HOW BIG PHARMA IS CORRUPTING SCIENCE, DOCTORS AND PUBLIC HEALTH POLICY?

Editions de l'École Normale Supérieure (ENS) has just published a French translation of an important book by Sergio Sismondo, Professor of Philosophy of Science and Technology at Queen's University in Kingston, Canada, entitled Le management fantôme de la médecine. The invisible hands of Big Pharma. They have also had the good idea of making it freely available online. It's well worth a read. In fact, it is crucial for anyone wishing to better understand the way in which, over the last few decades, the pharmaceutical industries have taken control of our health, by massively corrupting not only the medical research community, but also the national and international regulatory authorities and the world of medical scientific publishing, all with the help of consultancy firms such as McKinsey.

As Mathias Girel reminds us in his preface (to whom we already owe the preface to the French translation of Robert Proctor's major book, Golden Holocaust. La conspiration des industriels du tabac, in 2014), "the ghosts we're talking about here are very real, and they don't travel alone: they are ghostwriters, i.e. people working for the pharmaceutical industry who write articles that are then signed by researchers, but also contract research organisations (CROs), patient associations and opinion leaders". The aim is to trace the entire production chain, which culminates in publications in scientific medical journals, individual prescriptions of medicines by doctors, and even their use in the general population by governments as part of public health policies. And while these outcomes are highly publicised, the production chain behind them remains invisible. Hence the title of the book: The Phantom Management of Medicine. For Sismondo, this is nothing less than a "new model of science", a "corporate science, carried out by many hidden workers, for marketing purposes, and which draws its authority from traditional academic science". Basically, as the author says in his afterword, "The Phantom Management of Medicine is a book that explores the way in which the pharmaceutical industry merges science and marketing, particularly in North America and Europe". And this system for manufacturing knowledge is based on 'systemic corruption', to which the author has also devoted a recent article (Sismondo, 2021).

In this book, which is based on countless interviews, observations of meetings and readings of documents produced by industry and its affiliates, Sismondo analyses "the main tactics and practices used by pharmaceutical companies to influence medicine". He describes "the pathways that drug-related information and knowledge follow from contract research organisations [CROs] (who carry out the bulk of pharmaceutical research), to publication planners (who direct the production of journal articles written by ghostwriters), to opinion leaders (who are deployed to educate doctors about drugs) and beyond". He thus gives us an insight into the mechanisms for producing, circulating and consuming medical knowledge as the pharmaceutical industry sees them, i.e. in an intellectual universe where "research, education and marketing have merged". And the author reminds us that "the avalanche of knowledge that companies create and disseminate is not designed for the good of humanity, but to increase profits". In fact, "sometimes the quest for profits runs completely counter to the general interest". How is this possible?

First of all, industry has research (clinical trials) produced by contract research organisations, which in turn use subcontractors: "industry funds roughly half of all clinical trials - often randomised controlled trials, the most valuable form of medical knowledge - and sponsors most of the new trials undertaken each year". CROs [contract research organisations] working on their behalf "plan and conduct clinical trials to get drugs approved and to develop new arguments for prescribing drugs. They recruit doctors, who recruit trial subjects whose tissues, fluids and observable qualities can be transformed into data". CROs are thus "the pharmaceutical industry's first ghosts".

Secondly, thanks to the data collected, "the pharmaceutical industry produces a significant proportion of the scientific literature on patented or patent-pending drugs. In the most prestigious medical journals, nearly 40% of recently approved articles are the work of ghostwriters". Publication planners" then develop "publication strategies", set up "teams of professionals to think up and write articles", then "select the journals to which these articles will be submitted and choose the opinion leaders who will be the putative authors". This is how "medical science is shaped to serve marketing objectives (...) The result looks like medical science, and may even be high-quality science, but it is science designed to sell drugs".

In addition, "shadow management continues with the communication of medical science in the field. By giving lectures, opinion leaders contribute to the pharmaceutical industry's enormous influence on medical knowledge. Opinion leaders are the industry's zombies, the living dead who are sent to do the pharmaceutical industry's bidding".

