What Is Disease Mongering?

Twenty Years After the Corporate Sponsored Creation of Disease

Author’s Note

This essay was inspired by Michael Bryan’s brilliant recent essay “The Cult of Modern Medical Expertise,” which sent me back to the 2006 PLoS Medicine theme issue on disease mongering that anchors much of what follows.

In April 2006, PLoS Medicine published a theme issue titled “Disease Mongering.” Its contributors were serious critics: a psychiatrist, a general practitioner, a health policy academic, a medical anthropologist, a clinical psychologist, an investigative journalist. They named the machinery. They documented the funding. They exposed leaked internal documents. They warned publicly about what was coming.

The coming years exceeded their warnings. Twenty years later, the machinery they mapped runs at a scale they could not have measured.

This essay walks through what they found, updates it with what the intervening two decades have added, and then examines the wall those critics could not see past. That wall is the assumption underneath their critique: that disease mongering exaggerates a real underlying disease, when the disease categories themselves are constructions of the same paradigm that produces the mongering. The essay ends where the earlier work in this series has been building toward for some time, at the point where medicine’s normal operation and its most cynical expression turn out to be the same thing.

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In 2003, a market intelligence firm called Reuters Business Insight published a report for pharmaceutical industry executives titled Healthcare: The Lifestyle Drugs Outlook to 2008. The report contained a single sentence that told the industry what its future would look like: “The coming years will bear greater witness to the corporate sponsored creation of disease.”¹

The sentence was not a warning. It was a strategic outlook, written for shareholders and executives who needed to know where growth would come from. It named the mechanism without embarrassment because the audience was already inside the tent. Twenty-three years later, the prediction has been surpassed at every level its authors could have measured. Prescription volumes have climbed decade after decade. Diagnostic categories have multiplied. The age at which children are first medicated has fallen year by year. The fraction of ordinary human variation now labeled as pathology grows steadily. The report described a plan. The plan executed.

The name for this plan is disease mongering. The term was coined by the medical writer Lynn Payer in 1992 and defined by Ray Moynihan, Iona Heath, and David Henry in a 2002 BMJ paper as “the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments.”² The 2006 PLoS Medicine theme issue that followed remains the most complete public documentation of the machinery: how it operates, who runs it, and what it produces. This essay walks through the seven gears the PLoS authors identified, updates each with what the last two decades have added, and then examines the wall those authors could not see past.

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Gear One: The Manufacturers

The machinery begins with money. Pharmaceutical companies spend more on marketing than on research and development, and have done so for at least three decades.³ The revenue is generated not by curing disease but by managing it. A cured patient is a lost customer. A managed patient is an annuity. This is not a slur; it is the observable structure of the industry’s income statements.

Joel Lexchin’s 2006 PLoS essay documented the case of Viagra. Pfizer had a drug that was moderately effective for erection problems associated with diabetes, spinal cord damage, and prostate surgery, producing perhaps 50 to 60 percent success in achieving intercourse.⁴ Sold to that population, Viagra would have been a modest product. The commercial problem was that the eligible population was too small. The solution was to redefine erectile dysfunction so that far more men would qualify.

Pfizer’s website stated, without citation, that “more than half of all men over 40 have difficulties getting or maintaining an erection.” The figure came from the Massachusetts Male Aging Study, which had extrapolated from a sample of men aged 40 to 70 near Boston in the late 1980s.⁵ Out of thirteen published prevalence studies available by 1998, the Massachusetts figures were among the highest. A Dutch survey found that only 1 percent of men aged 50 to 65 had complete inability to achieve an erection. A Japanese study of men aged 40 to 79 found that only 20 percent reported more than mild concern about sexual function.⁶ Pfizer selected the highest available number and put it on the front page of the marketing.

Then came the redefinition of the target demographic. Pfizer’s initial American television campaign used former presidential candidate Bob Dole, born 1923. By 2003, the company had shifted to 39-year-old baseball player Rafael Palmeiro.⁷ Between 1998 and 2002, the group with the largest increase in Viagra use was men aged 18 to 45, and only one-third of these men had any identifiable medical reason for needing the drug.⁸ The condition had been transformed from a medical problem affecting a small population into a lifestyle enhancement available to any man who could obtain a prescription. Pfizer spent over 303 million dollars in direct-to-consumer advertising on Viagra between 1999 and 2001 alone.⁹ The money drove where money always drives, toward expansion.

Gear Two: The Marketers

In 2002, Ray Moynihan interviewed the local managing director of Roche in Australia, Fred Nadjarian, about the company’s marketing of the antidepressant moclobemide for social phobia. Roche had previously issued press releases claiming that more than one million Australians had an undiagnosed psychiatric disorder called social phobia. Government figures at the time put the number closer to 370,000. Nadjarian conceded the point directly: “A lot of disease estimates are blown out of all proportion... The marketing people always beat these things up.”¹⁰

Nadjarian was speaking of his own company. He was not a critic outside the industry. He was the managing director of the manufacturer that had run the campaign. His admission describes what happens inside pharmaceutical marketing as a matter of course: the marketing people always beat these things up. Not sometimes. Not occasionally. Always. The prevalence figures that reach the newspapers and the medical journals do not come from epidemiology. They come from strategy.

