I remember as a medical student being appalled at the spectre of well paid hospital doctors climbing over one another to get their hands on the free food and branded knick-knacks on offer at supposedly educational lunchtime meetings sponsored by drug companies. I found the blandishments of the company representatives preposterous—a view confirmed when I briefly joined their ranks in a subsequent career break. Ever since I have avoided such meetings and contacts with the world of pharmaceuticals—and I am sympathetic towards the approach of the No Free Lunch campaign (endorsed by Moynihan and Cassels), which recommends that doctors “just say no to drug reps” and send back their advertising paraphernalia.paraphernalia.
Selling Sickness is a spirited journalistic exposure of the methods used by the pharmaceutical industry to expand the market for its products. These include the redefinition of risk factors—such as raised cholesterol and blood pressure, or reduced bone mineral density—as diseases afflicting substantial sections of society and requiring treatment with medication. Another stratagem is to persuade both doctors and patients that conditions such as anxiety and depression, hitherto reckoned to afflict only a small minority, should be diagnosed—and treated—much more widely. Yet another trick is the naming of new disorders; Moynihan and Cassels focus on attention deficit disorder (in adults as well as children), premenstrual dysphoric disorder, and social anxiety disorder, each of which is linked to a specific drug treatment.
Yet another trick is the naming of new disorders
The pharmaceutical companies promote all these conditions through their cultivation of “thought leaders” in the relevant fields and through the presence of recipients of substantial financial favours on elite medical bodies concerned with defining diseases and promulgating guidelines on diagnosis and treatment. They also provide lavish hospitality at events ranging from prestigious specialist conventions to golf weekends for general practitioners.
The pharmaceutical companies promote all these conditions through their cultivation of “thought leaders”
Selling Sickness describes how “awareness raising” campaigns seek to transform the worried well into the worried sick. Whereas in the United States the direct advertising of drugs to consumers is possible, in Britain, where this is prohibited, campaigns promote awareness of conditions such as erectile dysfunction, prompting requests for prescriptions. The technique of “astro-turfing”—the formation by drug company public relations professionals of fake grass roots advocacy groups, often featuring celebrities—has helped to popularise new disorders and increase demand for treatments.
Moynihan and Cassels show how the diverse processes of “disease mongering” have helped to turn pharmaceuticals into a global $500bn (£271bn; €401bn) industry, one of the most profitable spheres of capitalist enterprise. Yet their narrow focus on the drug companies neglects the wider forces that have encouraged the medicalisation of the lives of individuals and society.
Whereas 20 or 30 years ago the medical profession was the main target of critics of medicalisation, today doctors appear more the victim of pressures from above and below, from government and from the public—and the drug companies have become the new demons.
On the one hand, politicians faced by a loss of prestige and authority have turned to health as a sphere in which they can forge points of contact with a remote and fragmented electorate. In the United Kingdom scarcely a week goes by without a government initiative seeking to raise popular awareness of some condition or other, exhorting people to modify their behaviour or lifestyle in some way in the cause of health, and encouraging them to seek medical advice and treatment. On the other hand, these initiatives find a ready response in an increasingly atomised society, in which individuals experience a heightened sense of frailty and vulnerability, which is often expressed in a preoccupation with health and the measures deemed necessary to achieve and sustain it.
Moynihan and Cassells quote approvingly a Canadian health advocate who claims that the demand for new medical technologies is “driven by opportunistic investors seeking new products and profits—not patients seeking new diagnosis and treatments.” This one-sided analysis misses the drive arising from people who seek out and embrace new diagnoses (often, like fibromyalgia or myalgic encephalopathy (ME), not linked to any specific drug treatment) and form organisations to demand that doctors recognise, diagnose, and treat them. Undoubtedly the drug companies have skilfully exploited these trends and have benefited handsomely from them, but they did not create them.
How can we break the cycle of dependency between the medical profession and the pharmaceutical industry? We must first recognise that the convergence between doctors and drug companies cannot be understood as merely the result of the corrupting effects of corporate largesse, however distasteful we may find these links. What is required is a wider challenge to the processes of medicalisation, one that redraws the boundaries between health and disease and between, on the one hand, medical practice involving the diagnosis and treatment of disease and, on the other, the worlds of lifestyle regulation and “recreational” drug use (including preventive treatments of dubious merit as well as medications of unproven therapeutic value).