Grievances against the pharmaceutical industry are common in new media spaces. Influencers on Instagram tell us to shun drugs and embrace the 鈥渘atural.鈥� Diatribes are shared on Facebook against the profit-seeking motives of Big Pharma. Podcasts, websites, and videos try to convince us that the prescription drug business simply cannot be trusted. Joe Mercola, an osteopath who has set himself up as the one-stop shop alternative to medicine, recently that 鈥渢he drug industry has become the #1 cause of death and disability worldwide, hands down.鈥�
This bag of grievances carries a heavy and myriad load of claims, some more believable than others. And it is precisely those more believable claims that help the conspiratorial pill go down.
鈥淪omething is wrong in medicine鈥�
In his unsparing criticism of the drug industry, Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients, Dr. Ben Goldacre writes about a drug called reboxetine as an example of one of the many problems with how drugs are developed. Reboxetine (known commercially as Edronax) is an antidepressant. Dr. Goldacre, a psychiatrist by training, remarks in his book that he had prescribed reboxetine in the past. Why? Because the published scientific evidence showed that it was quite effective.
The problem is that Dr. Goldacre, like every other doctor, had been misled. A total of seven trials pitting reboxetine against placebo had been run. All except for one had shown no difference between the two. But the only trial whose results were actually published was the one showing reboxetine was better than placebo.
Six negative trials. One positive trial. The six negative trials were buried and didn鈥檛 see the light of day until a research team unearthed them. This is one of the major problems with the pharmaceutical industry: there are tremendous incentives to only publish the results of clinical trials that favour them and to never share the results of negative trials. This skewing of the medical literature will necessarily impact the decisions doctors make. How can a physician judge the true worth of a drug when the portrait that emerges from the literature has been doctored?
The system in which drugs are developed and marketed is further warped in a multitude of ways. Drugs can be approved based not on the hard endpoints that we care about, like death and disease, but on surrogate markers, like an abnormal heart rhythm. It鈥檚 easier and faster to show that a drug reduces the risk of an abnormal heart rhythm, but this is not the same as showing that it will reduce the risk of dying from this abnormal heart rhythm. Clinical trials can also be stopped early. Sometimes, there is an arguably good reason for doing so: the difference between the drug and what it is compared to is so vast that it would be unethical to withhold the drug from the other participants. But sometimes, a trial is prematurely terminated simply because the data collected at this point favours the drug. It鈥檚 not unlike playing rock-paper-scissors and, when you lose, suddenly deciding to do best-of-3鈥� or best-of-4.
The pharmaceutical industry has also found ways to reduce the risks of studying new drugs and to wring out more money from pharmaceuticals whose patents are close to expiring. When a new type of drug has been shown to work and is approved for sale, other pharmaceutical companies can invest money into developing a slightly different version of this drug, what is referred to as a 鈥渕e too鈥� drug. Some of these molecules can be useful, by being safer or more effective in certain people, but they take time and money away from the trailblazing work of discovering brand-new classes of drugs. And when a profitable drug鈥檚 patent comes to an end, opening the door for other companies to manufacture it and sell it at a much lower price, the patent holder can use a trick of chemistry to hold onto their profits. Molecules can be left-handed or right-handed, mirror images of the same formula. As Dr. Goldacre reports in Bad Pharma, AstraZeneca was selling a heartburn medication known as omeprazole (Prilosec, Losec), which was a mixture of the left-handed and the right-handed forms of the drug. As the patent was running out, it launched esomeprazole (Nexium), which was a purified version of only the left-handed molecule. No difference in benefit, but AstraZeneca invested a lot of money in a direct-to-consumer campaign to convince patients this was the patented drug they needed.
To this pile of charges, we can add the way in which trials can be sliced and diced to rescue an overall negative study and make a drug shine; the medicalization of conditions like 鈥渇emale sexual dysfunction,鈥� which allows the industry to sell questionable drugs like flibanserin (Addyi); and the spread of drug reps in hospitals and clinics to convince doctors, using carefully selected data, that the latest drug their company makes is a game-changer when its benefits are actually much more debatable.
Faced with this damning portrait of an industry driven by profits, it鈥檚 no wonder that a racket of Big Pharma conspiracy theorists has grown. They believe that all pharmaceutical companies are in cahoots with each other and that they have corrupted academia and governments, poisoning the masses with poorly studied pharmaceuticals in a quest to keep us sick and drain our wallets.
The alternative they propose, however, has no grounding in reality.
Flying carpets will not save us
To those who oppose the pharmaceutical industry, the answer is to embrace nature. The idea is simple and alluring. It sketches a comforting picture of a benevolent Mother Nature seeding her earthly garden with the cures we will need: an herb for cramps, a tree for fevers, a spice for pain. The molecules produced by the natural world are perceived as being safe, while those manufactured by industry, though they can be the same, are regarded with suspicion. They are alien to our world.
This embrace of nature, comforting though it may be, is na茂ve. The chemicals plants produce, often to protect themselves against predators, are not necessarily safe for us. Snake venom and asbestos are all-natural, yet I don鈥檛 trust anyone who would prescribe them to me. Natural health products, a very lucrative industry onto itself, are known to suffer from adulterations and contaminations due to poorer regulations and the desire to cut costs on expensive products like saffron. Many of these herbal products may look like they come from small, family-owned businesses, but they are actually .
