Selling Sickness : A classic paper

This paper was published 13 years ago in the BMJ. It raises issues which are unfortunately as relevant today as they were when it was published. I am reproducing it, hoping that it will help to educate us to some of the issues that face healthcare today.
It can be found here 


Selling sickness: the pharmaceutical industry and disease mongering
Ray Moynihan, Iona Heath, David Henry

There's a lot of money to be made from telling healthy people they're sick. Some forms of medicalising ordinary life may now be better described as disease mongering: widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments.1,2 Pharmaceutical companies are actively involved in sponsoring the definition of diseases and promoting them to both prescribers and consumers. The social construction of illness is being replaced by the corporate construction of disease.

Whereas some aspects of medicalisation are the subject of ongoing debate, the mechanics of corporate backed disease mongering, and its impact on public consciousness, medical practice, human health, and national budgets, have attracted limited critical scrutiny.

Within many disease categories informal alliances have emerged, comprising drug company staff, doctors, and consumer groups. Ostensibly engaged in raising public awareness about underdiagnosed and undertreated problems, these alliances tend to promote a view of their particular condition as widespread, serious, and treatable. Because these “disease awareness” campaigns are commonly linked to companies' marketing strategies, they operate to expand markets for new pharmaceutical products. Alternative approaches—emphasising the self limiting or relatively benign natural history of a problem, or the importance of personal coping strategies—are played down or ignored. As the late medical writer Lynn Payer observed, disease mongers “gnaw away at our self-confidence.”2

Although some sponsored professionals or consumers may act independently and all concerned may have honourable motives, in many cases the formula is the same: groups and/or campaigns are orchestrated, funded, and facilitated by corporate interests, often via their public relations and marketing infrastructure.

Summary points

• Some forms of “medicalisation” may now be better described as “disease mongering”—extending the boundaries of treatable illness to expand markets for new products
• Alliances of pharmaceutical manufacturers, doctors, and patients groups use the media to frame conditions as being widespread and severe
• Disease mongering can include turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeing risks as diseases, and framing prevalence estimates to maximise potential markets
• Corporate funded information about disease should be replaced by independent information

A key strategy of the alliances is to target the news media with stories designed to create fears about the condition or disease and draw attention to the latest treatment. Company sponsored advisory boards supply the “independent experts” for these stories, consumer groups provide the “victims,” and public relations companies provide media outlets with the positive spin about the latest “breakthrough” medications.

Inappropriate medicalisation carries the dangers of unnecessary labelling, poor treatment decisions, iatrogenic illness, and economic waste, as well as the opportunity costs that result when resources are diverted away from treating or preventing more serious disease. At a deeper level it may help to feed unhealthy obsessions with health,3 obscure or mystify sociological or political explanations for health problems,4 and focus undue attention on pharmacological, individualised, or privatised solutions.3 More tangibly and immediately, the costs of new drugs targeted at essentially healthy people are threatening the viability of publicly funded universal health insurance systems.5

Recent discussions about medicalisation6 have emphasised the limitations of earlier critiques1 of the disabling impact of a powerful medical establishment. Contemporary writers argue that the lay populace has become more active, better informed about risks and benefits, less trusting of medical authority, and less passively accepting of the expansion of medical jurisdiction into their bodies and lives. Although these views may herald a more mature debate about medicalisation, the erosion of trust in medical opinion reinforces the need for wide public scrutiny of industry's role in these processes.

In this paper we do not aim for a comprehensive classification or definitive description of disease mongering, but rather we draw attention to an important but under-recognised phenomenon. We identify examples, taken from the Australian context but familiar internationally, which loosely represent five examples of disease mongering: the ordinary processes or ailments of life classified as medical problems; mild symptoms portrayed as portents of a serious disease; personal or social problems seen as medical ones; risks conceptualised as diseases; and disease prevalence estimates framed to maximise the size of a medical problem. These groups are not mutually exclusive and some examples overlap.

Go to:

Ordinary processes or ailments as medical problems: baldness

The medicalisation of baldness shows clearly the transformation of the ordinary processes of life into medical phenomena. Around the time that Merck's hair growth drug finasteride (Propecia) was first approved in Australia, leading newspapers featured new information about the emotional trauma associated with hair loss. The global public relations firm Edelman orchestrated some of the coverage but largely left its fingerprints off the resulting stories. An article on page 4 in the Australian newspaper featured a new “study” suggesting that a third of all men experienced some degree of hair loss, along with comments by concerned experts and news that an International Hair Study Institute had been established.7 It suggested that losing hair could lead to panic and other emotional difficulties, and even have an impact on job prospects and mental wellbeing. The article did not reveal that the study and the institute were both funded by Merck and that the experts quoted had been supplied by Edelman, despite this information being available in Edelman's publicity materials in May 1998.

Although Merck is prevented from advertising finasteride direct to consumers in Australia, it has continued to promote hair loss as a medical problem, with waves of advertisements urging balding men to “See Your Doctor.” The company argues that it does not describe baldness as an illness and that men have a legitimate right to be made aware of scientifically proved options to stop hair loss (statement from Merck spokesperson, 7 March 2002).( to be contd)