Introduction
Doctors call it the resurrection drug. They have watched as it freed patients from what seemed an inescapable death.
The medicine treats sleeping sickness, a disease far more lethal and terrifying than its name implies. Opportunistic tsetse flies spread the disease through much of Africa, devastating villages and killing tens of thousands of people a year. The jewel-eyed yellowish brown flies thrive in thickets along rivers where women and children go to collect water. With a bite, the bloodsuckers inject deadly parasites into their human victims. As the parasites multiply, their human hosts appear to go mad. The victims grow agitated and confused, slur their speech, and stumble. Finally come coma and death.
The pharmaceutical company that manufactured the medicine, a failed cancer drug with the tongue-twisting name eflornithine, abandoned it in 1995, seeing no profit in selling it in poor countries.
But the resurrection drug made its own revival a few years later—not in Africa, but in the United States, a land free of tsetse flies but with fourteen million women worried about unwanted facial hair. Another company began selling it in the form of a depilatory cream to minimize female mustaches. With its lavender-colored logo resembling a graceful swan and advertisements sporting young, beautiful models, eflornithine became another prescription drug marketing success.
The company christened its product Vaniqa.
This is a book about a great transformation in the prescription drug industry over the last twenty-five years. Once the most successful pharmaceutical companies were those with the brightest scientists searching for cures. Now the most profitable and powerful drugmakers are those with the most creative and aggressive marketers. The drug companies have become marketing machines, selling antidepressants like Paxil, pain pills like Celebrex, and heart medications like Lipitor with the same methods that Coca-Cola uses to sell Sprite and Procter & Gamble uses to sell Tide.
Selling prescription drugs—rather than discovering them—has become the pharmaceutical industry's obsession.
Prescription drug marketing now permeates every corner of American society—from Sesame Street to nursing homes to the nightly news. Medicine ads sprout from billboards, scoreboards, the hoods of race cars, and the back covers of magazines—all once venues of the similarly ubiquitous cigarette ads of the 1960s and 1970s. Imitating neighborhood grocers, the drugmakers offer coupons, free gifts, and deals to buy six prescriptions and get one free. They hold sweepstakes and scholarship contests. They pay to sponsor rock concerts, movie premieres, and baseball's major leagues.
The marketers make the use of their dangerous medicines look attractive and easy. Fentanyl, an addictive narcotic eighty times more potent than morphine, comes in a berry-flavored lollipop. Syringes used to inject children with growth hormone look like kaleidoscope-colored writing pens and PlaySkool toys. In 2006 drug companies gained approval to coat their pills with "pearlescent pigments" to enhance them with a shimmery satin luster and make them look as precious as their price.
During New York's 2003 Fashion Week, swimsuit models shimmied down the catwalk, showing off Johnson & Johnson's new contraceptive, a white-colored patch that was glued to the skin. By wearing the drug as a fashion accessory, one company executive explained, women "can look beautiful and feel confident."
Men attending professional golf tournaments in 2004 heard a different pitch. Step right up for free tips on your golf game, offered marketers working in a tent promoting Cialis, a drug for erectile dysfunction. Step right up for a free video lesson from a sports psychologist, the salesmen invited. By the way, they added, do we have the perfect drug for you!
America has become the world's greatest medicine show.
The marketing works. Never have Americans taken so many prescription drugs.
Americans spent $250 billion in 2005 on prescription drugs, more than the combined gross domestic product of Argentina and Peru. Americans spent more on prescription drugs in 2004 than they did on gasoline or fast food. They paid twice as much for their prescription medicines that year as they spent on either higher education or new automobiles.
The American prescription drug market is so lucrative that many foreign drug companies have moved in and now depend on Americans for most of their profits. For foreign executives, the math is simple. Americans spend more on medicines than do all the people of Japan, Germany, France, Italy, Spain, the United Kingdom, Australia, New Zealand, Canada, Mexico, Brazil, and Argentina combined.
As the medicine merchants have poured billions of dollars into selling their wares, they have become America's most powerful industry. In the process, they have transformed American life. The small white-capped whiskey-colored bottles that once took up a corner of the bathroom cabinet now play a role in lives that few products can match. Almost 65 percent of the nation now takes a drug available only by prescription. Children line up in the dining hall of their summer camps to get their daily doses. Pharmacies stay open twenty-four hours to meet America's demand. Even the dogs get Prozac if they howl too much at the moon.
The pharmaceutical companies build their laboratories on the campuses of public universities. They recruit patients for clinical trials at shopping malls and county fairs. On network television, the plots of prime-time shows revolve around brand name prescription drugs, at times at the suggestion of marketers at a pharmaceutical company.
The medicine promoters have turned what were once normal life events—menopause, despair from a divorce, anxiety caused by a workaholic boss—into maladies that can be treated with a pill. After all, when patients are customers and medicines are commodities, the industry thrives when people are ill—or believe they are.
