drawn by Doruk Golcu

Natural Selections (NS): Do you think things have changed since the publication of your book?

Marcia Angell (MA): More people are now conscious of some of the problems. Not just because of my book, there have been several books published at about the same time. They looked at somewhat different aspects, but they were all quite consistent. I think there’s some increased awareness.

NS: What is the increase in drug expenditures due to?

MA: We can divide it into three reasons: the increase in volume, the increase in prices of new drugs, and the inflation. Each is responsible for roughly a third.

NS: Do you think this increase in prices goes along with the huge cost of health care?

MA: It’s actually a little bit faster. Spending on drugs is still only about 12% of the total health bill, but the price of drugs is increasing faster than most other parts of the health care system.

NS: What do you think about this huge cost of health care in general in the US?

MA: It’s really the private insurance industry. Our health care system is a market-based system that involves hundreds, maybe thousands, of investor-owned private insurance companies. They keep their profits up but their premiums down by stinting on medical services, by not insuring high-risk patients at all—if they can get away with it, and by limiting the coverage of those that they do insure. They also try to get somebody else to pay for it—often the patient himself—through co-payments, high deductibles, or denying claims. We have a health care system that is based on avoiding sick people. Isn’t that strange? That’s how it works. And that takes a lot of paperwork and a lot of overhead, by which I mean profits, marketing, and administrative cost. We spend roughly twice as much as other countries on overhead, much of which serves the purpose of not providing the services to people who need them.

NS: Although the pharmaceutical industry is making huge profits, Pfizer is laying off more than 10,000 people. How can we explain that?

MA: It all goes to the nature of investor businesses. Wall Street demands companies’ profits to be higher this year than what they were last year. It doesn’t matter how profitable they are today. It matters how profitable they’re going to be tomorrow. That’s what investors are looking at and this is the reason why they buy the stock. So in a sense, you can call them victims of their own success. They are so enormously profitable that they have to keep up. When you run the 4-minute mile, then you have to do it in 3 minutes and 59 seconds. They have to go even beyond what they’re making today. This is not about matching the profit, it’s about surpassing the profit. That’s getting increasingly hard. So, they look to cut costs.

NS: Society in general, including patients, doctors, and the government, has some responsibility for the problem of prescription drugs. Can or should patients be educated?

MA: I’m reluctant to blame the victim. I do think that the public and the patients have bought on the belief that there is a prescription drug for every ailment and discontent. They have done that more than they should. They haven’t been sufficiently skeptical. I think they’re starting to question. I talk to groups made up mainly with people from the public. What I find is that they know something isn’t right about the pharmaceutical industry and about the health care system in general. But they don’t trust their instincts. They say, “It seems to me that they are charging too much for too little. But I don’t know, I’m not an expert.” They’re beginning to respond with an instinctive intuition that things aren’t right, but they’re not to the point yet where they’re willing to trust themselves. I think that patients have got to give their doctors permission not to prescribe a drug. When they go to see a doctor, it’s very easy for the doctor to hand out a few samples or to write a prescription. When doctors do that, it looks like they’re taking the complaint seriously. They’re getting the patient out of the office in a hurry and doctors are now under pressure to see more patients faster. It is an easy solution for everybody. I think that patients may have to say to their doctor: “Do I really need a drug for this? Isn’t there any treatment that might be better? If you do think I really need a drug, would you give me a generic drug or the cheapest version available?” This dialog has to go on and I think doctors would be relieved.

NS: In 1997, an Act of Congress softened regulations on direct consumer advertising on television. How did we get there and how is it regulated?

MA: As the industry became wealthier and wealthier, it became more and more influential. It has now an enormous amount of influence in Washington. So, the laws that relaxed the criteria for direct consumer advertising were a gift from Congress in 1997. To a large extent, the Congress is bought and paid for by special interests. The most special of all is the pharmaceutical industry, so they made it happen. The FDA is supposed to regulate the content of the ads to make sure that they are balanced and accurate. They don’t do that. It isn’t so much that you need new laws, you just need to enforce some you already have. I would prefer no direct consumer ads but given that there are, I think they can be regulated much better.

NS: Do you think a partnership between biotech companies, which have good ideas but lack the infrastructure to develop their discoveries, and the drug companies is bound to happen?

