Book Review

Is there a pill for greed?

The Globe and Mail, 11 September 2004

The Truth About the Drug Companies: How They Deceive Us and What To Do About It
By Marcia Angell
Random House, 305 pages, $34.95

When your aunt had depression 10 years ago, she took Prozac. When her son needed treatment a few years later, he got Paxil. Not long after, your friend was told by her doctor that Zoloft was the best pill for the job.

To some, this might seem evidence of the relentless march of the pharmaceutical industry to find new and better treatments for debilitating illnesses. But Marcia Angell, author of The Truth About the Drug Companies: How They Deceive Us and What To Do About It, sees it differently.

As a doctor herself and formerly editor-in-chief of the New England Journal of Medicine, a top U.S. medical journal, she argues that drug companies are simply not the innovative, risk-taking, entrepreneurial and virtuous powerhouses that they pretend to be. "This is an industry that in some ways is like the Wizard of Oz -- still full of bluster but now being exposed as something far different from its image," she writes. "Instead of being an engine of innovation, it is a vast marketing machine. Instead of being a free-market success story, it lives off government-funded research and monopoly rights."

Those three antidepressants are a great illustration. Prozac was the first of a whole generation of drugs known as selective serotonin reuptake inhibitors, or SSRIs. But in 2001, its patent expired. That meant generic companies could make the drug too, and the U.S. price fell by about 80 per cent. So Prozac's original exclusive makers, Eli Lilly, no longer poured money into marketing it for depression. (Instead, they were busy repackaging it in a lavender-and-pink capsule and touting it under a new name, Sarafem, for a brand-new illness, "premenstrual dysphoric disorder," under brand-new patent protection -- but that's another story.) By then, the makers of Paxil and Zoloft were eagerly promoting their "new" depression drugs.

Only, according to Angell, there wasn't very much new about them. They are what are known in the trade as "me too" drugs, because they're just variations on an old theme, not genuinely novel products. This is one of the reasons, Angell says, that drug companies lavish so much creativity and money on marketing: They need to convince you to spend several times more for a drug still under patent when a generic version might do just as well.

You wouldn't be alone in believing, for instance, that Paxil is the preferred treatment for anxiety. But the truth is that drug companies get exclusive marketing rights simply by testing out their product against a placebo and showing that it works better than nothing at all. (And they often have trouble making even that meagre claim.) The danger of comparing your new drug with drugs already on the market is that they may not be better, and they could be worse -- as was the case in 2002, when a public study compared blood pressure medications. It found that the older, cheaper diuretics were better than the new, and very expensive, ACE inhibitors and calcium channel blockers.

According to Angell, between 1998 and 2002, of 415 new drugs approved by the U.S. Food and Drug Administration, only a third were both new chemical entities and promised a "significant improvement" over available drugs. What's more, most of those new and useful entities were developed not by big pharma, but as a result of government funding through the U.S. National Institutes of Health. These days, at least a third of big pharma's drugs are purchased from the outside, Angell says.

Many of Angell's stories are unsettling. It made me uncomfortable to learn, for instance, that doctors are financially induced to enlist patients in clinical trials. Collecting data for trials does incur some costs, but she says the average "bounty" is about $7,000 per patient; in at least one case, physicians were paid $12,000 a head and $30,000 on the enrolment of a sixth participant. Drug companies also pay to have their reps shadow doctors as they go about their daily work: performing surgery, conducting examinations, dispensing medical advice. Often, the patients are allowed to believe company reps are medical professionals. (We know this because one duped patient sued.)

Angell also describes how top media personalities accept six figures for a day's work on what she calls "stealth ads," which are given away to TV stations and aired as "news breaks." Particularly unpalatable was the revelation that drug companies test blockbuster drugs on kids just to get the extra patent protection for doing so, even if the drug -- say, for high blood pressure -- has little relevance for the pediatric population.

Drug companies insist they couldn't do cutting-edge research if prices were lower. But that simply doesn't square with the huge profits they've been recording. For the past two decades, they've been the most profitable industry in the United States every year but one. And they haven't been squeaking into top place: In 2002, Angell says, the combined profits ($35.9-billion U.S.) of the top 10 drug companies in the Fortune 500 exceeded the profits ($33.7-billion U.S.) for all other 490 businesses combined. Angell also does a nice job of debunking the myth that it costs $800-million to discover each new drug; she puts the figure closer to $100-million.

Angell can be forgiven for focusing so intensely on the United States, since the situation there is uniquely awful. Despite publicly funding much of the basic research of drug discovery, Americans pay the highest prices in the world for prescription drugs. Prices are so high that an estimated one in four seniors either skip doses to make the drug last longer or don't bother to fill their prescriptions at all. Hence the much-publicized Rx trips to Canada, and the bustling trade in Canadian mail-order pharmacies.

But surely even Angell's U.S. readers would like to know more about how Canada (and every other developed country on the planet) manages to keep drug prices under control. Angell sketches Canada's policies in just a paragraph -- we have a review board that monitors world prices and makes sure ours don't exceed the median -- but if it's as simple as that, why don't Americans do the same?

This bare-bones approach throughout the book is the only real disappointment. I wanted more of the story behind how things happened, more of the complexity and nuance. Still, even as a skeletal primer, this is an excellent and important book. I can't think of anyone, apart from the very young and the fainthearted, who should not read it.