The strategy is written down. Moynihan, Heath, and Henry obtained a confidential internal document leaked from a medical communications company called In Vivo Communications, describing a three-year “medical education programme” for GlaxoSmithKline’s irritable bowel syndrome drug Lotronex.¹¹ The plan stated its objective in language a competent reader cannot misinterpret: “IBS must be established in the minds of doctors as a significant and discrete disease state.” Patients “need to be convinced that IBS is a common and recognised medical disorder.” The plan specified the creation of an Advisory Board of key opinion leaders from each Australian state, whose role was to advise the corporate sponsors on “current opinion in gastroenterology and on opportunities for shaping it.” Pre-launch newsletters were to “establish the market” and convince the “specialist market” that irritable bowel syndrome was “a serious and credible disease.” Advertorials would appear in leading medical magazines featuring interviews with advisory board members, because “the imprimatur of [board] members is invaluable in reassuring [general practitioners] that the material they receive is clinically valid.”¹²

The document explicitly stipulated that all publications and manuscripts had to be approved by the drug company’s marketing, medical, and legal departments. What was being purchased was not medical education. It was the manufacture of a disease state in the minds of doctors and patients, coordinated across professional bodies, patient groups, medical journals, and the general press.

Kalman Applbaum, a medical anthropologist writing in the same PLoS issue, made the point in structural terms. Pharmaceutical marketing had incorporated actors previously outside the drug distribution channel, including physicians, academic opinion leaders, patient advocacy groups, nongovernmental organizations, public health bodies, and ethics overseers, as active proponents of exchange.¹³ The distribution channel had absorbed the checks on the distribution channel. There was no longer any position outside the market from which the market could be evaluated.

A 2001 Pharmaceutical Marketing trade guide put it more directly to its intended readers. Drug marketers may need to “initiate a review of the whole way in which a particular disease is managed.”¹⁴ The strategy is not to sell a drug for a disease. The strategy is to sell the disease itself, and let the drug follow.

Gear Three: The Key Opinion Leaders

Every manufactured disease needs experts. The In Vivo document called them KOLs, key opinion leaders. Their function is to legitimize the marketing plan by lending it their credentials. The reader is meant to see them as independent authorities. Inside the industry, they are known as something else.

During Roche’s promotion of moclobemide for social phobia in the late 1990s, the company worked with what it publicly called “ostensibly independent medical specialists.” One of these specialists was described internally, by a Roche public relations agent, as “Moclobemide Man.”¹⁵ The phrase captures the entire arrangement in three words. From the perspective of the patient, the doctor, and the newspaper reporter, he was an eminent expert whose opinion on social phobia and its treatment merited public attention. From the perspective of the people paying him, he was branded merchandise.

Leonore Tiefer’s account of female sexual dysfunction shows the mechanism at its purest. In May 1997, before there was any drug for a female sexual condition, a group of pharmaceutical companies sponsored an invitation-only conference at Cape Cod titled “Sexual Function Assessment in Clinical Trials.”¹⁶ The companies bypassed existing sexology organizations and their annual conferences. They convened their own event and invited the sexologists they wanted to work with. Papers from the meeting were published in a special supplement of the International Journal of Impotence Research. The supplement’s introduction acknowledged the situation plainly: “In the area of female sexual dysfunction, there is widespread lack of agreement about the definition of sexual dysfunction, its pathophysiology or clinical manifestations, or the optimal approach for research or clinical assessment.”¹⁷ There was no agreed condition. There was, however, a conference, a supplement, and a set of consultancy relationships. From that base, the condition was constructed.

Irwin Goldstein, an erectile dysfunction researcher at Boston University, opened the first Women’s Sexual Health clinic in 1998, hosted the first FSD conference in 1999, and became editor of the Journal of Sexual Medicine launched in 2004.¹⁸ Jennifer Berman, his urology trainee, opened a UCLA clinic and became the female face of the condition, appearing on Oprah and in innumerable women’s magazines.¹⁹ Around this small group of urologists, the pharmaceutical industry constructed a professional infrastructure of journal, society, annual meetings, and textbooks for a condition that could not be defined.

David Healy’s disclosures at the foot of his own bipolar disorder essay illustrate the pattern from a different angle. Healy noted that he had been “speaker, consultant, or clinical trialist for Lilly, Janssen, SmithKline Beecham, Pfizer, Astra-Zeneca, Lorex-Synthelabo, Lundbeck, Organon, Pierre-Fabre, Roche, and Sanofi.”²⁰ Healy is a credible critic, and his declaration is a model of transparency. The point is that this list of consultancies is unremarkable for a senior figure in academic psychiatry. The compromised expert is not a bad apple. The compromised expert is the standard configuration.

