Pharmageddon

Introduction

My father smoked all his adult life. He had a number of physical disorders, including ulcerative colitis, ironically one of the few conditions for which smoking is beneficial. In 1974, when he was in hospital for colitis, a routine chest X-ray revealed a shadow on his lung. Dr. Neligan, the surgeon called in, advised my mother on the importance of an operation.

Our general practitioner at the time was Dr. Lapin, whom I remembered from childhood as being tall, silver-haired, and distinguished, often wearing a bow tie. He had spent time, I was told, as a doctor in the British army, a very unusual occurrence then in Ireland. To a child, Dr. Lapin had appeared effortlessly wise and seemed to transcend the boundaries of religion, politics, and division I saw elsewhere.

When my mother developed problems in the early 1960s after giving birth, Dr. Lapin had suggested she come to see him once a week, but at the time she felt the arrangement was too open-ended, and she could not afford it. She was seen instead by another doctor, diagnosed with an ulcer and ultimately received the standard operation of the day, which involved cutting the vagus nerve and partial removal of stomach. This left her with bowel problems for the rest of her life, and regrets for not having taken Dr. Lapin's offer of treatment for what she later regarded as postnatal depression.

When my mother consulted him about the wisdom of an operation for my father, Dr. Lapin was slow to comment. But when pressed, he pointed out that my father had a number of illnesses, any of which could kill him before the tumor would. Many people, he said, went to their graves with cancers, heart disease, or other problems, but these were not what killed them. An operation would take a heavy toll on him.

My mother relayed this perspective to my father and suggested that he take six months to build himself up and then have an operation if he felt stronger; he agreed. When this plan was mentioned to the surgeon, he responded, That's fine, but have him out of the hospital within 48 hours. When my mother revealed that my father still didn't know he had a cancer, the surgeon went straight from the phone to tell him. Without an operation my father would be dead within months, Dr. Neligan indicated, but an operation offered the prospect of a cure. My father, alarmed, agreed and the operation took place two days later. Dr. Neligan afterwards said there was little they could do about my father's tumor when they opened him up. He died six months later, his life almost certainly shortened by the operation.

If there had been progress to speak of in the treatment of lung cancer in the years since my father's death, his medical care might be viewed as one of those sacrifices that at least ultimately benefits others. But there has been little progress, even though advances on almost all medical fronts are trumpeted daily. Genuine progress has been made in some areas, but far less in most areas than many people have been led to believe. More importantly, when it comes to pharmaceuticals in particular, many of these apparent advances underpin and contribute to what in recent decades has become a relentless degradation in medical care, a replacement of Lapins with Neligans, a quickening march toward Pharmageddon. While drugs played no part in what happened to my father, they have played a huge role in fostering a surgical attitude to medical care, a kind of fast healthcare.

My father's illness came just as I entered medicine, seventy years after a momentous change in Western clinical practice. Around 1900, a series of new diagnostic measures, some based on blood tests, others linked to X-rays, and yet others involving the culture of sputum or urine samples for bacteria, enabled physicians to distinguish among many diseases and find remedies for some of them. Before this, the diagnosis patients got was based on how they looked and what they said about themselves when they walked through the door of a doctor's office—if they were weak and tired, they had debility; if they were wasting, they had consumption. If they were diagnosed with a tumor, it was because it was visible or could be felt; if they had diabetes, it was because their urine had a distinctive smell. With the development of new tests, however, the diagnosis only came after a blood test or X-ray confirmed what was wrong, perhaps weeks after the visit to a doctor's office or admission to hospital. And the tests revealed new conditions such as heart attacks and duodenal ulcers. Among the states of consumption, it became clear some stemmed from tuberculosis, while others did not.

