From the title, Deadly Medicines and Organised Crime: How Big Pharma has Corrupted Healthcare, Peter Gøtzsche makes the thesis of his book very clear. Not only does the pharmaceutical industry contribute to detrimental health outcomes through biased research, deceptive marketing, and disease mongering, but the industry’s business model meets the criteria of an organized criminal operation. Gøtzsche argues for this in two parts. First, he defines organized crime by drawing upon the United States Organized Crime Control Act of 1970, the centerpiece of which is the Racketeer Influenced and Corrupt Organizations Act (RICO) (18 U.S.C. §§1961-1968). RICO prohibits deriving income from a pattern of racketeering activity, including (among other things) murder, kidnapping, robbery, bribery, extortion, and dealing in a controlled substance. Second, he argues that big pharma derives much of its income from repeated racketeering activities. He does this in part by laying out his ‘hall of shame,’ which is a list of cases in which large pharmaceutical companies have agreed to pay settlement fines for fraud, illegal marketing, misrepresentation of research results, and other offenses, and in part by examining various deceptive activities that are standard in the industry, including manipulation of clinical trial results, coopting of university researchers, ghost writing, and deceptive marketing. Big pharma, he argues, engages in racketeering activity so often that “there can be no doubt that its business model fulfills the criteria for organised crime” (38). Gøtzsche is not alone in comparing the pharmaceutical industry to an organized criminal enterprise. In a striking passage, Gøtzsche quotes Peter Rost, a former Pfizer marketing vice president, as follows:
It is scary how many similarities there are between this industry and the mob. The mob makes obscene amounts of money, as does this industry. The side effects of organized crime are killings and deaths, and the side effects are the same in this industry. The mob bribes politicians and others, and so does the drug industry…. The difference is, all these people in the drug industry look upon themselves—well, I’d say 99 percent, anyway—look upon themselves as law-abiding citizens, not as citizens who would ever rob a bank…. However, when they get together as a group and manage these corporations, something seems to happen… to otherwise good citizens when they are part of a corporation. It’s almost like when you have war atrocities; people do things they don’t think they’re capable of. (38)
While Gøtzsche’s overall thesis is that big pharma is an organized criminal operation, the majority of his book is devoted to elaborating standard criticisms of the pharmaceutical industry. For example, he includes chapters arguing that very few patients benefit from new blockbuster drugs; that clinical trials tend to be biased; that conflicts of interest among both academic scientists and journals are rampant; that companies repeatedly fail to report unwanted results; that drug regulation is inadequate; and that industry often relies on threats of various kinds to protect sales. Most of the book covers terrain that has been covered elsewhere, including by two former editors of the New England Journal of Medicine—Marcia Angell, in The Truth about the Drug Companies: How They Deceive Us and What to Do about It (2004), and Jerome Kassirer, in On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health (2005). Given this, it is fair to ask what, if anything, Deadly Medicines adds to the existing body of literature.
The main virtue of Gøtzsche’s book, and the primary thing that it adds to the existing literature, is a wealth of detail. Gøtzsche, a co-founder of the Cochrane Foundation and director of the Nordic Cochrane Centre, is a physician and medical researcher who has worked in, and commented on, the pharmaceutical industry for many years; he has published over 50 articles in the ‘big five’ medical journals (Annals of Internal Medicine, BMJ, JAMA, Lancet, and New England Journal of Medicine), and his medical works have been cited over 10,000 times (xii). His book Mammography Screening: Truth, Lies, and Controversy (2012) is a highly respected work that brought attention to the dangers of over screening. From his background and experience in examining industry influence in medicine, he has a seemingly endless list of examples that he can bring to table—and while wading through Deadly Medicines, it sometimes seems as if he discusses all of these in detail. His book is thus a very useful resource for those interested in industry influence in medicine.
At the same time, there are at least two significant problems with the book. The first is that it is poorly structured and needlessly long. At many points, the book can feel like more of a litany of anecdotes than a sustained and well-structured argument. The stated thesis of the book is interesting and provocative, but the book is not tightly structured around it; if the book is organized around any conclusion at all, it is the claim that many pharmaceutical companies engage regularly in deceptive practices, such as those mentioned above. But this is not the main claim that Gøtzsche wishes to establish; he goes much further and concludes that big pharma fulfills the criteria for organized crime. This brings us to the second major problem with the book, which is that the organized crime thesis is in some respects underdeveloped and in other respects simply flawed. It is flawed in its treatment of ‘big pharma’ as an organized monolith. ‘Big pharma’ is not an organized entity but rather a collection of corporations, and as such, ‘big pharma’ could not be considered an organized criminal enterprise. Individual pharmaceutical companies could perhaps be organized criminal operations; ‘big pharma’ cannot. While it is provocative to say, as Gøtzsche and Rost do, that there are many similarities between ‘big pharma’ and the mob, a careful examination of the organized crime comparison would require rigorous examinations of the practices of individual companies. Gøtzsche does discuss individual companies—AstraZeneca, GlaxoSmithKline, Merck, Pfizer, Roche, and others are repeated targets—but his focus is on the industry as a whole, and given this focus and the numerous examples he provides of unethical behavior on the part of many different individuals and corporations, the organized crime comparison might seem more plausible than it really is. This leads us to the respect in which the argument is underdeveloped. To make the organized crime comparison compelling, one would need to focus specifically on particular companies and show how each meets the legal criteria of an organized criminal operation. Gøtzsche could perhaps have made his argument more coherent and more plausible by structuring the book around discussions of particular companies, their histories, and their standard practices—perhaps by devoting a chapter each to AstraZeneca, GlaxoSmithKline, Merck, etc.—and arguing that each of these corporations derives much of its income through repeated racketeering activities. Such an argument would also require a nuanced discussion of the legal standard of what constitutes repeated (or a pattern of) racketeering activities—something that is lacking from Deadly Medicines. As it stands, however, the book often feels like an unstructured list of anecdotes of bad corporate behavior on the part of many different companies. I agree completely that many pharmaceutical companies display bad behavior on a regular basis; but regular unethical behavior is not necessarily the same as behavior that satisfies the legal definition of organized crime.
Deadly Medicines makes a number of important points, and it is commendable for the wealth of detail that it provides. Because of this, it is useful as a resource for those interested in the pharmaceutical industry. However, if one is new to the sorts of issues that Gøtzsche raises and is looking for an entry into this literature, either of the books by Angell or Kassirer would be better places to start.
Justin B. Biddle
Georgia Institute of Technology
Atlanta, GA, USA
Angell, Marcia. 2004. The Truth about the Drug Companies: How They Deceive Us and What to Do about It. New York: Random House.
Gøtzsche, Peter C. 2012. Mammography Screening: Truth, Lies, and Controversy. London: Radcliffe, 2012.
Kassirer, Jerome. 2005. On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health. New York: Oxford University Press.