The pharmaceutical industry is a business. This banal and obvious fact needs emphasising because it is often forgotten or overlooked by both supporters and critics of the industry's ethos and activities. And the industry itself is happy to downplay its true motivations where this suits the circumstances. It can, for example, pose instead as educator, charity supporter, health service provider, and even patient advocate.
Figure 1.
Jacky Law
Constable, £9.99, pp 266 ISBN 1 84529 139 5
Rating: ★★★⋆
While such roles hardly mask the underlying commercial imperative, observers may be reluctant to consider them primarily in business terms. This would be a mistake, not least because, when viewed in this way, there is much to admire about the pharmaceutical industry. Other industries could perhaps learn from its energy, professionalism, flexibility, and ability to ensure that its interests are well represented wherever key healthcare decisions are taken. What is more, a focus on the pharmaceutical industry as a business need not deny the great advances the industry has provided and continues to offer, or the good intentions of many who work in it.
Indeed, the difference between the interests of industry and the public good is not necessarily a problem. Where medicines are affordable and scrupulously regulated, and offer genuine therapeutic benefits, the overlap between public health and the legitimate business interests of industry can be self evident. There is a danger, however, in taking such overlap for granted. Multinational pharmaceutical companies grew big through producing and promoting innovative medicines for major diseases. But it becomes ever more difficult and expensive to repeat such successes. Increasingly, therefore, the companies stay big by identifying and promoting diseases for their major medicines and refashioning and repackaging old products as “innovations.” Also, they commonly operate under regulatory and other statutory arrangements that appear to assume that what industry produces is inevitably worth having—an approach that is more patent focused than patient focused. In this environment, assuming or pretending that there is a direct relationship between industry's efforts and improvements in public health is, at best, naive.
These issues form the core of Jacky Law's excellent treatise on how major pharmaceutical companies dictate which healthcare problems are researched, publicised, and provided for. This concept is not novel. But what Law adds is a highly readable synthesis of evidence and commentary to argue how and why the pharmaceutical industry fails to address healthcare issues that really bother people.
Assuming that there is a direct relationship between industry's efforts and improvement in public health is, at best, naive
The author is clearly no great fan of the industry. But, refreshingly, she avoids the sort of lazy polemic that casts major pharmaceutical companies as an evil empire that continually foists its products on unwilling and unsuspecting healthcare professionals and patients. Nor does she shy away from criticising those outside the pharmaceutical industry—government, regulators, doctors and patients—who have encouraged or acquiesced in the industry's way of doing things.
Tracing the development of the modern pharmaceutical industry, Law correctly cites the failure of what she calls “the deal”—a regulatory framework broadly based on the idea that pharmaceutical companies always produce worthwhile products that society will automatically buy. In hindsight, of course, this settlement seems woefully optimistic. But it is important to remember that it came about at a time when companies really were producing innovative medicines relatively easily; when such development was affordable; when patients were passive and trusted doctors; and when doctors trusted the medicines. And even now, as the book makes clear, the guiding principles of the deal remain in place, despite being increasingly unfit for purpose.
A key example in the UK is the Pharmaceutical Price Regulation Scheme, the unique, grotesquely brilliant arrangement that dictates how much overall profit a major pharmaceutical company can make through sales of its brand-name products to the NHS. The scheme helps to control the national drugs bill. However, it also deliberately uncouples the price set, and the profit made on, an individual product from the costs incurred in developing, testing, and promoting that product.
The “deal” was bound to fail through the spiralling costs and increasing difficulty involved in producing genuinely innovative medicines, and society's mounting disinclination to pay, particularly for products of questionable value. These economic realities have been compounded by recent high-profile instances of regulatory failure, in particular, the problems surrounding the use of rofecoxib (Vioxx) and selective serotonin reuptake inhibitors. The book concisely reviews the evidence indicating that in these cases regulators repeatedly favoured the interests of pharmaceutical companies above those of patients.
Such information forms a key part of Law's championing of active and representative involvement in individual and societal decision making about health care. This view is compelling given the lack of trust patients and the general public have for regulators and the wider medical establishment. However, much less convincing is the book's suggestion that the UK government should have addressed parents' scepticism about official advice on the MMR (measles, mumps, and rubella) vaccine by making alternative single vaccines available on the NHS. This highly questionable proposal seems a rare lapse in an otherwise tightly argued text.
The final third of the book highlights how moves to strengthen and ensure more balance in the doctor-patient relationship could help lessen the often distorting influence of the pharmaceutical industry. This suggestion may seem wildly hopeful, particularly given the industry's proved adaptability. But as Law herself concludes, it would be a good start.
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