Logical Fallacies in Support of Propaganda and Disinformation

Health Care Renewal's original goal was to open discussion of US health care dysfunction.  We originally focused on issues discussed in my 2003 article (Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. Link here). These included ill-informed, incompetent, self-interested, conflicted or even corrupt leadership; and attacks on the scientific basis of medicine.  We soon found out that bad health leadership and attacks on science were facilitated by deceptive marketing, public relations, propaganda, and disinformation.  Furthermore, we then realized that logical fallacies were important tools used by deceptive marketers, propagandists, and disinformationists.

Introduction: Logical Fallacies

To help understand logical fallacies, we used two main sources.  One was the Nizkor project, a Holocaust educational resource, which contained a guide to logical fallacies (available here and here).  The impetus for publishing this guide was to counter the use of logical fallacies to push the agenda of holocaust deniers. Another was Logically Fallacious, a book by Bo Bennett PhD, and its accompanying website. 

Logically Fallacious defines logical fallacies thus:

Criteria for Logical Fallacies: 

It must be an error in reasoning not a factual error.

It must be commonly applied to an argument either in the form of the argument or in the interpretation of the argument. 

It must be deceptive in that it often fools the average adult.

Therefore, we will define a logical fallacy as a concept within argumentation that commonly leads to an error in reasoning due to the deceptive nature of its presentation. Logical fallacies can comprise fallacious arguments that contain one or more non-factual errors in their form or deceptive arguments that often lead to fallacious reasoning in their evaluation.

Our first semi-formal discussion of logical fallacies appeared in 2008. Its focus was how logical fallacies were used to support public relations/ propaganda about health care policy in support of the interests of pharmaceutical corporations. I confess it was rather personal.  The blog and I had come under written attack by a blogger who worked for a non-profit that was funded by and associated with the pharmaceutical industry.  The attacks featured "creative use of multiple logical fallacies."  My post attempted to analyze some examples.

Logical Fallacies in Health Care and Public Health

Since 2008 we published multiple posts about logical fallacies often featuring vivid examples. Logical fallacies were: used to obfuscate the role of an academic medical center in giving apparently preferential treatment to members of Japanese organized crime (Yakuza) (look here);  justify conflicts of interest affecting clinical researchers (look here, ); justify huge compensation given to managers of non-profit hospital systems (look here); justify a federal prosecutor who pursued unethical practices by health care corporations exiting the revolving door to become a defense attorney for such corporations (look here); justify a renowned academic medical center going into the contract research business (look here);  and justify use of a poor clinical research practice, an active run-in period before a randomized controlled trial (look here).

Then things got much wilder during the Trump years.  Early on, Trump and his enablers became known for a steady stream of propaganda and disinformation, often employing logical fallacies, and sometimes to support his health care or health policy ideas.  For example, by 2019, the Washington Post documented Trump's voluminous uses of the appeal to common belief fallacy to justify, among other things, his attacks on the Democrats health care agenda as a "disaster," and his boasts about a reform of the US Veterans Administration, reforms that actually preceded his time in office.

Then we heard about an unusual viral disease in China that quickly morphed into the COVID-19 pandemic.  Logical fallacies became a powerful tool for generating the onslaught of propaganda and disinformation about the pandemic.  The propaganda and disinformation came so fast and the pandemic situation was so unstable that I had trouble keeping up with it, other than documenting it on my Twitter feed.  However, once again logical fallacies were used by the disinformationists, eg, to justify decreases in coronavirus testing (look here); and to justify attacks against pandemic mitigation measures, such as mask wearing (look here).  

So now seems like a good time to catalog some of the logical fallacies that have most frequently or vividly been used in a health care or public health context to support deceptive marketing, propaganda, and disinformation to sell products and services, justify management behavior or misbehavior, or further leaders' self-interest.  The catalog is organized by the usual names of the cognitive fallacy arranged alphabetically.  Examples from the archive of Health Care Renewal of each fallacy will be provided.  Some will be from our early days, when logical fallacies were often used to support aspects of pharmaceutical/ biotechnology/ device company marketing and public relations practices, and to support public relations practices by hospital management and related groups.  Some will be more recent, and reflect the new (ab)normal, their widespread usage to generate propaganda and disinformation about the COVID-19 pandemic

Ad Hominem

There are several sub-types of the ad hominem fallacy. In particular, the circumstantial version is defined:

Suggesting that the person who is making the argument is biased or predisposed to take a particular stance, and therefore, the argument is necessarily invalid.

Example: Richard Epstein, a prominent market fundamentalist law professor, attacked critics of conflicts of interest affecting pharmaceutical marketing as those who "often treat the phrase 'market forces' as though it embodies the worst things in life," that is, as anti-capitalists (look here). 

Example: A physician decrying proposed restrictions on conflicts of interest in medicine called for leaders to "resist the temptation to join the separation witch hunt."  The implication is that people calling for more restrictions are witch hunters, that is embarking on a totally unreasonable and dangerous ideological crusade (look here). 

[Witch from The Lost King of Oz, Ruth Plunky Thompson, 1925]

Note that a person may be biased towards a certain point of view, and that bias could affect that person's arguments, but not necessarily.

The ad hominem tu quoque fallacy is defined:

Claiming the argument is flawed by pointing out that the one making the argument is not acting consistently with the claims of the argument.

Example: Since I worked on a project for and thus was paid as a consultant by Merck in 1997-9, it was implied my criticism of a pharmaceutical company in 2008 was hypocritical and therefore invalid (look here). 

Note that one's actions in one case do not necessarily affect one's arguments in another. 

Appeal to Authority

The appeal to authority is defined:  

Insisting that a claim is true simply because a valid authority or expert on the issue said it was true, without any other supporting evidence offered.

Example: An author tried to dismiss concerns about conflicts of interest affecting medical societies because physicians are so virtuous and responsible that conflicts could not possibly affect them (look here)  

Note that an authority may be more likely to make a valid argument, but there is no guarantee that all arguments made by an authority are valid.

Appeal to Common Belief

The appeal to common belief is defined:

 When the claim that most or many people in general or of a particular group accept a belief as true is presented as evidence for the claim.

Example: President Trump claimed that everyone knew that the Democratic health care policies were a "disaster," and that his reforms of the VA were extremely significant (although they were actually enacted during the previous administration (see the Washington Post in 2019). 

Just because many people believe something does not make it true.

Appeal to Common Practice 

The appeal to common practice has the following structure:

X is a common action.

Therefore, X is correct/moral/justified/reasonable etc 

Example: An author tried to dismiss concerns about conflicts of interest affecting physicians, particularly research physicians by saying publication bias "has been reported for more than 2 decades," implying that because it is common, worry is uncalled for (look here). 

Example: The CEO of a renowned academic medical center, formerly a high paid biotechnology executive, defended its venture into the contract research business by saying ""universities need to recognize this is how things are," and "the old way of doing things doesn't really work anymore." (Look here)

Just because some people do something does not mean what they do is justified, or based on truth.

Appeal to Fear

There are many kinds of appeals to emotion, generally defined as.

the general category of many fallacies that use emotion in place of reason in order to attempt to win the argument.  It is a type of manipulation used in place of valid logic.

