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Rapid Responses: Rapid Responses published:
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Public health or private profit?
- Sheila McKechnie (12 April 2002)
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The Consumer Society
- James M May (18 April 2002)
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Pharmaceuticals: selling sickness to healthy hypochondriacs
- Martin LeatherBarrow (19 April 2002)
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Prostate cancer: medicalization?
- Romaine HERVEY (20 April 2002)
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Drugs can be good for you
- Adam Jacobs (24 April 2002)
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Selling sickness - it was ever thus
- Jan Karmali, Aylesbury HP18 0LY (24 April 2002)
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Psychiatry should reduce commercial sponsorship
- Joanna Moncrieff, Phil Thomas, Co-chairperson, Critcal Psychiatry Network (24 April 2002)
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Physicians heal thyselves!
- Michael B. Ellner (25 April 2002)
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Deja vu all over again
- Matthew R. Anderson, Alison Karasz and Peter Lurie (1 May 2002)
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Novartis's imaginative interpretation of the DECODE study
- Robert J Flowerdew, Sinclair Scott (10 May 2002)
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Industry Works to Develop Medicines, Not Diseases
- Richard S Tiner, London, SW1A 2DY (17 May 2002)
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Lost opportunity
- Jim N Hardy (17 May 2002)
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Osteoporosis is a disease
- Philip N Sambrook, Judy Stenmark (17 May 2002)
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Pharmaceutical industry- independence of psychiatrists
- Detlef Degner M.D. (28 August 2002)
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drug mania
- dr .manan vasenwala (29 September 2002)
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NUMBERS GAME.
- BM Hegde (5 January 2003)
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Sheila McKechnie, Director Consumers' Association, NW1 4DF
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The issues raised in 'Selling sickness - the pharmaceutical industry and disease mongering' are borne out by recent research conducted by Consumers' Association, published as a policy report: 'Promotion of prescription drugs: public health or private profit?' (July 2001). We found many examples of pharmaceutical companies forming alliances with patient organisations in order to get their marketing messages out to a wider public under the guise of providing patients with much-needed information. There is now a great deal of pressure being employed to free drug companies up to reach the public directly. This raises some interesting and significant questions, the impact of which have not yet been fully considered. For example, why would pharmaceutical companies continue to fund patient organisations when they can communicate with patients directly? How will this affect what the patient organisations are able to do and the individuals who rely on their information and support? Will this increase usage of the internet for the purchase of drugs that doctors are not willing to prescribe – and with what safeguards and regulation to protect consumers from poor medical advice through this route? Perhaps the most important question of all is why there are proposals currently before the European Parliament to reduce regulation of the pharmaceutical industry and to enable direct to consumer advertising of prescription medicines. All the available evidence – and this is considerable – shows that this will bring about far-reaching and extremely negative consequences for public health throughout the EU, in order to satisfy commercial interests. |
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James M May, SGPR Woodbridge Hill Surgery, 1 Deer Barn Road, Guildford, GU2 8YB
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Editor - Thank you for your thought provoking articles about disease mongering - enough to make one quite insecure about one's own practice. Sadly though it seems to me that your observations still only scratch the surface of a deeper cultural malaise. Freud gave us permission to become obsessed with our inner feelings, lusts and desires, becoming less and less restrained by any thoughts of duty to others. There may, for example, be a historical soft spot for the Welfare State and the NHS, but come election time the selfish desire for lower taxes proves far stronger than any vision for a better society. At root is a romantic inner quest for happiness which has given up on a world beyond the self. 'Complementary medicine', among others, feeds on this introspection, offering imaginary cures often for fictitious diseases, and the vacuous promise of inner harmony and personal well- being. It is the sickness of a self-serving society manifesting itself increasingly as sickness in GPs waiting rooms. Anti-globalisation protestors have a point, but the root of marketing potential lies not in corporate power, but in the hearts of individuals, the 'innocent' public, who prefer to be seduced by transient pleasures than convicted by lasting good. We are not animals, not slaves to these hedonistic drives, but we seem to be giving up on real freedom in the name of consumer 'choice'. Pointing the finger outwards at multinationals may serve only to further conceal the real disease of our inner emptiness. James May
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Martin LeatherBarrow, Research Associate Department of Public Health & Epidemiology, The Medical School, University of Birmingham, England.
