Book Review: Globe and Mail
Big pharma: It's enough to make you sick
By ABBY LIPPMAN
Saturday, August 6, 2005 Page D8
Selling Sickness:How the World's Biggest Pharmaceutical CompaniesAre Turning Us All Into Patients
By Ray Moynihan and Alan Cassels
GreyStone, 254 pages,
The pharmaceutical industry is global. It's also powerful and rich. And lately, it's all over the news. Notices of different drugs pulled off the market (Vioxx) or having to carry "blackbox" warnings for users (SSRIs, DepoProvera) blazon newspapers' front pages. Cheryl Ladd and Kirk Douglas grace the entertainment pages telling us to "ask our doctors" about the medical marvels that helped them or their "loved ones" -- and can also help us -- while Guy Lafleur pushes Viagra in the sports section. Then, in the business section, we read details of the trial of drug-company giant Merck accused of suppressing facts about the dangers (deadly for perhaps thousands) of Vioxx, its medication for arthritis and acute pain.
We've generally assumed that the pills we take are necessary, that they work and are safe -- and that celebrities are entertainers, not health educators. We expect physicians to prescribe what they know is good for us, and government regulators to safeguard our health. But given all the recent news, could these assumptions be wrong?
Ray Moynihan's and Alan Cassels's Selling Sickness throws light on these taken-for-granteds, revealing some hard truths about pharmaceuticals and those who make, sell, regulate, prescribe and front for them. Drawing on extensive interviews and wide-ranging documents, these long-time, knowledgeable researchers of the pharmaceutical industry develop a chilling story of drug salesmen wining and dining physicians to encourage them to prescribe their newest, priciest product; of companies reporting only studies with favourable results to regulators; of experts heavily funded by drug companies writing clinical guidelines that change the threshold for "abnormality" and establish treatment standards; and of large sums of (hidden) money given to high-profile celebrities who help "brand" some product.
The 10 case studies in Selling Sickness illustrate the tactics Pharma (current shorthand for the entire industry) uses to sell sickness, among them: medicalizing the ordinary (menopause, for example); framing mild symptoms as diseases (shyness morphs into a psychiatric diagnosis); giving social conditions (being "too tired for sex") a medical label ("female sexual dysfunction"); creating "epidemics" by constantly changing diagnostic guidelines (e.g., lowering the bar for treatment of "high" blood pressure or "high" cholesterol). The extensive details Moynihan and Cassels provide make it all too clear how artificial -- and elastic -- the categories that separate the "normal" from the not-normal are; how little good taking branded pills for many "abnormalities" may actually do; and worse, how much harm these medicines can cause when the research that gets them regulatory approval is, as is often the case, hidden, short-term or biased.
The selling of sickness seems to follow a familiar pattern. A pharmaceutical company identifies a wedge condition, set of symptoms or "risk factors"; hires a PR firm to come up with a "disease" name, ideally something catchy with a pronounceable acronym (e.g., SAD); develops a drug, or adapts an existing one, to tout as a "fix" for this new medical problem; and begins massive marketing to physicians and the public. The media pick up the story, suggesting that the "new" disease is greatly undiagnosed/undertreated; the market expands; drugs sales rise. And voila! Another blockbuster is born.
To read Selling Sickness is to realize that the pervasive and systemic operations of the pharmaceutical industry may be much more dangerous threats to the health of Canadians than the currently demonized waiting lists that delay joint or eye surgery. It's not just one company making a bad drug. Rather, almost an entire industry seems engaged in manipulating our lives, working to make us all patients in need of a cure or, perhaps, just the "not-yet-sick" waiting for some pill to be developed that will fix something we didn't know we had.
As Moynihan and Cassels suggest, Pharma sells sickness mostly to make money. Whether they sell up front or through patient groups or celebrities, they can only do this because governments are also taking part, creating the conditions in which diseases can be created and profits made. This probably dates back to the 1980s, when health was labelled a "growth industry" and the Canadian government (along with that of the United States) lowered taxes for corporations, changed patent and advertising laws and regulations in favour of business, and altered how drug reviews are financed so as to speed approvals.
Selling Sickness meets the criteria for being "evidence-based," and has the right credentials: Five of the 10 cases described here were first laid out in the British Medical Journal in 2002. However, it is not the first book to call attention to the phenomenon captured in the phrase "a pill for every ill," or, perhaps more apt today, "an ill for every pill." More than 20 years ago, women's groups in Canada and the United States raised alarms about the turning of menopause into a "hormone deficiency" state, as well as about the use -- and evident harms -- of insufficiently tested drugs sold to women to prevent miscarriage or pregnancy.
Lessons learned from the women's health movement (then and now) offer models for how to deal with today's sickness- and drug-sellers. But Moynihan and Cassels don't sufficiently acknowledge the persisting gender bias of drug development and the decades-old medicalizing of women's bodies, even though six of the 10 conditions analyzed in Selling Sickness are conditions experienced by -- and treated more in -- women than men.
This is not coincidence: Women are sold sickness and also use drugs more often than men. Moynihan and Cassels are at their best detailing how selling sickness is happening. But their analytic lens isn't sufficiently wide, so they don't connect their themes to ongoing activities with huge potential to create diseases-in-waiting for drugs of the future (e.g., brain imaging to "see" why we [mis]behave as we do, or gene mapping to seek DNA patterns that make us "susceptible" to just about anything). Moreover, while Selling Sickness has abundant references to the actions of the U.S. Food and Drug Administration, the Canadian content sometimes feels more like an "add on" than part of an integrated whole.
A range of well-intentioned proposals is now under consideration in Canada and elsewhere to rein in some of the worst practices described in Selling Sickness. These include mandatory public registration of all drug trials, mandatory reporting of adverse drug effects and updated requirements for declarations about sources of funding by researchers, "expert" advisers and patient groups. If these come into practice, perhaps they'll alleviate some problems. But by themselves, they can't prevent the growing health burden caused by the continued massive selling of sickness -- and of harmful drugs.
Attaining this will also require tackling upstream driving forces and, for example, changing tax and patent laws to prevent the development of "me too" drugs; excluding entirely those with drug-company ties from decision-making and from regulatory bodies that judge if our medicines are effective and safe; enforcing laws against direct-to-consumer advertising of drugs and outlawing completely the "see your doctor" variety. And maybe even creating a publicly funded independent institute to do drug trials.
Selling Sickness is an important exposé of many of the dangers of letting corporate interests determine both who is sick and how to treat them. It shows why we must demand of government a firm, accountable, transparent commitment to ensuring we get the safe and effective medicines we need when we are sick with real diseases. But as always, primary prevention will be even better for our well-being, and this will require social policies that give everyone access to the resources that protect our health and keep us well.
Abby Lippman is a professor of epidemiology at McGill University and often uses this as a cover for her activism with Women and Health Protection, where she is on the steering committee, and with the Canadian Women's Health Network, where she is chairwoman of the board.