Pharmageddon

Pharmageddon

David Healy

UNIVERSITY OF CALIFORNIA PRESS
Berkeley   •   Los Angeles

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University of California Press
Berkeley and Los Angeles, California

© 2012 by David Healy

Library of Congress Cataloging-in-Publication Data

Healy, David, MRC Psych.

Pharmageddon / David Healy.
   p. cm.

Includes bibliographical references and index.
ISBN
978–0-520–27098–5 (cloth : alk. paper)
[DNLM: 1. Drug Industry. 2. Drug Utilization. QV 736]. I. Title.

LC-classification not assigned
338.4'76153—dc23

2011026063

Manufactured in the United States of America

20   19   18   17   16   15   14   13   12
10   9   8   7   6   5   4   3   2   1

In keeping with a commitment to support
environmentally responsible and sustainable printing
practices, UC Press has printed this book on Rolland
Enviro100, a 100% post-consumer fiber paper that
is FSC certified, deinked, processed chlorine-free,
and manufactured with renewable biogas energy.
It is acid-free and EcoLogo certified.

For over fifteen years I have been involved in
cases linked to injuries on drug treatment. This
book is for those who have survived to pass
their stories on, for the families who have been
left behind, and especially for those who have
struggled to put things right.

When she was a child I read Exodus

To my daughter     ‘The children of Israel…'

Pillar of fire

Pillar of cloud

We stared at the end

Into each other's eyes     Where

She said hushed

Were the adults

—George Oppen, “Exodus”

 

The new wood as old as carpentry

Rounding the far buoy, wild

Steel fighting in the sea, carpenter,

Carpenter

Carpenter and other things, the monstrous welded seams

Plunge and drip in the seas, carpenter,

Carpenter, how wild the planet is.

—George Oppen, “Carpenter's Boat”

Contents

Acknowledgments

Introduction

 

1. They Used to Call It Medicine

2. Medicine and the Marketers

3. Follow the Evidence

4. Doctoring the Data

5. Trussed in Guidelines

6. The Mismeasurement of Medicine

7. The Eclipse of Care

8. Pharmageddon

 

 

Notes

Index

Acknowledgments

I have accumulated so many debts it would take an ocean-going liner to accommodate everyone who should be acknowledged. Some of those to whom I am most indebted have been critics, a number of whom over the last decade have held open a forum for debate in which I've been able to test and discard ideas. Ocean-going liners have luxuries like showers and bidets. Over the past year I've given lectures on the subject matter of this book in several North American settings under the informal title of “The Shower and Bidet Approach to Medical Care,” as well as in Oslo, Uppsala, Bruxelles, Gent, and Milan, and I have Andy Scull, Joel Braslow, Ned Shorter, Cindy Hall, David Antonuccio, Masumi Minaguchi, Tom Ban, and others to thank for this, and much else. Joanna Le Noury, Margaret Harris, Stef Linden, Tony Roberts, and other colleagues in North Wales have helped supply the data for many of these talks.

It takes a lot to divert an ocean-going liner off course. Not so for a carpenter's boat like George Oppen's, where staying within the harbor walls seems advisable. There is a much smaller number of people to whom I owe particular debts who might fit on such a boat. These include Charles Medawar, Andrew Herxheimer, Vera Sharav, Annemarie Mol, Steve Lanes, Kal Applbaum, and Dee Mangin, who will see the beams they have contributed here but may feel they have been monstrously welded to the wrong seams, in which case they more than anyone are likely to turn green at the gills once the boat ventures out beyond the harbor mouth.

Far from getting outside the harbor, at one point it looked like the boat would never float, but Jonathan Cobb came to the rescue through wonderful editing. Rather magically he showed me how to write the book I thought I'd written. Bev Slopen, my agent, and Hannah Love, my editor, have also had to keep faith through some tricky moments. And finally Sarah, Helen, and Justin have had to put up with a lot, including “sibling” rivalry.