The companies have found the United States, with its consumer-driven culture, a perfect medicine market. We expect instant gratification of our desires and a quick fix for whatever bothers or distracts. Americans are eager to believe in the panaceas offered in the six drug commercials that regularly accompany each evening's news. We are told—and want to believe—that we can swallow a pill and soon be dancing on a dinner cruise, running on the beach, or playing football like John Elway, the former NFL quarterback and promoter of Prevacid, a heartburn pill. If we eat too many cheeseburgers and fries, there is comfort knowing one pill will settle our stomachs while another brings our cholesterol back down.
In the condos of Palm Beach, the bungalows of Los Angeles, and the farmhouses of Iowa, people are taking more and more pills. The average American collected more than twelve prescriptions from his pharmacy in 2006, up from eight prescriptions in 1994. Older Americans take home even more—an average of thirty prescriptions each year.
In 2003 Secretary of State Colin Powell explained the nation's new prescription habit to a journalist for the Arabic newspaper Asharq Al-Awsat.
"So do you use sleeping tablets to organize yourself?" asked the writer, Abdul Rahman Al-Rashed.
"Yes. Well, I wouldn't call them that," Powell replied. "They're a wonderful medication—not medication. How would you call it? They're called Ambien, which is very good. You don't use Ambien? Everybody here uses Ambien."
There is a problem, however, with the new American way, one that the drug companies and doctors prescribing the medicines do not like to talk about. Experts estimate that more than a hundred thousand Americans die each year not from illness but from their prescription drugs. Those deaths, occurring quietly, almost without notice in hospitals, emergency rooms, and homes, make medicines one of the leading causes of death in the United States.
On a daily basis, prescription pills are estimated to kill more than 270 Americans—more than twice as many as are killed in automobile accidents. Prescription medicines, taken according to doctors' instructions, kill more Americans than either diabetes or Alzheimer's disease.
America has become "a grossly overprescribed nation," says Dr. Arnold Relman, professor emeritus at Harvard Medical School and the former editor of The New England Journal of Medicine. "Again and again you see examples where patients get far more medication than they need. The average senior in America is probably taking twice or three times the medications they require."
Doctors prescribe one drug only to create new problems for the patient with the pill's side effects. Rather than realize the medicine is making them ill, patients believe they are just getting old and ask for even more pills. Arthritis patients get pain relievers, which raise their blood pressure. At their next visit, doctors prescribe medicines for hypertension, which come with a whole new set of adverse effects.
It is estimated that the nation may now pay as much to care for patients who were harmed by their prescriptions as it spends on those medicines in the first place.
Despite these injuries and deaths, the medicine merchants have not stopped with adults. They are now targeting the increasingly profitable and fast-growing medicine market for children. The companies' marketers have created storybooks, video games, and soft, cuddly toys to attract children's attention. They have also learned to aim their appeals at parents' desire to have the perfect child. Parents of short children are told that daily injections of human growth hormone can help their son grow inches and be better accepted by his peers. They are told that Ritalin will help their daughter get higher grades. An antidepressant, they learn, may help their shy child play with other kids. In 2002 and 2003 prescription spending rose faster for children than for seniors, baby boomers, or any other group.
But so far scientists know little about the long-term effects of using powerful adult drugs in children, making the booming pediatric market a grand American experiment. The drugs have already harmed thousands of children. Federal regulators received more than seven thousand reports of drugs harming infants and toddlers under age two between 1997 and 2000, according to a university study. More than 750 of those children died.
The vast majority of the industry's marketing dollars is directed not at consumers but at physicians, the gatekeepers whom patients trust. In 2004 the industry employed an army of 101,000 sales representatives to call on those doctors—two and a half times the size of its sales force in 1995. There is now one drug salesperson for every six physicians, each with an expense account that lets him shower doctors with gifts and cash. Surveys show that virtually every American physician now takes these handouts.
Sales representatives at a company called Tap Pharmaceutical Products gave frequent prescribers of its medicine Lupron television sets and VCRs for their offices and tickets to Broadway's Phantom of the Opera. When a doctor asked the drug company to pay to relocate his office, Tap's executives wrote a check. When physicians wished they could earn more money, Tap paid up to $25,000 for consultants to guide them on how to be better businessmen.
A training manual for Tap's salespeople explained they should expect doctors and hospitals to ask them for cash. The sales reps could deliver the money, the manual directed, as long as they remembered that "the primary factor" was "what will the grant do for you and your company." The company expected doctors receiving the gifts to return the favor by writing more prescriptions. "If a non-user physician asks for money," the manual instructed, referring to doctors who did not prescribe Tap's products, "ask for scripts."
By the beginning of the twenty-first century, doctors had come to count on the industry's handouts. "It's nice after an exhausting day at work to go to a dinner, sporting event or spa where we can discuss with our peers and learn more about treatments for various diseases," wrote Dr. Nancy Sika and Dr. Colleen Heniff in a letter to federal officials in 2002 when the government proposed restricting some of the gifts. "Why are we singled out by the government not to have the same perks as other businesses?
"As physicians we are a very ethical, intelligent group," they wrote. "I have not seen us be swayed to use a product just because we were taken out."
