From Creating Drugs to Creating Markets (A response to “Hating Big Pharma and Flibanserin”)

Brilliant article, if you haven’t yet read it, you should. Who’d want to live in a world where we were medicated into having the same feelings or desires as everyone else? It would be a bit like allowing Simon Cowell to be in charge of UK arts funding.

Our conception of the power and respectability of medicine stem from an out of date idea about what medicine is. Interventions focussing on curing or treating disease or physical injury no longer represents the main focus of medicine. Most new public health interventions (in the developed world at least) are no longer about saving millions of lives but small improvements to existing practises. As a result the creative and entrepreneurial pharmaceutical industry looks for other ways to sell patented compounds.

It is worth dwelling for a moment on the achievements of medicine in the last 100 years. In the UK the life expectancy of new born children in 1999 was 75 years for boys and 80 years for girls. In 1901 baby boys were expected to live for 45 years and girls 49 years. [http://www.parliament.uk/commons/lib/research/rp99/rp99-111.pdf]. A good chunk of this improvement is down to the continued in advances in preventative and curative medicine, and the investment by made by private firms in order to reap rewards when they demonstrated positive health outcomes.

The problem is that once the industry was established it needed to continue to introduce drugs and get paid for them. To the companies it makes no difference if the drug ends widespread childhood measles or if it has no positive impact at all. All that matters is that someone will pay for it.

As with all markets there are constant calculations going on in the background to work out what is the best way to make money. For much of the last 100 years the most cost effective thing to do was to pick a medical problem that didn’t seem to have effective or side effect free treatment and to pay for R&D to develop a better one. More recently, straightforward research had been taken and the cost of a health breakthrough began to rise. The balance began to tip so that the best use of investment became to create a market for products rather than create products for the market. This is borne out in the deployment of resource of the companies:

“Lauzon and Hasbani showed that between 1996 and 2005, these firms [pharmaceuticals] globally spent a total of US$739 billion on “marketing and administration.” In comparison, these same firms spent US$699 billion in manufacturing costs, US$288 billion in R&D, and had a net investment in property and equipment of US$43 billion, while receiving US$558 billion in profits”- http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050001

Once pharma’s engine of innovation became focussed on creating a market for their products rather than creating products the market wants, the whole market idea starts to look rather sorry.

This leads pharma to define a Platonic human experience and sell this ideal in pill form. The more people can be made to feel inadequate, the more effective this approach will be. It seems to me that the model that gave humanity so many improved health outcomes has run its course and should now be disbanded and replaced with something better.

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6 thoughts on “From Creating Drugs to Creating Markets (A response to “Hating Big Pharma and Flibanserin”)

  1. This is quality bathhousing. I’m a little hesitant about dividing the history of medical intervention into good-health-driven agenda vs bad-market-driven agenda. Health is (like everything) a social category and from the beginning of time socially-proclaimed medical professionals have looked to gain from delivering people “health” (while many have, as now, helped for altruistic reasons). But more relevantly, I was wondering, in the big health progressions of the 20th century – like Smallpox or something – was the research that produced vaccines funded predominately by governments?

    Hari wrote a good piece on how Mandelson, in all his New Labour glory, is wanting UK university science research to be directed to commercial ends rather than anything else, which surely will exacerbate the trend you talk about in this post.

  2. Hello,

    Some thoughts, although there is lots to say on all of this! Especially on the quest for profit, but that will have to wait for later. One thing at a time, hopefully with some coherence…

    Yes I’m mostly in agreement – though I’d agree with Sahil, health hasn’t ever been about a clean endeavour to eradicate pandemics, save millions of lives, and to act out of a charitable altruism – also neither are contemporary pursuits of health entirely dictated by markets, although there is a definite increasing trend. Health is social – although I’m sure we’d all agree on that being in this here bathhouse. Perhaps what it means to say this in one sense is, to paraphrase Mol, that “doing medicine is a technique mobilized to improve life rather than an assemblage of neutral scientific facts”. It’s this notion of improvment which is crucial to think about, as it’s about value – the changing ways in which healthy practices matter, and the changing ways in which what it is to be healthy are valued. Medicine has always existed in a moral economy, has always been made and practiced in a context where value matters. Imagining that pharmacological production -because it happens in laboratories and scientists do it – is a neutral process, a neutral reaction to empirical fact, isn’t right. I don’t think you’ve said this, but I just wanted to say it.