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Editor – Moynihan et al, are spot on to suggest that a lot of money can be made from healthy people who are led to believe that they are sick, or at least sicker than they actually are. One of the inherent problems in Western societies is that we are led to believe in a curative system of health from our youth. Because of this, one could argue that there is then a tendency especially in developed nations to rely upon the curative model, and consequently we become essentially indolent in our self-care management. This is good news for the pharmaceutical industry. The very fact that medicine is inextricably interwoven into economic, political and social processes implies that there is a perpetual expectation to move into fresh areas and deal with or create new problems. According to your particular perspective, this may be seen as a welcoming sign, in that it provides (more jobs, funding, titles and) more sick people with ways of maintaining a longer life span, or recovering more effectively from illness, it also presents a number of problems on several fronts. People may feel that many of there own life experiences are being taken over (as advocated by Illich) by a detached biomedical elite. The sick person who seeks medical treatment is in an intrinsically weak position (pun not intended). To reiterate there is indeed a lot of money to be made from selling sickness to a nation of healthy hypochondriacs. Indeed, as Gould (1985) cautions in his book entitled ‘The Medical Mafia’ the first thing to understand about the pharmaceutical industry is that it is Big Business. Its executives are not members of one of the pompously labelled ‘caring professions’, nominally devoted to the alleviation of human suffering (as much as they would like to be so regarded in the public eye). They are trades people, and trades people of a particularly hardnosed kind. As Collier (1989) points out, of all aspects of the medical profession and its practices, the most dominant influence is indeed that of the pharmaceutical industry. It provides not only the medicines needed for improving and maintaining health, but its influence insinuates itself in the fabric of medical research, post-graduate education and medical practice itself. Pharmaceutical companies are actively involved in sponsoring the definition of diseases and promoting them to both prescribers and consumers, for as Illich noted, they have a vested interest in sponsoring sickness. The major aim of all healthcare systems is to restore sick people to health, or improve health, by treatments of one sort or another. Thus, the value of modern pharmaceutical drug treatment to society has been for the most part unquestioned. However, some critics of the system have argued that the benefits in terms of health gains, especially after adequate evaluation, leave much to be desired. They have argued that they are often more modest than first supposed, and are often achieved at considerable cost, and sometimes considerable risks to patients (Mason and Freemantle, 1998). However, for the vast majority of their sales, they still need to get to the consumers, hence, the need to get to the doctors in the first instance. As Kerridge and Lowe (1997) comment in a compelling article in the Student British Medical Journal, drug companies do not seem to have a clear distinction between their marketing activities and other functions. The therapeutic, educational, and research activities of pharmaceutical companies can be influenced by promotional objectives, and alliances between industry and medical science can have serious conflicts of interest. During the course of my primary and secondary research, it became evident that many doctors are actually concerned about collaborating with drug companies, as they do believe that commercial objectives can override the patient’s interests. By the same token, there is also concern that many doctors still find time to receive too many visiting sales representatives. Even as the evidence mounts that doctors consultation rates have increased over the past 25 years, this aspect along with an overwhelming multitude of other factors upon doctors ' time (e.g. management, administration, audits, post-grad education, etc), they also seem to continue to accommodate the drug company representative. Indeed, evidence suggests that strong reasons exist for not seeing representatives, for their primary function is to sell their company’s product at all cost’s. They are an important part of the pharmaceutical industry’s promotion methods, and they are highly successful in altering doctors’ prescribing habits (Griffith, 1999). His emphasis would appear to be backed up by the Royal Australasian College of Physicians (1997), who in their ‘Ethical guidelines in the relationship between physicians and the pharmaceutical industry’ have suggested that doctors are indeed ‘targeted by drug companies’ exactly because they influence prescribing habits and therefore consumers of their products. There is also evidence to suggest that doctors may find it difficult to recognise the commercial influences inherent, that can often affect their prescribing habits, and thus, may very well underestimate the pervasive effects of commercial promotions. Indeed, there is no apparent evidence to suggest that doctors may be any more resistant