Book Review: the Lancet

An ill for every pill
Anne Harding

Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients
2005
Ray Moynihan and Alan Cassels


There's something very wrong here, I thought, my feverish 2-year-old in my lap, as we sat in a paediatrician's dingy waiting room one afternoon. Not a single intact children's book to take my son's mind off his misery, but plenty of colourful displays freshly stocked with glossy brochures touting drugs for attention deficit hyperactivity disorder (ADHD).

You'll see this sort of thing in almost any doctor's office in the USA?Zoloft clocks, Paxil pens, peppy pamphlets advising you to ?take charge of your health? by asking your doc about this or that medication?all of it much newer than the magazines on offer. And as Selling Sickness shows, this is just the tip of the iceberg. Beneath the surface, there's some much more sophisticated salesmanship going on.

Ray Moynihan, a journalist, and Alan Cassels, a policy researcher, describe in ten chapters?each one about a different ?sickness??how the pharmaceutical industry has pushed to widen diagnoses for various conditions, and even in some cases create them, so more people will take the drugs they sell. Given its lax regulations on drug marketing, the USA figures heavily in the book, but the authors' focus is global.

The book opens with a quote from the former head of Merck, who candidly told Forbes Magazine 30 years ago that he dreamed of being able to ?sell to everyone? by making drugs for healthy people. Using a dazzling array of techniques, and plenty of cash, the industry has come a long way toward making this dream a reality.

Enlisting doctors?from free pizza for medical students to thousands in consulting fees to physician ?opinion leaders??is an essential part of the strategy. But the key is to convince as many people as possible that they need a drug. To accomplish this, the industry creates ?patient advocacy groups?, complete with web sites; launches education campaigns for patients; and enlists celebrities willing to ?share their stories?. What these celebs don't share is that they're getting paid. Media outlets often take the bait, doing their part to raise awareness of these so-called diseases.

Moynihan and Cassels interview physicians free of drug industry influence fighting to get the word out to patients that they may not need a pill for every ill?or as one puts it, ?an ill for every pill.? And the authors close by citing what they see as two hopeful examples: the journal PloS Medicine, which takes no drug industry advertising and doesn't run pharma-funded studies, and the American Medical Student Association, which urges members to eschew free lunches from pharma and all that entails. Let's hope that by the time my son is old enough for ADHD drugs these forces prevail.

Book Review: BC Medical Journal

Book reviews

Selling Sickness. By Ray Moynihan and Alan Cassels. Vancouver: Greystone Books, 2005. ISBN 1553651316. Hardcover, 272 pages. $32.95.

This book is a must-read if you or your patients are concerned about the way the prescription drug business works. If you have wondered why the cost of medications in our system has gone from half to more than the cost of physician services over a decade, you’ll find some answers here. The writing style is journalistic without being sensational, has well-supported observations, and is an easy read.

There is a strong British Columbia connection since Mr Cassels is a drug policy researcher at the University of Victoria whom many of us have met or heard speak on drug issues. Some of the examples given in the book are very familiar, including references to activities of the Therapeutics Initiative, the work of some BC physicians, and several Pharmacare initiatives. Mr Moynihan is an Australian medical journalist who has written in the Lancet and the New England Journal of Medicine.

The focus is on the myriad avenues through which “big pharma” constantly influences every facet of medication use—marketing, regulation and policy, upward cost pressures, research, guideline development, and the seduction of physicians with money, peer pressure, prestige, and trinkets.

Serious questions are raised that our profession should be asking itself about the reluctance to establish stronger ethical boundaries with the pharmaceutical industry, regulation of financial relationships with sellers, acceptance of financial incentives, and frank conflict of interest. Material is drawn from several countries’ experiences and it reveals the cost of shrinking government support for research and evaluation; it leaves drug development to an industry that aims to fund only what might increase sales.

The chapter titles are descriptive: Selling to Everyone (Cholesterol, the Ads), Working with Celebrities (Menopause and the Public), Making Risks into Medical Conditions (Blood Pressure), Advertising Disease (Premenstrual Dysphoric Disorder), Taming the Watchdogs (IBS and the FDA), and so on.

The information in this book confirmed many things I had suspected. Physicians reading this book should recognize big pharma’s influence on the provision and cost of services and increased testing and office visits. The overlap from consumer advertising in the United States to the Canadian system and the number of patients sent to physicians’ offices specifically to request products they have been “sold” are further evidence of the industry’s sway.

The impact of siphoning billions of dollars away from other service needs, including physician services, and how we as a profession play a role in the uncontrollable rise in pharmaceutical costs are examined.

This is a timely book and I recommend it to anyone concerned about the bigger picture in health care. It makes clear that leaving our fate to the marketplace is risky and expensive and not necessarily a good thing for our patients’ health or our health care system.

—David Blair, MD
Victoria