The appeal to fear is one sub-type.  It is defined:

 When fear, not based on evidence or reason, is being used as the primary motivator to get others to accept an idea, proposition, or conclusion.

Example: A physician decrying proposed restrictions on conflicts of interest in medicine warned that "Those institutions that choose such inquisitional approaches will be blighted and suffer competitive disadvantages." The use of the emotionally charged word "blighted," in the absence of a clear argument that the blight would necessarily occur, made this an appeal to emotion, particularly fear (look here). 

Just because something is feared does not make it more likely.

Appeal to False Authority 

This is related to the appeal to authority, above.  The appeal to false authority is defined:

Using an alleged authority as evidence in your argument when the authority is not really an authority on the facts relevant to the argument.

Example: The CEO of a state hospital association justified the huge compensation given to local hospital system CEOs by quoting "management expert Peter Drucker" who asserted that hospital management is particularly difficult.  Note that she provided no evidence that Mr Drucker has any special expertise about health care (look here).  

Just because someone is said to be an expert in a particular field does not mean that person is an expert.  Just because a person is an expert does not make an argument based on that person's opinions right.

 Appeal to Ignorance

 This is also known as argument from ignorance.  Its definition is:

The assumption of a conclusion or fact based primarily on lack of evidence to the contrary.  Usually best described by, 'absence of evidence is not evidence of absence.'

Newer Example: President Trump called for a decrease in coronavirus testing apparently because he believes that diagnosing fewer cases would mean less actual disease: "Here's the bad part ... when you do testing to that extent, you're going to find more people; you're going to find more cases. So I said to my people, slow the testing down please." (look here and here). 

Newer Example: Governor Kristi Noem of South Dakota also claimed that there were more cases of coronavirus, and hence more hospitalizations for coronavirus in her state than other states because the state was testing at a higher rate (look here).  Thus she and the president seemed to equate diagnosis with disease, and were arguing that if there is less evidence of disease, there must be less actual disease.

Failure to see or detect something does not mean it does not exist.

Slippery Slope

The definition of the slippery slope is:

When a relatively insignificant first event is suggested to lead to a more significant event, which in turn leads to a more significant event, and so on, until some ultimate, significant event is reached, where the connection of each event is not only unwarranted but with each step it becomes more and more improbable.

Example: Richard Epstein, a prominent market fundamentalist law professor, attacked proposals of new restrictions on conflicts of interest affecting pharmaceutical marketing as leading to the prohibition of "the collaborative efforts that have long characterized standard practices [in research]." Yet none of the proposals he mentioned would have directly affected collaboration per se (look here).

Although things may appear to occur in sequence, a chain of causation may not be inevitable.

Special Pleading

The definition of special pleading is:

a fallacy in which a person applies standards, principles, rules, etc. to others while taking herself (or those she has a special interest in) to be exempt, without providing adequate justification for the exemption.

Example: An author attacked the credibility of a published critique of conflicts of interest affecting research sponsored by a particular drug company by saying that critique's authors had failed to completely disclose their alleged conflicts.  They were consultants to attorneys for plaintiffs who had sued the company.  Yet the author did not completely disclose his own conflicts in his article attacking the critiques, suggesting that he believed other people should have to fully disclose conflicts of interest, but he was exempt  (look here).

Straw Man

 [Scarecrow from Dorothy and the Wizard of Oz, L Frank Baum, 1908]

The definition of the straw man fallacy is:

when a person simply ignores a person's actual position and substitutes a distorted, exaggerated or misrepresented version of that position. 

Example: Because I had criticized manipulation and suppression of clinical research about particular drugs (SSRIs, Avandia, Vytorin), my critic implied "I suggested 'people should stop taking SSRIs, Avandia, and Vytorin.' He then added 'now I guess this should also apply to Zocor.'"  However, I had stated no such thing. (Look here)

Newer Example: A state Republican Chairman argued against pandemic mitigation members saying "We can’t live in a world where there’s never again a live, in-person concert or convention or gathering"  No one had credibly argued that pandemic mitigation meant that no such things would ever happen. (look here). 

Other Logical Fallacies Used to Support Propaganda or Disinformation

There are many other logical fallacies.  Some that have been used frequently lately by disinformationists in the political arena include:

- the abusive ad hominem fallacy: "Attacking the person making the argument, rather than the argument itself, when the attack on the person is completely irrelevant to the argument the person is making;" 

- cherry picking: "When only select evidence is presented in order to persuade the audience to accept a position, and evidence that would go against the position is withheld.

-the false dilemma: "When only two choices are presented yet more exist, or a spectrum of possible choices exists between two extremes.  False dilemmas are usually characterized by “either this or that” language"

- the red herring fallacy: "Attempting to redirect the argument to another issue to which the person doing the redirecting can better respond" 

Perusal of Logically Fallacious and the Nizkor project, as well as a number of other good sources, will reveal a catalog of fallacies and errors of reasoning, most of which are being used in contemporary political and sometimes specifically health care and public health related propaganda and disinformation.

Summary- Propaganda, Disinformation, and Logical Fallacies

As we noted recently, the coronavirus pandemic has been accompanied by a pandemic of disinformation, sometimes called the "infodemic."  In the US, while it would have seemed unthinkable up to 5 years ago, the biggest source of disinformation has been President Donald Trump (look here). Although Trump is now out of office, the barrage of coronavirus disinformation has continued apparently unabated, propagated by Trump's supporters (look here), foreign powers, eg, Russia (look here), and various anonymous internet-based trolls, bots, etc. The infodemic has likely had a major role in amplifying the pandemic by discouraging peoples' cooperation with pandemic control measures, and now generating vaccine hesitancy.  The result has likely been considerable morbidity and death.
If we hope to reduce suffering and death from the pandemic, we will need to confront the propaganda and disinformation that is driving it.

 Propaganda and disinformation operate through multiple mechanisms, including various forms of deception including manipulation and suppression of evidence; generation of specious arguments, including via the use of logical fallacies; and appeals to emotion and manipulation of human psychology.  Better understanding of logical fallacies will help us better counter propaganda and disinformation. 

Marketers Want Even More Control Over Hospitals

Once, a long time ago, in a galaxy far away, doctors and hospitals did no marketing, and pharmaceutical marketing was restricted to health care professional audiences.  Now, in the US, we have  often seen the negative effects of exuberant  marketing, often deceptive, on the health care system.

A Marketer Pushes More Marketing Influence on Hospital Management

Yet, in a post in the Marketing Insider section of MediaPost, a writer lamented that marketing does not have enough influence within hospitals.

About 10% of hospital budgets are designated for marketing. It’s been that way for years, with stagnant year-on-year growth.

That is in contrast to ... Amazon, of course:

Amazon reported record profits in 2018, earning $10.1 billion in net income compared with just $3 billion the prior year. Amazon ranked as the nation's fourth-largest advertiser in 2017, spending an estimated $3.4 billion in U.S. advertising and promotions.

It goes beyond Amazon, though:

Amazon is not the only company appropriately valuing marketing. Many modern consumer-focused enterprises are moving from seeking maximum ROI to actually transforming the marketing value chain.

