With so much negativity towards medicine these days, many doctors must be contemplating ear-plugs and wondering why they are bothering. Thanks to Harvard University researcher and family doctor John Abramson, that negativity is about to be turned up a notch. His book is the latest in a series of searing indictments of a medical profession apparently duped by the false promise of technology, and too often compromised by cold hard cash from the companies selling the drugs and devices. Yet this book comes with a refreshing respect for the healing potential of the doctor-patient relationship, and a clear commitment to making the healthcare system more humane. The title speaks of the United States, but the themes are global.
Figure 1.
John Abramson
HarperCollins, $24.95/$C34.95, pp 352 ISBN 0 06 056852 6 www.harpercollins.com/
Rating: ★★★
Much of the material about drug companies distorting science will be familiar to many readers, but there is a freshness here that carries great appeal. The author combines his personal journey towards increasing scepticism with a clear analysis of where the American health system is failing. The book's focus is big pharma's unhealthy influence, but it places that subject within a much broader global context: the growing commercialisation of medicine; the limits of the biomedical approach; and the moves to widen the ways in which communities and nations can try to improve human health.
As Britain's House of Commons health select committee investigates industry's influence over the entire health system, as authorities in the United States and elsewhere continue to be convulsed by revelations about the dangers of widely prescribed antidepressants, and as a global campaign to re-invent academic medicine takes shape—part run by the BMJ—Abramson's book could not be more timely. What it lacks in terms of a compelling narrative, it makes up for with powerful and engaging insights.
The personal journey starts with this doctor's bewilderment at discovering the truth about COX 2 (cyclo-oxygenase-2) inhibitors, the overhyped new class of anti-arthritis drugs, and his sense of betrayal at finding out that such distortions are no longer uncommon. The story of celecoxib (Celebrex) and rofecoxib (Vioxx), and the far-too-favourable portrayal of their risks and benefits in both marketing materials and published trials, is told through anecdotes about interactions with real patients.
Particularly fascinating is Abramson's argument that marketing campaigns encouraging unnecessary demand are undermining the trust between a doctor and patient. It is not a new argument, but he has a moving formulation of it. With great discomfort, we hear how this family doctor wrote a prescription for a much advertised pill that he was convinced his patient did not need, in order to maintain a relationship with that patient. In another scene, the author wonders how many people he may have injured in the 1980s, by prescribing a notorious class of anti-arrhythmic drugs, belatedly shown to take life away rather than save it. Importantly no one is singled out for blame in this book, but rather “the enemy is us.”
Moving from the personal to the political, the book explores the abundant evidence about the far-reaching pharma influence over medical practice, education, and research: from the friendly drug reps to the rigged trials, from the timid regulators to the bought-off thought leaders. “Doctors who allow their reputations and academic positions to be leveraged by drug companies for commercial purposes provide a crucial link in the chain of corporate influence,” Abramson writes. The media also come in for criticism for their mindless “break-through cure” formulas in medical news stories, boosting sales more than enlightening readers or viewers.
As I read this book, and watched the wider global debates about commercial influences on medical science, one question kept demanding an answer. Given what we know now of the distortion of medical knowledge and practice, why aren't more doctors, health professionals, policy makers, and patients clamouring for a form of health care characterised by much greater independence from unhealthy commercial influences?
Figure 2.
Abramson's themes are global
Abramson provides part of the answer: “Once a doctor starts questioning accepted medical knowledge, he or she immediately risks becoming an outsider, a boat-rocker, losing respect and legitimacy earned during those long years of training.”
The other part of the answer is that the push for major reform, though disparate, is in fact gathering steam. At the medical coal-face, many academic medical campuses, patient groups, and professional societies are now debating the extent of their entanglement with drug companies. Inside Westminster itself, while acknowledging the enormous value of medicines, a British parliamentary committee is discussing how it might wind back unhealthy drug company influence on the system as a whole. And finally, the long term campaign for clinical trial registries seems to be bearing fruit.
Without risking legitimacy, there are some small, simple, practical steps that concerned doctors can take, and many already have: stop seeing company reps, stop attending company sponsored education, stop accepting gifts, and stop accepting money to speak on companies' behalf. If a recent BMJ poll is any indication, there is considerable interest in these and other moves to enhance independence (http://bmj.bmjjournals.com/misc/docdrug.shtml).
Pursuing such disentanglement is not anti medicines, or anti drug company. On the contrary, it is about trying to achieve better informed decisions about how to use medicines, at the level of the patient and the population. The products drug companies make are essential ingredients to any health system, their excessive marketing and egregious influence-peddling, as Abramson shows, are simply unwelcome.