Big Pharma: Heroes or Villains?

25 12 2011

What is ‘Big Pharma’?

Many people have argued that alternative and complimentary medicines are suppressed because they threaten the status quo for ‘big pharma’.  Before we accept this claim, let’s unpack the idea of big pharma a little to understand the incentives at play and when it may be right not to trust big pharma.

Let me start by making it clear – big pharma, as a label for the largest pharmaceutical companies, deserves a healthy dose of outrage; but before we toss the baby out with the bathwater, but lets see when – and why.

Big pharma is just another name for ‘big business’: a big business is an organism that has grown beyond the people that founded it, such that rather than having emotions, conscience or guilt, it has KPI’s like turnover, cashflow and return on investment. Big pharma is in the business of making money and as such should generally be expected to default to that option unless constrained by law. The collective conscience of shareholders only tends to kick in when dirty laundry is put out on show. Ok, so firstly, I think we can agree, a business is not a charity.

Next we take this lack of compassion and combine it with size and complexity – we see we now have an organism susceptible to plain outright crookery – from the white collar sort, like insider trading – to the very tangible – such as the dumping of toxic waste. These practices usually require the corruption of people – but not always – it is very easy for companies to do bad things without any individuals having malicious intent; it could simply be negligence or incompetence, or it could simply be that profit sometimes comes before fairness.

Take for example the problem of selling DVD’s in the world market. They are small and lightweight and easy to ship worldwide. This usually means that the price would be similar worldwide, if dealers in one country were to raise prices, residents would simply import the product. However, the enormous wealth differentials that exist between, say, the USA and Mexico, mean that the company could set a high price to extract maximum value from the US market, but then essentially price themselves out of the Mexican market. If they lowered the price, they would sell more product but with much reduced profit margins.

This problem is thrown into stark relief in the case of drugs, where the most profitable option is often to cater to the richer countries. This is sound business – set your price high, keep your factory trim, reduce shipping costs, keep high margins. However, if the drug can radically improve health outcomes, this policy could be seen as unethical.

This is the sort of problem big pharma face routinely; they are not selling entertainment, they are sometimes selling life itself, and often find they need to play profits against ethics in they way I describe above. It is thus hardly surprising that the general public have a distrust and general suspicion toward Big Pharma. In addition to drug import controls, there are many other situations where governments have had to step in to ensure the pharmaceutical companies ‘do the right thing’, such as the case with antiretroviral drugs (for HIV) coming into Africa.

Now think for a moment on this thought experiment: what would happen if a small publicly traded company discovered a cheap and easily reproducible cure for cancer? Would they really be able to hold on and extract full value for their shareholders? History actually suggests they wouldn’t – the drug would become public property, or would simply be nationalised if the company tried to resist. Inventions like the major vaccines and the first antibiotics were often not patented, and we see if we look at the pharmaceutical industry that their biggest profits come predictably not from miracle cures but from drugs that cater to the maladies of the richer classes. The top targets are heart disease, heart-burn, stroke, mental health and asthma. Once you  add disorders like diabetes you have accounted for the most profitable chunk of the industry.

This trend raises fresh concerns, because there are many severe ailments that are simply not attractive to profit making operations, the poster-boys being malaria, TB and HIV/Aids. Drug companies can be bullied into doing work in these areas, but it tends to fall to governments and charities to fund research in the afflictions of the poor, or on the so-called ‘orphan diseases’ – ailments that affect too few people to ever make a profitable market.

Economists will also argue that profit making businesses, being creatures under the strict control of incentives, will be unlikely to aim for ‘cures’ because cures are ‘one-offs’. While this criticism has some sad validity (in the board-room if not in the clinic), we have to remember that the big drug companies only exist because they make profits; in an imagined world where the first dollars were always spent on the most dire diseases and we only get to do botox and erectile dysfunction once those are all solved we would have no private industry at all, so far fewer trained scientists, far less public knowledge and certainly no map of the genome. We have to remember that to some extent at least, the aging american taking their cocktail of pills every day for the last 50 years has in some sense subsidized the field doctor in rural Africa. Yes, they also subsidized Wall Street excesses, but perhaps it’s a deal worth making.

Publication Bias

Another area where drug companies increasingly in need government intervention is in drug trials; specifically, they are presently allowed to pick and choose what to publish; this sounds OK at first, because, surely, you assume, the drug company has to make a bulletproof case before the drug is licensed? Well, if you do 100 trials, you may well find 50 good results, and publish those, and simply sweep the duds under the carpet. What’s more is those duds could have revealed possible side effects or interactions that could actually turn out to be real issues later on down the road. This is going to be a big one in the next few years.

