Personal Views: In praise of the “devil”
Authors: Silvia Bonaccorso, Richard Smith
Journal: BMJ (2003)

When a pharmaceutical company misbehaves the whole industry instantly becomes the culprit. In contrast, when a doctor misbehaves the whole of medicine isn't condemned. For some reason the pharmaceutical industry is seen as the devil, while many others in health care are seen as saintly. This prejudice against the industry is unfair. Those who work in it resent being seen as part of the problem rather than part of the solution, particularly since the industry either developed or manufactured virtually every new drug to have emerged in the past century. Where would health care be without antibiotics, antihypertensives, immunosuppressants, antidepressants, anaesthetic drugs, lipid lowering drugs, and hundreds of others?

One of us (SB) has worked in the industry for many years and so has a partial view, but it was experiences as a physician in Buenos Aires in the 1970s that illustrated the value of the serious research oriented companies. The companies educated doctors when postgraduate training was often unavailable. That's still the case in much of the world. But the companies did much more. The hospital was generally short of everything—to the point where physicians had to be creative to provide for the patients. They had to rely on company representatives to provide the medicines needed to treat people. They never said no. They were always helpful and often committed their companies to provide a lifelong supply of medicines for patients with chronic diseases who couldn't afford to pay for the drugs they needed. The representatives were always courteous, helpful, unobtrusive, knowledgeable, and understanding.

The industry has a role not only in developing new drugs but also in manufacturing those discovered by others. Selman Waksman won the Nobel prize in 1952 for his work on antibiotics, discovering streptomycin and actinomycin D, but he observed that without Merck's collaboration most of his discoveries would have remained “bibliographic curiosities.” Penicillin was discovered in Britain in 1928, but the drug could not be produced on an industrial scale until the American pharmaceutical companies stepped in. The companies solved the problems of translating submerged fermentation from a pilot plant into large scale manufacturing.


Most research based companies behave ethically most of the time


Lord Howard Florey, who shared the Nobel prize with Alexander Fleming and Ernst Chain for the discovery of penicillin, observed in 1949 that: “Too high a tribute cannot be paid to the enterprise and energy with which the American manufacturing firms tackled the large-scale production of the drug. Had it not been for their efforts there would certainly not have been sufficient penicillin by D-Day in Normandy to treat all severe casualties, both British and American.”

And this was only the beginning. Research and manufacturing developments led by industry scientists gave physicians and their patients thiazide diuretics, angiotensin converting enzyme inhibitors, β blockers, H2 antagonists, non-steroidal anti-inflammatory drugs, anticancer drugs, corticosteroids, leukotriene receptor antagonists, all sort of antibiotics and antivirals, vaccines, and a myriad of other life saving and life improving medicines.

Perhaps the most powerful therapeutic story is how the industry confronted AIDS and transformed it from a death sentence into a chronic, manageable condition. Academia, government, and industry collaborated, and the experience was unique, meaningful, frustrating, exasperating, and sometimes depressing, but also wildly exhilarating and ultimately successful.

Why, when it has achieved so much, is the industry so often attacked? Some seem to object to it making profits, but we know that commercial companies can develop drugs in ways that the non-profit sector cannot begin to match. Companies are increasingly making some of their drugs available cheaply or for free in the developing world, but they cannot alone create the health infrastructure that is needed and reverse the huge inequalities in income.

Some object to the marketing of companies, but marketing—understanding and responding to customers' needs—is an essential component of commercial practice. Even though the industry is tightly regulated, there are sometimes excesses—but to paint a picture of a mendacious industry corrupting innocent doctors is to oversimplify the problem horribly. Most research based companies behave ethically most of the time—because success in the industry comes ultimately not so much from marketing but from developing genuinely innovative drugs that solve important medical needs.

The pharmaceutical industry must be held accountable through the media and other means—just like politicians and doctors—but it is in everybody's interest for the achievements of the industry to be highlighted as well. The media, and especially professional journals, should recognise that the failings are of individual companies rather than the whole industry and that it is sometimes just too easy to blame the industry rather than examine the failings of others in health care.