A new breed of physician and hospital emerged. In Boston, Richard Cabot was celebrated for his diagnostic acumen, and the reputation of Massachusetts General Hospital in the early decades of the twentieth century began to soar on the abilities of its physicians, aided by their new technologies, to get the diagnosis right, which, it was presumed, would lead to better medical care. But others were concerned. Alfred Worcester, a professor of hygiene and prominent Massachusetts physician, who was later lauded as a father of both modern geriatrics¹ and palliative care,² lamented that the demands of modern diagnosis diverted doctors away from developing and exercising their traditional knowledge of human nature. Worcester was troubled that the new testing requirements for making a diagnosis would alter a doctor's interactions with his patients. Absorbed in the new technologies, doctors would lose their ability to have an ongoing therapeutic influence over their patients.³

Good medical care, we might imagine, should manage to embrace the visions of both Cabot and Worcester. The new techniques after all made a great difference in our ability to help patients, and while humane medical care is wonderful, most people would regard a cure as excellent care even if they don't much like the doctor. Patients in the early twentieth century voted with their feet and sought out the new generation of specialists. But as my father's case illustrates all too vividly, there is a balance to be sought between caring and attempts at curing, and this balance is particularly important in the many instances where cures aren't possible.

Early concerns that medicine might lose its caring soul in exchange for earthly cures were sidelined in the 1940s and 1950s when a host of new life-saving treatments came onstream. While there were also great surgical advances, culminating in the dramas of the first kidney and heart transplants, the key breakthroughs occurred in the pharmaceutical domain. In addition to offering cures in their own right, new drugs like the immunosuppressants and antibiotics laid a basis for developments in surgery and other areas of medicine.

Despite these wonderful breakthroughs-indeed, some critics thought in part because of them-concerns about medical specialism reemerged in the 1960s framed in terms of medicalization. Concerned observers argued that we were ceding too much power to a medical establishment engaged in pathologizing huge swathes of daily life and not equipped to take it upon themselves to define what it meant to be human. The most powerful critique of medicalization came from the Austrian philosopher, Ivan Illich, in his book Medical Nemesis,⁴ published in 1975, the year my father died.

In retrospect, the mid-1970s can be seen as close to the acme of medicine's ascendancy. The pharmaceutical industry was still at this point a junior partner to the medical establishment. But as roles have shifted and the power of drug companies has become more apparent, references to medicalization since the mid-2000s have begun to be replaced by references to pharmaceuticalization, which increasingly sees our identities as a series of behaviors to be managed by drug use.

Then in 2007, Charles Medawar, Great Britain's leading healthcare consumer advocate, raised the prospect of something beyond pharmaceuticalization: I fear that we are heading blindly in the direction of Pharmageddon. Pharmageddon is a gold-standard paradox: individually we benefit from some wonderful medicines while, collectively, we are losing sight and sense of health. By analogy, think of the relationship between a car journey and climate change—they are inextricably linked, but probably not remotely connected in the driver's mind. Just as climate change seems inconceivable as a journey outcome, so the notion of Pharmageddon is flatly contradicted by most personal experience of medicines.⁵

By Pharmageddon, what Medawar and colleagues (myself included) had in mind was something quite different than a simple pharmaceuticalization, where we talk about our neurotransmitters rather than our moods, a biological reduction of secularism.⁶ Pharmageddon refers not to a change in the language of medicine or a change from religious to biological language, but to a process that was deployed in the first instance in the belief that it would better enable us to care for each other, though now it is a process that seems set to eliminate our abilities to care—a fate that beckons in spite of what everyone wants. At the heart of this process is the turn toward quantification in the middle years of the twentieth century. While genuinely helpful, this turn gave healthcare a set of scientific appearances that a handful of shrewd advisors and marketers have been able to manipulate to infect our abilities to care as if with a clinical immuno-deficiency virus (CIV). As a result the defense reactions that we might expect from prestigious journals and professional bodies just don't happen. Indeed the virus seems to have been able to subvert these bodies to its own purposes, so that when critical comments are raised they have reacted almost as though it was their programmed duty to shield a few fragile companies from the malignant attentions of a pharmaco-vigilante.

PHARMAGEDDON UNFOLDING

Since the 1970s, a profound change has been occurring both in the nature of the drugs marketed and in the practice of medicine. New drugs, like the statins, have continued to appear as have new diagnostic tests to measure, for instance, our cholesterol levels, apparently in the tradition of testing that led to so many medical advances in the early twentieth century. But where previous drugs and tests were geared toward the diagnosis and cure of diseases that posed an imminent risk to life, now medical practice is increasingly geared to chronic disease management with drugs that modify risk and lifestyle factors rather than save lives. This is a post-Worcester and post-Cabot world, in which pharmaceutical companies sell diseases rather than cures.