to the effects of advertising or gifts for that matter, than anyone else in society. Indeed prior to the 1988 Summer Olympics, the pharmaceutical company Searle invited Australian doctors who were prescribers of its antidiarrhoeal product, Lomotil (diphenoxylate and atropine), to enter a prize draw for a nine-day trip for two to the Olympics in Seoul, Korea. This prize, which included flights, accommodation, tickets to several events (including the opening ceremonies), was valued at $6,000 Australian. However, Searle was found to be in breach of the Australian Pharmaceutical Association (APMA) code, and was forced to cancel the promotion after an estimated 6,000 doctors had responded (Sydney Morning Herald, 1988). Finally, Moynihan et al, argue that the social construction of illness is being replaced by the corporate construction of disease. Ideologies are not peculiar to medicine under capitalism and absent under other social and economic arrangements. In capitalist societies, the treatment of health and healing as commodities to be bought and sold under market conditions produces certain economic benefits for various individual and corporate interests. All medical related systems embody ideologies, but the nature of these ideologies varies according to the structure of that society. Moreover, because in capitalism, health becomes a commodity like other commodities in the market place, the delivery of health is in turn shaped by the requirements for profit and efficiency. In the final synopsis, as Turner (1987) has argued before, there is a permanent tension between the requirements of the economy and the requirements of a healthy existence. Ceteris paribus ars longa vita brevis Chetley A (1990) ‘The Importance of Marketing’ A Healthy Business? World Health and the Pharmaceutical Industry. London and Atlantic Highlands, New Jersey: Zed Books. Collier, J (1989) In the pocket of the Industry: The Health Conspiracy. London. Century Hutchinson. Donahue JM, McGuire, MB. The political economy of responsibility in health and illness. Social Science and Medicine.1995; 40 (1):47-53. Illich, I (1976) Limits to Medicine. Medical Nemesis: The Expropriation of Health. Penguin, London. Griffith D (1999) Reasons for not seeing drug representatives. British Medical Journal 1999;319:69-70 (July, 10th) Gould D (1985) The Medical Mafia. London, Sphere. Kerridge and M. Lowe (1997) ‘There's no such thing as a free lunch’. Student British Medical Journal. Volume 5 September 1997 Katz AM (1992) Pharmaceutical promotion. New England Journal Medicine 1992;327:1687 Lexchin, J (1989) Doctors and detailers: Therapeutic education or pharmaceutical promotion? International Journal of Health Services. Vol.19, no.4, 1989 Margo J (1989) 'Medical men bewitch doctors'. Sydney Morning Herald. 14th January, 1989. Royal Australasian College of Physicians (1994) Ethical guidelines in the relationships between physicians and the pharmaceutical industry. Sydney: RACP, 1994-95. Bryan, S Turner (1987) Capitalism, Class and Illlness. Medical Power and Social Knowledge. Sage Publications, London |
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Romaine HERVEY, Emeritus Professor of Physiology Garth House, Beryl Lane, WELLS, Somerset BA5 2XQ
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EDITOR -- As a prostate cancer patient successfully treated by radical prostatectomy, I was appalled by Peter Gotzshe's (1) dismissive attitude to the condition and to surgical treatment. True, the total loss of erection and some urinary incontinence are unwelcome, as are the side effects -- gynaecomastia and perhaps a general loss of 'masculinity' -- of subsequent treatment with a testosterone receptor blocker. But life is still very worthwhile! And, as I know from my father's death from prostate cancer in 1967, dying with paraplegia from spinal bone secondaries is not a pleasant way to go. As I understand it radical prostatectomy is most appropriate when actively malignant cells are present but have not spread beyond the prostate capsule; this can be reliably diagnosed by biopsy guided by ultrasound scanning. I hope no-one will ever set up a randomized trial of radical prostatectomy in this situation against no treatment or 'watchful waiting'. In my younger days I believe I was one of the first to use matched double-blind trials (of motion sickness remedies, for the Navy in the early 1950s): but I am thankful that my treatment four years ago was guided by the judgement of a good clinician. Romaine Hervey Emeritus Professor of Physiology, University of Leeds Garth House, Beryl Lane, Wells, Somerset BA5 2XQ (1) Gotzsche P C Commentary: Medicalisation of risk factors. BMJ 2002; 324: 890-1. (13 April) [N.b. Modified 'o' in Gotzsche] [Professor G. R. Hervey, Garth House, Beryl Lane, Wells, Somerset BA5 2XQ phone 01-749-670161, fax 01-749-678020, email g.r.hervey@btinternet.com No competing interest.] |
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Adam Jacobs, Director Dianthus Medical Limited, SW19 3TZ
