Spending Ourselves to Death
In 1996, author John Robbins asked readers to imagine a vast, wealthy country where huge numbers of people kept falling off a steep, treacherous cliff. Many were badly injured by the fall. A great number died. Knowing something had to be done, the country’s medical establishment designed the best rapid-response ambulance fleet the world had ever seen. The injured were sped to hospitals where highly paid specialists saved lives with sophisticated, high-tech medical gizmos.
When a small group of concerned citizens came forward and suggested that a fence be built at the top of the cliff to prevent the frequent falls, they were pooh-poohed. Underlying the industry’s veiled ambivalence was greed: When people fell, other people got rich putting them together again. So, while the country funneled more and more money into the medical establishment, fewer and fewer citizens could afford care.
Reads like a scary story doesn’t it? Unfortunately, Robbins’s metaphorical depiction of America’s healthcare crisis – presented in his exposé of the medical industry, Reclaiming Our Health – rings even truer today than when it was first published in 1996.
Spending Ourselves to Death
Over the past few years, the cost of healthcare in the United States has risen markedly. In 1999, healthcare spending topped $1.2 trillion. According to the Center for Studying Health System Change, healthcare spending rose 10 percent in 2001 and triggered an average hike of 12.7 percent in health premiums for employer-provided plans in 2002. In March of 2002, the journal Health Affairs reported that, according to figures from the Health and Human Services Centers for Medicare and Medicaid Services, by 2011 healthcare spending is expected to reach 3 trillion dollars – nearly 17 percent of the nation’s gross domestic product.
The average worker today pays more than three times as much for health benefits than he did 20 years ago. At the same time, the trend toward healthcare corporatization has reached some ugly new lows. “Among developed countries, the United States is unique in having a substantial proportion of health services delivered by forprofit businesses,” writes Sidney Wolfe, M.D., director of the Public Citizen Health Research Group, in the journal Academic Medicine. “The quality of care is worse in for-profit HMOs, kidney dialysis centers, nursing homes, and hospitals than in nonprofits.”
Nowhere is the growing disconnect between profit and quality healthcare more obvious than in the bulging coffers of drug companies. Today’s pharmaceutical industry is enormously profitable, in large part because every step of a drug’s life is bought and sold – from research trials, to government approval, to prescriptions – in a multi-billion-dollar dance that garners riches for everyone involved, except those for whom the drugs are purported to help: patients.
When it comes to profiting from the sick and dying, someone is apt to get burned. If you want to make sure that someone isn’t you, start taking responsibility for your health now, before it begins giving you serious trouble. Because the only real way to beat the current healthcare system is to do your best to never need it.
How? First and foremost, begin by adjusting your perspective toward that of a fence builder, not an ambulance rider. Rather than waiting for trouble to strike and trusting that someone else will be there to clean up (and pay for) the mess, do everything in your power to build and maintain your health proactively. Strengthen the choices and habits that will protect it for a lifetime. Dare to live outside the passive “feed-me-fix-me” model that is so dominant in our culture, and instead, learn to take courageously good care of yourself – in sickness and in health. Finally, if you are having a hard time acting on directives like these, take a close look at the state of healthcare in this country, and let that be part of your motivation to rise above it.
The philosophical chasm between Eastern and Western medicine largely sums up the crux of today’s healthcare problem. Through the eyes of Eastern medicine, health is seen as a state of both physical and emotional well-being. Being healthy means being in balance and in harmony with yourself and surroundings. Disease is literally a dis-ease or imbalance in the body. Symptoms are hints dropped by the body, like a trail of breadcrumbs, directing us to the source of instability. Practitioners act as gardeners, cultivating life and nurturing growth. Treatment has a dual approach – the physician balances disharmonies and the patient accepts a personal responsibility to adopt lifestyle changes that support healing.
Western medicine occupies the opposite end of the spectrum. Westerners define health as an absence of pain. The emphasis is on man as a machine and doctors as conquerors of Mother Nature. Symptoms are to be suppressed with drugs. Disease is an invader, an isolated attack, something to be rooted out and destroyed. Easy-to-swallow pills and outpatient surgery make lifestyle changes a moot point.
