by Dr.Harald Wiesendanger– Klartext
What the mainstream media is hiding
If you want to sell a product, you don’t have to appeal to every single consumer. It is enough to win over a few select, well-connected, extremely popular people—“influencers”—to loudly praise it. Then it is merely a matter of time before their recommendation spreads like wildfire. This is what makes the opinion leaders of the medical profession so incredibly valuable to the pharmaceutical industry—and to evidence-based versus eminence-based medicine.
Have you always wanted to stay in a five-star hotel suite for free? Dine at Michelin-starred restaurants without the waiter bothering you with a bill at the end? Snag free tickets to the Olympics or a World Cup, box seats included? Spend a free beach vacation in Florida or Hawaii? Fly there in business class without having to buy a ticket? Enjoy the eye candy of provocative girls in exclusive nightclubs for free, whose uniforms look more like gift wrapping? Have fun in a boozy all-male group at a high-end brothel for zero cents?
Would you like to be so important that you get to deliver a much-applauded speech in front of over a thousand colleagues—and receive around 5,000 euros for it? Would you like to pocket nearly 7,000 euros for participating in a six-hour roundtable discussion, and just under 16,000 euros for an essay? (1) Your expert advice, given over eight days, should be worth over 350,000 euros? (2)
Then become a doctor. And make something of yourself. Run a large hospital, preferably a university hospital. Hold a professorship. Serve on the board of your professional association. Publish a medical journal. Get yourself elected to committees. Either way, it’ll almost certainly work out.
But who pays all those outstanding bills, who foots the bill for those astronomical fees? And what’s the point anyway?
The Power of the Silverbacks
Among gorillas, things rarely go like in a grassroots democratic debate club. At their head stands at least one older male with silver-gray back fur—an insignia of power that developed when its proud bearer was fully grown. The alpha primates direct their group with showy displays and roars. They block other gorillas from gaining access to power. Sudden aggressive outbursts can be expected at any time, as can the release of scent marks in times of anger or danger: If the silverback stinks, he has something to say.
In a figurative sense, “silverbacks” abound in medicine as in hardly any other area of life. The ones calling the shots are somewhat older men, often with gray temples and always with an extremely dominant presence. The herd listens to them and follows them. Anyone who defies them is in for a rough time. In the monkey kingdom, silverbacks are rewarded for their social status with easy access to females—among humans, this is often the case as well, but primarily with money and prestige.
What behavioral scientists call “alpha males,” social scientists refer to as opinion leaders or influencers: people who exert the greatest influence within a group as “opinion leaders.” They enjoy high prestige. People listen to them with particular attention. Quite often, people agree with their opinions, follow their recommendations, and base their own decisions on them.
For anyone who wants to sell a product, human “silverbacks” are of the utmost importance. Why should advertising and marketing limit themselves to directly sparking interest and the desire to buy in the end consumer? Isn’t it much easier, cheaper, and more effective to take a roundabout route? Isn’t it enough to win over a few select, well-connected, extremely popular people to praise the product as enthusiastically and loudly as possible? Then it’s only a matter of time before their praise spreads like wildfire.
The celebrated proponent of this approach, Canadian management consultant Malcolm Gladwell, enthuses in his bestseller The Tipping Point: How Little Things Can Make a Big Difference (2001): “A shoe brand written off as dead that becomes the ultimate fashion item overnight. A newly opened restaurant that instantly becomes a smash hit. A novel by an unknown author that becomes a bestseller without any advertising. There are countless examples of that magical moment that can set off an avalanche and spark a new trend. Like a virus, the new phenomenon spreads, much like an epidemic, unstoppably and across the board. Just as a single sick person can trigger a flu outbreak, a tiny, targeted nudge is enough to set a fashion trend or establish a new product as a mass-market item (…) A little effort can lead to a massive success.”
Pharmaceutical companies know this, too.