Gear Four: The Disease-Definition Bodies

The deepest gear defines what counts as a disease at all. Once the condition is inside the Diagnostic and Statistical Manual of Mental Disorders or listed in ICD codes or set by a World Health Organization threshold, the machinery downstream runs almost automatically. The definition drives the prescription, and the definition is written by panels riddled with the same conflicts.

Bipolar disorder entered the DSM in 1980. At that time, the criteria for bipolar I disorder, classic manic-depressive illness, required an episode of hospitalization for mania.²¹ It was a serious condition, uncommon, and treated primarily with lithium. Then, over the following two decades, the community-based categories were added: bipolar II, bipolar disorder not otherwise specified, cyclothymia. With each addition, the estimated prevalence rose. It moved from 0.1 percent of the population having bipolar I disorder to 5 percent or more once the community disorders were included.²² The underlying incidence of the original condition had not changed. What changed was the definition.

The word “mood stabilizer” barely existed before 1995. Healy tracked its appearance in medical article titles: near zero in the early 1990s, then rising to more than a hundred titles per year by 2001, and around 140 by 2003.²³ The concept had been invented to give a pharmacological rationale, the “quenching” of the kindling effect on future episodes, that would justify long-term prescription of anticonvulsants for a condition whose diagnostic criteria were being simultaneously loosened. Repeated reviews of the academic psychiatric literature could not produce consensus on what the term “mood stabilizer” actually meant.²⁴ The absence of a definition was not a defect of the marketing. It was the marketing’s condition of possibility.

The osteoporosis case shows the same mechanism outside psychiatry. The 1994 World Health Organization definition set the bone mineral density of young white women as “normal” and judged the bones of older women against this standard. The WHO study group meeting that produced this definition was funded in part by three pharmaceutical companies.²⁵ A menopausal woman with bones normal for her age was reclassified as diseased because her bones were compared to the bones of women thirty years younger. The definition of the disease produced, by construction, a large population of patients who required lifetime pharmaceutical treatment. The definition preceded the disease.

Iona Heath’s essay in the PLoS issue described this as the medicalization of risk factors, the recasting of biological variables distributed across a continuum as pathological states requiring intervention.²⁶ Blood pressure and lipid thresholds are lowered until the most recent European Society of Cardiology guidelines can identify 76 percent of the adult population of a Norwegian county as being at “increased risk.”²⁷ Each threshold reduction is presented as evidence-based prevention. Each generates a new patient population. Anyone taking preventive medication becomes, by definition, a patient. The definition is the disease.

Gear Five: The Manufactured Consensus

Once the definition exists and the KOLs are on retainer, the appearance of grassroots demand can be assembled. Patient advocacy groups perform this function. They provide the human face of the disease, testify at regulatory hearings, appear in the news media as victims, and lobby for insurance coverage. Many of them began as sincere organizations. Their subsequent funding trajectory is the point.

CHADD, Children and Adults with Attention Deficit/Hyperactivity Disorder, is the pre-eminent American advocacy group for people with the ADHD label. In the 2004–2005 fiscal year, 22 percent of CHADD’s revenue came from the pharmaceutical industry.²⁸ CHADD undertakes educational programs for teachers, acts as lead editorial consultant on ADHD content in school health publications, and produces materials sponsored by the manufacturers of the drugs prescribed for the condition it advocates for.²⁹

Impotence Australia was founded with an Australian $200,000 grant from Pfizer just as Viagra was being marketed. Its executive officer told the press: “I could understand that people may have a feeling that this is a front for Pfizer.”³⁰ The National Attention Deficit Disorder Information and Support Service in the UK, set up as a charity with backing from the Department of Health, received funding from Janssen-Cilag, UCB Pharma, and Eli Lilly according to reports in the British press.³¹ The Obsessive Compulsive and Anxiety Disorders Foundation of Victoria worked with Roche during Roche’s promotion of moclobemide for social phobia. The foundation’s chief at the time described the relationship directly: “Roche is putting a lot of money into promoting social phobia... It was a vehicle to raise awareness with the media too.”³²

The pattern is not universal. Some advocacy groups have refused industry funding and remained independent, and Health Action International has publicly warned other groups about the risks.³³ But the compromised groups vastly outnumber the independent ones, and the compromised groups are the ones the media call for comment when a new condition needs a face. The result is a manufactured consensus. The industry-funded groups say what their funders want said, and the mainstream press reports it as the voice of patients.

Gear Six: The Amplification

The manufactured consensus reaches the general public through journalism. Some of this journalism is directly placed by public relations firms. Some is the work of medical writers who genuinely believe what they are writing. The distinction, from a mechanical standpoint, does not matter. The output is the same.

