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. 2002 Jul 27;325(7357):216.

The pharmaceutical industry and disease mongering

The industry works to develop drugs, not diseases

Richard Tiner 1
PMCID: PMC1123728  PMID: 12142315

Editor—It is true that the pharmaceutical industry, with others, is involved in sponsoring the definition of diseases, as suggested by Moynihan et al.1 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. graphic file with name tiner.f1.jpg

More medicalisation is in fact needed, as indicated by Ebrahim and Bonaccorso and Sturchio.2,3 The rise of guideline led care around the Western world shows 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. Examples include the underuse of statins in the United Kingdom, the delay in the uptake of thrombolysis during the 1980s, and reliance on old psychotropic drugs when newer agents have a much more favourable profile of side effects.

Of course, disease awareness campaigns are likely to expand the market for drugs for a given disease, but the market will expand for competitors' 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. Not infrequently, major disease is detected as a result of a patient seeking medical advice after contact with a disease awareness campaign.

Moynihan et al imply that preventive 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 lipid concentrations, etc, are all well established but could not be done without the help 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 Europe patients cannot be targeted with promotional material and such material for health professionals in the United Kingdom has to comply with the code of practice of the Association of the British Pharmaceutical Industry. Moynihan et al imply that osteoporosis has been effectively sponsored by the pharmaceutical industry. However, far too many people who fall and develop a fracture are not considered for treatment of osteoporosis.

In conclusion, the pharmaceutical industry is not inventing disease but rather working hard to develop new, innovative drugs for the overall benefit of humankind.

References

  • 1.Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering [with commentary by P C Gøtzsche] BMJ. 2002;324:886–891. doi: 10.1136/bmj.324.7342.886. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Ebrahim S. The medicalisation of old age. BMJ. 2002;324:861–863. doi: 10.1136/bmj.324.7342.861. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Bonaccorso SN, Sturchio JL. Direct to consumer advertising is medicalising normal human experience: against. BMJ. 2002;324:910–911. doi: 10.1136/bmj.324.7342.910. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Jul 27;325(7357):216.

Article was insulting to people with osteoporosis

Linda Edwards 1

Editor—I was surprised that the BMJ published the unbalanced and poorly researched article of Moynihan in which osteoporosis was dismissed as a “risk masquerading as a disease” and compared in severity to baldness.1-1

This article was insulting to all men and women who have excruciating pain and severe loss of quality of life from osteoporosis.

The article wrongly stated that the risk of fracture for most people is low: in fact 1 in 3 women and 1 in 12 men over 50 are destined to have at least one fracture.

The article also implied that population screening is advocated for osteoporosis: it is not. Neither the National Osteoporosis Society nor the International Osteoporosis Foundation advocates screening all men and women. However they do advocate that those in high risk groups should seek their doctor's advice and be assessed. These same groups are advocated in the Royal College of Physicians' report on osteoporosis and in section six of the government's national service framework for older people.1-2,1-3

Moynihan et al also argued that we should not ask pharmaceutical companies to put money into campaigns to provide information about the disease. Why not?

All profit making companies should be expected to put money back into helping patients, provided that they do not tell patient organisations what to say. As a national society, we follow strict guidelines in our dealings with pharmaceutical companies, but we expect them to support some of our work and the enlightened ones do. A modest percentage of our income comes from pharmaceutical companies, which is useful, but we are not dependent on it.

A more appropriate target would be health authorities that currently provide no service for patients with or at high risk of osteoporosis, although good evidence shows that it would be cost effective to treat to prevent the high cost of further fractures.

The National Osteoporosis Society in the United Kingdom and our sister societies in other countries are certainly not “attempting to persuade millions of healthy women that they are sick,” but we do have a duty to inform people about the seriousness of osteoporosis. We must also provide information about diet, exercise, and other lifestyle measures that can be taken from the cradle to extreme old age to help prevent this devastating disease.

References

BMJ. 2002 Jul 27;325(7357):216.

Drugs can be good for you too

Adam Jacobs 1

Editor—Moynihan et al tell us that the marketing departments of pharmaceutical companies market pharmaceutical products.2-1 Shock horror. Well, tobacco companies market cigarettes, McDonald's markets junk foods, and motor car 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.2-2 This should not detract from the fact that many people genuinely suffer from the disorder, and that those people can be helped by treatment.2-3 Why is it wrong to help them?

