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BORN WITH A Junk Food DEFICIENCY
HOW FLAKS, QUACKS, AND HACKS PIMP THE PUBLIC HEALTH
By Martha Rosenberg
Copyright © 2012 Martha Rosenberg
All right reserved.
Chapter One WHEN THE MEDICATION IS READY, THE DISEASE (AND PATIENTS) WILL APPEAR—OR, WHEN TV MAKES YOU SICK
Can anyone remember life before "Ask Your Doctor" ads?
All you knew about prescription drugs came from the ads you peeked at in the Journal of the American Medical Association (JAMA) in your doctor's waiting room. They were full of vaguely ominous terms—nulligravida? hemodialysis?— as well as side effects and overdose treatments that you didn't understand and didn't want to understand. And they confirmed that the doctor knew more than you, more than he was telling you (and if this was more than twenty years ago, the doc probably was a "he"), and sometimes he was looking down on you.
In the 1950s, JAMA ads had a hokey feel to them, with cartoons and ads for soda pop, orthopedic shoes, and sickroom supplies. "Fifty million times a day at home, at work or while at play," says an ad, referring to the wide use of what seems to be a medicine but is actually Coca-Cola®. "Why look at the back of a 7-UP® bottle?" says another soft drink ad. "Here's why. On the back of the bottle are listed all the ingredients of this sparking, crystal-clear drink." Yes, soft drinks weren't just empty calories!
But by the 1960s, JAMA ads boasted slick, Mad Men–style ads for the tranquilizers Valium®, Librium®, and Miltown®; the antipsychotics Thorazine and Mellaril; the amphetamine Benzedrine; and antidepressants like Elavil® and Triavil. Commensurate with the psychoanalytical times, before biological psychiatry, in which people with emotional problems had "shrinks," neuroses, and "complexes," many ads suggest patients are motivated by drives and impulses they deny.
"Do you have patients who try to hide frustration behind conformity?" asks an ad for the antidepressant nortriptyline, depicting a bored, upper-middle-class couple in Burberry®-like attire. "They may be unable to face the pain of their depression," says the body copy. "Help them see behind the veneer and accept the reality" is the tag line. Other ads in the series accuse patients of "hiding their anger behind charm" and "hiding anguish behind arrogance."
One ad lacquers ageism and sexism onto denial by showing an older, wrinkly woman in a bouffant wig with hair bows, gigantic sunglasses, and garish jewelry.
The headline, "Lady, your anxiety is showing (over a coexisting depression)," is written across her nose to further the ridicule. "On the visible level, this middle-aged patient dresses to look too young, exhibits a tense, continuous smile and may have bitten nails or overplucked eyebrows," says the ad copy. "What doesn't show as clearly is the coexisting depression." The ad suggests the antidepressant and tranquilizer Triavil.
A third patient-in-denial ad depicts an upper-middle-class breakfast scene. Under a chandelier, a smiling wife and mother in a flowered housedress has prepared a breakfast of cooked cereal, juice, milk, and percolated coffee (who remembers coffee percolators?) for her executive-type husband and their college "co-ed" daughter, who is wearing pearls. The headline says, "The prehysterectomy patient who wears a façade of unconcern." When you turn the page, the husband and daughter have left—and so has the woman's smile. It's all an act.
Such ads elucidating the pathos of aging wives and mothers who are losing their looks, children, femininity, and purpose in life were rampant in 1960s and 1970s medical journals, before the women's liberation movement had taken hold. One such ad shows a woman at her child's graduation ceremony with the headline "Magna cum depression," referring to the empty-nest syndrome she will soon, presumably, experience.
Ads for hormone replacement drugs like Premarin® were even more ruthless.
"When Women Outlive Their Ovaries" is the headline for one, showing a grandmotherly woman in a frumpy cardigan sweater. "There we were—my husband at the peak of his career ... but no time for me," says the ad. "This wasn't a 'change,' it was a catastrophe."
Journal ads during the 1960s and 1970s also pushed drugs on men, who were having trouble with gender roles. The contemporary businessman, said ads for the antipsychotic Mellaril, "is always fearful about his standing with the boss," "misses half of what is said at meetings," because he is so "emotionally upset," "loses his temper with colleagues and subordinates," and "goes home at night and takes it out on his family." But ads of this era were still much harder on women who didn't comply with the social expectations of getting married, being a good wife, and having kids. Jan, we are told in an ad for Valium, is "psychoneurotic" because she is unmarried at age thirty-five. "You probably see many such Jans in your practice," says the ad—"The unmarrieds with low self-esteem. Jan never found a man to measure up to her father."
Some ads are almost sympathetic to "housewives" who, before the women's liberation movement, were supposed to find fulfillment taking care of others and their homes, with no job or career of their own. But instead of recomWhen the Medication Is Ready 19
mending freedom for women suffering from what early feminist Betty Friedan called the "problem that has no name" (the "problem" was suffered by women with material comforts but no intellectual outlet) the ads counseled tranquilizers and other psychiatric drugs. "Why is this woman tired?" asks the headline under a photo of a dissipated, bathrobe-clad young woman about to tackle a stack of dirty dishes. She may just need more sleep, says the ad, but she also may be one of "many of your patients—particularly housewives—[who] are crushed under a load of dull, routine duties that leave them in a state of mental and emotional fatigue. For these patients, you may find 'Dexedrine' an ideal prescription."
