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Review of Sickening: How Big Pharma Broke American Health Care. By John Abramson. Mariner Books.
The United States spends far more money on health care than other affluent countries and it has dropped to 68th in the world in “healthy life expectancy.”
According to Dr. John Abramson, a faculty member at Harvard Medical School, author of Overdosed America, and an expert witness in litigation involving drug companies, pharmaceutical companies bear considerable responsibility for the disparity.
In Sickening, Abramson reveals, Americans spent almost as much per person on prescription drugs as citizens of other wealthy nations. These days they spend twice as much, largely because of the volume of prescriptions for expensive brand-name products. Driven in no small measure by massive spending on marketing (about twice as much as expenditures on research and development of the drugs themselves), retail sales of prescription drugs in the United States, he points out, have increased thirty-fold since 1980. Recently, the cost of brand-name drugs has gone up 14 times faster than the Consumer Price Index.
Abramson provides a detailed, accessible cost-benefit analysis of more than a dozen of them, used to prevent or treat pain, heartburn, influenza, rheumatoid arthritis, diabetes, cardiovascular disease, and, most recently, Alzheimer’s, to make a compelling case that drug companies have created a chasm between “their claimed or implied value and their true value.”
To monetize their control over the information they disseminate about the health benefits of their products, Abramson claims, drug companies have managed to seize control over the research agenda (from academic medical centers and government agencies); own clinical trial data (and retain as proprietary secrets); and publish trial results non-transparently in peer-reviewed journals.
Because manufacturers make bulk purchases of reprints to distribute to physicians, medical journals, Abramson reveals, have a powerful interest in publishing articles favorable to brand-name drugs. In 2005, for example, reprint sales constituted 41 percent of the total income of The Lancet. Not surprisingly, the New England Journal of Medicine (which, along with the Journal of the American Medical Association and Annals of Internal Medicine, does not disclose such information) led the top five journals in the field in the percentage of published trials that were manufacturer-supported. While authors of articles are required to report conflicts of interest, Abramson points out, no such requirements exist for the journals themselves.
Abramson recognizes that reigning in the “largely unrestrained power" of drug companies buttressed as it is by legions of lobbyists in Washington D.C. and substantial campaign contributions to politicians, will not be easy. That said, his recommendations should command the attention of every American:
Require all authors, peer reviewers, and editors of medical journals to have access to the underlying data from clinical trials before deciding whether to publish articles. And include reviewers trained in statistical methods in the vetting process.
Empower the FDA not only to ensure that claims in direct-to-consumer advertisements are consistent with information in agency-approved product labels, but that they contain accurate and relevant summaries of benefits, risks, and costs (not just the co-pay) compared to other drugs or non-drug therapies. Create within the FDA a formal mechanism of health technology assessment (HTA), similar to the United Kingdom’s government-funded National Institute for Health and Care Excellence (NICE), with full access to clinical trial data, to formulate guidelines related to benefits and costs.
Congress should allow Medicare and Medicaid to negotiate prices with companies and establish “a public option” for purchasers of health insurance.
Most fundamental, according to Abramson, is the urgent need for a cultural shift in the United States, from reliance on new drugs and deviances to promote and preserve health, driven by profit maximization, to lifestyle changes in diet, physical exercise, and stress reduction (addressed in only 4 percent of medical research). Affected, to be sure, by socio-economic disparities, more than 80 percent of heart disease and diabetes, Abramson points out, can be prevented through adoption of healthier habits.
In many ways, Dr. Abramson concludes, health care “has become yet another test of our democracy.” Acknowledging that success “is by no means pre-ordained,” he chooses to believe that American citizens can rise to the challenge.
