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Selling Sickness: How Drug Companies Are
Turning Us All Into Patients

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seek medical advice and treatment. On the mote all these conditions through their cul- other hand, these initiatives find a ready I remember as a medical student weekendsforgeneralpractitioners.
Selling Sickness describes how “aware- opportunistic investors seeking new prod- ness raising” campaigns seek to transform ucts and profits—not patients seeking new another to get their hands on the free food the worried well into the worried sick.
diagnosis and treatments.” This one-sided ings sponsored by drug companies. I found possible, in Britain, where this is prohibited, diagnoses (often, like fibromyalgia or myal- gic encephalopathy (ME), not linked to any representatives preposterous—a view con- tions such as erectile dysfunction, prompt- specific drug treatment) and form organisa- firmed when I briefly joined their ranks in a ing requests for prescriptions. The tech- subsequent career break. Ever since I have nique of “astro-turfing”—the formation by diagnose, and treat them. Undoubtedly the drug company public relations profession- often featuring celebrities—has helped to somely from them, but they did not create that doctors “just say no to drug reps” dependency between the medical profession diverse processes of “disease mongering” have helped to turn pharmaceuticals into a first recognise that the convergence between Selling Sickness is a spirited journalistic global $500bn (£271bn; €401bn) industry, corrupting effects of corporate largesse, however distasteful we may find these links.
What is required is a wider challenge to the redraws the boundaries between health and medical practice involving the diagnosis and mineral density—as diseases afflicting sub- treatment of disease and, on the other, the stantial sections of society and requiring profession was the main target of critics of worlds of lifestyle regulation and “recrea- treatment with medication. Another strata- medicalisation, today doctors appear more tional” drug use (including preventive treat- ments of dubious merit as well as medica- patients that conditions such as anxiety and tions of unproven therapeutic value).
depression, hitherto reckoned to afflict only a small minority, should be diagnosed—and Michael Fitzpatrick general practitioner, London
loss of prestige and authority have turned to Competing interest: MF is the author of The health as a sphere in which they can forge Tyranny of Health: Doctors and the Regulation ofLifestyle (review BMJ 2001:322:305).
points of contact with a remote andfragmented Items reviewed are rated on a 4 star scale
Kingdom scarcely a week goes by without a See for review of BBC Radio 4’s (4=excellent)
the “gender bias” in the management of heart describes how the dysfunctions of love have disease. More generally, though, from what been, since classical times, not only meta- privileged vantage point can we assess what is phorically considered as illness, but at times a bias, responsible for incorrectly framing a also literally medicalised as disease.
Does lovesickness really exist? Duffin is The story of the emergence of hepatitis C biological realities. Some “symptoms” seem is one of litigation and cultural mores about stable over the centuries, she suggests, but deserving and undeserving sufferers. Political not its credibility as a medical problem. She draws on phenomena as diverse as adultery, research that constructed a new disease from what was essentially a left over category of als, and masturbation to argue that “love was liver disorder, and dividing it into two diseases once a card-carrying disease” (p 65) but with different meanings depending on how it appeared to disappear in the 20th century.
was contracted, through blood transfusion, or through lifestyle. But Duffin has already implied that it could not be otherwise: we cannot have a pure disease, untainted by the Conventionally, medicine deals with suggestingthatloveissimilartoobsessive unpleasantnessofpoliticsandmorality,for illnesses cannot become diseases without a social network to make them possible.
selection of diseases from the range of prob- passing details, but raise the question about lems that afflict us is neither inevitable nor the legitimacy of tracing such equivalences straightforward, as illustrated by the much through time. How can we know that there is which problems (whether they are those of debated candidate cases of those alphabet a real underlying illness if we recognise it women reluctant to leave violent husbands, disorders of modernity such as RSI (repeti- only from its endlessly varied manifesta- or injecting drug users at risk of hepatitis) tive strain injury) and ME (myalgic encepha- are seen as residing in the social order, lopathy). Given the large body of work that not? How can we read historical writings on rather than within a medical model. Again, explores the emergence, construction, and love from anything other than a 21st century hardly a new idea, but one well worth reiter- ating. Not all troubles are, or should be, the makes heavy weather of convincing readers Duffin’s arguments suffer a real tension between the relativism of a historian recog- categories, but emerge when social demand nising that biology has been a rather different Judith Green senior lecturer in sociology,
department of public health and policy, London Her first case study is lovesickness.
fastidiousness of a clinician anxious to correct School of Hygiene and Tropical Medicine a few wrong assumptions on the way, such as which also caters for non-residents and has The result of this experiment is astound- ing. EXIT, as the film has been named, is basi- tourism, both EXIT associations offer their cally a compilation of typical scenes from the society’s daily life. Perhaps in an attempt to let the viewer make their own decisions, Melgar fronted with an incidence of assisted suicide does not impose his own interpretation— while watching a news report a few years ago.
