The face of ‘Pharmageddon’

Charles Medawar – Social Audit Ltd

Next year, Health Action International (Europe)1 is
planning a conference on Pharmageddon? The question
mark denotes a hypothesis – a tentative, possible
truth, but well worth exploring.
To mark and support the occasion, Social Audit2 has
published an unusual, “Call for Abstracts” – inviting
contributions either for or against the essential proposition,
along with an offer of grants/prize money
of E 15,000 for the best received.
The rewards on offer are underwritten by a grant
from The Allen Lane Foundation (he founded Penguin
Books), and the rules are simple. We are looking
for submissions – reflections either for or
against – of no more than 350 words, and the closing
date is 31 December 2007. For further information
and the rules, please check the What’s New?
(from July 2007) at www.socialaudit.org.uk

Pharmageddon? The word is unfamiliar, its significance
unclear, but already it has the beginnings of meaning: it is a
concept that has now been formally defined as “the prospect
of a world in which medicines and medicine produce more ill-health
than health, and when medical progress does more harm
than good”.
This definition emerged from a small seminar held in London,
six months ago. After weeks more drafting, the critical
minds involved agreed both a definition of the problem and
a formal statement of what is to be feared and why. For details,
see www.socialaudit.org.uk.
The point of this initiative is neither to prove nor reject the
possible threat. We resolved simply to investigate and explore
the risks that might be involved. It follows that the submissions
we receive, and the conference planned by HAI(E)
may reflect quite polarised views. That’s fine; the only problem
would be studied indifference or mindless and concerted
opposition.
A paradox of progress?
Our working definition embraces several key ideas. One is
the thought that Pharmageddon represents, like Climate
Change, a classic ‘paradox of progress’. Individually, we may
still crave, enjoy and benefit from countless energy-dependent
benefits (e.g. air and car travel, home heat and light,
and countless bits of more and less essential equipment) –
yet collectively we seem to be sinking.
Between us, we also retain a strong capacity for resistance
to, and denial of, unpalatable reality. Thus, we still worship
fast cars and gaze at TV car commercials that promise the
freedom of hill-tops and lonely beaches, even as we sit in raffic
jams. The reality sinks in only after buying a new car:
later, the shine wears off and depreciation sets in.
As clinical practitioners, or individual consumers with access
to medicines, most people have seen, felt, witnessed
and/or imagined their sometimes miraculous effects and results.
But, to pursue the analogy, the risk of Pharmageddon is
to do with the way in which all drug travel changes the climate
of health, even when so many drug journeys seem vital
or worthwhile.
“Parallels seem to exist between health and environmental catastrophe.
The issues compare to the relationship between a car
journey and Climate Change: they are inextricably linked, but
not remotely connected in scale or relevance in the average driver’s
mind. Just as Climate Change seems inconceivable as a
journey outcome, so most personal experience of medicines flatly
contradicts the notion of Pharmageddon.”
Both because and in spite of all the benefits of good medicine,
it seems crucial to consider whether, collectively, we are
rapidly losing sight and sense of health. Increasingly it
seems this may be so. At least we need to challenge the dominant
fallacy that drugs more and more resemble magic
bullets and offer ever better solutions for the main trials of
life.
Over- and under-medication
The major pharmaceutical companies (the Pharmas) face a
critical problem – what is formally known as, ‘declining productivity
in drug innovation’. This problem was first publicly
acknowledged onwards from 2000 and is rapidly getting far
worse.3
New drug development (‘innovation’) created today’s Pharmas:
until recently, it was their economic lifeblood, their main
raison d’etre and source of growth. Now the cost of bringing
drugs to market is growing relentlessly, while output is falling;
the industry itself estimates that new drugs (<5 years
old) now account for only 16% of the top Pharmas’ total revenue.
4 Until about 2000, we rather took for granted the
economic immortality of the Pharmas; now there are real
doubts.
The continuing existence of the Pharmas depends on their
solving and/or adapting to this problem, but they have responded
mainly by increasing investment in marketing, lobbying
and public relations. The introduction of Direct-to-
Consumer drug promotion in 1997 underlines the present
trend – more aggressive and intrusive emphasis on products,
brands, ‘disease awareness’ and ‘health needs’. At the
same time, the Pharmas invest massively to secure systematic
and forceful involvement in professional, governmental
and public affairs.
