Microsoft word - selling sickness.doc

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.

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