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Pharmaceuticals as a market for "lemons": Theory and practice
Abstract
Drawing on economic theory and institutional analysis, this paper reframes Akerlof's theory of how a market for lemons operates and argues that each of the many markets for lemons must be studied empirically to document how different stakeholders cope with the problems of information asymmetry, secrecy, and power. Such markets are a new field for sociological analysis. To illustrate, the paper characterizes pharmaceuticals as a multi-tier market of information asymmetry in which actors in each tier have substantial control over how much they disclose about hidden risks of harm. Such a market rewards the production and sale of "lemons." Current incentives and institutional practices reward developing a large number of barely therapeutically innovative drugs and ignoring their often hidden or understated harmful side effects. They reward designing and executing substandard, biased trials that mislead the FDA and regulators abroad to approve new drugs without clear evidence of their degree of harm. Approved drugs are likely to be "lemons" but promoted as "safe and effective." The result is substantial hospitalizations and deaths from adverse drug reactions. A "risk proliferation syndrome" of institutional practices maximizes sales, profits, and exposure to toxic side effects. An "inverse benefit law" of marketing operates as companies try to maximize sales. The probability of benefits decreases but the chances of lemons adverse events do not. The details presented here deepen understanding of how markets for lemons thrive on information asymmetry, secrecy, and power. Lessons can be applied to other markets.
... Regardless of the more permissive regulations in the US and New Zealand or more prohibitive regulations in the rest of the world, drug companies employ numerous strategies to circumvent restrictions on promotional activities (Angell 2004;Light and Lexchin 2021;Viña-Pérez and Debesa-García 2017). These include highlighting unauthorized indications for a drug, disseminating material written by ghostwriters, visiting physicians' offices, sponsoring experts at conferences, advertising at congresses, promoting the opinions of medical specialists and opinion leaders, and funding patient advocacy groups. ...
... Both refer to blurring the distinctions between news and commercial content (Öntaş et al. 2024;Willis and Delbaere 2022). Efforts include contracting ghostwriters to publish favorable scientific results of clinical trials designed to hide risks and demonstrate benefits, paying journalists to write favorable stories about their products, funding patient groups to lobby for their use, seeking to control online commentary, and hiding their affiliations with health organizations (DeAndrea and Vendemia 2016;Light 2009;Light and Lexchin 2021). In the United States, newspapers allow pharmaceutical companies to post advertisements in a format similar to authentic news (Gellert 2019). ...
Many countries ban direct-to-consumer advertising (DTCA) of prescription drugs due to potential health and financial risks. However, the internet and social media now offer new ways for pharmaceutical companies to share information and promote products. Covert marketing—indirectly promoting products through news media—has emerged as an alternative. This study explores the digital news landscape for prescription drugs in Latin America, a region that prohibits DTCA. Through content analysis, it examines prescription drug coverage in both traditional and digital news media published between 1 January 2017 and 1 January 2019, as well as its spread via social media platforms in the region’s six largest economies. The findings show that over 62% of news posts lacked neutrality, with articles on new treatments 74% less likely to be neutral, 64% less likely to mention adverse effects, and over eight times more likely to be promotional. Brazilian news had the highest social media sharing rate, with an emphasis on regulatory topics. Overall, digital news in Latin America leans toward promotional content rather than balanced reporting on drug risks and benefits. To support responsible journalism and reduce corporate influence, stronger pharmacovigilance and adherence to professional guidelines prioritizing accuracy, independence, and integrity are needed.
... Although Akerlof's (1970) original article referred to used cars, similar observations were made elsewhere, such as the pharmaceutical market, which can be characterized as a multilevel market with information asymmetry because the side effects of drugs are often hidden. Light & Lexchin (2021) reported that new medical products with few benefits but greater or poorly understood risks thrive in such a market and can, in fact-contrary to Akerlof's theory-cost even more than cheaper and better-known old drugs because of the use of certain marketing methods (such as recruiting physicians to promote them). Salmi (2022) presented a case study of e-commerce from Algeria, which appeared to show that a sizeable proportion of prospective buyers refrain from confirming their orders, possibly due to a lack of information or trust. ...