Then comes the stage of dissemination, i.e. communication: "a sophisticated service industry surrounds all medical communication. (...) As agents of the pharmaceutical companies, medical training and communication companies create courses, plan conferences and seminars, conduct surveys and write articles and studies. All this material is then passed on to educators, researchers and doctors, who put it to good use". To top it all off, "these companies feed the journalists who write for general newspapers and medical magazines, providing them with technical details, scientific articles, names of experts to contact and even story lines. They even supply video clips to television channels, which then broadcast reports on the latest medical advances".

Finally, the industry has learned to use patient advocates and patient advocacy groups (PAGs) to its advantage, and they have become "other essential links in the drug market nebula". In the United States, two-thirds of these associations receive funding from the industry, with a particular focus on those that "give conferences or take part in discussions at the Food and Drug Administration". Sismondo even notes that, "in some extreme cases, ADPs are creatures of industry. They are entirely funded by one or more companies, their staff are recruited by professionals, and they find patients to enrol after the fact".

Ultimately, the pharmaceutical industries "exert systematic pressure on the circulation of scientific knowledge and the medical practices that result from it. It is a system of influence made more effective by the very fact that it is opaque and shadowy". And this system of influence is probably far more effective than advertising, even if the industries still make extensive use of this means of propaganda (Sismondo points out that, "for example, in 2016 in the United States, the pharmaceutical industry as a whole bought more than $3 billion worth of television advertising and spent almost as much on advertising in magazines, newspapers and other media. Of that amount, $300 million was spent on ads in medical journals").

The economic facts are clear: "overall sales of medicines are increasing by almost 10% a year, whether the year is good or bad". The old diseases have been joined by new ones, resulting from our modern lifestyles. But the problem is even more serious because, as Sismondo reminds us, even when diseases don't exist, or don't really exist, the pharmaceutical industries have an answer: "diseases can be shaped and adjusted to create a stronger, more profitable market". Sismondo recalls the well-known fact that, in order to increase their sales, pharmaceutical companies try to 'sell disease', as Moynihan and Cassels (2005) put it. In concrete terms, manufacturers "strive to increase awareness of the diseases for which their drugs can be prescribed, and thus increase the likelihood that people will believe they have these diseases". It is no longer a question of the increasing medicalisation of life but, more precisely and more globally, of the "pharmaceutisation" (pharmacolisation) of society. This concept has been the subject of a small body of scientific literature (particularly sociological) in the United States for the past fifteen years (Abraham, 2020; Williams et al., 2011). Sismondo cites examples which, while well known to specialists, are nonetheless important and edifying.

Let's start with a psychological illness, depression, which is now "one of the diseases most obviously governed by the existence of drugs". Sismondo summed up the evolution of the disease and its pharmaceutisation as follows: "until the 1960s, depression was a relatively uncommon diagnosis, and was associated more with the elderly. In the 1970s, it became a little more visible thanks to the manufacturers of the first generation of antidepressants. However, since the arrival on the market of Eli Lilly's Prozac in 1987, more and more people have been diagnosed with depression. The number of people affected by depression has risen [to the point where the WHO has announced that it will soon be the most widespread health problem in the world], the criteria for diagnosing depression have continued to broaden and estimates of the prevalence of depression have increased dramatically. Depression has become the 'common cold' of mental disorders". The first major financial success of these new "antidepressants" was Prozac. Thanks to Prozac, manufacturers were able to "market both the drug and the disease". In fact, "they invested massively in research into depression and antidepressants. They have widely promoted a theory of depression based on serotonin deficiency, then a theory of chemical imbalance, for which there is little evidence. They have established close links with psychiatrists and other doctors who write manuals, articles and clinical practice guidelines. They have funded awareness-raising and anti-stigma campaigns. The companies have succeeded in giving the illness status both medically and culturally, helping doctors to willingly recognise and diagnose it and patients to interpret their feelings and experiences in the co-ordinates of depression - perhaps even shaping their identity around it".