On the surface medical practice appears the same but underneath it's not. For instance, a small number of people have a genetic disorder that leads to excessively high cholesterol levels and for them drugs like the statins can save lives, almost in the way that antibiotics or insulin saved lives half a century ago. The statins can also save lives among people who have had strokes or heart attacks and who also smoke or are overweight, but in this case hundreds of people have to be persuaded to take them for the rest of their lives in order for a handful among them to be saved. For the most part, however, the statins are instead given to healthy people who have mild elevations of their cholesterol levels. Similarly, treatments for asthma or osteoporosis are now given to many people who would never have been diagnosed and treated before. Treatment happens now in response to results on a series of tests that have emerged in recent years—but these new tests don't help make a diagnosis that will lift a threat to our lives. Instead they effectively make a diagnosis of some drug deficiency disorder, and they often enter medical practice as part of the marketing strategy for a new drug.

These new diseases and their treatments have gained a purchase on us because they are presumed to represent the latest advances in a story of progress that runs through insulin and the antibiotics and will hopefully lead someday to cures for cancer. These are the drugs that, had they been available, some presume might have saved many of my father's generation. But far from saving either their lives or ours, clinical trials show that the indiscriminate use of drugs to lower lipids or blood sugars, to relieve respiratory wheeze, or to block stress hormones may even increase the risk of loss of life,⁷ and appear to be doing so in the United States, the country that makes the greatest use of the latest pharmaceuticals, where since the mid-1970s life expectancy has been falling progressively further behind other developed countries.⁸

If you looked around a restaurant, cinema, or office thirty or forty years ago that had a hundred or more people in it, you could predict that 5 to 10 percent of them might have a medical condition—sometimes unbeknownst to themselves—and a trained doctor would have been able to spot many of them just by looking. If you look around the same restaurant or office now at the apparently healthy people, those a doctor can't readily spot as ill, chances are that 80 to 90 percent of them could be diagnosed with one of these new disorders. Almost all will have cholesterol, blood sugar, blood pressure, bone density, or asthma numbers or one of an ever growing number of mental health disorders for which a pill will be suggested. Unlike being diagnosed with a traditional medical illness, these people won't be diagnosed because they are suffering and take themselves to a doctor. They will be diagnosed because an apparatus will come to them, perhaps coincidentally when they are at their doctor's for something else, or perhaps soon to a supermarket near them, an apparatus that will show them that their numbers are not quite right. It is only then that they will begin to suffer, either because of their discomfort and fear following a diagnosis or by virtue of the very real side effects triggered by the new pill they have been put on, a pill which has been marketed as an answer for any of us whose numbers aren't quite right.

Recent books have attempted to diagnose what lies at the heart of our growing disquiet at what is happening to medical care.⁹ These critical studies almost universally blame the pharmaceutical companies, who are now among the most profitable corporations on the planet and who, due to grossly inflated estimates of drug development costs and the emergence of blockbusters—drugs that gross at least a billion dollars per year—are supposedly making too much money. This money lets them buy lobbyists and influence, do a variety of things to turn the heads of doctors, as well as sponsor patient groups to lobby against attempts to limit in any way access to the latest high-cost treatments.

While making many excellent points and calling for action to tackle the problems the pharmaceutical industry poses, these concerned critics, largely from the medical profession, typically portray medicine itself as fundamentally healthy. The serenity of these physicians stems from their perception that, in contrast to an earlier time, medicine is now secure behind the ramparts of science. This science is not the laboratory science that emerged at the turn of the century with doctors like Richard Cabot but rather a science of randomized controlled trials (RCTs) that stems from the 1950s. In these trials new drugs are pitted against dummy pills, or placebos, and it is only if the new drug wins that it is allowed into use.