The Merck hair-loss campaign illustrates direct placement. Around the time Merck’s finasteride was approved in Australia, leading newspapers featured new coverage of the emotional trauma associated with hair loss. The global public relations firm Edelman orchestrated the coverage. An article in The Australian newspaper cited a new study finding that a third of all men experienced hair loss, referenced concerned expert commentary, and reported the establishment of an International Hair Study Institute.³⁴ The study and the institute were both funded by Merck. The experts had been supplied by Edelman. None of this was disclosed in the article, though it was available in Edelman’s own publicity materials.

The bipolar disorder expansion illustrates the medical journalism variant. In August 2002, TIME magazine put nine-year-old Ian Palmer on its American cover under the title “Young and Bipolar,” with the strapline “why are so many kids being diagnosed with the disorder, once known as manic-depression?”³⁵ The book The Bipolar Child, published in 2000, sold 70,000 hardback copies in six months.³⁶ A newspaper article that year described how a two-year-old girl named Heather in Tarrant County, Texas, whose mother had read the book, became the youngest child in the county to receive a bipolar diagnosis.³⁷ Massachusetts General Hospital ran clinical trials of Risperdal and Zyprexa on children with a mean age of four years old.³⁸ The hospital recruited trial participants by running its own television advertisements featuring clinicians and parents alerting other parents to the possibility that difficult and aggressive behavior in children aged four and up might stem from bipolar disorder. The advertisements were the point of entry. The trials produced the citations. The citations legitimized the diagnostic expansion. The pediatric population that would be prescribed antipsychotics for behavioral difficulty grew accordingly.

The medical journal literature functions as an amplification apparatus in its own right. Substantial fractions of published articles are ghostwritten by pharmaceutical industry contractors, industry-funded studies consistently produce more favorable conclusions than independently funded ones, and the journals themselves depend heavily on reprint revenue from positive drug studies.³⁹ The mechanism is not that individual editors are corrupt. The mechanism is that the incentive gradients across the entire literature slope in one direction.

Gear Seven: The Frontline

The machine ends at delivery, the point where the diagnosis lands on a real child in a real classroom, or a real patient in a real consulting room. This is where every previous gear becomes physical, and the frontline actors do not know what has been done to them.

Christine Phillips documented in the PLoS issue how teachers were absorbed into the ADHD diagnostic process. The DSM-IV accorded teachers a formal role in diagnosis through specialized assessment instruments such as the Conners Teacher’s Rating Scale. Teachers frequently agreed to administer psychostimulant medication during the school day.⁴⁰ In a study of 491 physicians in Washington DC, almost half of the ADHD diagnoses had been suggested first by teachers.⁴¹ Novartis, the manufacturer of Ritalin, established a website separate from its own industry site with specific resources for teachers, including a page titled “If parents ask...” which suggested responses teachers might make to concerned parents. The page told teachers to “make it clear to them that it is important for them, and their child, to understand and follow the doctor’s medical advice about medication and other therapies for ADHD.”⁴² In 1997, Novartis collaborated with the National Association of School Nurses in the US on a nationwide campaign that supplied 11,000 school nurses with a resource kit on ADHD.⁴³ The teacher who identifies the disruptive child in her classroom, the school nurse who administers the midday dose, the parent who reads the CHADD pamphlet: none of them see the KOL, the marketer, the manufacturer, the ghostwriter, the funded advocacy group. They see a child who cannot sit still and a professional consensus that says the child has a disorder.

The prescribing physician stands in the same position. Iona Heath’s 2006 essay described the situation from inside general practice. Doctors receive their continuing education from pharmaceutical company representatives. In the study she cited, 49 percent of doctors used pharmaceutical sales representative information monthly, 31 percent weekly, and 5 percent daily.⁴⁴ The pharmaceutical industry spends millions of dollars supporting the “education” of doctors because it is in its economic interest to do so. If prescribing activities and industry profits were not affected by this support, it would not be offered. The physician who writes the prescription is not a co-conspirator. The physician is the last actor in a chain of decisions made elsewhere, by parties whose interests do not align with the patient’s, and whose fingerprints have been carefully removed from the material the physician reads.

The seven gears form a complete apparatus. Money enters at Gear One and produces marketing strategy at Gear Two, expert legitimation at Gear Three, diagnostic categorization at Gear Four, manufactured demand at Gear Five, and public and professional amplification at Gear Six. At Gear Seven, the child receives the label and the pill. Each gear turns because the previous gear turns. The apparatus was not designed by a single conspirator. It was assembled over decades by ordinary commercial logic operating on a captured knowledge production system.

The Wall

The 2006 PLoS authors described this machinery with more care and specificity than anyone before or since. They were serious critics. They named the strategy, documented the funding, exposed the leaked documents, and quantified the growth in prescriptions and diagnoses. Their essays remain the essential public record.

