Editorial Note: This post continues from last week’s Persecution of Heretics. It’s about how only a Popular Movement with those suffering adverse effects on drugs speaking up can save us now. It adapts a talk given a month ago to the International Society for Ethical Psychology and Psychiatry in Los Angeles. It loses something without its slides. But it was recorded and may be put up on the web in due course. It was called:
Better to die on your feet than live on your knees
For the last 10 years I have regularly been asked whether things are getting better, with the interviewer anticipating an answer that, in response to efforts of Bob Whitaker, Peter Gøtzsche and others to spread the news about what industry has been doing wrong, ‘yes they are getting better’.
They aren’t getting better.
We are living in a New Censorship. This is an era when efforts to adhere to the norms of medicine and science by bringing treatment related adverse events to light risk being interpreted under trade agreements as an interference with the capacity of corporations to trade so that governments are all but obliged to shut down criticisms of corporations or their products.
In terms of adverse events for two decades the company response was that if controlled trials had not linked antidepressants to homicide or suicide then any links were just coincidental. Now that controlled trials have shown the link, the company response to very clear cases of treatment induced problems comes close to Holocaust Denialism.
So is it not time to speak up? Nope it’s not.
This lesson was brought home to me years ago by a PR person for Prozac delighted to inform me that I was doing more the sales of Prozac than anyone else or indications that when GSK were faced with a Paxil Causes Birth Defects labelling they figured this was a good time to sell Paxil.
So how do you puzzle Pharma?
Most of us concerned about the many harms in healthcare we see around us see ourselves figure that if “our” experts have the opportunity to speak the scales will fall from the world’s eyes.
But even if a program about the antidepressants were stuffed full of all the good guys saying all the things that they really want to say in an uninhibited way, the average person watching will hear Cymbalta, Humira and Abilify and will not hear what went with those words.
They see experts on screen regard themselves as the good guys. They infer many more experts off screen whose views are endorsed by “our” government and by every government, and by my doctor.
Their response is:
“why is our government letting a minority view like this be heard, one that is going to scare patients away from treatment, cost lives, leave people untreated so that they are a drag on the economy and lead to industry dis-investment in our country? Why is our government letting this happen?”
Programs like this are a fairy tale of good guys and bad guys – when the world isn’t like this. A fairy tale where good triumphs – when the world isn’t like this. A world where when a girl says the emperor has no clothes, people pay heed.
The medical model
I recently caused grief to the makers of a documentary called ‘Bought’, which is a beautifully produced program about the corrupting power of Pharma, by asking them to omit the sections that had me in them even though I was very pleased with the material that was actually there. My problem was the context. It was anti the medical model.
Most of you in the room are critical of the medical model.
I’m a supporter of the medical model. I have never called for a drug to be removed from the market and I can’t envisage calling for the removal of any.
I turn down invitations to meetings with great casts of speakers – like Bob Whitaker – which are heavily slanted toward nutritional or alternate approaches. I have nothing against good nutrition or many complementary treatments – except in so far as these can be perceived as replacing medicine.
Why? I want to save medicine not set up an alternate shop. This is where the 99% are always going to be. If Pharma can portray any of us as part of the 1% it might do wonders for our niche status but it will be the end of any opportunity to make a meaningful difference.
The actuarial model
I’m not asking any of you to come over to the medical model, but I do want you to recognize that this is where most patients and most doctors are. That said, there are huge areas of agreement between all of you here and me – I think what most people are reacting with hostility to is not the medical model but the actuarial model.
We likely agree that most controlled trials in medicine rely on surrogate outcomes and that these are flawed endpoints, particularly within mental health. This applies to psychotherapy trials also.
We likely agree that close to 100% of controlled trials of brand medicines are ghost written these days and when these advertisements are embedded in guidelines and accompanied by a lack of access to the data from the controlled trials in question, this is very dangerous.
These controlled trials and quantitative approaches in general – whether drug or psychotherapy trials – have helped industry steer healthcare into a risk management domain, an actuarial domain that poses real risks to individuals. It locates the risks in you rather than the environment or the lack of services your hospital offers and tells the management that the risks in you can be fixed with a pill.
Many of my medical colleagues see trials as the way to keep complementary, or or homeopathic treatments out of healthcare. This is what makes trials the touchstone of evidence based medicine, the one true article of faith, for many.
