Accusations of disease-mongering and medicalization---are they evidence based?

The pharmaceutical industry has been under fire for its marketing practices. The latest barrage of accusations is about disease-mongering and medicalization. The idea is that the pharmaceutical industry carves out new markets for its products by inventing diseases and inflating the public perception of diseases.

Some of the more shrill industry critics are featured in the documentary “Big Bucks, Big Pharma: Marketing Disease & Pushing Drugs”, which can be viewed from this blogpost by Big Red Pill. The video deals mainly with direct to consumer (DTC) advertising, a major focus of the purported disease-mongering.

I don’t like DTC ads. But drug companies are going to market their products one way or the other. Public pressure may change how they market their drugs, but it isn’t likely to change the amount they spend on marketing. The constant hammering against physician marketing has been effective. It’s led to an increase in DTC advertising. But I digress.

Near the beginning of the video Marcia Angell, author of The Truth About the Drug Companies: How They Deceive Us and What to Do About It accuses drug companies of re-defining what it means to have hypertension and high cholesterol. Wrong, Dr. Angell. Although treatment targets have been lowered no one has “re-defined” hypertension. Hypertension is and always has been defined as blood pressure which exceeds a threshold for cardiovascular risk. Recent evidence suggests that that threshold is much lower than previously believed. An analysis of one million adults in 61 prospective studies demonstrated that the threshold is at least as low as 115/75. These data, rather than any “re-definition of hypertension” by the drug companies, are the basis for the lowering of blood pressure goals in recent guidelines. Over the years we’ve gradually become more aggressive in treating hypertension and data cited in the JNC-7 report suggest that this effort has reduced stroke, coronary events and heart failure. So what are you saying, exactly, Dr. Angell? What fault do you find with these data? You evidently believe we should go back to older, higher BP targets, right? What BP target do you feel would be appropriate and how would such higher targets help patients?

And what about cholesterol? I don’t see anyone defining high cholesterol or making it into a disease. The disease is atherosclerosis. We moved beyond worrying about what’s defined as high or low years ago in favor of setting treatment targets appropriate for the patient’s risk. These treatment targets have been lowered not because of any re-definition of high cholesterol by industry, but because it’s supported by evidence. So, again, Dr. Angell, let’s play fair. You evidently don’t agree with the new treatment targets. What’s wrong with the evidence I’ve cited? What targets do you think would be appropriate and what evidence do you have to support your proposed targets?

The narrator goes on to state that “Big Pharma normalizes even the most obscure health disorders and presents them as common.” Then, as if to illustrate that point, the video cuts to an ad about restless leg syndrome (RLS) which says that nearly 1 in 10 people have the problem. So how does this ad present an obscure health disorder as common? In fact evidence supports the statement in the ad. The figure of 1 in 10 individuals is not in dispute if one checks published research, something the producers of the video didn’t seem to bother to do.

Then Dr. Bob Goodman of No Free Lunch fame weighs in and accuses industry of taking common everyday maladies and “medicalizing” them. He asserts that of all the things they do this is the one thing he would label as “evil.” But he doesn’t really define what he means by medicalization. And while he points out that such “medicalization” might make a person realize that he or she is not healthy or (gasp) end up taking a prescription medication he doesn’t explain what’s really wrong with that. I wish I could pin him down. Is medicalization anything more than defining a problem? The idea that common everyday miseries are defined and characterized is nothing new. Constipation has its own ICD-9 code as does headache. Medicalization?

The video is unconvincing. If accusations of medicalization and disease-mongering are to amount to anything more than half truth and innuendo some questions such as those I have posed here need to be answered.