These trials have laid the basis for what has come to be called evidence-based medicine. The results of RCT trials are also incorporated into evidence-based guidelines for the treatment of different diseases, and these guidelines, when embraced by particular agencies, constrain the prescriptions doctors can write. Many professionals involved in healthcare see such guidelines as keeping doctors within a straight and narrow path of therapeutic virtue, whatever the blandishments of pharmaceutical or medical equipment companies. Few suspect, as I will argue in chapters 5 and 6, that these guidelines in fact hand medicine over to the drug industry. Insofar as evidence-based medicine means that doctors stick to treatments that work and eliminate those that don't, many professionals involved in healthcare see it as offering the only possible basis for a universal healthcare system, if such a system were wanted. But as currently practiced, evidence-based medicine tolls a death-knell for the possibility of universal healthcare in the United States or its continued existence elsewhere.

Aware that something is wrong, we cast around for a villain and often settle on the insurance companies or other third party payers for our current woes. While many grievances against insurance companies are legitimate, they too have a diminishing grip on the healthcare agenda. Because only the drugs and the style of care that goes with them have been proven to work, insurance companies are trapped into reimbursing for these treatments and in the case of hospital stays often only for periods of time that permit little more than the institution of a drug treatment regimen. In doing this they are just following the guidelines drawn up on the basis of the best evidence by medical academics with no links to industry, guidelines that typically endorse the latest high-cost treatments over more effective, cheaper, and more humane forms of care.

The medical establishment, aware of problems in their interface with the pharmaceutical industry but not sure of the source of those problems, increasingly concedes there are senior figures and other opinion leaders in the field who have overly close links with the pharmaceutical industry or other conflicts of interest. But these academics are seen simply as the rotten apples that can be found in any barrel and the assumption is that their behavior will soon be put right by new rules on disclosure of links to pharmaceutical companies.

There is also an acknowledgment that pretty well all the trials that a new drug has to go through for approval are designed, and implemented, by pharmaceutical companies, and a growing awareness that rather than being written up in journals by the academics whose names appear on their authorship line, these papers have commonly been ghostwritten. But for most commentators these are simply more reasons to rein in the pharmaceutical industry, rather than reasons to consider the need for more far-reaching changes such as the nature of our current patents on drugs or the prescription-only status of many drugs, or for a close look at how these ghostwriting and other practices, as laid out in chapters 4 and 5, compromise clinical care itself.

Criticizing success is not a winning formula. In a market economy what company is going to try to be less successful? The door is left wide open for pharmaceutical companies to argue that the reason there are so many medical care problems is that the rest of the healthcare economy has not fully embraced the market.¹⁰ The argument is so seductive that even left-leaning commentators, whether in the United States or Europe, concede some validity to proposals that the way forward in health must involve some embrace of the market.¹¹

For the pharmaceutical industry, attacks from the medical community have turned into a version of rope-a-dope. Muhammad Ali-like, they let the medical George Foremans punch themselves out on issues like conflict of interest, the sponsoring of patient groups, and ghostwriting. Industry is happy to settle back on the ropes and take the punishment.

I will argue that the problems that give rise to attacks from the medical community and other commentators stem from three sources not acknowledged elsewhere. First, at the start of the modern era of medical practice, in the 1950s, the basis on which drugs are patented was changed, allowing companies to have monopolies on drugs in a way they hadn't had before. This permitted the development of blockbuster drugs, laying the basis for the marketing of drugs we now see. Second, also in the 1950s these drugs were made available on a prescription-only basis, putting a relatively small group of people with no training in or awareness of marketing techniques—doctors—in the gun sights of the most sophisticated marketing machinery on the planet. Third, having been under siege by industry for a century, in the 1960s we in medicine woke up to find a horse outside the gates of Troy in the shape of controlled trials and hauled it inside, not realizing that industry-designed trials provide wonderful evidence about the benefits of drugs but very little evidence of what might be best for patients.

