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A dangerous dose

The machinations of the drug industry add up to biased data and staggeringly high prices for consumers

The Truth About the Drug Companies: How They Deceive Us and What to Do About It
By Marcia Angell
Random House, 305 pp., $24.95

How does the drug industry deceive us? Let us count the ways. It deploys an army of 88,000 sales representatives to stalk the hallways of clinics and hospitals, bribing doctors with food and trinkets to listen to sales pitches. It plies attending physicians with expense-paid junkets to St. Croix and Key West, Fla., where they are given honoraria and consulting fees to listen to promotional presentations. It pays doctors to allow salespeople disguised as ''preceptors" to shadow them in clinics and watch them examine unsuspecting patients. It promotes new or little-known diseases such as ''social anxiety disorder" and ''premenstrual dysphoric disorder" as a way of selling the drugs that treat them. It sets up phony front groups disguised as ''patient advocacy organizations." It hires ghostwriters to produce misleading scientific articles and then pays academic physicians to sign on as authors. It sends paid lackeys and shills out onto the academic lecture circuit to ''educate" doctors about a drug's unapproved uses. It hires multinational PR firms to trumpet dubious studies as scientific breakthroughs while burying the studies that are likely to harm sales. It controls the mind of medical America by paying for 60 percent of continuing medical education, in part by laundering the money through for-profit ''medical education and communications" companies. It buys up the results of publicly funded research, claims exclusive marketing rights, and then charges the public vast sums to buy back what its tax dollars have produced. It maintains a political chokehold on the American public by donating more money to political campaigns than any other industry in the country.

It was not that long ago that the only people making accusations like this were aging refugees from the Berkeley counterculture, disaffected British Trotskyites, and card-carrying wing-nuts who spent their spare time brooding about alien abductions and the Kennedy assassination. Today, the very same accusations are coming from the most respectable, buttoned-down members of the medical establishment, many of them former editors of The New England Journal of Medicine. It is as if the sign-waving radicals looked up to find themselves joined by the Board of Elders from the First Presbyterian Church. One of the most vigilant of these former editors is Marcia Angell, now a faculty member at the Harvard Medical School. Her new book, ''The Truth About the Drug Companies," is a sober, clear-eyed attack on the excesses of drug company power. In patient, step-by-step fashion, Angell explains how our health care system works, the varied roles that the drug companies play in it, where the system has gone wrong, and what is needed to fix it. The result is a lucid, persuasive, and highly important book.

Through a series of legislative blunders, Americans have managed to create a drug industry that combines outrageously high profits with a disappointing lack of scientific originality. For many years the drug industry has reaped the highest profit margins of any industry in America. In 2002, the top 10 American drug companies had profit margins of 17 percent; Pfizer, the largest, had profit margins of 26 percent. So staggeringly profitable is the drug industry that in 2002 the combined profits for the top 10 drug companies in the Fortune 500 were greater than those of all the other 490 companies combined.

Why do we put up with this? According to official drug industry propaganda, these high profits are necessary to sustain a risky, financially punitive research agenda. Angell strongly disagrees. She argues that the industry research agenda is anything but a model of medical innovation. Of the 78 drugs approved by the Food and Drug Administration in 2002, only seven were classified as improvements over existing drugs. The most profitable drugs on the market today are ''me-too" drugs, such as Pfizer's Lipitor, the fourth of six chemically similar, cholesterol-lowering drugs. What the massive industry profits are really there to sustain, she argues, is an equally massive marketing budget. By the industry's own accounting, the largest drug companies spend over twice as much on marketing and administration as they do on research.

Angell proposes a number of sensible policy changes. The FDA should require that new drugs be tested against currently available standard treatments (and not just placebos) so that clinicians know how newly approved treatments compare with what they are currently prescribing. (This would also help discourage the development of ''me-too" drugs.) The Prescription User Fee, which drug companies pay the FDA to expedite approval of drugs, should be repealed and the FDA should be made financially independent of the pharmaceutical industry (which currently provides a hefty proportion of its funding). Exclusive marketing rights should be rolled back to open up competition from generic drugs. Drug prices should be transparent and as uniform as possible to all purchasers. The pharmaceutical industry should have no place at all in medical education -- no matter how much money it puts up. And the federal government should set up an institute to oversee the design and analysis of clinical trials, so that the industry cannot manipulate and withhold scientific data to suit its own marketing needs.

Will Angell's excellent book help fix the system? We can always hope so. Maybe a corner has been turned. It's possible that the ongoing debate over drug pricing, the suppression of research data, the push for a clinical trials database, and congressional hearings about conflict of interest at the National Institutes of Health will come together into some kind of backlash against the industry. But it seems unlikely. News of industry wrongdoing has become so routine that it hardly makes a ripple anymore. There are headlines for a day or so, some hand-wringing in the universities, the usual signs of public regret without any admission of wrongdoing, perhaps a blue-ribbon panel or two. But when all the fuss dies down, it's back to business as usual.

Carl Elliott is the author of ''Better Than Well: American Medicine Meets the American Dream" and co-editor of ''Prozac As a Way of Life."

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