Bad Pharma by @bengoldacre: the review

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English: Ben Goldacre speaking at TAM London O...

English: Ben Goldacre speaking at TAM London October 2009 (Photo credit: Wikipedia)

In one sense Bad Pharma: How drug companies mislead doctors and harm patients is the perfect book: this week I could read it, in two chunks over the exact time (to the minute) it took to me to fly to Eastern Europe and back.

Of course that alone would be a poor reason to recommend it, and there are plenty of others.

The sheer level of duplicity by the pharma companies and the scientific publishing companies is deeply depressing. The supine (or worse) attitude of the regulators just as bad.

Drug companies love to tell us how much it costs to develop a drug (though it turns out they fiddle the figures – adding in the opportunity cost of capital while, of course, ignoring any return – not so much the “double counting” that Ben Goldacre describes it as single entry book-keeping) – but how many of us know they spend more, much more, on marketing? That is their biggest cost and as Goldacre points out, most of that spend would be pointless if we had the information we needed – and could have – about which drug was more effective and which was not.

There remain annoyances in style – talking about “going forward”, writing of an an organisation “curating” data and a general tone which suggests he’s the clever scientist and we’ll all struggle with a bit of maths. But overall these are minor quibbles.

Overall, though, this is a polemic and so it would be good to see the response from the industry. Are they really the liars and frauds this book suggests they might be? Surely they cannot all be? Time for the industry to get its act together and issue a convincing reply if they want to rescue their reputation.

But Goldacre does deal with a few of the points that concerned me after the first chunk (the second half was better, as it goes).

On “me too” drugs he makes a reasonable case that companies could make a good return if regulators insisted on “better” and not just “the same”. The economics of that would be interesting to see, but I think I’d give that to Goldacre on points. More seriously even that the waste of money that many of these “me too” dugs represents is the fact that they may actually be less effective than the off-patent molecules they are replacing – the complete lack of rigour in the drug testing regime means that “me too” is essentially only validated against a placebo or a deliberately broken dose of a rival.

The book makes me worry about science in general. Much of the trickery, knavish and foolish behaviour by manufacturers, medics and scientific publishers could have direct analogues in other scientific fields, especially where a financial return is at stake (and for academics under pressure to make an “impact” that could mean everywhere). Medicine seems to be particularly broken, but the book has given me cause for concern about science in general.

One thing that is missing from Goldacre’s various lists of actions to be taken is a serious examination of how to influence public policy via politics. This is where his innate hostility to politicians seems to obscure his vision. Few politicians are likely to read this book from cover to cover – but some might, as I know some British MPs have already expressed concerns about “medicalisation” and “disease mongering” and the impact this is having on some of the most vulnerable. But there is surely no reason why MPs and eventually ministers should not take action on many of the points raised.

Of course, big pharma has many resources and big lobbying to fall back on (declaration of  – former – interest: in a past life I have been, indirectly, part of this) but  there are a few points to bear in mind in constructing a case to convince politicians: (1) no one serious is trying to close big pharma down, this is about reform not destruction, (2) big pharma will threaten to shift resources elsewhere – but what state wants to pay over the odds for duff medicines? Their bluff can be called (as, in his way, President Obama has already done over ACA) and (3) state medical services are amongst the most expensive public enterprises, only defence costs come close – that is a powerful, popular and populous answer to any threatening sabre rattling by recalcitrant drugs companies.

In the end, though, my gut feeling is that pharma will co-operate with a setting of the house in order. And as medicine in most developed countries is a monopsony they will have little choice in any case.