Adverse Reactions: The Fenoterol Story
Auckland University Press, $40.00,
At the outset I confess to a personal interest in this story. I am a physician (some physicians are among the villains of this piece), and I live with an asthmatic.
Neil Pearce is an epidemiologist with a fierce interest in the asthma “epidemics” which occurred in New Zealand in the 1960s and again in the 1980s. The former related to the dose of drug (Isoprenaline) in the inhaler. In New Zealand and five other countries that suffered an increase in deaths from asthma, the dose of the drug Isoprenaline forte was five times higher than the standard Isoprenaline dose. The standard dosage was the only formulation available to asthmatics in the United States and Canada whose populace did not suffer such an increase in asthma deaths.
Pearce became involved (as an epidemiologist) in trying to find the contributors to the next asthma epidemic in the 1980s. His involvement began in April 1988 and ended in December 1989. This book has not appeared until 2007 because he was too angry to write the story earlier. That anger is directed principally at the physician members of the Medical Research Council’s Asthma Task Force and at the drug company Boehringer Ingelheim, which manufactured the inhaled drug Fenoterol. Again, this drug was strongly implicated in the second asthma epidemic, but the evidence was necessarily one of strong association (as is always the case in epidemiological studies) rather than concrete proof. The drug company resisted the conclusions of Pearce’s assiduous study and later publication for the sake of sales. The task force is portrayed as resisting for the sake of their egos – they adopted positions and attitudes which denied the possibility that drug dose or type was involved in asthma mortality in the second epidemic.
Usually epidemiology is about as interesting as reading a bus timetable. It combines the seriously frowning discipline of statistics with the presentation of laboriously collected survey data. This usually flavourless mixture is enlivened by Pearce’s anger, indignation and frustration. He must have kept detailed diaries of all stages in the progress of the long process to publication of his group’s findings in their first paper and their further confirmation in the second.
So this isn’t an arid and boring account. It is a tale of frustration, determination and strategies and of his groups (the goodies) against drug companies and the Asthma Task Force (the baddies).
Boehringer Ingelheim makes Fenoterol, the drug which Pearce and others had implicated in asthma deaths. It was in the company’s interests to delay or stop publication of Pearce’s paper, distort its findings, publish refutation and organise “world expert” conferences to discuss its findings and provide opposing views. All of which happened. Their most astonishing action was persuading the editor of The Lancet to resile from printing the paper when he had previously accepted it for publication. So, even The Lancet editor necessarily joins the group of baddies. That Pearce examines not only his intellectual but also his emotional and personal responses to the numerous setbacks in publication of his findings adds momentum and depth to the tale.
That the drug company would go to such lengths and have such power in determining what is published in the scientific medical press is disturbing enough, but the company’s subsequent actions (on publication of the paper) in distributing “information packs” to all doctors in New Zealand is breathtaking. Commercial imperatives are one thing, denying and deriding scientific evidence is another. While the exact role of Fenoterol in the asthma epidemics in the 1980s still remains unclear, it is certain that it was a contributing factor. In the end, Helen Clark (then Health Minister) removed Fenoterol from the Drug Tariff, the New Zealand story closed and local asthma mortality declined.
Pearce suffered not only frustration, but also personal and professional attack in this episode. It doesn’t seem to have damaged him professionally. The back cover notes that he has had continuing academic advancement, but he certainly sustained some personal injury. His story of his own and his group’s single-minded determination and his insights into the equally determined strategies of one big drug company make this tale certainly worth reading. The reader will draw their own conclusions about the wider implications.
Rae Varcoe is an Auckland City Hospital physician and a reviewer.