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
Katherine Hobson

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.

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,
$32.95

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.

Book Review: Newsweek

A new book looks at how pharmaceutical companies are using aggressive marketing campaigns to turn more people into patients.

By Jennifer Barrett

Newsweek

Aug. 2, 2005 -

There are few Americans these days who aren’t popping pills to treat a complaint, or to prevent one. From headache medicine to cholesterol-lowering drugs to sexual-dysfunction aids, there seems to be a remedy for every disorder out there—and even some we didn’t realize existed (until we saw the ad, that is). In their new book, “Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients” (Nation Books), Ray Moynihan and Alan Cassels examine how the drug industry has transformed the way we think about physical and mental health and turned more and more of us each year into customers. NEWSWEEK’s Jennifer Barrett spoke with Moynihan, a medical writer for the Milbank Memorial Fund in New York and a regular contributor to the British Medical Journal, about how—and why—drug makers have begun targeting people who aren’t sick.


You write that drug makers now aggressively target the “healthy.” Why?
Ray Moynihan: The book opens with a quote from a former Merck CEO that it was a shame he wasn’t able to make Merck more like the chewing-gum maker, Wrigley’s, because then he’d be able to "sell to everyone." I think that does drive the marketing machinery of the drug companies now. Drug companies target lots of sick people and make fabulous drugs that extend lives and ameliorate suffering. But the so-called preventives are where the big money are: like the bone-density drugs or the cholesterol [-lowering] drugs. Increasingly we’re seeing the marketing shift to those types of drugs. People talk about the "worried well." There are many ways in which the drug companies target those people.

You mean people who are well but worried about being sick? How are they targeted?
The use of celebrities is now a standard way in which drug companies don’t just promote their drugs but try and change public awareness, public thinking and public perceptions about illness. In some cases the disease phrasing is legitimate and welcome. But when you have celebrities trying to change the way we think about sexual difficulties or stomach problems or symptoms of stages of life, these are insidious campaigns.

Why celebrities? I might take Serena Williams’s advice on a brand of tennis racket—but menstrual migraine medication?
[Laughs.] There’s actually a whole mini industry of celebrity brokers who bring together celebrities and drug companies. I’ve interviewed one of the brokers who talked about the reason celebrities work so well in getting people to think about conditions and to go to their doctors.

Why do they work so well?
Because people trust celebrities. But they are not telling you often enough that they are on the [drug company’s] payroll. Of course, if they did tell you as often as they should, your trust might diminish somewhat.

Aren’t there enough sick people that the drug companies can target? Why try and convince others they’re sick?
The marketing people and the sophisticated PR people who work for them are doing what shareholders demand of them. They’re looking for ways to maximize markets. One way is to redefine more and more people as sick. There’s an informal alliance between the drug companies and aspects of the medical profession and aspects of the patient advocacy world who all seem to have interests in defining more and more people as ill. We look at this condition by condition in the book, and what you see is a similar formula or process at work. Every time a panel of experts come together, they want to nudge the boundaries a little further out, whether it’s mental illness, cholesterol or high blood pressure.

How do you think this is affecting the American psyche?
Asclepius was the Greek god for healing and one of his children was Panacea. She is one we all worship—no matter if we’re Jewish or Christian or Muslim. We all want a panacea, particularly if we’re vulnerable or sick. The trouble is that there are vast commercial and professional forces trying to exploit the vulnerability we have and exploit our desire for a panacea. I don’t know what is happening to the American psyche. But I see a country bombarded with advertisements. We’re seeing fear of disease, decay and death becoming a central part of life. I’d like people to investigate the psychic impact of being told 10 times a day you might actually be sick.

You’re from Australia, though you focus on the United States for this book. Is America unique?
The marketing strategies of pharmaceutical companies play out globally. However, the U.S. is the epicenter of the selling of sickness, of disease-mongering. Americans make up less than 5 percent of the world’s population but the U.S. makes up 50 percent of the drug market.

Really?
That doesn’t mean the U.S. takes 50 percent of pills.

That’s a relief.
But it does account for half of total spending on drugs. It’s still extraordinary. And it’s at the high end of pill taking.

Why is that?
The U.S. is different because it allows direct-to-consumer advertising [of prescription medications], which has taken off in a huge way in the past eight to 10 years. It’s been around a long time, but there was a loosening of the regulations in the mid- to late '90s. New Zealand, too, is [unusual] in the world that way. In Australia and other countries, there is a strict ban on direct to consumer marketing. But so-called disease awareness programs, heavily funded by pharmaceutical companies, are not banned. So marketing strategies do play out in other places as well.

Have you heard from any drug companies since your book came out?
It’s been out for a month in Australia, and there hasn’t been anything out there to counter the journalism in my book. There’s been a very strong silence. The worrying thing about that is that it makes me think that I might be right.

If so, what do you hope would come from the book?
I hope a few more people become a bit more skeptical about the claims being made to them about drugs and disease, about the labels that are being attached to them, and the conditions they’re being told they have. It’s time for all of us to be a bit more skeptical.