Introduction

My father smoked all his adult life. He had a number of physical disorders, including ulcerative colitis, ironically one of the few conditions for which smoking is beneficial. In 1974, when he was in hospital for colitis, a routine chest X-ray revealed a shadow on his lung. Dr. Neligan, the surgeon called in, advised my mother on the importance of an operation.

Our general practitioner at the time was Dr. Lapin, whom I remembered from childhood as being tall, silver-haired, and distinguished, often wearing a bow tie. He had spent time, I was told, as a doctor in the British army, a very unusual occurrence then in Ireland. To a child, Dr. Lapin had appeared effortlessly wise and seemed to transcend the boundaries of religion, politics, and division I saw elsewhere.

When my mother developed problems in the early 1960s after giving birth, Dr. Lapin had suggested she come to see him once a week, but at the time she felt the arrangement was too open-ended, and she could not afford it. She was seen instead by another doctor, diagnosed with an ulcer and ultimately received the standard operation of the day, which involved cutting the vagus nerve and partial removal of stomach. This left her with bowel problems for the rest of her life, and regrets for not having taken Dr. Lapin's offer of treatment for what she later regarded as postnatal depression.

When my mother consulted him about the wisdom of an operation for my father, Dr. Lapin was slow to comment. But when pressed, he pointed out that my father had a number of illnesses, any of which could kill him before the tumor would. Many people, he said, went to their graves with cancers, heart disease, or other problems, but these were not what killed them. An operation would take a heavy toll on him.

My mother relayed this perspective to my father and suggested that he take six months to build himself up and then have an operation if he felt stronger; he agreed. When this plan was mentioned to the surgeon, he responded, “That's fine, but have him out of the hospital within 48 hours.” When my mother revealed that my father still didn't know he had a cancer, the surgeon went straight from the phone to tell him. Without an operation my father would be dead within months, Dr. Neligan indicated, but an operation offered the prospect of a cure. My father, alarmed, agreed and the operation took place two days later. Dr. Neligan afterwards said there was little they could do about my father's tumor when they opened him up. He died six months later, his life almost certainly shortened by the operation.

If there had been progress to speak of in the treatment of lung cancer in the years since my father's death, his medical care might be viewed as one of those sacrifices that at least ultimately benefits others. But there has been little progress, even though advances on almost all medical fronts are trumpeted daily. Genuine progress has been made in some areas, but far less in most areas than many people have been led to believe. More importantly, when it comes to pharmaceuticals in particular, many of these apparent advances underpin and contribute to what in recent decades has become a relentless degradation in medical
care
, a replacement of Lapins with Neligans, a quickening march toward Pharmageddon. While drugs played no part in what happened to my father, they have played a huge role in fostering a surgical attitude to medical care, a kind of fast healthcare.

My father's illness came just as I entered medicine, seventy years after a momentous change in Western clinical practice. Around 1900, a series of new diagnostic measures, some based on blood tests, others linked to X-rays, and yet others involving the culture of sputum or urine samples for bacteria, enabled physicians to distinguish among many diseases and find remedies for some of them. Before this, the diagnosis patients got was based on how they looked and what they said about themselves when they walked through the door of a doctor's office—if they were weak and tired, they had “debility”; if they were wasting, they had “consumption.” If they were diagnosed with a tumor, it was because it was visible or could be felt; if they had diabetes, it was because their urine had a distinctive smell. With the development of new tests, however, the diagnosis only came after a blood test or X-ray confirmed what was wrong, perhaps weeks after the visit to a doctor's office or admission to hospital. And the tests revealed new conditions such as heart attacks and duodenal ulcers. Among the states of consumption, it became clear some stemmed from tuberculosis, while others did not.