Each of them stopped at the same wall.

Moynihan and Henry defined disease mongering as widening “the boundaries of illness.”⁴⁵ Heath described it as “the pathologising of normal biological or social variation.”⁴⁶ Healy critiqued bipolar disorder’s expansion from a condition of hospitalization to a community disorder covering 5 percent of the population.⁴⁷ Lexchin distinguished Viagra’s legitimate use for organic causes such as diabetes and spinal cord damage from its illegitimate expansion into lifestyle enhancement.⁴⁸ Tiefer distinguished healthy sexual function from medical disorder.⁴⁹ In each case, the critique presupposed a real disease sitting underneath the fabrication, a genuine bipolar I, a genuine erection problem with an organic cause, a genuine social phobia, a genuine female sexual condition with a physical basis, being merely stretched or exaggerated by the market. The mongering was framed as inflation of the boundary. The boundary itself was accepted as real.

The boundary is not real. The categories the PLoS critics defended as legitimate are constructed by the same mechanism they were exposing.

There is a reason the critics stopped at the wall, and the reason is not lack of intelligence or courage. In 1910, Abraham Flexner produced a report on American medical education, funded by the Carnegie and Rockefeller foundations. Within a generation, that report reduced American medical schools from 162 to 66. The schools that survived taught allopathic medicine grounded in germ theory. The schools that closed had taught homeopathy, naturopathy, eclectic medicine, and various terrain-based approaches. The reduction was not principally an argument. It was a transfer of funding and licensure that removed the institutional basis for competing paradigms. By mid-century, a physician trained in the United States or Britain could complete an entire career without encountering Béchamp, without hearing the word terrain used in a technical sense, without being exposed to any framework in which disease might be understood as anything other than the invasion or misregulation of a body by external agents or by its own defensive mechanisms.

By 2006, that isolation was total. Healy trained in British psychiatry in the 1980s. Heath came out of Cambridge and London general practice. Lexchin came out of Toronto public health. Tiefer had spent her career in NYU psychiatry. Applbaum trained as a medical anthropologist within a discipline whose founding assumptions borrowed the medical categories they otherwise critiqued. None of them had been given, as part of their formation, a framework from which to see disease categories as constructions rather than discoveries. Their training was itself the product of the apparatus they were critiquing. The wall was invisible to them because they were made by the processes that made it.

The demonstration that they were inside the wall is available in their own material.

Healy defended bipolar I against the pediatric and community expansions. Bipolar I, in his framing, was manic-depressive illness with hospitalization for mania. But mania as a diagnostic category was constructed by Emil Kraepelin at the turn of the 20th century. Before Kraepelin, the cluster of experiences now grouped under manic-depressive illness had various names and no single boundary. The hospitalization criterion added by DSM-III in 1980 was not a discovery of a biological threshold. It was a committee decision about where to draw the line. Healy defends a construction of the late 20th century as though it were a natural kind.

Lexchin defended Viagra’s use for erection problems associated with diabetes or spinal cord damage as legitimate. But a man with spinal cord damage has spinal cord damage. His difficulty getting an erection is one symptom of an injury that has many symptoms. Calling this “erectile dysfunction” and treating it with a phosphodiesterase inhibitor is already the paradigm at work. The symptom is real. The disease category is imposed. What Lexchin defends as the medical baseline is itself a marketing construction, more sedately packaged than the campaign he critiques.

Tiefer’s case is the most explicit. She spent an entire essay documenting that female sexual dysfunction was invented at Cape Cod in 1997. There was no genuine underlying condition being exaggerated. There was only the invention. Even so, the framing of her essay assumed a legitimate baseline of “sexual difficulty” against which the invention could be measured. The critique operated at the second-order level while the first-order fabrication went unnamed.

The pattern repeats across every case. Bipolar. Erectile dysfunction. Social phobia. Osteoporosis. Female sexual dysfunction. The critics identified the expansion. They could not identify the original as itself an expansion, because they had no framework in which the original could be anything other than a discovery.

They described a symptom of the paradigm. The paradigm produced the disease categories.

The claim that the categories were manufactured from the start rather than merely exaggerated requires more development than this essay can carry. The terrain-based framework from which the claim proceeds is worked out at length in earlier essays: Symptoms as Adaptations, Four Causes, Seventy Thousand Diseases, and Extraction: The Middle Class as Colony. What follows here is not the argument in full. It is the point at which the argument becomes visible from inside the disease mongering literature itself.

Thomas Cowan, quoting Florence Nightingale, states the point directly: “The specific disease doctrine is the grand refuge of weak, uncultured, unstable minds, such as now rule in the medical profession. There are no specific diseases; there are specific disease conditions.”⁵⁰ The distinction is precise. A woman’s joints swell. That is a specific disease condition, real, observable, and demanding attention. Calling it “rheumatoid arthritis” is a construction. The label groups her joints with millions of other people’s joints on the basis of surface similarity, hides the specific causes producing the swelling in her particular body, and delivers her to a standardized protocol of drugs that will progress her from acute to chronic disease along Herbert Shelton’s mechanism. The label is the entry point to extraction. Removing the label does not deny her experience. It denies the machine.

