Book Review: Selling Sickness, by Robyn Williams
Saturdays at 12.10pm, repeated Mondays at 7.10pmwith Robyn Williams
Book Review: 'Selling Sickness'Saturday 30 April 2005
Summary In a market driven economy, is the pharmaceutical industry hyping disease to improve their bottom line? Are we as sick as the industry would like us to believe?
Program TranscriptI’m no economist but even I know we live in a market economy. Ever wondered where the market comes from? It’s a big issue for the pharmaceutical industry. Is it in fact now in the business of creating disease markets? Let me be clear – a small proportion of the population have serious illnesses or are at high risk of disease, and these people may benefit very greatly from drug treatments. No doubt about that. But the more of us that can be considered diseased or at risk of disease, the bigger the potential market and the potential profit. So there is plenty of rationale for drug companies to manufacture disease as well as drugs. This the fundamental argument of Selling Sickness, a book about big drug companies by Ray Moynihan and Alan Cassels. Take the market for SAD, Social Anxiety Disorder. GlaxoSmithKline are the makers of Paxil, the first drug approved for the treatment of SAD. According to the book, GlaxoSmithKline (then SmithKlineBeecham) claimed that SAD affects 1 in 8 Americans – a very tidy market – and a big expansion of what was previously considered a rare disorder. Indeed other estimates put the prevalence at less than 1%, and up to 4%. Presumably the rest of the people in the SAD market just have ordinary shyness. Or what about the market for osteoporosis prevention drugs? Recent definitions of low bone density put 30-50% of post-menopausal women in this market. That’s a big market. Osteoporosis prevention drugs currently are worth about $5billion per year – expectations are that could increase to $10billion per year. Just after I read this bit of the book, I opened my copy of a doctor’s magazine that had arrived in the mail, and sure enough, there was an ad featuring an attractive woman, Id say in her forties. The marketing promotes the idea of taking tablets to prevent bone loss, but what really matters is preventing fractures. Taking a drug to reduce hip fracture might be beneficial for women in their 70s and 80s when the risk of hip fracture is high. But for a woman in her forties or fifties the risk is very small. Most women of this age will be better off taking exercise rather than pills. Even in older women low bone density is only one of many factors contributing to hip fracture, along with poor balance, failing eyesight and muscle loss. But in the US, drug marketing keeps conditions like osteoporosis prominent in the consumer’s mind, fuelling the desire for drug treatment. A refinement of the strategy of expanding the disease market is to recast common experiences of human life as disease. Examples outlined by Moynihan and Cassels include menopause (think estrogen deficiency disorder), treatable by hormone replacement therapy – one of the most prescribed drug therapies ever. Or ageing (in men think erectile dysfunction) treatable by maybe the most famous lifestyle drug so far, Viagra. Or what about attention deficit disorder, perhaps otherwise known as childhood? It makes you wonder if they trying to convince us that we all need treatment? Stand by for the next disease expansion – female sexual dysfunction. Suffered by 43% of women – yes you heard that right, 43% of women according to its proponents with a market that might hit a cool $1billion by 2008. The treatment ? A Viagra like pill for women, or a testosterone patch. Of course this presupposes that the causes of female sexual dysfunction are largely physical (vascular, neurological and so on) and so curable by a chemical. I ask you, dear sceptical listener, does that sound likely to you? What about relationship issues, tiredness, stress, low self-esteem? Anyway, watch out for the new bedtime line: Not tonight darling, the dog ate my patch. (By the way, I cant take credit for that, its from Dr Leonore Tiefer, founder of a US based campaign against the medicalisation of women’s sexuality. For more on her confrontations with Pfizer, you’ll have to read the book. )So what you might say – take a drug, who cares? Except that, if drugs have effects, they also tend to have side-effects. In our quest for quick fixes , its easy to forget this. True, most side effects are minor but important, even life-threatening side effects do occur – as we’ve seen lately with Vioxx. Other examples are chronicled in Selling Sickness. So its important to think about both potential benefits and potential risks of prescription drugs, and to try to strike the right balance. The darkest side of this book though is the reported complicity between big pharma and doctors, researchers and regulatory authorities. According to Moynihan and Cassels90% of people who write clinical guidelines for doctors (for example on how to treat high cholesterol or depression) have conflicts of interest, because of financial ties to the pharmaceutical industry 60% of biomedical research in the US is funded by private sources mostly drug companies. In some fields like depression, its even higher. Half of the budget for the US regulator, the Food and Drug Administration, comes from drug companies on a user pays basis. That might be ok if FDA staff remained free and unconstrained in their views. But there is evidence emerging that freedom within the FDA is seriously under threat. Moynihan and Cassels are not alone in their assessment that some restraint on big pharma is needed. Last week the British Medical Journal published editorial comments that were deeply critical of the strategies of the industry , and recommended doctors just say no to drug company lunches and the like. This followed the release of a House of Commons Health Committee report on the pharmaceutical industry. They found an industry that buys influence over doctors, charities, patient groups, journalists and politicians and whose regulation is sometimes weak or ambiguous. The report recommends closer scrutiny of advertisements and limits on the marketing of new drugs. I want to say again, many prescription drugs deliver important benefits, and Moynihan and Cassels acknowledge this. Drug companies are of course commercial organizations under pressure to also deliver profits to their shareholders. They spend substantial money on research and development, resources that are not spent by government. They are in the world of private enterprise, and therefore the world of marketing. We need to be realistic about this two edged sword. I think the problem comes when drug company marketing becomes uncontrolled and unscrutinised. Then balancing benefits against risks and costs can get lost in the drive for ever bigger profits. This is what Moynihan and Cassels argue is happening . They make an interesting and thought provoking case. Their book is heavily based on US experience. In Australia we’re somewhat protected by the evidence based approach of the PBS – the Pharmaceutical Benefits Scheme and by marketing controls already in place on the pharmaceutical industry. Its important I think that at a minimum these controls are kept in place. Also it wont hurt if consumers keep an open and sceptical mind about the claimed benefits of all kinds of treatments.
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