Book Review

Bad Medicine: The Prescription Drug Industry in the Third World

N Engl J Med 1993; 328:217-218January 21, 1993

Article

Bad Medicine: The Prescription Drug Industry in the Third World
By Milton Silverman, Mia Lydecker, and Philip R. Lee. 358 pp. Stanford, Calif., Stanford University Press, 1992. $29.95. ISBN: 0-8047-1669-2

Since 1976 Silverman, Lydecker, and Lee have conducted quadrennial surveys that identify the single-drug entities or fixed-drug combinations marketed in North and South America, Africa, Asia, and Europe and describe the manufacturers' indications and warnings. Chapter 2 of their latest book, Bad Medicine, is largely devoted to describing their most recent survey. The actual findings of their survey are presented, in tabular form and without narrative, in the 68-page appendix. The remainder of the monograph is best described as medical journalism.

The book is actually a series of vignettes, based primarily on the authors' personal experiences with, contributions to, and interpretations of the conflicts among international and national pharmaceutical manufacturing and distributing corporations, national governments, and consumer groups. The protagonists are the authors, the “victims” of the pharmaceutical firms, and a host of international consumer advocates (the late Olle Hannsson is mentioned most often); the antagonists are the pharmaceutical industry and the “corrupt” or “ignorant” government officials who reportedly permit the marketing of costly drugs, often with little therapeutic value and with serious adverse side effects (meaning permanent disability or death) that are not described in the package inserts.

During the past several decades, these authors have published a number of books critical of the pharmaceutical industry, especially firms that market their products in the Third World. Among the authors, Milton Silverman, Ph.D., born in 1910, began his professional career as a journalist and may currently be characterized best as an investigative reporter and science writer. His wife, Mia Lydecker, began her career as a “research associate” almost 30 years ago. Philip Lee, M.D., has had a distinguished career in academic medicine and in government service. The overall writing style and character of their book are journalistic. The references for any given chapter are many, but they are mostly nonscientific publications, newspaper articles, and personal communications. For instance, in the discussions of the 1906 Pure Food and Drug Law, the 1938 amendment to the Food and Drug Law, and the 1962 Kefauver-Harris Amendment, Silverman and Lee's 1974 publication Pills, Profits and Politics is cited; however, the discussion of those laws in Pills, Profits and Politics is unreferenced.

The authors' style can be irritating at times, as in this sentence:

[The Physicians' Desk Reference] is cited here, not because it represents the final word on any drug but because the information it contains is based on material that has been approved by a governmental agency of considerable standing, is accepted by many if not most physicians and drug experts.

In this example, it is worth noting that despite the primary thrust of the authors' previous studies and current survey, in which they specifically address the information provided by manufacturers to patients and clinicians, they fail to identify the Food and Drug Administration as the government agency in question. Furthermore, they fail to describe the FDA review process that is involved in the development of the package insert attached to each unit shipped from the manufacturer and that is also published in the Physicians' Desk Reference (but which is rarely provided to the ultimate user -- the patient).

Chapter 8, “The Drug Swindlers,” is essentially a verbatim duplication of an article previously published by the three authors (International Journal of Health Services 1990;20: 561-72). The only differences consist of minor editorial interventions and the final two paragraphs.

Despite its scientific failings, or possibly because of them, Bad Medicine is good reading for a rainy Saturday afternoon. It is insightful, in parts, and it tells a good story.

Harold M. Ginzburg, M.D., J.D., M.P.H.
United States Public Health Service, Rockville, MD 20857