The wolf in sheep’s clothing

OK. Today we look into the shadow side of our current medical system. Big Pharma. It is pretty much an accepted fact that the companies that we rely on to do the R&D and develop the life-saving drugs that we need also indulge in some pretty shady ethics.

We all know it. During my medical training changes were underway to reduce the influence that drug companies had on doctors’ prescribing practice. Over the 5 years of my residency training, drug companies went from overtly funding luxury retreats, dinners, gifts (pens and pads of paper and the like) and hospital teaching rounds lunches (much coveted by sleep- and time-deprived doctors-in-training) to overtly funding… well, less. And the covert funding continues unabated. Some changes have taken place but the relationship between Big Pharma and doctors is still deeply etched into the system.

Whether we like it or not, they rely on us and we rely on them. It is an intricately intertwined relationship that can’t easily be unpicked. To me, corporate interests piggybacked to essential social services is the ultimate and most sinister wolf in sheep’s clothing.

When I was training, I failed to see what all the fuss was about. Most of the time, I didn’t connect the face of the drug rep to the company they represented, or the drugs they sold. I was simply grateful for the tuna sandwich when I’d been up for 30 hours, or the pens I used and repeatedly lost somewhere in the labyrinth of hospital wards.

When I was training, I was administering care to people who were near death and restoring them to a more stable state of health. The drugs were necessary and which one I chose had more to do with the bacteria that turned up on culture than the rep who turned up with the lunch.

But it got a little more murky when I began to provide care for the chronically ill as a consultant.

There were usually a few new drugs on the market that all did the same thing, and competition for space on my prescription pad was intense. The tactics were subtle.

A system is in place where, all along the food chain, people feel good about their role in providing care. The doctor feels good about offering a new drug to a patient who has suffered for a long time, and for whom all the old tried and true remedies have failed. The rep feels good about being a conduit for access to effective treatments. The research scientist feels good about participating in drug trials that eventually get more useful drugs to market. But further up the chain, and farther away from the patients themselves, the good feeling comes from market share and sales figures. Higher up in the hierarchy there are people making decisions on fiscal outcomes, not health outcomes.

The facts are that within the Pharma industry people, governments and regulatory bodies are paid off and evidence is distorted. Negative studies are hidden and positive studies are published. Side effects, including death, are seen as the cost of doing business.

It’s a broken system but one so ingrained into the way we deliver care that it feels almost impossible to change.

I liken it to the use of plastics. Our world now relies on plastic from everything to daily hygiene to food delivery, from packaging to essential products. It’s bad for us. It’s bad for the planet. It’s bad for marine life. We desperately need to reduce our use of plastics but again, up the food chain are a few people who have a large financial incentive to keep us using them. And so, global use increases year on year. And so, each time I visit the beach I find more syringes, water bottles, bags, tampon applicators, etc washed up on shore. A mass of plastic the size of Texas is floating somewhere in the Pacific. I shudder to think about the vast quantity of what’s floating out there in the deceptively clean-looking ocean. It’s a perfect metaphor for the health care system at the moment: deceptively clean and calm on the surface, but all sorts of murky stuff knocking about in its depths, and some of it is now washing up on the shore for those of us looking for it to find. It’s our responsibility to point it out to the rest who might not be looking.

I was gratified to see a piece in the British Medical Journal blog rallying for awareness of Big Pharma’s nefarious behaviour. The author, Richard Smith, a former editor of the BMJ, wholeheartedly supports a book by Peter Gøtzsche, the head of the Nordic Cochrane Centre, entitled Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare.

Much of this book is also shocking and in a similar way: it shows how science can be corrupted in order to advance particular arguments and how money, profits, jobs, and reputations are the most potent corrupters.

He comments too how “the industry has bought doctors, academics, journals, professional and patient organisations, university departments, journalists, regulators, and politicians. These are the methods of the mob”.

The book itself details how doctors, as key opinion leaders, are being bought by Pharma and are, in fact, the hired guns of the industry.

Smith also points out this disturbing truth:

The doctor and author Ben Goldacre, in his book Bad Pharma raises the interesting thought that doctors have come to see as “normal” a relationship with the drug industry that the public will see as wholly unacceptable when they fully understand it. In Britain doctors might follow journalists, members of Parliament, and bankers into disgrace for failing to see how corrupt their ways have become. At the moment the public tends to trust doctors and distrust drug companies, but the trust could be rapidly lost.

The operative phrase here is “failing to see”. Because most doctors, contrary to many popular conspiracy myths, truly believe they are doing the right thing. People trust doctors and doctors trust Evidence Based Medicine implicitly. Not all of us see the emperor as naked. And even fewer are willing to point it out to others. Most doctors are in it to help. And it is natural to simply avoid the inconvenient truth of industry corruption when you are face to face with patients in need.

In our desire to help, we accept a broken system because we’d rather offer Something even if that something comes with unpleasant terms and conditions. Tragically, we’ve grown accustomed to terms and conditions that should be considered completely unacceptable.

We doctors have been raised to trust the science. No – it goes farther than that. We’ve been raised to believe that science is the only thing that can be trusted. Above feelings and intuition or a niggling sense that something doesn’t seem quite right. Perhaps this is why so many of us have slid our gaze past the truth of the corruption within our own system. We cannot trust our sense that something is not quite right. We can only trust the double-blind, randomised, placebo-controlled trial. Good science overrides good sense. So often doctors will sneer at the pseudoscience of the intuitive. Yet we ignore the fact of the unpublished negative trials, the creative rearrangement of data – the pseudoscience within our own trusted literature.

It’s complex. Humans are complex. So, what to do?

Well, on a large scale, government policies and industry standards need to change. I don’t have a lot of faith this will happen any time soon. There’s simply too much money at stake. But on an individual level, one can do quite a lot. Here are just a few suggestions:

  1. Education. Education of the consumers of these products – the patients. Patients need to know how shaky the evidence really is for some drugs (like antidepressants) and need to be willing to undertake alternative treatments which, to be honest, are often much more difficult than taking a pill. And education of the so-called hired guns: the doctors. We all need to see that the emperor is naked. Doctors need to accept the difficult task of pointing out this flaw in our revered system of care and begin to seek alternatives. Also much more difficult than prescribing a pill.
  2. Prevention. Now more than ever, we need to turn our attention to prevention of illness, and avoidance of chronic illness. Most chronic disease is preventable. We need to do our part to intervene before lifelong medication becomes our only option.
  3. Reimagine. We need to reimagine what health means. This is already happening on a grassroots scale, with more and more people exploring mindfulness and meditation, healthy eating, exercise and yoga as lifestyle choices. These changes are exciting to see, and may the trend blossom into a massive sea-change.

I believe that this is what makes us unique amongst the species here on our beautiful blue planet, and what will ultimately save us: our imagination. From this creative well has sprung the most wondrous achievements but also the most damaging. We need to harness this immense creative power and reimagine a new path to health for each individual and for our planet – the large and increasingly unhealthy organism of which we are an integral part.

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