Though you are not supposed to judge a book by its cover, it is hard to ignore the myriad of colorful pills behind the blurb in yellow on this one: ''Before you see a doctor, you should read this book. Eric Schlosser, author of Fast Food Nation.'' One gets the immediate sense that this is another expose of corporations, in this case those making us sick instead of fat. And indeed it is; and not a bad expose. Abramson tries a little too hard to seem a commoner though, or perhaps the marketing department for Harper is to blame, defining him on the back cover as having worked ''as a family doctor with the National Health Service Corps in Appalachia and for twenty years in a small town north of Boston. He is a clinical instructor at Harvard Medical School.'' The Harvard name presumably implies credibility, the small town and Applachia links seek to make him real. But the ''small town'' is Burlington, Massachusetts, where he worked at the Lahey Clinic, a large medical center affiliated with Harvard and Tufts. Burlington is hardly small town, basically a suburb of Boston; this would be like calling Palo Alto, without naming it, a small town outside of San Francisco.
Be that as it may, this is a book by an academic physician, one who taught at the downtown Boston campus of Harvard Medical School for years (with full professor Herbert Benson); this is an academic physician criticizing other academic physicians as well as the pharmaceutical industry. It is a critique from the standpoint of a proponent of family practice and public health, and, at its core, it is not really just a critique of the pharmaceutical industry, it is a critique of ''biomedical reductionism'', of the idea that medicine is about nothing but molecules and pills, rather than people. To that extent, it is worthy, though hardly new. What is new is the detailed indictment of the pharmaceutical industry as a symptom of this biomedical reductionism.
Compared to other books, such as Marcia Angell's The Truth about the Drug Companies, (which I reviewed previously in Metapsychology 10:5), this book is superior. Abramson makes much repeatedly of the fact that he quit practicing medicine to write this book so that he would have the time to research it well; being skeptical, I checked a few of his references to see how he interpreted them, and by and large I have little to quibble with. Abramson had some public health training as a Robert Wood Johnson fellow (another academic activity, though he does not have a MPH degree) and he seems reasonably well trained statistically. Much is made by the book's blurbs about his use of his statistical background to cut through the marketing spin that is woven into pharmaceutical research, and indeed he does a reasonably good job in that sense, better than most other books on this topic. The references are infinitely more detailed and medical journal based, for instance, than Angell's book, which was highly reliant on popular newspaper articles. The broadness of Abramson's reach, covering all aspects of medicine as well as some parts of psychiatry, is also useful.
There are a few aspects of this book that deserve critique, however. Perhaps most importantly, for me, the tone of the book was bothersome. It was about as shrill as Angell's book, leaving the reader feeling like he is being scolded. I am not sure if that was Abramson's intention; it seems that this might be his first book, or certainly his first popular book, and I am sure he struggled with how to make complex topics accessible to the general public. I also imagine his editors emphasized keeping things simple and straightforward. But, like Angell, that is a fatal flaw, for this is not a simple or straightforward topic. Simply making the drug companies evil personified fails to convince. As a reader, I felt drawn toward wanting to disagree with Abramson, if only because he was so insistent and adamant in his black and white world. I am sure he is right in many ways, but the tone is far from balanced. In contrast, one might take a look at some of John Kenneth Galbraith's writings; in the Affluent Society, for instance, he indicts capitalism repeatedly, but never in a way that makes the reader feel scolded. It is possible that if Galbraith were a new writer, his New York editors would revise his writing to make it starker (for example The Affluent Society might become The Fleecing of America: How the Rich get Richer and the Poor get Ignored). Is it possible to write an intellectually satisfying popular book these days, without talking down to one's readers?
Another problem is the selectivity of the studies and topics he reviews. For instance, in one example, on page 303, he highlights problems with studies of antidepressants and the role of the pharmaceutical industry in promoting those agents both for depression and for anxiety conditions (like ''social anxiety disorder''), what others call disease-mongering – the creation of diseases to market drugs where no real disease-entities existed or by excessively expanding the scope of previously narrow disease-concepts. Now anxiety and depression are conditions that are amenable to this critique, as made David Healy in the Antidepressant Era (reviewed in Metapsychology 2:46) has also made. But what about other conditions? Let's take schizophrenia. Who is engaging in disease-mongering with that condition? In fact, the diagnosis of schizophrenia is much less frequent today, in the era of pharmaceutical industry power, than it was from the 1950s to the 1970s, when that industry was much weaker. Abramson cites some research showing the benefits of exercise for depression, even more so than antidepressants in one study. But are there more benefits with exercise for schizophrenia compared to antipsychotics? In other words, what he has done is to choose conditions in which his argument is strong, ignore those in which it is weak, and then leave the impression that his argument applies to all conditions. This leaves the impression that all illnesses are suffering from disease-mongering, a dogma that I have labeled disease-mongering mania (see www.plos.org for more on this). This could be unfair, though. He may have chosen the illnesses he has – depression, anxiety, osteoperosis, hypercholesterolemia, diabetes – because those are the chronic conditions that affect large parts of the population, and with which family practitioners are often faced. Schizophrenia, in contrast, affects fewer people and is a more severe illness (we can leave aside the fact that the reason we think schizophrenia affects fewer people is because psychiatrists have defined it narrowly, despite the existence of drugs which the pharmaceutical industry would have motive to market in larger numbers to people with this diagnosis). Yet the point is still there: Abramson's arguments do not apply for all, or even most, medical illnesses, but they may apply to many of the more common chronic conditions that people have.