A new breed of physician and hospital emerged. In Boston, Richard Cabot was celebrated for his diagnostic acumen, and the reputation of Massachusetts General Hospital in the early decades of the twentieth century began to soar on the abilities of its physicians, aided by their new technologies, to get the diagnosis right, which, it was presumed, would lead to better medical care. But others were concerned. Alfred Worcester, a professor of hygiene and prominent Massachusetts physician, who was later lauded as a father of both modern geriatrics
¹
and palliative care,
²
lamented that “the demands of modern diagnosis diverted doctors away from developing and exercising their traditional knowledge of human nature.” Worcester was troubled that the new testing requirements for making a diagnosis would alter a doctor's interactions with his patients. Absorbed in the new technologies, doctors would lose their ability to have an ongoing therapeutic influence over their patients.
³

Good medical care, we might imagine, should manage to embrace the visions of both Cabot and Worcester. The new techniques after all made a great difference in our ability to help patients, and while humane medical care is wonderful, most people would regard a cure as excellent care even if they don't much like the doctor. Patients in the early twentieth century voted with their feet and sought out the new generation of specialists. But as my father's case illustrates all too vividly, there is a balance to be sought between caring and attempts at curing, and this balance is particularly important in the many instances where cures aren't possible.

Early concerns that medicine might lose its caring soul in exchange for earthly cures were sidelined in the 1940s and 1950s when a host of new life-saving treatments came onstream. While there were also great surgical advances, culminating in the dramas of the first kidney and heart transplants, the key breakthroughs occurred in the pharmaceutical domain. In addition to offering cures in their own right, new drugs like the immunosuppressants and antibiotics laid a basis for developments in surgery and other areas of medicine.

Despite these wonderful breakthroughs-indeed, some critics thought in part because of them-concerns about medical specialism reemerged in the 1960s framed in terms of medicalization. Concerned observers argued that we were ceding too much power to a medical establishment engaged in pathologizing huge swathes of daily life and not equipped to take it upon themselves to define what it meant to be human. The most powerful critique of medicalization came from the Austrian philosopher, Ivan Illich, in his book
Medical Nemesis,
⁴
published in 1975, the year my father died.

In retrospect, the mid-1970s can be seen as close to the acme of medicine's ascendancy. The pharmaceutical industry was still at this point a junior partner to the medical establishment. But as roles have shifted and the power of drug companies has become more apparent, references to medicalization since the mid-2000s have begun to be replaced by references to pharmaceuticalization, which increasingly sees our identities as a series of behaviors to be managed by drug use.

Then in 2007, Charles Medawar, Great Britain's leading healthcare consumer advocate, raised the prospect of something beyond pharmaceuticalization: “I fear that we are heading blindly in the direction of Pharmageddon. Pharmageddon is a gold-standard paradox: individually we benefit from some wonderful medicines while, collectively, we are losing sight and sense of health. By analogy, think of the relationship between a car journey and climate change—they are inextricably linked, but probably not remotely connected in the driver's mind. Just as climate change seems inconceivable as a journey outcome, so the notion of Pharmageddon is flatly contradicted by most personal experience of medicines.”
⁵

By “Pharmageddon,” what Medawar and colleagues (myself included) had in mind was something quite different than a simple pharmaceuticalization, where we talk about our neurotransmitters rather than our moods, a biological reduction of secularism.
⁶
Pharmageddon refers not to a change in the language of medicine or a change from religious to biological language, but to a process that was deployed in the first instance in the belief that it would better enable us to care for each other, though now it is a process that seems set to eliminate our abilities to care—a fate that beckons in spite of what everyone wants. At the heart of this process is the turn toward quantification in the middle years of the twentieth century. While genuinely helpful, this turn gave healthcare a set of scientific appearances that a handful of shrewd advisors and marketers have been able to manipulate to infect our abilities to care as if with a clinical immuno-deficiency virus (CIV). As a result the defense reactions that we might expect from prestigious journals and professional bodies just don't happen. Indeed the virus seems to have been able to subvert these bodies to its own purposes, so that when critical comments are raised they have reacted almost as though it was their programmed duty to shield a few fragile companies from the malignant attentions of a pharmaco-vigilante.

