Book Review: Pharmaceutical Life Sentences

Arthur Daemmrich

The book's third case explores cholesterol and definitions of risk for coronary heart disease through the testing and marketing of Mevacor. Greene argues that treatment of high cholesterol declined over the course of the 1970s and then rose again in the 1980s in concert with a new wave of chemotherapeutic interventions. With a high-profile launch in 1987 Mevacor aligned with public health efforts by the National Cholesterol Education Program and other groups seeking to push Americans to be tested for cholesterol levels. Greene argues that Mevacor's marketing introduced the medical community and the public to the word statins (now commonly known as a class of cholesterol-lowering drugs) and the concept of using a pill to treat high cholesterol.

In a conclusion that brings the three cases together, Greene describes various reactions to a 2003 British Medical Journal article in which two epidemiologists advocated the development of a preventative "polypill." The hypothetical tablet would be made from a combination of commonly taken drugs: a statin, various blood pressure-lowering agents, folic acid, and aspirin. Although the pill was never marketed nor tested in a clinical trial, the authors did seek to patent the concept. Strikingly, a CNN poll revealed that 95% of viewers over 55 would take it if it were available. Physicians were more skeptical, at least to the degree that letters to the editor of the British Medical Journal cited by Greene offer a representative sample. In this example Greene elegantly brings to the fore a conundrum for contemporary medicine: the drug-consuming public has readily adopted numerical risk factors as a way to talk about disease and thus will accept drugs that treat those numerical values, even when physicians understand that in many cases they are treating probabilities, not clearly defined diseases.

Some readers may wish for more definitive policy statements, but Greene, through his focus on issues of disease diagnosis and definition, has done a greater service by raising broader relevant questions. As our pharmaceutical life sentences lengthen (which seems vastly preferable to the stark alternative of death) we need a more engaged policy discussion. For the good of the U.S. health-care system the discussion must shift from narrow questions of conflict of interest and restructuring the FDA to issues of how to balance decision-making control for defining disease and deciding on treatment, given the different stances of physicians, industry, regulators, and patients. In addition, policy debates must clarify, as Greene puts it, which forms of engagement among marketers, public health decision makers, and medical practitioners are productive and which are deceptive. If we can move the current debate in Congress and the upcoming presidential debates in this direction, there may yet be reason to hope that not all health-care issues end in stalemate.

Arthur Daemmrich is an assistant professor in the Business, Government and the International Economy Unit at Harvard Business School. He is the author of Pharmacopolitics: Drug Regulation in the United States and Germany.