"I'm restless, nervous, tired all the time and always nagging," says another "dirty dishes" ad, this one for the antidepressant Sinequan®. (Maybe the women needed a dishwasher, not a prescription.) Another ad in the Sinequan series shows a clothesline with similar I'm-exasperated copy. "A lot of little things are wrong," says the ad. "Headaches, diarrhea, this rash on my arm. And sometimes I think I don't like being married." Another Jan who can't find a husband to measure up to dear, old dad?
"Bad" wives—especially nagging wives—made a regular appearance in drug ads. "A sleeping pill for night squawks" was the sexist headline for an ad for the hypnotic sedative Doriden, in a 1969 issue of JAMA.
"She has insomnia ... so he's awake," continues the copy. "Restless and irritable, she growls at her husband. How can this shrew be tamed?" Ouch.
Psychiatric drugs were not only the answer to maladjusted, nagging housewives, suggested ads published throughout the 1960s and 1970s; they were also the answer to bad employees. "Sally Wilson has lost her reputation," floats the headline over a woman in reading glasses with a ream of papers, who appears to be a secretary. "In the last week or so, Sally Wilson's year-old reputation as an unpredictable grouch has melted away." Sally has also "been coming in on time and turning out more work," the ad goes on to say. "Sally's menopause had triggered symptoms that hormone therapy by itself apparently hadn't helped," but adjunctive Valium has "helped her relax."
In the 1950s and 1960s, traditional psychoanalytical theories held that the birth of children, especially a son, would give housewives peace and fulfillment beyond their clothesline and kitchen sink. But drug ads of that era showing women with children often suggest otherwise. In a 1956 ad for Serpasil, brand name of the hypertensive drug resperine, once given as a mood leveler, a mother screams as her Davy Crockett–inspired son runs through the living room with a toy rifle.
Seated on a couch in a pinafore apron, with a canister-style vacuum cleaner at her feet, the harried mother appears to be screaming and resembles Lucille Ball crying "Awwww, Ricky" on the 1950s sitcom I Love Lucy. "Raise the emotional threshold against everyday stresses," says the ad's headline. Serpasil "acts as a gentle mood-leveling agent [and] ... sets up a needed 'tranquility barrier' for the many patients who, without some help, are incapable of dealing calmly with a daily pile-up of stressful situations."
Today, of course, little Davy Crocketts would be treated for attention deficit hyperactivity disorder (ADHD), oppositional-defiant disorder, conduct disorder, and bipolar disorder. (And husbands whose wives keep them awake would be given sleeping pills.) But today's tradition of giving kids adult medications that are sometimes dangerous was evident decades ago in medical journals.
As early as 1956, ads for the antipsychotic Thorazine said it "reduces hyperactivity and aggressiveness, decreases anxiety and hostility [and] improves mood, behavior and sleeping patterns ... in belligerent, overactive children." It was also advertised for childhood vomiting. The tranquilizer Miltown was similarly advertised for "a wide range of tension/anxiety-related disorders of children and adolescents, ranging from tics and tantrums to 'school headache' and stammering." And it wasn't only kids whose minor conditions were medicated with major psychoactive drugs. Thorazine was advertised for treatment of alcoholism, asthma, bursitis, arthritis, cancer, the fear of cancer, ulcers, psoriasis, senility, menopause, and hiccups in adults. Yes: hiccups.
The amphetamines and stimulants Benzedrine, Dexedrine®, and Ritalin® were similarly marketed for a breadth of maladies from depression, menopause, and alcoholism to "middle-age and senile let-down" that includes "a sense of frustration and inadequacy" and "waning gonadal function."
Some ads confirm what patients often suspected: that they were a bother to doctors. An ad for the sleeping pill Quaalude said, "Now the physician has one less tired, sleepy and apprehensive patient to contend with." Other ads, especially those addressing elderly and menopausal patients, unabashedly recommend palliation (drugs for what were really life problems not medical problems) with whatever works.
"At 65 he's collected, among other things, an ailing wife, a decreased income, grown children he seldom sees, and various physical symptoms—real or imagined," reads an ad for the Thorazine-like antipsychotic Mellaril, with a full-page photo of a wizened man who looks closer to ninety than sixty-five.
DAWN OF A NEW MARKET
One night in 1997, as Americans were parked on the couch in front of an episode of Touched by an Angel, they were touched by something else unexpected: an ad for a prescription allergy pill called Claritin®, promoted directly to the consumer! Prescription drugs had never been sold directly to the public before, because, without a doctor's recommendation, how could people know if the medication was appropriate or safe? Soon, ads for Xenical®, Meridia®, Propecia®, Paxil®, Prozac®, Vioxx, Viagra®, Singulair®, Nasonex®, Allegra®, Flonase®, Pravachol®, Zyrtec®, Zocor®, Flovent®, and Lipitor® followed. By 2006, the pharmaceutical industry (a.k.a. Pharma) was spending $5.5 billion a year on direct-to-consumer (DTC) advertising—as much as the US government was spending for an entire month on the Iraq War.
