Pharmageddon. David Healy

common neurotransmitters, norepinephrine and serotonin, are lowered in depression and that antidepressants could top them up. By 1970, psychopharmacologists had abandoned these hypotheses because of clear inadequacy.²⁶ But twenty years later, the idea that serotonin was low in depression and restored to normal by treatment was resurrected within the marketing departments of SmithKline Beecham, Lilly, and Pfizer, as part of the sales pitch for Paxil, Prozac, and Zoloft. It was marketing copy par excellence, too tempting to spurn. In fact, mindless patter about restoring chemical balances did a great deal to make the SSRIs among the most profitable income streams for the pharmaceutical industry from 1990 onward. In similar fashion when selling drugs for osteoporosis, cholesterol reduction, asthma, and other conditions, marketers cherry- pick from the language of the appropriate science to dress up their products. As they put it themselves, they leverage the bits of the science base that suit them.

      In addition to using information from the basic sciences, one of the clearest strategies companies use is to market diseases in the expectation that sales of the pills promoted for them will follow. This has happened from the 1950s onward, when Merck educated physicians to recognize raised blood pressure (hypertension) and its consequences after their new diuretic agent, Diuril, turned out to have antihypertensive properties. They convened symposia and sponsored studies on the benefits of monitoring hypertension.²⁷ This approach speaks directly to clinicians in clinical language. It also puts an ethical onus on them to eliminate a disease by prescribing a pill—one that comes sanctioned by the experts in the field.

      Patients also have to be softened up so they are receptive to the idea of being prescribed a statin, or an antihypertensive, or a biphosphonate for their bones. In the United States direct-to-consumer advertisements school people on the importance of their “figures”—their lipid levels, blood pressure, and bone densities—or alert them to the possibility that what they regard as restless legs may be in fact be an illness,²⁸ or that feelings of urgency as regards micturition, low grade pain, or less than perfect sexual potency may be illnesses that can be treated. Ask your doctor if…

      Elsewhere in the world promotional stories appearing in the health pages of newspapers and magazines fulfill the same function. PR firms place stories in the media and help sponsor books such as Listening to Prozac,29 while marketers increasingly utilize Internet sites where patients can diagnose themselves and take the resulting information back to their doctors. If there is a buzz around some disorder the British, Australian, or French media are naturally going to be interested to feature it, even though direct-to-consumer ads are not permitted in these countries. They may portray the condition as one that may be as effectively treated without medication, or indeed the program may come out vigorously against regarding certain states as disorders in need of treatment, but simply raising consciousness about the condition is taken advantage of by clever drug marketers. The company touch is subtle—sponsored symposia, for instance, will regularly feature talks by academics advocating nondrug approaches to an illness. These talks fill the same role as the comic at a burlesque show—a straight man is needed at intervals between the disrobing women.³⁰

      Capturing understanding is the prelude to selling pills. The marketer aims to convert people from thinking that childhood has its vicissitudes and developmental stages and that most distress and abnormalities are transient to thinking in terms of diseases and chemical imbalances that cry out for treatment, from depression to ADHD, autism to juvenile bipolar disorder. The normal elevations of blood lipids and thinning of bones that go with age are transformed into diseases—moreover, diseases that have become as much commodities as are iPods and as subject to fashion, with the main determinant of the fashion cycle being the patent life of a drug.

      So successful have the marketers been that it is now common practice among them to assume that few if any doctors will have any medical thoughts in their mind other than what is put there by either their own company or one of their competitors. They find even fewer physicians aware of how they are being sold pills, much less able to put up a challenge. Even if there were a challenge, just as Che Guevara has ended up as an establishment logo, so also can many forms of protest be incorporated by the marketers’ machinery.³¹ Just as a hostile review can sell books, companies have even learned how to increase sales in the face of FDA requirements to issue warnings about hazards such as birth defects due to Paxil, by “controversializing” the issues.

       BRAND NEW MEDICINE

      When asked to comment on the significance of the French Revolution, Mao Tse-tung and Chou En-lai are reputed to have said it was still too soon to judge. Two hundred years ago, in the midst of that revolution, Western medicine took on much of its modern character. In addition to the traditional and private relationship between doctor and patient, a new duty to look after the health of the wider population emerged, setting up new relationships between doctors and their patients and the state. One of the key players in shaping the new medicine was Philippe Pinel, among the most prominent of a new breed of doctors who stood in contrast to the society doctors of the eighteenth and nineteenth centuries that made a living treating wealthy patients with hypochondriacal ailments.³²

      Faced with the competing pressures on doctors, Pinel stressed that physicians needed to combine their roles as givers of care and as scientists. It was only through the application of science, he said, that doctors would be able to distinguish among the conditions they were treating and establish the natural history of each. This would give them the best chance to discover the anatomical basis of these conditions and might lead to new therapies for both individual patients and the wider community.

      Pinel’s approach both to science and its public dimension was vindicated in the 1880s, when laboratory science began to demonstrate links between diseases and microbes. Once it was clear infections were transmissible, medicine had to have a public dimension. In our day this dimension is global. Drug-resistant tuberculosis in Russia and AIDS in Africa pose threats to all of us.³³

      If in principle the mission of medicine has been to treat the diseased and dying wherever they are, that of the pharmaceutical industry has increasingly been to protect its patents and its profits. The clash of these values came to a dramatic head in the late 1990s with the struggles to make antiretroviral drugs available in sub-Saharan Africa for the treatment of HIV-AIDS, just as Glaxo Wellcome and SmithKline Beecham were in merger talks. The first of the antiretroviral drugs, zidovudine, also called AZT, was developed in university laboratories with public funding—the first of which, for marketing and distribution purposes, was offered to Burroughs Wellcome (prior to the merger with Glaxo) to patent, which it did and then marketed as Retrovir.³⁴ The fear of AIDS in the 1990s ensured that Glaxo Wellcome and other companies marketing these drugs had a rich return on these products.

      In the early 1980s AIDS appeared to be confined to the United States or the Western Hemisphere, but by the 1990s it was clear that there were far higher rates of infection in Africa and a risk of the disorder spreading to Asia and elsewhere. The rates were so high that many African countries faced being crippled by the disease. Supported by all other companies, GlaxoSmithKline (GSK) refused to either permit other companies to offer the drug in generic form at much lower prices or to lower the price on AZT themselves to a level that would make it possible for the hundreds of thousands suffering in Africa to benefit from it and thereby stem the tide of an enormous tragedy. To do so, GSK argued, would breach patent law in a manner that would compromise future drug discoveries. It was as though the companies who produced diphtheria antitoxin a century earlier had refused to make it available. The outrage of almost the entire world forced GSK to back down.

      Glaxo and other pharmaceutical companies have been willing to treat the West and, more recently, the wealthy parts of China, India, and Brazil, as gated communities, within which one form of healthcare will be available and outside of which no questions will be asked. Some of those inside the gates may regret this policy, but provided their children and families are not the ones dying from diphtheria or AIDS these regrets are unlikely to lead to action. But this is short-sighted in the extreme. The same patent and marketing factors that have led companies to lose interest in developing drugs for Third World diseases if these do not afford a sufficient return on investment by today’s blockbuster standards, mean that the drug companies are no longer likely to play the kind of role they once did in