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Moynihan et al tell us that the marketing departments of pharmaceutical companies market pharmaceutical products [1]. Shock horror. Well, tobacco companies market cigarettes, McDonalds markets junk foods, and motor manufacturers market cars. The difference is that pharmaceutical products can be good for your health. To pick one of the examples given in the paper, Moynihan et al would have us believe that there is something evil about raising awareness of social phobia. Social phobia is a difficult disorder to define, as there is a continuum from normal shyness to a disabling psychiatric disorder, and it is not therefore surprising that estimates of its prevalence vary wildly [2]. This should not detract from the fact that there are many people who genuinely suffer from the disorder, and that those people can be helped by treatment [3]. Why is it wrong to help these people? Of course there is a conflict of interest when pharmaceutical companies market their products, and Moynihan et al are right to point out that prescribers should be aware of this when listening to the marketing messages. However, we should not assume that advice about prescribing originating from pharmaceutical companies is wrong just because the company stands to gain. Moynihan et al recommend that information provided by pharmaceutical companies should be replaced with information from unbiased sources. A fine idea in principle, but providing high quality information is expensive. Who is going to pay for it, if not the pharmaceutical companies? References 1. Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002;324:886–890 2. Furmark T. Social phobia: overview of community surveys. Acta Psychiatr Scand 2002;105:84–93 2. Ballenger JC, Davidson JR, Lecrubier Y, et al. Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 1998;59 (Suppl 17):54–60 |
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Jan Karmali, General Practitioner The Surgery, Waddesdon,, Aylesbury HP18 0LY
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Moynihan et al's article on "Selling sickness" gave me an overwhelming sense of deja vu. Long before reading medicine as a mature student, I did a degree in psychology and spent several years in the late 60s and early 70s working for a market research company in London which specialised in qualitative or "motivational" consumer research. As "Hidden Persuaders", in the words of Vance Packard's seminal text, our task was to use psychoanalytical techniques to delve into the attitudes and motivations of the consumer. Our purpose was to provide the marketing and advertising departments of all sorts of companies with ammunition to exploit the fears, weaknesses and desires of consumers, all the better to sell the companies' products. Three examples spring immediately to mind: exploiting women's worries about vaginal odour/hygiene in order to sell vaginal deodorants; developing a new range of therapeutically useless pharmaceutical products for emerging Third World markets, playing on the superstitions of the uneducated, "native" mind; and, promoting "safe", low-tar cigarettes to combat the new government health warnings on cigarette packets. I am only surprised that the medical world has so belatedly caught on to the devious techniques employed by companies for decades, at which the pharmaceutical industry excels. I have always been amazed by the naivety and unworldliness of doctors in their uncritical acceptance of drug company sponsorship of medical education and their willingness to accept the "evidence" of drug company representatives about the wonderful properties of the latest drug. I am fortunate that my previous incarnation has armed me with a jaundiced view of their blandishments. As a footnote, in time my conscience prevailed, I went off to Latin America as a community development volunteer, returned to the UK to work for a human rights voluntary organisation and eventually went to medical school in my mid-30s. I have been a GP for 11 years, but my memory of the methods used in marketing and advertising is a clear as ever. Dr Jan Karmali, General Practitioner.
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Joanna Moncrieff, Senior Lecturer, UCL, and Co-Chairperson of Critical Psychairty Network Dept of Psychiatry and Behavioural Sciences, 48, Riding House St., London W1N 8AA, Phil Thomas, Co-chairperson, Critcal Psychiatry Network
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Dear Sir, We would like to congratulate Moynihan et al (1) on their enlightening article on the manipulation of medical knowledge by the pharmaceutical industry. They mention social phobia as one example, but as Double suggests (2) this process is endemic in psychiatry. Since the 1950s drug treatments have dominated psychiatric practice and set the agenda for the majority of psychiatric research. This is despite the fact that it remains difficult to demonstrate that long-term outcomes are any different than they were 100 years ago (3). The influence of the pharmaceutical industry is particularly pernicious in psychiatry where the possibilities for colonising ever more aspects of human life are potentially limitless. Psychiatry is an area of controversy, where different paradigms and approaches to treatment are hotly contested. The financial muscle of the pharmaceutical industry has helped to tip the scales in favour of a predominantly biological view of psychiatric disorder. This has submerged alternative therapeutic approaches, despite the fact that user-led research indicates that service users find a wide variety of non-medical approaches valuable in coping with emotional distress (4). We believe that it is time to uncouple the "unholy alliance" between psychiatry and the pharmaceutical industry. Psychiatric service users are profoundly suspicious of this relationship. Last year they organised a demonstration against sponsorship of the Royal College of Psychiatrists conference reported by the national press (5). Members of the Critical Psychiatry Network supported this demonstration. In the interest of education and science, the medical Colleges must be seen to be independent from the commercial interests of the pharmaceutical industry. The starting point in this debate has to be absolute transparency concerning the relationship between the Colleges and the industry. In February this year we wrote to the President of the Royal College of Psychiatrists requesting information as to the extent of drug company sponsorship. We await a reply. The Critical Psychiatry Network argues that the Royal College of Psychiatrists must decline commercial sponsorship for all educational activities including its annual conference. These steps are necessary to distance the profession from the industry and improve its credibilty with service users and the public. We shall be campaigning actively to achieve this. Yours etc. Dr Joanna Moncrieff Dr Phil Thomas Co- chairpersons of the Critical Psychiatry Network References 1) Moynihan R, Heath I, Henry D. 2002 The pharmaceutical industry and disease mongering. BMJ, 324, 886-891. 2) Double D. 2002 The limits of psychiatry. BMJ, 324, 900-904. 3) Healy D, Savage M, Michael P, Harris M et al. 2001 Psychiatric bed utilization: 1896 and 1996 compared. Psychological Medicine, 31, 779-790. 4) Faulkner A. 2000 Strategies for Living: a report of user lead research into peoples strategies for living with mental distress. London: Mental Health Foundation. 5) 'Psychiatry agenda set by drug firms'. Guardian newspaper, July 9th, 2001 |
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Michael B. Ellner, President, Health Education AIDS Liaison PO Box 1103, New York, Ny 10113
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Anyone who takes the time to examine the actual evidence can see that the manufacturing of "treatable diseases" has become a vital part of conventional medical practice. Hep C is a pefect example of how prefabricated correlations, dubious surrogate markers and sensational estimates are passed off as scientific proofs. I ask in all seriousness, can anyone provide a single scientific citation for an electron micrograph of purified hep C? In lieu of a gold standard one has to wonder just how the tests for hep C have been validated! Clearly the media terrorism will sell drugs and millions of otherwise healthy people, who happen to test positive on these bogus tests, will be frightened into taking toxic and life-threatening drugs as a result. Sooner or later, the public will catch on and you will have no one to blame but yourselves! |
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Matthew R. Anderson, Assistant Professor 360 E. 193rd St., Bronx, N.Y., 10458, USA, Alison Karasz and Peter Lurie
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EDITOR- Moynihan et al.'s article on disease-mongering by the pharmaceutical industry (1) reminded us of an old Bronx baseball saying, originating with Yogi Berra: "It's deja vu all over again." 3M has for years sponsored the 3M/National Vaginitis Association (www.vaginalinfections.com). The 3M/NVA produces a newsletter for health professionals (The Vaginitis Report) and materials for patients. Like the groups described by Moynihan et. al., the 3M/NVA is ostensibly an educational resource run by health professionals. Unfortunately, its activities involve a large element of disease-mongering. Mild symptoms are offered as portents of serious disease and doctors are encouraged to be aggressive in their attempts to diagnose and treat vaginal infections, specifically bacterial vaginosis. As luck would have it, 3M produces a drug that treats bacterial vaginosis. More recently, the 3M/NVA established a toll-free number to distribute a free “educational brochure” promoted by TV personality Deborah Norville. The Association provides a further example of what Moynihan describes as using statistics to "maximise the size of a medical problem." An Association-sponsored survey found "that one-third of women believe that vaginal odor is normal, and approximately 24% believe that it's normal to experience vaginal itching". (2) This is offered as evidence of women’s "lack of knowledge" regarding vaginal health. The Association website encourages women to contact a health-care provider when they experience such symptoms. In fact, there is good evidence from the primary literature that both odor and itching frequently occur in normal women. (3;4) The model of vaginal complaints as due to infectious agents has been heavily promoted by 3M though the Association and is implicit in the very naming of their website which refers to vaginal “infections”. Yet we know that many women with vaginal complaints do not have an identifiable infectious pathogen. (5) It is time for clinicians to rethink the almost reflexive response, encouraged by the pharmaceutical industry and its front groups, of reaching for the prescription pad when a patient presents with vaginal complaints. As Yogi Berra once said: “You can observe a lot just by watching.” Matthew Anderson, MD & Alison Karasz, Ph.D.
