Bad Pharma: How drug companies mislead doctors and harm patients - Ben Goldacre. Fourth Estate. 2012
The dedication at the front of Ben Goldacre’s new book Bad Pharma reads, quite simply and quite beautifully, “To whom it may concern”. This reflects Goldacre's approach well; his outwardly-unassuming-yet-also-strident style, but also his philosophical position. It’s not who you know; it's what you know. It’s not the individual cherry-picked story; it’s the broader, more rigorously uncovered trend. It is the data; not an anecdote. Good data too. Good, big, full and thorough data.
And that’s largely what the book is about: when it comes to the drugs we are prescribed, the data isn’t quite what it could be. It’s not that it’s necessarily rubbish, just a bit patchy and not always efficiently applied. Dangerously patchy – worryingly so, scandalously so – even if it’s not always too obvious. The trials used to test drugs are too frequently badly designed, tested on small numbers of people, often unrepresentative people, and then analysed poorly, sometimes deliberately poorly. The result being that doctors do not know as much as they could about the effects of the treatments they prescribe.
The medical establishment knows they have gaps in their knowledge. It’s a sort of known unknown, or at least a loosely acknowledged one. Goldacre describes how medical students are advised not to prescribe a new drug till it’s been around a while; to check nothing bad happens. Think about that for a moment. I mean, you might choose to wait a few months after a new phone’s been released before you upgrade your current one; see what other people say and let the manufactures iron out problems. But that’s a phone. This is medicine. To blithely say “see how it plays out” when it comes to prescribing drugs is to turn the public at large into test-dummies, and makes rather a mockery of the whole medical trials business. The book might be called “Bad Pharma”, but Goldacre’s target is not just the pharmaceutical industry, but bad medicine, bad regulations and bad publishing too (for a taster on that, check out this column on medical ghostwriting). They’ve been covering up gaps for a while; not necessarily as a giant conspiracy, more a collective lack of vision interlaced with a few outright attempts to mislead.
Just as phone-hacking exposed blind eyes, mismanagement and corruption in the media and the recent financial crisis made us all look again at the sausage factory that makes the economy go round, Bad Pharma hopes to open a window into how medicine really works, and worry us enough into wanting to make it a lot better. I should stress the making it better part. It’s a depressing book – expect to wince in places – but it’s a hopeful one too. Goldacre’s quite clear about how he thinks we can fix things, with a neat set of ideas for ways out of these problems at the end of most chapters, and a clear afterword which recaps and pulls out what he feels are the most important problems and things we, the readers, can do.
I should also emphasise that at no point does Goldacre suggest we throw the whole system out. It’s not the idea of industrialised medicine that’s necessarily the problem, just that we’re not holding it up to strong enough standards. He is walking a tricky line here, as many use critique of “Big Pharma” quite loosely as reason to reject contemporary medicine entirely (the title Bad Pharma is as much a play on this well-worn phrase as it is a nod to his previous book and Guardian column, Bad Science). Indeed, many have called Goldacre a “Big Pharma” shill for his stance on homeopathy or vaccinations (rather harder to make that argument now…). On the other side, aspects of the medical establishment are sceptical that change can be as straightforward as he suggests (see, for example, Michael Rawlins’ review in the Lancet).
There’s also a more political critique to be made, as one might query Goldacre’s target here. For many, the various scandals of trust we’ve lived through the past decade – the City, MPs expenses or hacking – are symptoms of a larger broken system. Perhaps a larger economic change is what is required. Goldacre says he wants to make the pharmaceutical industry the sort of place people could be proud to work in, not critique the basis of its existence. This is not the more straightforward attempt to apply science in the justification of the status quo as you could find in, for example, the final chapter of Mark Henderson’s Geek Manifesto. Still, Goldacre’s reply to the first question in this interview with readers of the Observer might rile a few on the left. Whether you feel Goldacre’s warnings are a sign that more of medicine should be put under public control probably depends on your personal politics. Still, seeing as the privatization of medicine is such a topical issue, perhaps it is a failing of a book that this ideological question isn’t addressed more explicitly.
There’s another problem too. It’s, honestly, a bit of a slog to read. Great as this book is, in many ways, a rip-roaring yarn to warm you on winter’s night this isn't. Even the kindest of reviews say it could probably do with a bit more of an edit. It can get a bit repetitive in places and is rather abstract. This is not necessarily Goldacre’s fault. This is complex stuff, it takes time to explain, which Goldacre does very well, with a gracious and generous style. The repetition and constant recaps are actually very useful, even if they aren’t especially gripping. Not for the first time, I found myself thinking Goldacre’s probably a brilliant teacher. I’m sure his students adore him. Still, I don’t always want to play student with a popular science book.
It’s a book about infrastructures and abstractions, not people. Or rather it is about people, but lots of them at once, and that’s sometimes hard to handle. It comes from people and goes back to them though. As the Economist review put it, the upshot of Goldacre’s prose is anything but abstract. It’s life or death in some cases. And it’s important. Our society runs on infrastructures and abstractions, it’s part of the benefits of modernity. But it can be hard to relate to people en masse (just ask the people who first tried to explain the welfare state, e.g. Isotype). One of Goldacre’s concluding points – that we can look at bad behaviour of characters like Richard Sykes or Mark Porter, but “These are meaningless, banal, lucky-dip examples: ignore them, forget their names, because they are not the norm” – is highly laudable in its own way. This attitude is part of the book's epistemological strength, but is also perhaps its rhetorical failing. This might depend on personal taste. Some readers will probably prefer patterns to characters, and it’s not as if the book is bereft of examples, it’s just more about the larger picture, that’s all.
In conclusion, I’d certainly recommend this book. You might well find yourself pulled in by Goldacre’s charm or simply the brave attempt to tell stories about modernity. I hope it finds a wide readership; more people should be at the very least talking about these issues, and preferably before a serious scandal compels us to have that conversation. The suggested solutions of the book might not suit everyone, but it’s worth taking time to see where he’s coming from. If you disagree with his methods, get involved and learn enough to critique them and offer alternatives that you would find more convincing. Even if you disagree with his suggestions for change, Goldacre offers a courteous introduction to the problems of the current way we make medicine.
Alice Bell is an academic and writer interested in science's relationships with the rest of society. She is currently researching science policy at the University of Sussex. She keeps a personal blog.
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