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 eliminating disorders like diphtheria or bacterial endocarditis. Indeed, they didn’t develop AZT or the other retrovirals for AIDS; these applications were developed elsewhere with public funds. They are not likely to develop better anticonvulsants for epilepsy or bring treatments for multiple sclerosis on the market, since even within the gated communities of the developed world the incidence of these conditions is such that it is not worth their while to make the investment. Return on investment rather than elimination of disease is, after all, what drives a pharmaceutical company.
This philosophy is as diametrically opposed to that of Philippe Pinel, Alfred Worcester, and Richard Cabot as it is possible to get. For over a century patients have assumed that the knowledge a doctor like Cabot brings to helping them stems primarily from what is known about the condition being treated or that what a doctor like Worcester brings stems from a judicious appraisal of the limits of current knowledge and treatments. But in the past two decades what is “known” has come increasingly to be dominated by the self-interested constructions of the pharmaceutical companies, through the activities they sponsor, the kind of research they promote, and the information they choose to reveal—or conceal. Under siege, doctors like Dr. N have turned to the appearances of science and spend their time filling standardized forms in medication clinics rather than talking to or looking at their patients. In this process they have become the faithful if unwitting collaborators of the pharmaceutical companies, almost as though the debates between Cabot and Worcester about the purpose of medicine had not taken place a century ago—or worse, almost as though Clark Stanley marketing snake oil or Thomas Beecham marketing his pills had not faded away in the face of developments in medical science or a growing commitment to medical care of the type Pinel and Worcester advocated but had instead taken over the health service business.
In 1909 Beecham’s Pills ran into trouble when their claims to be a cure-all for lifestyle problems included suggestions that this combination of aloes, ginger, and soap, whose retail price was 500 percent of its costs of production, might be useful for “maladies of indiscretion.”35 This claim was read as offering a “morning after” service. In 2009, GSK, whose fortunes at the time of the patent disputes over AZT rested on the SSRI Paxil, a drug a former CEO had derided as a lifestyle drug but which Glaxo had inherited when taking over SmithKline Beecham, lost a legal verdict to Michelle David, who claimed Paxil had caused congenital heart defects in her son Lyam