This paper focuses on the problem of so-called "lemon markets", first described by George Akerlof, where information asymmetry about product quality leads to dysfunctional outcomes such as poor average product quality and relatively low levels of trade, resulting in a loss of collective wellbeing. In the age of online commerce, the problem is especially relevant, given that consumers buy many more products without relying on personal experience than at any time in the past. Possible solutions to the problem suggested in the literature are reputation building on the part of producers and improving the information available to consumers, e.g., by way of publicly accessible consumer reviews (even though these can be gamed or faked by sellers). The paper presents the results from a classroom experiment that simulated a "lemon market". The advantage of using a classroom experiment is that while the market is recreated along a small number of rules and incentives, in line with neat economic models, the participants are real, living decisionmakers, displaying the deviations of actual human behaviour from that of a hypothetical "rational actor". In all, 294 students majoring in business information technology participated, making up 11 simulated markets. The results presented focus mainly on the supply side, namely, the quantities and prices of goods offered, and nine supply curves are estimated (for three quality grades of goods in three phases of the game). The research concludes that under perfect information, the market performs efficiently. In the condition where only sellers but not buyers have information about product quality, the volume of trade declines, although not as drastically as previous findings have suggested, and the market shows signs of recovery, albeit at a suboptimal equilibrium. After the option of consumer feedback is introduced, the market shows further convergence toward the socially optimal state. The results reaffirm that consumer feedback plays an important role in filling the information gap when product quality is uncertain; however, it is not sufficient in itself to overcome the "lemon market" problem. Other important influences on consumer behaviour under uncertainty are suggested, such as risk-taking, changing attitudes towards the act of (online) purchases, and cultural factors.
... [11] Scholars such as Donald W. Light have analysed the phenomenon of 'lemon markets' in the context of the pharmaceutical industry and further analysed how 'lemon markets' thrive on information asymmetry, secrecy of information and power of agents . [12] There are also scholars on cross-border e-commerce 'lemon market' formation of the possibility and the Matthew effect on the inhibition of the possibility of the formation of the lemon market to analyse and explore, and further put forward strategies conducive to the development of cross-border e-commerce in China [13] . ...
In recent years, e-commerce platforms featuring agricultural and sideline products have sprung up in the public, but the products they sell are of varying quality, making it difficult to achieve overall profitability.This paper presents a statistical analysis of Grocery community group-buying platform, and reflects on the community group-buying platform for low-quality products formed under the influence of the 'lemon market' by means of questionnaire survey method, interview method, and the theory of 'lemon market' of George Akerlof.It points out the intrinsic causes of the 'lemon phenomenon' of Grocery and the dilemma of the quality of online shopping for the general public, and puts forward the methods to make Grocery become a high-quality e-commerce platform for community group purchases, to promote the sale of agricultural products and fresh products on the platform of Grocery and to break the geographic restriction to bring more high-quality products into the public's view, so as to fit in with the theme of revitalisation of the countryside, promoting the development of rural e-commerce and to make contribution to the comprehensive revitalisation of the countryside in China.
... Success in the commercial model can yield enormous gains for the individuals involved, especially compared to the opportunities available within the PDP model. This has mixed effects, to be sure, with the incentives to achieve success creating support for investment but sometimes driving poor or even immoral behaviour in some situations [25]. The pharmaceutical industry has become notorious for "financialization": many firms appear to have an emphasis on maximizing returns to shareholders, which allows them to pay extraordinary executive compensation and to fund large share buybacks [26]. ...
Background
There is an inconsistency in the way pharmaceutical research is financed. While pull mechanisms are predominantly used to incentivize later-stage pharmaceutical research for products with demand in the Global North, so-called neglected diseases are chiefly financed by push funding. This discrepancy has so far been ignored in the academic debate, and any compelling explanation for why we draw the line between push and pull at poor people is lacking.
