Selling Sickness: Trying New Drugs

Notes on Selling Sickness (2005) by Roy Moynihan and Alan Cassels

Selling Sickness explains how pharmaceutical companies establish diseases in order to sell treatments (drugs). In some cases, the treatment helps. In others, it may hurt. In most cases, it’s not clear at all who benefits from feeding millions of First World consumers all these drugs.

The book positions itself as controversial, but I don’t agree. Almost everything they describe is plainly true. Large corporations are trying to make money and will push as far as they can, including some level of regulatory capture. I don’t think anyone disagrees with this. What might be controversial, however, is the way we regard this situation. The authors resort to dramatic rhetoric about fear-mongering corporations, helpless victims, and the brave few who will stand for truth. Here, I’ll summarize their claims and offer my own, less dramatic take.

Constructing “Conditions”

Although there could be other ways to think of health, the contemporary pharmaceutical industry has learned to sponsor the construction of a condition, encourage doctors to find it in many patients, and link it in everyone’s mind with a treatment (xii). They aim to “create an inextricable bond between the conditions and the drug. And it works. Think ADD and you think medication” (74)

How do they do this?

Winning Buy-In from Doctors

Companies offer plum consulting gigs to doctors who will play ball (tow their line), and have been very successful in encouraging research activity around certain conditions to get them to develop the way they want. For example, by sponsoring a conference on ADHD, a company can develop a condition to get it included in the DSM or classified as a particular type of problem, such as a neurotransmitter problem. This book is full of excellent examples, including that 8 of the 9 experts who wrote the (then current) cholesterol guidelines for the US Federal Government also served as paid speakers, consultants or researchers to the world’s major drug companies.

To me, this sounds like regular life. In many professions, it becomes difficult, after a certain point, to raise your income by doing better at your job, and it becomes interesting to find other opportunities related to your main gig. I imagine doctors get lots of offers for side gigs, and this is probably one of the less sketchy things you could go for. At the same time, the impulse from the pharmaceutical industry is pretty normal: get your issue on the map so you can sell a solution to a problem no one cared about before. Beauty products are most infamous for this kind of marketing, stirring up worries that they alone can solve, and yet it is normal and legal. I asked a skin care specialist one time what happens if my skin gets so dry it cracks and she told me the disappointing truth: nothing.

By the most ideal standards of medicine, however, the influence of pharmaceutical marketing tends to push conditions along towards legitimacy faster than is reasonable and tends to get drugs to the market a bit fast too. The authors did not present evidence that this pace is dangerously fast, but it’s a great point that the corporate influence does not encourage patience, rigor, exploring alternatives, or rethinking older conditions. Just making new ones to sell treatments for.

Osteoporosis is a good example the book spends a chapter on. The group that defined the term for the World Health Organization “decided that ‘normal’ bone density was the bone density of a young woman (a thirty-year old) — a definition that…automatically defined 30 percent of all post-menopausal women as having a disease” (142). I believe the authors here are betting that most of their readers are considerably over 30 and will be shocked. But I can see the sense in which it is reasonable. Regardless of age, any biological system that becomes dangerously weak should be strengthened. Research does not support the idea that thinner bones around the age of menopause correlate with later fractures, but the concept of osteoporosis lives on (145–147). Overall, though, this seems like a deeper question that the group quickly moved past in order to define a new condition that then could be treated.

In addition to developing the field overall, pharmaceutical companies also work on relevant doctors from early on to get them to diagnose a particular condition more often and to prescribe a particular treatment more too. Companies use “detailers” who seek out doctors early in their career and try to win their favor by various clever means. Moynihan and Cassels mention “food, flattery, friendship — and lots of free samples” (22), but I’m sure the exact means are a moving target. You can demand regulation limiting what these detailers can do to influence doctors, but these are basically sales people willing to respect boundaries yet ready to push the envelope and listen to someone complain about their day, bring them some home made treats, invite prospects to fun events, or do whatever it takes to get the doctor thinking about a particular condition and a recommended treatment.

Passing the FDA

This is a whole can of worms, but the especially relevant part is that the current model for how a company gets the FDA to test their drugs is that they finance the test. This “user pays” model has effectively meant that the FDA is funded by the companies it is supposed to regulate, and so the agency has become pliant (19). This is simple regulatory capture and normal in most industries.

Marketing to The Buyers

Convincing potential buyers that they need your drug is a very different activity. For this pharmaceutical companies need to get people to believe that they should take new drugs.

Educational content marketing is key here. This phrase means convincing people of an idea by spotlighting credible, factual sources that happen to support your concept. Patient advocacy groups are critical here. A drug company gives money to a patient advocacy group (which may be partly organized under the direction of the drug company, but also has legit sufferers) so that the patients can meet up and play golf, talk about their condition, and eat sandwiches (61–73). The advocacy group provides real life sob stories to anyone in the press who needs compelling narratives to add color to a story on a related topic (“meet Johnny, a lifelong sufferer of condition X you never heard of but are now emotionally driven to read more about”). The patient is totally sincere; the advocacy group is on mission; the press get real stories; the drug company sells to an expanding market.