The Big Picture

When criticizing the pharmaceutical industry it is easy to get caught up in the weeds, for there are weeds, but let’s also try to remember that this century has seen unparalleled improvements in life expectancy world-wide, and the improvements in child mortality in the third world do owe a lot to the sometimes cold-hearted business models intrinsic to western medicine.

Before I move on, and being a scientist, I wanted to make another point about big pharma. While it’s true that big money is involved, we have to remember that the Pareto principle applies here too – the majority of the profits come from the minority of the research. There are legions of perfectly good people, motivated by no more that the desire to help people in distress working in healthcare all around the world. Drugs are highly integrated with other therapies at the clinical level and the people actually running trials ‘in the trenches’ face-to-face with the patients (and often dealing with terrible trauma)  are rarely shareholders in big pharma, and many would not even think for a second they are part of what people would call big pharma. Yet it is they who have gradually built up our current understanding of the human body, not the men in suits.

Conclusion

To me, the idea of executives at the top 5 drug companies has become conflated with the idea of the ‘canon’ of western medicine. The idea that the whole world of ‘proven medications’, the result of countless years of hard graft (and the learnings from millions of deaths), can be dismissed because it’s under the control of ‘fatcats’ is a sick tragedy. Western medicine is simply a name for ‘what has been statistically been proven to help’, and the idea that even a tiny fraction of the scientists who developed it would be working to suppress good ideas from outside the ‘fold’ sounds frankly paranoid. Yes big pharma has some warped incentives that cause it to focus on the wrong things and leave the poor out in the cold, but all for-profit publicly-traded businesses do that! Ask yourself for a minute – even if a cure for heart disease were found that threatened the profits to Pfizer and friends, could they really recruit a worldwide network of conspirators who think a cure for cancer is something worth selling their very souls for to suppress?

It hard enough to run a real business, let alone running one so effectively in complete secrecy in the face of so much scrutiny. If they have that much skill and power, they should go legit, they would make a real killing!





Medical Trends: The Holistic View

21 04 2010

There is clearly a lot to be learned about medicine from history.

Indeed many effective treatments can (and have) been identified not by close examination of the human body, but but the close observation of patterns in statistics.

Thus is is possible with good data, a good eye, and quite a bit of spare time, to see many of the contributing factors to disease or accidents. The famous cases include the realisation that the plague was carried by rats and that cholera was in the water. Thus was born the science of epidemiology.

I think if I was starting university again right now, there is a good chance I would have steered towards that as a profession – for it has saved countless lives, and can be done from the safety of a nice desk, replete with good coffee and a supply of biscuits. I have never been drawn to a life of tending to the ill or injured, so this would have been a nicer way to get my benevolence ‘hit’.

Alas, I studied engineering, and though perhaps I could use epidemiological methods to predict metal fatigue or bridge collapses, I am not sure that would be very useful. We engineers seem to spend much more time looking at the costs of making something, and then the price you can sell it for.

Anyway, time for the science bit…

Epidemiologists looks for patterns relating illnesses to other things: other illnesses, location, professions, exposure to animals, and many more.

There are some pretty major trends in health happening right now. For a good example, look at Hans Rosling’s presentation at TED recently. He shows, among other things, that people are living longer than ever before. Despite all the talk of the world going to pot, it seems there is an untold story – the story of how life expectancy in the developing world has been climbing beautifully for several decades. The stats tell a story of a golden age in humanity.

To go off on a slight tangent, I have to say what a pity it is that the media focus so much on the wars and tragedies. Of course, they sell sensation, so they will continue, but we humans are not used to getting news from the whole planet – we have barely got out of the trees and only left our small villages for cities an eye-blink ago. Evolutionarily speaking, our fears were programmed in a much smaller environment where news did not travel very far – the story of a death would be significant because you didn’t know very many people. Nowadays we get more news and we also know far more people because of the world of celebrity (blame the media again), and because we are so ‘networked’ (its the ‘new’ media this time) we also know a huge number of people by association. Thus we receive bad news far more often and tend to overvalue its direct threat to us.

Now let me get back on track. We are living in a golden age – better nutrition, cleaner water, the understanding of the theory of germs, and of course, advances in medicine (think vaccines, think penicillin, think surgical methods). We have benefited hugely from a better understanding of how the body works and of how fungi, bacteria and viruses work.

The activity is higher than ever on countless fronts: dementia,  HIV/AIDS, epilepsy, stroke, heart disease, and so on… but what about the big kahuna? I refer of course to cancer.

