Malcolm Gladwell writes with an outsider's clarity and wit, which has served him well in such books as the Tipping Point, an excellent and readable introduction to phenomena in sociology and marketing. Hell, he can even make ketchup compelling.

But he's now tackling drug prices, and while he makes some excellent points, I wonder if his final conclusion isn't off the mark.

It is accurate to say only that the United States has a different pricing system from that of other countries. Americans pay more for drugs when they first come out and less as the drugs get older, while the rest of the world pays less in the beginning and more later. Whose pricing system is cheaper? It depends...

In fact, drug expenditures are rising rapidly in the United States not so much because we’re being charged more for prescription drugs but because more people are taking more medications in more expensive combinations. It’s not price that matters; it’s volume.

So true, and not emphasized enough. But then Gladwell focuses on a significant problem in prescription drugs: new meds with side-benefits that aren't cost effective or particularly efficacious. An example he gives is pravachol (one of many "me too" cholesterol-lowering drugs), which was shown to lower strokes in a small, select population but actually raises stroke incidence in a bigger, more vulnerable population.

He doesn't squarely blame the drug companies for advertizing these benefits, and he doesn't exclusively blame doctors for overlooking the caveats buried in the scientific literature. Instead, he implicates a new target: medical journal editors, for not doing their jobs and properly highlighting the advantages and drawbacks to new drugs. This criticism is all the more damning, since a powerful former editor, Marcia Angell of the NEJM, has just written a book about Big Pharm's duplicity (and, um, dropped the ball on pravachol).

I've edited some manuscripts myself (for publications with substantially smaller impact than the New England Journal of Medicine), but can still vouch for its difficulty. Clarifying the results and conclusions of some scientist-authors can be like herding cats. And even after I've done a spiffy job, I still can't be sure which section of the paper, which figure or conclusion, will be seized upon by other authors. Some data that I considered superfluous might be the puzzle piece that allows another lab to move forward.

I don't think it's different for clinical publications on drug efficacy. I'd bet that, no matter what results an author uncovers, and no matter how skillfully these results are arranged and highlighted by an editor, drug company marketers will still find material to work with. They'll always be able to find obscure, questionable benefits to justify new drug prescriptions over less-profitable generics. These results will make their way into Big Pharma handouts and presentations, where they'll be repeated ad naseum for years. They've got more money, and they've got more interest. The editors can't compete.

Via Medrants.