So Whose Body Is It?

RITA CARTER

This article first appeared in  Prospect magazine
MEDICINAL DRUGS ARE AMONG the most important commodities we have - our very lives often depend on them. Yet we have less control over whether we get them, less say in which ones we are allocated, and less knowledge about them than we have about almost anything else we consume. In the UK we are not allowed to see advertisements for prescription drugs in case we start pestering for them, and we meekly accept that we may only take what the experts say we should take. People who demand six parameters of choice in their takeaway coffee open up and swallow pills they can’t even name, provided they come from someone with “Dr” before their name.

 We relate to drugs in this curious way because they terrify us. So scared of them are we that in practically every highly-organised society we proceed from the basis that they should all be banned, all the time, to everyone. The only ones we don’t outlaw are those proved to have health benefits, and these are doled out to us as though by a nanny to her infants. We rationalise this prohibitive attitude by pointing up the risks associated with pharmaceutical products. Yet in most cases drugs are less risky than countless everyday things which we would not dream of restricting. Cars, alcohol and cigarettes are the obvious examples, but a glance through mortality statistics shows that seemingly benign objects like stepladders, household chemicals, deckchairs, DIY tools - even peanuts - are potential killers. Nor does the system actually protect us from adverse drug effects - the real fiascos - antibiotic abuse and widespread tranquilliser addiction, for example - happened largely because of the way pharmaceutical products are handed out, not despite it.   

In Britain the consumer has even less control over the drugs they take than elsewhere because, in addition to laws which prevent us from getting many of them without a chitty from the doctor, drug distribution is subject to State control.  Nearly all GPs are employed by the National Health Service and almost all the prescription drugs which are handed out annually to people in the UK are done so on NHS prescriptions. [1] Because the recipients do not pay directly for their drugs many seem to think they don’t pay at all, and this has encouraged the notion that you should be grateful for anything you get and not ask questions. GPs are not allowed to write private prescriptions during NHS consultations, and as the number in private practice is minute, this means that people cannot easily obtain rationed drugs, even if they are happy to pay the price. And the new policy of clinical governance is currently shifting decisions about drug-taking even further away from the individual. Until recently the doctor decided whether and what to prescribe, ostensibly on the basis of what seemed best for the individual patient. Now doctors are being forced to treat according to binding guidelines designed to provide cost-effective care for all on an equitable basis - a very different thing. The much-trumpeted policy of "doctor-patient collaboration" is meaningless given that ultimately the power lies entrely with the doctor. The result is that thousands of people are deprived of things which could make their lives better, and in many cases they suffer unnecessarily, or even die.

Take ‘flu. It doesn’t often kill the rich people in the world but it is very unpleasant and for many of them it is the most serious illness they will experience in any one year. Recently a manufacturer came up with a product, Relenza, which reduces the duration of this illness by nearly half and helps stop it spreading [2] In a heavy ‘flu winter, like this one, some quarter of a million days of misery could be avoided if every ‘flu victim in Britain took Relenza at the first sign of illness.[3] Far from encouraging its use, however, in the UK Relenza is effectively banned. Ironically, the banning has been done by the National Institute for Clinical Excellence (NICE) - an organisation supposedly set up to make medical practice better.

 Xenical is another restricted drug. This ingenious product gobbles up fat from food in the gut before it can be absorbed. It helps people lose weight when all else has failed and the worst risk it carries is to produce a condition delicately known as faecal leakage.[4] Its potential health benefits to the nation are huge, and its attraction to those who merely want to eat more than they should yet stay slim are obvious. But to get Xenical in this country you either have to be seriously obese and go through an elaborate series of diagnostic hoops, or buy the drug through a dodgy slimming clinic or internet site which will charge you far more than the true market cost.

Then of course there is Viagra. Viagra can restore sexual function in some impotent men, and may also increase sexual pleasure for normal men because it can help prolong intercourse.[5] It has certain risks - but no more than, say, unprotected sex with a stranger. But to get Viagra legally in the UK you have to be formally diagnosed with a condition which makes Viagra the only means you have of achieving sexual intercourse.[5] Having passed this hurdle you are allowed two pills per week. 

This system of doling out treatment according to what Nanny thinks best was acceptable when the NHS was set up because effective drugs were few, expectations were low, and the principle of equity was unsullied. But it cannot survive. Designer and “lifestyle” drugs, including products that can enhance normal life as well as relieving illness, are pouring onto the market. Soon we will be able to mould our bodies and tweak our personalities at will, trading the slow, painful journey to self-improvement with something popped from a blister-pack. Medicinal-but-hardly-essential products like Viagra and Relenza are the bridge between old-style medicines and this new type of “lifestyle” pharmaceutical. Beyond, and already in development, are pills which will boost our memories, control our appetites and twiddle our genes to slow down ageing. These products will be seen less as medicine and more as consumer goods, and people are going to want them, just like they now want designer clothes and mobile phones. 

Astonishingly, the Government seems to think it can keep the lid on consumer demand by banning and censoring. Hence NICE is revealing itself as an instrument for rationing, and direct-to-consumer advertising (DCA) looks set to remain outlawed. But these old tricks are unlikely to work for much longer. The post-war generation is not toddling off into old age with the stoic acceptance of their parents and they will fight, like the seasoned consumers they are, for anything which can help stave off physical degeneration. Many of the new lifestyle drugs will be designed to combat ageing, and, thanks mainly to the Internet, there is no way that the existence of these products can be kept a secret. Indeed, our new ability to access information which is meant to be forbidden to us has already forced one change in British censorship rules.  In the six-month gap between Viagra getting its US licence and getting licenced over here UK rules prohibited its maker, Pfizer, from even mentioning the drug’s name. Yet people could call up 20,000 sites and 140,000 web pages dedicated to the drug.[6] The situation became so absurd that the then Health Secretary, Frank Dobson, agreed to allow Pfizer, exceptionally,  to put out advance information. The Government’s subsequent attempts to restrict access to the drug led to the amusing spectacle of a Minister of State pronouncing on how many times a man might reasonably be expected to enjoy sexual congress courtesy of the public purse.Dobson was also forced to make an exception for Viagra to the usual prohibition on NHS GPs prescribing privately.