IMHO, this shows how managers who run, or at least pontificate about running hospitals do not seem to have an idea what hospitals actually do.  How does a hospital, the locus for providing care to sick and injured people, care provided by highly trained health care professionals sworn to put patients' values ahead of all other concerns, compare to a web-based retailer, or to most "consumer-focused enterprises?"

Furthermore, the post pushes the value of marketing beyond just raising awareness of or promoting a product,

Part of the reason hospital systems are starting to spend more on marketing is that the function is broadening. Marketing teams are being asked to take on more strategic tasks, from managing the hospital’s brand and reputation to operationalizing patient engagement.

Traditionally, patient experience falls under the purview of quality or safety. But in the last decade, health systems have seen the marketing department’s impact on the patent experience, even going so far as to have marketing report to the chief patient experience officer.

One might think that the typical patient who comes to a hospital wants to experience an improvement in their condition, their symptoms, their function, reduction of their pain, or sometimes the remission or even cure of their problem.  I do not see how any rational person seeking a fun experience would choose to go to a hospital.  What marketing has to do with health care quality or safety completely escapes me.

The Rationale: a Misinterpretation of  the Social Determinants of Health

The rationalization for involving marketers in patients' experiences was:

Leaders are seeing that the care they provide accounts for just 20% of patients’ optimal outcomes. The rest is attributable to factors like social determinants of health. Today, if hospital systems want to keep patients healthy, they have to influence experiences patients have outside the hospital walls.

The notion that marketing by a hospital would be an optimal way to positively influence social determinants of health is bizarre, to use a polite term.  To quote an article entitled "Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity" published by the Kaiser Family Foundation,

Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care.

What could hospital marketing do to affect such factors?  Instead, the writer explained:

Hospitals and health systems are moving beyond simple outreach and using the principles of marketing — such as segmentation, personalization and meeting consumers where they are — to engage patients in changing behavior and getting them invested in their own well-being.

Health systems must ensure that every time a patient interacts with their brand, that interaction keeps patients engaged and satisfied and delivers on the fundamental promise that they make to their patients: making and keeping them well.

Again, what has that to do with socioeconomic status, education, neighborhood and physical environment, employment, and social support networks? Rather than talking about social factors, the writer appears to be talking about some efforts to change individual patients' behavior.

However, the KFF article made a clear distinction between social determinants of health and individual health behaviors, while asserting that social determinants of health may influence individual behaviors, but not necessarily the other way around:

While there is currently no consensus in the research on the magnitude of the relative contributions of each of these factors to health, studies suggest that health behaviors, such as smoking, diet, and exercise, and social and economic factors are the primary drivers of health outcomes, and social and economic factors can shape individuals’ health behaviors. For example, children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health such as lack of safety, exposed garbage, and substandard housing. They also are less likely to have access to sidewalks, parks or playgrounds, recreation centers, or a library.4 Further, evidence shows that stress negatively affects health across the lifespan5 and that environmental factors may have multi-generational impacts.

Thus, to argue that hospital marketing could influence individual patient behaviors and thus positively affect social determinants of health makes no sense.

Summary: Managerialism, Again

I applaud the writer's implication that

hospital systems want to keep patients healthy

(As an aside though, hospitals cannot want anything, but the people who work in them can.)

But however well intended, or at least rationalized, marketers pushing their greater involvement in patient experience, even if it is not self-serving, seems like just another push for the managerialism that already haunts health care. 

Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work.  Managerialism has become an ascendant value in health care over the last 30 years.  The majority of hospital CEOs are now management trained, but lacking in experience and training inmedicine, direct health care, biomedical science, or public health.  And managerialism is now ascendant in the US government.  Our president, and many of his top-level appointees, are former business managers without political experience or government experience.

We noted an important article that in the June, 2015 issue of the Medical Journal of Australia(1) that made these points about managerialism:
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals

Managerialism may be a major cause of  mission-hostile management. In non-profit hospitals, mission-hostile management threatens care of vulnerable patients, particularly by prioritizing hospital revenues, and the financial self-interest of management over patient care. Note that the rise of the manager-leader occurred at a time when management schools increasingly preached the dogma that maximizing shareholder value, usually equivalent to maximizing short-term revenue, should be the first, if not the only goal of all managers (look here).  For example, an article on the miseducation of Sheryl Sandberg, Facebook's chief operating officer, asserted that

Harvard Business School, like much of the M.B.A. universe in which Sandberg was reared, has always cared less about moral leadership than career advancement and financial performance.

Managerialists may be convinced that they are working for the greater good.  However, I am convinced that our health care system would be a lot less dysfunctional if it were led by people who actually know something about biomedical science, health care, and public health, and who understand and uphold the values of health care and public health professionals - even if that would cost a lot of very well paid managerialists their jobs.

 Reference

1.  Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM.  The scourge of managerialism and the Royal Australasian College of Physicians.  Med J Aust 2015; 202: 519- 521.  Link here.

Johnson and Johnson's "Landmark" Opioid Settlement, or Just Another Chapter in the Story of Corporate Management's Impunity?

Introduction: our Chronic Narcotics Problem

Narcotic addiction has plagued human societies for hundreds of years.

[Print, 1880, opium den, London]


So as I have written before, after seeing too many dire results of narcotic addiction during my training and early career, I was dismayed how narcotics were pushed as the treatment of choice for chronic pain in the 1990s, with the predictable result that the US was once again engulfed in an epidemic of narcotic abuse.  In the last few years, the narcotics (now called "opioids") epidemic has frequently been in the headlines.  A few days ago, a judge decided that one large pharmaceutical/ biotechnology/ device company bears some blame for the problem

The Johnson and Johnson "Landmark" Settlement

On August 26, 2019, the New York Times reported a "landmark," per the headline, settlement:

A judge in Oklahoma on Monday ruled that Johnson & Johnson had intentionally played down the dangers and oversold the benefits of opioids, and ordered it to pay the state $572 million in the first trial of a drug manufacturer for the destruction wrought by prescription painkillers.

The judge wrote

that Johnson & Johnson had promulgated 'false, misleading, and dangerous marketing campaigns' that had 'caused exponentially increasing rates of addiction, overdose deaths' and babies born exposed to opioids.

It seems like a big story, big enough for another NYT article to fret over how the settlement might damage Johnson and Johnson's sterling reputation.  

For Johnson & Johnson, which has said it plans to appeal, the decision represents another blow to its reputation as the trusted brand of parents, doctors and nurses.

Wall Street Journal editorialists fretted even more,

the ruling could have far larger, and more dangerous, consequences by opening a vast new arena for product-liability suits.

And warned the opioid epidemic will not

be eased by bankrupting America's pharmaceutical companies

Maybe threats to this upstanding company inspired US President Trump, while running the most conflicted and corrupt administration ever (look here), to promote another fine Johnson and Johnson product.  On August 23, 2019, the Atlantic reported,

President Donald Trump said on Wednesday that the government will purchase 'a lot of the drug esketamine, a derivative of ketamine.

Though ketamine is known as a recreational hallucinogen, Trump asserted that a new nasal-spray derivative would be of great benefit to veterans with depression. As he left the White House for a veterans’ conference in Kentucky, he told reporters that he had instructed the Department of Veterans Affairs to make a large purchase—overriding a recent decision by the doctors who manage the hospitals’ formulary of which drugs are to be prescribed.

