Sickening: How Big Pharma Broke American Health Care and How We Can Repair It

Book Title: Sickening: How Big Pharma Broke American Health Care and How We Can Repair It

Author: John Abramson

Publication Details: HarperCollins Publishers, 2022, 304 pp., $28.00, hardcover

False beliefs occurring in medicine are not just embarrassing, as in the parable “The Emperor Has No Clothes”; they have contributed to the loss of life. In his book Sickening: How Big Pharma Broke American Health Care and How We Can Repair It, John Abramson, MD, MS, discusses how physicians are unwittingly being led into false beliefs about medications. Despite the increased focus on evidence-based medicine, the scientific method is not being applied in multiple cases of bringing new treatments to market. Beliefs are being manipulated by the commercialization of medical knowledge rather than being based on actual data. 

Dr Abramson is a family physician with a Master of Science and 25 years of experience teaching health care policy at Harvard. He has also served as an expert in pharmaceutical litigation. He previously authored the 2008 book Overdosed America: The Broken Promise of American Medicine.  

Sickening is divided into three parts. Part one tells the stories of four medical treatments marketed despite questionable benefit or harm to patients. First is the story of rofecoxib and the loss of over 40,000 Americans due to suppressed data about its harm. Second is the fraudulent, off-label marketing of gabapentin, which resulted in a lawsuit with penalties easily covered by about 6 months in sales.  Third, he discusses how little statins do to prevent vascular events for people without a history of vascular disease.  And fourth, he covers the promotion of insulin analogs, which show no increased effectiveness over human insulin for most patients with diabetes.

Part two describes the business of pharmaceutical companies and the paradoxically inverse relationship in the US between higher costs and worse population health outcomes. Problems with the industry include lack of data transparency, huge marketing budgets, lack of price controls, and the financial interdependence of medical research and publication outlets. Dr Abramson presents evidence from a pharmaceutical company’s internal documents stating that the “purpose of data is to support...marketing of our product" (p. 116) and to identify ways of “aligning marketing messages" with ensuing publications (p. 148). The scientific method does not appear to be upheld. The complicity of medical researchers and prestigious journals in this process is partly due to a complete lack of access to the full data. Only the companies have all the data; they share what they like to make the most profit. The intertwining of financial interests (eg, journals making money from reprints) results in even more concerns about the lack of checks and balances on the information being disseminated.

Part three looks at the societal level. Dr Abramson reviews policy changes over the past decades, including the Affordable Care Act. He contrasts US policies with those in other nations with better population health. Of note is the relationship to population health when countries spend more on social services than health care as inequity harms population health. He details recommended policy and calls on everyone to demand better oversight and protection of population health.

The author's repeated call throughout the book is for transparent data from pharmaceutical companies. This is fundamental to determining the efficacy of a medication by independent researchers. Multiple types of biases inflate the reported efficacy of treatments, and he is not the only one concerned. ^2-5 Some argue that pharmaceutical companies’ “ghost-management of research” has led to the “epistemic corruption” of medical knowledge. ⁶ The current state of affairs described by Dr Abramson and others is indeed sickening.

Dr Abramson writes clearly, and while the book is hard to stomach, it flows easily. Part one grabs the reader's attention with personal stories of patients who have been harmed. Parts two and three provide details without getting bogged down in them, although there is some repetition of points. Dr Abramson’s writing shows empathy toward physicians who cannot possibly know the extent of the problems. That is why this book should be on every physician’s reading list. Unfortunately, Dr Abramson is unable to provide much hope given the current situation. In the afterward, he details the FDA approval of Aduhelm in 2021, overruling the Advisory Committee's almost unanimous recommendation against it. With this decision, the FDA appears no longer to be completely independent of the influence of major pharmaceutical companies.

The emperor's trusted officials said nothing out of fear they would lose their positions. In the modern-day scenario, the weavers have learned to share their gold to keep truth at bay.