However, marketing a drug is far more delicate in markets where prescriptions are required than it is for other products. When it is not the consumer who decides whether they need it, but their doctor who issues the prescription, the goal is to persuade the doctor to prescribe it. On the one hand, a doctor’s unmatched social prestige eases the burden of persuasion, as the patient trusts their doctor to a degree they would never trust a manufacturer’s advertising messages. On the other hand, however, enlisting doctors as sales promoters is far more difficult than hiring a flashy young woman as a YouTube “influencer” for clothes or makeup. After all, doctors are exceptionally intelligent, educated, and critical individuals. Aren’t they far more likely to see through crass commercial interests than the average person? Don’t they maintain a far greater emotional distance from pushy pill peddlers?
Eminence-based rather than evidence-based medicine
The opinion leaders of the medical industry provide excellent help in this predicament—the KOLs, short for “Key Opinion Leaders,” as the masterminds of pharmaceutical marketing call them. For practicing physicians look up to KOLs. They teach and conduct research as professors. At medical continuing education events, they stand at the lectern.
In university hospitals, they sit in executive chairs and head medical professional organizations. They organize and lead major conferences. They have distinguished themselves as authors of standard works, as editors, or as regular contributors to respected medical journals. They advise and participate in decision-making within influential committees and boards. As expert advisors, they find a receptive audience among political decision-makers.
Take, for example, the anesthesiologist J.B. He was once a big shot in Germany’s top-tier medicine. At conferences and in his lectures, the chief physician at Ludwigshafen University Hospital was regarded as a brilliant speaker. It only became clear that he often deliberately fed his impressed audience nonsense after he was exposed in 2010 as a brazen data fabricator. For years, he had touted the drug hydroxyethyl starch (HES)—a blood plasma substitute made from corn or potato starch—as a true miracle cure. As he claimed to have discovered in several of his own studies, HES infusions stabilize patients’ circulation even in cases of massive blood loss and render transfusions unnecessary.
J.B. lost his job, his professorship, and his reputation when it came to light that he had been diligently fabricating data: In reality, HES not only failed to help in any way, but could actually cause significant harm. (3)
Professor H.-J. M., director of the Psychiatric Clinic at Ludwig Maximilian University of Munich from 1994 to 2012, was above any suspicion of industry ties. He was a leading figure in his field: as the author or co-author of several textbooks and over 1,100 scientific papers, as the editor of leading journals, and as a member and president of numerous professional societies. He eagerly “advised,” researched, and lectured for at least 14 pharmaceutical giants, ranging from AstraZeneca to Bristol-Myers Squibb, Eli Lilly, and GlaxoSmithKline, as well as Janssen-Cilag, Lundbeck, Merck, Novartis, and Pfizer. He praised the weight-loss drug Acomplia at a promotional event hosted by the manufacturer and in an article for the highly respected British Medical Journal for its “favorable risk-benefit profile”—in some cases even after the U.S. Food and Drug Administration had already denied approval of the appetite suppressant due to severe side effects: depression, suicidal thoughts, anxiety, memory impairment, seizures, respiratory infections, nausea, and diarrhea. M. was equally emphatic in his praise of the antidepressant Valdoxan—active ingredient agomelatine—which the European Medicines Agency refused to approve due to a lack of efficacy. (4)
M. is in good company.
Professor W. M., Director of the Department of Psychiatry and Psychotherapy at the University Hospital of Bonn, spoke on behalf of Bristol-Myers Squibb and Otsuka and conducted research for six other pharmaceutical giants; he is the spokesperson for two “competence networks” for dementia funded by the Federal Ministry of Research, and the lead editor of the authoritative journal Der Nervenarzt; from 2012 to 2014, M. served as president of the German Society for Psychiatry and Psychotherapy, Psychosomatics, and Neurology (DGPPN), and he chaired its annual congresses on multiple occasions. (5)
One of W.M.’s predecessors as DGPPN chair (2001/2002), Professor M. S., promoted the controversial antidepressants Cymbalta, Solvex, and Cipralex, as well as the neuroleptics Zeldox and Abilify, at promotional events hosted by Pfizer, Merz, Pharmacia, and Lundbeck. (6)
As a “consultant” and speaker for a dozen or so pharmaceutical giants, Professor S. K. of the Psychiatric University Hospital Vienna went all out. (7) From 2005 to 2009, he was president of one of the three leading global societies in his field, the World Federation of Societies of Biological Psychiatry; he chaired the Division of Pharmacopsychiatry of the World Psychiatric Association (WPA); from 2012 to 2016, he served on the executive committee of the International College of Neuropsychopharmacology (CINP).