'There’s a product that’s made right now that just came out by Johnson & Johnson which has a tremendously positive—pretty short-term, but nevertheless positive—effect,' Trump said. But that statement is contrary to the evidence. A review by the Food and Drug Administration of what limited studies have been done with esketamine found mixed results, leaving many scientists unsure if the drug is indeed effective and safe. Just last week, the agency published a report that said the drug was not reliably better than placebo.

Should the Wall Street Journal (and perhaps President Trump) really be so worried? Was this settlement really so dire?

The March of Legal Settlements Continues

In fact, this particular settlement did not seem very harsh.  Per the first NYT article,

The amount fell far short of the $17 billion judgment that Oklahoma had sought to pay for addiction treatment, drug courts and other services it said it would need over the next 20 years to repair the damage done by the opioid epidemic.

The amount of the settlement would be unlikely in and of itself to give corporate leadership pause, given that the company's revenues exceeded $81 billion last year (look here).

While the judge found that Johnson and Johnson caused a "public nuisance," this seems unlikely to inspire much shame in corporate leaders, who took no overt responsibility for the narcotic epidemic:

In a statement about the Oklahoma case, Michael Ullmann, the general counsel and executive vice president of Johnson & Johnson, referring to the company’s pharmaceutical subsidiary, said that 'Janssen did not cause the opioid crisis in Oklahoma, and neither the facts nor the law support this outcome.'

'We recognize the opioid crisis is a tremendously complex public health issue,' he said, 'and we have deep sympathy for everyone affected.'

And like many other legal settlements which we have discussed in the past, this one caused no one at Johnson and Johnson who approved, directed, or implemented the deceptive marketing and other bad behavior to suffer any negative consequences. 

Ignoring Another Corporation's Dismal Record

Furthermore, the settlement, like most others we have discussed, ignored Johnson and Johnson's extensive track record of misbehavior.

The second NYT article did allow that the company has withstood

a series of damaging setbacks to its brand, including a spate of lawsuits over whether its talcum powder led to ovarian cancer, and high-profile cases over other potentially flawed products, like pelvic mesh and the anti-stroke drug Xarelto, which has caused excessive bleeding.

'Johnson & Johnson is a corporation under duress on a number of fronts,' said Stephen Hahn-Griffiths, an executive at Reputation Institute, which tracks public perception of companies through regular surveys.

However, that barely scratched the surface of Johnson and Johnson's record.  In a 2018 post we discussed accusations that Johnson and Johnson tried to cover up the adverse effects of its baby powder.  However, we also discussed a settlement the company made of allegations it gave kickbacks to patients to facilitate its over-pricing of Tracleer, a drug for pulmonary artery hyptertension.  These were just the latest in a long string of misadventures by the company, as we have been documenting over years.  (Our collected posts on Johnson & Johnson are here.  An updated version of their legal record from 2010 to 2016 is at the end of this post.)

Perusing the list suggests that this giant company is a poster child for bad behavior by health care organizations.  It has faced a multitude of allegations leading to settlements, and sometimes findings of guilt.  The charges included many instances of deceptive and unethical marketing, some that promoted drugs or devices for use in situations in which they may have had harms outweighing their benefit, some that involved concealing knowledge of their risks, and some of selling adulterated drugs or defective products. 


What is striking is that the company and its management have not faced more consequences for this sorry track record.

Although the company has paid multiple fines and made numerous monetary settlements over the years, none have been big enough to affect its immense revenues.  Furthermore, ultimately the monies used to pay them came from all Johnson & Johnson employees in the form of smaller paychecks; customers, patients and the public at large in the form of higher prices; and only to some extent by investors in the form of slightly lower profits.  Meanwhile, it appears that the company's top managers made an immense amount of money, possibly in part as rewards for the revenues produced by the misadeventures.

Former Johnson & Johnson CEO William Weldon, upon his retirement in 2014, was to receive a retirement package estimated to be worth from $143 to $197 million (look here).  In 2010, his total compensation was $29 million (look here).   According to the 2012 Johnson and Johnson proxy statement, his 2011 total compensation was greater than $26 million. As far as I can tell, Mr Weldon never suffered any negative consequences for his company's sorry record, and retired a very rich man. (look here).

Current CEO Alex Gorsky received  $25 million total compensation in 2014 (look here).  More recently, the New York Times reported his 2017 total pay was $22.8 million, making him the seventh highest paid health care executive that year. 

While management made so much money, very rarely has anyone who was involved in authorizing, directing, or implementing bad behavior had to suffer any negative consequences, therefore appearing to enjoy impunity.

So what was to deter management from embarking on further misadventures, as long as the results might be enlarging their personal wealth? 

And why should we expect that this settlement will lead to any meaningful solution to the ongoing narcotics (opioid) epidemic?

Summary: Meaningless Settlements and the Impunity of Top Management

Nothing changes.  We have seen many legal settlements by health care organizations of charges of  fraud, bribery, and kickbacks.  Often such behaviors appeared to risk patient harms.  However, the companies involved usually paid tiny fines that relative to their revenues.  Rarely did they have to admit responsibility, and almost never did a settlement cause company managers and leaders to  suffer any negative consequences for enabling, authorizing, directing or implementing the bad behavior.

Thus it seems that US health care is rigged to benefit top insiders and their cronies, and is part of a larger rigged system.  We have previously discussed how market fundamentalism (or neoliberalism) led to deregulation, which enabled deception, fraud, bribery, and intimidation to become standard business practices, concentrating corporate power while top managers got rich. Other employees, patients, customers, vendors and suppliers, and the public at large lost out.   In health care, these changes led to an increasingly costly system which produced increasingly bad results. 

We have called for true health care reform to derig the system. Unfortunately, despite our hopes, perceptions of a rigged system may not always inspire honest reform. Instead, they can facilitate the rise of demagogues and would be dictators.  Donald Trump cried out that only he could fix our problems and drain our swamps, but the waters are now rising (look here) while he has enjoyed his own impunity (look here).  

The "landmark" settlement by Johnson and Johnson should remind us of the reforms we have not achieved.  However, to have a chance of truly reforming health care, we need to accomplish wholesale government reform. We need to excise the deception, crime and corruption at the heart of our government and restore government by the people, of the people, and for the people. 

Appendix - A Look at Some of Johnson and Johnson's Legal Record 2010-2016

Derived from our previous blog posts - 

 2010
- Convictions in two different states for misleading marketing of Risperdal
- A guilty plea for misbranding Topamax

2011
- Guilty pleas to bribery in Europe by DePuy subsidiary
- A guilty plea for marketing Risperdal for unapproved uses  (see this link for all of the above)
- A guilty plea to misbranding Natrecor by subsidiary Scios (see post here)

2012 
  - Testimony in a trial of allegations of unethical marketing of the drug Risperdal (risperidone) by the Janssen subsidiary revealed a systemic, deceptive stealth marketing campaign that fostered suppression of research whose results were unfavorable to the company, ghostwriting, the use of key opinion leaders as marketers in the guise of academics and professionals, and intimidation of whistleblowers. After these revelations, the company abruptly settled the case (see post here).
-  fined $1.1 billion by a judge in Arkansas for deceiving patients and physicians again about Risperdal (look here).
-  announced it would pay $181 million to resolve claims of deceptive advertising again about Risperdal (see this post).

