Ghost-Managed Medicine: Big Pharma’s Invisible Hands by Sergio Sismondo
Sergio Sismondo coined the term “ghost-management” to characterize the broad behind-the-scenes activities of the pharmaceutical industry after he successfully infiltrated publication planning conferences and seminars from 2007 to 2017 as sort of academic spy. His academic espionage mission provided valuable intelligence. In addition to revelations from lawsuits against the pharmaceutical industry and accounts from former ghostwriters turned whistleblowers, Sismondo’s information from within has been crucial to understanding the corruption in the conduct and reporting of industry-sponsored medical research. Ghost-Managed Medicine exposes the conspiracy to conceal the players in the marketing of drugs, including ghostwriters, key opinion leaders, patient advocacy organizations, contract research organizations, publication planners, and even medical journal editors and publishers. The credibility of the claims conveyed by the industry depends on the invisibility of these players.
Publication planning of ghostwritten articles is the bedrock of this scheme. It is conducted by pharmaceutical companies working in conjunction with medical communication firms to plant marketing messages in medical journal articles. Medical communication firms also produce continuing medical education programs, medical conference [End Page E-12] presentations, and lunch and dinner drug talks from the same content that produced the journal articles, all delivered by physicians who have the greatest influence on prescribers, namely, the key opinion leaders or thought leaders.
Sismondo’s main example of the harm done to patients is the case of OxyContin (oxycodone), now infamous for its part in the opioid epidemic in North America which has taken over 200,000 lives (30–31). Sismondo begins his book describing a common scenario in which a patient takes a drug as prescribed by his physician. For prescribing strategies, the physician relies upon an article she read in a medical journal and a presentation at a medical conference. From this point Sismondo describes how the patient and physician’s trust that they are operating rationally is largely misguided because of a system designed to conceal all of the invisible forces of marketing which influenced the information available. But now let us suppose that the patient suffers a serious adverse event or even death as a result of the drug’s side effects. It turns out, as is so common in these situations, that the drug company concealed the adverse event in the articles published in the medical journals and was able to do so because the critical data from the clinical trials is the intellectual property of the company. Neither the ghostwriters nor the nominal “authors” on the articles ever see that data. In the case of OxyContin, one of the influential ghostmanaged medical journal articles was reprinted 10,000 times for distribution to prescribing physicians (34).
One of the most alarming revelations of this book is Sismondo’s discussion of the role of medical journal editors as co-conspirators in the corruption of medicine. Sismondo, who attended meetings of the International Society of Medical Planning Professionals and the International Publication Planning Association, reports that in addition to ghostwriters and medical communication executives, publishers and medical journal editors attended these meetings and gave lectures as stakeholders in the business of publishing the results of industry-sponsored clinical trials. Some medical journal editors gave sales pitches at these meetings, essentially soliciting publication planners to submit ghosted articles to their high-impact journals (91–94). Medical journals in this respect continue to be part of the problem rather than the solution to the problem. Instead of demanding rigorous peer review of submissions and an independent analysis of the data, most editors are eager to publish favorable articles of industry-sponsored trials and rarely publish critical deconstructions of ghostwritten clinical trials. This is due to the simple [End Page E-13] fact that medical journals and their owners have become dependent upon pharmaceutical revenue that comes in the form of advertising, reprint sales and, more recently, fees for open access.
Commenting on the role of ghostwriters in the process, Sismondo writes:
Articles are produced by teams, perhaps no one member of which meets requirements for authorship. In this largely unseen process, pharma companies initiate and fund the planning, research, analysis, writing and placing of articles, and typically maintain control of data throughout. In the corporate production of knowledge, medical writers perform their functions, just as planners, company scientists and statisticians do. Authors are there to give a sheen of legitimacy and independence to articles.(104)
If the reader is struck by the distinction between a writer and an author, a distinction that could only make sense in the bizarre world of pharmaceutical publication planning, it is because the “author” is merely a name purchased in the marketing of drugs, typically a key opinion leader who might or might not have had a role to play in the actual research.
