Following a small seminar in May 2007, Pharmageddon was formally defined as, "the prospect of a world in which medicines and medicine produce more ill-health than health, and when medical progress does more harm than good".

This concern was later outlined in a 1,250 word statement, which also questioned whether parallels might exist between the global health climate and impending environmental chaos. The issues seemed comparable to the relationship between a car journey and Climate Change - inextricably linked, but quite unconnected in the average driver’s mind.

Just as Climate Change might seem inconceivable as a journey outcome, so most personal experience of medicines flatly contradicts the notion of Pharmageddon. But, to pursue the analogy, the threat of Pharmageddon is to do with the way in which all drug travel changes the climate of health, even when so many journeys with medicines seem vital or worthwhile.

Pharmageddon was proposed as a hypothesis, an attempt to steer away from the orthodox view that all is well, bar some unfortunate exceptions to the general rule. This initiative proposed the need to question the rules themselves, and the ability of the drug establishment to promote real health.

Mountainous evidence from both past and present proves that it is dangerous to assume good health outcomes, just because presumed drug benefits appear greater than unknown harms. It seems especially mad to proceed on that basis, when assessments of benefit are routinely marked by irrational exuberance, and worse, and when standards of investigation of harm are so poor. The leadership tendency to believe that ‘no evidence of harm’ equates to ‘evidence of no harm’, brings the threat of Pharmageddon closer still.

This initiative on Pharmageddon assumes that adverse drug effects, horrible as they sometimes can be, should not distract from the underlying problem. Collectively, these ill effects signal major system dysfunction, and the prospect of worse to come. The time frame is unclear, but Pharmageddon stands for the end product of an over-powerful and self-serving pharmaceutical industry, a drug regulatory system that is chaotic and misconceived, professional commitment that proceeds largely on the basis that meaning well means doing good, and generalised subscription to a conspiracy of goodwill.


The Call for Abstracts

In July 2007, on behalf of the seminar group, Social Audit and Health Action International (HAI) proposed a conference on Pharmageddon? Thanks to an intrepid grant from the Allen Lane Foundation, the "call for abstracts" came with an offer of €15,000 in awards for the best received. The deadline was the end of the year.

Crucially, people were asked to limit their submissions to 350-words. We were looking for essential propositions and skeleton arguments, and wanted readers well engaged. We repeatedly emphasised that we would welcome arguments against Pharmageddon? and not just in favour of the idea.

By the closing date, 49 people had sent in 66 submissions. Remarkably, not one abstract challenged the notion of Pharmageddon. However, too many submissions - from both patients and professionals - simply offered good evidence of bad personal experience with medicines, and rather left it at that.

The challenge in this initiative was to establish whether qualitative evidence pointed to some risk of Pharmageddon. Could problem vectors be identified, and how do problematic elements relate to some whole? Is the nub of the problem the failure of bottles of medicine, or the failure of the system of medicines’ marketing, prescribing and control? For all the evidence of great talent, commitment and dazzling inputs in medical science, what are the outputs in terms of health?

Social Audit (CM) was not involved in the judging, but read all entries and short-listed them. As well as anonymising the copies sent to judges, they were formatted to one entry per page, weighting brevity to print size. The 40 short-listed submissions were considered by a panel of five judges, convened by HAI (TR and TA). Judging was blind, and resulted in close agreement on the best 15 submissions.

The best are excellent and deserve to be closely read and more. But what do they all add up to? Collectively they leave so much untouched and unsaid, but together they contain the germ of an idea - that the drug establishment is pretty much incapable of understanding how it might be wrecking what medicine should stand for and what health needs to be.


And the winners are …

Many thanks to everyone who responded and congratulations to the following. Abstracts are hyperlinked to the title of each submission. Any proposed linkage between abstracts is down to us, not the contributors.