2013
-  settled case by shareholders alleging that management made misleading statements and withheld material information about manufacturing problems (see this post)
-  Janssen subsidiary pleaded guilty to a charge of misbranding Risperdal, and settled for a total of $2.2 billion allegations that it promoted the drug for elderly demented patients and adolescents without an indication, and despite evidence of its harms (see this post).
 -  DePuy subsidiary agreed to settle with multiple plaintiffs for $2.5 billion allegations that it sold defective mental-on-metal artificial hip, and hid evidence of its harms .
-  Janssen subsidiary was found by two juries to have concealed harms of its drug Topamax (see this post for this and above case).
-  Ethicon subsidiary's Advanced Surgical Products and two of its executives agreed to settle charges by US FDA that is sold mislabeled products used to sterilize equipment such as endoscopes (see this post).
- fined by European Commission for anticompetitive practices, that is, collusion with Novartis to delay marketing generic version of Fentanyl (see this post).

2014 
- DePuy subsidiary settled Oregan state charges that it marketed the ASR XL metal-on-metal hip joint prosthesis without disclosing its high failure rate (see this post).

2015
-  found by jury to have concealed harms of Risperdal.
-  Ethicon subsidiary found by jury to have concealed harms of its vaginal mesh device.
-  McNeil subsidiary pleaded guilty to marketing adulterated Tylenol. (see this post for three items above.)

2016
- subsidiary Aclarent settled allegations that it sold its Stratus device for unapproved uses.  Two former executives of that subsidiary also were found guilty of distributing misbranded and adulterated devices (see this post) 
 

Just Another Small Health Care Scam... the Trump Network and its Bogus Diagnostic Tests and Unproven Vitamin Treatments Resurfaces

Introduction

On Health Care Renewal, we frequently discuss deceptive marketing schemes designed to sell tests and treatments whose benefits for patients do not clearly outweigh their harms, and sometimes which are useless or dangerous.  In fact, we have to be selective about discussing such cases, because they are all too common.  Therefore, we tend to focus on cases involving the biggest and most powerful health care organizations, and/or the worst risks to patients.

We have generally not discussed the myriad promotions of dubious "nutritional" tests and therapies, because there are just so many of them, the players involved are generally small, and these products were effectively deregulated in the US by the 1994 Dietary Supplement Health and Education Act.

However,...

Just Another Multi-Level Marketing Scam?

In 2016, we posted about what appeared to be just another nutritional scam, but one that seemed at the time to have broader implications.  A colorful account of how it worked came from a 2011 New Yorker article, which focused on a marketer named Izzo:

He would order the vitamins from a company called Ideal Health. She would earn a commission on the sale and he, in turn, would become a part of her team and encourage other people to buy the vitamins. For those sales, Izzo would earn a commission, as would she (his 'upline'), and then the people he sold the vitamins to would become part of his sales team and would go on to create their own sales teams, who would go on to create their own sales teams, etc., ad infinitum, all of them funneling commissions from their sales up to Izzo and the woman on the phone. As he listened, 'something clicked,' Izzo says. 'I saw the beauty of the business model. And I said, ‘How can I do this, and do this big?’ '

Note that this was an interesting scam in that it involved a multi-level marketing (MLM) model, which sometimes are called pyramid schemes. What most interested the New Yorker back then, however. was that the scam got connected to a prominent, flashy New York businessman, one Donald J Trump, yes, that Donald J Trump:

'The name is hot!' Donald Trump booms over the speakerphone from his office at 725 Fifth Avenue, where, ever since The Apprentice breathed new life into his brand, he has presided over an ever-diversifying array of businesses. He is, of course, speaking of his own name. 'It’s on fire!'

In March 2009, Trump purchased Ideal Health, rebranding it the Trump Network. Though the packaging has now been imprinted with the Trump family crest, the product line is still much the same. There are the two multivitamins: Prime Essentials and the more expensive Custom Essentials, the ingredients of which are determined by the Trump Network–branded PrivaTest, a urine test that claims to determine which vitamins the user needs. There’s also a line of healthy snacks for kids called Snazzle Snaxxs, QuikStik energy drinks, and a Silhouette Solutions diet program. With the Trump investment, the company has added a skin-care line that goes by the seductively foreign name BioCé Cosmeceuticals.

How much of a scam was this?  The trick to this scheme was that it involved not only the sale of nutritional supplements, but the use of bogus urine testing to develop customized nutritional regimens.

 The Trump Network sold many health and wellness products, and its main one was a customized nutritional supplement whose composition was determined by a urine test, called the PrivaTest.

A former marketer provided STAT with a kit for Ideal Health’s PrivaTest. It contained a urine collection cup, five test tubes, a cold pack, a biohazard bag, a prepaid FedEx mailing label, and detailed instructions. Customers collected their urine and shipped it to a lab for analysis. That lab analyzed the urine with three tests and produced a report, which was sent to The Trump Network.

The Trump Network bundled the report with a package of pills and shipped it all back to the customer. The pills were marketed as 'Custom Essentials,' formulations based on the results of the test and manufactured by another lab. In all, there were 48 formulations.

According to an archived version of The Trump Network’s website that can still be found online, the PrivaTest, along with a month’s worth of the Custom Essentials, cost $139.95. Retesting was available for $99.95, plus shipping and handling. The company recommended retesting every nine to 12 months.

Other products purportedly tested for food allergies, stress, and digestive health. One claimed to measure 'the balance between your ‘good’ estrogen and your ‘bad’ estrogen.'

There was, however, no evidence that any of this testing meant anything, or that nutritional regimens constructed using it would do any good for patients.   First, there appeared to be no publicly available data on how the tests worked, what they actually tested, or how accurate they were.  Then there was no data about how the test results could rationally be used to suggest particular mixes of vitamin supplements.  Also, there was apparently no public data about what vitamins were in the potions sent to consumers, their purity, their strength, etc.

The New Yorker asked some experts about this:

 While the FDA may not have evaluated the tests or supplements, independent scientists have — and raised many questions.

Cohen, one of several scientists who reviewed materials from Ideal Health and The Trump Network, said that the tests were marketed too broadly and seemed to be 'pathologizing normal human life.'

The website, for example, recommended its “AllerTest” to anyone who had dark circles under their eyes, occasional digestive problems, fluctuating blood sugar, sinus and respiratory problems, or tiredness after eating.

'Does your blood sugar fluctuate?' Cohen said, laughing. 'If your blood sugar does not fluctuate, you are extremely ill. You will not be long on this planet.'

What’s more, the AllerTest did not measure food allergies, as the network’s website claimed it would, according to outside analysis of materials from the testing lab and Ideal Health publications.

The test measured information about an antibody known as immunoglobulin G, or IgG, according to company publications. The antibody is normally produced in the body and not indicative of a food allergy, said Dr. Robert Wood, director of pediatric allergy and immunology at Johns Hopkins School of Medicine.

