Book review: Bad Pharma

Title: Bad Pharma. How drug companies mislead doctors and harm patients (2012)
Author: Ben Goldacre
Publisher: Fourth Estate, London

Ben Goldacre, a UK based doctor, has become a popular medical and science writer. His previous book Bad Science was a big hit, he has popular web and Twitter profiles, and he is a regular public speaker and newspaper contributor. His new book, Bad Pharma, specifically targets the problems with medicines. It does not restrict itself to the pharmaceutical industry (although drug companies are the main target), the book also details problems with government regulators, patient advocate organisations, doctors, medical colleges, governments, journals, universities, academics and even ethics committees. Fortunately, the book also offers solutions.

The central thesis is that we do not reliably know what drugs, if any, we should be using to treat patients because the evidence on which we rely is so distorted at so many levels. The distortions come from biases in study design, analysis and reporting, the latter including such things as selective outcome reporting, ghost writing, company spin and, worst of all, withholding of unfavourable study results by industry (who sponsor most of the drug trials).

The importance of this is that all of these separate biases are in one direction: they favour the drug in question, leading to an overestimation of the benefits and an underestimation of the harms. I can’t help but like this kind of stuff, as it fits the central thesis of my blog: that benefits are overestimated and harms underestimated in medicine in general.

The problems listed extend further than this central thesis, to include drug company influence over prescribing, both directly by drug rep contact, gifts and sponsored medical education, and via the patients by sponsorship of patient advocate groups and by direct to consumer advertising.

Drug regulators and other government institutions are criticised as being misdirected, lacking authority, lacking enforcement and of being biased due to ‘regulatory capture’ whereby a state regulator ends up promoting the interests of the industry it is supposed to monitor. Personally, I found this most interesting because much of this was new to me. I expect most readers would be shocked by all of the chapters in this book.

Even ethics committees are targeted; not for their existence, but for the obstructions they raise, and whether these are proportionate and evidence-based.

It is a big book that makes big statements and big recommendations. Some of the recommendations may appear utopian (such as waiting room disclosure of all financial interests, withdrawal of industry sponsorship of medical education, and an amnesty for disclosure of all previously withheld data and ghost written articles) but that doesn’t make them unreasonable, only unfeasible, at least in the current environment. But that’s OK, because books like this help to change the environment.

The book aims to increase awareness of the problems with medicines, and in so doing, to change the system for the better – to improve patient outcomes. It achieves the first of these aims by spelling out the problems clearly and backing them up meticulously. Even Dr Goldacre’s most ardent critic would find several reasons to rethink their position after reading this book. Whether he is able to achieve the latter aim remains to be seen, but I hope he does.