Well it has not been cured. The ‘cure for cancer’ has long been held up as the iconic challenge to medical science. Only trouble is, the challenge is flawed. There is no one ‘cancer’ – there are many different cancers  – and the little bastards are all subtle and complex – and even if you can kill one, killing it will often kill off something else, because cancers are not as alien as say viruses – they are in fact our own cells turning on us.

So rather than looking at cellular function and cunning ideas like rna interference, what can we do with epidemiology?

Cancer death rates are not independent of the death rates from other causes...

Yes, cancer is not an ‘epidemic’ – we are not studying its spread, but we can certainly study correlations and seek causation (think smoking tobacco or working with asbestos). Smarter people than I are already poring over this sort of data, and there is much hand-wringing nowadays because the ‘easy’ causes have most been found and now we are looking at the weaker correlations, where the link is not certain, or where the sacrifice to benefit ratio is unclear. Think barbecue meat, think E numbers and so on.

But I don’t want to talk about that sort of cause. What I am wondering is relates more to age…

Cancer is somewhat a statistical process – it may arise as a random mutation, which, as fate would have it, is also bad for one’s health. Many mutations result in no effect or perhaps cell death or perhaps just reduced function of the cell.  There are very few mutations that actually allow for continued (and sometimes rampant) growth and macro level harm. As the mutation is a random event, the chance of occurrence will depend on the number of ‘cellular events’ that occur in a lifetime – this is determined by two factors, the frequency of the events – and the length of the lifetime.

Now add to that randomness the fact that many cancers are slow growing – they may take too long to harm or kill you and something else gets you first.

These two factors together go to show you that the longer you live, the greater the risk of cancer development. Add to this the probable third factor that older cells are more likely to go haywire, and you can easily see why cancer is more commonly suffered by older people.

Does this mean that you risk of ‘catching’ cancer ‘today’ is less if you are younger? Well yes, if your cells (or immune system) are in better shape, mutations may be rarer and you may fend off some that do occur – however, your chance of ‘having’ cancer (rather than ‘getting’ it) are accumulative with age, so this is a very strong factor when looking at screening (looking for cancers that already exist). It is often only worthwhile screening for cancer in older people where the ‘hit rate’ makes the costs (false positives) justifiable.

This age affect is well known, but I am wondering if another factor may be throwing a curve ball into the stats – the longer lifespan of people generally.

As some types of cancers are being treated more effectively (prevented/slowed/cured), and as death from other causes (heart disease, pneumonia, tuberculosis, etc.) drops, does that not give cancer more fertile ground to wreak its havoc?

In other words, will curing other ailments, to some extent, tend to push us into the waiting arms of cancer?

And if this is already happening, perhaps the cancer death rates, hiding underneath the massive advances there may actually be an  underlying increase in death from cancer due to the increased survival of everything else.

———————

So! We all die of something eventually. I guess the question medical science now needs to ask is:  what is the best way to die? Should we be saved from one death only to have another? Will cancer rates start to creep up again as advances against cancer slow and lifespan continues upward? Time will tell!





Unproven medicine : an alternative name for alternative medicine

16 07 2009

“Alternative and complimentary therapies”. They sound so nice. So warm and fuzzy. Surely they augment the cold clinical scientific approach to regular medicine, and have a more holistic approach catering to the soul and spirit as well as the flesh?

I argue not. Hear out my logic…

Any treatment that has proven to provide reliable benefit, is automatically added to the canon of ‘western’ medicine. Therefore the only treatments left available for ‘alternative’ to claim, are those that are unproven, or worse, treatments known to be actively harmful.

Promoters of alternative medicine will argue that western medicine is still woefully weak, and not tuned into holistic and spiritual matters and that such things defy proof. This is clearly claptrap. If you do a well designed double-blind, placebo-controlled test of an ‘alternative therapy’ and the outcomes are no better than for the placebo, then the participants who got the treatment are no better off, spirit or no spirit.

I personally prefer the sort of benefits that can be detected!

How did this situation come to pass, where unproven medications have such a grip?

I think there are three main ingredients:

  1. People make money from other people’s fear (in both western and alternative medicine) and that causes folks on both sides to hide or twist the facts – and also erodes the public’s trust.
  2. The fact that complimentary medicines do actually offer benefits – the well-known benefit of care and attention and also the benefit of the placebo effect – muddies the waters.
  3. It is however the human weakness of putting far too much value on anecdotal evidence that assures the future of unproven medicine.

I think that people who understand this do a disservice to our communities by giving this bad medicine the label ‘alternative’ or ‘complimentary’, so I would like to propose the term ‘unproven medicine’. I would however welcome some more lyrical suggestions!