In The Constant Gardener, ‘now a major motion picture’, John Le Carre puts the drug companies in the position that the evil empire of the Soviet Union occupied in his Cold War novels.1 Perfidious big pharma is revealed to be testing dangerous drugs on impoverished Africans, suppressing information about their lethal side-effects, and murdering whistleblowers. Le Carre's convoluted tale is presented as ‘a magnificent exploration of the dark side of unbridled capitalism’. It is remarkable that this preposterous depiction of the pharmaceutical industry should strike such a popular chord. Yet, while drug companies claim that they have made a major contribution to health and welfare with a range of new medications, many accept the view that big pharma is a ruthless and corrupt form of capitalist enterprise.
Nor is the indictment of pharmaceuticals confined to fiction. High profile scandals — such as those culminating in major litigation against manufacturers of some SSRI anti-depressants and COX-2 anti-inflammatories — have brought the pharmaceutical industry into some disrepute. For Marcia Angell, former editor of the New England Journal of Medicine, the industry is ‘now primarily a marketing machine to sell drugs of dubious benefit’, which ‘uses its wealth and power to corrupt every institution that might stand in its way, including the US Congress, the Food and Drug Administration, academic medical centres and the medical profession itself’.2 For journalists Ray Moynihan and Alan Cassells, the industry is ‘fundamentally distorting medical science, corrupting the way medicine is practised and corroding the public's trust in their doctors’.3
The current backlash against big pharma is to some extent a result of the way that a small number of drugs have been over-promoted and over-used. In the quest for increased sales, drug companies have sought to expand the market for some of their products by encouraging people to consider themselves ill and doctors to treat them with new (and expensive) medications. Techniques such as ‘astro-turfing’, the formation by drug company PR professionals of fake grass roots advocacy groups, often featuring celebrities, have helped to popularise new disorders and increase demand for treatments. As more and more people take medications for which their need is less and less clear, the balance of benefits to risks shifts towards the latter, a trend reinforced by the wider climate of risk aversion. This ultimately provokes a tendency to over-react, as patients blame drugs for the problems they experience and critics of big pharma find a popular resonance for their accusations.
Critics complain that instead of developing new products, the major drug companies have concentrated on ‘me-too’ imitations, and on a range of protectionist strategies for stretching out monopolies on existing products. Although the industry uses its R&D investment to justify the exorbitant costs of new drugs (like Herceptin® for breast cancer), much of this expenditure is in fact devoted to marketing. There is little dispute that as big pharma's profits have soared over the past two decades, the flow of useful new drugs onto the market has slowed to a trickle.
For all its claims to entrepreneurial flair, big pharma turns out to be highly dependent on state patronage. In 2003 the US federal government agreed to fund prescription charges for the over-65s by guaranteeing a payment of $400 billion to the drug companies. Not only did this ‘bonanza for big pharma’ provide a guaranteed market, by prohibiting the government from bargaining it allowed the industry to set its own prices. The network of links between the industry, the political process and regulatory agencies, in the US and in the UK, has rendered the regulatory process ineffectual.
On closer inspection big pharma is neither a great satan poisoning and corrupting the world, nor a model of thrusting capitalist enterprise and altruistic commitment to public health. It is something of a paper tiger, a cautious and conservative industry relying on a small number of ‘blockbuster’ drugs and clinging to its restrictive practices and state subsidies. While it has benefited handsomely from the increasing medicalisation of society, it has also become a victim of the blame and compensation culture that has advanced in parallel with it.
- © British Journal of General Practice, 2006.
