomics and Policy Council, (sponsored by Pfizer, Inc.) which may beaddressed at: http://www.dcri.duke.edu/ccge/publications/pepc/.

And there does seem to be a real need for the development of somesort of documentary, something suitable for airing on the DiscoveryChannel or similar outlets, that describes and details the immense chal-lenge of drug discovery and development that might be used in classesas well.

Ultimately, academics are usually willing to present both sides of thestory. Reasoned debate is our nature, after all. And while this alone maynot heal the rift, it certainly should make it easier to communicate acrossthe gap.

REFERENCES

1. Shah S. ‘The Constant Gardener’: What the movie missed. The Nation [serialonline]. 2005; (Aug 30). www.thenation.com/doc/20050912/shah (on-line only) (ac-cessed 2006 Sept 28).

2. Atkinson M. Cold comfort pharm. Village Voice [serial online]. 2005; (Aug 30).www.villagevoice.com/film/0535,atkinson,67300,20.html (accessed 2006 Sept 28).

3. Goldberg J. Pfizer vs. al Qaeda. National Rev Online [serial online]. 2005; (Aug31). www.nationalreview.com/goldberg/goldberg200508310810.asp (accessed 2006Sept 28).

4. Zipp JF, Fenwick R. Is the academy a liberal hegemony? The political orienta-tions and educational values of professors. Public Opinion Q. 2006; 70(3):304-26.

5. Will GF. Academia, stuck to the left. Washington Post [serial online]. 2004 Nov28:B07. www.washingtonpost.com/wp-dyn/articles/A15606-2004Nov26.html (ac-cessed 2006 Sept 28).

6. Murawski MM, Mychaskiw M. The academy’s public responsibility. J PharmMarket Manage. 2005; 16(1):3-7.



7. Husar DA. Letter to President Bush. Pharmacist Activist [serial online]. 2006;(Mar). www.pharmacistactivist.com/2006/march_2006.shtml#letter (accessed 2006Sept 29).

8. American Association of Colleges of Pharmacy. 2004 CAPE Educational Out-comes. www.aacp.org (accessed 2006 Oct 4).

doi:10.1300/J058v18n02_04



Documents

Ivory Towers, Dark Towers