Once the label is understood as a construction rather than a discovery, disease mongering ceases to be an aberration of medicine. It becomes visible as medicine’s normal operation. Every disease category is a candidate for the same treatment as bipolar disorder or erectile dysfunction or female sexual dysfunction, because every disease category was manufactured by the same paradigm. Germ theory needs pathogens because pathogens are patentable and terrain interventions are not. The military metaphor of immunity needs diseases against which drugs can be sold to modulate it. The concept of “genetic predisposition” needs a genome to blame so that the four causes of disease, toxic exposure, nutritional depletion, electromagnetic radiation, and psychological strain, remain outside the frame of investigation. The categories exist to justify the interventions. The interventions produce the wealth transfer. The wealth transfer is what medicine is now for.

This is what the PLoS critics could not say. They were doctors and journalists critiquing their own profession from the inside, and to say the categories were fabrications was to lose the platform from which they were speaking. They did the work available to them, and that work was substantial and honorable. The sentence they could not write is the one their evidence supports: there is no real disease being mongered, because there was no real disease to begin with. The machinery does not exaggerate a boundary. It manufactures the appearance of a boundary where none exists.

What the Prediction Built

In 2003, Reuters Business Insight told pharmaceutical executives that the coming years would bear greater witness to the corporate sponsored creation of disease.

The prediction was made because the pattern was already unmistakable. It produced, in the years that followed, the four-year-olds at Massachusetts General Hospital enrolled in Risperdal trials, recruited through television advertisements aimed at their parents. It produced a childhood pharmaceutical injection schedule that has expanded relentlessly, delivered before informed consent is even possible, correlating with a chronic illness prevalence in American children that continues to climb with each cohort measured. It produced a healthcare economy that consumes close to 20 percent of United States GDP while the population it serves grows measurably sicker each decade.

Then it produced the injection program of 2020 and 2021. Billions of doses of experimental products, delivered to healthy populations over eighteen months, on the strength of a category labeled “pandemic” that was itself manufactured by the same apparatus the 2006 critics had been mapping. The scale of that program exceeded anything the disease mongering literature had described. It was not, however, a departure from what that literature described. It was the seven gears running at maximum output, on a target population that included the entire species. The 2006 critics had believed themselves to be documenting excesses. They were documenting the operating principle.

The machinery ran because the wall held. The disease categories were still assumed real. The regulatory bodies were still assumed independent. The medical journals were still assumed to publish knowledge rather than promotion. Each of these assumptions had been demonstrably false for decades before 2020. The apparatus depended on their continuing to hold in public consciousness. Regulatory capture and epistemic capture do not purchase the ability to deceive. They purchase the ability to be believed while every element of the deception is visible.

The Reuters analyst who wrote the 2003 sentence was describing an apparatus that had been operating for at least a decade before he wrote. What Heather’s mother had read three years earlier was an early product of that apparatus. A book teaching her to see her toddler’s tantrums as bipolar disorder. A diagnosis waiting at the end of the referral. A prescription billed to insurance. A lifetime of managed illness ahead. Reuters was writing to executives who needed the truth so they could allocate more capital to what was already working. The prediction and the child are the same event, separated by the apparatus that connects one to the other. The machine ran to schedule. It is still running now.

How to Explain This to a Six-Year-Old

Imagine a boy who owns a lemonade stand. He wants to sell lots of lemonade. But the children in his town already drink water and nobody feels thirsty, so nobody buys.

The boy has an idea. He starts telling everyone that plain water is dangerous. He says that people who only drink water have a special sickness called “thirst disease.” He gets some kids who look important to agree with him. He puts posters up around town. He asks the teachers at school to check the children for thirst disease. He starts a club for parents whose children have thirst disease, and gives them free hats. He gives a friendly newspaper reporter a story about a very sad girl who had thirst disease and now feels better because she drinks his lemonade.

Soon everybody in town believes that thirst disease is real. Parents worry about it. Doctors write it down on charts. Children get lined up at school to be checked for it. Everyone starts buying the boy’s lemonade because they are afraid of thirst disease. The boy makes so much money he opens more stands.

The trick is that thirst disease was never a real sickness. The boy made it up so he could sell more lemonade. That is disease mongering. Making up a sickness, or making a small feeling seem like a big sickness, so that people will buy something you want to sell them.

Here is the harder part. Some grown-ups noticed what the boy was doing. They wrote important papers about it. They said the boy was making thirst disease sound worse than it really is. But they still thought there was a real thirst disease underneath, just a smaller one. What they missed is that the boy made up thirst disease from nothing. There was never any real version of it to make smaller or bigger. The whole thing was invented so he could sell lemonade.