Such a cowboy approach to medicine leaves little for patients to do but surrender to doctors’ orders. This power dynamic between physician and patient is in itself a recipe for disaster, but add profit mongering to the mix and the system very quickly begins to buckle.
“People want easy answers – it’s a cultural dysfunction of the United States,” says Barbara Brenner, executive director of Breast Cancer Action, an advocacy group based in San Francisco. “Pills look like easy answers. The dysfunction is exploited by the pharmaceutical industry and, at the end of the day, that’s about capitalism.” The controversy surrounding hormone replacement therapy illustrates the point.
Since its inception in the 1930s, hormone replacement therapy (HRT) was heavily hyped (by pharmaceutical companies and the doctors they convinced) as a fountain of youth and panacea for the woes of older women, such as heart disease and brittle bones. By the ’90s, Premarin, a synthetic hormone made by Wyeth-Ayerst, was the most widely prescribed drug in the United States. Yet the true benefits of hormones were never clearly established. In Overdose, a book about harmful drug-company practices, a top FDA official is quoted as saying, “The predominant use of Premarin is a practice pattern of American physicians, probably resulting from advertising.”
In early 2002, results from one of the most exhaustive studies ever undertaken on HRT exploded the myth of hormones as a prerequisite for a woman’s healthy aging. The National Institutes of Health (NIH) planned to follow more than 16,000 postmenopausal women in a double-blind trial over eight years. Their goal? To chart the pros and cons of HRT. Half the group downed HRT, while others swallowed placebos. The trial was abruptly halted three years ahead of schedule because of the alarming nature of the preliminary results.
Researchers found that, contrary to everything they’d been told about the benefits of hormones for postmenopausal women, the drugs were doing more harm than good. After years of selling women on HRT as a boon to heart health, researchers discovered that those on HRT were 29 percent more likely than their placebo-popping counterparts to have heart disease and 41 percent more likely to suffer from a stroke and blood clots. More bad news followed when it was discovered that the group on HRT was 26 percent more at risk for invasive breast cancer than those on a placebo.
The study grabbed headlines around the world and sent millions of women storming into physicians’ offices demanding answers. Meanwhile, women’s health advocates steamed. Cynthia Pearson, executive director of the National Women’s Health Network, called the widespread belief that hormones were good medicine “a triumph of marketing over science.”
“Millions of women took HRT on the advice of their physicians, who honestly believed that the treatment prevented heart disease, the biggest killer of women,” she wrote in response to the study. “HRT doesn’t prevent heart disease; it causes it. Women were placed in the way of harm by their physicians, who acted as unsuspecting patsies for pharmaceutical companies.
“Spinning science has to stop,” she continued. “HRT is not the only therapy being over-promoted by drug companies to healthy people. Pharmaceutical companies have bought physicians, have bought scientists, and have bought clinical medicine. Science must be separated from advertising.”
If one wonders how it came to pass that thousands of doctors routinely prescribed hormones to millions of women without demanding sound, scientific proof of the therapy’s benefits, one need only look to the far-reaching, green-fisted arm of America’s pharmaceutical giants. Take a look at how they operate and it becomes abundantly apparent that the process of bringing new drugs to market has far less to do with saving lives than it does with lining pockets.
Ushering a new drug to market begins with clinical trials. In the not-so-distant past, independent researchers conducted clinical trials at academic research centers. Research universities, although not insulated from industry influences, brought an important degree of intellectual rigor and quality to the process.
Academicians, however, are known for playing by the rules, something that causes much consternation for drugcompany executives. For starters, trial results aren’t always positive, which means bad publicity if the data is published in a medical journal – something academics are apt to do. Secondly, independent academicians like to design unbiased trials that objectively measure the worth of a drug. But with $500 million at stake – roughly the cost of bringing a new drug to market in the United States – pharmaceutical companies are less interested in rigorous academic pursuit than they are in fast, positive results.
Enter the contract research organization (or CRO). As private, nonacademic research groups, CROs do the job faster and cheaper than ivy-tower stick-in-the-muds. Best of all, CROs allow drug companies to control all aspects of the trial process, from how the study is designed to how results are interpreted.
