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  1. Alexandra Barratt, MBBS, PhD
  1. University of Sydney, Sydney, New South Wales, Australia

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    Thirty years ago Henry Gadsden, chief executive of Merck, told Fortune magazine he wanted Merck “to be more like chewing gum maker Wrigley’s.” Gadsden said it had long been his dream to make drugs for healthy people, because then Merck would be able to “sell to everyone.”

    This is the starting point and central thesis of Moynihan and Cassel’s book Selling sickness—that pharmaceutical companies are working to turn us all into patients and generate ever bigger profits for themselves (and ever greater healthcare costs for health care systems). They make a compelling case that big pharma has deliberately used its influence to broaden disease definitions to expand its markets. For example, they report that Glaxo Smith Kline (formerly Smith Kline Beecham) has claimed that social anxiety disorder (SAD) affects 1 in 8 Americans. Other definitions put the prevalence variously at <1% or, in some studies, up to 4%. By more broadly defining the criteria for SAD, the pharmaceutical company created a greatly expanded market for its drug Paxil, the first drug approved for the treatment of SAD.

    Moynihan and Cassels cite many other examples to advance their argument—including high cholesterol, high blood pressure, osteoporosis, depression, and attention deficit disorder. They further argue that big pharma is creating new “diseases” that are usually regarded as inevitabilities of life. Naturally, the companies then provide treatments for these “diseases” (eg, hormone replacement therapy for menopause, Viagra for erectile dysfunction (ageing?) in men, and, the latest disease creation, female sexual dysfunction). Suffered by 43% of women (yes, you read that correctly: 43%), it can be treated by a Viagra like pill for women or a testosterone patch. Of course, this presupposes that the causes of female sexual dysfunction are primarily biological. As an evidence-based and sceptical reader, does this sound likely to you? What about relationship issues, tiredness, and stress? Nevertheless, watch out for the new bedtime line “Not tonight darling—the dog ate my patch.” I can’t take credit for that; it comes from Dr Leonore Tiefer, founder of a US-based campaign against the medicalisation of women’s sexuality. For more on her confrontations with Pfizer on this issue, you’ll have to read the book.

    Moynihan and Cassels argue that big pharma is aided in its marketing efforts by doctors who serve its interests, even if indirectly, in return for handsome inducements. They report, for example, that 90% of people who sit on clinical guidelines committees have conflicts of interest because of financial ties to pharmaceutical companies.

    Thankfully, some organisations have recently been critical of the industry. The BMJ has called on doctors to “just say no” to drug company lunches and the like. The House of Commons Health Committee report on the influence of the pharmaceutical industry (www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/4202.htm) concluded that the industry had been left to its own devices for too long, that some of its practices now act against the public interest, and that the current regulatory system is inadequate. It made a range of recommendations to strengthen the regulatory system and to force full publication of industry research.

    But the regulatory and research influence is difficult to tackle. Moynihan and Cassels make a strong argument about the inability of the US Food and Drug Administration (FDA) to stand up to the industry. Half of the FDA’s budget comes from drug companies on a “user pays” basis. And increasingly expensive drug trials reflect the research agenda and questions of the industry rather than those of doctors and patients. It’s a depressing story, not least because they’re probably right.

    Most of the examples and the citations are American. The US has <5% of the world’s population but 50% of the global market in prescription drugs. Cassels is Canadian and Moynihan is Australian. Both of these countries are protected against the full force of big pharma by having publicly funded health systems and evidence-based agencies making decisions about the provision of prescription medicines. Furthermore, unlike the US, direct to consumer advertising is limited. Nevertheless, this book is informative and alarming reading wherever you live. They claim, and I agree with them, that along with regulatory and advertising controls, a major antidote to selling sickness is scepticism—of drug industry claims and drug company funded research. Evidence-based medicine has a big role to play in maintaining balance between the important benefits of appropriately used prescription drugs and the risks of unsubstantiated claims and promotions by the industry.

    Moynihan R, Cassels A. Selling sickness. Vancouver: Greystone Books, 2005.

    Selling sickness can be obtained from www.amazon.co.uk for £7.99.

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