The authors point out that this kind of “education” is incredibly thin and horribly distorted. There’s no balance of facts presented, larger context, or invitation for critical thinking. I would compare it to the “education” offered by the Soviet Union in topics like history: learn this and act like you believe it. (Someone I knew who grew up in soviet Serbia said she never had any homework in a history class! It was just a bunch of stories to justify whoever was in charge now.)

Pharmaceutical marketing also often involves celebrities. Celebrities can say whatever they want, unlike a pharmaceutical company. The company hires a firm to find a celebrity who cares about a condition, then makes a deal for the celebrity to talk more about the condition in exchange for payment. This gets around FDA regulation and is very effective at reaching consumers (43). It reminds me of Jenny McCarthy’s role in the anti-vaxxer movement, wherein she can express any opinion with minimal regulation and many people listen. Others involved in the movement, such as Andrew Wakefield are much more constrained and can get in a heap of trouble for even implying the wrong thing.

Finally, the marketing budget includes direct to consumer advertising, which has quadrupled to $6 billion in the last twenty years.

The Nay-Sayers

Pharmaceutical corporations do meet resistance trying to construct new conditions. This book portrays such resistance in heroic terms, as a defense of rationality, science, and sanity. However, the authors’ description of the resistance should show you how slight the friction is on this great engine of drug distribution. Some of the charming rebels are doctors: “as physicians working in a federal government hospital, they never see drug company detailers, and they refuse offers of industry-sponsored speaking work” (11).

In other words, these challengers have no economic support for their side and are isolated from mainstream practice. The book points to several doctors who have tried to bring attention to this topic in terms of corruption and corporate interest, but it seems clear that they are not winning much ground and will ultimately serve just to limit this overall process from excess. (In other words, keep it running smoothly.)

There are points in “selling sickness” cycle that are vulnerable, but most of the mechanisms I’ve summarized so far seem quite secure. The marketers can fund research that supports ideas they would benefit from; the detailers can encourage doctors to use a treatment a bit more often; the consumers who have some symptom to complain about and want to upgrade their life are motivated to hear inspiring stories and try new drugs. Direct to consumer advertising could definitely go away and marketers would need an alternative. The rest sounds rather stable in our social moment, as long as the money keeps flowing.

The Money

The success of selling sickness has driven major increases in the cost of health insurance. The money to nurture new conditions, research new drugs to treat them, and get traction on the market comes from the pharmaceutical companies. Where do they get it? From sales. Think of the drug store counter: someone picks up drugs, makes a co-pay, and triggers a payment from their insurance to the pharmaceutical company. These transactions fund the creation of new conditions.

(Interesting aside: many have made a similar argument about the money spent buying illegal drugs as a contribution to street gangs who distribute it and the drug cartels that produce it. The parallel here is clear and I‘m pretty sure the impact of buying alcohol is much more benign, if considered in similar terms.)

When someone buys statins to treat their high cholesterol, they throw in some money and their insurance usually does too. The authors don’t go here, but what are the effects exactly of this spend? I’ll ignore the co-pay as that person’s choice and hope they are just buying drugs they want. I suspect that the insurance money is not a very good deal for society, because we are effectively all cross-subsidizing other people’s drug buys, and they may well be buying things they don’t need that won’t help them. Some things that are wrapped up in drug costs, and thus ultimately shared by everyone using this insurance, are

• the overhead of an insurance system
• the R&D to make new pills and develop new conditions
• the marketing budget

This contributes to higher premiums for everyone. I’m not mad about splitting the bill, but I do see that health insurance is functionally a barrier between the poor who can easily fall deep into poverty with a single medical problem and the rich who are immune because their health is “covered.” So “selling sickness” also means “making health care more expensive” which means “trapping the sick poor in poverty,” which sounds pretty bad.

Anyway, my point in this section was just that insurance is an important player in the whole phenomenon and that everyone who is insured is supporting “selling sickness” with their premiums.

Are Conditions Socially Constructed or What?

This section is a clarification that I find more important than the book, but you should skip it if you already know or don’t care.

Although Moynihan and Cassels imply that there is some underlying truth to whether a condition is “real” or not, I disagree. In their account, corporations are sponsoring the creation of new diagnostic conditions and therefore sketchy charlatans. In my account, our existing diagnostic conditions are equally constructs, and the real question is not whether a condition (such as “high cholesterol”) is fundamentally true, but whether it is helpful.

In my interpretation, constructing a condition or disease is not about lying. Like any scientific body, the medical establishment is constantly testing out concepts that group together observable symptoms with techniques for measuring things with ways of changing things. The goal is just to create a concept with some “validity,” which generally means it is robust enough to yield impressive, predictable results. When “scientists discover” prions or climate change or subatomic particles, it’s really the same thing. The working theory gains enough evidence that others working in the field try it out. They decide to take the theory seriously, test it in other conditions, assume it and build on top of it, compare it with other accepted theories, and try to make even better explanatory concepts.

Other people use these concepts to build technology, typically for revenue.

