‘I think these people are drug pushers, just like street drug pushers … It is outrageous that these people pushed this drug, addictive as they knew it was, onto the market and in effect damaged millions of innocent people.’
Three top executives were excluded from government business for 12 years.83 Purdue trained its salespeople to tell doctors that the risk of addiction was less than 1%, which isn’t true, as the risk is similar to that of other opiods.82
Purdue gave Massachusetts General Hospital in Boston $3 million to have its pain centre renamed as ‘MGH Purdue Pharma Pain Center’.18 The agreement also involved that the pain specialists at the hospital should use ‘Purdue-designed curriculum written, in part, to encourage wary doctors and pharmacists to prescribe pain-killers such as OxyContin.’ Total corruption.
In Denmark, OxyContin was also extremely aggressively pushed, to such an extent that it became a common conversation subject even among doctors who rarely use morphine-like drugs. The salespeople were like tsetse flies going after everything that moved in a white coat. The drug is highly expensive and provides no advantage over far cheaper alternatives, but even so, it proved necessary for the drug committee at my own hospital to ban the drug altogether, so that the clinicians could no longer order it from the pharmacy.
The crimes are so widespread, repetitive and varied that the inescapable conclusion is that they are committed deliberately because crime pays. The companies see the fines as a marketing expense and carry on with their illegal activities, as if nothing had happened.
It is also important to note that many of the crimes would have been impossible to carry out, if doctors had not been willing to participate in them. Doctors are complicit in the crimes when they accept kickbacks and engage in other types of corruption, often in relation to illegal marketing. It is curious that doctors can get away with getting paid by the companies for doing exactly this without being punished. When drugs are marketed for non-approved uses, we don’t know whether they are effective or whether they are too harmful, e.g. if used in children. This practice has therefore been described as using the citizens as guinea pigs85 on a large scale without their informed consent.
Even when doctors use drugs only for approved indications, the crimes have consequences for their patients. Doctors only have access to selected and manipulated information16,17,18,19,20,21,22,42 and therefore believe drugs are far more effective and safe than they really are. Thus, both legal and illegal marketing lead to massive overtreatment of the population and a lot of harm that could have been avoided.
Many crimes involve large-scale corruption of doctors who receive money to induce them to prescribe drugs that are often 10 or 20 times more expensive than older drugs that are equally good and sometimes even better. The US Office of the Inspector General of the Department of Health and Human Services has warned that, as many of the existing practices involving gifts and payments to doctors are intended to influence their prescribing, they might potentially violate federal anti-kickback laws.69 Unfortunately, the only organisation that seems to have taken the writing on the wall seriously is the American Medical Student Association, which voted for a total ban on the acceptance of all gifts and favours to medical students.69
It’s organised crime
In 2004–5, the Health Committee in the British House of Commons examined the drug industry in detail17 and found that its influence was enormous and out of control.86 They found an industry that buys influence over doctors, charities, patient groups, journalists and politicians, and whose regulation is sometimes weak or ambiguous.87 Furthermore, the Department of Health is not only responsible for the national health service but also for representing the interests of the drug industry. The committee’s report made it clear that reducing the influence of industry would be good for everybody, including the industry itself, which could concentrate on developing new drugs rather than on corrupting doctors, patient organisations, and others.88 The report also said that we need an industry that is led by the values of its scientists, not those of its marketing force, and the committee was particularly worried about the increasing medicalisation, i.e. the belief that every problem requires a pill.
Nevertheless, the British government did nothing in response to the Health Committee’s damning report, likely because the British drug industry is the third most profitable activity, after tourism and finance.88 After having been shown unequivocal and massive evidence of unhealthy industry influence on public health, government officials declared that there was no evidence of unhealthy industry influence on public health!89
The Department of Health defended the industry, citing its trade surplus of more than £3 billion and argued that drug company representatives were giving doctors good information. It even defended the rising numbers of prescriptions for antidepressants although this is pretty indefensible, as I shall explain in Chapter 17. Alleged promotional excesses were dismissed with the argument that appropriate mechanisms were in place. This is what Ben Goldacre calls ‘fake fixes’.90 The public is repeatedly given false reassurances that the problem has been fixed.
