Jeffrey Robinson

Toronto: McClelland & Stewart Ltd. ISBN: 0-7710-7566-9

This has not been a good year for the pharmaceutical industry on the literary front. First came the John LeCarré novel, The Constant Gardener, which portrayed pharmaceutical companies as willing to sacrifice people in Third World countries and to engage in murder in order to protect profits. Now, in the nonfiction department is Prescription Games: Money, Ego and Power Inside the Global Pharmaceutical Industry by Jeffrey Robinson.

LeCarré and Robinson share the same point of view about what motivates drug companies. In an interview with the British magazine The Spectator LeCarré talks about why he chose the pharmaceutical industry as the subject of his novel: "My subject — and the subject of The Constant Gardener — is the dilemma of decent people struggling against the ever-swelling tide of heedless corporate greed, and our own complacency in letting the corporations get away with it." Robinson voices similar sentiments in the Epilogue to Prescription Games: "Because we cannot stop taking medications, we are asked to tolerate recklessness in the name of progress, to accept dishonesty in the name of research and development, and to turn a blind eye to greed in the name of shareholder satisfaction."

Before I go on, I need to confess a conflict-of-interest in reviewing this book. Robinson interviewed me while doing research and I am quoted approvingly a couple of times in the chapter dealing with drug promotion. So it should come as no surprise that I approached Prescription Games with a bias in favour of the book. And for the most part I was not disappointed.

Robinson doesn't break any new ground with his book or reveal any great unknown scandals but he covers his material well and as a bonus includes a substantial amount of Canadian content.

The chapter dealing with patents and intellectual property rights is particularly relevant these days in light of the recent Free Trade Area of the Americas meeting in Quebec. Back in the early to mid 1960s three reports came out in succession all documenting high Canadian drug prices and all identifying the patent system as the main culprit. Robinson documents how the 1969 Liberal government dealt with that situation by passing a law allowing generic companies to market drugs even before the patents on them expired. By the early 1980s this system of compulsory licensing was saving Canada hundreds of millions of dollars in drug costs. However, it fell victim to Brian Mulroney and his desire for a Free Trade Agreement with the United States. Despite the noises that Jean Chrétien and his Liberals made prior to the 1993 election the policy set by Mulroney remains intact.

Whatever the costs of protecting intellectual property rights here in Canada they pale in comparison to those borne by countries in the developing world. Until the past few months the major pharmaceutical companies were using intellectual property rights provisions in the General Agreement on Tariffs and Trade to keep prices for HIV/AIDS medications out of reach of most people in subSaharan Africa where 23 million are infected. The price of 100 units of Nevirapine, a drug that can prevent transmission of the HIV virus from mother to child was US$430 in Norway and US$874 in Kenya.

The example of drugs in the Third World provides a perfect illustration of how profits motivate the actions of the giant multinational pharmaceutical companies. Africa represents about 1% of the world market for drugs and because there is no money to be made there drug companies don't bother to put any resources into looking for drugs for the problems that are endemic on that continent. When Glaxo's Malarone was approved in mid-2000, it was the first new anti-malarial drug developed by a drug company in forty years. All the others had come from institutions or out of U. S. army research.

There are some exceptions to this profit driven behaviour by drug companies and Robinson highlights probably the best known one, the decision by Roy Vagelos, president of Merck, to donate Mectizan for as long as necessary to wipe out river blindness in parts of Africa. However, Robinson doesn't explore what else Merck was doing at the same time. In Canada and everywhere else in the world, including countries in Africa where malnutrition was widespread, Merck was marketing an antihistamine-like drug as an appetite stimulant; in Thailand Merck was allowing its distributor there to sell an irrational antibiotic combination.

The battles between Dr. Nancy Olivieri, the Hospital for Sick Children in Toronto and the generic giant Apotex are all featured prominently. By now most readers will be familiar with the basic outline of this story? Olivieri felt compelled to make public serious side effects from a drug she was testing, Apotex the sponsors of the trial she was undertaking threatened to sue her and the hospital refused to back her. Robinson tells this story but adds a few lesser known details. Such as how Olivieri and her colleagues, acting on their own, exposed Dr. Gideon Koren, a prominent doctor at Sick Kids, as the author of hate mail directed at her and her supporters.

The last area where Canada features prominently is in the chapters on drug advertising, particularly the ongoing fight around direct-to-consumer advertising of prescription drugs. Right now DTCA is only allowed in the United States and New Zealand, but the drug companies are pushing hard for it to be legalized in Canada. Over two billion dollars was spent in this area in the U. S. last year and according to a survey by Time magazine that Robinson refers to, nearly 30% of people said that if a doctor did not give them the drug they requested they would consider switching doctors.

The book makes some claims that even I find hard to believe. Robinson cites unnamed critics to the effect that we are paying nine times too much for prescription drugs — the $9 billion we now spend on prescription drugs could be reduced to $1 billion. There is also a glaring error in Robinson's description of the treatment for thalassemia, the blood disorder that Olivieri was treating. These relatively minor quibbles aside Prescription Games is a good companion to The Constant Gardener. One is fiction, the other fact, both tell the same story.

Dr. Susan Love's Menopause & Hormone Book

Susan M. Love, M.D., with Karen Lindsey
NY: Three Rivers Press, 2003

In this second update to her 1997 bestseller, Dr. Susan Love's Hormone Book, a full explanation of the goals and findings of the Women's Health Initiative trials is supplied. These are the studies which led to a reassessment of the benefits of and drawbacks to hormone therapy. The findings are carefully explained (with drawbacks outweighing benefits) and the whole notion of menopause as "disease" analyzed and dismissed. Chapter 4, Prevention and Risk is an excellent primer on understanding research and is useful for anyone interested in any aspect of medical research. Chapter 7, on Breast Cancer, is first on the agenda of BCAM members. In sum, if a woman has had breast cancer, or is considered to be at high risk, any dose of estrogen or progesterone carries a price. As the author tells us, there is no free lunch. As always, Susan Love offers a straightforward narrative with medical terminology and complexity clarified and the author's point-of-view consistently honest and aboveboard.