Review of Ghost‐Managed Medicine: Big Pharma’s Invisible Hands. Sergio Sismondo, Manchester, UK: Mattering Press, 2018, 231 pp.

This review is collectively authored by Prof. Murphy Halliburton and the advanced undergraduate anthropology students who took his “Anthropology of Pharmaceuticals” class in Spring 2019 at Queens College, CUNY, in which this book was assigned. In the eyes of this audience, this work was highly compelling, readable, and rewarding.

Sergio Sismondo’s Ghost-Managed Medicine is a truly important book that offers a comprehensive resumé of how pharmaceutical companies create and manage professional and popular knowledge about pharmaceuticals and health. This management operates from many angles. Direct-to-consumer advertising and the influence of pharmaceutical company representatives on doctors are significant and will be well known to readers. But just as crucial in Sismondo’s analysis of this “ghost-managed” reality is the role of publication planning, where companies write articles for medical journals and then find doctors who are willing to be listed as the authors before sending them to journals, and the efforts of “key opinion leaders,” who are doctors trained by pharmaceutical companies to educate other doctors on pharmaceutical products and/or the health conditions they address. The book is based on academic research, though it is written like a journalistic exposé akin to other, popular tell-all books about the questionable practices and abuses of the pharmaceutical industry, such as Marcia Angell’s The Truth about the Drug Companies and Ray Moynihan and Alan Cassels’s Selling Sickness.

The chapters of Ghost-Managed Medicine are oriented around key actors involved in shaping medical knowledge and practice, including publication planners, key opinion leaders, drugs reps, and patient advocacy groups. The introductory chapter engages in a brief literature review, highlighting work from Science and Technology Studies as well as contemporary social theory—including Antonio Gramsci’s concepts of hegemony and common sense, which are invoked to help explain how the realities shaped by pharmaceutical companies are perceived and, eventually, taken for granted.

The second chapter examines how clinical trials are conducted and how results are reported. Sismondo observes that often only positive results of trials are published, and he shows how clinical trial work is outsourced to contract research organizations who are “creating downward pressure on the implementation of ethical standards” (p. 56) by, among other things, increasingly looking to India, Eastern Europe, and other places outside North America and Western Europe to conduct clinical trials.

Chapter 3 focuses on publication planning, which is the process whereby companies ghost-write articles and then find doctors who are willing to put their names on them as the authors before they are sent to peer-reviewed journals. In this eye-opening chapter, based on Sismondo’s participant observation at publication planning conferences, we learn that the main purpose of these publications is to push a marketing agenda by promoting awareness of new pharmaceuticals, usually with multiple articles reporting on different phases of clinical trials. Sismondo estimates that 40% of medical journal articles that mention in-patent drugs are ghostwritten in this way. What is striking is the lack of input that the “authors” of these articles have in the process. While they are officially expected to review the article and suggest changes, in many cases the so-called authors do not see the article until it is completed by the corporate authors and has been subjected to several revisions within the publication planning company. They merely sign off their approval of the manuscript by consenting to have themselves listed as authors. Sismondo ultimately does not find this to be a wholly nefarious or fraudulent process. He suggests that the science behind the writing is still sound in many cases, citing the high acceptance rates of these manuscripts. His main concern is the lack of transparency and the influence of corporations in interpreting the results of their trials.

The following chapter continues the exposé of ghostwriting, offering the perspective of those, including journal editors, who defend this practice. Sismondo explains that for many editors “[a]s long as companies follow the ‘rules’ of science and of medical publishing, they are valued contributors” (p. 94). The reader in this chapter is challenged to reconcile this with the more scandalous observation from the first conference on publication planning that Sismondo attended. At that conference, he reports, “there was a debate about whether authors on articles should be allowed to see the data reported in those articles. Yes, a debate, with people arguing on both sides!” (p. 91). He later presents a case in which a physician was prohibited from seeing the data that formed the basis of an article on an osteoporosis drug by Proctor & Gamble that he was asked to author. Because of this, the potential physician author backed out of signing his name to the study. He did later see the data for this study, which confirmed his suspicion that the company had “misleadingly focused” on the portion of the data that was most supportive.

In the latter part of Ghost-Managed Medicine, Sismondo considers the role of key opinion leaders (KOLs) and pharmaceutical representatives who visit doctors to promote their products. KOLs are regularly called upon to give “educational” presentations that physicians attend for continuing medical education (CME) credits. Sismondo claims these KOLs are “possessed, inhabited by the spirits of the companies they’re speaking for, like the original zombies of Haitian folklore” (p. 116). As an example, he explains that KOLs are given PowerPoint slide presentations, which they are not allowed to alter in any way when they present at CME sessions. It is alarming to learn how continuing education for physicians, which is designed to update and deepen doctors’ knowledge of their field, is being co-opted by pharmaceutical companies to educate physicians about their products. More precisely, companies employ KOL physicians to educate other physicians, thereby keeping themselves in the background as a ghostlike presence that is rarely clearly seen but is pulling the strings in creating medical realities.

Pharmaceutical companies also engage patient advocacy organizations and “other vocal creatures” (p. 161) to promote their products. We are told of how Sprout Pharmaceuticals enlisted patient advocates and invoked feminist ideologies to promote their new drug for something called “female sexual dysfunction.” This campaign “put the blame for the lack of female sexual dysfunction drugs on sexism, and put pressure on the FDA to approve flibanserin as a matter of women’s equality” (p. 162). Men had drugs for erectile dysfunction, so why shouldn’t women have a pill for their sexual dysfunction, advocates asked the FDA, leading to the eventual approval of Sprout’s product. Sismondo goes on to focus on gender-oriented promotions by pharma companies, including an example of an effort to identify a new disease known as “vaginal atrophy.” Most of the scientific publications on this alleged ailment are based on research by Novo Nordisk and promotes an estrogen treatment produced by this company.

Overall, Sismondo’s work is an effective and disturbing study of how pharmaceutical companies “systematically influence the production, distribution, and consumption of medical knowledge” (p. 177). If there is a weakness in the text, it is that some of the claims in relation to the scholarly literature on social theory, such as the invocation of Gramsci’s concepts of hegemony and common sense to explain the success of pharmaceutical companies in getting physicians and others to believe and advocate for a constructed reality composed by pharmaceutical company practices, are not followed up later in the text. Nevertheless, Ghost-Managed Medicine effectively packages insights from scholarly research on the pharmaceutical industry for a broad audience. The students in this class found the book to be a compelling page turner and a more exciting read than typical scholarly texts they are assigned for undergraduate courses. At the same time, they extracted as much insight on the sociocultural construction of medical knowledge and practice as they would from other texts in medical anthropology and related fields. Also, on the issue of audience and readability, the book is published by Mattering Press based in Manchester, UK, which, in order to access a broad readership, has made the book available in PDF and e-book formats on their website (matteringpress.org). However, readers are encouraged to purchase the print version to make it possible to continue to make the e-version available for free. Although Mattering Press does not (yet) have the market reach of the major commercial publishers that produced the tell-all books about the pharmaceutical industry mentioned above, it has made available an important book on the power of pharmaceutical industries to shape medical knowledge that has, in this class at least, proven to be a compelling read and teaching tool for college undergraduates.

References Cited

Angell, M. 2004. The Truth about the Drug Companies: How They Deceive Us and What to Do about It. New York: Random House.

Moynihan, R., and A. Cassel. 2006. Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All into Patients. New York: Nation/Perseus.

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