per annum worldwide; they grew even during the financial crisis. Once the markets in China and India come fully into play the profits can only grow larger, likely doubling. The markup on these drugs is on the order of several thousand percent, so they are now worth more than their weight in gold. There simply are no other goods in any other part of the economy that produce returns like these, and the profit margins of the companies that produce them far outstrip those of any other companies.
If this outlay of money saved our lives or restored productivity it would be readily justifiable, but in most cases when doctors talk about lowering our cholesterol levels with a statin they are not treating a disease, they are talking about risk management. They are not talking about saving our life but giving us a treatment for life. The statin prescribed for us may lower our cholesterol levels, but of even greater importance is the marketing by pharmaceutical companies that has changed both the doctors' and our perceptions so that lowering cholesterol has come to seem as important as treating a disease like tuberculosis.
This marketing is moving us steadily from what was the practice of medicine to a healthcare products limited market, and indeed not just a market but the creation of a new healthcare universe—a universe where the focus has shifted from medicine, in which progress occurred slowly but patients benefited, to a healthcare products market in which science and progress have become marketing terms and where benefits accrue to companies even while patients suffer harm.
It is easy to say that in the process we are poisoning our abilities to care. But what is care and where is the evidence that it is being poisoned? Care is what doctors bring to patients afflicted by something that threatens to take their life or leave them disabled. The ideal care will involve a cure. But what if the threat of disability and death comes from a treatment? Drug-induced injuries are now the fourth leading cause of death in hospital settings. They are possibly the greatest single source of disability in the developed world. The cost of drugs is often picked out in debates about the rising cost of healthcare, but healthcare providers spend more on remedying treatment-induced health problems than they do on drugs without any apparent effort to staunch this hemorrhage of lives or money. Why should 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