The result has been the creation of new health climate in the
The face of ‘Pharmageddon’
Charles Medawar – Social Audit Ltd
Next year, Health Action International (Europe)1 is
planning a conference on Pharmageddon? The question
mark denotes a hypothesis – a tentative, possible
truth, but well worth exploring.
To mark and support the occasion, Social Audit2 has
published an unusual, “Call for Abstracts” – inviting
contributions either for or against the essential proposition,
along with an offer of grants/prize money
of E 15,000 for the best received.
The rewards on offer are underwritten by a grant
from The Allen Lane Foundation (he founded Penguin
Books), and the rules are simple. We are looking
for submissions – reflections either for or
against – of no more than 350 words, and the closing
date is 31 December 2007. For further information
and the rules, please check the What’s New?
(from July 2007) at www.socialaudit.org.uk

Pharmas’ main markets, especially the USA and EU, and a
growing tendency to overmedication. This threatens personal
and public health both directly and in other ways.
The most direct threat is iatrogenesis – personal, social and
cultural – resulting from increased clinical exposure and the
spread of ‘health anxiety’. Though he wrote long before the
drug marketing revolution, Ivan Illich (1974) remains the seminal
authority on this. He warned of the risks of medicalisation,
the generally dehumanising and damaging effects of
professional interventions: Beyond direct drug injury (clinical
iatrogenesis), he was concerned about the ill-effects of
medicine on culture and community, “the paralysis of healthy
responses to suffering, impairment and death” that resulted
from “the expropriation of health”.5 Writing in the early 1970s,
unsurprisingly, Illich pointed the finger at health professionals:
“the medical establishment has become a major threat to
health”, but the Pharmas have decisively gained the upper
hand since then.
In higher-income countries, the main indirect effect of overmedication
would be unsustainable demand on, and the ultimate
breakdown of, national health services.
Lewis Thomas (1979) wrote eloquently on this – again, long
before the drug marketing revolution:
“The trouble is, we are being taken in by the propaganda, and it
is bad not only for the spirit of society; it will make any healthcare
system, no matter how large and efficient, unworkable. If
people are educated to believe that they are fundamentally fragile,
always on the verge of mortal disease, perpetually in need of support
by health-care professionals at every side, always dependent
on an imagined discipline of ‘preventive’ medicine, there can be
no limit to the numbers of doctors’ offices, clinics, and hospitals
required to meet the demand. In the end, we would all become
doctors, spending our days screening each other for disease.
“We are, in real life, a reasonably healthy people. Far from being
ineptly put together, we are amazingly tough, durable organisms,
full of health, ready for most contingencies. The new danger to
our well-being, if we continue to listen to all the talk, is in becoming
a nation of healthy hypochondriacs, living gingerly, worrying
ourselves half to death”.6
The other key strand in the Pharmageddon hypothesis is that
over-medication and under-medication are, in global terms,
simply two sides of the same coin – and that a strong causal
link exists between the two. As richer countries succumb to
overmedication, they strengthen a drug establishment that
necessarily perpetuates health deprivation elsewhere. That is
the main problem for the two billion people worldwide who
cannot get the essential drugs they need; with improved access
to medicine we could save 10 million lives a year.
What of the future?
Pharmageddon underlines the need to be concerned about
the ‘health’ fate of our children and grandchildren – and
about the state of the global community that will increasingly
determine their health and well-being.
Meanwhile, we should not just ritually applaud the new
drugs that emerge, taking their merits for granted, especially
when they are sold at an average price that seems increasingly
uneconomic and unaffordable. We must try harder to
understand where we’re at and where we’re going; Pharmageddon
is a code-word for doing just that.
Pharmageddon is also about the future, the destiny of today.
How will it be when the whole shape of medicine is changing
– both the knowledge base and its applications - and
now that the pharmaceutical industry has come to dominate
the medical establishment and the thrust and ethos of drug
research, regulation, prescribing, availability and use?
