Book Review in the Journal of the American Medical Association

BOOK Review JAMA, September 7, 2005—Vol 294, No. 9
Selling Sickness: How the World’s Pharmaceutical Companies Are Turning Us All IntoPatients, by Ray Moynihan and Alan Cassels, 241

pp, $26, ISBN 1-56025-697-4, New York, NY, Nation Books, 2005.
Selling Sickness, directed by Catherine Scott, produced by Pat Fiske, cowritten by Ray Moynihan, videocassette, 52 min, color, $390, rental $75, New York, NY, First Run/Icarus Films, 2004.

At the American Medical Association meeting in June 2005, six separate resolutions were introduced advocating for limitations or outright bans on direct-to-consumer marketing of prescription drugs.1 Marketing, an important if not critical preoccupation of the major pharmaceutical producers, is no longer aimed just at physicians. Since the 1990s, research has confirmed that drug company–sponsored research funding and gift giving could significantly affect clinical trial outcomes and individual physicians’ prescribing patterns.2,3

Selling Sickness goes one step further, alleging that, in an effort to increase sales, drug manufacturers have begun to repackage medical conditions and advertise them directly to the general public as diseases in need of pharmaceutical treatment. Companies have benefited from the more permissive climate established in 1997 by Food and Drug Administration (FDA) relaxation of drug advertising regulations.

As a result, the authors argue, current advertisements provide little realistic information about the marginal benefits of drug treatment for most people, while leaving out potentially serious adverse effects. This provocative hypothesis comes at a time of tremendous turmoil in the pharmaceutical industry. In August 2004, GlaxoSmithKline (GSK) settled a lawsuit brought by the New York attorney general alleging concealment of data showing increased suicidal and violent impulses in children and adolescents taking Paxil. As part of the settlement, GSK agreed to establish an online registry of all sponsored clinical studies.

Congressional hearings were held on Paxil in September 2004, and in November 2004, hearings were called yet again on Vioxx, a top-selling antiarthritis

drug. It was alleged that despite aggressive public advertising, Merck had not fully disclosed its own research showing increased risks of heart attack and stroke associated with the drug. Amid national headlines, in October 2004 companion proposals were introduced in the Senate and House for the establishment of a national clinical trials registry.4,5 The legislation was reintroduced as a bipartisan Senate bill in March 2005.6 The motivation for the registry is to provide a comprehensive, publicly available, and unbiased source of information about the safety and effectiveness of any drug, biological product, or medical device.

Selling Sickness and its accompanying documentary film claim that consumer- oriented advertising is designed not only to support drug sales, but also to create new markets for drugs by convincing people they need more medicine.

Moynihan, an award winning Australian health care journalist, and Cassels, a researcher at the University of Victoria in Canada, bring an international perspective to bear on the United States, which with less than 5% of the population accounts for almost 50% of the global market in prescription drugs (p ix).

While drug companies defend their advertising efforts as a means of educating the public and preventing undertreatment, Moynihan and Cassels make the rhetorical point that, in fact, most undertreatment is not located in the industrialized Western nations. On the other hand, the risks of overtreatment, a more probable state of affairs in the United States, are much less recognized and publicized.

As a contrast, the authors cite Europe, where in 2003 the central drug regulatory agency put an abrupt stop to Eli Lilly’s attempt to advertise Sarafem/Prozac because of “considerable concern that women with less severe pre-menstrual symptoms might erroneously receive a diagnosis of PMDD [pre-menstrual dysphoric disorder] resulting in widespread and inappropriate short and long-term use of fluoxetine” (p 116).

The book is organized as a series of case studies, each focused on a particular drug. Each chapter explores a different aspect of drug marketing, with evidence drawn from published editorials, news reports, academic journals, and, most interestingly, original interviews with physician-spokespersons and pharmaceutical sales experts. One sales executive describes “the art of branding a condition” (p 70) as the synergy created when pharmaceutical companies bring so-called physician thought-leaders, prescribing physicians, and patient advocacy groups together—usually through personal network development and funding for community outreach and scientific study.

This same executive notes, “the area that has been most ripe for condition branding has been anxiety and mood disorders” (p 127). Indeed, while the book addresses a variety of medical conditions, including hypercholesterolemia, hypertension, and osteoporosis, the film focuses primarily on the treatment of depression, using the example of Paxil as a focal point. The film emphasizes interviews with patients and parents of former patients and concludes with dramatic excerpts from testimony taken at congressional hearings on the drug.

The book provides a more methodical examination of the specific mechanisms of marketing a drug. These are laid out as a broad survey of a landscape dominated by industry efforts to increase drug sales: advocacy for expanded medical testing and stricter definitions of risk levels to expand the range of use, gifts and research grants as well as cultivation of leading academic physicians as spokespersons, advertisements and publicity appearances featuring celebrities without disclosure of their paid status, funding of promotional activities and materials distributed by patient advocacy groups, publicizing of misleading statistics and downplaying of negative or inconclusive research, lobbying of the FDA for rapid approval or approval of marginally beneficial drugs, and, finally, promotion of drugs as a means of functional enhancement for an otherwise healthy individual.

Some of these promotional activities are notable for their subtlety; they pose as educational efforts to increase the public’s health. A former sales representative writes that the best “product champions” were physicians who delivered a seemingly balanced message, who were not crude, and who could “sell without selling” (p 39). The running theme of these individual analyses is that marketing drugs is, for the most part, based on a misconception of actual risk-benefit ratios.

While many patients are aptly treated for what may be life-threatening conditions, a great number are not and are instead taking drugs under what amounts to a false premise of great benefit or greatly decreased risk. Selling Sickness is a bracing condemnation of contemporary pharmaceutical marketing techniques. It suffers perhaps from an overly broad brush, and the authors at times seem to apply the general premise of overtreatment with excessive liberality to all drugs.

Nonetheless, this book is a welcome, bitter tonic to the surfeit of glossy advertising and lucrative enticements that surround any practicing physician today. It provides substance and legitimacy to the rationale behind emerging efforts to counteract the pervasive influence of the pharmaceutical industry: minimizing conflicts of interest in medical practice and research, publishing the work of authors who are free of excessive industry ties, specifying and clarifying the indications for drug therapy, and providing balanced and dependable sources of information about the risks and benefits of medication use to patients. In our current climate, these are aims with which any ethical physician would agree.

Sue Sun Yom, MD, PhD
M. D. Anderson Cancer Center, Houston, Tex
ssyom@mdanderson.org

1. American Medical Association. Resolutions 507, 519, 532, 533, 534, 536 (Reference Committee E). In: Delegates’ Handbook. June 2005. Chicago, Ill: American Medical Association, 2005.
2. Als-Nielsen B, Chen W, Gluud C, Kjaergard LL. Association of funding and conclusions in randomized drug trials: a reflection of treatment effect or adverse
events? JAMA. 2003;290:921-928.
3. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283:373- 380.
4. Fair Access to Clinical Trials Act of 2004 (FACT Act), S 2933, 108th Cong, 2nd Sess (2004).
5. Fair Access to Clinical Trials Act of 2004 (FACT Act), HR 5252, 108th Cong, 2nd Sess (2004).
6. Fair Access to Clinical Trials Act of 2005 (FACT Act), S 470, 109th Cong, 1st Sess (2005).