Spring 2006

Life and Health

The Sickness Business

Brian Orchard

Life expectancy in the United States has risen from 47 years back in 1900 to nearly 78 today. This remarkable increase is the result of various factors, including better nutrition, better hygiene and stunning medical advances. Improved life expectancy figures across the developed world support the positive role that scientists and health-care professionals have played. People are not only living longer but enjoying a higher standard of health.

As we enter the age of genetic engineering, the scope and speed of developments in scientific medical knowledge is breathtaking. However, beneath the surface of these tremendous advances are areas of growing concern.

Since the Middle Ages the Western trend has been to look increasingly to science for an understanding of life’s important questions. Whereas religion once acted as the final authority concerning matters of life and death, it has been progressively marginalized. Now scientific research is regarded as the defining voice of authoritative knowledge.

Our Medicalized World

The scientific approach has had an enormous effect on all areas of society, but perhaps none so close to us as in the area of medicine. There has been a clear shift in the way behavioral issues and diseases are defined: modern biomedicine is influenced by the notion that most disorders are of organic origin. This provides a physiological basis for problems rather than a social-behavioral one. It suggests that the way we think and the choices we make have little or no bearing on our well-being—that our physical, mental and emotional complaints are almost certainly evidence of some underlying organic condition that requires drug therapy. In other words, what were previously regarded as moral or social disorders are now regarded as treatable medical conditions.

The late sociologist Ivan Illich was one of the first to voice concerns about this shifting approach. In the mid-1970s he raised the issue of drugs and other medical technologies being used in a way that denied the role of personal responsibility in human suffering. He argued that the medicalization of society (including the assumption that behavioral conditions in themselves constitute illness and therefore need to be treated by medicine) was harmful in two ways: it introduced a wide range of hazardous side effects, defined as clinical iatrogenesis, or doctor-caused problems (from the Greek iatros [physician]); and it removed personal responsibility, creating dependency on health care.

The development of both medical science and the pharmaceutical industry since the mid-’70s has been staggering, so those voicing concerns today have a more complex situation to deal with than in Illich’s day. The term medicalization now carries the added negative connotation of overuse and inappropriate application of drugs.

David Melzer, clinical senior research associate at the Department of Public Health and Primary Care, together with Ron Zimmern, director of the Public Health Genetics Unit at Strangeways Research Laboratory (both at the University of Cambridge), editorialize in the British Medical Journal that “genetics could drive a new wave of medicalisation if genetic tests are accepted without appropriate clinical evaluation.” They go on to comment: “Over time, the tendency has been to expand diagnostic and treatment boundaries, and to include in the ‘disease’ category people with milder manifestations of pathology and lower levels of risk.” Melzer and Zimmern call it an example of “premature medicalisation—of attaching the ‘disease’ label before it has been established that prevention or treatment is clearly beneficial.” The BMJ apparently shared their concern as it devoted the entire issue to the question of “too much medicine?”

A Depressing Story 

The role of the large drug companies is also causing alarm. Ray Moynihan is a medical journalist for the New England Journal of Medicine and The Lancet. He and Canadian science writer Alan Cassels address the subject in their book Selling Sickness: “The marketing strategies of the world’s biggest drug companies now aggressively target the healthy and the well. The ups and downs of daily life have become mental disorders, common complaints are transformed into frightening conditions, and more and more ordinary people are turned into patients… . The $500 billion … pharmaceutical industry is literally changing what it means to be human.”

One illustration of the concern about drug companies relates to drugs to relieve depression. Australian pharmacist and educator Gail Bell explains the problem from an Australian perspective in her essay “The Worried Well,” published in Australia’s second Quarterly Essay of 2005: “In 2004, twelve million prescriptions for this group of drugs were dispensed through the Pharmaceutical Benefits Scheme (PBS), a figure that contains both newly initiated scripts and monthly repeats of established regimes and equates to well over a million annual users. More people than ever before in the history of Australia are taking antidepressants. Five million PBS scripts in 1990, 8.2 million in 1998, twelve million last year, 250,000 of which were written for patients under twenty years old.” In a country of only 20 million people, these figures are alarming.

The trend is repeated in numerous other countries. For example, Moynihan and Cassels remark that in the United States, a small army of detailers (the sales representatives who introduce and promote new drugs to doctors and pharmacists) have “helped instill and reinforce the notion that depression is a widespread psychiatric disease most likely due to a chemical imbalance in the brain, best fixed with a modern group of drugs called selective serotonin reuptake inhibitors, or SSRIs, that includes Prozac, Paxil, and Zoloft… . Drug company spending on sales representatives and their free samples is the biggest component of the roughly $25 billion … now outlaid annually in the United States for promotion… . And at every opportunity, it is not just drugs being sold, but very particular views of disease.”

There is no simple answer to this issue of medicalization. Mental illness and clinical depression are very real and crippling conditions, and many people are greatly helped by medication. The issue is not treatment of very real cases of mental illness but the relationship between drug companies, medical practitioners and patients. These groups do not operate in isolation; however, the power of the juggernaut pharmaceutical companies is of growing concern.

Under the Influence of Drug Companies 

Three issues are most often raised in relation to the practices of drug companies. The first is the redefining of disease to turn a profit, as Sarah Ross, a clinical research fellow in Aberdeen, Scotland, illustrates: “[One] example of profit-driven medicalisation is Viagra. An increase in society’s emphasis on sex has increased expectations, and changed what people think is normal in terms of sexual behaviour. Viagra has cashed in on this. The medical treatment of a condition has in part to do with whether there is an available treatment and how serious the problem is. Pharmaceutical companies are producing treatments and then creating or exaggerating conditions to sell them” (“Beyond Reasonable Boundaries”).

