Pharmageddon. David Healy
this be? If we turn to the evidence base to care for and ideally cure this new disorder afflicting us, we find there is none—no guidelines, no studies, but instead close to a blanket dismissal of any evidence that things could be going wrong.
When it comes to care, the billions of dollars wrapped up in pharmaceutical sales only tell part of the story. Until recently in medicine there was vigorous debate on the appropriateness of various approaches to tackling disease and caring for patients, and medical meetings were filled with academics passionately arguing quite different points of view in discussions that often hinged on managing the risks of a treatment. But the money put into the marketing of pharmaceutical blockbusters is steadily silencing debate about differing therapeutic options and any discussion of the hazards that blockbusters pose. This is not just a problem in the United States—the silence is now being extended worldwide.
Fifty years ago many European countries put universal healthcare in place. Today, at a critical juncture in the history of healthcare, the United States is seeking to expand healthcare coverage. Fifty years ago it made sense to use taxpayer dollars to treat real diseases such as pneumonias and tuberculosis, for example, raising people from their deathbeds and putting them back to work, or taking them off disability lists and restoring them to productivity. This is an investment. If we can cure life-threatening or disability-producing diseases, the use of taxpayer dollars pays for itself—it would make the United States, for example, wealthier and better enable it to compete with China, Japan, and Europe. But treating raised cholesterol levels and other “number disorders” in an ever greater proportion of the population when medical necessity doesn't call for it is more likely to lead to a decrease in American productivity by increasing health anxieties and giving patients unpleasant side effects, if it doesn't actually kill them prematurely—and such pill dispensing is exactly what Americans do more than any other country on earth. This is an expense rather than an investment. Moreover, this is an expense that is crippling American industry, given that virtually everyone now has some set of numbers that pharmaceutical companies portray as needing “treatment.”
The Obama administration and others have suggested that the only rational way forward is to embrace evidence-based medicine. But just as the insurance companies have found, anyone turning to this source will be faced by controlled trials which demonstrate that the most recent drug treatments work and supposedly save money. They will encounter guidelines drawn up by the most distinguished and independent figures in the field, advocating the use of the latest drugs. They will be told the biggest problem lies in doctors failing to adhere to evidence-based guidelines. A new generation of web-based companies is even offering to build devices into electronic medical records to ensure adherence to the latest guidelines in a way that would make it impossible for doctors to exercise discretion.
In a world where corporations can market bottled water to us, it appears to have occurred to virtually no one to ask how such marketing power might be applied to drug therapies. If the goal of medical marketing is to find out what doctors want in order to get the doctors to sell the product to themselves—and it is—and if doctors say they are influenced by the evidence above all else—and they do—it should not come as a surprise that industry might set about ensuring the evidence points in the right direction. The availability of drugs on a prescription-only basis in these circumstances makes the job of company marketers a great deal easier than it might otherwise be by enabling them to zero in on a small number of consumers who, when it comes to marketing, are often more naïve than the average adolescent.
We have an extraordinary paradox that attracts absolutely no comment. On the one hand the medical establishment portrays evidence-based medicine as our best means of reining in the pharmaceutical industry, while on the other hand pharmaceutical companies are now among the most vigorous advocates of evidence-based medicine. And it is just this kind of evidence that administrations in both the United States and Europe seem to think will help control health costs. If catch 22 hadn't existed we would now have to invent it.
AVOIDING PHARMAGEDDON
While ghostwriting by pharmaceutical companies has begun to make the news, there is little awareness of the extent to which medicine's major journals have been complicit in the practice and how, faced with articles on treatment hazards, our journals self-censor for fear of legal actions. There is no analysis to explain how treatment guidelines drawn up by academic bodies that are independent of the pharmaceutical industry invariably endorse the latest company products.
All the while doctors and patients complain about the profound changes in their clinical encounters. Where once we consulted our doctors because we had a problem and met a doctor who could spot differences in us from one visit to the next, someone who might have spotted a treatment-induced problem, we are now likely to meet a different face each time we go to the clinic. The main task of many doctors has changed from monitoring us for evidence of life-threatening diseases or the adverse effects of treatment to monitoring the results on computer screens from the latest tests of our risk factors, and managing those numbers on the basis of guidelines. Not unreasonably, the managers who increasingly run health systems from the United States to Europe assume that if the job involves looking at numbers on a computer screen and then following guidelines for what to do next, doctors should be interchangeable.
The engagement of a doctor with the person in front of him or her now means increasingly that on the basis of targets linked to guidelines the role of the doctor is to “educate,” to cajole or coerce us into treatment for conditions we never knew we had, with treatments that in some instances are more likely to injure or kill us than improve our well-being. This is what caring has become.
Doctors complain about all this, but without an analysis of the forces pushing them to one side and unless they can offer an alternate model of care, such complaints are idle. Blaming the pharmaceutical industry without pinpointing anything they do other than make more profits than some might like is just scapegoating. Are the scapegoaters, we might ask, doing anything other than complaining? By the end of chapter 2 it will be clear that current patent law and prescription-only arrangements for drugs may in fact give rise to many of our more superficial difficulties—but are there any doctors or others seeking to change these arrangements? By the end of chapter 4, it will be clear that blockages to our access of the data from clinical trials constitute a serious breach of scientific norms, but it will be far less clear that there are any doctors taking a stand against this breach.
All of these issues come to a focus in chapter 7 in a description of a patient injured by treatment. Here we see at its clearest the divide between what medicine at its best once was and what it risks becoming. On the basis of the “evidence”—the published reports of controlled trials—our doctor may appear to have little rational option but to deny that the prescribed treatment could have caused us any problems. There is no evidence-based approach to determining whether treatments have injured a patient or what to do when it happens. Why ever not?
Avoiding Pharmageddon is not primarily a matter of containing the escalating costs of healthcare—although this is important. It is a matter of restoring the conditions in which doctors can diagnose what is afflicting us and can offer the appropriate care. This kind of care is not something intangible nor something that looks like current efforts to get health professionals to smile more and encourage their patients to have a nice day or other efforts to deliver a “good service.” When it comes to treatment-induced injuries it will increasingly require those whom we entrust with our care to have the “right stuff.”
While on the surface physicians and others in healthcare are now encouraged to become our partners, in fact the impulse to nurture us when we are afflicted so that we can realize our potential to its fullest extent is being thwarted by processes that render treatment-induced problems invisible. As a result, a vast reservoir of idealism and goodwill that those working in healthcare bring to their work daily is being squandered. And insofar as the essential wealth of a nation is people functioning at their best, rather than oil or other resources in the ground, our countries and economies are being correspondingly impoverished.
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