This is an important and brave book. Carl Elliott, like Atul Gawande and Jerome Groopman, writes about medicine in a style so engaging that he easily captures and holds the attention of general readers as well as those in the medical profession. But Elliott’s story—the corruption of the medical profession by the pharmaceutical industry—is dark, despite his leavening wit. As he states at the outset, “My interest is in how medicine has gone wrong, not in what there is to admire.”
A physician and philosopher who teaches at the University of Minnesota’s Center for Bioethics, Elliott knows his subject. He describes in vivid detail how drug companies shower billions of dollars on the medical profession—on distinguished medical school faculty to promote drugs as well as on ordinary doctors to get them to prescribe them—with the help of a panoply of intermediaries. Among these: private research firms, medical education and ghostwriting companies, and various patient advocacy groups.
This part is nothing new. Much of this information has been covered in earlier works, including my 2004 book, The Truth about the Drug Companies: How They Deceive Us and What to Do about It. Another earlier book, Jerome Kassirer’s excellent On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health, also targeted the medical profession for criticism. But this is a fresh look, with the emphasis squarely on the doctors who sell themselves, not just the companies buying them.
The obvious question is whether doctors are knowingly serving the interests of the pharmaceutical industry or simply being seduced. Elliott shows that there is plenty of room for both explanations. Doctors, like most experts, are easily flattered and are great believers in their own objectivity and good intentions; they also have a strong sense of entitlement.
In accord with the admonition of Watergate’s “Deep Throat,” the book’s six chapters “follow the money” as it wends its way from drug companies to doctors. The first chapter, “The Guinea Pigs,” deals with the private research companies—called “contract research organizations,” or CROs—hired by drug companies to conduct their clinical trials, and with the vulnerable people who are paid to be human subjects in these trials.
Elliott asks, “What happens when both parties involved in a drug trial see the enterprise primarily as a way of making money?” He tells the story of SFBC, the CRO that once ran the largest drug-testing site in North America. Located in a former Holiday Inn in Miami, and since closed by Miami-Dade County for fire and safety violations, it had 675 beds, some of them occupied by undocumented immigrants participating in drug trials under what Elliott calls “ethically dubious conditions.” A commercial ethical review board that OK’d the research was owned by the wife of an SFBC vice president. (If this sounds familiar, you might have read an earlier version by Elliott in the New Yorker.)
In his second chapter, “The Ghosts,” Elliott describes how drug companies hire medical education and communications companies to ghostwrite papers to be submitted to medical journals, then pay medical school faculty to sign them. According to Elliott, ghostwriting is not only common, but “probably close to the norm.” Ghostwritten articles might extol an existing drug, suggest off-label uses for it, or simply draw attention to a dubious medical condition (something like social anxiety disorder, for instance) for which a drug is in the offing. Most medical journals (although not Health Affairs) are largely supported by pharmaceutical money, and so, Elliott makes clear, they are not in a strong position to enforce authorship standards or otherwise bite the hand that feeds them.
The third chapter, “The Detail Men,” a version of which first appeared in the Atlantic Monthly, deals with the roughly 100,000 sales representatives that the drug companies send out to befriend doctors, wine and dine them, and ply them with gifts—and convince them to prescribe the company’s drugs, since the sales reps’ salaries and bonuses depend on it. But to be successful, sales reps can’t be too obvious. In Elliott’s words, “Drug reps pretend that they are giving doctors impartial information. Doctors pretend that they take it seriously. Drug reps must try their best to influence doctors, while doctors must tell themselves that they are not being influenced.” Nevertheless, Elliott correctly points out that “over the past twenty years, the evidence that gifts and payments have a profound influence on doctors has become virtually indisputable.”
The next chapter, “The Thought Leaders,” explains how well-known faculty members from prestigious medical schools are courted by drug companies. For the industry, they end up becoming the best sales reps of all. Called “key opinion leaders” (KOLs), they have influence far beyond their numbers in determining which drugs are prescribed and under what circumstances.
Their influence is exerted by word of mouth, through the papers and textbooks they write, their talks at professional meetings and continuing medical education courses, and their service on company speakers’ bureaus. Drug companies pay them very well. Elliott cites a study showing that the industry spends just under one-third of total marketing outlays on KOLs. If true, that’s an enormous amount of money.
Disclosure is not the answer to these conflicts of interest, Elliott believes, since “doctors get to keep accepting industry money; the drug companies get to keep giving it.” In fact, he writes, “asking KOLs to reveal their industry ties is not that much different than asking them to reveal their honors and prizes.”
The fifth chapter, “The Flacks,” concerns the vast public relations industry devoted to expanding markets for prescription drugs while making it look like education or public service. Some of the biggest advertising agencies in the United States also own CROs and medical education and communications companies.
According to Elliott, one of their principal activities is persuading doctors and the public that an illness is underappreciated and undertreated. They write articles to that effect, recruit KOLs to help, sponsor public events to promote awareness of the disorder—such as National Bladder Health Week—and pay celebrity patients to talk about how the condition affects their lives. In 2000, for example, the supermodel Lauren Hutton was paid by Wyeth to talk about hormone replacement therapy in the guise of spontaneous conversations about her life.
Moreover, according to Elliott, “virtually every patient advocacy group in the country relies on industry support.” He mentions the National Alliance for Mental Illness (NAMI), which in recent years received two-thirds of its donations from the pharmaceutical industry.
Finally, in his last chapter, “The Ethicists,” Elliott talks about his own piece of the profession: biomedical ethics. Drug companies have begun to hire ethicists as consultants, and Elliott fears that his field is being coopted by an industry that hires ethicists mainly to improve the industry’s image. “What is unclear,” he says, “is whether hired ethicists actually have the power to stop unethical actions. Do they modify company policy in a meaningful way, or are they hired to make selling easier?”
So what can we conclude from Elliott’s book? Medical journal publications might be trustworthy, but maybe not; medical school faculty might be disinterested, but maybe not; practicing doctors might prescribe drugs on the basis of scientific evidence, but maybe not. And as Elliott says, “We have constructed a medical system in which deception is often not just tolerated but rewarded.”