That is what has happened to a lot of the sicknesses that grown-ups now take medicine for.

In Print

Five of my books are now available as paperbacks, printed to order through Lulu and shipped worldwide. The Unvaccinated lays out the completely unvaccinated as a comparison group across twenty chapters and five appendices — as far as I know, the only book of its kind. Medicalized Motherhood follows a woman through 123 documented interventions from teenage pill to postpartum discharge. Drilling for Profit argues that cavities, gum disease, and crooked teeth are a dietary problem the dental profession treats surgically. What Your Vet Can’t Tell You applies the same critique to pets — food, vaccines, and a profession trained by the industries whose products cause the harm. Escape from Psychiatry documents the fabrication of the DSM, the collapse of the serotonin hypothesis, and the specific damage done by every major psychiatric drug class.

A physical book reaches the person a Substack post never will — the sceptical relative, the friend who won’t click a link but might open a book, the visitor whose eye lands on a coffee table. Buy one to keep, and one to give away.

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Notes

1. Coe J. (2003). Healthcare: The Lifestyle Drugs Outlook to 2008, Unlocking New Value in Well-being. London: Reuters Business Insight, 243 p. Quoted in Moynihan R, Henry D. (2006). “The Fight against Disease Mongering: Generating Knowledge for Action.” PLoS Medicine 3(4): e191.

2. Moynihan R, Heath I, Henry D. (2002). “Selling Sickness: The Pharmaceutical Industry and Disease Mongering.” BMJ 324: 886–891.

3. Angell M. (2004). “Over and Above: Excess in the Pharmaceutical Industry.” CMAJ 171: 1451. See also Applbaum K. (2006). “Pharmaceutical Marketing and the Invention of the Medical Consumer.” PLoS Medicine 3(4): e189.

4. Lexchin J. (2006). “Bigger and Better: How Pfizer Redefined Erectile Dysfunction.” PLoS Medicine 3(4): e132, citing Burls A, Clark W, Gold L, Simpson S. (1998), “Sildenafil: An oral drug for the treatment of male erectile dysfunction,” Report 12, West Midlands Health Technology Assessment Collaboration.

5. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. (1994). “Impotence and its medical and psychological correlates: Results of the Massachusetts Male Aging Study.” J Urol 151: 54–61.

6. Blanker MH, Bosch JLHR, Groeneveld FPMJ, Bohnen AM, Prins A, et al. (2001). “Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old.” Urology 57: 763–768; Masumori N, Tsukamoto T, Kumamoto Y, Panser LA, Rhodes T, et al. (1999). “Decline of sexual function with age in Japanese men compared with American men.” Urology 54: 335–345.

7. Warren J. (2003, December 14). “In an oversexed age, more guys take a pill.” New York Times, cited in Lexchin (2006).

8. Delate T, Simmons VA, Motheral BR. (2004). “Patterns of use of sildenafil among commercially insured adults in the United States: 1998–2002.” Int J Impot Res 16: 313–318.

9. Findlay S. (2000). Prescription Drugs and Mass Media Advertising. Research brief. Washington DC: National Institute for Health Care Management.

10. Nadjarian F., managing director of Roche Australia, quoted in Moynihan R, Heath I, Henry D. (2002). “Selling Sickness.” BMJ 324: 886–891.

11. Confidential draft document from In Vivo Communications, quoted and analyzed in Moynihan, Heath, and Henry (2002).

12. Ibid.

13. Applbaum K. (2006), op. cit.

14. Cook J. (2001). “Practical Guide to Medical Education.” Pharmaceutical Marketing 6: 14–22.

15. “Moclobemide Man” attribution: personal communication from Roche public relations agent, 1998, quoted in Moynihan R. (1998). Too Much Medicine? Sydney: ABC Books, pp. 137–168, cited in Moynihan, Heath, and Henry (2002).

16. Rosen RC, O’Leary MP. (1997). Proceedings of The Cape Cod Conference: Sexual Function Assessment in Clinical Trials. Int J Impot Res 10 (Suppl 2): S1–S140.

17. Ibid., p. S1.

18. Tiefer L. (2006). “Female Sexual Dysfunction: A Case Study of Disease Mongering and Activist Resistance.” PLoS Medicine 3(4): e178.

19. Berman J, Berman L, Bumiller E. (2001). For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life. New York: Henry Holt.

20. Healy D. (2006). “The Latest Mania: Selling Bipolar Disorder.” PLoS Medicine 3(4): e185, competing interests declaration.

21. Harris M, Chandran S, Chakroborty N, Healy D. (2005). “The impact of mood stabilizers on bipolar disorder: the 1890s and 1990s compared.” Hist Psychiatry 16: 423–434.

