The anti-pharma industry industry

Yes, this is no typo. There is indeed a whole industry against the pharma industry. That industry generates revenue by bashing the pharmaceutical industry. Am I paranoid? Maybe. Maybe not. There was a time when I was regularly invited to speak on behalf of the pharma company where I worked. Even if it was in the evening, I liked the debate and the exchange of views with other stakeholders, but more often than not the debate was not about healthcare at all. It was about industry-bashing. The other speaker had typically written a book on medicines and pharma. They are mostly doctors. Their source of information? Not their day-to-day medical practice, but other books about the pharmaceutical industry, freely copying arguments, quoting and adding to it. My main activity during these debates was to counter all the attacks the industry got to endure. And often attacks were blunt and easy to counter. But there was little opportunity to discuss what really matters: how to improve research and healthcare for the benefit of patients. How to collaborate to move things forward. This was clearly never the agenda of the accusing party. No constructive dialogue. Only destructive disinformation.

Somehow it all started in 2004 with Marcia Angell's "The Truth About The Drug Companies", in which she accuses industry of every possible malpractice, from rigging clinical trials over hiking prices of non-effective drugs and using "its wealth and power to co-opt every institution that might stand in its way, including the US Congress, the FDA, academic medical centers, and the medical profession itself". In sum, everybody who is not Marcia Angell. Her arguments are questionable, often claims without evidence, and if evidence is to be found, the scientific value of her sources are also questionable (such as Public Citizen or mainstream media). Regardless, her book was a great success and very influential. It spawned an entire industry of books written by doctors or former industry executives (often with an axe to grind) : John Abramson "Overdosed America", Alan Cassels "Selling Sickness", Jacky Law "Big Pharma", Katherine Greider 'The Big Fix, How The Pharmaceutical Industry Rips Off Consumers", Irving Kirsch "The Emperor's New Drugs", David Healey "Pharmageddon" (which is a great title, by the way), etc. etc.

The interesting thing is that they typically repeat and repeat the same thing. Next, Angell's book not only gets translated, but is copied in original work by like-minded authors in other parts of the world. In Denmark, Peter G?tzsche writes "‘Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare’, in Germany, Frank Wittig publishes "Die Weisse Maffia" about the conspiracy between doctors and pharmaceutical companies to make you sick, J?rg Blech ("Heillose Medizin") and Bernd Hontschik "Patient im Visier: Die neue Strategie der Pharmakonzerne". Some are even hilarious fiction - although not intended as such - like the so-called Dr. Peter Yoda (also from Germany) "who will have to live the rest of his life underground" out of fear of the industry he accuses in "Ein medizinischer Insider packt aus" (when the author gets recruited by the shady company running the world, this is the deal "Your starting salary would be US $150 million with a commission possibility which could bring it to over a billion dollars one day. Your first job would be for the American government and you could start on it tomorrow" ... very credible indeed). In Sweden you have John Virapen ("Side Effect: Death") and in the US also Peter Rost (both fired by their respective pharma companies, and exposing alleged malpractices after they left). In France you have Bernard Dalbergue "Omerta Dans Les Labos Pharmaceutiques", Antoine Béguin "Effets Secondaires: Le Scandale Fran?ais"; Nicolas Chevassus-Au-Louis "Malscience: De La Fraude Dans Les Labos". In Belgium we have Dirk Van Duppen with "De Cholesteroloorlog". Etc. Etc. It's probably the same in Spain, Italy and other countries. They all share the same arguments, the incredible generalisations, only using evidence that supports their narrative, etc.

And then of course there is Ben Goldacre with "Bad Pharma", a book which was for sale in every airport bookshop in the world during its year of launch (at least I saw it wherever I travelled). A huge sales success. And like all the other books, it does not care about facts or evidence. It makes all the methodological mistakes that he accuses the industry of (omitting evidence, making claims without evidence, jumping to conclusions, and even misrepresenting data from scientific publications). The interesting thing about Goldacre is that I fully agree with his recommendations for more transparency in clinical trial results. He also managed to create the All Trials campaign which forced industry to become more transparent. Good for him (and us). But did it really require so many false accusations and disinformation? Did it really require Goldacre to violate all the principles of the integrity of the scientific method which he advocates for?