David King proposes future threats beyond Pharmageddon: "At stake is not just the expropriation of health, but the expropriation of life itself". See: Biocalypse. In Genomics, Medicalisation and the Pharmaceutical industry, King then outlines his concern that genomics will become a potent driver of medicalisation, promoting "a new understanding of the body as inherently flawed."

Alan Cassels also submitted two winning abstracts. In Planting Paranoia and Harvesting Patients, he warns that routine diagnostic testing may forever turn healthy people into ailing patients. He elaborates the point in Rooting for Cancer, contrasting the activities of radiologists and truffle pigs.

Andrew Herxheimer also links two themes. Consistent and transparent measurement is basic to Describing Pharmageddon. He exemplifies the lack of it, by reference to the many unknowns in drug safety monitoring: Pharmacovigilance needs a complete rethink.

Between them, these analysts propose daunting challenges – not only to dull indifference and complacency, but also to understanding the scenery on the road map to Pharmageddon. King adds vital perspective, explaining the dynamics and proportions of the problem. Cassels illustrates them vividly in human and familiar scale. Herxheimer then emphasises how gross generalised deficits of understanding underpin great magnification of benefit and gross and persistent under-estimation of risk.

The other winning entries, in different ways, all reinforce the fear that it would so easy to fail to recognise the threat that Pharmageddon might be. Many thanks and congratulations to:

Donald Light - The Hidden Epidemic of Harm Caused by Medicines; Jerome Burne - Just how well is our watchdog guarding us? Jennifer Reck - A System Map of Pharmageddon; Dee Mangin - Expropriation of the manner of our dying: a Sisyphean path to Pharmageddon? Bernard Junod (collective authorship on behalf of - Factors behind the epidemic of breast cancer diagnoses in France; Michael Weingarten - The medicalisation of healthy womanhood; Amanda Cundiff - Genetically Engineered Rice to Treat Children in the Third World; Lilia Ziganshina, Irina Burashnikova, Airat Ziganshin - The Picture From 1/6th of the Globe: who will be lucky to live in the future world? And Andre Menache - Pharmageddon.


Where now?

Part of the Pharmageddon hypothesis is the supposition that, if we were individually capable of knowing, synthesising and digesting all obtainable information on health outcomes and drug benefits and harms, we would be bound to change tack. Parallels with Enron would surely be seen. Public abhorrence of the gulf between appearance and reality, prescribing and health, expectation and outcome, investment potential and return, and scientific integrity, or not – might well bring the present system crashing down.

This was one of the scenarios contemplated by one participant at the original seminar on Pharmageddon: "I just have the conviction somewhere in the back of my head that it is all going to collapse in our lifetimes.  I say this sometimes in conversations with people who, in view of their positions, I would expect to jump on me very fiercely for expressing such thoughts, but a surprising majority have the same uneasy (or liberating?) feeling ... once I had promised absolute confidentiality and anonymity - even industry people largely took the view that we were approaching a precipice." 

But the Pharmageddon hypothesis also postulates that collective denial of the relevance of such factors is already too well fuelled and established to precipitate such a collapse. Hence another seminar perspective: a model of progressive and perhaps intractable infection, by something analogous to a very seductive virus of the mind – "one that takes hold very slowly by embracing, gently entwining itself with, mainly happy hosts, and members of the drug establishment above all".

Meanwhile, the pharmaceutical industry’s growing commitment to unhealthy agendas mainly reflects its inability to cope with its own, perhaps terminal illness – ‘declining productivity in drug innovation’. Does the industry really expect to survive by investing more and more in marketing, lobbying and public relations, and by ever more aggressive and intrusive emphasis on products, brands, and ‘health needs’? The only certainty is that regulatory complacency and dismal political leadership will encourage the industry to try.

And where do we go from here? We think that a further seminar would be very helpful, and with wider participation - both to refine the focus and to sketch the plan of the inaugural conference on Pharmageddon? Watch this space.

Charles Medawar - Social Audit Ltd
Tim Reed and Teresa Alves - Health Action International (Europe)


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