Carl Elliot. White coat, black hat. Boston: Beacon Press; 2010. pp 211 ISBN 978-0-8070-6142-8 $24.95

For about two decades now, the pharmaceutical industry – particularly its marketing and sales arms – has been receiving a lot of flak. The bad publicity has come from all sides – articles in learned medical journals, in general newspapers and magazines, in movies and from whistleblowers in the industry – and has reached such an extent that the public approval of the industry in the USA dropped from 80% in 1987 to a mere 9% in 2005, putting its reputation just above the oil and tobacco industries. Carl Elliot in his book, aptly subtitled “Adventures on the dark side of medicine”, drives one more nail in the coffin of the drug industry. Elliot illustrates how Big Pharma stoops low and how medical professionals join hands with them, knowingly or unknowingly.

Why does the industry use such tactics? Elliot explains what they do in order to remain a high profit industry. After all, in 2002, the combined profits of the top 10 drug companies exceeded the combined profits of the other 490 companies in Fortune 500. His book could well have been subtitled “A brief history of the marketing practices of drug companies”.

The key players in this game are, as the titles of the six chapters state, the guinea pigs, the ghosts, the detail men, the thought leaders, the flacks and the ethicists. Some of the human guinea pigs, in the USA, at least have learnt to abuse the system which abuses them; practically all, however, are in it for the money and not for altruistic purposes like the companies would have us believe. We are told about how ghost writers are used by the industry to write convincing “evidence-based” articles. How ghosts can affect medical science to its detriment is particularly clear when one realises that thalidomide was sold as a pill for morning sickness – after a ghost wrote up an article without the company even performing the required research. The detail men, of course, are the pharmaceutical company representatives, the reps. These reps (the statistics: one drug rep for every 2.5 doctors in the US in 2005) are suave, charming, friendly – and bring gifts that are difficult to resist. The thought leaders, as a particularly eye opening essay describes leaders in the field (“key opinion leaders”), are carefully selected and groomed to parrot drug company policy – often without even realising it.

Pharmaceutical sales are increased in many ways, some of which are disease branding (“increasing” the incidence of uncommon diseases or creating “new” diseases), the use of video news releases (a commercial in the guise of a news story) and commercials masquerading as public service advertisements. Incredibly, fake but legitimate-looking journals have been produced by the industry to carry articles extolling the virtues of certain of their products. Parts of the story are strongly reminiscent of what happens in John Grisham novels.

How do changes in society and in our thinking affect drug sales? In the 1980s, direct to consumer (DTC) sales were shunned; the arrival of patient empowerment meant that DTC advertising suddenly made ample sense. Advocacy groups (funded partly by pharma) also played a part in promoting sales. While in 1991, 80% of industry-sponsored trials were conducted in academic centres, by 2004, 70 % were in the private sector.

The part which took me quite by surprise, though, was the last one. Because the Indian Journal of Medical Ethics carries no drug company ads and the National Bioethics Conference that the journal has organised has never received drug industry financial support, I had always assumed that there could be no healthy relationship between an ethics organisation and pharma. I am now disabused of that notion. It appears that there are many ethicists on the payroll of drug companies and that there are institutional review boards and centres for bioethics which have been supported by grants given by the drug industry. Not that they think differently from the other bodies – the American Medical Association in 2001 launched a campaign to educate doctors about ethical issues arising from drug company gifts: the campaign was funded by the industry.

Readers of the book will be exposed to humongous financial figures: the $21.1 billion settlement given by Wyeth to settle the litigation for the drug Fen Phen; the DTC advertising budget in 2005 in the USA alone was a staggering $29.9 billion.

Facts such as these make it abundantly clear that the nexus between pharma and medicine is much, much deeper than I’d previously thought and I am forced, pessimistically, to agree with Elliot’s conclusion, in his foreword to the book: “I doubt that… financial ties [between American medicine and industry] will disappear anytime soon.”

Because there is more than reasonable evidence that there are numerous such conflicts of interest, many of them blatant and many of which palpably mislead us, anyone affected by healthcare – patients as well as doctors – must read this book to see why modern medicine is, at least in part, a scam.