PharmAware UK, with its slogan "creating ethical and professional doctors" is a campaign arm of Medsin UK.  PharmAware aims "to maximise good practice and ethical interactions between healthcare professionals and pharmaceutical companies to enhance patient care".  Alongside this it aims to educate and campaign on various international pharma issues through its branches at medical schools around the UK.

Medsin UK is a network of students with an interest in health and there are branches at universities across the UK.  Medsin is a national network of students across the UK that are interested in global health and there are Medsin branches at many universities, which organise activities at a local level.  Medsin is the UK part of the International Federation of Medical Students' Association (IFMSA), though students from any discipline are welcome to become involved.  

The International Federation of Medical Students' Associations (IFMSA) is an independent, non-governmental and non-political federation of medical students' associations throughout the world, which was started in the Netherlands as a charity.  In 2007 IFMSA had 102 National Member Organisations from 100 countries on six continents and represented more than 1 million medical students worldwide.

On 21st February, ANH Medical Director, Dr Damien Downing was invited to speak at the AGM of the Pharmaware Bristol group. Following is a summary of Dr Downing’s presentation.

Pharmaware AGM, Bristol, Feb 2009

Dr Damien Downing

Summary

We are all taught to depend on the evidence for clinical decision-making. But does the research tell us the truth?  How do we know?  Do we really need pharma?  Can we afford it?  And what is coming next?

Do we need pharma?

The global market for pharmaceuticals in 2007 was estimated at US $712 bn.  The BMJ Clinical Evidence website documents that only 13% of medical treatments examined have been demonstrated to have a beneficial effect, and the largest proportion, 47%, are of unknown effectiveness. But this story is little-told.

The benefits of some of the key earners are far from impressive:

• Cancer chemotherapy ($13bn worldwide) 2% impact on 5-year survival
• Statins ($30bn) 17% reduction in coronary events, but 25% muscle symptoms if the patient exercises
• HAART ($10bn) 4-12 years delay in progression to AIDS in USA and Europe, but 4-12 months in sub-Saharan Africa

So the evidence is there that pharmaceuticals work in some cases—but at a price.

Do we hear the truth?

A 2008 study looked at the effect of pharmaceutical advertising on what journals publish about dietary supplements, and found a powerful influence; in journals with the most of such adverts, 67% of studies had negative (unsafe or ineffective) conclusions, while in those with the fewest adverts the figure was 4%.  But negative findings are commonly hyped in the media (which costs money in PR and lobbying) and the positive ones go unheard.

Several years ago Hickey and Roberts wrote about specific ways to design a trial to show the absence of a benefit from these vitamins in heart disease (Hickey S. Roberts H. (2004) Ascorbate: The Science of Vitamin C, Lulu Press).  In relation to a recent study critical of nutrients they commented: “We intended our advice to show how NOT to perform a trial of vitamin C and E in heart disease.  Perhaps someone should explain that to them”.

Can we afford pharma?

The ecological effect of pharma is considerable.  In the UK healthcare represents 8.4% of the GDP (twice that in the USA). That makes healthcare a major player in terms of carbon footprint, pollution and even resource depletion.

Pharmaceuticals contaminate the environment:

• via factory run-offs; a study in India in 2007 found “astronomical” amounts of antibiotics in a major river, coming from manufacturing plants
• via patients’ urine; bioactive levels of contraceptives have been found in urban water systems worldwide
• via disposal of unused medications; Associated Press estimated that as much as 250 million pounds of unused pharmaceuticals may be flushed into US sewers every year by hospitals and care homes.

Incinerators, including hospital incinerators, which are often in urban locations, release quantities of particulates, pesticides and heavy metals that have been shown to cause damage to health, increasing rates of cancer, heart disease and even autism.

What is coming next?

In 2003, GSK’s Vice President for Pharmacogenetics, Dr Allen Roses, said, “the vast majority of drugs - more than 90 per cent - only work in 30 or 50 per cent of the people……I wouldn't say that most drugs don't work. I would say that most drugs work in 30 to 50 per cent of people.”

At the time, many of us thought he was “doing a Ratner” (after the claim made by UK jewellery tycoon Gerald Ratner who referred to his products as “crap” and paid the price by triggering the subsequent collapse of his business), robustly stating the truth about his products.  But now we can see that this was the start of a roadmap for the future—have everybody genomically-tested (perhaps at birth), so we know which drugs will work on them, as well as what diseases they may risk from the environment.  The first risk from this is that employers, insurers and government agencies will use the information to deprive people of work, insurance or civil rights.  But some of the major genomic variations occur in as many as 50% of us.  An example is the common variation in the GSTM1 gene.  This deletes an important enzyme in the process of detoxing exogenous chemicals in the liver, and thereby predisposes to (at the very least) allergies, cancer and cardiovascular disease.  Is the solution to disenfranchise that 50% who are more vulnerable to it, or to clean up the environment?

What is the solution?

“Improving human health is inextricably linked to restoring ecological well-being”, (Kenny Ausubel 2004)

Sustainable healthcare means “functioning harmoniously with both the human body and the environment”.  In a time when even our banking system is proving unsustainable, we have to realise that the solution will not come from industry or from government—it has to come from us all. It’s up to you.

Save the individual, save the planet.

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