If nothing else, Pharmageddon stands for the lament that the
state of world health represents a colossal waste of what medicine
and medicines could accomplish, by structurally harnessing
all the talent, energy and commitment that is there.
Increasingly, it seems this is not happening, and it is neither
morally defensible, nor in the best interests of our future. It
is damaging to the climate of health, the oxygen of community
and the core of personal well-being.
There surely are problems but, at the same time, we need to
accept that Pharmageddon is not just the product of greed or
malevolence, but the natural outcome of something more
like a ‘conspiracy of goodwill’ – a universe driven by self interest,
but dominated by a complex of corporate bodies all
competing to survive. If Pharmageddon seems to beckon, it is
in spite of what everyone wants, not because of it.
Many people have concerns about many different flaws in
the present system of pharmaceutical medicine, but what do
they all add up to? Our starting point is simply that the
word, Pharmageddon, may mean something important and
deserves to exist, if only as a description of forest rather than
trees.
If you have read thus far and have an open mind, perhaps
you would like to flex it? You have until the year end, to submit
a <350 word abstract (not the paper) for any presentation
you would want to give or hear at the inaugural conference
on Pharmageddon?
Thanks to the Allen Lane Foundation, the prizes are substantial
– and please bear in mind that the point of this competition
is to procure merit, whatever your point of view. The
judging will be blind: the only instruction judges will get is
that imagination and intellectual hygiene count most. The
prizes/grants are on offer for views that go either way.
Charles Medawar
Director, Social Audit Ltd
P O Box 111
London NW1 8XE UK
Endnotes
1 HAI Europe, part of the global HAI network, is a regional network
members from Europe and North America (and sometimes
beyond), and has a core staff in the regional coordinating
office based in Amsterdam. HAI Europe’s current focus areas
are: medicines prices (tackling the challenges of price, affordability
and availability); drug promotion (educating to improve critical
appraisal); essential Innovation, research and development
(to meet public health needs), and public-private Interactions,
(enhancing equitable access to HIV/AIDS medicines and the
benefits and risks of public private interactions). HAI Europe
has received funding for core and/or project work from: - Netherlands
Ministry of Foreign Affairs, Netherlands Ministry of
Health, Welfare and Sport, Swedish International Development
Cooperation Agency, Danish Ministry of Foreign Affairs,
Finnish Ministry of Foreign Affairs, British Department for International
Development, World Health Organisation, Rockefeller
Foundation, Ford Foundation, MEDICO, Medecins Sans
Frontieres, Oxfam GB, and HAI Europe membership fees. See:
www.haiweb.org.
2 Social Audit Ltd was set up as an independent, non-profit organisation
in 1972, to act as the publishing arm of Public Interest
Research Centre Ltd, a Registered Charity (No 1112242). Our
aim is to ask timely questions about the centres of power
whose decisions and actions shape public life. What, in social
terms, do these organisations give to and take from the community,
and how do they explain and justify what they do? We
have, for many years, specialised on issues relating to medicines
policy and drug safety. Our work has been funded mainly
with grants from a Quaker institution, the Joseph Rowntree
Charitable Trust; with core funding also from the Allen Lane
Foundation and the 1970 Trust. Individual projects have been
supported by other organisations including Consumers Association,
Social Science Research Council, Allen Lane Foundation,
Dag Hammarskjold Foundation, Nuffield Foundation, Ford
Foundation, MIND, Trocaire and War on Want. See:
www.socialaudit.org.uk.
3 Medawar C, Hardon A. Medicines out of Control? Antidepressants
and the Conspiracy of Goodwill. London: Social Audit,
2004. (Originally published by Aksant Academic Press, Amsterdam).
4 Centre for Medicines Research, International Pharmaceutical
R&D Factbook, Philadelphia and London, Thompson Scientific,
2007 (also reported on PR Newswire, 24 September 2007)
5 Illich I. Limits to Medicine - Medical Nemesis: the Expropriation
of Health, (London: Marion Boyars, 1976 (originally published
in Ideas in Progress, January 1975).
6 Thomas L. The health-care system, in The Medusa and the
Snail - more notes of a biology watcher, New York: Bantam,
1979.