    Also, I’d argue that patient advocacy does a lot to disable any kind of Platonic-human-experience making which remains exclusively under the remit of Big Pharma. Desire and value plays a role too. A woman prescribed a cocktail of drugs to treat manic depression has an effect when she refuses one brand because it reminds her of death, and accepts another when the pill reminds her of “a little blue egg, full of hope”.

    Interestingly, the UK-based charity the Wellcome Trust spends more than £600 million on funding health research per year, which is, so I’m told though I should check my facts, more than the UK government. The Wellcome Trust was born out of a pharmaceutical empire spearheaded by the eccentric quasi-anthropologist Henry Wellcome, which was in turn, more recently (1995?), subsumed by Glaxo Smith Kline.

    Also, although I should read Hari’s piece first, I’m tempted to argue that as it’s becoming nearly impossible to consider health research as separate from the business of pharmacology, it’s a little redundant of Mandelson to be proclaiming that research should be directed towards commercial ends. Sadly. Agree? What to do?

  3. I feel we need a bit of devil’s advocate – below isn’t the strongest argument ever, but…

    Firstly, it’s easy to blame big pharma but they’re just doing their job – making money. Surely we have to look behind them, at the regulatory procedures that allow them to behave in the way they do, where it’s actually much harder to apportion blame, and much harder to see an alternative.

    It has been argued that this whole approach – creating a disease in order to cure it – emerged back in the 60s when US regulators tried to crack down on the dangerous and unregulated drugs market. At the time, charlatans were making all sorts of outrageous claims for all sorts of untested and potentially dangerous crap, so government tried to control it. As part of that, they insisted that drugs had to cure a specific disease. This makes sense, because if you’re going to ask for evidence of efficacy, you need to have something against which you can measure that. It worked well for more directly biological problems, (like smallpox, or perhaps even erectile dysfunction), because it got rid of all the drugs that claimed to cure it but didn’t (you can see the consequences of a system without regulation in a South Africa that refused to crack down on Matthias Rath).

    However it didn’t work so well for more psyhcological ailments. It meant companies could no longer sell ‘tonics’ that just promised to make you feel generally better, but instead had to start promoting diseases so they could market the cure. Most famously in anti-depression drugs (the company behind the first big anti-depressant distributed a free copy of ‘how to recognise depression’ to every GP in the US, along with their flyer).

    The question is, what do you do about it? Presumably we still want a mechanism for regulating drugs, and presumably we still want a system that produces new drugs. Drugs companies are good at coming up with small incremental improvements to drugs – fueled by the patent system – which do make life better. My mum’s just finished a course of chemotherapy, which I imagine was significantly less traumatic than it would have been 10 years ago, as minor refinements have decreased the side effects and improved its efficacy. We can’t take for granted the enormous amount of good drugs companies have done, even if they havne’t done good intentionally.

    If you want to stick with pharma but solve it through regulation, then how do you draw the line between something that is a disease and something they’ve invented? Depression drives thousands of people to kill themselves each year – it’s hard to argue that’s not real. Can you suggest a viable method? Alternatively, perhaps we abandon pharma and try relying on the state instead. But universities have no track record of bringing drugs to market, and it’s hard to imagine them doing it very well. I don’t think appealing to pharma’s better natures is going to work.

    Perhaps, when it comes to westernised ‘lifestyle’ medicines, we have to take some responsibility as society. Rather than blaming drugs companies we need to accept that we’re the ones falling for it. If they successfully create a market then that market exists – if we have a problem with it then we’d better address the market, not just shout indignantly at the drugs companies. It’s like blaming the media for reporting things we don’t like. I’d be interested to know the social demographics of people being put on or buying these drugs. (By the way, I think patent rights for poor countries is a very different issue – in that case we do need a mechanism, like the patent pool, whereby the market can be distorted).

