By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website
Health Care Corruption as a Taboo Topic
Transparency International (TI) defines corruption as
Abuse of entrusted power for private gain
In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.
Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.
The report did not get much attention. Since then, health care corruption has been nearly a taboo topic in the US. When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects benighted less developed countries. On Health Care Renewal, we have repeatedly asserted that health care corruption is a big problem in all countries, including the US, but the topic remains anechoic.
Yet somehow, a substantial minority of US citizens, 43%, seemed to believe that corruption is an important problem in US health care, according to a TI survey published in 2013 (look here). But that survey was largely ignored in the media and health care and medical scholarly literature in the developed world, and when it was discussed, it was again in terms of results in less developed countries. Health Care Renewal was practically the only source of coverage in the US of the survey’s results.
Transparency International’s New Report on Corruption in the Pharmaceutical Sector
Now Transparency International (TI) has tried, and Health Care Reenewal will try again. In June, 2016 Transparency International published a new report entittled
The report’s executive summary states:
Within the health sector, pharmaceuticals stands out as sub-sector that is particularly prone to corruption. There are abundant examples globally that display how corruption in the pharmaceutical sector endangers positive health outcomes.
In my humble opinion, the report is particularly significant in that it classifies as corrupt various kinds of activities that occur within the pharmaceutical sector (and also in other parts of health care) which are often discussed publicly as anything from standard operating procedure through unfortunate errors to unethical behavior. These include many activities which we have frequently discussed on Health Care Renewal. For example,
Manipulation of Clinical Research
We have frequently discussed how pharmaceutical companies, and biotechnology, medical device, and other health care companies and organizations, may manipulate clinical research to enhance the likelihood that is results will favor their products and marketing goals, even if the results are biased, inaccurate, could mislead physicians and patients, and ultimately harm patients. The TI report included:
As pharmaceutical companies rely on gaining market entry in order to recoup R&D costs, when there is a lack of oversight in clinical trial data publication a conflict of interest exists in which a pharmaceutical company may have an incentive to manipulate clinical trial data. When clinical trial data is manipulated medical literature can become biased with positive findings fabricated, positive findings exaggerated or negative results hidden. This can result in inadequate prescribing patterns because HCPs rely on clinical trial data to make decisions on which medicines to use to treat patients.
Suppression of Clinical Research
We have frequently discussed how health care organizations (as above) may outright suppress clinical research when the results fail to support their interests. The TI report included:
Transparency and access to information through mandatory clinical trial registration, sanctions for not registering results or providing clinical trial information, and the publication of both positive and negative results are commonly discussed as helpful tools to curb corruption. With the European Medicines Agency (EMA) as a notable positive exception, public agencies and authorities do not require R&D-based pharmaceutical companies to make their raw data publicly available, making it impossible to verify whether the reported results are accurate. Based on laws and regulations clinical trial data is considered to be proprietary information, which allows pharmaceutical companies to conceal important data from the public domain.
Manipulation of the Dissemination of Clinical Research
We have frequently discussed how health care organizations may manipulate the dissemination of clinical research, through various forms of publications, presentations, courses, media summaries, etc, to favor their products and marketing goals, even if the results are misleading and could harm patients. For example, a while back we discussed the problem of “ghost-written” articles appearing in scholarly journals. The TI report included:
The practice of ghostwriting is also a risk with clinical trials. Ghostwriting involves the writing of clinical trial publications by industry and then having a highly esteemed researcher pass these findings off as their own without disclosing their actual involvement with the authorship of the article. It is a common practice, particularly in industry led trials. Ghostwriting is done to increase the prestige and reputation of the findings, while simultaneously researchers are able to improve their reputation, which can lead to promotions. Clearly this practice can result in inaccurate results being published.
We have frequently discussed how marketing of pharmaceuticals (and nearly everything else in health care) may be deceptive, favoring companies’ products and services, but again misleading health care professionals and patients, and ultimately risking patient harm. In the extreme, pharmaceutical companies (and other health care organizations) may resort to bribes or kickbacks. The TI report included:
There are several methods for a corrupt pharmaceutical company to unethically market its medicines. At its most simple a pharmaceutical company can bribe a HCP directly with payments so its medicines are more likely to be prescribed. More abstrusely individuals may include a pharmaceutical company’s medicine on the national list that is reimbursed by public funds, in return for an indirect bribe by being sent to inappropriate holiday destinations for lavish conferences.
Corrupt marketing practices also include pharmaceutical companies providing misleading information regarding the safety and efficacy of a medicine to influence doctors’ prescribing habits and encouraging off-label, unlicensed use to increase sales.
Finally, the report mentions such issues as the revolving door, regulatory capture, etc, etc, etc
A Striking, and Strikingly Anechoic Report
Again, while the report summarizes information that is likely familiar to most Health Care Renewal readers, what is striking is that it describes manipulation of clinical research, suppression of clinical research, manipulation of dissemination of clinical research, and deceptive marketing as corruption. That is a sentiment rarely heard in the US, and one that appears nearly taboo.
Demonstrating the strength of the taboo, this striking report has gotten almost no attention in the media or scholarly medical and health care literature in the developed English-speaking countries. Let me note the important exceptions, however.
I learned of the report from a brief news item from the BMJ, the prestigious UK journal that seems most at the forefront of championing the integrity of medical and health care research.(1) The only substantial news article I could find on the report was also from the UK, in the Independent. Its sub-title is worth repeating:
Transparency International says corruption is making a few rich and wrecking the health of some of the world’s poorest people
Also, there were brief articles in Reuters, and in (web-only) FiercePharma. That is about it so far.
