How Tainted Is Medicine?

Correspondence in the Lancet Vol. 359, No. 9319 18 May 2002:

Sir-In your brave April 6 editorial (1) you have finally outlined some important features of the perverse relations between multinational pharmaceutical companies and doctors worldwide. However, you miss one very important point: it is increasingly difficult (not to say practically impossible) for clinicians, and I suspect also scientists, to give invited lectures or to chair sessions at national or international meetings (including those of reputed scientific societies) wthout their names being suggested by the drug companies sponsoring the event, or without the companies permission.

Lectures are given on the same topic by the same speakers all over the world for years, and the free debate and exchange of contrasting opinions is, de facto, banned. It was not the same 20 years ago, but in the past 15 years this trend has become a rule, to the damage of medicine and freedom. Many speakers and chairmen have also contributed to clinical practice guidelines.

What you call important research must absolutely be funded not by drug companies but by charities-again, really independent and not supported by drug companies-or by national health institutions. The independence, expertise and seriousness of members of granting bodies in such national institutions should be carefully assessed and guaranteed, which is again a very difficult aim to reach. Whenever a drug company funds research (however important and apparently independent it seems) it must, in one way or another have commercial gain in return; this is right and justified if research is done within the company, not so if funded outside, such as in universities.

It is time to reconsider very seriously the support of drug companies for research and meetings organisation. There are no strong reasons to continue to pursue a policy that will bring, as you rightly outline, medicine into disrepute and will hinder rather than favour real scientific progress.

Sandro Vento

Department of Pathology, Section of Infectious Diseases, University of Verona, Via Morosini 7, 37138 Verona, Italy (email ventosandro@yahoo.it)

1. Editorial. Just how tainted has medicine become? Lancet 2002 359:1167


Sir-As family physicians we read, and resonated with, the concerns you express (1). We think you were mainly aiming your criticisms at journal editors and consultants who accept money from big pharma, thereby losing any possibility of maintaining objectivity, perspective and impartiality.

We suspect that the malaise goes deeper still. We drafted this letter with a pen advertising pantoprazole. We drink coffee from mugs advertising doxazosin and lansoprazole. Our mouse mats advertise celecoxib.

We sense that big pharma is now rapidly setting an agenda that makes commercial sense for them, but which may or may not be justified in terms of benefit to patients. Direct-to-consumer advertising and other awareness-raising activities can bring to light cases of disease that otherwise would go undiagnosed and untreated. Doctors are being pushed in the direction of treating lower levels of the iceberg of disease.

There are, however, two questionalble assumptions behind this strategy. First that every disease must be discovered, and second that treatment is best done using drugs. The current example is controvesy over what to do about asymptomatic prostate cancer (2).

Another illustration is provided by obesity and type 2 diabetes. The drugs industry develops drugs for this expanding market. Guidelines are issued supporting the use of expensive drugs to treat obesity (3, 4). No-one stops to ask just why we are starting from here? And could we start from somewhere else please? Treating obesity with drugs is about as honest and effective as treating jaundice with camouflage cream.

The difficulty for us as family physicians is that an unbalanced agenda is being set, with big pharma doing what it does very well, and with no counterbalancing forces coming from government-backed research or from within the profession itself.

The result is that the big, clinically useful, randomised, controlled trials that inform our day by day treatment of patients are all coming from drug company research. Somewhat unsurprisingly these trials all show that powerful drugs work well. How many trials of unsuccessful treatments are published or noticed?

Who in the National Health Service is developing other ways of thinking about medicine? Who is thinking about new systems of care that may involve self-care, empowerment of patients, exercise and non-pharmaceutical techniques? Who has an overview that can allow us to see beyond the next prescription?

We feel we are becoming like the man with the hammer to whom everything looks like a nail. Each diagnosis is simply becoming a product opportunity waiting to happen. We are becoming, willingly or unwillingly, agents of big pharma, prescribing a pill for each ill.

Peter Davies, Seth Jenkinson

Mixenden Stones Surgery, Mixenden, Halifax HX2 8RQ UK (email: npgdavies@doctors.net.uk)

1. Editorial. Just how tainted has medicine become? Lancet 2002 359:1167

2. Yamey G, Wilkes M. The PSA Storm, BMJ 2002; 324:431

3. Guidance on the use of sibutramine for the treatment of obesity in adults: technology appraisal guidance no 31. London: National Institutes for Clinical Excellence, 2001

4. Yanovski SZ, Yanovski JA. Obesity. N Engl J Med 2002; 346:591-602


Sir-Hard on the heels of your timely Editorial (1) you publish your April 13 news item (2) on a clinical trial undertaken in the USA on St John's wort and major depression (3). The title of the news piece implies that the herbal preparation from the yellow-flowered plant does nothing to mellow the mood in the treatment of depression, contrary to previous reports (4).

Financial sponsorship of the trial is credited to the National Centre for Complementary and Alternative Medicine (US) and the National Institutes of Mental Health (US). In other words, the US government. Impeccable indeed, or was it? Under financial disclosures, we learn that the principal investigator alone holds stock in Pfizer, American Home Products, GlaxoSmithKline, Wyeth-Ayerst, Lichtwer and the American Psychiatric Association, has been a scientific adviser to Allergan, Solvay, Pfizer, GlaxoSmithKline, Forrest Pharmacuticals Inc, Ely Lilley, Ancile, Roche, and Organon. Unbiased?

DW is a part time independent consultant to Lichtwer Pharma

David Wheatley

69 Broughton Avenue, Richmond, Surrey TW10 7UL UK

1. Editorial. Just how tainted has medicine become? Lancet 2002 359:1167

2. Larkin M. St John's wort not effective for major depression, report US researchers. Lancet 2002; 359:1317

3. Hypericum Depression Study Group. Effect of Hypericum perforatum (St John's wort) in major depressive disorder. JAMA 2002; 287:1807-14

4. Linde K, Mulrow CD. St John's wort for depression (Cochrane review). In: The Cochrane Library, issue 2. Oxford: Update Software, 1999.


Sir-We notice that you illustrate your Editorial (1) with a reference to the editor of the British Journal of Psychiatry. The ghost writing of academic articles has also been of concern for you, the British Medical Journal, the Journal of the American Medical Association and the New England Journal of Medicine.

Although ghost writing and editors conflicts of interest may be a concern, the primary issue seems to lie in the potential discrepancy between the reports editors publish or that academic investigators put their names to, and the raw data. If there is no discrepancy, it could even be said that an editors's connections may facilitate the publication of important studies, and ghost writers may ensure a more rapid publication of better written articles. However, if discrepancies exist, your policy of asking editors to divest themselves of all such commercial links upon assuming their duties is no real protection against reports that show only part of the data.

Given that there are good grounds to think there are serious discrepancies between publications in your journal, the Journal of the American Medical Association and the British Medical Journal, as well as the British Journal of Psychiatry, and the datasets from which they derive, we call on you to advocate the only logical answer to the problem-a refusal to publish studies without the entire raw dataset being made available.

G E Berrios, D Healy

Department of Psychiatry, University of Cambridge and Robinson College, Addenbrookes Hospital, Box 189, Cambridge CB2 2QQ, UK (email: geb11@cam.ac.uk)

1. Editorial. Just how tainted has medicine become? Lancet 2002 359:1167