The greatest conspiracies are rarely organised overtly, rather they exist implicitly. And that is what Bed Goldacre details in Bad Pharma. The book details the extent of manipulation and dishonesty present in the drug industry, and this extends far beyond pharmaceutical corporation employees. The companies, the journals read by doctors, the doctors themselves and the regulators, all are complicit in the story he tells.
The pharmaceutical industry, and medicine in general, are clear cases of information failure. This economic concept refers to when one party in a transaction knows far more than the other. This is to be expected with regards to doctor-patient relations and for this reason, doctors are simultaneously highly respected and extensively regulated. Where the system shows its flaws is when pharmaceutical sales teams can exploit their greater information to influence doctors, who will then allow that influence to affect their approach to patients. Doctors are highly vulnerable to this as the sheer amount of information provided to them is beyond their ability to process, Goldacre illustrates this by showing that the average General Practitioner (GP) would have to read 600 hour’s worth of papers a month, even if they were to only skim each paper for a few minutes, just to stay current. This is, obviously, impossible. Therefore, doctors are both grateful for those who distil (or claim to) findings into an easy to understand message. Suspiciously often this message is “prescribe my company’s latest drug” and, again, due to both time and publishing limitations (more on the latter below) it can prove difficult for doctors to find second opinions to this message.
Most of the issues are created well before this stage, however. Goldacre demonstrates how even the basic structure of trials is deeply flawed and skewed in such a way as to benefit the company paying for it. Stopping the trail early if desired and even changing the outcome the trial is measuring halfway through (!!!) are just two ways this occurs. And then fewer than half of all trials are published. The result of this is that while a series of trials may show balanced or even negative results for a drug it is possible to merely publish the positive ones and pretend that they were the only trials. If an academic were to remove the more negative half of their data points it would be cited as clear academic misconduct, yet when done at an industry level it is merely standard operating procedure. Additionally, papers are often ghost-written by companies or have their methodology withheld. The list goes on and on.
Goldacre is insistent on avoiding conspiracy theories throughout and hence refuses to cast doubt on the motives of regulators but their refusal to, well, regulate is astonishing. Regulators constantly withhold data citing commercial secrets or patient privacy, concerns that are far overblown. He makes a very persuasive argument that regulators misinterpret their role. Drugs are measured and approved on their effectiveness versus a placebo, rather than rival treatments. This is, of course, a low bar to entry. A drug coming to the marketplace does not mean it is even as good as it’s rivals, let alone better, it could be far worse. Therefore, the regulator cannot function as a “black box” and just churn out “good” or “bad” results for drugs, doctors must be able to see all the data and findings to know which drugs are best for which patients. Regulators regularly announce fixes to the problems he and others have identified (trials behind withheld etc.) but they rarely follow through with effective enforcement. The same is true of journals that declare they will only publish studies that include all trials and then flout their own rules.
Ultimately there is much that can improve in the industry and the book is packed with practical solutions. The structural issue of pharmaceutical companies spending double on marketing and sales what they do on research and development will be hard to change as to do so unilaterally would be to put themselves at a disadvantage to competitors. Likewise, for changing any dubious practices. The only path forward is genuinely tough, enforced legislation to help enforce a profound cultural shift.
Goodreads score: 4.1