Review in Greenleft.org
Corporate power threatening our health
Selling Sickness: How Drug Companies are Turning Us All into Patients
By Ray Moynihan & Alan Cassels
Allen & Unwin, 2005
254 pages, $26.95 (pb)
REVIEW BY PHIL SHANNON
Thirty years ago, the retiring head of the Merck pharmaceutical company told Fortune magazine that he was distressed that the market for his company’s drugs was limited to only sick people. If he could make drugs for healthy people, he would be able to “sell to everyone”. That dream is now coming true.
One of the reasons why the global pharmaceutical industry has stacked the weight on its 12-digit bottom line, say Ray Moynihan and Alan Cassels in Selling Sickness, is its strategy for selling new perceptions of disease to the healthy. Drug companies have marketed common complaints as frightening and widespread diseases for which they have the answer in a new drug.
Cholesterol-lowering drugs (statins) are the biggest selling of these new drugs. Although high cholesterol is a risk factor for cardiovascular disease, drug companies have successfully narrowed the focus on heart health to blood-cholesterol, despite it being only one of a suite of risk factors (among smoking, physical inactivity, diet and diabetes), all of which could be more effectively addressed, without the risk of the serious side-effects of statins, through prevention.
The rise of statins up the revenue charts has been aided by drug companies greatly exaggerating the almost non-existent benefits of statins for those without a heart condition, and by lowering the threshold for high cholesterol to catch in its net more of the healthy, an outcome achieved through funding the medical experts who set the official threshold. Eight of the nine members of the US expert panel that in 2004 revised the cholesterol threshold downwards, so trebling the US market to 40 million (one in every four) adults, were on drug company payrolls.
As with cholesterol, so has hypertension (high blood pressure) been turned from a risk factor into a disease treatable by drugs. Nine of the 11 experts who lowered the official US threshold to redefine millions more people as sick and in need of anti-hypertensive drugs, had financial links to drug companies whose anti-hypertensives have had their modest benefits overblown by the drug company promotional machine.
Mental health offers a field day for drug marketing. Depression, inflated to include people often just going through ordinary life experiences such as teenager angst, has been successfully sold as a chemical (serotonin) imbalance in the brain treatable by anti-depressants such as Prozac, despite the scientific debate over the causes, and therefore treatments, of depression. Anti-depressants, however, show only modest advantage over placebo drugs and carry with them serious side effects including, ironically, increased risk of suicidal thinking and behaviour among the young.
“Social anxiety disorder” is a pure marketing construct that has been so successfully promoted in the US as a disease affecting all those who may suffer shyness or uneasiness in social situations, that GSK’s anti-depressant Paxil, approved for its “treatment”, succeeded in outstripping sales of Prozac in 2002.
Attention-Deficit/Hyperactivity Disorder (ADHD) has been another spectacular success story in transforming public perceptions about a mental health disorder. Psychiatrists on drug-company payrolls have sold a neurobiological explanation for ADHD, and scripts for amphetamine-based drugs such as Ritalin have soared. ADHD, however, is a condition whose prevalence is inappropriately expanded to encompass not just children with severe symptoms of hyperactivity or inattention, but a vastly greater number of kids who fidget and can’t sit still or who drift off in class. Prescribing lifelong speed to adults (whose “symptoms” include that they “drum their fingers”) has also been a marketing spin-off, “one obscenity too many”, says a livid Moynihan, “when each year millions of adults and children ... will die early from preventable and treatable life-threatening diseases”.
Women’s health is a profitable hunting ground for drug companies. Menopause has been successfully turned from a normal physiological state into a disease requiring long-term treatment through Hormone Replacement Therapy. HRT, however, whilst useful for short-term treatment of hot flushes and sleeping problems, makes no difference to general health and vitality, mental health or sexual satisfaction, and its long-term use increases the risk of many of the problems it is supposed to prevent, such as heart attack, stroke, blood clots, breast cancer and dementia.
Similarly, the drug company Lilley, seeking to save the profitability of its soon-to-be-off-patent and therefore less profitable Prozac, has turned pre-menstrual symptoms, which can be severely disabling for some women, into an entirely invented mental illness called “pre-menstrual dysphoric disorder”, claimed to affect 7% of women and treatable by Prozac (renamed Sarafem), with its exorbitant mark-up from its new patent-protected use.
Another marketing construct is “female sexual dysfunction”, a “disease” made to order for Proctor and Gamble’s testosterone patch. Testosterone is useful for the small numbers of women with chronic, biologically based sexual problems, but is useless and potentially harmful for the 43% of healthy women who report occasional lack of sexual desire and sexual performance anxiety.
Osteoporosis has also been the subject of marketing propaganda, exploiting the natural tendency for bone density to decrease with age and thus increasing the risk of hip and other bone fractures, particularly among elderly women. Drug company money lies behind the experts who set the World Health Organisation’s definition of normal bone density to classify half of all women over 50 as suffering from osteoporosis and osteopenia (pre-osteoporosis). Sales of drugs to slow bone density loss have benefited, despite their modest benefits and serious side-effects, at the expense of prevention through diet, lifestyle and reduction of falls hazards.
In all these cases, drug companies have sold a perception of a disease as widespread, severe and above all treatable by drugs. The creative engines behind this strategy are the marketing wizards “working from chic offices in Manhattan, London, Toronto or Sydney”, paid by drug companies to change the way we think about health conditions. The internal documents from the public relations world give the game away with refreshing candour. They write about “creating markets” for drugs, “expanding the patient pool” by changing public perceptions of what is normal and what is sickness, and exploiting “market opportunities” through the “corporate sponsored creation of disease”.
The PR glitz is multifaceted and sophisticated. Massive advertising blitzkriegs selling drugs and fear scare people to their doctors. An army of drug company sales reps (80,000 in the US) — bearing warm doughnuts for their clients, invitations to lavish banquets at conferences in five-star hotels, and sponsorship of medical education of practising doctors — prime doctors to sell the companies’ drugs.
Although doctors tend to deny that they are influenced by drug company advertising, sales reps and perks, researchers have demonstrated that doctors exposed to drug company cultivation are more likely to diagnose a debatable disease, to favour drugs over non-drug treatment and to prescribe more expensive drugs over cheaper ones.
Drug companies are also masters of advertising posing as educational “awareness raising” campaigns. They also fund patient advocacy groups that pitch the same line as the drug companies about the cause and (drug) treatment of a disease. Two-thirds of charities and patient advocacy groups accept sponsorship from drug companies.
The political reach of drug companies is extensive, aided by drug company user-funding (50% in the US, 100% in Australia) of government regulatory agencies. These agencies, funded by the companies whose drugs they are assessing, can be inclined to soft pedal on the rigour of drug approval and monitoring. Corporate-friendly management, regularly replenished with industry blood and political appointments, sidelines and suppresses scientists who adhere to evidence rather than pleasing the drug companies.
It has been 30 years since drug bosses once saw health as the absence of a drug sale. They have worked hard with the marketing spivs to correct this barrier to profits. Without saying so directly, Moynihan’s excellent book shows that one of the major disease threats to people’s health and financial well-being is the corporate power of the pharmaceutical companies.
From Green Left Weekly, September 7, 2005.