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. We should not assume, however, 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. This is 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

  • 2-1.Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering [with commentary by P C Gøtzsche] BMJ. 2002;324:886–891. doi: 10.1136/bmj.324.7342.886. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Furmark T. Social phobia: overview of community surveys. Acta Psychiatr Scand. 2002;105:84–93. doi: 10.1034/j.1600-0447.2002.1r103.x. [DOI] [PubMed] [Google Scholar]
  • 2-3.Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Bobes J, Beidel DC, 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. [PubMed] [Google Scholar]
BMJ. 2002 Jul 27;325(7357):216.

Authors were incorrect in their comments about Osteoporosis Australia

Philip Sambrook 1,2, Judy Stenmark 1,2

Editor—Moynihan et al raise several important issues in their article on disease mongering, so it is a pity that they followed a rule well known in journalism: “don't let the facts get in the way of a good story.”3-1

With respect to osteoporosis, they make several incorrect assertions and are selective in citing the literature. Osteoporosis Australia is not a medical foundation but an independent charity to promote the cause of patients with osteoporosis. It has received funding from industry but also from the federal and state governments. The risk test developed by the International Osteoporosis Foundation refers to women with an early menopause before age 45, not “any menopausal woman.” Also, it does not state that a single risk factor is sufficient to justify bone density testing, rather that a woman should take the whole checklist to a doctor for discussion about the need for further testing.

The authors express concern that pharmaceutical companies often fund meetings “where the disease [is] being defined.” Osteoporosis Australia and the National Prescribing Service convened a fracture summit in 2001 to develop an evidence based approach to the management of osteoporosis. This meeting, which included representatives of the Pharmaceutical Benefits Advisory Committee, specifically excluded any funding by the pharmaceutical industry. Its outcome concluded that there was only weak evidence to support what the authors suggest are “moderately effectively non-pharmacological strategies, such as weight bearing exercise.”3-2

The authors are selective in their reporting relating to bone density, which is widely accepted as the best predictor of fracture risk. The article by Wilkin quoted to suggest that bone density is not an accurate predictor of individual fracture risk was also accompanied by a commentary that challenged this conclusion, but the author failed to cite this counter view.3-3

It seems that the authors would have people with osteoporosis be reassured that they don't have a real disease, just a risk factor–low bone mass. Much of the rest that the authors say is from “conversations with industry insiders” and numerous personal communications. This is not evidence but hearsay. The article is written in tabloid style, and perhaps a tabloid newspaper is where it should have been published. Rational debate is to be encouraged, but selective reporting by authors with agendas is inappropriate.

References

  • 3-1.Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering [with commentary by P C Gøtzsche] BMJ. 2002;324:886–891. doi: 10.1136/bmj.324.7342.886. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit. Med J Aust. 2002;176:S1–16. doi: 10.5694/j.1326-5377.2002.tb04475.x. [DOI] [PubMed] [Google Scholar]
  • 3-3.Wilkin TJ. Changing perceptions in osteoporosis [with commentary by R Eastell] BMJ. 1999;318:862–865. doi: 10.1136/bmj.318.7187.862. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Jul 27;325(7357):216.

It was ever thus

Jan Karmali 1

Editor—Moynihan et al's article gave me an overwhelming sense of déjà vu.4-1 Long before reading medicine as a mature student, I did a degree in psychology and spent several years in the late 1960s and early '70s working for a market research company that specialised in qualitative or “motivational” consumer research. Our task was to use psychoanalytical techniques to delve into the attitudes and motivations of the consumer. Our purpose was to provide companies' marketing and advertising departments with ammunition to exploit the fears, weaknesses, and desires of consumers so that they bought the companies' products.

Three examples spring to mind: women's worries about vaginal odour and hygiene were exploited in order that vaginal deodorants were sold; a new range of therapeutically useless pharmaceutical products was developed for emerging Third World markets, playing on the superstitions of the uneducated, “native” mind; and “safe,” low tar cigarettes were promoted to combat the new government health warnings on cigarette packets.

I am surprised that the medical world took so long to catch on to the devious techniques at which the pharmaceutical industry excels. I have always been amazed by doctors' naivety 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 have been a general practitioner for 11 years, but my memory of the methods used in marketing and advertising is clear.

References

  • 4-1.Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering [with commentary by P C Gøtzsche] BMJ. 2002;324:886–891. doi: 10.1136/bmj.324.7342.886. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Jul 27;325(7357):216.

Déjà vu all over again

Matthew Anderson 1,2,3, Alison Karasz 1,2,3, Peter Lurie 1,2,3

Editor—Moynihan et al's article on disease mongering by the pharmaceutical industry5-1 reminded us of an old Bronx baseball saying, originating with Yogi Berra: “It's déjà vu all over again.” 3M has for years sponsored the 3M/National Vaginitis Association (www.vaginalinfections.com). This produces a newsletter for health professionals (the Vaginitis Report) and materials for patients. Like the groups described by Moynihan et al, the 3M/ National Vaginitis Association is ostensibly an educational resource run by health professionals.