Moynihan and Cassels state that “the epicentre of this selling is of course the United States, home to many of the world’s largest pharmaceutical companies… . With less than 5 per cent of the world’s population, the US already makes up almost 50 per cent of the global market in prescription drugs.” Spending has increased by almost 100 percent in just six years, they add.

The second cause for concern is that pharmaceutical companies dominate clinical research. Here the worry is the degree to which the drug companies finance scientific research and payroll those who write the standards. Moynihan and Cassels report that “an estimated 60 per cent of biomedical research and development in the US is now funded from private sources, mainly drug companies… . Almost all the clinical trials of the new antidepressants were funded by their manufacturers rather than public or not-for-profit sources.” They remark, “Eight of the nine experts who wrote the latest cholesterol guidelines also serve as paid speakers, consultants or researchers to the world’s major drug companies… . One ‘expert’ had taken money from ten of them.” This brings objectivity into serious question.

The third troubling area of drug company influence is in the medical education of doctors, who are positioned between drug suppliers and consumers. Ben Lerner, whose Florida practice focuses on a holistic approach to health, refers to “an ‘unholy alliance’ between pharmaceutical manufacturers and doctors who are informing the population that they are in fact ill. Doctors go to school to learn how to help. Nonetheless, due to the speed at which information is coming across a doctor’s desk, and given how busy doctors are with their medical practices, they couldn’t possibly keep up.

As a result, doctors are forced to rely on the greatly-skewed opinions of pharmaceutical reps and the biased research paid for by their companies for their prescribing advice” (“Medicalisation: Disease Mongering”).

The job of all these drug company representatives is not only to educate doctors regarding the particular drugs their company produces but to increase the doctor’s knowledge of the expanded base of diseases that can be treated by their drugs.

There are other aspects of the role drug companies play in medicalization, but these three observations provide sufficient insight to raise awareness of the seriousness of the problem. Many medical journals have been prepared to publish their own warnings within the profession. The New England Journal of Medicine, the Journal of the American Medical Association, the British Medical Journal, the Annals of Internal Medicine and The Lancet have all featured articles about the overuse of drugs and the medicalization of the normal human ups and downs of life.

Supply and Demand

Surely the patient should be the starting point for dealing with this troubling trend. As a consumer, the patient is at the end of the medical supply chain and is key to the whole process. Without consumers providing an ever-increasing demand, the supply-demand cycle is broken.

There is no doubt that the process of wisely seeking medical help is daunting. Doctors are experts in their field, and because we patients cannot know all the complex interactions between our bodies and drugs, we generally comply with medical direction with a degree of faith and confidence in the acknowledged experts. While most doctors are sincere in their efforts to help patients, the subtle factors we have briefly reviewed are present. If a doctor is overworked by patient volume, and new drug treatments are coming at him or her at a speed that is impossible to keep up with, the doctor is in turn forced to have a degree of faith in the sales reps of the drug companies. Thus, perhaps somewhat unwittingly, patients are brought into the medicalization chain.

Coupled with this vicious cycle are the cultural forces that form our views of life. One powerful force in society today is the willingness to find ways of avoiding responsibility for our actions. Many illnesses are the result of lifestyle choices. Obesity, smoking and indulging in recreational drugs generally result from choices people make. Each has consequences. When Newsweek’s Elise Soukup asked U.S. Health and Human Services secretary Michael Leavitt in December 2005, “What do you think is the biggest thing that could improve America’s health?” he replied, “Focusing on wellness instead of treatment. We’ve been talking about epidemics. We’re seeing an epidemic of chronic disease. Obesity is one example. And we can improve our habits and focus on our health.” Rather than change our lifestyle, however, it is much easier to have the medical profession prescribe a pill to alleviate the consequences of poor choices.

Similarly, much alarm has been voiced about how readily children are diagnosed as suffering from “attention deficit/hyperactivity disorder” (AD/HD). It is certainly easier to give children a drug to calm their behavior than to look for other possible causes of the problem.

Of course, many people are genuinely helped by the amazing advances in medicine. In other cases, however, medicalization does little more than financially benefit the health-care and pharmaceutical industries. We need to take ownership of our lives by addressing root causes rather than immediately seeking a medical quick fix. Perhaps we do not actually need the degree of medicalization that is being offered to us.

One effective way to take more responsibility for our lives would be to consider the possibility that there are timeless principles—actually unseen laws—in existence that, if followed, produce happiness, peace of mind and better health. These laws were designed for our well-being to allow the maximum fulfillment in life, and they are found in the Bible. Moses reminded the Israelites just before he died: “This is the commandment, and these are the statutes and judgments which the Lord your God has commanded to teach you … that your days may be prolonged… . And the Lord commanded us to observe all these statutes … for our good always, that He might preserve us alive” (Deuteronomy 6:1–2, 24). These are the same laws that Jesus Christ upheld, both by example and by teaching, while He walked on earth. Applying these laws can help us change our lifestyle at the most basic level and produce greater health and happiness.

As individuals we cannot realistically change the behavior of the big drug companies, which are driven largely by profit. But we can determine to use medication responsibly, and we can help ourselves by coming in line with a way of life that constitutes healthy living.