Thursday, 15 September 2016

Sex, lies and pharmaceuticals

I just finished reading the 2010 book "Sex, Lies and Pharmaceuticals - How Drug Companies Plan to Profit from Female Sexual Dysfunction" by Ray Moynihan and Barbara Mintzes. The authors (or I should say the main author, since it appears that Moynihan wrote most of the book, with Mintzes contributing one chapter) describe the book as "an expose of how medical science is imperceptibly merging with pharmaceutical marketing".

I thought the book started off well, but by the time I got to about page 60 (of around 220) it was getting a bit tired, and seemed to be simply re-iterating many of the same points with only slightly different examples and characters. However, that doesn't mean that the point is not important. This book is essentially about supplier-induced demand, but taken to a different level.

Supplier-induced demand occurs when there is asymmetric information about the necessity for services. What services the customer (in this case the patient) needs is known to the supplier (in this case the doctor), but not to the customer. So, the supplier has an incentive to overstate the necessity for the services. The supplier essentially exploits the ignorance of the customer to their advantage.

Of course, we would hope that doctors are not quite so manipulative when it comes to their patients. However, in this case it is not the doctors but the pharmaceutical companies who are encouraging the sale of unnecessary products, with the doctors simply being unwitting intermediaries. Moynihan and Mintzes explain:
In order to maximise sales, the industry must 'create the need' for its newest and most expensive products. Sometimes that means selling sickness to the wealthy healthy, helping transform common ailments into widespread conditions that require treatment with the latest pills. Applauded for producing medicines that extend life and ameliorate suffering, drug companies no longer simply sell drugs; they increasingly sell the diseases that go with them.
How do the pharmaceutical companies 'sell the diseases'? By creating special relationships with the leading researchers in the field to develop definitions of the disease (in this case, female sexual dysfunction) that will suit the pharmaceutical companies' treatments; by developing and funding new surveys that demonstrate that the disease is widespread in the general population; by developing new tools to diagnose patients with the disease; by 'educating' doctors to recognise the disease (by using the new tools developed by the pharmaceutical companies or their pet researchers) and recommend treatment using the pharmaceutical companies' products.

The book zeroes in on one condition: female sexual dysfunction (FSD), which as the authors note is highly contested (read the "Criticism" section of that Wikipedia link for a little bit more detail). The authors note:
A forward-looking business intelligence report in 2003 named FSD drugs as an area of great future growth for the pharmaceutical industry, part of the burgeoning 'lifestyle' market including medicines for baldness, smoking cessation and obesity.
The profitability of drugs for rich-world diseases is beyond doubt, but the efficacy of the treatments for FSD described in the book very much is. Moynihan and Mintzes give a thorough rundown of the various machinations used by the pharmaceutical companies to get their products approved (by the FDA or their equivalents in Europe and Australia), and adopted by doctors. The critics of the pharmaceutical companies' actions rightly argue that the companies are medicalising a condition that is more than likely just normal variation in desire and arousal. That is, FSD may not necessarily be a problem that needs solving. And initially at least, karma appeared to be in the critics' favour [*]:
Despite a decade of pouring millions into conducting surveys of the condition, designing tools to diagnose it, sponsoring education about it and running trials of drugs to treat it, by 2009 the pharmaceutical industry had so far failed to come up with a sexual medicine that showed meaningful benefits for women.
Which is not surprising, if they are trying to treat a problem that may be more psychological than medical, if there even is a problem. Overall, despite the repetitive nature of the book I found it to be a good read. There is an overall note of caution that should be the book's key message, as the authors write in the conclusion:
...behind your doctor's decision to offer you a medical label and a medication is a global web of entanglement so vast it's invisible to the naked eye.
And it's that invisibility that makes the supplier-induced demand here all the more insidious.


[*] I note that since the writing of the book, flibanserin was approved by the FDA for the treatment of FSD in 2015.

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