Unfortunately, its activities include 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/National Vaginitis Association established a free telephone number to distribute a free “educational brochure” promoted by a television personality.

The association provides a further example of what Moynihan et al describe as using statistics to “maximise the size of a medical problem.” A survey sponsored by the association found that “one-third of women believe that vaginal odor is normal, and approximately 24% believe that it's normal to experience vaginal itching.”5-2 This is offered as evidence of women's “lack of knowledge” about vaginal health. The association's website encourages women to contact a healthcare provider when they experience such symptoms.

In fact, good evidence from the primary literature says that both odour and itching occur in women without vaginal complaints.5-3,5-4 The idea that vaginal complaints are due to infectious agents has been heavily promoted by 3M through the association and is implicit in the very naming of its website, which refers to vaginal infections. Yet we know that many women with vaginal complaints do not have an identifiable infectious pathogen.5-5

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 also said: “You can observe a lot just by watching.”

References

  • 5-1.Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering [with commentary by P C Gøtzsche] BMJ. 2002;324:886–891. doi: 10.1136/bmj.324.7342.886. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-2.3M/National Vaginitis Association. National survey reveals most women still are unaware of bacterial vaginosis (BV), the most common vaginal infection. St Paul, MN: 3M/NVA; 2002. . (21 February 2002.) [Google Scholar]
  • 5-3.Doty RL, Huggins GR. Changes in the intensity and pleasantness of human vaginal odors during the menstrual cycle. Science. 1975;190:1316–1318. doi: 10.1126/science.1239080. [DOI] [PubMed] [Google Scholar]
  • 5-4.Priestley C, Jones B, Dhar J, Goodwin L. What is normal vaginal flora? Genitourinary Med. 1997;73:23–28. doi: 10.1136/sti.73.1.23. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-5. Centers for Disease Control and Prevention. Guidelines for treatment of sexually transmitted diseases. MMWR 1998;47(RR-1). [PubMed]
BMJ. 2002 Jul 27;325(7357):216.

Will industry's latest moves promote public health or private profit?

Sheila McKechnie 1

Editor—The issues raised by Moynihan et al are borne out by research conducted by the Consumers' Association.6-1,6-2 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 lot of pressure to allow drug companies to reach the public direct.

This raises some interesting and important questions. For example, why would pharmaceutical companies continue to fund patient organisations when they can communicate with patients direct? How will this affect what the patient organisations can do and the people who rely on their information and support? Will it increase the use of the internet for the purchase of drugs that doctors are not willing to prescribe, and what will the safeguards and regulation be to protect consumers from poor medical advice through this route? Perhaps the most important question of all is why proposals are 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 shows that this will bring about far reaching and extremely negative consequences for public health throughout the European Community in order to satisfy commercial interests.

References

  • 6-1.Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering [with commentary by P C Gøtzsche] BMJ. 2002;324:886–891. doi: 10.1136/bmj.324.7342.886. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6-2.Consumers' Association. Promotion of prescription drugs: public health or private profit? London: CA; 2001. . (Policy report.) [Google Scholar]
BMJ. 2002 Jul 27;325(7357):216.

Psychiatry should not accept so much commercial sponsorship

Joanna Moncrieff 1,2, Phil Thomas 1,2

Editor—Moynihan et al mention social phobia as one example of the manipulation of medical knowledge by the pharmaceutical industry,7-1 but, as Double says, this process is endemic in psychiatry.7-2 Since the 1950s drug treatments have dominated psychiatric practice and set the agenda for most psychiatric research, even though it remains difficult to show that long term outcomes are any different from those 100 years ago.7-3

The influence of the pharmaceutical industry is particularly pernicious in psychiatry, where the possibilities for colonising ever more aspects of life are potentially limitless. In psychiatry different paradigms and approaches to treatment are hotly contested. The financial muscle of the pharmaceutical industry has helped to favour a predominantly biological view of psychiatric disorder. This has submerged alternative therapeutic approaches, even though user led research indicates that service users find a wide variety of non-medical approaches valuable in coping with emotional distress.7-4

It is time to uncouple the alliance between psychiatry and the pharmaceutical industry. Users of psychiatric services are profoundly suspicious of this alliance and last year organised a demonstration against sponsorship of the Royal College of Psychiatrists' conference.7-5 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; there has to be absolute transparency concerning the relation between the colleges and the industry. In February this year we wrote to the president of the Royal College of Psychiatrists requesting information about 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 credibility with service users and the public. We shall be campaigning actively to achieve this.

