In Part III of this series, we elaborated a bit on how vested interests can infiltrate our medical system through what we referred to as the questionable institutional ties. This includes, among others, ties between medical publishers and pharmaceuticals, ties between government and food corporations, ties between research communities and their funding partners, and ties between health charities and pharmaceuticals. We also discussed how such ties could reduce the quality and the integrity of our research, promote the adoption of questionable health policies, and potentially misinform the medical communities about the benefits and harm of a treatment.
In this final part of our series on medicine, we will continue to explore around the theme of vested interests, this time on how it manifests itself not just on an institutional scale — but on an individual scale as well.
Vested Interests (Continued)
Big Pharma’s Agenda
While the pharmaceuticals’ relentless pursuit of profit is generally well recognized by the public, the extent of their misconducts, and their impacts on our medical system as a whole, remains a topic that leaves much to be explored.
For example. GlaxoSmithKline (GSK), a multi-billion pharmaceutical multinational and manufacturer of toothpastes and painkillers, in addition to paying out the highest amount of drug-fraud settlement ($3,000,000,000) in the history of medicine, was also involved in a series of bribery claims in China, Poland, Iraq, Jordan and Lebanon.
(for the record, that detective is in jail now for another reason — spying on Chinese nationals)
For example. in July 2013, Chinese Police detained 4 GSK China’s executives, and accused GSK of using a network of more than 700 middleman and travel agencies to (financially and sexually) bribe doctors and lawyers to promote their drugs. The bribery was valued to be around £0.32 billion, which, as gigantic as it sounds, only represents 4.57% of GSK’s total operating profit in 2013 (£7 billion)! In fact, the wealth of GSK is such that some of their executive in China even managed to hire corporate detective to determine who were doing the whistleblowing!
Here is a more recent one that attracted less attention from the media. On August 6, 2014, a whistleblower familiar with GSK’s Syrian operations wrote an anonymous email to two of GSK’s top executives, accusing GSK of bribing doctors in Syria in order to promote the sale of various medications, such as the drugs for cancer treatment and blood clot prevention. The same email also accused GSK of bribing officials at the Syrian health ministry to obtain the permission to illegally resell certain vaccines. Fortunately though, the alleged bribes only ran in the tens of thousands — admittedly a relatively small amount for a gigantic multinational.
However, if there is anything more worrisome, it would be the fact that the misconducts perpetrated by GSK is merely a reflection of the rampant trend of dishonesty that is common among the pharmaceutical multinationals:
- In the United States, Pfizer was fined $420,000,000, followed by the March 2010 settlement of $142,000,000, due to their fraudulent promotion of the anti-seizure drug Neurontin.
- While Merck was aware since 1996 that their painkiller Vioxx could cause thrombosis, they continued to promote it while ignoring reports of patients suffering from heart attacks while taking the drug. This would prompt a 7-year investigation which culminated in Merck’s November 2011 $950,000,000 settlement with the U.S. Justice Department, in exchange for prosecution over their fraudulent marketing of Vioxx. In fact, a similar past episode did occur in 2007, where Merck agreed to pay a settlement of $4.85 billions — all to relieve themselves from the 27,000 liability lawsuits related to the drug.
- In April 2010, Astrazeneca, the London-based manufacturer of the antipsychotic medication Seroquel, reached a settlement of $520,000,000 with the U.S. Justice Department to avoid federal investigation on the illegal marketing of the drug. Previously, Astrazeneca was accused of overemphasizing favourable research and concealing evidence of association between Seroquel and the increased risk of diabetes.
- In November 2013, Johnson & Johnson reached a settlement of $2,200,000,000 with the U.S. government, to avoid criminal investigation over the unethical promotion of their psychotropic drugs Risperdal and Invega. The company was accused of paying kickbacks to pharmacists and urging them to promote the drugs in ways that are unapproved by the Federal Drug Administration (FDA).
- In 2007, Bristol-Myers Squibb (BMS) reached a $515,000,000 settlement with the U.S. Justice Department, in exchange for the prosecution of illegal marketing of the antipsychotic Abilify and the antidepressant Serzone. According to the Justice Department, BMS literally sent a “special task force of sales teams” to nursing homes, in an attempt to market Abilify to the elders as a dementia treatment — a treatment option unapproved by the FDA. The U.S. government also accused BMS of offering kickbacks and luxury-resort vacations to medical professionals and pharmacists — in exchange for the unapproved promotions of these drugs.
Competing Interests Between Patients and Health Care Providers
While many prospective practitioners undoubtedly enter the medical school with a strong aspiration to improve patients’ well-being and save lives, depending on the field of study, there might come a point where they are struck by the reality of the situation — perhaps they might find themselves under an enormous tuition debt after graduation; perhaps they might find themselves under intense pressure to set up a clinic and procure medical materials/cutting-edge technologies.
In many cases, the process of establishing financial independence would then determine a practitioner’s approach to medical practice — sometimes for the remainder of their career. Other times, the practitioners might find themselves becoming increasingly busier, with little time to review their practices with continuing education, or reflect upon their role in the medical system. Of course, none of these are good signs — for it is in this pursuit of cost-effectiveness that patients can be turned into clients, and health care into sick care.
Practitioners attempting to cater to as much patients as possible, might just end up helping as little of them as possible — A quintessential characterization of a greedy algorithm
Another salient remark to be made about our medical system, is that the survival of the practitioners depend mostly on the successful monetization of treatments. While not inherently undesirable, the drive towards more treatments usually translates into more focus on making patients return more often, and less focus on prevention.