Main body
Clinical development of new pharmaceuticals is chiefly financed by free market pull mechanisms. Even in cases where markets fail to deliver adequate incentives, demand enhancement mechanisms are used to replicate pull funding artificially, for example, with subscription models for antibiotics. Push funding in clinical research is almost always used when the poverty of patients means that markets fail to create sufficient demand. The general question of whether push or pull generally is the more efficient way to conduct pharmaceutical research arises.
Conclusions
If the state is efficient in directing limited budgets for pharmaceutical research, push funding should be expanded to global diseases. If private industry is the more efficient actor, there would be enormous value in experimenting more aggressively with different approaches to enhance market demand artificially for neglected diseases.
The rapid expansion of AI adoption (e.g., using machine learning, deep learning, or large language models as research methods) and the increasing availability of big data have the potential to bring about the most significant transformation in entrepreneurship scholarship the field has ever witnessed. This article makes a pressing meta-contribution by highlighting a significant risk of unproductive knowledge exchanges in entrepreneurship research amid the AI revolution. It offers strategies to mitigate this risk and provides guidance for future AI-based studies to enhance their collective impact and relevance. Drawing on Akerlof's renowned market-for-lemons concept, we identify the potential for significant knowledge asymmetries emerging from the field's evolution into its current landscape (e.g., complexities around construct validity, theory building, and research relevance). Such asymmetries are particularly deeply ingrained due to what we term the double-black-box puzzle, where the widely recognized black box nature of AI methods intersects with the black box nature of the entrepreneurship phenomenon driven by inherent uncertainty. As a result, these asymmetries could lead to an increase in suboptimal research products that go undetected, collectively creating a market for lemons that undermines the field's well-being, reputation, and impact. However, importantly, if these risks can be mitigated, the AI revolution could herald a new golden era for entrepreneurship research. We discuss the necessary actions to elevate the field to a higher level of AI resilience while steadfastly maintaining its foundational principles and core values.
Regulatory agencies must balance patient demands to access new treatments for fatal diseases with limited treatment options while ensuring drug safety and efficacy. However, questionable U.S. regulatory actions resulted in the early approval of AMX0035 to treat amyotrophic lateral sclerosis (ALS) by reconvening advisory commissions to obtain positive decisions and designating the drug as a new molecular entity. Data from one randomized clinical trial suggests minimal delays in disease progression and longer survivability, but debate remains about the lack of confirmatory evidence of effectiveness owing to study limitations. A patient's decision-making process details the experience of using the drug, including perspectives on access, cost, effectiveness, and adverse effects. In line with the “nichebuster” business model, the drugmaker, Amylyx Pharmaceuticals, is charging US$158,000/year/patient and thus forecast to turn a profit on a drug with debatable clinical effectiveness prior to completing a Phase 3 trial. Early marketing approval, despite community demands, is unnecessary and may have reduced access because of the end of a compassionate use program, and the high price tag results in restricted coverage and high out-of-pocket costs. Also, the drug's key ingredients are available as a generic and a supplement.
This article offers marketing and public policy researchers and professionals a peek into pharmaceutical marketing from the practitioner's perspective. Through an interview process with eight active pharmaceutical marketing managers and medical doctors, the authors highlight some of the most pressing challenges facing pharmaceutical marketing practitioners today. They identify three key themes: (1) the need to overcome strongly rooted negative patient perceptions of the pharmaceutical industry, (2) the need to communicate overwhelming amounts of complicated information to patients and physicians, and (3) the need to break away from a stale promotional model. The authors briefly summarize the practitioners’ views on each topic, highlight relevant findings from marketing and public policy literatures, and offer avenues for future research to help address these challenges.