Riddle: What kind of treatment do such people likely ensure for the mentally ill in their clinics?
Professional ethics mocked
Austrian journalist Hans Weiss conducted a telling test. Disguised as “Peter Merten, freelance strategic consultant” for a Viennese pharmaceutical company, he approached five globally renowned psychiatrists in leadership positions at university hospitals or major medical centers in 2007 and 2008. (8) He lied, claiming his company had developed a fantastic new antidepressant—and made them a tempting yet unethical offer. Would they be willing to be paid to conduct a clinical trial that the World Medical Association classifies as unethical, or at the very least ethically questionable: one involving critically ill patients suffering from severe depression? The necessary “placebo control” would have required withholding their proven therapy from every other patient for months, instead administering only an ineffective sham drug—and this despite the fact that medical students learn as early as their first semesters how excruciating the psychological distress is in the most severely depressed patients, and how significant the risk of suicide is. Mertens’ offer to the study director included a fee of 8,000 euros. Per participating patient, of course. With fifty subjects, that would amount to a hefty 400,000 euros.
The devastating result: All five of those lured in agreed to participate or, at the very least, were “open” to further negotiations. Could they have violated medical ethics more blatantly? “The health of my patient,” states the World Medical Association’s Declaration of Helsinki, “shall be my first consideration. The physician shall act solely in the patient’s interest in the practice of medicine. In medical research, considerations regarding the well-being of the research subjects shall take precedence.”
(9)
Notes
For more details, see Harald Wiesendanger: The Health Care System – How to See Through It, Survive It, and Transform It
1 Calculated based on the standard average hourly rate and time spent, according to which the pharmaceutical industry compensated opinion leaders around 2007; see Cutting Edge: Pharmaceutical Opinion Leader Management – Cultivating Today’s Influential Physicians for Tomorrow (2007), cited in Hans Weiss: Corrupt Medicine – Doctors as Accomplices of Corporations, 3rd ed. Cologne 2008, pp. 84–86. Certainly, a generous “inflation adjustment” has been added since then.
2 R. Abelson: “Whistleblower suit says device maker generously rewards doctors,” New York Times, January 24, 2006.
3 Veronika Hackenbroch: “Too good to be true,” Spiegel Online, November 29, 2010: www.spiegel.de/spiegel/print/d-75376536.html.
4 According to Hans Weiss: Corrupt Medicine – Doctors as Accomplices of Corporations, op. cit., pp. 148 ff., 259.
5 According to Hans Weiss: Corrupt Medicine, op. cit., pp. 163, 258; entry on W. M. at Wikipedia.de, accessed on December 30, 2016.
6 According to Hans Weiss: Corrupt Medicine, op. cit., pp. 169 ff., p. 261; entry on M. S. at Wikipedia.de, accessed on 12/30/2016.
7 Hans Weiss: Corrupt Medicine, op. cit., pp. 171 ff. and 265; Entry on S. K. at Wikipedia.de, accessed on Dec. 30, 2016.
8 See Hans Weiss: Corrupt Medicine, op. cit., pp. 141–191.
9 See “WMA Declaration of Helsinki,” www.bundesaerztekammer.de/fileadmin/ user_upload/Deklaration_von_Helsinki_2013_DE.pdf, accessed on 12/30/2016.
This text is part of a series of articles that includes the following additional posts:
1) Trained Demigods – How Doctors Become Drug Dealers
2) A Visit from the Rep – A False Friendship by Script
4) Off-Label – Crossing Boundaries as Routine
5) The Bought Observer – When the Doctor Becomes a “Researcher.”
6) Like Greased – When Doctors Play “Kickback.”
7) “Tit for Tat” – Reciprocity as the Secret to Success
8) Brainwashed – Education and Training as Brainwashing
9) Insatiable Hired Mouths – The Sinister Power of Paid Opinion Leaders