is a gold-standard paradox: individually we benefit from some wonderful medicines while, collectively, we are losing sight and sense of health. By analogy, think of the relationship between a car journey and climate change—they are inextricably linked, but probably not remotely connected in the driver's mind. Just as climate change seems inconceivable as a journey outcome, so the notion of Pharmageddon is flatly contradicted by most personal experience of medicines.”5
By “Pharmageddon,” what Medawar and colleagues (myself included) had in mind was something quite different than a simple pharmaceuticalization, where we talk about our neurotransmitters rather than our moods, a biological reduction of secularism.6 Pharmageddon refers not to a change in the language of medicine or a change from religious to biological language, but to a process that was deployed in the first instance in the belief that it would better enable us to care for each other, though now it is a process that seems set to eliminate our abilities to care—a fate that beckons in spite of what everyone wants. At the heart of this process is the turn toward quantification in the middle years of the twentieth century. While genuinely helpful, this turn gave healthcare a set of scientific appearances that a handful of shrewd advisors and marketers have been able to manipulate to infect our abilities to care as if with a clinical immuno-deficiency virus (CIV). As a result the defense reactions that we might expect from prestigious journals and professional bodies just don't happen. Indeed the virus seems to have been able to subvert these bodies to its own purposes, so that when critical comments are raised they have reacted almost as though it was their programmed duty to shield a few fragile companies from the malignant attentions of a pharmaco-vigilante.
PHARMAGEDDON UNFOLDING
Since the 1970s, a profound change has been occurring both in the nature of the drugs marketed and in the practice of medicine. New drugs, like the statins, have continued to appear as have new diagnostic tests to measure, for instance, our cholesterol levels, apparently in the tradition of testing that led to so many medical advances in the early twentieth century. But where previous drugs and tests were geared toward the diagnosis and cure of diseases that posed an imminent risk to life, now medical practice is increasingly geared to chronic disease management with drugs that modify risk and lifestyle factors rather than save lives. This is a post-Worcester and post-Cabot world, in which pharmaceutical companies sell diseases rather than cures.
On the surface medical practice appears the same but underneath it's not. For instance, a small number of people have a genetic disorder that leads to excessively high cholesterol levels and for them drugs like the statins can save lives, almost in the way that antibiotics or insulin saved lives half a century ago. The statins can also save lives among people who have had strokes or heart attacks and who also smoke or are overweight, but in this case hundreds of people have to be persuaded to take them for the rest of their lives in order for a handful among them to be saved. For the most part, however, the statins are instead given to healthy people who have mild elevations of their cholesterol levels. Similarly, treatments for asthma or osteoporosis are now given to many people who would never have been diagnosed and treated before. Treatment happens now in response to results on a series of tests that have emerged in recent years—but these new tests don't help make a diagnosis that will lift a threat to our lives. Instead they effectively make a diagnosis of some drug deficiency disorder, and they often enter medical practice as part of the marketing strategy for a new drug.
These new diseases and their treatments have gained a purchase on us because they are presumed to represent the latest advances in a story of progress that runs through insulin and the antibiotics and will hopefully lead someday to cures for cancer. These are the drugs that, had they been available, some presume might have saved many of my father's generation. But far from saving either their lives or ours, clinical trials show that the indiscriminate use of drugs to lower lipids or blood sugars, to relieve respiratory wheeze, or to block stress hormones may even increase the risk of loss of life,7 and appear to be doing so in the United States, the country that makes the greatest use of the latest pharmaceuticals, where since the mid-1970s life expectancy has been falling progressively further behind other developed countries.8
If you looked around a restaurant, cinema, or office thirty or forty years ago that had a hundred or more people in it, you could predict that 5 to 10 percent of them might have a medical condition—sometimes unbeknownst to themselves—and a trained doctor would have been able to spot many of them just by looking. If you look around the same restaurant or office now at the apparently healthy people, those a doctor can't readily spot as ill, chances are that 80 to 90 percent of them could be diagnosed with one of these new “disorders.” Almost all will have cholesterol, blood sugar, blood pressure, bone density, or asthma numbers or one of an ever growing number of “mental health disorders” for which a pill will be suggested. Unlike being diagnosed with a traditional medical illness, these people won't be diagnosed because they are suffering and take themselves to a doctor. They will be diagnosed because an apparatus will come to them, perhaps coincidentally when they are at their doctor's for something else, or perhaps soon to a supermarket near them, an apparatus that will show them that their “numbers” are not quite right. It is only then that they will begin to suffer, either because of their discomfort and fear following a diagnosis or by virtue of the very real side effects triggered by the new pill they have been put on, a pill which has been marketed as an answer for any of us whose numbers aren't quite right.
Recent books have attempted to diagnose what lies at the heart of our growing disquiet at what is happening to medical care.9 These critical studies almost universally blame the pharmaceutical companies, who are now among the most profitable corporations on the planet and who, due to grossly inflated estimates of drug development costs and the emergence of blockbusters—drugs that gross at least a billion dollars per year—are supposedly making too much money. This money lets them buy lobbyists and influence, do a variety of things to turn the heads of doctors, as well as sponsor patient groups to lobby against attempts to limit in any way access to the latest high-cost treatments.
While making many excellent points and calling for action to tackle the problems the pharmaceutical industry poses, these concerned critics, largely from the medical profession, typically portray medicine itself as fundamentally healthy. The serenity of these physicians stems from their perception that, in contrast to an earlier time, medicine is now secure behind the ramparts of science. This science is not the laboratory science that emerged at the turn of the century with doctors like Richard Cabot but rather a science of randomized controlled trials (RCTs) that stems from the 1950s. In these trials new drugs are pitted against dummy pills, or placebos, and it is only if the new drug “wins” that it is allowed into use.
These trials have laid the basis for what has come to be called “evidence-based medicine.” The results of RCT trials are also incorporated into evidence-based guidelines for the treatment of different diseases, and these guidelines, when embraced by particular agencies, constrain the prescriptions doctors can write. Many professionals involved in healthcare see such guidelines as keeping doctors within a straight and narrow path of therapeutic virtue, whatever the blandishments of pharmaceutical or medical equipment companies. Few suspect, as I will argue in chapters 5 and 6, that these guidelines in fact hand medicine over to the drug industry. Insofar as evidence-based medicine means that doctors stick to treatments that “work” and eliminate those that don't, many professionals involved in healthcare see it as offering the only possible basis for a universal healthcare system, if such a system were wanted. But as currently practiced, evidence-based medicine tolls a death-knell for the possibility of universal healthcare in the United States or its continued existence elsewhere.
Aware that something is wrong, we cast around for a villain and often settle on the insurance companies or other third party payers for our current woes. While many grievances against insurance companies are legitimate, they too have a diminishing grip on the healthcare agenda. Because only the drugs and the style