Melgar merely takes the role of the passive observer. There is no narrative to guide you although I never questioned the choice of the nor is there a journalist interviewing anyone suicide candidate,” he recalls. “It was more the and summarising things for you. Instead the suicide assistant’s perspective that bewildered film builds on the intimate conversations French speaking Switzerland release date: between its characters, including suicide can- didates, other members of EXIT, relatives, German speaking Switzerland release date: idea of making a documentary film. In view of the delicacy of the subject, the society’s president, Dr Jérôme Sobel, initially hesi- Little by little, the viewer learns about the motivations of candidates for suicide, their tated to agree to the project. “Then again, wehad nothing to hide,” he says. Melgar was ups and downs, and about their feelings for their loved ones. We learn how difficult it is to eventually given the opportunity film virtu- be an accompanying volunteer worker. “This ally all of the society’s activities over a year.
is not something you can do as regularly as legislation with regard to assisted suicide. If clockwork. It’s an exceptional act every single time. I’m exhausted after every assisted assistance—for example, by providing the doctors. Active euthanasia, however, remains the process of an assisted suicide can be.
They simply drink a glass of “magic potion” and fade in the company of their loved ones.
three organisations in Switzerland: EXIT forGerman speaking Switzerland; EXIT for Raghav Chawla fifth year medical student,
French speaking Switzerland, also known as University of Lausanne, Switzerland EXIT ADMD; and Dignitas. Unlike Dignitas, BMJ VOLUME 331 24 SEPTEMBER 2005
Seniorcliniciansareoftencastigatedfor visualisetheguidelinesoncardiopulmonary academics resuscitation I learnt at medical school. I was I was recently sent a PhD thesis to mark.
taught well—a process reinforced by years of in evidence based guidelines make it difficult attending arrests. In the 1970s the compres- sion to breath ratio was 5:1, with 60 sternal leaflet entitled “Safety—everyone’s neuronal loss incapacitate the senior clini- responsibility.” On my forthcoming visit mind are the specified doses of bicarbonate, calcium, and “lignocaine.” But nowadays this imprinted knowledge could potentially fail suggests that revalidation should require me during advanced life support testing.
doctors to pass regular summative knowledge bins labelled “toxic waste” and avoid tests. No doubt educationalists will seek to examinations, and we will face some form of experiences with PhDs, I think I’ll return multiple selection questionnaire, probably evolved to 10:2, to continuous, and ended up, linked to a visit to a simulator to resuscitate a at least for now, at 15:2. But this knowledge plastic doll. An industry will establish itself only overlays the old, and I feel uncomfort- entire Soundings column to the injuries I around such tests, and—given time, a few had sustained by falling over my own half courses, and plenty of practice—I might hope the theory is evidence based, ward survival after cardiac arrest has actually altered little continuous feed printouts of two years’ worth of data, had taken up residence in a candidate, but over-attentive supervisors who keep multiple drafts of their pupil’s container is stowed securely under a desk.
and the threat of violence from masters or peers. A safe learning strategy was to keep thing old is difficult. Unlearning is not the same as forgetting. Forgetting enables you to avoid attracting attention. And I became very start again without the problem of trying to good at this. My daughter’s schooling has resolve conflicting information. Unlearning summarising (more or less accurately) the produced few basic science problems that I is far more challenging, because you have to cannot solve, even though I have not thought alter information, and in so doing you have about physical chemistry or the physics of to challenge your beliefs. Unlearning a fact time to reach a fitting conclusion to his or light for 30 years. But I loathe being forced implies that all the time spent learning it into artificial situations in simulators or originally was wasted. Unlearning a method of learning requires fundamental alteration changes to practice and policy. Examiners of your mental processes, even though the ship. I listened carefully to experts, made original way worked perfectly well for you.
approached from a sitting position with a The dividends of unlearning are negligible: the opinions of others. Nowadays, of course, after much effort you still possess the same interactive groups, facilitated learning, and amount of valid knowledge. Maybe that’s plenary report-back sessions have replaced generally been written last, in a flood of debating inefficiently for 40 minutes, argue and psychologists who make a living out of emerging blearily from their garret after about who reports back, and watch politely facilitating our thought processes, I offer six months’ writing up, realises that their this: think about unlearning and teach us all while a guru covers a whiteboard in random how to do it. I predict a great future for scrawl. There is nothing for me to latch on unlearning. But in the meantime, if you wish to, note down, and remember. I return home washing up, small children, in laws, etc.
advanced life support bear in mind that I certificate, feeling cheated that I have paid know five sets of guidelines not one, and that errors I may make in following the current the thesis is posted, and send directly to change with time. But unlike a computerhard drive my mind does not replace old Chris Johnson consultant anaesthetist, Anaesthetic
Trisha Greenhalgh professor of primary health
information with new; the original remains Department, Southmead Hospital, Bristol intact to confuse. My retentive mind can still BMJ VOLUME 331 24 SEPTEMBER 2005



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