A bone mineral density test can only predict one-sixth of future hip fractures,20 but despite such sobering observations, the test has become the gold standard for deciding which people to treat. Consumer sites on the internet are usually industry sponsored and they say that the test is good and predicts the risk of fracture, whereas health technology assessment organisations say the opposite.20 The effect of the drugs is small, even for women at high risk of fractures: If 100 women who have already had a vertebral fracture are treated, one hip fracture is perhaps prevented.21 I say perhaps because several studies suggest that long-term treatment leads to the opposite effect, an increase in hip fractures,22,23,24 which may be explained by the fact that the new bone induced by the drugs is not of the same type as bone formed naturally.
Moreover, people who are told they have brittle bones may stop exercising, which is a bad idea, as it strengthens the bones. A woman I knew who was perfectly healthy received a bone scan for no good reason and was told she had brittle bones. She was very fond of her sports, but stopped immediately, as she feared falling and breaking a bone. So, already the diagnosis pestered her life and it also increased her risk, as exercise prevents fractures. It’s bad medicine to screen healthy people without knowing from randomised trials that screening does more good than harm. That’s not the case for osteoporosis; there are no trials of screening. I don’t say that no one should be treated; I am only saying that far too many are being treated. The industry must be immensely grateful for the WHO group’s assistance, as the industry sells its drugs also for osteopenia, which is a market of around 400 million women.
The osteoporosis-osteopenia madness has been subject to many jokes. Should we also treat those at risk of being at risk (those with osteopenia who may cross the arbitrary border to osteoporosis when they get older)?19 When a colleague of mine left his home for a skiing holiday, he remarked that he now suffered from a prefracture.
Another joke, which unfortunately is taken seriously, is that people hold conferences about prehypertension, which starts when your diastolic blood pressure climbs over 80 mm Hg. Here is a tragedy: the American Heart Association recommends to screen children for high blood pressure, starting at age three.25 We showed in our review of health checks that screening for hypertension (at any age) isn’t beneficial.13,14
We also have prediabetes. Trials have been performed to demonstrate that by treating healthy people with a glucose-lowering drug, you can lower their risk of developing diabetes.26 That is a marvellous joke. Since the diagnosis depends on the blood glucose level, it wasn’t necessary to conduct trials, as the result was given, a sort of circular evidence. Therefore, once drug treatment stops, there isn’t any difference in the incidence of diabetes, so the drug didn’t prevent anything from happening. The whole exercise was one of boosting sales of drugs like rosiglitazone, which was investigated in such a trial, the DREAM trial.26 The dream was a nightmare, as the drug kills people. A further point is: how would you find healthy people and start treatment? This cannot be done without screening and we showed in our review of health checks that screening for diabetes doesn’t work. It doesn’t reduce morbidity or mortality.13,14
It’s seducingly easy to convince healthy people to take drugs they don’t need for a disease they don’t have. The Australian artist, Justine Cooper, invented a hilarious hoax,27 which can be seen on YouTube.28 It looks like a TV commercial and advertises Havidol (have it all), with the chemical name avafynetyme HCl (have a fine time plus hydrochloric acid). Havidol is good for those who suffer from dysphoric social attention consumption deficit anxiety disorder (DSACDAD). Feel empty after a full day of shopping? Enjoy new things more than old ones? Does life seem better when you have more than others? Then you may have the disorder, which more than 50% of adults have. The ad says that Havidol should be taken indefinitely, and that side effects include extraordinary thinking, dermal gloss, markedly delayed sexual climax, inter-species communication and terminal smile. ‘Talk to your doctor about Havidol.’ Some people believed it was for real and folded it into real websites for panic and anxiety disorder, or for depression.
An even more hilarious video on YouTube29 featured Ray Moynihan as the victim,27 the journalist who wrote Selling Sickness with Alan Cassels. It’s about an epidemic – motivational deficiency disorder – first announced in the BMJ’s 1 April issue in 2006,30 and like Havidol, it was believed by some people. In its mild form, people cannot get off the beach, or out of bed in the morning, and in its most severe form it can be lethal as the sufferer may lose the motivation to breathe. Moynihan says ‘All my life people have called me lazy. But now I know I was sick.’ The drug is Indolebant, and its champion, neuroscientist Leth Argos, reports how a patient’s wife telephoned him and was in tears. She said that after using Indolebant, her husband had mowed the lawn, repaired the gutter and paid an electricity bill – all in one week.
I shall let big pharma get the last word in my book, so here is your final laugh, offered by Stephen Whitehead, chief executive of the Association of the British Pharmaceutical Industry, in the BMJ in October 2012 in response to an article that was critical of the drug industry. I bring it in its entirety:31
McCartney makes several disparate claims about the drug industry. She states that the financial relations between charities and the industry are ‘unclear’ and implies that this unduly influences the daily activities of the third sector. In reality, the Association of the British Pharmaceutical Industry’s code of practice requires that companies publicly declare their financial transactions with charities and the nature of their relationship. Those who fail to meet their obligations are subject to sanctions of the Prescription Medicines Code of Practice Authority – the arm’s length administrator of the code. Charities are protective of their independence and wholly committed to the patients they serve – any malign influence is fiercely resisted.
Secondly, medical representatives do seek to engage with clinicians to educate them on the latest available treatments. There are strict rules about how this is conducted. I think it is important that clinicians are offered the chance to learn about new and innovative drugs and make their own decisions about their suitability for patients.
Finally, cooperation and partnership between the drug industry and the wider health community are valuable, despite negative preconceptions. By working together we can improve health outcomes, drive innovation, and save the NHS time and money. This should be, and is, conducted within strict guidelines that ensure commercial interests are secondary to patients’ needs. This drive towards closer working has not been pushed by the drug industry but by all healthcare stakeholders. Earlier this year a range of signatories, including the Department of Health and the medical royal colleges, approved principles for working in partnership with the life sciences sector for the good of patients.
It may be fashionable to criticise the drug industry, but we shouldn’t be quick to criticise the good work done to help people live healthier lives.
What a level of irony at the highest levels in the drug industry. Talking about codes of practice, strict rules and strict guidelines as the panacea solution for an industry that is the worst of all industries in routinely breaking the law to such an extent that it is organised crime that results in the deaths of innocent people in huge numbers! It’s not only fake fixes, it’s the ultimate joke. After I had lectured at a Prescrire meeting in Paris in January 2013 about the pervasive crime in the drug industry,32 I had a chat with Alain Braillon who inspired me to finish my book with a cartoon.
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