Once CROs were established, it didn’t take long before money began flowing away from public universities and into private labs. By the year 2000, 60 percent of research grants from pharmaceutical companies were awarded to CROs, while only 40 percent went to academic trialists, according to the New England Journal of Medicine. Although the Journal editors labeled the terms of most CROs “draconian for self-respecting scientists,” they admitted that many researchers sign on knowing that if they don’t accept the job, someone else will.
Even the country’s esteemed medical journals, once considered bastions of scientific integrity, are not above drug-company bias. As long as pharmaceutical advertisements are the lifeblood of medical-journal budgets, the delicate line between business and editorial will blur. In 2000, the Massachusetts Medical Society ignited controversy by naming Jeffrey Drazen, M.D., as editor-in-chief of its New England Journal of Medicine. Drazen, at the time a leading asthma researcher, had not only pocketed a good deal of drug-company money but had also been reprimanded by the FDA for giving “misleading information on a drug’s efficacy to pump up sales.” Nonetheless, Drazen kept his job and continues to edit the Journal today.
FDA Out of the Way
Of course, regardless of high-profile studies and glowing clinical trials, a drug’s market success is doomed without the FDA’s final stamp of approval. Not the sort to leave this important step to chance, pharmaceutical companies simply stack FDA advisory committees in their favor.
In 2000, an investigative report by USA Today found that at 55 percent of FDA advisory-committee meetings, half or more of the advisors had financial interests in the drug being evaluated. With more than a hint of irony, the authors noted that over the past few years, “the FDA has followed every advisory committee recommendation to approve or reject a medicine – except once.” (The exception was Relenza, a flu drug that was later approved.)
Even when FDA approval is a relatively sure bet, that doesn’t mean a drug is on it’s way to star status. One of the keys to creating a blockbuster drug is getting it prescribed by doctors. Essentially, drug companies must convince doctors to prescribe their products while encouraging patients to ask for it by name.
To this end, pharmaceutical companies employ small armies of salespeople. Lugging roller bags chock full of freebies, drug company representatives spread out into thousands of doctor’s offices each day. As omnipresent in physician’s waiting rooms as outdated National Geographics and fake ficas, drug reps deliver dozens of one- to three-minute sales pitches each day. Between 1994 and 2000, the number of salespeople employed by America’s drug makers more than doubled from 35,000 to 80,000.
“Brand-name drug makers in the U.S. employ 81 percent more people in marketing than in research,” according to a report by Families USA, a healthcare advocacy group based in Washington, D.C. When it comes to luring physicians’ attention, drug samples, coffee mugs, pens, pocket protectors, and golf balls are just the beginning. Many drug salespeople ply doctors with expensive dinners, cruises to the Bahamas and courtside seats to the NBA. Each year, drug representatives spend between $8,000 and $13,000 on every doctor, according to the Journal of the American Medical Association. Although medical leaders are calling upon their colleagues to exercise restraint, relatively few do.
Although getting the message directly to doctors makes up the bulk of pharmaceutical marketing costs, more and more drug companies are now bypassing the doctor’s office altogether by marketing straight to potential patients.
In the past, the FDA required drug makers to include the entire consumer- warning label in drug advertisements. This rule made print ads feasible but television commercials, with their tight time restrictions, were out of the question.
But in 1997, after years of intense lobbying by drug companies, the government eased up. According to new FDA regulations, as long as viewers are told about the drug’s major risks and given a source of more information, such as an 800 number or Web site, pharmaceutical companies can promote their products as much as they’d like. As a result, prime-time television is plastered with drug ads. One report estimated that Americans watching television in late 1999 saw an average of nine prescriptiondrug commercials a day.
The ability to hawk drugs directly to consumers is a boon for drug companies. When Schering-Plough, the maker of Claritin, began its infamous television campaign against allergens in 1998, sales of the allergy drug more than doubled to $2.1 billion. Not to be outdone, the next year, Pfizer sank $57 million into an ad campaign for its competing allergy drug Zyrtec and was rewarded with a 32 percent jump in sales. Meanwhile, that same year, prescriptions for Allegra skyrocketed 50 percent after its parent company, Aventis, spent $43 million promoting the drug. Overall, more than $2 billion was spent on advertising prescription drugs directly to consumers in 2001.