Against this background, discussions of conflict of interest and ghostwriting, while important, only scratch the surface. We need to ask whether faith in controlled trials when we are not allowed to see the data from those trials can protect us against the biases introduced by commerce. Whether making drugs available on prescription-only status is appropriate in an age of blockbuster drugs. Whether the basis on which we now permit drugs to be patented is delivering the benefits to society that patents were originally designed to provide. As I will argue, every assault on industry paradoxically has instead reinforced the apparent need for controlled trials, prescription-only privileges, product patents, and further regulatory arrangements, and together these have bound the medical profession and government ever tighter to the pharmaceutical industry. These are the changes that among them laid the basis for companies to create blockbusters, and as long as these changes remain unquestioned industry is happy to settle back on the ropes and take a pounding.

At times of change, there is a temptation to extol the virtues of some former golden age. But while the dogs may bark, the caravan invariably moves on. Generations of us have put our faith and the lives of those we love in the hands of doctors offering the latest in medical developments. Progress may be slow in many areas, but when it comes to life, death, and disability most of us—like my father—will opt for those who offer us hope however slender the odds may be. Up till now, we have been correct to do so. Is there a reason to think an author raising the prospect of Pharmageddon should detain us any more than concerned critics from Alfred Worcester to Ivan Illich have done in the past? Can the best critique do anything other than ask us to give up hope?

Worcester, Illich, and others talked about losing our humanity and our ability to care. In part these critiques failed, even though no one wants to lose their humanity or ability to care, because there were no specifics about what it means to care nor how to recognize the moment at which our humanity is threatened. In part they failed because until recently, whatever the drawbacks to developments, there was little doubt that life expectancies were increasing. All this is now changing. We are in a world where increasingly we need protection from the latest miracle cure to ensure we do not die prematurely.

It would never be good care to withhold a cure. But traditional medical wisdom as practiced by Worcester to my father's doctor, Dr. Lapin, stressed the quintessential importance of being able to recognize when a treatment might make things worse rather than better. This philosophy was best expressed two hundred years ago by Philippe Pinel, a doctor looking after the mentally ill in Paris in the midst of the French Revolution: It is an art of no little importance to administer medicines properly, he said, but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.¹²

Cures almost by definition should lead to a fall in drug consumption, and good medical care as defined by Pinel should too. But instead we have seen an astonishing and relentless increase in the sale of supposed panaceas that do little or nothing to save lives or significantly improve their quality. The consumption of blockbuster drugs has grown from 6 percent of the pharmaceutical market in 1991 to 45 percent in 2006,¹³ with the top ten drugs accounting for $60 billion in annual sales.¹⁴ Where once the pharmaceutical industry made its money from drugs that cured, the big money now lies in marketing chronic diseases for which the current best-selling drugs in medicine offer little benefit. We are quite literally taking pills to save the lives of companies who have a greater interest in the vitality of the diseases they market drugs for than in our well-being. The only historical parallel we have here is the flourishing of patent or proprietary medicines in the late nineteenth and early twentieth centuries.

In 2010 the global market for pharmaceuticals was worth over $900 billion, more than the government bailout of the US economy following the 2008 financial crisis. Half of this came from sales within the United States and almost all came from treatments for chronic disease management rather than for life-saving treatments. Aside from treatments for cancer, in the global market for pharmaceuticals that year the best sellers were the antidepressants, mood stabilizers, and other central nervous system drugs ($50 billion), followed by the cholesterol-lowering statins ($34 billion), which along with other drugs for cardiovascular disorders were part of a $105 billion market, proton-pump inhibitors for acid reflux ($26 billion), the blood-sugar-lowering hypoglycemics ($24 billion), treatments for asthma like Advair (alone worth close to $8 billion), treatments for osteoporosis, and drugs like Viagra for sexual functioning.¹⁵

These celebrity or blockbuster drugs have been showing growth in sales of 10 to 20 percent per annum worldwide; they grew even during the financial crisis. Once the markets in China and India come fully into play the profits can only grow larger, likely doubling. The markup on these drugs is on the order of several thousand percent, so they are now worth more than their weight in gold. There simply are no other goods in any other part of the economy that produce returns like these, and the profit margins of the companies that produce them far outstrip those of any other companies.

If this outlay of money saved our lives or restored productivity it would be readily justifiable, but in most cases when doctors talk about lowering our cholesterol levels with a statin they are not treating a disease, they are talking about risk management. They are not talking about saving our life but giving us a treatment for life. The statin prescribed for us may lower our cholesterol levels, but of even greater importance is the marketing by pharmaceutical companies that has changed both the doctors' and our perceptions so that lowering cholesterol has come to seem as important as treating a disease like tuberculosis.