Although DTC advertising was never illegal, according to the Food and Drug Administration (FDA), it was widely thought to be until the FDA issued guidelines for advertisers in 1997. A push for DTC advertising also came from AIDS patients who wanted greater involvement in their own care and to know what their doctors knew about the drugs they were taking. A funny thing happened as Americans viewed all these pill ads. People discovered they weren't as healthy as they thought. Suddenly, they suffered from seasonal allergies, social anxiety, high cholesterol, depression, bipolar disorder, ADHD, erectile dysfunction, low testosterone, gastroesophageal reflux disease (GERD), irritable bowel syndrome, dry eye, fibromyalgia, chronic fatigue syndrome, seasonal affective disorder (SAD), restless legs syndrome, and worse. In fact, the parade of symptoms and diseases was so all encompassing, comedian Chris Rock said he was ready for a DTC ad asking, "Do you fall asleep at night and wake up in the morning?"
"Yeah, I got that!" he joked.
Before the advent of DTC advertising, gastroesophageal reflux disease, or GERD, was a hidden epidemic. This condition vaulted Nexium® to the fourth-best-selling drug in the country, once the drug's marketing campaign made people realize they suffered from the problem. "The implication in the direct-to-consumer ads is if you have heartburn you're well on your way to cancer of the esophagus," says Marcia Angell, MD, a former editor of the New England Journal of Medicine and author of The Truth about the Drug Companies. "For most people who have heartburn, the best way to treat it is probably to lose a little weight, get out and take a walk or drink a glass of milk, but that somehow is seen as less good than taking a prescription drug."
The fact that DTC advertising debuted at the same time as the World Wide Web doubled its power. Even if ads and websites weren't advertising drugs directly to consumers, the world of diseases and prescription drugs, once tucked into JAMA ads, was suddenly open to anyone who could operate a mouse. You could even buy drugs online, no doctor or prescription necessary.
Theoretically, all the newly and readily available medical information created a better-informed patient. It was the same reason the trailblazing feminist book Our Bodies, Ourselves was published thirty years earlier—patients have the right to know and be participants in their own healthcare. But three features of DTC advertising did more harm than good—unless you were Pharma. Diseases were created or overplayed, sometimes called disease du jours. Risks of disease—fears of getting a condition or the condition getting worse—were whipped up to sell drugs. And extreme drugs were marketed when milder and cheaper drugs would do. The best example of this last point is Vioxx, which was billed as a "super-aspirin" for everyday arthritic or menstrual pain but ended up causing twenty-seven thousand heart attacks and sudden cardiac deaths before its removal from the market in 2004. Yet before Merck even settled the Vioxx cases, the dangerous epilepsy drugs Lyrica®, Topamax®, Neurontin, and Lamictal® and the antidepressant Cymbalta® were similarly marketed for simple pain, even though all carried suicide warnings and Topamax is also linked to birth defects. It was obvious that no lessons had been learned from Vioxx.
Other examples of DTC advertising excess are antipsychotics like Seroquel ®, marketed for simple depression and to children, and costly, genetically engineered, injected drugs like Prolia®, Humira®, Enbrel, and Remicade®, marketed as first, rather than last, choices in autoimmune conditions. The lucrative but dangerous new drugs, called monoclonal antibodies (moAbs) and tumor necrosis factor (TNF) blockers invite cancers and lethal infections because they suppress the body's immune system, and it can't fight infections. 31 They are even pushed for asthma. In 2008, the FDA announced that forty-five people died from fungal diseases from taking Humira, Enbrel, Remicade, and Cimzia®—20 percent of the 240 patients who got sick. Humira, in particular, was investigated by the FDA in 2008 for thirty reports of childhood cancer and its links to lymphoma, leukemia, and melanoma in children. In 2011, the FDA warned that Humira can cause "a rare cancer of white blood cells" in young people. The same year, five patients died during Humira trials in Italy, and the entire drug class was found to be linked to heart risks.
But when a drug like Humira earns a company an average of $20,000 per patient per year—that's potentially $7 billion a year—cancer, fungal infections, and heart side effects are but details. The deaths might not have been Humira-related but rather "bad luck," said a researcher with the Italian trials, and an avalanche of Pharma articles disputed the heart findings. Meanwhile, Abbott Laboratories is seeking to broaden Humira indications, including an approval for ulcerative colitis.
In addition to normalizing dangerous drugs like Humira, the advent of DTC advertising and health websites led to disease glamorization, a "sickness culture," symptom chasing (cyberchondria), the exchange of incorrect information, and self-diagnosis (the latter because so many sites had "symptom checkers" and self-quizzes). It also changed the doctor/patient relationship forever.
Excerpted from BORN WITH A Junk Food DEFICIENCY by Martha Rosenberg Copyright © 2012 by Martha Rosenberg. Excerpted by permission of Prometheus Books. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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