'There’s no disease condition for which the IgG antibodies have any relevance at all,' Wood said.

Note that this did not discuss, but implied that administering bogus tests to people and patients could either make them think they have important medical problems when they do not, or make them think that they do not have problems which they actually have.  Thus systematically administering bogus tests to a population could harm that population.

 In any event, like many such scams, the whole thing eventually faded away, and Trump pulled out of the licensing deal in 2011.

There basically ended our post, noting that maybe it was significant that a then 2016 presidential candidate who was favored to win the Republican nomination once got involved in such an obvious, if relatively small-time health care scam (and one involving a possible pyramid scheme, and bogus diagnostic testing to boot).  And yet this story, like many involving unethical health care practices, seemed to fade away.  Of course, in this case, it was also rapidly drowned out by the increasing chaos being produced by Trump and his cronies.

But wait, there is more.

The Class Action Lawsuit Against Trump and Family for Allegedly Fraudulent Multi-Level Marketing Schemes

The Trump candidacy, of course, despite many predictions to the contrary, did not fade away.

And in 2018, a story appeared that again was nearly drowned out by the then ongoing Trump chaos.  As reported by the NY Times in October, a lawsuit surfaced:

The 160-page complaint alleges that Mr. Trump and his family received secret payments from three business entities in exchange for promoting them as legitimate opportunities, when in reality they were get-rich-quick schemes that harmed investors, many of whom were unsophisticated and struggling financially.

Those business entities were ACN, a telecommunications marketing company that paid Mr. Trump millions of dollars to endorse its products; the Trump Network, a vitamin marketing enterprise; and the Trump Institute, which the suit said offered 'extravagantly priced multiday training seminars' on Mr. Trump’s real estate 'secrets.'

Voila, the Trump Network scam reappears.

Of course, early in the NYT article was the caveat:

the lawsuit comes just days before the midterm elections, raising questions about whether its timing is politically motivated.

The Times always likes to report on both sides of the argument, regardless of the merits, but anyway...


Again, all was silent, while chaos raged about other matters, at least until early 2019, when Trump's legal filed their protest asking a judge to dismiss the lawsuit, as reported by Bloomberg,

In a filing Monday, the Trumps claimed they had nothing to do with any alleged fraud. Donald Trump provided celebrity endorsements to ACN from 2006 to 2015, but never owned or controlled the company. And the plaintiffs haven’t identified a single fraudulent statement made by any of the other defendants, the family said.

'No plaintiff is alleged to have paid or lost money to the defendants or to any Trump business, and no defendant is alleged to have solicited any plaintiff for anything,' the Trumps said in the court filing. 'It is undisputed that ACN -- and ACN alone -- through a network of ACN representatives, solicited and collected fees from plaintiffs, for the benefit of ACN'”

At least in the Bloomberg report, there was not a word about the small health care scam that was also alleged, and certainly not about the evidence from that New Yorker article from long ago about how involved Trump was in that, but never mind, and all was silent once again, until....

However, in July, 2019,this month, the judge ruled, again per Bloomberg,

President Donald Trump, his company and three of his children must face a class-action lawsuit in which people claim they were scammed into spending money on fraudulent, multilevel marketing ventures and a dubious live-seminar program.

U.S. District Judge Lorna Schofield in Manhattan ruled Wednesday that the case can go forward with claims of fraud, unfair competition, and deceptive trade practices. The decision likely opens the door for the plaintiffs to start gathering evidence from Trump and his company, including documents and testimony.

The implications are important.  The suit is not just against the Trump Organization, but against Donald J Trump personally, and three of his children.  Absent another challenge from the Trumps et al, there could soon be a discovery process, meaning lots of documents, emails, etc, the sorts of information Trump et al have struggled to keep secret in other contexts, might be disclosed.  Furthermore, additional coverage of this legal development underlined Trump's personal involvement with these schemes - as did, by the way, the old New Yorker coverage of the Trump Network nutritional testing scam, facts that long vanished from the public eye.

For example, Salon reported,

The complaint added, 'Central to Defendants' fraudulent scheme was a company called ACN, a multi-level marketing company ('MLM') that offers a business opportunity to individual participants. From 2005 to at least 2015, Defendants received millions of dollars in secret payments to promote and endorse ACN. In return, Donald J. Trump ('Trump') told prospective investors that '[y]ou have a great opportunity before you at ACN without any of the risks most entrepreneurs have to take,' and that ACN's flagship videophone was doing 'half-a-billion dollars' worth of sales a year.' Trump also told investors that he had 'experienced the opportunity' and 'done a lot of research,' and that his endorsement was 'not for any money.' Not a word of this was true.'"

It has since been revealed that Donald Trump earned $450,000 each for three speeches that he delivered for American Communications Network.

So it appears that Trump personally profited quite a bit from these little scams

Discussion

The nearly anechoic Trump Network story just adds to Trump's and cronies' long history of deception, unethical behavior, and to the questions about crime and corruption that have swirled around them for years, including times well before anyone ever could conceive of Trump as US President.  However, unlike many of the other cases (see this most recent summary here), this one involves health care, diagnostic testing, and patients, not just investors, as potential victims.

Thus this just adds to concerns that the Trump regime is enabling worsening of the ongoing problem of health care corruption in the US.  As we have said before, health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,

However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

Yet,  Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

In the last few years, as discussed here, voluminous reports have surfaced about the corruption of the Trump regime (although none of which, of course, mentioned the small case of Trump's sleazy health care scams).  They included numerous, ongoing cases of Trump's violations of the emoluments clauses of the US Constitution, which forbids a President from receiving payments from foreign countries, of US or state and local governments.  They included numerous appointments of gross instances of the revolving door, in which people with leadership positions in industries, including health care corporations, were given control over agencies which regulate and enforce laws pertaining to the corporations they previously served. They included numerous instances in which US government decisions were made seemingly to benefit Trump, his associates, and his conflicted appointees.  They included instances in which the federal government was used to promote Trump's ongoing business interests.

And now they should include one small health care scam that might have harmed patients.

So anyone concerned about health care corruption needs to realize that when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail. Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption? The only way we can now address health care corruption is to excise the corruption at the heart of our government.  

It was just a small health care scam...

The Mysteries Surrounding Rhodes Pharmaceuticals, the Sackler Family's Second Opioid Company

 Mysteries still abound in the not so wonderful world of health care dysfunction, so, quick, the game's afoot...

Today's mysteries involve beneficial ownership.  Beneficial ownership questions are important to anti-corruption campaigners.  Beneficial ownership simply refers to "anyone who enjoys the benefits of ownership of a security or property, without being on the record as being the owner." (per Wikipedia). Concealing who really owns a company enables concealing sources of funds (as in money laundering), market power (when the owner also owns competitors), and sources of political influence, and enables those benefiting from the actions of the company to escape responsibility for their consequences.

A few months ago, a big question about the beneficial ownership of a local (to me) company suggested important local and national health care implications, and yet the case has remained anechoic.  The case has some mysterious aspects.

The  Mystery of the Ownership of Rhodes Technologies and Hence Rhodes Pharmaceuticals Solved

In September, the UK based Financial Times reported,

The billionaire Sackler family, which has been blamed for fuelling the US opioid addiction epidemic, owns a second drugmaker that churns out millions of addictive painkiller pills every year, the Financial Times can reveal.