And while the drug industry can be chastised for sometimes manipulating how clinical trials are run and reported, the world of natural remedies fares even worse. Their studies typically involve a very small number of participants and a short follow-up, and just like with pharma, positive studies get rapidly published while negative studies can easily linger in drawers. If you scrutinize a drug company鈥檚 trial but fail to bring the same degree of criticism to a dietary supplement company trying to convince you that a study in 14 people with no control group is all the evidence it needs to sell you a pill a day, I worry that we have landed in the hypocrisy zone.
When not promoting supplements, the people denouncing Big Pharma will focus on lifestyle modifications. While good health habits are important and do reduce the risk of illness, eating enough fruits won鈥檛 cure cancer and going to the gym will not immunize you against respiratory infections.
At best and, in my opinion, rarely, so-called alternative medicine can treat superficial symptoms or distract from them, but it does not address the underlying problem. To quote Dr. Goldacre鈥檚 pithy survey of the situation, flaws in aircraft design do not prove the existence of magic carpets.
If the planes of the pharmaceutical industry have weaknesses hidden from us, the solution is not to embrace the supernatural. It鈥檚 to fix the planes and better regulate their manufacturers.
From secrecy to transparency
In 2013, Dr. Goldacre and many others announced the AllTrials campaign, whose aim was to ensure all clinical trials would be registered publicly and all results reported. The campaign, whose has been signed by over 95,000 people, is not trying to end the pharmaceutical industry, but rather to flood its arena with transparency.
Why? Because pharmaceuticals have benefitted the world. Insulin and the epinephrine contained in the EpiPen have saved countless lives. Salbutamol and many similar drugs have rescued people having asthma attacks and allowed their condition to be more manageable, while antihistamines have made allergies more tolerable. Medications have transformed an HIV infection from a death sentence to an undetectable condition, and pre-exposure prophylaxis has reduced the risk of contracting the virus in the first place. Statins and blood thinners (and even aspirin!) have changed the landscape for people with cardiovascular problems. There has been stunning progress in our fight against cancer, especially for paediatric tumours, and the recent discovery of drugs that modulate the immune system to treat cancer was awarded .
Childhood vaccinations have prevented the death and disability of so many children, and even though a loud contingent of anti-vaxxers would have us believe that every death since the pandemic started is due to vaccination, real-world data has shown us what the pharmaceutical companies had demonstrated during their trials: the COVID-19 vaccines were and continue to be a potent part of our protective measures, especially against hospitalization and death.
Some of these drugs may be overprescribed, some of their benefits may have been exaggerated, and the pricing on many of these pharmaceuticals is egregious. But we can鈥檛 deny the utility of pharmaceuticals because we don鈥檛 like the system that births them.
The AllTrials campaign has made progress. The tenth largest pharmaceutical company in the world, GlaxoSmithKline, and pledged to register and release the results from all of its trials, going back to the company鈥檚 founding in 2000. Major non-industry funders of clinical research, like the Wellcome Trust and the Bill and Melinda Gates Foundation, have committed to . European law has changed . The reporting rate for European Union clinical trials has . Shifting an entire industry away from secrecy toward transparency is a long and arduous process, and we can鈥檛 expect a 180-degree turn within a decade. But it beats crossing our fingers and hoping magical thinking will cure our ills.
In Bad Pharma, Dr. Goldacre makes further proposals. The very patients who participate in clinical trials testing new drugs should be told, in no uncertain terms, if the company behind the trial can hide the results if they don鈥檛 like them. Unpublished trial results should be labelled research misconduct and there should be consequences. Doctors, often courted by drug companies, should refuse industry-funded teaching opportunities on either side of the podium. Sunlight and the equivalent of an enforced church-state separation are what is needed here.
As for the #1 cause of death worldwide, which Joe Mercola blames on pharma, it was actually pre-pandemic, followed by cancer. In the United States, COVID-19鈥攖he virus, not the vaccine鈥攚as . You may have heard that it鈥檚 medical error instead, but that is a myth based on bad approximations.
None of these numbers will sway those enthralled by the Big Pharma conspiracy theory. To them, these numbers have been manipulated, if not outright fabricated, by corrupt agencies puppeteered by the all-powerful drug industry. Their malignant distrust leads to conspiracy ideation, which backs them into a corner. If industry, government and academia are all irreparably corrupt, where do we go in the face of disease? Their answer is to turn a blind eye to the flaws of the alternative medicine and dietary supplement industry and jump in feet first.
The way out is actually to invest in improving the pre-existing system. As Dr. Goldacre mentions in his book, 鈥淒rug companies around the world have produced some of the most amazing innovations of the past fifty years, saving lives on an epic scale. But that does not allow them to hide data, mislead doctors and harm patients.鈥�
Take-home message:
- There are legitimate criticisms of the ways in which drugs are developed and marketed by the pharmaceutical industry, from the withholding of negative results to the use of representatives to exaggerate the benefits of new drugs to doctors
- The people who endorse the 鈥淏ig Pharma鈥� conspiracy theory will often promote the rejection of pharmaceutical drugs and their replacement with lifestyle modifications and dietary supplements, but the former is often inadequate to treat disease and the latter is almost always based on poor studies
- Pharmaceuticals are useful but the drug industry needs more transparency and regulation, and initiatives like the AllTrials campaign have made progress on that front