22. Angst J. (1998). “The emerging epidemiology of hypomania and bipolar II disorder.” J Affect Disord 50: 163–173, cited in Healy (2006).

23. Healy D. (2006), op. cit., Figure 1.

24. Sachs G. (1996). “Bipolar mood disorder: Practical strategies for acute and maintenance phase treatment.” J Clin Psychopharmacol 16: 32s–47s; Bowden CL. (1998). “New concepts in mood stabilization.” Neuropsychopharmacology 19: 194–199; Ghaemi SN. (2001). “On defining ‘mood stabilizer.’” Bipolar Disord 3: 154–158.

25. Green C, Bassett K, Foerster V, Kazanjian A. (1997). Bone Mineral Density Testing: Does the Evidence Support Its Selective Use in Well Women? Vancouver: British Columbia Office of Health Technology Assessment. See also Moynihan R, Heath I, Henry D. (2002).

26. Heath I. (2006). “Combating Disease Mongering: Daunting but Nonetheless Essential.” PLoS Medicine 3(4): e146.

27. Getz L, Kirkengen AL, Hetlevik I, Romundstad S, Sigurdsson JA. (2004). “Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice.” Scand J Prim Health Care 22: 202–208.

28. CHADD. (2005). CHADD Annual Report 2004–2005, cited in Phillips CB. (2006).

29. Phillips CB. (2006). “Medicine Goes to School: Teachers as Sickness Brokers for ADHD.” PLoS Medicine 3(4): e182.

30. Moynihan R. (2000, November 13). “Taking the soft option.” Australian Financial Review: 29, cited in Moynihan, Heath, and Henry (2002).

31. Foggo D. (2005, October 9). “ADHD advice secretly paid for by drugs companies.” Sunday Telegraph, cited in Phillips (2006).

32. Moynihan R. (1998). Too Much Medicine? Sydney: ABC Books, pp. 137–168, cited in Moynihan, Heath, and Henry (2002).

33. Mintzes B. (1998). Blurring the Boundaries. Amsterdam: Health Action International.

34. Hickman B. (1998, May 21). “Men wise up to bald truth.” The Australian: 4, cited in Moynihan, Heath, and Henry (2002).

35. TIME magazine, US edition, August 19, 2002, “Young and Bipolar,” cover story, cited in Healy (2006).

36. Papolos D, Papolos J. (2000). The Bipolar Child. New York: Random House, cited in Healy (2006).

37. Brooks K. (2000, July 19). “Families with mentally ill children confront health care shortcomings, undeserved stigma of ‘bad parenting.’” Fort Worth Star-Telegram: 1, cited in Healy (2006).

38. Mick E, Biederman J, Aleardi M, Dougherty M. (2004). “Open trial of atypical antipsychotics in pre-schoolers with bipolar disorder.” Acta Psychiatr Scand 110: 29; Mick E, Biederman J, Dougherty M, Aleardi M. (2004). “Comparative efficacy of atypical antipsychotics for pediatric bipolar disorder.” Acta Psychiatr Scand 110: 29. Cited in Healy (2006).

39. See discussions in Moynihan R, Bero L, Ross-Degnan D, Henry D, Lee K, Watkins J, et al. (2000). “Coverage by the news media of the benefits and risks of medications.” N Engl J Med 342: 1645–1650; and Angell M. (2004). The Truth About the Drug Companies: How They Deceive Us and What to Do About It. New York: Random House. Specific figures on ghostwriting prevalence, industry funding effects on published conclusions, and reprint revenue vary by study and by specialty.

40. Phillips CB. (2006), op. cit.

41. Sax L, Kautz KJ. (2003). “Who first suggests the diagnosis of attention-deficit/hyperactivity disorder?” Ann Fam Med 1: 171–174, cited in Phillips (2006).

42. Novartis Pharmaceuticals Corporation. (2005). “If parents ask...” adhdinfo.com, cited in Phillips (2006).

43. Novartis Pharmaceuticals Corporation and National Association of School Nurses. (1997). ADHD education campaign, cited in Phillips (2006).

44. Caudill TS, Johnson MS, Rich EC, McKinney WP. (1996). “Physicians, pharmaceutical sales representatives, and the cost of prescribing.” Arch Fam Med 5: 201–206, cited in Heath (2006), Figure 1.

45. Moynihan R, Henry D. (2006). “The Fight against Disease Mongering.” PLoS Medicine 3(4): e191.

46. Heath I. (2006), op. cit.

47. Healy D. (2006), op. cit.

48. Lexchin J. (2006), op. cit.

49. Tiefer L. (2006), op. cit.

50. Nightingale F., quoted in Cowan T. (2025, March 26). “Are medical diagnoses real entities?” Webinar. See also Unbekoming, Symptoms as Adaptations: A Critical Examination of Medical Categorization (April 2025), Four Causes, Seventy Thousand Diseases, and Extraction: The Middle Class as Colony (November 2025).