Book Review: The New Zealand Listener
July 30-August 5 2005 Vol 199 No 3403
by Noel O'Hare
We've never been more health-conscious, yet drug companies are finding new illnesses" to ensure a growing market for their products, say two health researchers.Health spending is up 40% over the past five years, yet hospital waiting lists are so long that there are waiting lists to get on the waiting lists. If politicians were asked to play word association, "health spending" would be strongly linked with "bottomless pit". Why the explosion in health spending when we have never been more health-conscious or knowledgeable about the prevention of disease?One factor is the increasing medicalisation of daily life, creating a market-driven approach to health. When ill-health is seen as a business opportunity, there is no percentage in preventing it, except with drugs and expensive technologies. So, market logic dictates that new diseases need to be created and existing ones redefined to expand the market for their treatment. Cynical? According to a new book, Selling Sickness – How Drug Companies Are Turning Us All Into Patients, by Ray Moynihan and Alan Cassels, that's exactly what's happening.
Moynihan is an Australian medical journalist who writes for the British Medical Journal and the New England Journal of Medicine. Cassels is a Canadian researcher and writer who works on drug policy issues."The definition of what's normal gets smaller and smaller and the definitions of what's abnormal just seem to grow. And that happens, condition by condition.
That's what I've been trying to expose," says Moynihan, who was in New Zealand recently to address the Royal College of General Practitioners' Conference.In chapters ranging from cholesterol to female sexual dysfunction, Selling Sickness catalogues how medical conditions have been deliberately expanded. In the case of cholesterol, official US cholesterol guidelines were rewritten several times to increase the number of people recommended for statin drug treatment from 13 million in the 90s to 40 million in 2004. The public wasn't told, though, that many of the experts who drew up the guidelines had multiple ties to drug companies.
Hypertension, also a big earner for drug companies, is another condition where the goalposts have been moved. An estimated 50 million Americans were classified as at risk because of high blood pressure under new guidelines published in 2003. The guidelines also introduced a new category called "prehypertension". Anyone with a systolic pressure of 120 to 139 or a diastolic pressure of 80 to 89 was to be considered "pre-hypertensive".
One of the most disturbing attempts to reclassify healthy people as ill was the redefinition of osteoporosis. Any woman who did not have the bone density of a 30-year-old was labelled "abnormal". According to various redefinitions, between 30 and 50% of post-menopausal women suffer from low bone density and are at risk to osteoporosis. As a result of drug company fear-mongering, the global market for osteoporosis drugs exceeds $5b, though the benefits from taking the drugs are small.
The market for antidepressants has been expanded as a result of blurring the boundaries between ordinary life and mental illness. Putting your "out of control" behaviour down to premenstrual syndrome (PMS)? It could be premenstrual dysphoric disorder (PMDD). Suffering from a little-known psychiatric disorder called social phobia? Distracted? Disorganised? Is it just modern life or adult attention deficit disorder?
The marketing campaigns masquerading as health education or awareness-raising have, the authors say, one purpose: to "profoundly reshape our views of what constitutes treatable illness, and at the same time channel people towards the latest pill".
After the success of Viagra, female sexual dysfunction (FSD), a new condition, entered the medical marketplace. Pfizer, the company that struck gold with Viagra, was in the forefront of promoting FSD as a common disorder. About 43% of women are said to suffer from this. Suddenly, many women's preference to curl up with a good book rather than get excited about their paunchy middle-aged partner's Viagra erection constituted symptoms of a disease. When Moynihan wrote an article for the British Medical Journal questioning the prevalence of the condition and the role of drug companies in its promotion, there was an immediate worldwide response.
"It was quite extraordinary," he says. "A PR company sent an email to women's groups around the world to get them to join a campaign to counter the argument." Moynihan was shocked to learn later that Pfizer had secretly hired the PR company. So pervasive is drug company influence that it's almost impossible to tell what is medicine and what is marketing.
As the authors say: "The extent of the pharmaceutical industry's influence over the health system is simply Orwellian. The doctors, drug reps, medical education, ads, patient groups, guidelines, celebrities, conferences, public awareness campaigns, thought-leaders and even the regulator's advisers – at every level drug company money is lubricating what many believe is an unhealthy flow of influence.
"The cost has been enormous both in creating public anxiety about health and in public-health spending. "If you ask people what their risks are of [contracting] particular diseases, they often overestimate their risk because the fear-mongering has been so intense," says Moynihan. For instance, the risk of a non-smoking 65-year-old man with elevated blood pressure having his first heart attack in the next five years is between 5 and 6%. Most people, though, believe the risk is between 40-50%. One marketing ploy is to stress the relative risk and downplay the absolute risk of a disease. If a drug reduces your risk from 3% to 2%, that's a relative reduction of 33%, but only a 1% reduction in absolute terms. Studies have shown that people are less likely to take a drug if they are given the absolute risk.
Since, as research also shows, GPs are heavily influenced by drug company sales reps and promotional literature, they may be just as likely to exaggerate the risks when advising patients.GPs exposed to drug reps are also more likely to favour drugs over non-drug therapy and to prescribe expensive drugs when equally effective but cheaper drugs are available.
The classic example is diuretics, which have been used for decades to reduce the risk of heart attack and stroke. ALLHAT, a large-scale independent study, showed that diuretics were more effective than newer more expensive drugs, but doctors continued to prescribe the latter. One Australian study estimated that taxpayers could have saved $100m if the cheaper drug had been prescribed.There are some hopeful signs that the medical profession has started to acknow-ledge that its relationship with the pharmaceutical industry is corrupting and steps need to be taken to disentangle itself.
The American Medical Student Association is taking a hard line on drug company sponsorship, with a "PharmFree" campaign. In New Zealand, the Royal College of General Practitioners this year decided not to have drug company sponsorship of its annual conference. There is also a debate here about the industry funding of health advocacy groups.
However, as well as disentangling from these potentially corrupting influences, we need to find different ways of defining illness and drawing the line between healthy and sick, Moynihan believes. "I don't think any rational person can leave it up to panels that are riddled with conflicts of interest to tell us who, for example, has high cholesterol and who hasn't. I don't want to turn to a cholesterol panel where eight of the nine members have multiple links to drug companies. I'd like to find some genuinely independent body that can start educating us all about what are illnesses and what's health.
And if we are ill, what the best strategies are for fixing it and, more important, how we can prevent illness without necessarily needing to medicalise everyone. "The pharmaceutical industry has perverted the whole notion of prevention. Prevention is no longer about stopping smoking, exercising and so on, it's about long-term drug use. The trouble is, you end up with large numbers of people on multiple drugs for the rest of their lives."