Employing a qualitative content analysis of online comments made on YouTube and letters to the editor published in US newspapers, we examine the deployment and neutralization of the evil corporation master frame in debates on two distinct biotechnologies, vaccines and genetically modified organisms. This study builds on previous research by outlining three diagnostic components of the evil corporation master frame: dishonesty, greed, and the contamination of authority. It also finds that supporters of vaccines and genetically modified organisms seek to neutralize the evil corporation master frame through aggressive, defensive, endurance, and redemptive framings. This study provides ideational detail for the ways that controversial biotechnology is constructed. The particularly vexing anti-vaccine movement is not dissimilar from other challenges to mainstream science as disparate movements draw on the same master frame. It also demonstrates how defenses of genetically modified organisms and vaccines tend to reify the anti-corporate stigma that sustains challenges to scientific authority.
Live streaming commerce innovatively combines e-commerce and live streaming, and it is booming. However, like traditional e-commerce, live streaming commerce is facing challenges from “lemon market”. The article applies signaling theory from a perspective of game theory and finds that high-quality sellers can stand out in the market by releasing two kinds of additional signals, which are signals that increase cost and signals that increase risk, and proposes relevant research hypotheses. Then, the researcher designs an experiment to explore how the additional signals affect the audiences’ purchase intention. The data collected shows that additional signals increasing cost can improve audiences’ purchase intension through improving the product quality and sellers’ credibility perceived by the audience while additional signals increasing risk cannot achieve the same effect. At the end, possible explanations for the unproven hypothesis and further research directions are provided.
This retrospective review assesses the frequency of surrogate measures used for the first time vs subsequent times in a cancer setting and the surrogate’s strength of correlation with patient-centered outcomes.
Importance
Since the introduction of the Fast Track designation in 1988, the number of special regulatory programs available for the approval of new drugs and biologics by the US Food and Drug Administration (FDA) has increased, offering the agency flexibility with respect to evidentiary requirements.
Objective
To characterize pivotal efficacy trials supporting the approval of new drugs and biologics during the past 3 decades.
Design, Setting, and Participants
This cross-sectional study included 273 new drugs and biologics approved by the FDA for 339 indications from 1995 to 1997, from 2005 to 2007, and from 2015 to 2017.
Main Outcomes and Measures
Therapeutics were classified by product type and therapeutic area as well as orphan designation and use of special regulatory programs, such as Priority Review and Accelerated Approval. Pivotal trials were characterized by use of randomization, blinding, types of comparators, primary end points, number of treated patients, and trial duration, both individually and aggregated by each indication approval.
Results
A total of 273 new drugs and biologics were approved by the FDA in these 3 periods (107 [39.2%] in 1995-1997; 57 [20.9%] in 2005-2007; and 109 [39.9%] in 2015-2017), representing 339 indications (157 [46.3%], 64 [18.9%], and 118 [34.8%], respectively). The proportion of therapeutic approvals using at least 1 special regulatory program increased (37 [34.6%] in 1995-1997; 33 [57.9%] in 2005-2007; and 70 [64.2%] in 2015-2017), as did indication approvals receiving an orphan designation (20 [12.7%] in 1995-1997; 17 [26.6%] in 2005-2007, and 45 [38.1%] in 2015-2017). The most common therapeutic areas differed over time (infectious disease, 53 [33.8%] in 1995-1997 vs cancer, 32 [27.1%] in 2015-2017). When considering the aggregate pivotal trials supporting each indication approval, the proportion of indications supported by at least 2 pivotal trials decreased (80.6% [95% CI, 72.6%-87.2%] in 1995-1997; 60.3% [95% CI, 47.2%-72.4%] in 2005-2007; and 52.8% [95% CI, 42.9%-62.6%] in 2015-2017; P < .001). The proportion of indications supported by only single-group pivotal trials increased (4.0% [95% CI, 1.3%-9.2%] in 1995-1997; 12.7% [95% CI, 5.6%-23.5%] in 2005-2007; and 17.0% [95% CI, 10.4%-25.5%] in 2015-2017; P = .001), whereas the proportion supported by at least 1 pivotal trial of 6 months’ duration increased (25.8% [95% CI, 18.4%-34.4%] in 1995-1997; 34.9% [95% CI, 23.3%-48.0%] in 2005-2007; and 46.2% [95% CI, 36.5%-56.2%] in 2015-2017; P = .001).
