The Money Trap

For more than 30 years, the physician Joel Lexchin has been a crusading Cassandra, warning Canadians of the commingling of interests between the medical profession and the pharmaceutical industry—and the dire risks it poses to drug safety and public health. His 1984 book, The Real Pushers: A Critical Analysis of the Canadian Drug Industry, foreshadowed by decades the rise of a booming literary genre devoted to the pharmaceuticalization of medicine—from Marcia Angell’s 2004 book, The Truth About Drug Companies: How they Deceive Us and What to Do About It, to Ben Goldacre’s Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients (2012).

Lexchin, a professor at the University of Toronto’s department of family and community medicine (he is also a professor emeritus at York University’s school of health policy and management), is a go-to source for journalists writing about drug safety, or the lack thereof. Many of these stories have been inspired by Lexchin’s own tireless research, including the headline that more than 100,000 Americans die annually from prescription drugs taken exactly as prescribed.

In August, Lexchin’s name also surfaced as a signatory on an urgent open letter sent by a group of physicians to then-federal health minister Jane Philpott calling for a Canadian equivalent of the U.S. Physician Payments Sunshine Act, which requires drug companies to report publicly any payment or gift of more than US$10 to an individual doctor. (Philpott responded that health care is a provincial matter; in September, Ontario introduced legislation that would reveal drug company payments and gifts to doctors, dentists, and pharmacists.) Their concern is warranted. Data gleaned from the 2010 U.S. legislation revealed rampant conflicts of interest between opioid manufacturers and U.S. doctors, with more than US$46 million paid out between 2012 and 2015. Another study showed links between payments received from statin manufacturers and doctors writing prescriptions for their brand name drugs, as opposed to generics.

Yet somehow Lexchin’s clarion call, one echoed by like-minded academics and physicians, has not ignited mass outrage or government action in Canada, even amid the current opioid crisis. The lack of traction could stem in part from the fact that Lexchin is not a showman; he writes policy papers with such titles as “Involuntary medication: The possible effects of the Trans-Pacific Partnership on the cost and regulation of medicine in Canada.” Moreover, his message may not be one that Canadians want to hear: that in drug safety, monitoring, and transparency, Canada lags far behind the U.S. and EU; that industry interests compromise the public health system; and that government inaction puts citizens at risk.

Such willful blindness is one target of Lexchin’s new book, Doctors in Denial: Why Big Pharma and the Canadian Medical Profession are Too Close for Comfort. In it, he identifies a “comfort zone” in which physicians—individually and in groups—believe taking money or gifts from drug companies won’t create bias or colour critical faculties, despite bountiful evidence that it does. It is precisely this kind of ego, ironically, that is targeted by industry when it solicits doctors to be “key opinion leaders” (KOLs), paying them thousands of dollars to speak at conferences or dinners to influence their peers’ prescribing habits.

But doctors, like all humans, are vulnerable to the “rule of reciprocity”—a sense of duty to repay a perceived act of kindness or a gift, Lexchin explains. This gift need not be big: One study cited shows that doctors wrote more prescriptions for a drug after its manufacturer paid for a $20 meal.

Given just how enmeshed the drug industry has become in health care—stealthily influencing what and how medical students learn, educating doctors about drugs, funding academic health centres and professional bodies, advertising in medical journals—the feeling of reciprocity runs deep. Nearly half of Canadian doctors, according to a 2016 study, receive some sort of industry remuneration. Their “continuing education” includes being pitched new drugs and devices over pepper-crusted ahi tuna in upscale restaurants or at luxe ski lodges. According to Lexchin, only one in ten of these newly approved therapeutic drugs offer a benefit to patients, and little is known of their safety before they come to market. Certainly doctors don’t get the complete story from pharmaceutical reps; Lexchin cites one meta study that concluded that representatives provide minimally adequate safety information in just 1.2 per cent of cases. The upshot, Lexchin argues in a book dense with statistics, research, and anecdotal examples, pits two diametrically opposed ideologies: medicine’s duty to public health and industry’s mandate to maximize shareholder profit. The losers, he believes, are public health and the citizen.

