Interview

Britain’s own drug barons

Drugs are big business, and not just in Columbia or Panama. Joe Collier, pharmacologist and critic of the industry talks to healthmatters about Britain’s ‘legal’ drug problem

Doctors and pills go together, don’t they? But the ‘pharmacological revolution’ is a relatively new event — there are still doctors working who can remember penicillin being introduced. What effect has the drugs industry had on doctors and the NHS?

Over the last 20-30 years the ways in which the drugs industry has shaped Medicine have changed. The industry has become more subtle in its approach, more covert in its workings and more widespread in its influence. Drug promotion was a crude business in the early 1960s and 1970s, but not now. Pharmaceutical companies have learned to catch the public eye and promote their own ‘goodness’, and they have insinuated themselves deeper into medical research, partly because government money is less available than in the past.

By drug promotion do you mean the freebies given to doctors to encourage them to prescribe brand X not brand Y?

It isn’t that simple. Drug promotion is now both precise in its aim and diverse in its approach. Drug company representatives still visit many GPs and act as a major source of information about new products for them, but the industry also seeks out particular opinion-makers and targets them with well-researched approaches to particular markets. Advertising has become even more important to the industry over the years — the advertising company that created an image for Tagamet is reputed to have been ‘made’ by that campaign.

The industry pays attention to the public to set a tone rather than to promote specific products, though there is some advertising for them too. Organisations like the Association of British Pharmaceutical Companies work to maintain public goodwill and promote the industry’s good name as a national service, branding critics like me as ‘unpatriotic’.

The Office of Health Economics produces research work about health policy issues within which industry thinking and objectives have a high profile. In other words drug promotion is now as much about promoting the industry and the idea of medicines as it is about particular products.

You mentioned the industry’s role in medical research?

The current best guesstimate is that about 60% of medical research is funded by the drugs industry. That means that emphasis shifted away from study of non-drug therapies and long term trends in health and illness; and medicine itself becomes biased. AIDS is an example of this. The drugs industry might prefer a ‘curative’ approach rather than the study of human sexual behaviour, even if changing behaviour promises greater benefit, and is indeed the only approach available in the Third World.

Medicine’s ‘drug connection’ goes further. Postgraduate medical education is dependent on drugs industry support, and the Royal Colleges — committed to maintaining professional standards — use industry funding too. Recently, three charities argued that in future they should not get more than 10% of their income from the industry; while the editors of medical journals come under pressure to publish information provided by the industry, by being wined and dined, or ‘phoned up insistently, or warned off material critical of the drug companies. Journals, such as the British Medical Journal, depend heavily on drugs industry money — its editor said as much in his review of my book Nature.

The Committee on Safety of Medicines (CSM) scrutinises drug safety, but more than 50% of its members have links with the industry which only came to light recently, and which need only be declared after their appointment to the CSM. We don’t yet know what influence this has, if any, on any particular drug being passed as safe, but it may reduce the CSM’s overall critical view of the field.

Why doesn’t the government try to regulate all this?

The Department of Health contributes to the ‘drug connection’ as well. The system for regulating industry profits — the Voluntary Pharmaceutical Price Regulation Scheme — is shrouded in secrecy and allows generous profits to be made on the medicine bought by the NHS. The drugs industry is treated by government as a high-risk area, even though it has never failed. In reality, manufacturing medicines is not a high-risk activity — unlike its nearest comparison armaments production, where failure is common. The industry is powerful enough to ensure that chemical innovation is rewarded with product licences even if there is nothing genuinely new being launched, only a rehash of some already existing drug type.

One reason why the drugs industry gets away with this lies with the relevant legislation, the Medicines Act of 1968. The government does not implement the act fully, failing to review product licences every five years and failing to regulate drug promotion. However, even if fully implemented the act fails to deal with the real issues. It does not define ‘clinical efficacy’ (the effectiveness of a new medicine), and it does not require manufacturers to prove ‘relative efficacy’ (the superiority of their new product over an existing one). Instead it concentrates on ‘relative safety’, which is necessary, but insufficient, because it stifles research and understanding. We have lots of drugs against arthritis but nobody knows which are the most effective, and we know too little about arthritis itself. Ironically, even the safety of these medicines has been overestimated — remember the Opren scandal ?

How could a future government change this?

The Medicines Act needs to be strengthened to give better control of the drugs industry, but there is a deeper issue that needs attention too. The industry is responsible for ‘over-drugging’ us, and a de-escalation of drug production is needed. This will have to be approached carefully because we must not crush the real expertise that is present within the industry.

There may be casualties, but they will be necessary when we sort out the unreal economy created by the drug companies.