Quotes of the Day

Marcia Angell's latest book didn't turn out as she'd first imagined. Four years ago the Harvard academic started delving into clinical trials. But when her research uncovered disturbing goings-on throughout the realm of medicine, "I found," she says, "that all roads were leading to the drug companies." This wasn't the conclusion of an innocent who'd blundered into the field. A former editor-in-chief of the New England Journal of Medicine, Angell understood better than most the methods of big pharma, but she still thought the industry was dedicated to finding new medicines. She's now sure she was wrong.

About to be published in Australia and New Zealand, The Truth About the Drug Companies (Scribe Publications; 319 pages) is an unrelenting attack on the practices of the world's largest medicine makers, which Angell portrays as rich behemoths that have abandoned the once noble goals of their industry in pursuit of profit. It's hard to argue with the rich bit: according to the latest Fortune 500, U.S. giant Pfizer had revenues last year of $53 billion, of which $11 billion were profits.

The companies' typical response to complaints about the price of prescription drugs is to cite their huge research and development costs. This amounts, Angell writes, to a veiled threat: We make these drugs that save and improve your life - don't whine that they should be cheaper, because if they were we couldn't keep discovering new ones. But Angell argues that the industry not only exaggerates the costs of bringing drugs to market but spends much more on marketing and administration than on research, which it prefers to leave to government-funded scientists, intervening only when it smells a buck. Its main business, she maintains, is producing minor variations on existing drugs - renamed and repackaged but usually no more effective - and backing them with lavish campaigns aimed at convincing doctors and the public that a remarkable new drug is in their midst. "Once upon a time drug companies promoted drugs to treat diseases," Angell writes. "Now it is often the opposite. They promote diseases to fit the drugs." To create new markets, she argues, big pharma has been complicit in pathologizing a host of minor complaints. A spot of heartburn used to be a nuisance most of us put up without a thought of reporting it to our doctor. Now, writes Angell, it's called "gastroesophageal reflux disease ... and marketed, along with the drugs to treat it, as a harbinger of serious esophageal disease - which it usually is not."

Big pharma couldn't get away with a lot of what it does without help, says Angell, who describes a world in which researchers are all too eager to align themselves with industry in order to make money from their discoveries, and who accept industry funding to conduct, and interpret the results of, trials of drugs in which they may have a financial stake. Then there are the doctors who, seduced by the standard three-pronged charm offensive of drug company sales reps - food, flattery and friendship - respond by prescribing certain drugs with a frequency they wouldn't otherwise have contemplated. "Researchers are shameless in colluding with the drug companies in a lot of their shenanigans," says Angell from her home in Cambridge, Massachusetts - and for her that's the most demoralizing part of the mess. "In a sense drug companies are doing what investor-owned companies do - they're trying to maximize profits." But the medical profession, she says, "has fiduciary responsibilities to the public and it's letting its greed get in the way (of meeting them)."

All forms of the questionable conduct Angell describes have occurred in Australia and New Zealand, only on a smaller scale, says David Henry, professor of clinical pharmacology at the University of Newcastle and coauthor of the foreword to the Australasian edition of Angell's book. Just-published research in which Henry was involved suggests that a large portion of Australian specialists are "confident engagers" with industry, convinced that whatever largesse they receive doesn't affect their prescribing.

The newly redrafted ethical guidelines of the Royal Australasian College of Physicians urge members to refuse free drug samples and gifts. But working party chairman Paul Komesaroff rejects the notion of drug companies as out-and-out bad guys. Where Angell decries a grubby alliance between industry and many doctors, Komesaroff sees a complex relationship that needs to be untangled only partially, and with the greatest care. Angell, he says, is an "effective polemicist who's made an important contribution to raising these issues ... but there has to be an effective dialogue between industry and the profession because each depends on the other" to help patients.

Angell suspects that events may change industry practices before regulations do. The flow of new drugs is slowing to a trickle, patents on many blockbuster drugs are close to running out, and falling profits are being further eroded by legal costs incurred fighting allegations of dubious practices. Her hope is not that big pharma collapses, but that it returns to the business of trying to produce better medicines. For the companies, would that really be such a bitter pill to swallow?

• Daniel Williams
• An angry insider says drug giants put profit ahead of public health - and seduce doctors into helping them