Sismondo’s use of the term “corporate production of knowledge” to describe this process throughout the book is particularly noteworthy. Given that the main problems with the ghost-management of corporate-sponsored medical research are the failures to do rigorous testing, manipulation of the efficacy and safety results and outright deception involved in the reporting of results via the ghostwriting of manuscripts, in what sense does this count as knowledge at all? The word “fraud” comes to mind as a more accurate description and the vast number of successful plaintiffs’ lawsuits has demonstrated the point. But here we have stumbled upon a philosophically-sensitive issue, for even when the process functions at its very best, in an uncorrupted, disinterested, rigorous manner, we might still pause at claiming we have arrived at what we might call “knowledge.” Philosophers of science and epistemologists are well aware of the difficulty. Justification remains elusive. Leaving this aside for the moment, however, there is still a common-sense distinction between honest and dishonest testing, accurate reporting and spin, and scientific integrity and scientific fraud. Honest testing, accurate reporting and scientific integrity are the subject matter of epistemology; dishonest testing, spin and fraud have become the subject matter of a new discipline, agnotology, the study of how the public is kept in the dark intentionally by manipulation and deception.
I would classify Sismondo’s work as agnotology. But having done a superb service to exposing the ghost-management of corporate medical [End Page E-14] research, there is a question of whether he views the corporate production of knowledge as just another social construction, neither better nor worse than non-commercial, academic science. He identifies his approach to these topics from frameworks established in Science and Technology Studies, a field that always treats “knowledge as something constructed, and not just waiting to be found” (10). While he acknowledges that “it is beyond doubt that some of the claims that drug companies make and promote are poorly justified, and some are false in egregious ways” (12), he views the knowledge produced by these companies as within the medical mainstream. The data produced is “of reasonably high quality using the most valued of research tools; they go on to analyse it using standard statistical means, and construct articles that pass the scrutiny of peer reviewers at many of the best medical journals” (12–13). Yet Sismondo also believes there are serious concerns about the practices of pharmaceutical companies since the medical world is influenced by their agenda. He writes: “The flood of knowledge that companies create and distribute is not designed for broad human benefit, but to increase profits” (13).
Rather than describe the pharmaceutical industry’s business as a ‘corporate production of knowledge,’ I would rather Sismondo had said it has the “appearance of science” since, after all, its prime directive is sales. It is the development of blockbusters that should cause the most alarm, for the recent record shows this is where there is most potential for misrepresentation. Physicist Richard Feynman introduced the term “cargo cult science” during his 1974 commencement address at the California Institute of Technology as a means of exposing the façade of commercial science. This refers to the story that certain Pacific Islanders have been known to build mock airports with control towers, runways and mock airplanes with the expectation that planes will land and bring material wealth, although nothing actually functions as an airport. No planes land even though what is created has the form of an airport. So, with regard to the pharmaceutical industry, all the co-conspirators create the appearance of science, i.e., clinical trials, medical journal articles, scientific posters, speakers at conferences, etc., but there is very little that could count as genuine attempt at knowledge.
If passing peer review demonstrates that the corporate production of knowledge qualifies as mainstream medicine, then something is seriously wrong with peer review in medicine. Indeed I believe that Sismondo himself provides the evidence why this is the case although he does not come to this conclusion in his book; the players involved maintain the [End Page E-15] status quo in a win-win situation for themselves except when patients are harmed, the resulting lawsuits reveal the corruption and the industry suffers reputational harm for producing pseudo-science and polluting our scientific record with misrepresentations of the data.
Although I have disagreements with Sismondo over his philosophical perspective, I believe Ghost-Managed Medicine should be read by every physician who prescribes medications and patients who rely on the information conveyed to them by their physicians, as it encourages a healthy skepticism about medicine in a market economy.