Peter Lurie, MD, MPH
No competing Interest Corresponding Author: Matthew Anderson, MD, Email: andersonma@aol.com, Montefiore Family Health Center, 360 E. 193rd St. Bronx, N.Y., 10458, USA Reference List (1) Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. British Medical Journal 2002; 324:886-891. (2) National survey reveals most women still are unaware of bacterial vaginosis (BV), the most common vaginal infection. 3M/National Vaginitis Association . 2002. 2-21-2002. (3) Doty RL, Huggins GR. Changes in the intensity and pleasantness of human vaginal odors during the menstrual cycle. Science 1975; 190:1316- 1318. (4) Priestley C, Jones B, Dhar J, Goodwin L. What is normal vaginal flora? Genitourinary Med 1997; 73:23-28. (5) Centers for Disease Control and Prevention. Guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47(RR-1). |
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Robert J Flowerdew, General Practitioner Douglas, Lanarkshire, ML11 0SH, Sinclair Scott
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Editor. We attended a meeting on Diabetes Mellitus and Coronary Heart Disease organised by the Lanarkshire Health Care Committe with Post Graduate Education Allowance accreditation and sponsored by Novartis. The meeting was aimed at the Primary Care Team involved in Chronic Disease Management. One of the statements made at the meeting was that high post-prandial Glucose concentrations double the risk of death in Diabetics.We questioned this statement and asked to see evidence for this claim, and the following day were presented with the DECODE study (1) by the Novartis representative. The DECODE study is a meta-analysis from 13 prospective European cohort studies looking at the relationship between Glucose Tolerance and mortality. The aim of the study was to compare the Oral Glucose Tolerance Test with the Fasting Glucose Levels as diagnostic tools for Diabetes Mellitus and Glucose intolerance and predictors of mortality in the European Population. The study found that mortality is significantly related to high Glucose concentrations 2 hours after a Glucose load (the Oral Glucose Tolerance Test) independently of Fasting Glucose Levels. This is a particularly important finding in that current guidelines led by the American Diabetes Association are putting more emphasis on Fasting Glucose Levels as a screening tool for diagnosing Diabetes Mellitus in preference to the Oral Glucose Tolerance Test. The study concludes that the Oral Glucose Tolerance Test is more sensitive than the Fasting Glucose Level at identifying people with impaired Glucose tolerance and Diabetes, for which there are effective, evidence-based interventions known to reduce morbidity and mortality. Summary of results 31% of Diabetics as identified by the Oral Glucose Tolerance Test had normal Fasting Glucose concentrations. glucose(mmol/l) mortality rates fasting blood glucose > 7 16% normal fasting glucose: 2 hour OGTT > 11.1 15% normal fasting glucose: 2 hour OGTT 7.8-11.1 12% normal glycemic fasting and at 2 hours 6.4% The meeting used the DECODE study as a major source of evidence in changing clinical practice, i.e. managing post-prandial Glucose Levels in Diabetic patients.The DECODE study does not investigate whether reducing post-prandial Glucose concentrations reduces mortality in Diabetics, in fact it does not look into the treatment of Diabetes, but is an investigation into the diagnosis of Diabetes in an unscreened population. This is a fundamental misinterpretation of the DECODE study and we believe is driven by a deceptive analysis by Novartis, who quote the study in their literature (2), implying that it suggests the mortality rate in Diabetics can be reduced by reducing post-prandial Glucose Levels.The DECODE study is the only study mentioned in the Novartis literature, apart from small print references at the end of the pamphlet. The irony of this is that the speaker emphasised the Fasting Glucose Level as the important screening tool in Diabetes, in preference to the Oral Glucose Tolerance Test. Should drug companies be allowed to indiscrimately use notable papers, which practitioners have often heard of, but not always read, in support of their products, thus gold-stamping them ? Novartis have invented a disease, high post-prandial Glucose concentration in Diabetic Patients, and come up with a product, nateglinide, a short acting B-cell stimulant to be taken with meals, reducing post-prandial Glucose spikes, and by inference, reducing mortality in Diabetic patients. Nateglinide costs about 4 times more than gliclazide. (1)DECODE study group. Glucose Tolerance and Mortality : comparison of WHO and American Diabetic Association critera. Lancet, 1999 ; 354 : 617-621. (2)Leaflet by Novartis advertising STARLIX : Clarity and Control in Type 2 Diabetes. Robert Flowerdew and Sinclair Scott,
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Richard S Tiner, Medical Director ABPI, 12 Whitehall, London, SW1A 2DY
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Dear Sir The suggestion that pharmaceutical companies sponsor diseases so that they can then promote them to prescribers and customers (Moynihan et al, “Selling sickness: the pharmaceutical industry and disease mongering”) appears on analysis to emerge as the fact that pharmaceutical companies are actively involved in sponsoring the definition of diseases. If so, this is true. Both the pharmaceutical industry and regulatory authorities that license new medicines need to develop closely-defined definitions so that the safety and efficacy of new medicines can be properly measured. However in real-life situations prescribers do not always adhere to the licensed indications when prescribing. There is no doubt that, rather than over medicalising, there is in fact a need for more medicalisation as indicated by Ebrahim , and Bonaccorso and Sturchio and highlighted by Moynihan and Smith in their