Unless there is some radical change in the way drugs are marketed we will soon be seeing more and more chaotic farces like that surrounding the launch of Viagra. As each new lifestyle drug comes out we will see NICE struggling to come up with a convincing excuse for banning it; GPs will become even more beleaguered as they are forced to refuse their patients each new goodie; dodgy drug mail-order sites will flourish and eventually UK-based pharmaceutical companies - which accunt for billions of pounds worth of exports and more than 60,000 jobs [1] - will pack up and move to places where they can market their wares more freely..

Yet it doesn’t have to be that way. Instead of making it especially difficult to get hold of lifestyle drugs it could be made especially easy. Such products could be put on sale (after safety trials and along with full information) without prescription and sold like any other commodity. A tax could be levied on them, which could be earmarked for the NHS. Pharmacists could (and would be pleased to) take on the task of advising on appropriate use. It would be no more unfair than allowing (as we do) unrestricted purchase of breast implants or a collagen-enhanced pout.

You might expect that the argument for de-restriction of drugs would be pursued most forcibly by the people who make them, but to date the pharmaceutical industry has been curiously quiet on the subject. One reason for this restraint is that the industry’s position within the NHS prescribing system is very cosy. . Since 1958 its profits have been effectively guaranteed through an agreement between Government and industry called the Pharmaceutical Price Regulation Scheme (PPRS). Under this scheme, in exchange for capping prices on NHS drug sales, the industry is allowed to operate in a way that allows a generous 17-20% return on capital invested..[7] The prescribing system is , anyway, useful to the pharmaceutical companies because it provides a ready-made distribution network and has the added advantage of putting a “learned professional” between them and a writ if anything goes catastrophically wrong.

The system will not work so well for the industry, however, when lifestyle drugs form a much greater proportion of its output.. Unless there are big changes these products are unlikely to find an easy market here, as has been shown by the way that their forerunners - Viagra and so on - have been dealt with. Sir Richard Sykes, the chairman of Glaxo, which makes Relenza, was furious when the product was banned and even threatened to take his company to America.

 “ This recommendation appears to demonstrate that the UK can no longer be seen as ...a suitable market for the early launch of new medicines” he wrote to Tony Blair. “The Government has repeatedly and rightly stressed the need for British companies to invest in research and development and innovate... The NICE judgement....will send out precisely the opposite signal and represent a clear disincentive to innovation and the development of new medicines.”

Sykes’ statement is the first public demonstration of industry exasperation. But more will be seen soon if the Government refuses to let up on its ban on direct-to-consumer advertising. Many new drugs are unavailable in Britain because their makers see no point in launching them here when they can’t advertise them to the people who will be using them. In the USA DCA works so well for the manufacturers that they now spend more on it than on advertising to medical professionals. [8] Pressure for change is therefore increasing within the industry and the combination of this and consumer demand must eventually destroy the restrictive practices surrounding drugs. The longer the Government holds out against it, however, the more chaotic the collapse will be.

In terms of advantage to the UK citizen, the change, when it comes, will go much further than simply allowing ageing baby-boomers to reduce their wrinkles or burn off fat without exercising. Allowing people greater knowledge of, and access to lifestyle pharmaceuticals will have a knock-on effect on the use of conventional therapeutic drugs, which will in turn have a beneficial effect on the nation’s health. . At the moment the UK lags dismally behind its European neighbours in its healthcare outcomes. Survival rates for all types of cancer, for example, are well below the European average.[9] One (of many) reasons for this is the slow take-up of modern drugs. Under the present system the average spend per head on drugs is kept at a low 25p per day - half as much as in France and Germany.[1]. This is not enough to buy state-of-the-art treatment, and de facto rationing has been in force for years. Given the choice it is likely that most people would be willing to pay more, and most could afford to - the 25p drugs spend is less than a quarter of what we spend on tobacco and alcohol. [1] Private, unrestricted sale of non-essential drugs would leave more money available for the NHS to purchase life-saving products and to prescribe generously to those who cannot afford to pay privately.

More important than these practical benefits is the underlying issue of liberty. Our bodies are the most personal possessions we have - the very last things over which we should surrender control. We have ceded our rights over them because in illness we regress, and long for some strong parental figure to kiss us better. Over centuries we have encouraged the medical profession to take that role, and have thus colluded in creating a paternalistic system in which we do not even have the right to know about, or determine, what we consume. When doctors’ most powerful tools were confidence and the placebo effect medical paternalism was acceptable because it increased the therapeutic effect of those things. But it is not delivering us best use of the armoury of drugs. It is time to take responsibility for our own health. Time, in short, to grow up.

References:

1 Pharma Facts and Figures (ABPI) January 2000
2 Glaxo Wellcome datasheet Relenza
3 Extrapolation from population mortality survey 24/12/99
4 Sjostrom et al, Lancet 1998 vol 352 pp 167-172
5 Pfizer; datasheet Viagra
6 Letter, Melanie Phillips, in BMJ
7 “Understanding the PPRS”, ABPI January 2000
8 Competitive Media Reporting, report 10.2.98


© Rita Carter 19XX/2007 - ritacarter.co.uk