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Interviewed by Médicos Sin Marca, renowned researcher and Cochrane Collaboration co-founder Peter Gøtzsche underlines that the drug industry works for profits, not for patients.
“Deadly Medicines and Organised Crime”, his last book, is a comprehensive report about the influence of the drug industry on healthcare.
With the aim of –hopefully– increasing awareness about the relationship between the drug industry and doctors and its side effects, Médicos Sin Marca interviewed Peter C. Gøetzsche, a well known researcher and Cochrane co-founder. The Cochrane Collaboration is a global independent network of healthcare practitioners, researchers, patient advocates and others, which responds to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about healthcare interventions. It is a not-for-profit organisation with collaborators from over 120 countries that work together to produce credible, accessible healthcare information. It is free from commercial.
In your career, you first held a position within the pharmaceutical industry. You moved on and became one of the most consistent critics of its research procedures. What made you take this turn?
I quickly realized that the drug industry routinely lies to doctors, both in its marketing and research, and deceives them in other ways, with harmful effects for the patients and our national economies. I couldn’t see myself pursue a career in such an environment. Many years later I found out that the drug industry not only lies routinely but is also the most criminal of all industries (1, 2, 3), with no respect for human lives (4).
In your opinion, why is it so difficult for doctors to question the ethical standards regarding how we relate to the industry?
In your experience, which are the common reactions of doctors when they listen to or read what you have studied and revealed?
I have been a bit surprised but also encouraged by the fact that by far most doctors sympathize with what I am doing. Like me, they know that the current system is corrupt and they would like to see it changed. The few negative reactions usually come from unscrupulous doctors who are totally corrupt and from naïve doctors who believe the industry propaganda about working for patients. The industry doesn’t work for patients, it works for profits and its drugs are a major killer of patients, only exceeded by heart disease and cancer.
How do you think that the relation between Big Pharma and doctors could be questioned today without making doctors feel threatened by this?
I question this relationship all the time, and if we don’t make doctors feel embarrassed, we won’t see any changes for the better. In the beginning, the Danish Medical Association tried to ignore me, and typically avoided any discussion of the issues by saying that doctors and industry needed to collaborate. True, but this does not necessarily mean that cash or other goods should be handed over from the industry to the doctors. This flow of money leads to loss of credibility. The Association has now realised that it cannot any longer pretend that there is no problem and it has started to support much needed reforms.
In your last book, you say that Big Pharma commits ‘organised crime.’ This sounds like a very hard accusation that might be easily rejected by these companies. Should we not focus on bias and unintentional behaviour instead?
I don’t provide accusations in my book, I give the readers the facts. It is such a well-documented fact that Big Pharma commits organised crime that it cannot be rejected by the companies. The companies have not tried to dispute this because they know perfectly well how corrupt their business practices are. Instead, they have said that the examples in my book are old and that it is much better now. These are lies. I document organised crime for the ten biggest companies based on cases from 2007 to 2012 and I also document that the crimes are increasing, which is not surprising because when crimes pay, they will increase. We are not talking about bias, we are seeing organised crime and fraud all the time, and it is certainly not unintentional. It is deliberate.
You have been particularly critical about pharmacological practices in psychiatry. Could you tell us which issues that have especially caught your attention?
It is more or less everything related to drugs. I had already seen much but was nevertheless deeply shocked when I found out what is going on in psychiatry, which is why I called my first chapter on psychiatry the drug industry’s paradise. Psychotropic drugs have many harms and one of the worst is that when patients try to stop them, they often become worse. Their doctors then usually tell them that it is because they still need the drugs. In actual fact, what many patients experience when they try to stop are withdrawal symptoms. They have become dependent on the drugs, but psychiatrists often deny this. They have learned from the drug industry to never blame the drug but to always blame the disease when there are problems.
Psychiatrist David Healy has said that, “There is probably no other area of medicine in which the academic literature is so at odds with the raw data.” I agree and I don’t know of any other specialty where there is so much overdiagnosis and overtreatment, or where the harms of the drugs are so debilitating and persistent compared to the benefits. Luckily, some of the world’s most eminent psychiatrists have realized that their specialty is in deep crisis, so there is hope for the future.
How important is the use of active placebos in psychiatric drug trials?
Drug companies don’t use active placebos at all because they know that it would reveal that many of their drugs are ineffective. A Cochrane review of old trials that had compared a placebo that contained atropine, in order to mimic some of the side effects of antidepressants, found no effect of tricyclic antidepressants on depression. Thus, what we measure in psychotropic drug trials are not true effects but mainly bias, due to unblinding of the trial drugs.
In your research about morbidity and mortality associated with use of NSAIDs, you have concluded that they have cost more than 100k lives. How did you obtain this figure?
NSAIDs have caused hundreds of thousands of deaths worldwide. My calculations are rather simple. I compared sales with the increased risk of dying when taking NSAIDs, which has been documented in meta-analyses, and also considered length of treatment. The worst thing about these deaths is that many of those treated didn’t need the drug in the first place. They could have been treated with drugs that wouldn’t have killed them, or taken no drugs at all, as many pain conditions can be endured and go away by themselves.
Polypharmacy is common nowadays. It looks like an area of big uncertainty. What has medical research done so far to shed light on this subject?
Very little. Drugs are evaluated one by one and we know very little about what happens when several drugs are taken simultaneously and interact with each other or potentiate each others’ effects. These interactions kill many patients, often after having pestered their life before they die. It is indisputable that we use far too many drugs, particularly in the elderly who tolerate them badly.
During the last few years many voices –including yours– have claimed that screening under certain circumstances might be harmful. What have been your main findings regarding breast cancer screening?