editorial “Too much medicine?” The rise of guideline led care around the Western world demonstrates the fact that far too many serious diseases are underdiagnosed and undertreated. Failure to put evidence-based medicine into practice is quite legitimately addressed by the pharmaceutical industry which has developed medicines which are preventative, curative or alleviate many important conditions. Examples include the under use of statins in the UK, the delay in the uptake of thrombolysins in the 1980s and reliance on old psychotropics when newer medicines have a much more favourable side effect profile. Of course, disease awareness campaigns are likely to expand the market for medicines in that area, but it will be for competitor products as well as those of the sponsoring company. However the real value of disease awareness campaigns is exactly what it says: making consumers aware that treatment may be available for their condition. Many patients live in stoical ignorance that something can be done to improve their quality of life and, not infrequently, major pathology is detected as a result of a patient seeking medical advice following contact with a disease awareness campaign. Moynihan appears to suggest that preventative medicine is threatening the viability of publicly funded healthcare systems. Yet clearly, it is far better to prevent disease than to treat it when it is established. The benefits of stopping smoking, treating hypertension, reducing raised blood lipids etc are all well established but could not be done without the assistance of the pharmaceutical industry. In choosing the diseases that Moynihan et al detail as sponsored by the pharmaceutical industry, it is unfortunate that the Australian experience has been highlighted. In the UK, when MSD launched Propecia for male pattern baldness, it deliberately chose to do so with the medicine available on private prescription only so that it would not be a drain on the NHS. In Europe, patients cannot be targeted with promotional material and all promotional material for health professionals in the UK has to comply with the ABPI Code of Practice and be signed off by the company medical department. Moynihan’s article would suggest that osteoporosis has been effectively sponsored by the pharmaceutical industry. In fact, far too many people who fall and develop a fracture are not considered for treatment for osteoporosis. Consumers should be informed that fractures in later life may be due to osteoporosis and that there are methods of treatment, of which medicines are just one group. Sheila McKechnie from the Consumers’ Association claims that all available evidence of direct to consumer advertising shows that this will bring about far-reaching and extremely negative consequences for public health throughout the EU. This is fundamentally untrue and, indeed, there is published evidence to show that patient compliance and understanding of disease is improved following DTCA . However this is not really relevant, as the pharmaceutical industry has no current plans to seek this ability to advertise to the general public, although a relaxation of laws on the provision of information would be welcome. In conclusion, the pharmaceutical industry is not inventing disease but rather working hard to develop new, innovative medicines for the overall benefit of mankind. Yours sincerely Richard Tiner (Dr Richard Tiner, Medical Director, Association of the British Pharmaceutical Industry, 12 Whitehall, London SW1A 2DY, Email: rtiner@abpi.org.uk) |
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Jim N Hardy, GP principle bethnat green health centre 60 florida street, London E2 6LL
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Editor, Moynihan et al (1) have been given a great opportunity by your editorial team to illustrate the parlous state of current biomedical practice. Instead of grasping the nettle they have gone for the easy targets: the fringe illnesses we all of us see day in day out and to which we respond with concern and understanding, but in general, not with drugs. They argue that we are complicit in the construction of illness on the fringes; that in some way we are adding to the disease pantheon. This may be true and I would be the first to highlight the construction of disease for the benefit of multinational interest (2), but as inferred earlier they miss the point. What about cardiovascular disease, respiratory disease, gastrointestinal disease and psychiatric illness? Why not draw attention to the pharmaceutical industry's heist of mainstream practice? Answer: Too risky. The BMJ is a mainstream rag overseen by an editorial board that consistently fails to encourage discussion of key issues. Jim Hardy, 60 Florida Street, London E2 6LL (1) R Moynihan, I Heath, D Henry, P Gotzsche.Selling sickness:the pharmaceutic industry and disease mongering. BMJ:324:886-891. No 7342 13 April 2002. (2) J Hardy. Doctors are part of an economic hegemony. BMJ 2001; 322:439. 19.2.2001 |
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Philip N Sambrook, Professor of Rheumatology University of Sydney 2006, Judy Stenmark