PHARMAGEDDON UNFOLDING

Since the 1970s, a profound change has been occurring both in the nature of the drugs marketed and in the practice of medicine. New drugs, like the statins, have continued to appear as have new diagnostic tests to measure, for instance, our cholesterol levels, apparently in the tradition of testing that led to so many medical advances in the early twentieth century. But where previous drugs and tests were geared toward the diagnosis and cure of diseases that posed an imminent risk to life, now medical practice is increasingly geared to chronic disease management with drugs that modify risk and lifestyle factors rather than save lives. This is a post-Worcester and post-Cabot world, in which pharmaceutical companies sell diseases rather than cures.

On the surface medical practice appears the same but underneath it's not. For instance, a small number of people have a genetic disorder that leads to excessively high cholesterol levels and for them drugs like the statins can save lives, almost in the way that antibiotics or insulin saved lives half a century ago. The statins can also save lives among people who have had strokes or heart attacks and who also smoke or are overweight, but in this case hundreds of people have to be persuaded to take them for the rest of their lives in order for a handful among them to be saved. For the most part, however, the statins are instead given to healthy people who have mild elevations of their cholesterol levels. Similarly, treatments for asthma or osteoporosis are now given to many people who would never have been diagnosed and treated before. Treatment happens now in response to results on a series of tests that have emerged in recent years—but these new tests don't help make a diagnosis that will lift a threat to our lives. Instead they effectively make a diagnosis of some drug deficiency disorder, and they often enter medical practice as part of the marketing strategy for a new drug.

These new diseases and their treatments have gained a purchase on us because they are presumed to represent the latest advances in a story of progress that runs through insulin and the antibiotics and will hopefully lead someday to cures for cancer. These are the drugs that, had they been available, some presume might have saved many of my father's generation. But far from saving either their lives or ours, clinical trials show that the indiscriminate use of drugs to lower lipids or blood sugars, to relieve respiratory wheeze, or to block stress hormones may even increase the risk of loss of life,
⁷
and appear to be doing so in the United States, the country that makes the greatest use of the latest pharmaceuticals, where since the mid-1970s life expectancy has been falling progressively further behind other developed countries.
⁸

If you looked around a restaurant, cinema, or office thirty or forty years ago that had a hundred or more people in it, you could predict that 5 to 10 percent of them might have a medical condition—sometimes unbeknownst to themselves—and a trained doctor would have been able to spot many of them just by looking. If you look around the same restaurant or office now at the apparently healthy people, those a doctor can't readily spot as ill, chances are that 80 to 90 percent of them could be diagnosed with one of these new “disorders.” Almost all will have cholesterol, blood sugar, blood pressure, bone density, or asthma numbers or one of an ever growing number of “mental health disorders” for which a pill will be suggested. Unlike being diagnosed with a traditional medical illness, these people won't be diagnosed because they are suffering and take themselves to a doctor. They will be diagnosed because an apparatus will come to them, perhaps coincidentally when they are at their doctor's for something else, or perhaps soon to a supermarket near them, an apparatus that will show them that their “numbers” are not quite right. It is only then that they will begin to suffer, either because of their discomfort and fear following a diagnosis or by virtue of the very real side effects triggered by the new pill they have been put on, a pill which has been marketed as an answer for any of us whose numbers aren't quite right.

Recent books have attempted to diagnose what lies at the heart of our growing disquiet at what is happening to medical care.
⁹
These critical studies almost universally blame the pharmaceutical companies, who are now among the most profitable corporations on the planet and who, due to grossly inflated estimates of drug development costs and the emergence of blockbusters—drugs that gross at least a billion dollars per year—are supposedly making too much money. This money lets them buy lobbyists and influence, do a variety of things to turn the heads of doctors, as well as sponsor patient groups to lobby against attempts to limit in any way access to the latest high-cost treatments.