Many other chronic diseases of contemporary society are also subject to this pharmaceutisation, including hypertension, diabetes, hypercholesterolaemia and osteoporosis.
Another way for Sismondo to put it is this: "There was a time when people generally considered themselves to be in good health, unless they fell ill or had unusual symptoms or frailties". Now we talk about "risk" and we are all affected, all potentially ill. Jules Romains had Doctor Knock say in 1923: "Every healthy man is a sick man who doesn't know it". A century later, his prediction has come true beyond even his wildest imaginings. Today, as Sismondo writes, "we are all, always, in poor health. Most of the ailments we suffer from are chronic, so treatments can last a lifetime. And since we are all, in many ways, in poor health, the treatment - however successful - of risk factors or pathologies never ends". For Big Pharma, it's a jackpot. And the rest is even worse.

In particular, Sismondo develops the example of opioids in the United States, where we find "almost all the elements mentioned in the rest of the book".

Let's remind ourselves of the facts: over the last twenty years, more than 200,000 American citizens have died because of opioids sold on prescription as painkillers but which were in fact just as dangerous and addictive as heroin. The cause was "a surge in prescriptions for painkillers, particularly OxyContin", authorised by the Food and Drug Administration (FDA) since 1995. The case is as follows: "the painkiller contained in OxyContin is oxycodone, an old morphine derivative similar to heroin in its structure and general effects. The selling point of the new drug was its high concentration of oxycodone combined with a continuous-release mechanism that its manufacturer, Purdue Pharmaceuticals, called 'Contin'. The so-called Contin mechanism, patented in 1980, was supposed to moderate the euphoric, heroin-like effects and relieve pain for twelve hours. The result, it was claimed, was a low-addictive opioid. For Purdue, OxyContin was a good substitute for its previous slow-release opioid, MS Contin, which had been abused as a recreational drug". At the same time, the Drug Enforcement Administration (DEA) authorised production quotas for potentially addictive painkillers, which "led to an almost forty-fold increase in oxycodone production between the early 1990s and today".

So an industrialist has made a fortune selling a drug equivalent to heroin that has killed hundreds of thousands of people, all with the blessing of the US government. How is this possible? Surrounded throughout his operation by consultancy firms such as the American McKinsey and the French Publicis, the industrialist began by inviting over 5,000 participants to more than 40 conferences on pain management, all expenses paid. "These conferences established a base of prescribers and, more importantly, a base of opinion leaders to sit on Purdue's speakers' bureau and give paid presentations to other prescribers". This list included 2,500 doctors, 1,000 of whom were active. Thanks to the influence of opinion leaders, Purdue was able to finance more than 20,000 educational events to promote the use of opioids to treat pain aggressively". The company then entered into a paid agreement with the Joint Commission on Accreditation of Healthcare Organizations, which describes itself as an "independent, not-for-profit organization" made up of physicians and which is at the origin of the American accreditation system. Thanks to this agreement, and with the help of another manufacturer with more infrastructure (Abbott), Purdue was able to distribute its product to all American hospitals.

And the corruption doesn't stop there. The company has also made gifts to medical students and to organisations such as the American Geriatrics Society and the American Academy of Pain Medicine. For example, "on a panel of the American Geriatrics Society that drafted guidelines for the treatment of chronic pain in the elderly, more than half of the members had been paid for consultations or conferences by one or other of the companies that manufacture opioids". The corruption went so far that, after a law was passed in 2016 (the Ensuring Patient Access and Effective Drug Enforcement Act), the industry "ensured that the DEA could not investigate distribution or the companies. Although the DEA vehemently opposed the law, it was muzzled by a two-pronged strategy: DEA employees were systematically offered jobs directly or indirectly related to the industry - a total of fifty employees were transferred - and highly-funded legislators made their overall support for the DEA contingent on its silence on the law".
Finally, of course, throughout this huge marketing operation, the industry enlisted the support of scientists. Firstly, by funding a large number of randomised clinical trials, which were then published in the leading medical journals under collective authorship, although it was not known who had actually conducted the research, who had written the article, etc. "In other words, it was the scientists who were responsible for the research. "In other words, it is almost certain that these studies were conducted in a ghost-like fashion. It was also necessary to conceal the undesirable effects of the "drug", in this case the addiction, which is perfectly similar to that caused by heroin, and the risk of death by overdose, which is just as lethal.