MA: It all depends. There are a lot of biotech companies, particularly start-up companies, that are connected to universities. They have one product and are not profitable. In fact, most biotech companies are not profitable at all. The investors invest in them because they are gambling. What these companies are hoping is that a big pharmaceutical company will come along and buy them. Then, the university, the faculty researchers, and the small biotech company all gain. This is done usually on the basis of public-funded research, performed initially in the university, then handed off to the biotech company for initial development, and then handed off to the pharmaceutical industry for marketing—that’s mainly what they do with clinical trials. So everything would depend on the product. Sometimes the public pays twice; it pays for most of the research and most of the development, and then it pays again at the drug store. Overall, does it make sense to go from the university to a biotech to a big pharmaceutical company? I don’t see anything wrong with that if the terms are reasonable.

NS: Do you think we should go towards personalized treatments?

MA: I favor anything that works. By work I don’t mean that earns a profit, I mean helping people’s health care. I don’t see how it can work commercially for the big pharmaceutical companies. After all, if we look at their current behavior, they are trying to sell drugs to the biggest possible market. A market of one person is not that much of a market. Just in Economics 101, why would you make a drug for one person? I don’t see the incentive. Insofar if they do that, it would be at exceedingly high prices. Who is going to pay for those? Is it a kind of new boutique drug development that the wealthy might get but nobody else would? That worries me a lot.

NS: In the US, all kinds of dietary supplements are sold commonly over-the-counter. Should they be more controlled?

MA: There is currently no pre-marketing regulation of dietary supplements. They were removed from the requirement that they have to show effectiveness and safety to the FDA in 1994 by the DSHEA [Editor’s note: Dietary Supplement Health and Education Act of 1994]. It was made so that you can put anything you want in a bottle, put it on the shelf, and sell it, without clinical trial whatsoever. The only stipulation is that you are not allowed to claim that the dietary supplement either prevents or treats a medical condition. To go around the legislation, companies have developed code-language. For example, supplement bottles are labeled with the mention “this dietary supplement promotes prostate health,” therefore, they haven’t claimed that it cures prostate cancer or that it prevents it, but everyone knows what the supplement is supposed to do. It has become a huge business.

The difference between the US and Europe, as far as I am aware, is that Europe regulates manufacturing standards; what is said to be in that bottle has to be in the bottle. It is just as bad in terms of whether it is effective as doing anything or not, but at least you know that it is not just weeds from somebody’s backyard in a bottle. In the US, tests on dietary supplements have been performed. For example, Consumer Report tested several bottles of dietary supplements supposed to contain a certain concentration of ginseng. Some of them did not have ginseng at all, some had ten times that concentration. You don’t really know what’s in that bottle. That’s dangerous, and it’s also a scam since some dietary supplements haven’t been shown to be effective at all. I am very critical of this. I think that if you take something for your health, you are entitled to know whether it is effective. No matter how they coach the language, companies ought to show that their product is made according to the FDA’s standards of safety and effectiveness. The FDA can get involved only after reports that something happened. For example, Ephedrine was removed from the market after there were many reports of death.

NS: You wrote a review of the movie The Constant Gardener for The New York Review of Books. Is it really a fiction that the third world is our guinea pig?

MA: No, that is not a fiction, it’s true. In that respect, everything that the book said and that the movie said about the behavior of the pharmaceutical industry in general was correct. What was not correct was the particular story of the two people. There is no way, I think, that the drug companies would have a woman murdered who did what she did; they don’t have to do that. She wouldn’t even be on their radar screen, even if they were willing to do it. The kind of things that this fictional character exposed is really standard practice for drug companies, they don’t try to hide it. So it was an odd combination of the real with the unreal.

NS: Drugs, such as HIV microbicides for instance, are currently in clinical trials in Africa. What are the chances that such trials would take place in the US?

MA: It would depend. There are trials in Africa that I’m sure could not take place in the US. Others perhaps could, it varies. If drug companies go to underdeveloped countries, they can escape, to a large extent, the scrutiny that they would undergo if they were in developed countries. So we don’t quite know what they’re doing, and that’s the problem.

NS: What are your future plans?

MA: I just became a grandmother and I am spending lots of time in Seattle. I also teach at Harvard Medical School. This book has kept me very busy. Now I am regrouping.

Reference

Marcia Angell, The Truth About the Drug Companies: How They Deceive Us and What to Do About it (Random House, 2004)

The authors wish to thank Gloria Phipps for her kind help in arranging this interview.