The tale of the little fish that dared to swim in a big pond

In this parable on the relationship between pharmaceutical and botanical companies, consultant Joerg Gruenwald argues that the big fish of the drugs world don?t like small-fry botanical companies swimming in their pond.

Long ago the apes knew which small fish to eat when they didn?t feel well. This knowledge was passed on to humans, who used this tradition for many thousands of years and everybody lived happily together. This knowledge was passed down from generation to generation and everyone shared the fish because everybody wanted to be healthy.

Today 80 per cent of the world?s population still has small fish as their main source of medicine. But in some parts of the world, new things started developing about a hundred years ago.

Some smart guys found little tricks to modify the small fish and give them a number tag (patent) and a little ?r? in a circle (brand name) to make the small fish into big fish. The big fish were automatically more expensive than the small fish and the sellers of big fish became richer and richer. When you get a taste of money and power, you will always want more and look for new ways to get it. So the sellers of big fish created more big fish or took over the big fish of their competitors and became even richer.

But strangely enough, the small fish were still out there and some people claim the small fish are just as good as big fish. In fact, lots of people prefer the small fish. This started to worry the big-fish sellers, especially when small-fish sellers started to take over part of the market, so new strategies were needed.

After thinking for a long time, the sellers of big fish came up with three ideas to discredit their rivals:

  • Small fish don?t work
  • Small fish are dangerous
  • The best of the as-yet-unknown small fish must be gotten rid of as quickly as possible

Let?s see how they promoted these three ideas:

?Proving? that Small fish don?t work
To protect their own fish, the sellers of big fish enlisted the help of their friends—the politicians—to create rules that make it very difficult for new fish to enter the pond. They called these ?drug regulations? and only the very rich could afford to meet them.

In particular, they said that you have to prove a new fish is better than a dead fish. They called this a ?placebo-controlled, double-blind study? and made it so expensive that most small companies could not afford to do it.

But strangely enough, the small fish were still out there and some people claim the small fish are just as good as big fishEventually, even small companies started performing these trials on their small fish. And they were so successful that a nice little fish called St John became famous. The fame of St John grew internationally until it became a $500 million market. This made the sellers of big fish really mad. They decided to conduct a trial between a big fish (sertraline), the small fish (St John?s wort) and a dead fish (placebo) because they were sure that the big fish was better.

Big-fish sellers always have a lot of friends because they have lots of money, so doctors like them, pharmacists like them and politicians like them. But strangely, the clinical trial didn?t turn out as they had expected. Neither big-fish sertraline nor small-fish St John was better than dead-fish placebo.

?We know!? said the sellers of big fish. ?We have our friends in the media. We pay them so much money through advertising that they have to help us!? So they told the media that small-fish St John wasn?t any better than dead-fish placebo. So St John got hit by a negative press campaign based on a study that was equally bad for the big fish.

What do we learn from this? We learn that your friends will always look after you.

Small fish are ?dangerous?
Another nice little fish has been living in the South Pacific for thousands of years and is used on a daily basis in a beverage to relax people. It makes you feel friendly so you don?t fight anymore and can be at peace with the world.

The little Kava fish became very popular in many parts of the world. The big-fish sellers didn?t like this, not at allThis small fish is called Kava and it even sold well in areas where the sellers of big fish live. This is because many people there work too much, are afraid of losing their jobs and worry about what the future will bring. So this little fish from the South Pacific became very popular in many parts of the world. The big-fish sellers didn?t like this, not at all. This was their territory and they had other big fish to help stressed-out people. So they tried strategy number two: Small fish are dangerous.

Beginning in a hospital in Switzerland, the big-fish sellers found a case where a person took the Kava fish and later developed a liver problem. This was a good start. Now they could ask all their doctor and pharmacist friends if they had ever seen a similar case. Since 30 per cent of cases of liver enzyme elevation are diagnosed in doctors? surgeries, they were sure to find some examples. They searched long and hard but most cases were not really conclusive.

Eventually, they could only find two cases, which they said were clearly related to the small fish. Because they knew that only two cases sounded a little bit weak, they also summarised a lot of other cases, which were not conclusive but where small fish might have contributed.

They also used the first strategy at the same time, and said that the small-fish Kava doesn?t work. The problem was that there were many placebo-controlled, double-blind studies showing the exact opposite, so they had to find new arguments. They claimed the quality of the studies was not good enough, the dosages were not always the same, and that the preparations were different.

In the end, they had found arguments to fit all the studies, and could say that the small-fish studies were not good enough, the small fish does not work and that there may be some risk associated with it. So, the small-fish Kava was taken off the market. Even better for the sellers of big fish, when one country made this strange decision, neighboring countries eagerly followed and Kava was banned all over Europe.

What is really odd is that people in the South Pacific still use the small fish every day and think that everyone else is really stupid. They never get liver problems from small fish.

Getting rid of the best unknown fish
Since the sellers of big fish have to protect their pond, they are constantly looking for new small fish that may cause unwanted ripples. When the small fish are not very well known, they bypass strategies one and two and try strategy three. In other words: ?Don?t let anybody know there is a small fish that might be good for you.?

The best example is the small fish Hoodia from South Africa. This small fish was used for thousands of years when men went hunting in the bush and stayed away from home for many days. Since they couldn?t take food with them, they took this little fish and it would keep them from feeling hungry. But this secret was very well kept and only a few people knew about it.

The big-fish sellers? spies are constantly looking out for new threats to the market, and they soon found out that this little fish might disturb the huge market for appetite-suppressant drugs. They were lucky that this small fish only lives in a very limited area and grows very slowly. So they decided to buy all the Hoodia fish in the world and then all these little fish just disappeared from the market. So what is the moral of these tales? Well, one might be that big fish don?t like small fish, and try to discredit them whenever possible. Another is to be careful which pond you swim in, or you might just get eaten by a big fish, too!

Joerg Gruenwald is a director of Phytopharm Consulting, Berlin, Germany
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