To get a bit more perspective, let us listen to what a retired ophthalmologist had to say on the state of affair of medical practices:
“[…] And that’s not all. You also have to run a business, unless you are practicing in a hospital or as employee in a clinic. If you have your own practice, you have to deal with things ranging from rent or property ownership, to managing employees, dealing with accounting, and a myriad things ranging from office admin software to insurance companies. Imagine filing cabinets for thousands of patients, possibly dozens of new ones on busy days. Not making mistakes becomes statistical fiction, before long.
These days in many countries (the U.S. appears to be championing this, putting lawyer fees as yet another priority over health) you also have to worry about malpractice, being able to pay malpractice insurance, and in some places the proliferation of practices that reduce the value of previously government limited licenses. It’s not worth to many, and in the past ten years I’ve seen scores of professionals quit the business altogether.
All this just as a moment of perspective. When I sometimes may sound derisive about individuals in my field, it’s not a mater of lack of respect. There simply isn’t time to stay up on studies, there simply isn’t the margin of error to start playing around with alternative therapies. The moment a patient leaves your office, the next one is already coming in. Before they come you are dealing with your staff, and after they go you are dealing with paperwork. A lot of your ongoing education, like it or not, does end up coming from the pharma reps (or lens sales, in this particular field). You get up at 5am, you get home at 9pm. It’s not much of a life, unless you happen to venture in a fortuitous specialization.”
— Alex Frauenfeld, Behavioural Ophthalmologist of The Frauenfeld Clinic Archive, December 15, 2014
In a sense, this is the price we pay for outsourcing health to individuals who make their living through prescriptions and medical operations: if we manage to find the right practitioners, then more health to us! But unless we are deliberately naÏve, we shouldn’t be surprised if:
- A surgeon decides to operate on a patient, whose disease is in actuality fully reversible via lifestyle changes.
- A psychiatrist prescribes antipsychotic medications and receives commissions from its manufacturers, knowing full well (or maybe not!) that such medications carry the risk of further destabilizing the patient’s mental condition.
- An eye doctor prefers offering glasses/contact lenses to provide compensation for nearsightedness, rather than recommending myopia rehabilitation to his/her patient (for a rather-humorous take on traditional ophthalmology, we recommend Jake Steiner’s provocative blogpost on transient axial length change 😉 ).
- Instead of putting the emphasis on healthy diet and appropriate cleaning, a dentist proceeds with tooth extraction, followed by a referral to an implantologist — not because of the latter’s competence, but because of the latter’s offer of referral bonus.
Despite all these motives, it would be unfair to characterize the money matter or the corporate rewards as the practitioner’s primary interests. For one. there are indeed times where practicing medicine unconventionally can anger both the medical associations and the patients, potentially culminating in liability lawsuits, loss of reputation, personal attacks/harassment and revocation of medical license. While such punishments can certainly play a critical role in discouraging medical malpractices, it can also dissuade the practitioners from following their own experience and conscience.
Unless medical practitioners are paid in such a way that does not incentivize standard medical treatments, medicine could continue to remain, for the most part, as a commodity — rather than a genuine service of care.
And of course, the competing interests between patients and health care providers don’t just manifest themselves on an individual scale either. For example. when asked about the lack of emphasis on nutrition in medicine, Peter Attia, a former surgeon and co-founder of the Nutrition Science Initiative, put up the following response:
“I think nutrition science falls into a little bit of a no man’s land. On the one hand, it is expensive to do properly the way, for example, major drug research is done. On the other hand, there is no great opportunity to monetize the results through intellectual property. So there’s a bit of a funding void. While everyone would agree that it’s probably more important that we know what to eat to be healthy than to know which drug to take to improve condition X, the economic forces appear to be conspiring against this elucidation.”
What to Make of All These?
Since The Sustainabilitist was originally set up in part to promote critical thinking, we feel compelled enough to mention that we have no intention to portray mainstream Western medicine through a reductionist black-and-white lens, for the following reasons:
- It’s fairly easy to conjure up countless scenarios where mainstream Western medicine has clearly helped people get out of their immediate chaos, such as in the treatment of external injuries and the control of infectious diseases. Although we believe these treatment options still have rooms for improvement, we do agree that in principle, the methodologies adopted by mainstream Western medicine can effectively address those issues.
- As is the case with many institutions, our medical system has made significant improvement over the recent years. with some branches evidently progressing faster than others — The dogmas from the old days are silently fading away, and the next generation of researchers and practitioners more open to novel concepts and viewpoints.
Insofar as the chronic diseases are concerned, however, we believe that patients seeking for treatments would be better off searching for viable/sustainable alternatives, as evidence-based medicine is hardly implementable with the existing data manipulation we are currently aware of. Of course, this does not mean discounting the usefulness of a practitioner, but that the mainstream Western medicine no longer has the monopoly on matters pertaining to health.
In particular, we can easily envision the patients taking the responsibility of self-education and self-care, while at the same time having the practitioners monitor the state of their health and offer some clues along the way. In this age of Internet proliferation, it’s about time that we stop taking a passive stance towards our own well-being. Instead, we should shift our mentality towards regaining our health sovereignty and reestablishing the traditional principle of health as the ultimate metric of prosperity.
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