Conclusions and Relevance
In this study, more recent FDA approvals of new drugs and biologics were based on fewer pivotal trials, which, when aggregated by indication, had less rigorous designs but longer trial durations, suggesting an ongoing need for continued evaluation of therapeutic safety and efficacy after approval.
Fewer than half of new drugs have data on their comparative benefits and harms against existing treatment options at the time of regulatory approval in Europe and the USA. Even when active-comparator trials exist, they might not produce meaningful data to inform decisions in clinical practice and health policy. The uncertainty associated with the paucity of well designed active-comparator trials has been compounded by legal and regulatory changes in Europe and the USA that have created a complex mix of expedited programmes aimed at facilitating faster access to new drugs. Comparative evidence generation is even sparser for medical devices. Some have argued that the current process for regulatory approval needs to generate more evidence that is useful for patients, clinicians, and payers in health-care systems. We propose a set of five key principles relevant to the European Medicines Agency, European medical device regulatory agencies, US Food and Drug Administration, as well as payers, that we believe will provide the necessary incentives for pharmaceutical and device companies to generate comparative data on drugs and devices and assure timely availability of evidence that is useful for decision making. First, labelling should routinely inform patients and clinicians whether comparative data exist on new products. Second, regulators should be more selective in their use of programmes that facilitate drug and device approvals on the basis of incomplete benefit and harm data. Third, regulators should encourage the conduct of randomised trials with active comparators. Fourth, regulators should use prospectively designed network meta-analyses based on existing and future randomised trials. Last, payers should use their policy levers and negotiating power to incentivise the generation of comparative evidence on new and existing drugs and devices, for example, by explicitly considering proven added benefit in pricing and payment decisions.
Objective
To investigate pharmaceutical or medical device industry funding of patient groups.
Design
Systematic review with meta-analysis.
Data sources
Ovid Medline, Embase, Web of Science, Scopus, and Google Scholar from inception to January 2018; reference lists of eligible studies and experts in the field.
Eligibility criteria for selecting studies
Observational studies including cross sectional, cohort, case-control, interrupted time series, and before-after studies of patient groups reporting at least one of the following outcomes: prevalence of industry funding; proportion of industry funded patient groups that disclosed information about this funding; and association between industry funding and organisational positions on health and policy issues. Studies were included irrespective of language or publication type.
Review methods
Reviewers carried out duplicate independent data extraction and assessment of study quality. An amended version of the checklist for prevalence studies developed by the Joanna Briggs Institute was used to assess study quality. A DerSimonian-Laird estimate of single proportions with Freeman-Tukey arcsine transformation was used for meta-analyses of prevalence. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to assess the quality of the evidence for each outcome.
Results
26 cross sectional studies met the inclusion criteria. Of these, 15 studies estimated the prevalence of industry funding, which ranged from 20% (12/61) to 83% (86/104). Among patient organisations that received industry funding, 27% (175/642; 95% confidence interval 24% to 31%) disclosed this information on their websites. In submissions to consultations, two studies showed very different disclosure rates (0% and 91%), which appeared to reflect differences in the relevant government agency’s disclosure requirements. Prevalence estimates of organisational policies that govern corporate sponsorship ranged from 2% (2/125) to 64% (175/274). Four studies analysed the relationship between industry funding and organisational positions on a range of highly controversial issues. Industry funded groups generally supported sponsors’ interests.
Conclusion
In general, industry funding of patient groups seems to be common, with prevalence estimates ranging from 20% to 83%. Few patient groups have policies that govern corporate sponsorship. Transparency about corporate funding is also inadequate. Among the few studies that examined associations between industry funding and organisational positions, industry funded groups tended to have positions favourable to the sponsor. Patient groups have an important role in advocacy, education, and research, therefore strategies are needed to prevent biases that could favour the interests of sponsors above those of the public.