Doctors in Denial charts a history of cozy cooperation between the medical profession and industry dating from the 1950s. (Readers craving a recap of 1987’s Bill C-22, which amended the Patent Act, will find it here.) Doctors bought into industry talking points, Lexchin writes, including the threat that allowing lower-priced generics to enter the market would drive out pharmaceutical research and development in Canada. (In fact, even with patent extensions, R&D spending declined as a percentage of sales between 1988 and 2015.) One consequence: Canadians now pay $12.5 billion annually for prescription drugs; drug prices in this country are among the highest in the world. But the true cost is even higher, Lexchin argues. It gives us a health care system that focuses on drug therapies, before patient safety or care that does not involve pharmaceuticals.

Lexchin’s first exposure to industry-government-medical profession triangulation dates to 1973, when he was a first-year medical student at the University of Toronto. Drug industry education in the curriculum was an hour split between a pharma rep and a government rep talking about Ontario’s public drug plan, and around 20 pages of reading that was “mildly critical” of the industry, he writes. When Lexchin and a few other students argued that the panel wasn’t “well-balanced,” Lexchin was invited to join the panel. The pharma rep, outraged by what Lexchin calls “unfriendly” comments made during the session, didn’t return the following year.

The political embrace of neoliberalism a decade later played out in the health care sector, Lexchin writes, where federal and provincial governments, placing their faith in the power of the market, withdrew from “direct intervention and responsibility.” Into this breach, industry eagerly stepped, funding professional societies and health centres. Slashes to federal funding of scientific research created another gap to be filled. Industry spent $107 million to fund research at Canadian universities and hospitals in 2014, Lexchin writes; the book provides a chart showing that the medical school at McMaster University, in Hamilton, for one, receives more than 35 percent of its total research income from corporate sources.

Such relationships have normalized a quid pro quo. Lexchin presents myriad examples, including this one: In 1999, Robert Prichard, then the president of the University of Toronto, wrote to the federal government to support generic drug companies, Apotex in particular, regarding patent-protection regulations. This happened just as the school was negotiating for a big grant from Apotex. Or there is the case of the British psychiatrist David Healy, a pharma lit star thanks to his 2012 book Pharmageddon, who had a job offer from Toronto’s Centre for Addiction and Mental Health (CAMH) abruptly rescinded in 2000 after he gave a lecture that linked Prozac to suicide risk. There was no indication that Eli Lilly, Prozac’s manufacturer and a major CAMH donor, intervened, but that is irrelevant, Lexchin writes; it doesn’t mean institutional self-censorship didn’t occur.

The recent restrictions on industry influence, such as eliminating some gifts to doctors, have mostly been window dressing, Lexchin contends. Conflict-of-interest policies are non-existent at more than half of Canadian health centres, including hospitals. Not that making such disclosures solves the problem; it can in fact sanitize the situation, while dismissing the stealth power of bias. Authors who report conflicts of interest, for instance, tend to review products and clinical trials involving the companies that sponsored them more positively than those who do not.

In the book’s foreword, Dr. Brian Goldman, host of CBC Radio’s White Coat, Black Art, writes of acting as a KOL for Purdue Pharma Canada, the manufacturer of OxyContin, in the 1980s and ’90s, giving paid speeches to fellow doctors about “safe and responsible” prescription of drugs for chronic pain. He admits he was “swayed by flimsy scientific evidence” that the drugs could benefit patients without causing addiction. Lexchin’s book concludes with 40 pages of proposed remedies—among them a national pharmaceutical plan, a Canadian sunshine act, and greater government research funding —in hope his profession will “regain the trust society has placed in it.”

Lexchin’s research permeates another recent Pharma Lit offering: Sharon Batt’s Health Advocacy Inc.: How Pharmaceutical Funding Changed the Breast Cancer Movement. Batt, an adjunct professor in the department of bioethics at Dalhousie University, expands the conversation into new terrain, exploring how industry infiltrates patient advocacy groups employing the same tools that have been so successful with doctors: building personal relationships, funding meetings, travel, and gifts, and offering “unrestricted educational grants” that invariably come with conditions. The KOL has been joined by the POL, or “patient opinion leader” as drug companies groom articulate patients to get their message out.