In the end, sales of OxyContin made the fortune of the company involved (Purdue Pharmaceuticals), whose owners (the Sackler family, who are of course involved in philanthropy, particularly towards universities) became incredibly wealthy as a result. The 600 million dollars or so in fines paid afterwards are a drop in the ocean compared with the tens of billions that this legal drug has brought in. It's all part of the business plan. However, the health and social consequences of this affair are catastrophic: not only has the industrialist contributed directly to the deaths of hundreds of thousands of people, but he has also turned the American drug market upside down by throwing hundreds of thousands of people (mainly from the working class) who have become addicted into the arms of drug traffickers (Quinones, 2015). Incidentally, as Anne Case and Angus Deaton (2021) write, "many who have followed the opioid scandal closely see little difference between the behaviour of these legalised dealers and that of the illegal purveyors of heroin and cocaine who are so widely despised and condemned". In both cases, the aim is "to line their own pockets by destroying lives". Except that here, these organised crimes are committed with the blessing of the public authorities.

In this French translation, Sergio Sismondo has added an unpublished afterword (written in June 2023) in which he revisits the Covid crisis in a way that fully supports our own analyses (Mucchielli, 2022a). He begins by noting that "as the pandemic was defined as a public health crisis, and not simply as a problem of individual health, the pharmaceutical industries entered into direct dialogue with governments, trying to make the latter - who are the regulators of healthcare spending in general and drug spending in particular - their allies". It is therefore clear that "the pandemic has accelerated the blurring of boundaries between the pharmaceutical industry and other stakeholders, such as governments, regulatory bodies and academic institutions. Collaborations and partnerships have become essential to speed up the research, development and distribution processes. However, this entanglement has also raised concerns about conflicts of interest, undue influence and the risk of compromising decision-making". Sismondo also notes that "the pharmaceutical industries have also addressed themselves directly to a large audience of non-specialists, presenting their vaccines as the solution to this crisis, using the tools of public relations" (always the same consultancies, starting with McKinsey).

Sismondo then develops two concrete examples. The first is how this vast system of corruption enabled Gilead Sciences to resell an antiviral (Remdesivir) that had already been shown to be ineffective in previous viral epidemics (Hepatitis C and Ebola), with the blessing of the US government health services headed by Anthony Fauci. The second is the way in which other manufacturers (led by Pfizer and Moderna) have claimed to have developed "95% safe and effective vaccines" and have sold them around the world with the blessing not only of national governments but also of international organisations, led by the World Health Organisation (WHO) and the European Union (EU). He concludes that "without knowing the background infection rates in the populations studied, without full transparency about trial methodologies, and without full reporting of adverse events, these high vaccine efficacy scores do not tell us everything we need to know to evaluate vaccines. But as public relations tools, they have been very effective.

Sismondo concludes by writing that "ideally, therefore, the book should have included research into the industry's strategies for dealing with governments and the general public, both of which are crucial to the commercial success of their products in times of pandemic". In fact, the Covid crisis is a perfect illustration of the author's point, which could, for example, have focused more closely on other aspects of this crisis, such as the Lancet scandal (Mucchielli, 2022b) or the serious adverse effects caused by the forced administration of these experimental genetic therapies in the general population. But it is undoubtedly still a little too early for the effects of this immense abduction on people's consciences and bodies to be recognised and analysed by intellectuals who, for the most part, were unable at the time to understand and resist the industrial and political propaganda being deployed with more force than ever. They will certainly regain their lucidity and courage in the months and years to come.

How Big Pharma is corrupting science, doctors and public health policy: https://qg.media/blog/laurent-mucchielli/comment-big-pharma-corrompt-la-science-les-medecins-et-les-politiques-publiques-de-sante/

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