Systematic review registration
PROSPERO CRD42017079265.
Background
In situations of unmet medical need or in the interests of public health, expedited approval pathways, including conditional marketing authorisation (CMA) and accelerated assessment (AA), speed up European Medicines Agency (EMA) marketing authorisation recommendations for medicinal products. CMAs are based on incomplete benefit-risk assessment data and authorisation remains conditional until regulator-imposed confirmatory postmarketing measures are fulfilled. For products undergoing AA, complete safety and efficacy data should be available, and postauthorisation measures may include only standard requirements of risk management and pharmacovigilance plans. In the pivotal trials supporting products assessed by expedited pathways, surrogate endpoints reduce drug development time compared with waiting for the intended clinical outcomes. Whether surrogate endpoints supporting products authorised through CMA and AA pathways reliably predict clinical benefits of therapy has not been studied systematically. Our objectives were to determine the extent to which surrogate endpoints are used and to assess whether their validity had been confirmed according to published hierarchies.
Methods and findings
We used European Public Assessment Reports (EPARs) to identify the primary endpoints in the pivotal trials supporting products authorised through CMA or AA pathways during January 1, 2011 to December 31, 2018. We excluded products that were vaccines, topical, reversal, or bleeding prophylactic agents or withdrawn within the study time frame. Where pivotal trials reported surrogate endpoints, we conducted PubMed searches for evidence of validity for predicting clinical outcomes. We used 2 published hierarchies to assess validity level. Surrogates with randomised controlled trials supporting the surrogate-clinical outcome relationship were rated as ‘validated’. Fifty-one products met the inclusion criteria; 26 underwent CMAs, and 25 underwent AAs. Overall, 26 products were for oncology indications, 10 for infections, 8 for genetic disorders, and 7 for other systems disorders. Five products (10%), all AAs, were authorised based on pivotal trials reporting clinical outcomes, and 46 (90%) were authorised based on surrogate endpoints. No studies were identified that validated the surrogate endpoints. Among a total of 49 products with surrogate endpoints reported, most were rated according to the published hierarchies as being ‘reasonably likely’ (n = 30; 61%) or of having ‘biological plausibility’ (n = 46; 94%) to predict clinical outcomes. EPARs did not consistently explain the nature of the pivotal trial endpoints supporting authorisations, whether surrogate endpoints were validated or not, or describe the endpoints to be reported in the confirmatory postmarketing studies. Our study has limitations: we may have overlooked relevant validation studies; the findings apply to 2 expedited pathways and may not be generalisable to products authorised through the standard assessment pathway.
Conclusions
The pivotal trial evidence supporting marketing authorisations for products granted CMA or AA was based dominantly on nonvalidated surrogate endpoints. EPARs and summary product characteristic documents, including patient information leaflets, need to state consistently the nature and limitations of endpoints in pivotal trials supporting expedited authorisations so that prescribers and patients appreciate shortcomings in the evidence about actual clinical benefit. For products supported by nonvalidated surrogate endpoints, postauthorisation measures to confirm clinical benefit need to be imposed by the regulator on the marketing authorisation holders.
Background
In November 2017, the Food and Drug Administration (FDA) approved a version of a second-generation antipsychotic, aripiprazole, embedded with a sensor (Abilify MyCite).
Objective
To systematically review the evidence supporting the FDA’s approval of digital aripiprazole and how that evidence was disseminated in the scientific literature and news reports.
Study selection
Prospective, double-blind, randomised controlled trials (RCTs), non-randomised and non-comparative studies were included if they focused on the use of digital aripiprazole. All scientific publications citing the trials were included if written in English. For the news reports, all languages were included if an English translation was available, and all records that were published after FDA approval were included.