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The recent article by Moynihan et al (1) raises a number of important issues certainly worthy of appropriate debate. It is a pity therefore that Mr Moynihan, a journalist, decided to follow a rule well known in his profession namely “don’t let the facts get in the way of a good story” in this article. The British Medical Journal has been a strong proponent of evidence based medicine, but this article is anything but evidence based. For example, with respect to Osteoporosis the authors’ make a number of incorrect assertions and are very selective in citing the literature. Osteoporosis Australia is not a medical foundation but an independent patient group originally conceived by the Arthritis Foundation of Australia, but now evolved into a separate charity to promote the cause of patients with osteoporosis. It has received funding from pharmaceutical companies, but also from the Federal and State Government and other sources. The one minute risk test developed by the International Osteoporosis Foundation refers to women with an early menopause before age 45, not “any menopausal woman” as the authors incorrectly imply and does not state that a single risk factor is sufficient to justify bone density testing. Rather it states that the patient should take the whole checklist along to their general practitioner for discussion about the need for whether further tests are necessary. The authors express concern that pharmaceutical companies often fund meetings where the “disease was being defined”. Importantly, the authors’ would have been aware when writing their document, that Osteoporosis Australia and the National Prescribing Service convened a Fracture Summit in Melbourne in 2001 which included representatives of the Pharmaceutical Benefits Advisory Committee on the panel to look at the magnitude of the problem of osteoporosis using an evidence based approach. Osteoporosis Australia and the National Prescribing Service specifically excluded funding of the meeting by the pharmaceutical industry. The outcome of this meeting, recently published (2), concluded there was no RCT evidence to support what the authors’ suggest are moderately effectively non-pharmacological strategies such as weight bearing exercise. The Summit does however make recommendations about dietary calcium supplementation and vitamin D. In regard to bone density, again the authors’ are selective in their reporting. Bone density is widely accepted as the best predictor of future fracture risk. The article by Wilkin (3) quoted by the authors to suggest that bone density is not a sufficiently accurately predictor of an individual’s risk of fracture was also accompanied by an expert commentary that challenged his conclusions (4), but the authors’ failed to cite this counter view. The authors also suggest there is promotion of inappropriate bone density testing. Our Fracture Summit rather concluded that screening of unselected populations is not recommended by any authoritative group in the field (2). It seems the authors’ would have sufferers of Osteoporosis, who sustain hip fractures, kyphosis or reduced quality of life, be reassured that they don’t have a real disease just a risk factor, low bone mass. Whilst we accept the role of education and debate, the overall tone of this article is inappropriate. Much of what the authors have to say comes from “conversations with industry insiders” and numerous so called “personal communications”. This is not evidence, but rather hearsay. It is written in tabloid style and perhaps that is where it should have been published. Rational debate is to be encouraged but selective reporting by authors’ with agendas is inappropriate. Yours sincerely, Philip N Sambrook
Judy Stenmark
References (1) Moynihan R, Heath I, Henry D, Selling sickness: the pharmaceutical industry and disease mongering, BMJ, 2002, 324, 886-891 (2) Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit, Med J Aust, 2002, 176, S1-S16 (3) Wilkin TJ, Changing perceptions in osteoporosis, BMJ, 1999, 318, 862-864 (4) Eastell R, Commentary: Bone density can be used to assess fracture risk, BMJ, 1999, 318, 864-865 |
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Detlef Degner M.D., senior physician Department of Psychiatry,University of Goettingen,D-37075 Goettingen , Germany
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I think that there are many complex problems mixed in the article of R.Moynihan et al. and in the responses. There is a general trend to globalisation in industry systems ,but also in science and research groups. There is also a tendency to intensify cooperations between universities and industry in Europe (not only triggered by politics). Different interests of industry,politics and physicians (psychiatrists)are normal,these conflicts(for example costs and dependency) are complex but interdependent,and are solved in a fair way.The individual patient and his optimal (psychopharmacological) treatment must become the mean point of interest. The relevance of independent drug surveillance studies is great, for example the AMSP project in Germany,Switzerland and Austia with a continous drug monitoring of patients with psychopharmacological drug treatment(severe adverse dug reactions). D.Degner,M.D. |
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dr .manan vasenwala, consultant-cardiologist(non-invasive) aligarh-202002. india
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for every ill there is a ready made answer in form of a pill.the number of pills an average person consumes is astounding.it also shows how convinced patients are of their "efficacy". the pharmaceutical companies have a lot of vested interests in promoting this trend. recently, i have come across an advertisement suggesting that taking statins is as good as aspirins for ihd. i think the article by moynihan et al was very comprehensive and timely. but whether it will open eyes and ears in relevant quarters is to be seen. manan |
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BM Hegde, Vice Chancellor Manipal-576 119. India
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Dear Editor, An interesting addition to the long list of "doctor-thinks-you-have a disease" syndromes that keep the pharmaceutical and technology tills moving. An unethical game with a potentially dangerous drug, indeed. This is one of the reasons why modern medicine, at times, becomes unattractive to even those with free access! Congratulations for publishing this article. May the author's tribe increase for the good of mankind. yours ever, bmhegde Competing interests: None declared |
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