But patients tell stories of how their doctors gave in to the sales pitches. Mrs. Albert F. Rust of Kirtland Hills, Ohio, said she was horrified as she watched a doctor switch her elderly mother to a new drug that was heavily promoted from one that seemed to be helping her. "The representative of the company has been after me to switch my patients," the doctor had explained.
"We were helpless," Mrs. Rust said. "I cried and so did Mom. She was 87 years old and a timid elderly person. I won't forget her confusion and sadness."
Because only about 10 percent of the price of most brand name pills goes to cover the cost of the raw chemicals and manufacturing, the industry has plenty left even after paying for advertisements, research, and the high salaries and expensive perks of its executives. While patients and taxpayers have been left with emptied pockets, the drugmakers have been flush with cash. From 1995 to 2002 they were the nation's most profitable industry. In 2004 the pharmaceutical companies turned nearly sixteen cents of each dollar of revenue into profit, according to Fortune magazine. That compares with the median profit earned by America's five hundred largest public companies that year of a little more than five cents.
With their hoards of cash, the companies have readily handed money to patient groups, hospitals, universities, medical schools, physician societies, government agencies, and just about any organization they want on their side. Harvard, for one, has a lecture hall named for Pfizer in a building named for Mallinckrodt, another company.
The industry's cash-filled coffers have given it a stranglehold on medical science. Most of the nation's best academic medical minds have at some time been on the industry's payroll as consultants. As the drug companies' influence has grown inside our universities, research priorities have abruptly shifted to hurt the public's interest. Professors see more money in working on the next blockbuster heartburn medicine than in studying the environmental causes of cancer. They and the companies that financially support them are more interested in developing hair loss treatments and other lifestyle drugs for rich Americans than in discovering cures for diseases like malaria, which is devastating poor countries and killing a child every thirty seconds.
The drug companies' chain of influence is so complete that there are few people left to look objectively at the effects of their products on the nation's health or at the consequences of their power for society.
Washington is the axis of the industry's power. The pharmaceutical companies spent more on lobbying between 1998 and 2004 than any other industry. By 2004 the companies employed a legion of lobbyists so large there were more than two for each member of Congress. By using their wealth to buy influence, the drug companies have repeatedly squelched attempts to regulate their prices and promotional practices. The United States is the only developed country in the world that does not control prescription drug prices. Only the United States and one other country, New Zealand, allow drugmakers to advertise to consumers. The industry has also won new laws that have added years to the average length of time their products are protected from competition by patents. Another law allowed the companies to profit from medical discoveries made by taxpayer-funded scientists. And when these new measures boosted the drug companies' profits, other laws gave them tax credits so lucrative that as a group they pay far lower taxes on average than other major industries.
Overall, the pharmaceutical industry has created a market for its products in the United States in which ordinary economics no longer apply. Patients do not get the best medicines for their ailments at the best prices. Instead, America's medicine market is one where more competition can mean prices will rise rather than fall. It is also a mar- ket in which patients suffer when they get the wrong drug because the industry's powerful promotional forces have distorted the available medical information. No one knows how many people are swallowing expensive new pills when older, far cheaper drugs that are not promoted would be best.
Medicines can and do save lives. Antibiotics, first sold in the 1940s, have saved millions of people from infections that otherwise would have been fatal. Vaccines have virtually wiped out diseases like polio. Children with leukemia can now survive into adulthood because of medicines discovered in the decades following World War II. In the 1990s protease inhibitors and other antiviral drugs sharply reduced the death rate from AIDS. The drug marketers have told us these stories over and over.
The tragedy lies not with the medicines but with the marketing and the unprecedented power these companies now have over the practice of medicine. We've come to a time when decisions on how to treat a disease have as great a chance of being hatched in a corporate marketing department as by a group of independent doctors working to improve the public's health. In too many cases, whether a medicine helps or harms a patient has become secondary to how much it will bring shareholders in profits. That is the story of this book, the one that doesn't get told.
In its broadest terms, this book is about how America's for-profit medical system—filled with incentives to make money and disincentives for good care—has failed. While we are swallowing too many pills, we are also undergoing unneeded surgeries, X-rays, and CT scans. The companies striving to sell us as many pills, medical devices, and hospital stays as possible have goals that conflict with a basic tenet of medical intervention: do not overtreat.
Instead, the medical marketers of the twenty-first century work by the advice given to displaymen employed by the nation's department stores in the early 1900s as they learned to seduce the masses into buying more shirts, dresses, and toys.
"Sell them their dreams," a radio announcer urged a convention of displaymen in 1923. "Sell them what they longed for and hoped for and almost despaired of having . . . Sell them this hope and you won't have to worry about selling them goods."
Like the displaymen before them, the medicine merchants have learned to sell us our hopes and dreams, a pill for our every desire. Too few of us realize the dangers.
Excerpted from Our Daily Meds by Melody Petersen. Copyright © 2008 by Melody Petersen. Published in March 2008 by Sarah Crichton Books, a division of Farrar, Straus and Giroux, LLC. All rights reserved.