    Secondly and very quickly, in Sahil’s reply to the first post he mentioned the story about lapdancers getting more tips. I think you’re confusing observation with interpretation. The point of scientific study (perhaps less rigorously applied in social science, I admit), is that a scientist measures something and then publishes it, clearly laying out their methods and their results. They also draw conclusions, but to some extent (and obviously not completely) the two processes are separate. You can certainly disagree with the conclusion that women lapdance more provocatively because they’re at a more fertile time of the month, but if you want to disagree with the finding that women receive more tips during ovulation than at other times of the month, then you have to find flaw in the method, not the sexual politics. Perhaps the researcher didn’t take a representative sample of the women, or didn’t reliably find out how much they received in tips, or biased their results in some other way. This could be because they were trying to proove what they believed to be true, but you still need to find the flaw in the method…

  4. A quick reply on the one issue, scientific study and social scientific study should remain methodologically separate for the reasons you outline. If social scientists were involved simply in beard-stroking acts of (partially blindfolded) observation then that’s fine, if pointless.

    But patently they are not, and the method they adopt is not an asocial space closed off from critique on social grounds. So if you can make an observation (which, I should add, involves pretty choppy waters morally) and choose to publish it (often funded by public money as well) you cannot simply stand aside and say – “I obverse A = B, which implies A causes B, but I’ll leave you to say that”.

    It’s not good enough because explanation, in positivist approaches like this, derives directly from observation.

    The method is wrong because it cannot account for the complexities and social influences that form the observation. So you get things like this:

    “As for the prostitutes and their use of condoms, economists interviewed many working girls and discovered that they would often leave a condom unused in exchange for a 25 per cent increase in pay. That may strike you as likely to be a result of their lack of education, until you discover that the danger money negotiated by the prostitutes was very similar to the premium in pay received by lumberjacks, soldiers, firefighters and other people in risky professions. They risk their lives for money, but it’s carefully calculated, well-informed and disturbingly rational risk” – in The Logic of Life, by Tim Hardford (another version of Freakonomics).

    That is an interesting observation, but I find it completely inadequate to collapse the complexity of the that socialised moment (women working as prostitutes, men finding condom use undesirable, there being a risk of HIV/AIDS etc etc) into the explanation of a “rational choice”. The positivist approach takes as a given all the social structures (patriarchy, poverty, etc) that a richer approach would problematise. In doing so it masks more than it reveals.

  5. Looking at the history of medical advances I thought some consideration of smallpox might be interesting. Sahil referred to this in an earlier post so in brief:

    A guy called Edward Jenner was a kind of country doctor from Gloucestershire who heard about a rumour that milkmaids rarely got small pox and a theory that exposure to cow pox was providing some form of protection. In 1796 he took extracts from a cow pox ‘pustule’ on the hand of a milkmaid and inserted it into an incision of the 8 year old son of his gardener. 6 weeks later Jenner injected him with small pox to no effect.

    He published a study stemming from this work in a paper which described how his vaccine inoculation, from the Latin ‘vacca’ meaning cow. In a stroke inventing the science of immunology. Unlike a modern pharmaceutical, Jenner set out to make the discovery available to as many people as possible. Even building a shed in which he vaccinated people for free in his garden. The treatment was not patented or protected and Jenner declared ” No matter what trials and tribulation lay before me, to dedicate the whole of my life ridding the world of small pox”.

    If you like you can read Jenner’s original papers on small pox here: http://www.bartleby.com/38/4/

    I’m not sure what this tells us about how Pharma could be reformed, but it is a good yarn. I think this illustrates how when science and medicine were the preserve of the independently wealthy, the issues were certainly different. He never tried to profit from his work, but he did test out his theory on the hired help. In a system where we don’t rely on those that pursue knowledge for its own sake for medical innovation, someone still has to pay.

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