We have published so much in this area that I cannot say what have been our most important findings. What I can say is that mammography screening doesn’t reduce the occurrence of advanced cancers and therefore doesn’t do what it was supposed to do. Further, screening doesn’t make women live longer. It leads to a lot of overdiagnosis and overtreatment, and the treatment of healthy overdiagnosed women likely kill at least as many as screening helps avoid dying from breast cancer. Finally, there are the false positive diagnoses that are later refuted. The cumulative risk of a false-positive result after 10 mammograms ranges from about 20% to 60%. The psychological harm inflicted on all these women is substantial and long-lasting, and it means that utility analyses of screening that incorporate the benefits and harms invariably come out negative. Screening for breast cancer should therefore be stopped and some countries are slowly and painfully realizing this now.
Big Pharma and the law
The United States has recently approved the Physician Payments Sunshine Act, which makes it compulsory for pharmaceutical companies to disclose direct and indirect payments to doctors. What is your opinion about this sort of measure?
It is long overdue that such measures be introduced in all countries. It gives the public a much needed insight into the scale of the corruption, and it gives the patients the possibility to choose a doctor who doesn’t take industry money. Further, I would expect such transparency to lead to a substantial reduction in the level of corruption.
With regard to legislation, which other aspects of the relationship between doctors and industry should be contemplated?
Above all, marketing of drugs should be forbidden, as marketing of tobacco is, since it is similarly harmful. Imagine what a world we would have if there were no advertisements for drugs and no salespeople. Good drugs will always be used by doctors, so there is no need for marketing. It should also be forbidden for doctors who take industry money or other favours to sit on guideline or drug committees, or to provide advice to drug agencies or other public institutions. Lawyers are not allowed to represent both sides, the same principle should of course also apply to doctors.
Cochrane & medical data
The flow of information from research to point-of-care is extremely complex and liable to bias. What could you recommend to clinicians aiming to be updated and free of bias as much as possible?
They should only trust independent sources of information. They should see papers on industry-sponsored drug trials as nothing else than an advertisement for the drug. Even in our most respected peer-reviewed journals, such papers are generally unreliable. If possible, they should avoid using drugs from companies that claim that their detailed clinical study reports, which they submit to the drug regulators, are confidential and who will not share their anonymised raw patient data freely with independent researchers.
The Cochrane Collaboration has consolidated itself as a secure and trustful knowledge resource in healthcare. Which are Cochrane’s aims in the long term?
One of the most important aims for Cochrane is to reduce bias. Readers of Cochrane reviews need to be aware, however, that the reviews are too positive, on average, because Cochrane researchers usually cannot get access to all data from all trials that have been carried out with the studied intervention. A major objective for Cochrane is therefore to push hard for setting all data generated by patients’ altruism free for everyone to see. Anything short of this is unethical, so it’s surprising that we have allowed drug companies and researchers for so long to claim that they ‘own’ the data and can keep them secret. According to the European Ombudsman, to whom we filed an appeal and a complaint in 2007 over the extreme secrecy that the European Medicines Agency maintained back then, the drug industry cannot legitimately own patient data, although they pretend they do. Data generated by the patients’ willingness to run an unknown risk by participating in trials belong to us all.
NGO’s & Médicos Sin Marca
In our organisation —Médicos Sin Marca (Unbranded Doctors)– we have tried to state as clearly as possible our point of view and proposals, with ideas like ‘there is no place for industry in medical education’. However, these ideas might look a bit radical for many. How important do you think that NGO’s like ours could be for driving a change in the ethical standards within medicine?
Organisations such as Médicos Sin Marca, the Spanish NoGracias, the Norwegian Doctors Against Corruption, the Danish Doctors Without Sponsors, the US Public Citizen, No Free Lunch, the International Society of Drug Bulletins, the journal Prescrire and Health Action International are important drivers for change. It is not the slightest bit radical to say that there is no place for industry in medical education. It is well documented that ‘medical education’ sponsored by drug companies is marketing in disguise and that this activity leads doctors to make irrational decisions that harm their patients and to use far too expensive drugs that have nothing to offer compared to cheaper alternatives.
Peter C. Gøtzsche
Director of The Nordic Cochrane Centre
Professor Peter Gøtzsche graduated as a Master of Science in biology and chemistry in 1974 and as a physician in 1984. He is a specialist in internal medicine; worked with clinical trials and regulatory affairs in the drug industry 1975-1983, and at hospitals in Copenhagen 1984-95. He cofounded The Cochrane Collaboration in 1993 and established The Nordic Cochrane Centre the same year. He became professor of Clinical Research Design and Analysis in 2010 at the University of Copenhagen.
Dr Gøtzsche has published more than 70 papers in «the big five» (BMJ, Lancet, JAMA, Ann Intern Med and N Engl J Med) and his scientific works have been cited over 15,000 times. He is author of «Rational Diagnosis and Treatment. Evidence-Based Clinical Decision-Making» (2007), «Mammography Screening: truth, lies and controversy» (2012), and «Deadly medicines and organised crime: How big pharma has corrupted health care» (2013).
He has an interest in statistics and research methodology. He is a member of several groups publishing guidelines for good reporting of research and has co-authored CONSORT for randomised trials, STROBE for observational studies, PRISMA for systematic reviews and meta-analyses, and SPIRIT for trial protocols.
Dr Gøtzsche participated this year in the Cochrane’s mid-year meeting in Panama. There he participated with MSM in a forum on the influence of the drug industry on clinical decisions.
He has been one of the most consistent voices denouncing the improper behaviour of the drug industry and he has studied the costs associated with these practices, not only in terms of money, but especially regarding morbidity and mortality.
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