The Sacklers are best known as the owners of Purdue Pharma, the privately held drugmaker that makes the now infamous opioid painkiller OxyContin, which has been described as 'heroin in a pill'.

However, an FT analysis of company registration documents has established that the family also owns Rhodes Pharma, a little-known Rhode Island-based drugmaker that is among the largest producers of off-patent generic opioids in the US.

Furthermore,

Rhodes Pharmaceuticals was set up in 2007, four months after Purdue pleaded guilty to federal criminal charges that it had mis-marketed OxyContin over the previous decade.

The little-known company now makes several opioid-based products containing highly-addictive drugs such as oxycodone, morphine and hydrocodone, according to a US Food and Drug Administration database. Many of its drugs are made in factories owned by Purdue.

The Mystery of the Mysteriousness of the Rhodes Companies and Facility

The FT report was noted by our local on-line news site, GoLocalProv, which tried to find out more about the company. It reported,

And tucked away in Coventry, Rhode Island, along a country road, is Rhodes Technology — surrounded by massive security. The company’s website has been under -reconstruction for the past few years -- all an effort to keep a low profile.

A 2005 version of the Rhodes Technologies’ website GoLocal uncovered said, 'We have very broad capabilities in developing sophisticated chemicals and offer confidential production of high purity APIs and finished dosage forms of innovative pharmaceuticals, as well as marketing and sales services. A multi-million dollar investment in a new cGMP facility completed in 2002 added controlled substances to our manufacturing capabilities. Rhodes is a diversified, dependable firm well positioned for partnerships.'

The marketing arm of the Rhodes Technologies is Rhodes Pharmaceuticals and it self-describes itself as 'a privately held company headquartered in picturesque Rhode Island....developing and distributing quality pharmaceutical products since 2008.'

Emails and requests for an interview were not responded to by Rhodes Pharmaceuticals.

GoLocalProv article included a blurry picture of a large factory building apparently copied from an old website.  I could find no pictures or descriptions of the Rhodes facility on the web other than the picture below from Google Satellite:

The satellite picture does suggest that the Rhodes facility is apparently massive.  However, I could find nothing, at least via web searching, to otherwise describe it.  Despite its size, I could find no coverage of the company, the facility, the buidling of the facility (which likely was quite a project), or anything else relevant in local media, or on the web.

The reasons to keep the ownership of this company mysterious are not hard to fathom.  But the reasons for the company itself to maintain such a "low profile," and for its facilities to be so well hidden, and to have such "massive security" (not otherwise described by GoLocalProv), are ongoing mysteries.

The Mystery of the Sackler Family's Opioid Market Power Partly Solved


It appears that the Sackler's previously secret ownership of Rhodes enabled them to conceal their market power. Per the FT,

Purdue Pharma has always insisted that its drug OxyContin cannot be considered a prime culprit in the crisis because it accounts for only 1.7 per cent of overall opioid prescriptions in the US.

However, Rhodes and Purdue combined accounted for 14.4m opioid prescriptions in 2016, according to figures seen by the FT, giving them a total share of 6 per cent of the US opioid market.

That puts the combined Rhodes-Purdue in seventh place among opioid makers by market share, behind Teva, the generic drugmaking giant, and well ahead of other pharma groups that have been named in lawsuits, such as Johnson & Johnson and Endo.

'This further debunks the Sackler family’s whole claim that they are not responsible for the crisis,' said Andrew Kolodny, a professor at Brandeis University who is one of the foremost experts on the US addiction epidemic.

He added: 'They have always said, ‘Why is everyone picking on us, we’re only 2 per cent of prescriptions?' A spokesperson for the family declined to comment.

A second GoLocalProv article also revealed that

The billionaire family whose company is being sued by states and cities across the country for their role in creating the opioid crisis is now launching a new recently patented antidote for the drug known as ‘heroine in a pill.’

Both oxycodone and the new drug will be produced side-by-side at the Rhodes Technologies plant -- an affiliate company of Purdue Pharma -- in Coventry, Rhode Island.

To corroborate that,

The U.S. Patent and Trademakr [sic] Office information shows the Rhodes Technologies’ plant in Coventry, RI is assigned the patent for the new drug. Rhodes Technologies is the subsidiary of Purdue Pharma owned by the Sackler family.

Calls and emails to Rhodes Technologies and its affiliated marketing company Rhodes Pharma have not been responded to.

Note that the "new drug" that is considered an "antidote" to oxycodone is simply a minor modification of an old drug, buprenorphine, already used to treat opioid addiction.  Per Stat News,

The patent concerns a new formulation of buprenorphine, one of the medications shown to help people with opioid addiction. It is already approved by the Food and Drug Administration in tablet and film form, but the patent describes a wafer that could dissolve even faster than existing forms when put under the tongue.

The patent says that the faster the treatment dissolves, the less risk there is for diversion.

So now we know more about the power of the Sackler family in the opioid market.

The Mystery of Accountability for Deceptive Marketing of Opioids Partly Solved

Purdue Pharma has a long and sorry history of deceptive marketing of its narcotics, and has been accused of being a major driver of the ongoing opioid (narcotic) epidemic.  The case has recently been very well covered in the media.  (Our latest discussion is here, our discussion of Purdue Pharma's first legal troubles, which were fairly anechoic at the time, is here, and all our Purdue Pharma related posts are here.)

It appears that the Sackler's concealed ownership of Rhodes Technologies/ Pharma also put them in a position to generate more financial conflicts of interest among physicians which could be used to enable more deceptive marketing.  A search of the ProPublica "Dollars for Docs" data base revealed that Rhodes paid $1.43M to physicians from August, 2013, to December, 2016.  They paid the most, $121K, to a single physician in Saint Charles, MO.

Admittedly, their contribution to physicians' conflicts of interest was modest compared to that of the Sackler's better known Purdue Pharma, $27.9M over the same time period, but it should not be overlooked.

So we now know a bit more about the extent Sackler family owned opioid manufacturers enlisted physicians to market their products, at times deceptively. 

The Mystery of the Sackler Family's Political Influence

This is admittedly speculation, but it is possible that Rhodes Technologies/ Pharma was also used as a vehicle for political influence to affect policy making relevant to the Sackler's interests.  Purdue Pharma certainly has a track record of such influence.

For example, we noted here that Purdue Pharma donated money to the Washington Legal Foundation in support of its efforts to weaken enforcement of laws that could have penalized the company's misbehavior.   In particular, the Washington Legal Foundation challenged the responsible corporate officer doctrine that allowed legal action against corporate executives for company wrong-doing that occurred on their watches.  Perhaps corporate leaders were worried that its executives could again face penalties, given the Purdue Pharma executives had previously pled guilty to misbranding Oxycontin (look here).  Purdue Pharma had also worked with the Washington Legal Foundation to push against guidelines from the Centers for Disease Control that would have potentially reduced opioid prescribing.

Furthermore, we noted here that Rudolf Giuliani, now President Donald Trump's lawyer, and previously and probably currently highly influential in the Trump regime, formerly represented Purdue Pharma and had helped mitigate the company's punishment for past mischief, an interesting example of the revolving door from the pharmaceutical industry to government.