Most people are just concerned about the ghostwriting of trials and the hiding of data but I don’t think controlled trials work. Unless we are very alert, controlled trials get answers that can be deeply misleading as when a trial of antidepressants appears to show that these drugs that can cause suicide in fact save lives or thalidomide is safe and effective.
Controlled trials can be useful but they are mechanical exercises and not a substitute for thought. Unless handled with care, they generate ignorance not knowledge – and they aren’t handled with care.
An equally serious problem is the fact that drug treatments that have supposedly been shown to work by controlled trials are made available on prescription only.
Prescription only status was introduced as a means to contain addicts. You must all sense that when you go to a doctor today, there may be pleasantries but you are essentially treated like an addict. The reality is so shocking that we manage to ignore it but there are times when ignoring it becomes impossible.
This managing of addicts model becomes a problem against the background of an apparatus that dictates what a doctor is going to do, marketing that is better characterized as propaganda, guidelines and a range of other pressures. Most doctors are at a point where it is close to impossible for them not to treat you with inferior, more dangerous and more expensive treatments. They do not have the freedom to treat you with what they might treat themselves with.
Mind, brain and power
Most of you here believe that in the mental health field managing the mental, or cognitive or psychological sides of clinical issues is more important than biology and drug treatment.
I don’t know if we are all mind or all body or some mix of the two – the question is irrelevant. What is relevant is who exercises power over us and we are entering a world where despite the rhetoric of the times about empowerment and recovery, those of us who attend doctors and the doctors we attend are increasingly disempowered.
It is becoming impossible to practice medicine, as you’ll see when I define what I mean by medicine.
The place where this becomes most apparent is in the domain of adverse events. Forty years ago it only took two to three years from the point that the drug was released to the market to a recognition of its major risks, but today it can take 20 or 30 years before these risks are recognized.
Forty years ago, at the height of the troubles between Ireland and England when the IRA were at war with England, four innocent Irish people were jailed in Guildford, leading to efforts by English people to get these innocent Irish out of an English jail.
In response, the most senior judge in Britain, Lord Denning, the Master of the Rolls, considering the situation said that the prospect that innocent people could have been jailed was so awful that even if they were innocent they should remain in jail so that public confidence in the law was not shaken.
This is a response rather like one imagines the response of the Bishops in the Catholic Church who, when faced with the scandal of pedophile priests, denied the reality of what was happening so that public confidence in the Church would not be damaged.
You might say we have seen where that ends but not so – Catholics are only questioning the Church now that it has lost its grip on them. The situation we are in medicine is more like that of foot soldiers in the armies of ISIL. When questioning leads to beheading, there’s not as much questioning.
We have managed to engineer a situation where in order to maintain public confidence in healthcare, the level of denial of adverse events on treatment is coming close to psychotic. In order to maintain the fiction, the “system” intimidates its agents – doctors – who slipped into this role by virtue of the fact that all these drugs are made available on prescription-only.
Getting engaged to a doctor
Medicine was a relationship where you bought certain problems to a person who had a medical training as opposed to a pastoral or other training.
You expected this person to exercise professional judgement on your behalf. They would neither be an agent of the State nor in hoc to private interests.
You expected wisdom from a good doctor – an ability to recognize that unhappiness after a birth was more likely linked to unhappiness in a marriage than to hormones. Someone who knew that children’s development varied and few if any children needed treating with drugs. Someone who would rarely recommend anything in pregnancy.
Someone who would review your lifestyle and situation and might know the issues facing your community and would often make recommendations about altering something in these areas rather than dispense a medicine in response to ticking a sufficient number of boxes on a standardized list of questions.
Unlike others you could go to who could do all these things, a medical person if faced with the right kind of problem could also use a poison. The magic of medicine lay in the ability to bring good out of certain bad situations through the use of a poison – or a mutilation in the case of surgery.
To do this requires vigilance on the part of the doctor and the patients and the patient’s family. It cannot be done where the fact that drugs are poisons is denied. It cannot be done in a culture in which drugs are regarded as fertilizers to be sprinkled as widely as possible and from as young an age as possible.
Because they are poisons and mutilations, as Philippe Pinel said two hundred years ago the doctor only becomes a true practitioner of the art when she knows when not to poison or mutilate.
Continued in Part 2.