Paying the Bills
As marketing and advertising budgets skyrocket, so do price tags on prescription drugs. In each year from 1997 to 2001, the amount Americans spent on prescription drugs rose nearly 20 percent. Meanwhile, roughly 65 million people nationwide lack insurance coverage for prescription drugs.
Employers are the main source of health insurance for Americans, but how much longer will they be able to foot the bill? According to the Alliance for Health Reform, employer-plan rates will rise up to 15 percent in 2002, and early quotes for 2003 are higher still. The Alliance cites the growing use of prescription drugs as one of the main factors behind the price surge.
Meanwhile, drug companies blame the high price of prescription drugs on rising costs of research and development. Those wonderful lifechanging and -saving drugs, they say, depend on years of expensive clinical work – costs they must recuperate in order to continue innovating. Yet, many critics suggest pharmaceutical research-budget numbers are grossly inflated. A Families USA report found that America’s largest drug companies spent an average of 11 percent of revenues on research and development. That number pales in comparison to the 27 percent of revenues they funneled into marketing, advertising and administration. Even drug-company rosters show the discrepancy. Between 1995 and 2000, brand-name drug makers upped marketing staffs by 59 percent while cutting research staffs by 2 percent.
Getting the Truth
As easy as it is to blame money-hungry drug and device companies, greedy HMOs, ill-informed doctors and corrupt governmentindustry alliances, there are also plenty of people in science, medicine and government doing a lot of good, and who are working hard to improve the sorry state of affairs. There are also plenty of other culprits that stand accused in all this – including us, the American population.
For one thing, we live in a capitalist society that, while it does some things (like innovation and entrepreneurship) brilliantly, also tends to incent and reward some downright dreadful business and investment practices. As long as the pharmaceutical and medical industry is driven by stock profits and shareholder returns, many of these problems are unlikely to go away. They are, to some extent, just hardwired into the larger system – a system from which many of us benefit. Certainly, we can tell our elected officials how we feel about the mess, or we can divest from pharmaceutical stocks we don’t feel good about, but even so, if the history of “healthcare reform” is any indication, we must also prepare for change to come slowly and to take a jagged course.
Fortunately, there is another class of problems about which we can do a great deal and on which we can have a very direct impact. Those problems concern our tendency to be passive and ignorant about our health; our willingness to let social norms, advertising, media and industry influences steer our fate; our eagerness to look for and accept quick fixes; our resistance to acknowledging our role in creating our ill-health; and our slowness to strike out on the healthier, safer paths we know exist, but that seem “too weird” or “too much work.”
The best way to take ownership of your health is this: Make building and preserving your body’s natural vitality a top priority. Instead of focusing on treating disease, focus on prevention through diet and exercise.
If sickness does strike, size up the strengths and weaknesses of various healing systems and decide which best suit your condition. Western medicine is adept at handling acute medical emergencies, preventing the transmission of infectious disease and treating bacterial infections with antibiotics. However, when it comes to dealing with subtler health problems, such as allergies, chemical imbalances, chronic illness or pain, autoimmune diseases and many types of mental illness, an Eastern or naturopathic approach is often a wiser and more self-respecting choice. Most people feel a combination of these tactics – Integrative Medicine – offers the best of both worlds.
Ultimately, each of us has the ability – and responsibility – to build our own fences at the top of Robbins’s metaphorical healthcare cliff. “We need to release ourselves from the belief that our health is primarily dependent on medical technology,” writes Robbins, “and restore our faith in ourselves, in our own minds and hearts, and in the activities that truly generate and protect health.”
As screwed up as the medical system is, there’s no point in just worrying and blaming, feeling bewildered and victimized by it. Instead, as Robbins points out in Reclaiming Our Health, we must remember: “The medical establishment will only get off its pedestal when we get off our knees.”