His point is well-taken: many of those chronic conditions are best approached with a preventive public health model, rather than a pill-based (or surgical) medical treatment model. This is a basic fact taught in the first week of public health school, including the one I attended, and I agree with him. Many physicians are acculturated to simply think about treatment rather than prevention, and the pharmaceutical industry is incentivized to promote this approach, and so his critique is valid. The related critique of biomedical reductionism follows: if we take a broader (some would say bio-psycho-social) view of illness, then we would not just focus on symptoms, molecules, and pills. Again, I would agree, though the alternatives to biomedical reductionism have, in practice, been failures. The bio-psycho-social model, for instance, has largely failed to serve as a powerful model for medicine for many reasons (for an additional discussion of this see www.blogspot.nassirghaemi.com ). And the benefits of biomedical reductionism should not be underestimated. The fact that cardiac procedures are overdone, for instance, does not mean that they should not be done at all. The fact that pills are overprescribed also does not mean that they need not be prescribed in general. Abramson does not make those extreme claims, but the overall simplistic tenor of the book might leave less educated readers prone to misinterpretations.
Finally, I must make a point about marketing and capitalism. It is a shame that medicine has become a business, as Abramson points out; that corporations with for-profit motives as their primary goal have so much influence (although curiously Abramson is hardly critical of the managed care profiteers, while being as harsh as Isaiah with the pharmaceutical companies). Yet I can only see a few principled stands here. One stand would be to argue for nationalized health care through and through, from the insurance that pays for treatment to the drug discovery and research process. Let it all be funded by the government. Let us take medicine completely out of the capitalist marketplace. Galbraith might have supported this view; it is not different, in principle, than saying that the government should take care of the postal services, as it does (although there are private companies that augment basic mail delivery), or that the government should take care of military services, or public schooling, or highway construction. The government handles some sectors of our economy, and the world has not come to an end. Why not add medicine to that list? Angell, to her credit, is more forthright on this topic; Abramson does not address it.
Another approach would be more piecemeal: let us have the government regulate medical care more aggressively; this is the usual suggestion, and what Abramson recommends as well. I think either approach would be an improvement, though experience suggests that sometimes government control is helpful, and sometimes it is not, depending on what is being controlled. In the case of scientific research, years of experience suggests that government funding by and large is helpful, although there is a certain price to pay there also. For instance, much NIH funding is quite conservative; new ideas are rarely funded; in reality, much creative research in academic centers happens these days because of the easier availability of pharmaceutical industry funds (of course much wasted marketing disguised as research goes on as well).
Until any reform happens academic medical researchers like me have to figure out how we can conduct important research that helps the public health in the current environment. My approach has been to accept pharmaceutical industry research funding only for studies I design, conduct, analyze, and write completely by myself or with academic colleagues. To contribute to medical education, where speaking fees are provided, I generally limit myself to continuing medical education programs, where one is paid through a university, not promotional settings, where one is paid directly by a pharmaceutical company. I avoid any pharmaceutical stocks in my retirement accounts. This is not perfect, but it is as good as can be done with an imperfect system, if one wants to conduct research and be an active educator. Abramson does not address in much detail how ethical research can be conducted in this environment. It is easy enough to identify the enemy but he, like Angell, fails to tell us how we can live with that enemy, given that it is not going away tomorrow; we need a practical approach to ethical medical care and research that can be implemented today in a system that often rewards an absence of ethics.
Instead of engaging with those hard questions, the book gives the impression that marketing, profit, and capitalism are vile things, which they may well be (to use a tone that Galbraith might approve), but it is ironic to get this implication from a book that is itself such a product of marketing, with all that flows from the marketing prowess of major publishers, including reviews from major newspapers, invitations to major TV shows, and its own website (www.overdosedamerica.com). The publishing industry makes profits based on books no matter what is in those books. Frequently, the most wrong and misleading books are those that make huge profits, such as the ubiquitous tomes that attack modern medicine and urge alternative or herbal treatments for everything. Those books probably are harming the public health. But why does no one attack the book industry for what it is doing? Probably because it would be hard to get the book industry to publish those attacks, at least by the kind of major publisher that is needed to reach mass audiences. Abramson himself will garner some profits from his book, as he should, especially since he quit his profession to write it. But does that mean that he is biased by the fact that he is profiting from his book? He writes that we should ''follow the money''; well, if we follow the money with him one might conclude that he made his book sensationalistic, oversimplified, and portrayed matters as being starker than they are – all so he could sell more books. I do not believe such is the case, personally, because I do not assume that one should always judge people's views based on how much profit they are making from those views. Sometimes following the money is correct, sometimes it is not.
This gets us again to the core issue: the book is valid in many respects, but oversimplified. Bad research is common; the pharmaceutical industry is too powerful; medicine is too biological. But good research happens too, the pharmaceutical industry sometimes provides useful treatments, and often medicine needs to be biological. Abramson did good research; I only wish he provided us with more balance and less...marketing.
© 2006 Nassir Ghaemi
Nassir Ghaemi, M.D., M.A., M.P.H., Associate Professor, Department of Psychiatry and Behavioral Sciences; Director, Bipolar Disorders Program, Emory University School of Medicine. Dr. Ghaemi is author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, Johns Hopkins University Press, 2003.