This marketing is moving us steadily from what was the practice of medicine to a healthcare products limited market, and indeed not just a market but the creation of a new healthcare universe—a universe where the focus has shifted from medicine, in which progress occurred slowly but patients benefited, to a healthcare products market in which science and progress have become marketing terms and where benefits accrue to companies even while patients suffer harm.

It is easy to say that in the process we are poisoning our abilities to care. But what is care and where is the evidence that it is being poisoned? Care is what doctors bring to patients afflicted by something that threatens to take their life or leave them disabled. The ideal care will involve a cure. But what if the threat of disability and death comes from a treatment? Drug-induced injuries are now the fourth leading cause of death in hospital settings. They are possibly the greatest single source of disability in the developed world. The cost of drugs is often picked out in debates about the rising cost of healthcare, but healthcare providers spend more on remedying treatment-induced health problems than they do on drugs without any apparent effort to staunch this hemorrhage of lives or money. Why should this be? If we turn to the evidence base to care for and ideally cure this new disorder afflicting us, we find there is none—no guidelines, no studies, but instead close to a blanket dismissal of any evidence that things could be going wrong.

When it comes to care, the billions of dollars wrapped up in pharmaceutical sales only tell part of the story. Until recently in medicine there was vigorous debate on the appropriateness of various approaches to tackling disease and caring for patients, and medical meetings were filled with academics passionately arguing quite different points of view in discussions that often hinged on managing the risks of a treatment. But the money put into the marketing of pharmaceutical blockbusters is steadily silencing debate about differing therapeutic options and any discussion of the hazards that blockbusters pose. This is not just a problem in the United States—the silence is now being extended worldwide.

Fifty years ago many European countries put universal healthcare in place. Today, at a critical juncture in the history of healthcare, the United States is seeking to expand healthcare coverage. Fifty years ago it made sense to use taxpayer dollars to treat real diseases such as pneumonias and tuberculosis, for example, raising people from their deathbeds and putting them back to work, or taking them off disability lists and restoring them to productivity. This is an investment. If we can cure life-threatening or disability-producing diseases, the use of taxpayer dollars pays for itself—it would make the United States, for example, wealthier and better enable it to compete with China, Japan, and Europe. But treating raised cholesterol levels and other number disorders in an ever greater proportion of the population when medical necessity doesn't call for it is more likely to lead to a decrease in American productivity by increasing health anxieties and giving patients unpleasant side effects, if it doesn't actually kill them prematurely—and such pill dispensing is exactly what Americans do more than any other country on earth. This is an expense rather than an investment. Moreover, this is an expense that is crippling American industry, given that virtually everyone now has some set of numbers that pharmaceutical companies portray as needing treatment.

The Obama administration and others have suggested that the only rational way forward is to embrace evidence-based medicine. But just as the insurance companies have found, anyone turning to this source will be faced by controlled trials which demonstrate that the most recent drug treatments work and supposedly save money. They will encounter guidelines drawn up by the most distinguished and independent figures in the field, advocating the use of the latest drugs. They will be told the biggest problem lies in doctors failing to adhere to evidence-based guidelines. A new generation of web-based companies is even offering to build devices into electronic medical records to ensure adherence to the latest guidelines in a way that would make it impossible for doctors to exercise discretion.

In a world where corporations can market bottled water to us, it appears to have occurred to virtually no one to ask how such marketing power might be applied to drug therapies. If the goal of medical marketing is to find out what doctors want in order to get the doctors to sell the product to themselves—and it is—and if doctors say they are influenced by the evidence above all else—and they do—it should not come as a surprise that industry might set about ensuring the evidence points in the right direction. The availability of drugs on a prescription-only basis in these circumstances makes the job of company marketers a great deal easier than it might otherwise be by enabling them to zero in on a small number of consumers who, when it comes to marketing, are often more naïve than the average adolescent.