The rising status of patients and patient groups as front-line health policy influencers since AIDS activism makes them attractive targets for drug companies, Batt writes. A patient-activist group is “probably a more trusted source for patients than the company making the product.”

Federal cuts to health spending in the ’90s reduced funds to advocacy groups. The ability of NGOs with charitable status to advocate politically was also curtailed just as government-industry bonds were tightening. Batt refers to a government scientist being fired in the ’80s for saying publicly that the Meme breast implant leaked potential carcinogens.

Health Advocacy Inc. is both scholarly treatise and memoir. Batt, diagnosed with breast cancer in 1988, founded one of Canada’s first patient-led advocacy groups and witnessed schisms in the movement during the 1990s over accepting industry funding. Some saw doing so as a means to a righteous end: “All money is dirty money; why can’t we just put it to clean use?” is how one advocate put it. Others feared they would be co-opted. By 2000, Batt writes, most groups took money from PHANGOs, her acronym for “pharma-funded NGOs.” The ones that don’t are not as well-funded or vocal. The book comes alive in the final chapters in which she recounts industry’s stealthy modus operandi and how it outmanoeuvered grassroots breast-cancer patient groups.

The arrival of PHANGOs was, for industry, Batt writes, a new path to government influence, goodwill, and markets. The conversation among patient groups turned to topics benefitting pharma, such as the need for rapid access to expensive new drugs and aggressive therapies. In this neoliberal-friendly arena, patients became “stakeholders”—which earned them a seat at the policy table, Batt writes, but also conflated patient interests with industry goals.

The influence of PHANGOs is pervasive, and often so subtle it’s undetectable. Of 14 patient groups that responded to a 2007 World Health Organization call for input to draft global strategy on “neglected diseases,” eleven received industry funding. They also argued in favour of strong intellectual property protections for drug manufacturers, in briefs that occasionally employed identical phrasing. And we have seen the proliferation of faux patient movements such as Even the Score, a campaign created in part by Sprout Pharmaceuticals to lobby for its third FDA application for Addyi, an antidepressant billed as “female Viagra.” Even the Score cried sex discrimination, arguing that men had access to similar drugs. The FDA approved the drug in 2015, overruling its own clinical reviewers.

Like Lexchin, Batt calls for a radical overhaul. Advocacy groups should not take money from the pharmaceutical industry, she argues, pointing to the progressive model of Germany, where a small tax on drug insurance coverage funds patient advocacy, and drug prices are much lower.

Lexchin and Batt are required reading. In the meantime, pharma is already shifting its strategy to a fleet of new tools, such as employing native marketing to reach the public directly via unlikely allies such as soap opera plotlines. Earlier this year, the drug company Incyte Corp. partnered with ABC’s General Hospital over a story line in which a lead character is diagnosed with a deadly, rare blood cancer. Incyte’s sole product is the only FDA-approved drug targeting the genetic mutation that causes said cancer. Though never named, the drug is a mere Google search away.

The drug industry is also jumping to fill another funding void by sponsoring conferences attended by the very people supposed to write objectively about it. Undark.org, a non-profit digital magazine that covers science, recently reported that the European Conference of Science Journalists, which met in Copenhagen in June, received funding from Johnson & Johnson, a company currently facing lawsuits in multiple U.S. states for misrepresenting opioid risks in its marketing. The magazine also notes that Johnson & Johnson contributed at least $400,000 to this year’s World Conference of Science Journalists, convening in San Francisco in October; more than 20 percent of the event’s $2.5-million budget was paid by industry. Again, corporate sponsors and organizers insisted that programming wouldn’t be influenced, even as Johnson & Johnson representatives called a meeting with event organizers to discuss possible speakers and topics, including “the importance of pharmaceutical research”; it also organized a field trip to one of its labs. Anyone who reads Lexchin and Batt won’t require a crystal ball to predict how this story ends.