US News and World Report: Q&A with Alan Cassels
On the Bookshelf: A profit motive to find illnesses
US News and World Report
August 23, 2005
More and more people are being identified as sick, even though many feel perfectly fine. The pace of this medicalization has picked up, according to Alan Cassels, a Canadian pharmaceutical policy researcher. His and medical author Ray Moynihan ' s new book, Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients, argues that pharmaceutical companies aim to increase profits by targeting the well in addition to the sick. Cassels offer some cautionary tales for people considering adding another drug to the medicine cabinet.
Experts have warned of "overmedicalization" for 30 or so years. Why is it getting worse? Is it the direct marketing of prescription drugs to consumers in the United States?
There's been a barrage of TV advertising. We didn't have this in-your-face marketing five years ago. It has caught the public's attention. But it's a complicated, pervasive influence at many levels. It's also tied to pharmaceutical companies' detailing [promotional samples to doctors] and continuing medical education. A lot of that is funded by industry. And I don't think that who is defining disease—who is actually at the table when they decide cholesterol levels should be this instead of that—has been looked at carefully.
You talk about anticholesterol drugs to bolster your claim that drug companies are "selling to everyone." What do you find when you look at research about who is helped by the anticholesterol drugs called statins?
When you look at systematic reviews, for people who are at high risk [of heart disease], there are benefits to modifying lifestyle and taking a cholesterol-lowering drug. But there is no benefit from the drugs for healthy women who have not already had heart disease. [Whether men with no previous disease are helped by statins is a matter of debate.] Yet it seems like you are not taking care of yourself if you don't get your cholesterol checked. I don't know what my cholesterol is, and I don't want to know. For many people, it isn't worth the cost, and the benefit is marginal.
So if the studies show no benefit for certain groups, how do these drugs get approved and prescribed to those people?
They do a lot of extrapolations—if it's good in this population, it must be good in this population and that population and that one. You end up marketing drugs to people who are of moderate to low risk. These are healthy people who you say are now patients, and they assume all the attendant costs and risks.
You also argue that high blood pressure is but one risk factor for cardiovascular disease and shouldn't automatically trigger drug treatment. But haven't the drugs to combat high cholesterol, high blood pressure, and other diseases helped raise life expectancy?
For some conditions, yes—for example, childhood leukemia. The general life expectancy is getting a little longer. Some of that has to do with basic stuff like vaccinations, trying to exercise, trying to eat properly. Our acute care system is also better. And people didn't use to wear seat belts, and they smoked more. And yes, some of the improvement is from drugs; I don't want to throw the baby out with the bath water. But chronic stuff—arthritis, Alzheimer's disease—the treatments for those are really quite marginal and have very little effect on the length and the quality of life.
Why are people receptive to being told they're sick?
We have an instant-gratification kind of lifestyle. You've got a problem; you want a quick fix. We shouldn't be surprised if some of our medical care looks like that. At one level, we're getting what we're asking for. There's also a huge amount of ignorance. We think we're getting something that is safe and effective, but we forget that every drug that has benefits can also harm.
You criticize the barrage of freebies and consulting fees that doctors get from pharma companies, as well as the practice of asking doctors to evaluate drugs when they have ties to the companies. Are doctors complicit?
When you look at the amount of money that large corporations are spending on things like pizzas and pens for doctors—these are businesses. They do this because it works. For physicians to say it won't influence judgment is naïve. And when people are involved in careers devoted to researching these drugs, the drugs become like their children; they are emotionally invested in these drugs. Asking them to stand back and be objective about them is like asking me to judge my kids in a beauty contest.
So what do you do if you're told you have, say, high blood pressure or low bone density and need medication?
There are a couple of basic and important questions that anyone should ask a physician. What exactly is the diagnosis of the condition? What would happen if I did nothing? If I am at an increased risk of something, how is it quantified? How much does that alter my risk of getting a heart attack? Ask about the entire spectrum of treatments. Are there nondrug, nutritional, lifestyle, as well as drug treatments? Ask if the drug has been tested in people like me. What happened? How many people benefited, and how many people were harmed?
What makes you optimistic that these trends will change?
I am very hopeful when I look at the new generation of physicians in the U.S. and Canada. Residents and med students are declaring themselves "pharm free." They are actively saying there's a problem. More physicians aren't seeing drug reps. Primary care physicians have little time, and they are less and less likely to spend that time hearing sales pitches. And people are savvier. They ask if their doctor is seeing drug reps, if his or her clinical judgment is being toyed with. It's not all doom and gloom. There are hopeful trends, and there are very good, thoughtful health professionals out there thinking about these things.