Ok, here is an example to avoid being accused of doing the same. Early in the book, Goldacre writes about industry-sponsored trials resulting in too many positive results: "three researchers from Harvard and Toronto found all the trials looking at five major classes of drugs (…) then measured two key features: were they positive, and where they funded by industry? They found over five hundred trials in total: 85 per cent of the industry-funded studies were positive, but only 50 per cent of the government-funded trials were. That’s a very significant difference”. But then you check the source, published in the Archives of Internal Medicine, and what do the authors conclude? This : "Among 546 drug trials, 346 (63%) were primarily funded by industry, 74 (14%) by government sources, and 126 (23%) by nonprofit or nonfederal organizations. Trials funded by industry were more likely to be phase 3 or 4 trials (88.7%; P< 0.001 across groups), to use an active comparator in controlled trials (36.8%; P = 0.010 across groups), to be multicenter (89.0%; P < 0.001 across groups), and to enroll more participants (median sample size, 306 participants; P < 0.001 across groups). Overall, 362 (66.3%) trials had published results. Industry-funded trials reported positive outcomes in 85.4% of publications, compared with 50.0% for government-funded trials and 71.9% for nonprofit or nonfederal organization-funded trials (P < 0.001)". So Goldacre 'forgot' to mention that most industry trials were phase 3 and 4, which is significant in the context of getting positive results, but he also fails to mention that not-for profit research funders got a 71.9% positive response. He also fails to explain the difference in the need to publish between industry and public researchers. By any measure, all this is disinformation. And it will be hard to deny that it's not deliberate. My point here is not to write a review of "Bad Pharma", but there are dozens of examples like this, with possibly the worst one his 50-page chapter of how clinical trials can be manipulated ("a common dark practice"). A great overview of 15 'possibilities' of fraud, offering only suggestive 'evidence' for 11 trials since 1990, of which only 2 happened after the year 2000, and then he concludes : "So, we have established that there are some very serious problems in medicine (...) These problems are frighteningly common". My oh my ... so much for intellectual integrity.

Obviously I have not read all those books, but at least some of them, and thorougly, with my iPad in hand to verify the sources they mention. It is shocking how little scientific integrity these authors demonstrate. It's all about effect and scandal. And the content is always the same, often using the same references, or replicating what others have written without even verifying whether it's correct or not. Of course, it is their right to accuse the industry, and of course many industry practices begged for this kind of book industry. Industry is its own worst enemy, and will probably continue to be that for quite a while. On the other hand, because of their exaggerations, unsubstantiated claims and misrepresentations, most of these books are unethical themselves. Their objective is not to inform people. Their objective is to sell.

There is no value in this kind of publications. It does not help patients any further. Quite to the contrary, it creates distrust, it gets replicated by the Church of Scientology in their war against psychiatry, it gives ammunition to the lunatics of the anti-vaccines movement. It is the primary source of information for some politicians and journalists who do not read scientific publications, and hence results in bad policy-making because they trust these authors. It creates a strong foundation for populists to clean up imaginary swamps. It polarises the different actors in their dialogue. Many of the arguments that were originally used by Angell pop up time and time again in conversations with policy-makers and payers, and they need to be countered again and again with the real and latest statistics in hand, but as every psychologist and communicator knows: once a thought is engrained in the brain, it's very difficult to change it, even with obvious evidence. These books create memes that pollute constructive dialogue.

Facts matter, regardless from whom they come. And so is their correct interpretation and representation.

And the worst thing is that the pharma industry never reacts to these books. Individual companies won't because they don't want to end up owning the debate. Industry associations won't because they don't want to give these authors a platform for further exposure and communication. And both arguments are right. In the short term, at least.

It is a business. This industry-bashing is an industry in its own right. Apart from all the books that are being published, the authors are part of the lecture circuit, organised by NGOs, sick funds and patient organisations. As as speaker, you get a few hundred euro for time and effort. As an author, you can ask for money to be interviewed.

Once the evening panel discussion is over, the author rushes to the exit, where a table is set up with piles of his books. People leave the meeting room and they can buy the books, signed by the author. I ask him how often he does evenings like this one. Oh, he says, three times a week on average. Indeed, an industry in its own right.