References

  • 7-1.Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering [with commentary by P C Gøtzsche] BMJ. 2002;324:886–891. doi: 10.1136/bmj.324.7342.886. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7-2.Double D. The limits of psychiatry. BMJ. 2002;324:900–904. doi: 10.1136/bmj.324.7342.900. . (13 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7-3.Healy D, Savage M, Michael P, Harris M, Hirst D, Carter M, et al. Psychiatric bed utilization: 1896 and 1996 compared. Psychol Med. 2001;31:779–790. doi: 10.1017/s0033291701003968. [DOI] [PubMed] [Google Scholar]
  • 7-4.Faulkner A. Strategies for living: a report of user led research into people's strategies for living with mental distress. London: Mental Health Foundation; 2000. [Google Scholar]
  • 7-5. Psychiatry agenda set by drug firms. Guardian 9 July 2001.
BMJ. 2002 Jul 27;325(7357):216.

Authors' reply

Ray Moynihan 1,2,3, Iona Heath 1,2,3, David Henry 1,2,3

Editor—We welcome the comments and criticisms of our paper, seeing them as part of what we hope will be an ongoing and growing debate about disease mongering. Many of the experiences and views described in the correspondence confirm or expand our concerns about these issues.

We note the acknowledgement by Tiner from the Association of the British Pharmaceutical Industry that “the pharmaceutical industry, with others, is involved in sponsoring the definition of diseases” and welcome his wider reactions to the BMJ's theme issue on medicalisation. Similarly we are pleased to receive feedback from the National Osteoporosis Society but reject assertions that our article was unbalanced or poorly researched.

In response to Jacobs, we agree that pharmaceutical treatments can offer great help to those who genuinely suffer from disorders, including social phobia. However, as he rightly points out, we recommend a preference for independently funded information about both disorders and treatments.

In response to Sambrook and Stenmark's letter from Osteoporosis Australia, we acknowledge a mistake in relation to the way our article reported on the recommendations for the one minute risk test for osteoporosis. However, regarding the sources of funding for Osteoporosis Australia, the organisation's website (www.osteoporosis.org.au) mentions four sponsors, Aventis (a pharmaceutical company that markets the drug risedronate), the Australian Dairy Corporation, Kraft Singles (a popular brand of sliced processed cheese), and Caltrate (a brand of calcium supplement marketed by Wyeth Australia). In other words, while Osteoporosis Australia may indeed receive funding from governments, its site lists commercial sponsors that have a vested interest in some of the activities of Osteoporosis Australia and also appears to be promoting some of the sponsors' products.

We agree that the evidence for the efficacy of exercise is not as strong as for some drug interventions, as Sambrook and Stenmark assert. However, systematic reviews of randomised trials have shown an attenuation of the decline in bone mineral density with exercise,8-1,8-2 and a systematic review found that some forms of supervised exercise reduce the incidence of falls.8-3 Observational studies have shown a protective association between regular exercise and hip fracture.8-4 The website of Osteoporosis Australia recommends exercise for the “prevention of osteoporosis.”

Sambrook and Stenmark attempt to discredit our article by describing evidence based on “conversations with industry insiders” and “personal communications” as “hearsay.” Several of the “personal communications” to which they refer were interviews with pharmaceutical company representatives to check facts and include company arguments and perspectives. The “conversations with industry insiders” and other confidential interview material were referred to in our article because of their direct relevance. As these authors may or may not know, public relations experts active in corporate funded disease awareness campaigns are often liable to be far more candid in confidential interviews than in public “on the record” statements.

Sambrook and Stenmark claim that bone densitometry “is widely accepted as the best predictor of future fracture risk.” We are not sure what this statement means, but the performance of the test is poor. In a review of bone mineral density measurement the British Columbia Office of Health Technology Assessment summarised published data from five independent evaluations of the predictive performance of bone density measurements.8-5 Depending on the threshold values used and the assumed lifetime incidence of hip fracture, studies reported predictive values for positive results in bone mineral density tests ranging from 8% to 36%. This report also emphasised that women of menopausal age are most commonly referred for testing. The majority of these women are at low risk of osteoporotic fracture within the next few years. If the test leads to unnecessary treatment and anxiety (typical effects of disease mongering), it may do more harm than good. We do not seek to downplay the real suffering caused by osteoporotic fractures, and welcome the increasing emphasis on various forms of prevention and effective treatments of those at high risk, particularly elderly people.

References

  • 8-1.Wolff I, van Croonenborg JJ, Kemper HC, Kostense PJ, Twisk JW. The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women. Osteoporosis International. 1999;9:1–12. doi: 10.1007/s001980050109. [DOI] [PubMed] [Google Scholar]
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