In the case of pharmaceuticals, the technology people (who make pills) and the science people (who decide there is indeed a condition the pill might treat) are not always aligned. Pharmaceutical companies have an interest in finding an alignment, and that is where Moynihan and Cassels think things have gone too far.

Selling Sickness: Negative Externalities

Moynihan and Cassels offer a few good arguments why we should not construct new conditions just to distribute treatments/drugs of questionable value.

First, the the fetishization of drugs as a silver bullet to a problem is bad because the drugs are not nearly as effective as other measures they may supplant. “To us, the implication is that smokers, obese individuals, or those who live a sedentary lifestyle can safely continue to smoke, remain overweight, or take little exercise, provided they take medication to reduce their cholesterol values” (15). To the extent you can demonstrate a tradeoff between taking drugs and doing other things that help, this is a compelling argument. (For anyone who can remember Ivan Illich’s Medical Nemesis, which is a really far out book, he considers any medicalized “condition” to be a distraction from specific social conditions causing symptoms. I found this pleasing because I almost never see anyone cite that old priest’s medicine book!)

Second, new abstractions of health may be less robust than the older concepts they rethink. For example, statins treat a new concept of health: “high cholesterol levels are bad.” But the older abstraction is that you want to avoid “heart disease” and “stroke.” The authors see “heart disease” and “stroke” as much more solid abstractions than “cholesterol level” and so argue that the newly minted conditions are often less robust concepts than those they effectively replace. In the case of cholesterol, their point is quite strong: pills designed to reduce cholesterol have “a small and, clinically, hardly relevant improvement” (14) because they only change the cholesterol level but not the rate of heart disease or premature death. Another example is “high blood pressure,” which is often treated as a condition itself when it should probably just be seen as an indicator of other conditions. The authors point to research showing that this indicator is so finicky it should not even be measured by doctors, because the reading you get from a patient is so biased by the circumstances in the clinic.

This issue of “bad abstractions” means that the new treatments may be less effective than you’d expect, which is bad, and this is because the condition itself is not well formulated, which means medicine would be working with worse concepts/conditions than it should, which is also bad. I’m all for new diagnostic categories and conditions and scientific concepts, because I think this is how you get cool new ideas like “germs” and “vaccines,” but to the extent the current process is giving us poor ones, real progress may well be slowed even though apparent progress is up.

Third, the authors argue that medicine should be for the sick poor and not the rich well. In other words, industry should focus on those who most need products rather than those who can pay for them. Or maybe they think of this as a specific moral imperative for medicine, and so I assume they are also against cosmetic surgery, elective procedures, and serious veterinary work for pets. They write, “getting cholesterol down in the West, while not treating those dying of AIDS in African nations is just obscene” (17). This is a nice sentiment and certainly offers the moral high ground, but is meaningless in my book. The automobile industry should also make cars for poor people and teachers should focus their efforts on those worst at learning, rather than those best at learning where they usually compete to be. If there was more to this point than empty moralism, I’d be more interested.

The case of legal speed is particularly interesting here, as the entire “adult ADD/ADHD” condition can be seen as a way to permit some people to get all the speed they want and use it daily. “[T]he elephant in the room in this story is the fact that amphetamines like Ritalin can have positive effects on attention and focus not only for kids or adults diagnosed with this disorder, but for virtually everyone — even horses — ” (78). So being mad at adults for medicalizing their life challenges and getting speed makes some sense when you assume that medicine is for people with more serious life challenges.

Fourth, some drugs have bad side effects. The examples here are not devastating, but certainly some drugs have been recalled and some are not that great. Statins (for cholesterol) are particularly guilty of race but nasty side effects (18). Generally, the business will have to face these impacts directly and it seems the users are taking risks that should be explained to them by their doctor. I think that, if this book were written today, it would have focused more on Fentanyl and opioid abuse, which are also progeny of the pharmaceutical industry, but not related to creating new conditions. They are just hella dangerous pills sold to treat old, well-established conditions.

What’s Next?

I wish the market dynamics explained in this book were easier to understand. I wish it were more obvious when someone suggests you have a disease and could get drugs for it that there are downsides. I wish the public could decide to stop funding the condition of new diseases tailor-made for specific drugs and spend the money on bike lanes, women’s shelters, and education.

But this seems unlikely! Instead, the trend will probably continue with new frontiers in genetic pre-dispositions, where companies can sell drugs to people who are not even experiencing symptoms but may be at slightly higher risk in an actuarial table! Ideally, some of these will be legitimate and new disorders in the latest DSM include Irritable Bowel Syndrome, Hoarding Disorder, and Internet Gaming Disorder.

The best of medicine is still sanitation, vaccines, and clean water. But there are a lot of add-ons and features that work wonders in some cases. As humans continue to experiment, we get the system that capitalist democracy affords, and selling sickness seems to be it.

If you have been diagnosed with a condition that was established and publicized to sell a treatment, the good news is that someone with your symptoms 100 years ago would just have ignored it! So fuck it! The other good news is that 100 years from now, there might be a treatment that really works or the condition might be revoked, like hysteria was in the 1950s! The bad news is that, in the meantime, you have to pay for pills that might not help. So I hope you enjoy them. It seems like most people are game.