Findings
In the primary evidence search, no RCT comparing digital aripiprazole with a non-digital formulation, other active comparators or placebo was found. Only three non-comparative uncontrolled cohorts were found. No study provided data on remission, quality of life or any efficacy outcome. Fourteen scientific papers were identified that cited the trials and 70 news stories met the inclusion criteria. Almost 80% (11/14) of the scientific papers and three-fourths (52/70) of the news stories conveyed an unsupported impression of benefit.
Conclusions
Regulatory approval for this first-ever digital drug was based on weak evidence, and there was no evidence of better adherence with the digital version of aripiprazole compared with the non-digital version. The possibilities afforded by this technology make room for a new type of evergreening (ie, patenting of older drugs with a sensor as a ‘new invention’). Both the scientific literature and news reports conveyed an unsupported impression of benefit.
Trial registration number
CRD42018089515.
The goal of this paper is to expose the research misconduct of pharmaceutical industry-sponsored clinical trials via three short case studies of corrupted psychiatric trials that were conducted in the United States. We discuss the common elements that enable the misrepre-sentation of clinical trial results including ghostwriting for medical journals, the role of key opinion leaders as co-conspirators with the pharmaceutical industry and the complicity of top medical journals in failing to uphold standards of science and peer review. We conclude that the corruption of industry-sponsored clinical trials is one of the major obstacles facing evidence-based medicine.
Ghost-Managed Medicine by Sergio Sismondo explores a spectral side of medical knowledge, based in pharmaceutical industry tactics and practices. Hidden from the public view, the many invisible hands of the pharmaceutical industry and its agents channel streams of drug information and knowledge from contract research organizations (that extract data from experimental bodies) to publication planners (who produce ghostwritten medical journal articles) to key opinion leaders (who are sent out to educate physicians about drugs) to patient advocacy organizations (who ventriloquize views on diseases, treatments and regulations), and onward. The goal of this ‘assemblage marketing’ is to establish conditions that make specific diagnoses, prescriptions and purchases as obvious and frequent as possible. While staying in the shadows, companies create powerful markets in which increasing numbers of people become sick and the drugs largely sell themselves. Most agents for drug companies aim to tell the truth, but the truths they tell are drawn from streams of knowledge that have been fed, channeled and maintained by the companies at every possible opportunity. Especially because those companies have concentrated influence and narrow interests, consumers and others should be concerned about how epistemic power is distributed – or ‘political economies of knowledge’ – and not just about truth and falsity of medical knowledge. In pharmaceutical companies’ ideal worlds, medical research, education and marketing would be tightly fused. Doctors trying to educate themselves would turn to companies’ agents, such as researchers and educators sponsored to spread particular messages, local sales reps hired to change doctors’ behaviour, or journalists supplied with news stories. Ghost-Managed Medicine shows that the real world of medicine is not very far from the worlds that the companies want to create. Big Pharma’s many invisible hands are busy throughout medicine, and medicine changes as a result.
Pharmaceutical companies have moved beyond just producing medicines to also controlling the knowledge about the products that they make and the diseases they are designed to treat. One of the tools that they employ in this pursuit is the use of experts or people known as Key Opinion Leaders (KOLs). Although KOLs are paid by pharmaceutical companies and their messages are crafted by these companies, they are presented to doctors and the public as independent experts. Some KOLs are “bought” by the companies they work for, but most are sincere in their beliefs about the products that they are speaking about and deny that their role places them in a conflict-of-interest position. One-third of the marketing budget for pharmaceutical companies is spent on KOLs and this spending is justified by the return that companies get. KOLs are intensively trained by firms contracted to drug companies to present the “correct” message. Pharmaceutical companies need to maintain the fiction that KOLs are independent sources of information. However, when KOLs deviate from the message, they are no longer of any use to the company that they are working for. The content of the talks given by KOLs can be scientifically valid, but deceptive at the same time, through a variety of techniques. The message from pharmaceutical companies overwhelms that coming from any other source and KOLs are part of the way that companies control knowledge.