The report itself suggests why it has been so anechoic, just like nearly every other attempt to expose health care corruption to public discussion. Essentially, there is so much money to be made through pharmaceutical (and by implication, other health care corruption) that the corrupt have the money, power, and resources to protect their wealth accumulation by keeping it obscure. In the TI Report itself,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.
Keep in mind that the money made from corruption does not just go to innocent peoples’ retirement funds that are invested in pharmaceutical stocks. It predominantly goes to top corporate executives and managers, and their cronies who preside over the corrupt practices.
I might as well repeat myself once again. As I wrote in 2015,
If we are not willing to even talk about health care corruption, how will we ever challenge it?
So to repeat an ending to one of my previous posts on health care corruption…. if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption. Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations’ misbehavior, and thus taking such action will require some courage. Yet such action cannot begin until we acknowledge and freely discuss the problem. The first step against health care corruption is to be able to say or write the words, health care corruption.
1. Torjesen I. Group calls for more to be done to tackle corruption in the pharmaceutical industry. BMJ 2016;353:i3099. Link here.
Working in PR, I was summarily fired for making an excuse of illness to avoid meeting a PhRMA lobbyist who was a reputed pedophile. This guy was able to arrange an appointment with the Prime Minister of Japan at 2 week’s notice. If you have any idea how rigidly controlled the PM’s agenda is dictated 3 months out into the future, you start to realise their power is absolute.
Thank you, Yves, for posting this important piece by the excellent Roy Poses.
The healthcare-industrial complex (“HIC”) is 2-3x the size of the MIC in the US. After Wall St. / Asset Management, is there a larger global honeypot to plunder?
My current favorite absurdly named, absurd drug is Movantik: it treats unfortunate side-effects from opioid use (and abuse). Of course, it, too has side effects: but there’s sure to be a new drug soon to treat those, too! Can’t let an epidemic go to waste… there’s MONEY to make.
Don’t forget the recent story in Bloomberg about how Pharma has corrupted patient charities.
Also, the money they give to “patient advocacy” groups completely skews the information patients get about what causes their disease and the cheapest, best treatment options.
An article in Sciencedaily recently also explains their influence on the bodies that produce clinical guidelines.
There really is no substitute for reading the literature yourself, if you can. This type of corruption is eroding the trust in a number of other professions, like accounting and law. Professional ethics are subsumed by the prime drive of managerial looting.
Deceptive marketing…Not to mention deceptive advertising of pharmaceutical, nutraceutical and other “health” products.
But you know, business is the sacred cow these days.
Not to mention marketing corruption where pharma sales people routinely give their business credit cards
to Dr.’s so the Dr. can charge personal purchases.
Your link to Health Care Renewal does not work. Please delete this after correcting.
I spent 700 dollars on the cat to get teeth,ultrasound ,shots,fleas and bloodwork. My vet is very competant more so than most MDs I meet and he s not starving. ….So what are we getting for 3 trillion except medical incompetance as 3rd leading cause of death. I get health care fraud is 18 % of gdp and MIC and wall street are about 12……..Also did you see the story that Oracle was making up revenues?
From Journal of Law Medicine and Ethics (2013) Institutional Corruption of Pharmaceuticals and the Myth of
Safe and Effective Drugs -http://ssrn.com/abstract=2282014
Thanks to a tip from another NC commenter (sorry, I cannot remember who), I’m just finishing Charles Hugh Smith’s new book: “Why Our Status Quo Failed and Is Beyond Reform.”
Very pertinent to this thread, and in fact, to a great deal that’s posted on NC. I recommend it.
Typo in the title “Tranparency…: Should be “Transparency…” It made it hard to search on Twitter and google.
Manipulation of Clinical Research – “pharmaceutical companies selling high-dose opioids seized upon a notion, based on flimsy scientific evidence, that regardless of the length of treatment, patients would not become addicted to opioids.”:
Deceptive Marketing – “A former Insys Therapeutics sales rep has pleaded guilty to violating federal kickback laws in connection with an alleged scheme to boost sales of an opioid painkiller…….The drug, which was approved in 2011 to treat acute cancer pain, is a form of the fentanyl narcotic that carries a high risk of dependency.”:
“Fentanyl is approximately 80 to 100 times more potent than morphine and roughly 40 to 50 times more potent than pharmaceutical grade (100% pure) heroin.”
“In the little time we may have before our health care bubble bursts”?
Can anyone elaborate on the evidence for this? Thanks!
My apologies for typo in the title – I am embarrassed. I took the post down, fixed the title, and reposted, which might help with the search sites.
The URL for the original post is now http://hcrenewal.blogspot.com/2016/06/transparency-international-reports-on.html
Please, no apologies necessary. Keep up the great work Roy.
This is the same mass media that doesn’t report on most of the Clinton Foundation’s crimes.
I have renamed the news hour on TV “the Pharmaceutical Hour” due to the ads. Why do we Americans put up with this bullshit???
Can I point to Ben Goldacre’s brilliant book Bad Pharma
(I won’t give the Amazon link because the so-and-sos cheat on their taxes)
Also the looming antibiotic crisis, e.g.
A perfect example of how a free market does not necessarily produce optimal outcomes. What is the incentive to produce a drug that people stop taking when they get better?
The corruption extends to vaccines, too, and if any subject is taboo, it’s corruption of vaccine science. Yet we’ve had the CDC, the primary sponsor of vaccine science, taken to task for deliberately falsifying information on lead in Washington, DC, water. More recently the CDC whistleblower, Dr. William Thompson, alleged that the CDC deliberately removed significant data in an MMR/autism study. We also have clear deception regarding aluminum adjuvant safety: see vaccinepapers.org.
According to the BMJ, the CDC receives about 25% of its funding from industry sources: http://tinyurl.com/jydos4q