So I think it is reasonable to say that whether Sackler-owned Rhodes Technologies/ Pharma was also used as a tool to conceal political influence remains a mystery.

Summary

So we now know that the Sackler Family, owner of Purdue Pharma, also owns a generic pharmaceutical company that manufacturers an important portion of the narcotics sold in the US.  Thus the share of the opioid market held by the Sackler family is likely four times larger than was previously apparent .  The Sackler's generic drug company is now known to have paid physicians a small but important amount to assist in its marketing of opioids.  It is also possible that the generic company also has been used to increase the family's influence over politics and policy that increased opioid sales and hence its responsibility for the opioid epidemic.  Thus, it is likely that the Sackler family's responsibility for the ongoing opioid epidemic is larger than was previously appreciated.

Why the Sackler's may have concealed their ownership of the company seems obvious.  Why the company and its physical plant were so secretive is not so clear.  

It is unknown whether the family owns similar companies that have not been discovered.  It is unknown whether big pharmaceutical and other big health care corporations similarly have concealed beneficial ownership of other companies that could be used to conceal all manners of mischief.

Anti-corruption campaigner have pushed to reveal the beneficial ownership of all corporate entities.  (Look here for the relevant report from Transparency International.) They have made little headway, so far.  The case of the mysteries surrounding Rhodes Technologies/ Pharma should be another impetus to support this campaign. 

True health care reform requires all sorts of transparency, now particularly including transparency about corporate beneficial ownership.  

More on the Opiate Abuse Epidemic: Where Again Does the Finger Point?

In a recent blog post we pointed to conservatives' efforts to implicate Medicaid funding as somehow causative of, or at least promoting, the opiate "crisis." After all, funding for medications means people will use, and sometimes abuse, those medications. Meds they might otherwise ill be able to afford. (Implied solution: cut Medicaid.)

We also alluded to some of the logical fallacies in such thinking. Here, though, let's take it to another level: the blame game, where does it lead? Where does the finger point? Those who agree with Ronald Reagan that government is the problem, not the solution, fall into the trap of blaming public action and civic institutional development for the ills of our society.

But gosh, why is it that private actors get a bye? Isn't it possible that something other than public action could end up being the culprit? What creates this blind spot?

For one thing, those (they're discussed in the blog link above) who point fingers at Medicaid overlook inconvenient truths. Take the state-by-state data. True, West Virginia is among the top states, as it happens, for both Medicaid and addiction rates. But then look at New Hampshire. With Ohio, it is a close second for addiction but affluent enough to be near the bottom of states receiving Medicaid/CHIP. Somehow the great conservative logicians seem to miss data like this.

For another thing, when you go from the "faceless bureaucrats" to the families that run things in this country, there's the matter of privacy. There's a queasy feeling about ratting out your private "friends," even when they're not really friends at all. Even when they're polluting your environment or selling you (in our new parlance) some newly slavered S on toast. And private actors, once in the, well, let's say billionaire realm, can manage to protect their brand even while working behind the scenes to ruin--allegedly--people's health through false advertising. Turns out New Hampshire doctors prescribe opiates at about double the national rate, responding not to government but to private (Big Pharma) signals.

Such private matters have been the case, allegedly, with the family that brought you all the flavors of the pharmacologic gift that keeps on giving: oxycodone. We know this is the case especially, more recently along with fentanyl, with this drug in its most controversial form, Oxycontin. Oxycontin was brought to your local pharmacy by the still barely-known Sackler family. It's a dramatic story of a family out of Brooklyn by way of the medical schools of Glasgow and then the boardrooms and development offices of some of this nation's most prestigious citadels of culture.

Two recent discussions of the Sacklers point to their possible culpability in spreading a false gospel of SOAP: a Safe Opiate Administration Policy. Last fall we considered blogging on the first of those discussions in The New Yorker. But it's hard to access some literature hidden behind paywalls, so we held off. Now, however, a shorter and in a number of ways more accessible piece on the Sacklers now emerges in The Guardian.

The New Yorker piece, by investigative reporter and staff writer Patrick Radden Keefe, shows how this family of physician-entrepreneurs built an "empire of pain," as he styles it, starting as far back as the mid-20th century. This was the era of Estes Kefauver's aggressive committee hearings. But even congressional inquiry was no match for the aggressive advertising tactics and casuist hyperprofessionalism--hiding behind the degree--tactics of an Arthur Sackler, who "caught Kefauver in an error," notes Keefe, "and said, 'If you personally had taken the training that a physician requires to get a degree, you would never have made that mistake.'”

In related fashion, for health care the Sackler Brothers were among the first to use the megaphone of social media as a tool, in its primitive mid-century form, for disseminating messages to a gullible medical profession. They were sales geniuses, understanding the nudge-value of throwing money around. They created Medical Tribune, one of the most successful and impactful of what came to be known as throwaway journals These throwaways hit doctors' mailboxes on a daily basis. (Medical Tribune was biweekly but there were lots of others.) Conflict of interest? Why do you ask? Potentiating the message that opiates were safe, especially when there was a "clear need" for such agents? Question answers itself.

Toward the end of the last century, the story of the Sackler family and opiates took two other important turns. In 1995 OxyContin received FDA approval for moderate-to-severe pain. (Not long after, in the great tradition of the Revolving Door, the very FDA official who oversaw the drug's approval left the agency and went to work for the Sacklers at Purdue.)

Some of us recall that that was about the time an alarming tsunami of patients began to flood through our doors. Their complaint was stereotyped: months or even years after a mild-to-moderate injury, long after full healing could easily be documented, "If I don't take this medicine I get my pain back." Awareness of addiction was just about as conspicuous in its absence for us and our patients alike.

Some time also in the mid- to late-twentieth century, Sackler family largesse in the funding of the arts became an international phenomenon. While family names appeared conspicuously on galleries in prestigious institutions around the world, on the company website they equally conspicuously disappeared from the list of directors--up to eight in all.

This past week, New York journalist Joanna Walters, in The Guardian, related the story of Nan Goldin, a renowned Brooklyn artist-photographer. Goldin went from a case of tendinitis to a full blown OxyContin addiction that turned her into a recluse for three years. It is accessible with no paywall and makes intriguing reading. We watch Goldin out herself as an addict and valiantly seek to mount a counter-messaging movement. Goldin's verdict: "I don't know how they live with themselves."

And so here we are. Private actors buy their way forward into the benign and beneficent ranks of the cultured plutocracy. They do so while covering their tracks backward as the real vectors of an epidemic. (See Arthur Sackler's fascinating 1987 obituary in his own journal, extolling the "Renaissance Man" and implying he received medical school training at NYU.)

Meanwhile, the logicians in Washington, DC, still parrot Ronald Reagan that "government is the problem." No, Wisconsin Senator Ron Johnson, government, of which you are allegedly a part, is not the problem. Unless you're it. Those whom you protect with your flawed logic and equally flawed ideology are the problem. We suppose it's no wonder that last year, at an event in the state that both you and the Speaker of the House call home, Donald Trump kept calling Paul Ryan "Ron."