When asked directly about whether the department understood that there was a fundamental conflict between the industry’s drive for profit and the government’s responsibility for public health, the reply was that the ‘stakeholder relationship’ between government and industry ‘brings many gains and many innovative medicines … with huge impacts on health outcomes’.
I’m speechless. With a governmental attitude of total denial it’s no great wonder that crime flourishes in the drug industry and spreads like weeds.
The centrepiece of the US Organized Crime Control Act from 1970 is the Racketeer Influenced and Corrupt Organizations Act (RICO).91 Racketeering is the act of engaging in a certain type of offence more than once. The list of offences that constitute racketeering include extortion, fraud, federal drug offences, bribery, embezzlement, obstruction of justice, obstruction of law enforcement, tampering with witnesses, and political corruption. Big pharma does so much of this all the time that there can be no doubt that its business model fulfils the criteria for organised crime.
A previous global vice president of marketing for Pfizer turned whistle-blower when the company wouldn’t listen to his complaints about illegal marketing5 holds a similar view:92
It is scary how many similarities there are between this industry and the mob. The mob makes obscene amounts of money, as does this industry. The side effects of organized crime are killings and deaths, and the side effects are the same in this industry. The mob bribes politicians and others, and so does the drug industry … The difference is, all these people in the drug industry look upon themselves – well, I’d say 99 percent, anyway – look upon themselves as law-abiding citizens, not as citizens who would ever rob a bank … However, when they get together as a group and manage these corporations, something seems to happen … to otherwise good citizens when they are part of a corporation. It’s almost like when you have war atrocities; people do things they don’t think they’re capable of. When you’re in a group, people can do things they otherwise wouldn’t, because the group can validate what you’re doing as okay.
When a crime has led to the deaths of thousands of people, we should see it as a crime against humanity. Whether they are killed by arms or by pills should make no difference for our perception of the misdeed. But, until recently, there was a remarkable complacency with even lethal crimes. This may be about to change, at least in the United States. In 2010, the Justice Department charged a former vice president for GlaxoSmithKline.34
One of the pharmaceutical industry’s standard responses when scandals are revealed in the media is that its practices have changed radically since the crimes were committed. This isn’t true; in fact, the crimes are steeply increasing. According to Public Citizen’s Health Research Group, three-quarters of the 165 settlements comprising $20 billion in penalties during the 20-year interval from 1991 to 2010 occurred in just the past 5 years
of that period.93 An update showed that in just 21 months, till July 2012, an additional $10 billion in settlements were reached.94
In contrast to the drug industry, doctors don’t harm their patients deliberately. And when they do cause harm, either accidentally, by lack of knowledge, or by negligence, they harm only one patient at a time. As the actions of senior executives in the drug industry have the potential to harm thousands or millions of people, their ethical standards should be much higher than those of doctors, and the information they give about their drugs should be as truthful as possible after meticulous and honest scrutiny of the data. None of this is the case, and when journalists ask me what I think of the ethical standards of the drug industry, I often joke about it and say I have no answer as I cannot describe what doesn’t exist. The only industry standard is money, and the amount of money you earn to the firm decides how good you are. There are many decent and honest people in the drug industry, but those who make it to the top have been described as ‘ruthless bastards’ by criminologist John Braithwaite who interviewed many of them.12 In the United States, big pharma beat all other industries in terms of crimes. They have more than three times as many serious or moderately serious law violations as other companies, and this record holds also after adjustment for company size.12,61 Big pharma also has a worse record than other companies for international bribery and corruption and for criminal negligence in the unsafe manufacture of drugs.12 In a 5-year period, from 1966 to 1971, the FDA recalled 1935 drug products, 806 because of contamination or adulteration, 752 because of sub- or superpotency and 377 because of label mix-ups.61
Bribery is routine and involves large amounts of money. Almost every type of person who can affect the interests of the industry has been bribed: doctors, hospital administrators, cabinet ministers, health inspectors, customs officers, tax assessors, drug registration officials, factory inspectors, pricing officials and political parties. In Latin America, posts as ministers of health are avidly sought, as these ministers are almost invariably rich with wealth coming from the drug industry.12
In the beginning of this chapter, I asked the question whether we are seeing a lone bad apple now and then, or whether pretty much the whole basket is rotten. What we are seeing is organised crime in an industry that is completely rotten.
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