Book Review: Philadelphia Inquirer

Selling Sickness
How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients
By Ray Moynihan and Alan Cassels

Nation Books. 254 pp. $25

Reviewed by Sherry Jacobson

Ray Moynihan and Alan Cassels, coauthors of Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients, make a strong case against the pill-popping habits of many Americans. Specifically, their book takes aim at our habit of using pills to control such conditions as high cholesterol, high blood pressure, osteoporosis and menopause.

Both authors are outsiders to the U.S. health care system. Moynihan is an Australian journalist who has covered the business of health care for nearly a decade, including prize-winning reports in the British Medical Journal. Cassels is a Canadian health policy researcher in British Columbia.

As someone who has written about medical problems for years, I've got to admit that the book makes a pretty convincing argument that the public is being manipulated. Americans are forking over a fortune in hopes of avoiding severe illnesses, and drug companies are getting richer in the process.

But the authors make their strongest case by dissecting pharmaceutical claims that a certain medication can prevent a certain disease. Take high blood pressure, for example.

U.S. medical guidelines indicate that more than 40 million Americans suffer from high blood pressure or hypertension, a condition that increases the risk of suffering a heart attack or stroke. One medication purports to cut the risk by a third. So why not take it?

The authors want you to examine the numbers more closely. If you have elevated blood pressure but no other health complications, your risk of suffering a heart attack or stroke could be about 3 percent during the next five years. When medication cuts that risk by a third, your risk drops by a mere percentage point.

The authors also theorize that drug companies pressure government regulators, particularly the U.S. Food and Drug Administration, to create new disease categories. They wonder whether these new categories - including premenstrual dysphoric disorder, social anxiety disorder, irritable bowl syndrome, and female sexual dysfunction - even exist but for the drugs that have been invented to tackle them.

The book also criticizes doctors for promoting the benefits of medication without revealing their own financial connections to the drug's manufacturer, as well as Hollywood celebrities who market their personal health problems on talk shows without mentioning that drug companies are paying them.

And the news media, of course, take a major hit for not blowing the whistle on the entire charade.

What's a conscientious health-care consumer supposed to do?

The authors urge consumers to employ a "healthy skepticism" whenever they hear claims of a new, but rampant, disorder and, of course, to be wary of the perfect remedy that would combat it.

But consumers also need to be smart enough to know when they're sick enough to need the medication. The authors wisely conclude: "Sometimes, of course, diseases are real, painful and deadly, and treatment with the latest and most expensive drug or other medical technology or procedure is highly desirable."

The trouble is, you have to know the difference.

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This review appeared originally in the Dallas Morning News.

Book Review: Oprah Magazine

One Nation, Overmedicated
Have we handed drug companies the power to define diseases? It's time to take back our health.

IN A PROVOCATIVE NEW BOOK, Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients, our nation's growing reliance on "lifestyle" medications is put in the spotlight. Ray Moynihan, an award-winning medical writer, and Alan Cassels, a drug policy researcher at the University of Victoria in British Columbia, argue that Big Pharma tries to medicalize our lives, then works to convince us that its products are the only cure.

And we believe it, the authors say; drugging ourselves to treat problems that may not even be real diseases, including severe PMS (now rebranded premenstrual dysphoric disorder) and shyness (now social anxiety disorder).

When medications do have proven benefits, Moynihan and Cassels write, pharmaceutical companies often exaggerate a product's usefulness to encompass the widest possible group of patients--some of whom are unlikely to derive benefit from the drug. As one example, Selling Sickness highlights the widespread marketing of cholesterol-lowering drugs to healthy women:
Reliable research has shown that some groups, like men with known heart disease, clearly benefit from medication that can reduce their risk of heart attack. There's much less proof that the drugs help women with no history of disease.

The book's charges are compelling, but we shouldn't throw the baby out with the snake oil: Women who do have heart disease may need a prescription to lower their cholesterol, and certain patients with other ailments, such as osteoporosis or attention deficit disorder, really can benefit from medications. The problem isn't the drugs themselves--it's the hyperactive way they're promoted, the way consumers clamor for them, and the way too many doctors and patients believe there's a pill for every ailment.

There's no simple solution, but you can do some things to protect yourself. Ask tough questions before accepting a prescription:

* Exactly what condition is this medication supposed to treat?
* Are there nondrug approaches (such as diet or exercise) that I can try first?
* Has this medication been proven useful in patients like me (that is, people who are my age, my sex, my level of health)?

If your doctor doesn't have an answer to that last question, consumer-friendly; impartial Web sites can help you do the research yourself:

* Consumer Reports' new site (crbestbuydrugs.org) provides information about the effectiveness of approximately 100 drugs.
* The Medical Letter offers in-depth analysis of both new and older medications on its site (medicalletter.org).

You can take back control over the prescriptions in your bathroom cabinet. As Selling Sickness reminds us, if you get suckered into using medications you don't need, the only benefit is to the companies that sell them.
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By Jerry Avorn, MD
Jerry Avorn, MD, is a professor of medicine at Harvard Medical School and the author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs (Knopf)