Richard Smith: “This house needs new drugs”—no it doesn’t

richard_smith_2014Last week I took part in a debate at the Cambridge Union on the motion “This house needs new drugs.” The motion was proposed by the chief executive of AstraZeneca, a global pharmaceutical company that is moving its global headquarters to Cambridge and emphasising science over marketing.

The Cambridge Union is designed in part to prepare students for a place in Parliament with the rows of seats in the debating chamber facing each other, despatch boxes from which we spoke, and the president in the speaker’s chair. Before the debate we dined in dinner jackets in a room filled with pictures of past officers of the Union, many of them now familiar faces of politicians. Jacob Rees-Mogg spoke at the Union a few weeks ago, filling the 450 seats with many people left outside. It’s his natural environment. We had only about 120 in our audience, 40 of them employees of AstraZeneca.

One person could probably have won the debate alone for the proposers if she had been able to speak. She was a young, extremely healthy looking student who two years ago had cancer that seemed terminal, but is now cured—with experimental drugs. She grabbed me at the end of the debate to make her point to me, disappointed that I seemed dismissive of new drugs.

The chief executive started the debate by asking how many people in the audience had ever taken pharmaceutical drugs. Remarkably, a handful hadn’t. Drugs can save lives and relieve suffering, and—clearly sensitive on the price issue—he made the point that all drugs eventually become generic: what is now expensive can soon be cheap. Many conditions cannot currently be cured, and there is clearly a need for new drugs. Perhaps over-reaching himself, he talked of meeting a scientist in San Francisco who said that there was no reason we couldn’t live for 300 years. He ended by emphasising how pharmaceutical companies provide jobs, support for science, and income for UK Plc. AstraZeneca, he said, is the biggest private investor in research in the UK.

The two other proposers—the chief executive of a breast cancer charity and the chief executive of a trade association for biotech companies—underlined the points made by the chief executive of AstraZeneca, emphasising that sick patients badly want new treatments and that the industry is vital for Britain’s economy.

Three of us opposed the motion. The first opposer, a cardiologist, said that too many drugs are being prescribed for small benefit with many side effects, many new drugs are extremely expensive, but add little value, and unfortunately the power of the pharmaceutical industry is introducing bias into every part of science from its inception through to publication and promotion.

Believing that debates are more theatrical than intellectual events I was more dramatic than coherent. I started by asking how many people wanted to live 300 years—a very few did. I said that I hoped that they would manage it without being “Sans teeth, sans eyes, sans taste, sans everything” (getting the quote wrong). Cheekily I said that the chief executive’s argument about jobs and income were exactly that used by the tobacco industry.

I couldn’t resist pointing out that having found it increasingly difficult to invent new drugs the pharmaceutical industry has turned to inventing diseases (social phobia, female sexual dysfunction, and baldness as examples). But my core arguments were that we could achieve much more to improve health globally by getting off-patent drugs that everybody agrees are effective to the majority of the world, including some in Britain, who currently don’t get them; combining off-patent drugs with different modes of action into polypills could achieve more than inventing single new drugs; most new drugs for cancer have had very little benefit and yet are hugely expensive; inventing new, inevitably expensive, drugs further divides the rich from the poor; spending money on expensive new drugs takes resources away from education, housing, the environment, and reducing poverty, all of which will do more for health than healthcare. “There are no drugs for health,” I concluded; “health is staying away from all drugs, including alcohol and tobacco, as we can discuss in the bar afterwards.” My weak joke worked in the heated atmosphere.

The Cambridge Union has rules that people in the audience can stand up to make a point or ask a question. Speakers can either accept the speech, eating into their allocated 10 minutes, or decline to take the speech, looking churlish. Perhaps it was because the audience was warming up or because I’d got under the skin of the AstraZeneca employees, but I was interrupted many times, whereas the first two speakers weren’t interrupted at all and the third only once. I accepted the point that I’d overdone it by arguing that drug costs were bankrupting the NHS when they are only 10% of the budget, although if I’d been faster on my feet I would have pointed out that the extraordinary cost of many new drugs might change that. Another interrupter was appalled that a doctor could accept somebody dying when there were drugs that could keep them alive, no matter for a short period.

Between the lead speakers the audience were invited to make speeches, and several students and AstraZeneca employees did so. The quality of these speeches was high and added to rising energy in the chamber.

The third opposer, a pension fund manager, gave the best speech. He began by comparing the three proposers to those sailing on the whaler Pequod, the ship chasing Moby Dick. He compared the AstraZeneca chief executive to the monomaniacal Captain Ahab, and, having just finished reading Moby Dick for the second time, I imagined that he was comparing AstraZeneca’s pursuit of new drugs to the doomed chase of the white whale that leaves only Ishmael alive to tell the tale. But I was wrong: he was making an economic point.

Since the boom time of the 80s the cost of producing a new drug has increased hundredfold—despite many of the tools of the researchers—gene sequencers, computers—having fallen dramatically in price. The fund manager looked for other industries where prices had increased so radically and thought of the oil industry, where oil must be extracted from ever more difficult and remote places, but the real price of producing oil has actually fallen. The only industry he could find where costs had increased so dramatically was whaling—because they killed so many of the whales.

Pointing to me and the cardiologist, the only medical speakers, he said how the pharmaceutical industry’s customers seemed to be dissatisfied. Rising costs and dissatisfied customers is a dangerous combination, and as a fund manager he needs to put his funds where profits are most likely. He worries that pharmaceutical companies’ research departments are losing money. He saw two possible explanations for the rising costs: either we are reaching the end of what can be discovered, or the methods used to make the discoveries are inadequate and inefficient. Unfortunately, he said, if you dismissed one explanation you promoted the other.

The whaling industry died not primarily because of rising costs, but because other sources of oil were found to provide light and power. The aim of pharmaceutical companies is to provide therapeutic benefit, and perhaps the time has come for fund managers to invest in other means of producing therapeutic benefit. Indeed, he concluded, the problem might be with intellectual property—because a “compositional patent” on a drug is the strongest kind of patent. Patents for other means of producing therapeutic are weaker and open to challenge.

At the end of the debate people filed out, just as in Parliament, through the Aye or the Nay doors. People had stated how they would vote at the beginning, and so we could see if people had changed their minds during the debate. The pleasing result was that both sides had “won”: the motion that “This house needs new drugs” was supported by about two thirds of the audience, but the opposers had moved some 15% of the voters away from supporting the motion to opposing it.

The debate was filmed and is available to view here.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS was given a dinner and wine but paid his own fare to Cambridge and back (not very much). AstraZeneca provided support to the Union, but the debate was part of the Union’s routine debates not a corporate event.