Selling sickness The business, the actors, the procedures There is a confluence of interests among pharmaceutical corporations, supposedly independent scientific institutions that lead the market, individual doctors whose role becomes more and more important as well as their income. Even patients associations are often supported with the funds of the pharma industry. Marco Bobbio Head Cardiologist in Santa Croce and Carle Hospital, Cuneo The term “disease mongering” means literally the selling of sickness and it was used for the first time in 1992 by the physiologist and medical journalist Lynn Payer (1945-2001) who became famous when she published her first book in 1988 “Medicine and culture”1 where she critized medicine for focusing its interests around scientific proofs and neglecting the non repeatable singularity of the individuals. In her following book “Disease mongering” Payer developed a further reflection affirming that since it is not easy to distinguish normality from pathology, doctors, pharmaceutical companies and medical diagnostic industry were extending the diagnosis criteria in a way to increase the demand for services and products. These phenomena that can now be observed by everybody was anticipated by Payer’s description on how the system was implemented in three steps: 1) transforming common complaints into medical problems, 2) making them look dangerous and 3) proposing therapies whose benefits are highly praised while their risks are underestimated. By doing so enormous economical resources are then removed from the treatment of people who are really ill to a larger mass of people that are not sick. The author comments with irony that it is really a big business being able to convince substantially healthy people that they are a little bit sick or slightly sick people to be seriously ill2. Since the concept of disease is fluid it is possible to induce the demand for treatment and assistance by including among the “unhealthy” the largest number of subjects. At an earlier time, in 1976, the Russian philosopher, theologist and historian, Ivan Illich had focused his attention to the medicalization of society. His book “Medical nemesis: the expropriation of health” formed a generation of physicians and intellectuals. In Medical Nemesis3 Illich talks about the Greek Nemesis, the divine vengeance reserved to those mortals who had usurped prerogatives that gods claimed jealously for themselves. Nemesis is the answer of nature to hubris, to the individuals’presumption of trying to acquire characteristics belonging to the gods. Our modern hubris healthcare has determined the medical nemesis. Illich provided much data to rethink the premises of research and clinical practice criticizing the lack of a global vision and dreading a world set on to study more and more limited aspects of health and disease. There is a rich literature flourished in recent years which brought to the attention of a large public other examples and convincing proofs. Thomas Szasz4, a psychiatrist from New York, questioned the fact that mood disorders and social malaise are under the pharmacological control which he
considered as a new form of despotism. Jörg Blech5, a German scientific journalist, describes the methods used by pharma industry in order to medicalize the society. Ray Moynihan, a British scientific journalist and Alan Cassels, a Canadian researcher, had a great impact with their book6 “Selling sickness; how the world’s biggest pharmaceutical companies are turning us all into patients”. They report how anxiety and depression as a real disease concern only a small percentage of the population but are now diagnosed and treated in thousands of people Some risk factors such as blood cholesterol, blood pressure or bone density are now considered as real pathologies that need drugs. Last, the British journalist, Jacky Law7, reveals how the search for profits does not coincide anymore with health care but is a gigantic machine where marketing determines what needs to be studied and induces the needs for drugs. Mrs Law declares that there is a tendency to neglect the human aspect in the physician role (with the wisdom, consolation, encouragement it involves) to promote instead the technical aspect of it where the industry exerts a bigger control. Confluence of interests. In many fields of medicine there is a confluence of interests among: -the company producing a drug (similar examples can be found also in the propaganda for diagnosing surveys, prosthesis and medical devices), -the scientific societies that take advantage of the opportunity to be more visible and lead the market with a supposed independency, -the single doctors whose role (and sometimes their income) becomes more important, -the patients associations which are often financially supported in a direct or indirect way by the pharmaceutical corporations themselves. In nowadays informatic era websites are more and more important. Some of them are set up by societies which are financially sustained by drug companies. Usually they do not advertise openly any pharmacological therapy: the trick would be immediately unveiled. Duglas Ball, director of the Department of Pharmacy of Kuwait University, investigated the link between websites and patients associations. He analyzed the form of advertisement and the financial support of 69 organizations8. Only 4% of the websites reported the conflict of interests. Only one third reported the source of financing and in very few cases the donations were listed in detail, whereas a third of the websites displayed the logo of a pharmaceutical firm or the link to access to the company information. It is because of these characteristics that these “educational” programs focusing on a single pathology allow wide synergies (both horizontal and vertical) among the actors of the entire healthcare line: suppliers of services and assets, operators, patients representatives. For all these people the sale of disease is by itself valuably interesting because of its potential of economic as well as professional carrier development even beyond the activities that are directly sustained by the industry. Each nosological entity with market potentialities triggers an alliance at a global as well as at a local level so that the campaign originally planned by the marketing experts multiplies almost spontaneously in an endless number of streams.