We have an extraordinary paradox that attracts absolutely no comment. On the one hand the medical establishment portrays evidence-based medicine as our best means of reining in the pharmaceutical industry, while on the other hand pharmaceutical companies are now among the most vigorous advocates of evidence-based medicine. And it is just this kind of evidence that administrations in both the United States and Europe seem to think will help control health costs. If catch 22 hadn't existed we would now have to invent it.

AVOIDING PHARMAGEDDON

While ghostwriting by pharmaceutical companies has begun to make the news, there is little awareness of the extent to which medicine's major journals have been complicit in the practice and how, faced with articles on treatment hazards, our journals self-censor for fear of legal actions. There is no analysis to explain how treatment guidelines drawn up by academic bodies that are independent of the pharmaceutical industry invariably endorse the latest company products.

All the while doctors and patients complain about the profound changes in their clinical encounters. Where once we consulted our doctors because we had a problem and met a doctor who could spot differences in us from one visit to the next, someone who might have spotted a treatment-induced problem, we are now likely to meet a different face each time we go to the clinic. The main task of many doctors has changed from monitoring us for evidence of life-threatening diseases or the adverse effects of treatment to monitoring the results on computer screens from the latest tests of our risk factors, and managing those numbers on the basis of guidelines. Not unreasonably, the managers who increasingly run health systems from the United States to Europe assume that if the job involves looking at numbers on a computer screen and then following guidelines for what to do next, doctors should be interchangeable.

The engagement of a doctor with the person in front of him or her now means increasingly that on the basis of targets linked to guidelines the role of the doctor is to educate, to cajole or coerce us into treatment for conditions we never knew we had, with treatments that in some instances are more likely to injure or kill us than improve our well-being. This is what caring has become.

Doctors complain about all this, but without an analysis of the forces pushing them to one side and unless they can offer an alternate model of care, such complaints are idle. Blaming the pharmaceutical industry without pinpointing anything they do other than make more profits than some might like is just scapegoating. Are the scapegoaters, we might ask, doing anything other than complaining? By the end of chapter 2 it will be clear that current patent law and prescription-only arrangements for drugs may in fact give rise to many of our more superficial difficulties—but are there any doctors or others seeking to change these arrangements? By the end of chapter 4, it will be clear that blockages to our access of the data from clinical trials constitute a serious breach of scientific norms, but it will be far less clear that there are any doctors taking a stand against this breach.

All of these issues come to a focus in chapter 7 in a description of a patient injured by treatment. Here we see at its clearest the divide between what medicine at its best once was and what it risks becoming. On the basis of the evidence—the published reports of controlled trials—our doctor may appear to have little rational option but to deny that the prescribed treatment could have caused us any problems. There is no evidence-based approach to determining whether treatments have injured a patient or what to do when it happens. Why ever not?

Avoiding Pharmageddon is not primarily a matter of containing the escalating costs of healthcare—although this is important. It is a matter of restoring the conditions in which doctors can diagnose what is afflicting us and can offer the appropriate care. This kind of care is not something intangible nor something that looks like current efforts to get health professionals to smile more and encourage their patients to have a nice day or other efforts to deliver a good service. When it comes to treatment-induced injuries it will increasingly require those whom we entrust with our care to have the right stuff.

While on the surface physicians and others in healthcare are now encouraged to become our partners, in fact the impulse to nurture us when we are afflicted so that we can realize our potential to its fullest extent is being thwarted by processes that render treatment-induced problems invisible. As a result, a vast reservoir of idealism and goodwill that those working in healthcare bring to their work daily is being squandered. And insofar as the essential wealth of a nation is people functioning at their best, rather than oil or other resources in the ground, our countries and economies are being correspondingly impoverished.

There is a climate change taking place in modern medicine that is quite different than the loss of perspective bemoaned by Worcester and generations of doctors since. Coming to grips with the factors driving this shift in climate may involve changes to things like patent law, prescription-only status for drugs, and access to the data from clinical trials, but it also needs doctors and patients as individuals to take action. In the face of global warming, actions on an individual scale can seem futile, but in medicine as in climate change, adding one to another can make a difference. Pharmageddon is part of that effort. It is written in the belief