Views & Reviews From the Frontline

Exploiting non-communicable disease

BMJ 2012; 344 doi: (Published 22 February 2012) Cite this as: BMJ 2012;344:e1278
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

The developed world is ever more cynical about Big Pharma, having suffered decades of marketing spin, drug scandals, and the manipulation of research. So drug companies are now eyeing the developing world, with its huge populations, rapidly increasing wealth, and light touch regulation. This is the new colonial frontier, ripe for a health land grab. Non-communicable diseases are the new commodity to exploit. Because they require lifelong prescriptions, chronic diseases are a profit goldmine for drug companies. The World Health Organization supports and legitimises this activity. Meanwhile, wealth inequality, poverty, and basic public health are the elephant in the room.

Risk modification through medication has now gone global. High cholesterol and hypertension, for example, aren’t actually diseases but risk factors for vascular disease. These risk factors are extremely common in the developing world, and there are potentially billions of patients. Drug interventions are based on now classic studies, involving thousands of patients over a number of years. But these were big studies for a reason: they had to be. The events were so infrequent that only a large study would detect a significant effect of treatment. For example, in the case of high cholesterol, 2% of people might die in the statin treatment group, against 3% in the control group, over the five year study period. The death rate gives a headline grabbing 33% reduction. But the absolute reduction is only 1% over five years. In other words, 100 people needed to be treated to delay one death. As the study lasted five years, however, you need to treat 500 people a year to delay one person dying per year. This is the treatment paradox: the person taking the treatment almost never benefits from years and years of popping pills. Any improvements are seen only at a population level.

But it gets worse. In the case of hypertension and cholesterol, the studies were done 20 years ago. Since then the prevalence of vascular disease has halved, but this changing epidemiology has not been adequately explained. So the absolute benefit of treatment also may have halved, thus potentially doubling the number needed to treat for the same benefit. So for the example above this would now be 1000 people a year to delay one person dying each year. Finally, add in the inverse care effect—it is low risk, better educated patients who present for treatment—and the real numbers needed to treat will be much higher. The promotion of polypharmacy is pointless for the many and is very resource intense. No doubt the drug industry will seize this as an opportunity to promote expensive branded drugs. Will limited heath resources be siphoned off by Big Pharma and away from public health programmes in the developing world?


Cite this as: BMJ 2012;344:e1278