In the US, the fully integrated drug company - doing research, manufacturing chemicals, combining them into active medications, marketing them to physicians and selling them to pharmacies - arose after the Second World War. Dominique Tobbell's Pills, Power, and Policy begins with the establishment of these large integrated companies, and shows how the alliances and struggles that gave them initial success also formed the basis of the industry's rise as a political player in the US. Its evolving power has been exercised continually since the late 1950s - and forcefully in response to every attempt to reform US medicine at the federal level.
What Tobbell contributes is her connection of fine historical attention to the development of large pharmaceutical companies in the 1940s and 1950s with a longer story of lobbying and politics in the decades that followed. The book is exclusively focused on the US; this is perhaps somewhat unfortunate, because the events Tobbell describes have had important consequences elsewhere. The US is in many ways an outlier, but it has become the largest player in the pharmaceutical arena.
Tobbell argues that political configurations around medical and drug reform in the US have not changed dramatically since the 1950s. Those struggles have involved the overlapping interests of integrated pharmaceutical companies, physicians and their lobby organisations, and sometimes academic researchers, often arrayed against companies that sell generic drugs, plus pharmacists and consumer groups advocating lower prices and increased access. Added to the fray more recently have been major health insurance companies, government funders and state regulatory agencies.
The most significant attempt to regulate the pharmaceutical industry began with the Senate hearings and investigation launched in 1959 by Estes Kefauver, a Democrat, in response to popular resentment of high drug prices. Although its initial focus was the issue of competition, the Kefauver investigation quickly found itself asking whether companies engaged in excessive marketing, whether measures to ensure safety were strong enough, and whether patent and other regulatory structures encouraged research that most benefited the public.
In the course of the Kefauver hearings, the industry established and consolidated a defence that has endured to the current day: the "drug industry story". It took the lion's share of the credit for the tremendous gains in US public health made over the 20th century, and linked its success to a free enterprise system that generously rewarded research advances with lengthy monopolies and allowed physicians substantial freedom from regulation. The industry, through its lobbying groups and member companies, dispatched some 500 speakers to Rotary and Kiwanis clubs to tell the drug industry story: it claimed to have reached 100,000 community leaders. With the powerful American Medical Association speaking in unison on the benefits of free enterprise and the evils of socialised medicine, the most radical measures proposed by Kefauver, including much-reduced patent protection on drugs, fell by the wayside. Other attempts in the 1960s and 1970s met similar fates.
Tobbell argues that although the US pharmaceutical industry recently may have appeared to change its approach, even to the point of supporting healthcare reform, one need only scratch the surface to see long-established priorities and confluences of interest, grown to include the federal government as a potential partner rather than always an opponent. And thus, she notes, we can understand why, even in its attempt to provide universal healthcare, the US has taken the opposite route from that of other highly developed countries by expanding private rather than public healthcare.
Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and its Consequences
By Dominique A. Tobbell
University of California Press
310pp, £44.95 and £18.95
ISBN: 97805201135 and 1142
Published: 1 April 2012