Pharmageddon. David Healy

of Health budget for research on Alzheimer's disease, arthritis, autism, epilepsy, influenza, multiple sclerosis, sickle cell disease, and spinal cord injury combined.⁶ Given that Lipitor was only one of six statins on the market at the time, anyone trying to get out a competing medical message—that statins have a very limited role in healthcare or that there are alternate ways to lower cholesterol through diet and other approaches—faces a daunting challenge. With money like this behind them, twenty-first-century corporate marketers are supremely confident they can sell anything. Bottled water, oxygen, and with the right packaging, even inferior mousetraps. And if they can do this, why not homeopathic or relatively worthless medicines?

      Pharmaceutical companies have perhaps done more to undermine traditional markets than any other industrial companies. Not coincidentally, from Lilly's 1951 ad to a 2005 book by Hank McKinnell,⁷ then CEO of Pfizer, they are also the corporations most active in spreading the message that there is no alternative to a free enterprise system. But while in fact many industrial corporations came to the conclusion a century ago that the capitalism of cutthroat competition and free markets didn't work as well as it might—at least not for them—no other branch of industry has been able to pursue this agenda in quite the way pharmaceutical companies have.

      To begin to see how pharmaceutical companies have engineered what they have, we need to return to the mid-nineteenth century when the first science-based companies began producing goods made possible by the new physical and chemical sciences. These sciences formed the basis of electrical manufacturing as well as the chemical and metal industries, leading to a string of new goods from automobiles to plastics, explosives, dyes, rubber products, artificial fibers, and, later, pharmaceuticals. In all these cases, competition between companies should in theory drive prices down in an open market, especially when increasing automation reduced the cost of production. Faced with the risk of falling profits, the new manufacturing companies commonly banded together in cartels to keep prices artificially high. A cartel presents the world with apparent competition between companies when in fact the companies have agreed among themselves to coordinate prices and market arrangements, allowing them to enjoy the advantages of de facto monopolies.⁸ But government resistance to cartels mounted in the United States and Europe at the end of the nineteenth century.

      Companies needed to find another way to maintain or increase their profits. It was this that led to a turn to marketing. For manufacturers the problem was that as the genuine need for automobiles, plastics, dyes, nuts and bolts as well as mousetraps were increasingly met with capacity to spare, ever more production could only drive prices down. If prices could not be rigged by cartels, could demand be maintained or increased by tapping into what people might be persuaded they wanted or needed?⁹

      An appreciation of the opportunities that marketing opened up led to the emergence of marketing departments within companies and the first university courses on marketing in the 1920s.¹⁰ In a supreme irony, much of the raw material for these courses came from a brilliant set of ad hoc developments that underpinned the marketing of proprietary, over-the-counter medicines in the nineteenth century. The early exponents of the new science of marketing realized that the true experts on understanding what people might be persuaded they needed were quacks pushing worthless medical remedies. It was these who more than anyone else created advertising and shaped modern marketing.¹¹

      One of the first lessons that proprietary medicines taught later marketers came in the 1830s, when a war broke out in the newspapers between Samuel Lee, Jr. of Connecticut who produced “Bilious Pills” and another Samuel Lee from Connecticut who also produced a Bilious Pills remedy. Far from leading to market collapse, this dispute spurred demand for Bilious Pills, and soon other proprietors across the country were joining in with their own preparations. In contrast to the producers of dyes and metal goods, these businessmen found competition among producers led to increase in sales for their commodities, without prices falling. In the drug domain this phenomenon has been demonstrated again and again from the marketing of Aspirin as a brand name product in the nineteenth century to that of Lipitor and Vioxx in this century.¹²

      In 1804, there were some ninety over-the-counter proprietary medicines listed in New York. By 1857, this had swollen to more than fifteen hundred countrywide. The growth in business paralleled the growth of the press and literacy. Where there were two hundred newspapers in 1800, there were four thousand by 1860. The proprietors of these remedies took advantage of this explosive growth and were among the first to market nationally. They also marketed heavily: the proprietary medicines industry spent more than any other industry on advertising in the second half of the nineteenth century. By the end of that century up to $i million was being spent on telling the American people about the benefits of Scott's Emulsion, just one of an estimated fifty thousand compounds in a trade that had a retail value of several hundred million

      dollars.¹³

      The proprietary medicines industry was the first to market lifestyles rather than the compounds per se—this was marketing before the modern term had come into being. There was a simple reason for this: there was little if any value in these substances. The key ingredients were on the bottle rather than in it—the branding. It was no accident that one of the leading early lights in advertising, Claude Hopkins, would say that “the greatest advertising men of my day were schooled in the medicine field”¹⁴—schooled, that is, in how to persuade the public that Carter's Little Liver Pills, Lydia Pinkham's Vegetable Compound, Clark Stanley's Snake Oil Liniment, or Coca Cola or, later, 7-UP would restore health or beauty, resolve halitosis, conquer fatigue, or ward off calamity. The money thrown into the marketing campaigns came from huge markups in the selling price of these compounds, typically inflated to five times their cost of production.¹⁵

      Marketing does exactly the same thing today when it gets us to believe that a particular running shoe or music system is not only necessary for its stated function but will deliver what we desire more generally in life—our unmet needs. These are the suggestions that underpin the marketing of bottled water and other such items that most people for most of the twentieth century never imagined could be marketed. And as the bottled waters of the twenty-first century along with the proprietary medicines of the nineteenth century (which contained little more than water) show so clearly, the differentiation between one product and another is seldom based on actual differences in the products but hinges rather on brand recognition, on how effective competing marketers are in encapsulating wish fulfillment, and in saturating potential purchasers with their message.

      While there were differences in emphasis between medical men like Cabot and Worcester, during the period from 1850 to 1950 medicine was united in an implacable opposition to medical quackery and proprietary remedies—and by extension to marketing. In early nineteenth-century Europe and the United States, there was no licensing of physicians and no training in science as part of their education. Hospitals were almshouses for the poor rather than institutions with a mission to treat effectively. When people got sick, they increasingly turned to the remedies being advertised nationally and sold by salesmen, who peddled everything from cures for cancer to elixirs for love or eternal youth.

      Faced with a proliferation in wild claims for cures for everything from consumption to nervous problems, the first European and American associations of physicians that emerged in the mid-nineteenth century committed themselves to ensuring medical doctors knew what they were prescribing and knew what there was to know about the conditions they were treating.¹⁶ In cases where no treatment seemed to work any better than judicious waiting, the new breed of doctors were educated in the virtue of waiting with their patients, trained to recognize as had Philippe Pinel that there was often a greater art in knowing when not to prescribe than in prescribing.

      In Europe the greatest concern regarding these remedies was voiced over markups of 500 percent or more for compounds that contained little that might actually help patients.¹⁷ In the United States, where the proprietary industry flourished to the greatest extent, physicians expressed greater concern over the injuries some of these potions could cause. As Oliver Wendell Holmes put it at a meeting of the Massachusetts Medical Society in 1860, “I firmly believe that if the whole materia medica [the available drugs] could be sunk to the bottom of the sea it would be all the better for mankind—and all the worse for the fishes.”¹⁸