Author: David Menkes
Position: Academic Psychiatrist
Institution: University of Auckland
E-mail: menkesd@waikatodhb.govt.nz
Additional Authors: Annemarie Jutel
Submitted Date: November 07, 2006
Published Date: November 8, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Dorothy Porter describes multiple threats to health posed by profit-driven corporations, including the fast-food and tobacco industries (1). It seems odd that she neglects to mention how corporate interests also promote illness through 'disease mongering', a phenomenon covered in PLoS Medicine in April 2006. From an economic perspective, disease mongering can be seen to distort healthcare, medicalising swathes of the human condition, and wasting diagnostic and therapeutic resources.

Disease mongering is thus broadly relevant to understanding illness in its social context. Explicit consideration of whose interests are at stake is integral to critical appraisal of evidence regarding diagnoses, their investigation and treatment. Because clinical trial and other 'evidence' is readily selected and 'spun' by vested interests (2), we applaud Stanford University's recent decision to sharply curtail commercial access, banning doctors at its hospitals from accepting even trivial gifts from industry representatives (3). Unfortunately, commercial penetration of hospitals is but one mechanism by which clinical decisions are influenced by those whose primary motive is profit rather than patient care. Beyond supplying pens and pizza, companies distribute literature, fund medical education and sponsor conferences, reflecting powerful commercial incentives to promote products by developing relationships with doctors. The skill of industry representatives resides in their ability to 'work' relationships, inducing doctors to use and recommend products, with remarkably little awareness they have been so affected (4).

In each of the four domains of social medicine described by Stonington and Holmes (5) -- patient-doctor encounter, patient beliefs, culture of medicine, and the large scale forces that shape medicine -- disease mongering plays an important role. Examples include patients seeking advertised prescription medicines (6), socially constructed 'diseases' (7), and the FDA's inability to regulate the pharmaceutical industry (8). Successful disease mongering convinces healthy people they are sick, at risk, or require unnecessary treatment; particular excesses are evident in poor countries (9). Taking into account sick role absenteeism, the social and economic burden of disease mongering is staggering. 'Big Pharma' should take its place alongside 'Big Food' and 'Big Tobacco' in Porter's model of social determinants of health.

References

1. Porter D (2006) How did social medicine evolve, and where is it heading? PLoS Med 3(10): e399. DOI: 10.1371/journal.pmed.0030399\
2. Smith R, Roberts I. Patient safety requires a new way to publish clinical trials. PLoS Clinical Trials 2006;1(1):1-3.
3. Richter R. New Policy Limits Drug Industry Access. Stanford Report. [serial on the Internet], 2006 September [cited 2006 September 13]. Available from http://news-service.stanf...
4. Elliot C. The drug pushers. Atlantic Monthly. April 2006: 2-13.
5. The PLoS Medicine Editors, Stonington S, Holmes SM (2006) Social medicine in the twenty-fi rst century. PLoS Med 3(10): e445. DOI: 10.1371/journal. pmed.0030445
6. Mansfield PR, Mintzes B, Richards D, Toop L. Direct to consumer advertising. BMJ 2005;330:5-6.
7. Jutel A. The emergence of overweight as a disease entity. Soc Sci Med 2006; 63:2268-2276.
8. Vedantam S. FDA Told U.S. Drug System Is Broken: Expert Panel Calls For Major Changes. Washington Post, 2006 Sept 23; A:1. http://www.washingtonpost...
9. Menkes DB. Hazardous drugs in developing countries. BMJ 1997;315:1557-1558.