From complaint to disease Roberto Satolli, cardiologist and scientific journalist, has summarized which are the premises to turn a complaint into a disease. He has identified that the script is carried out in 4 steps (with very little variation) once it is outside the scientific world and it is addressing to a large public9. Providing numbers. The first step is to impress the reader by focusing the attention on the number of people affected by a certain ailment. The order of magnitude is of many millions even if the data are often unascertainable. Arousing anxiety. The following step is to emphasize the seriousness of the ailment and generating fear for its negative effects on health, wellbeing, work, social relationships. Persuading to do medical tests. Later on, advising to undertake a long series of clinical examinations: questionnaires in order to understand whether one is ill, medical visits to find the illness, medical or surgical interventions. Other examinations, other therapies. Minimizing the disease. Finally ending with a reassuring message:” do not worry, there is a pill that will take care of it”. Usually this system is very effective. It induces a real epidemic of diagnosis spreading the idea that more diagnosis means more well-being while in reality it begins an epidemic of medical treatments as stated by Gilbert Welch10, Professor of Medicine and Community and Family Medicine in Dartmouth. Fashions If we try to analyze which are the themes presented in international and local conferences, in scientific or popular science magazines, as well as in articles of newspapers or polished periodical publications, we would find that there is a leading topic connected to the marketing launching pad and ready to be consumed. There has been a period of time in which the big theme was sexual impotence: placards on cities’ walls, luring posters in pharmacy stores. Sessions on all congresses dealt with it: sexuality and the cardiopathic, sexuality and nephropathic, sexuality and the elderly, sexuality from the point of view of the family doctor. Since some years there has been the revival of a disease called metabolic syndrome which was already being discussed during the 50s. It catalyzed the attention of doctors with different specialties when the drug rimonabant was issued. It will be interesting to see if and how much of the focus on metabolic syndrome will fade in the next years after that rimonabant has been withdrawn from the market. There has been a period of great emphasis on the cholinesterase inhibitors for Alzheimer treatment. In Italy the associations of relatives of Alzheimer patients went into action to ask the free distribution of donezepil in spite of that fact that the evidence of its effectiveness was rather modest and not constant. Recently the doctors have been bombarded of information about the danger of a high cardiac frequency. The slogan “slower the better” opened the path for the sale of the first drug able to reduce heartbeats without having an impact on cardiac activity.
The phenomenon of selling disease prophesied by Illich and described by Payer has now become true in many clinical environments. It is this a phenomenon that involves us as doctors, researchers, teachers who are often unaware to vehicle messages that concern other parties, sometimes actors with an interest on it. Being able to reflect on these mechanisms allows us not to give up our professionality to passing fads, but to claim an independency of judgement in order to be able to find the better treatment for each of our patients. Notes 1. Payer.L. Medicine & culture. Notions of health and sickness in Britain, the US, England, West Germany and France Victor Gollancz, London 1989 2) Payer L. Disease mongers: how doctors, drug companies, insurers are making you feel sick. John Wiley and Sons, 1992. 3) Illich I. Medical nemesis: the expropriation of health. Marion Boyar Publisher, London 1976. 4) Szasz T. The medicalization of everyday life. Syracuse University Press 2007. 5) Blech J. Die Krankheitserfinder. Wie wir zu Patienten gemacht werden. Fischer, Frankfurt am Main, 2003/ Inventing Disease and Pushing Pill: Pharmaceutical Companies and the medicalization of Normal Life, Routledge Taylor & Francis Group< London and New York, 2006. 6) Moynihan R., Cassels A. Selling sickness; how the world’s biggest pharmaceutical companies are turning us all into patients, Vancouver/Toronto, Greystone Books 2005 7) Law J. Big Pharma. How the world’s biggest drug companies market illness. Constable and Robinson, UK, 2006. 8) Ball ED, Tisocky K., Herxheimer A. Advertising and disclosure of funding on patient organization website: a cross-sectional survey. BMC Public Health 2006;6:210-14 9) Satolli R. I mezzi di informazione sono strumento inconsapevole di medicalizzazione, consumi inappropriati e iatrogenesi? Cardiologia 2008. Atti del 420 convegno internazionale del dipartimento cardiologico. A. De Gasperis J.Medical Books Viareggio 2008:20-26 10)Welch HC. Should I be tested for cancer? Maybe not and here’s why. University of California Press. Berkely 2004.
Európakiállítás Eredmények Leeuwarden Hollandia, 2011. szeptember 1-4. Magyar eredmények EGY szuka, Ultimate Joy's Fake the Funk bull terrier T.: C. C. A. Maton, t.: Rebman György EGY szuka, Fajtagyőztes, Morgótelki Bella drótszőrű magyar vizsla T.: Fele Tibor, t.: Hámori Tibor EGY szuka, Luxatori Zeline rövid szőrű magyar vizsla T+t.: Hámori Tibor EGY kan, Fajtagyőztes, Bonett B
VITALIZE CHEMICAL PEEL ™ ( Formerly Precision Peel ) INFORMATION & INFORMED CONSENT Patients with active cold sores or warts, wounded, sunburn, excessively sensitive skin, dermatitis or inflammatory rosacea in the area to be treated should be excluded from the Vitalize Peel™ because the procedure could potentially precipitate a flare up or spreading. Inform the esthetician if yo