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Prescribing by Numbers

Drugs and the Definition of Disease

Jeremy A. Greene

Publication Year: 2006

The second half of the twentieth century witnessed the emergence of a new model of chronic disease—diagnosed on the basis of numerical deviations rather than symptoms and treated on a preventive basis before any overt signs of illness develop—that arose in concert with a set of safe, effective, and highly marketable prescription drugs. In Prescribing by Numbers, physician-historian Jeremy A. Greene examines the mechanisms by which drugs and chronic disease categories define one another within medical research, clinical practice, and pharmaceutical marketing, and he explores how this interaction has profoundly altered the experience, politics, ethics, and economy of health in late-twentieth-century America. Prescribing by Numbers highlights the complex historical role of pharmaceuticals in the transformation of disease categories. Greene narrates the expanding definition of the three principal cardiovascular risk factors—hypertension, diabetes, and high cholesterol—each intersecting with the career of a particular pharmaceutical agent. Drawing on documents from corporate archives and contemporary pharmaceutical marketing literature in concert with the clinical literature and the records of researchers, clinicians, and public health advocates, Greene produces a fascinating account of the expansion of the pharmaceutical treatment of chronic disease over the past fifty years. While acknowledging the influence of pharmaceutical marketing on physicians, Greene avoids demonizing drug companies. Rather, his provocative and comprehensive analysis sheds light on the increasing presence of the subjectively healthy but highly medicated individual in the American medical landscape, suggesting how historical analysis can help to address the problems inherent in the program of pharmaceutical prevention.

Published by: The Johns Hopkins University Press

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pp. vii-xi

This week, in clinics and hospitals across the country, thousands of perfectly healthy-feeling adults will receive a diagnosis for a disorder that they did not know they had. There are several such disorders: imperceptible to patients, they produce no fevers, no chills, no headaches, no stomachaches, no pains....

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pp. xiii-xv

This book, and along with it my own double life as a physician-historian, would not have been possible without the support of many individuals. There is not enough space here to properly acknowledge the many acts of generosity that have helped to eventually bring this work to publication. First I must thank my principal dissertation adviser, Allan M. Brandt, who introduced me to the powerful...

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Introduction. The Pharmacopoeia of Risk Reduction

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pp. 1-17

The audience assembled in the hotel ballroom October 29, 1957, came from surprisingly diverse backgrounds: some had started their careers as salesmen, others as financial analysts, basic research scientists, or practicing physicians. But the group gathered in the Boca Raton Club for the fifty-first annual meeting of the American Drug Manufacturer’s Association was focused on a common set of interests: the financial and material future of the prescription drug...

PART ONE: Diuril and Hypertension, 1957–1977

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1. Releasing the Flood Waters: The Development and Promotion of Diuril

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pp. 21-50

Thousands of small white tablets of chlorothiazide—better known by the brand name Diuril—emerged from Merck Sharp & Dohme production plants in January of 1958 amid a dazzle of research symposia, journal advertising, and record prescription rates for a novel agent. Diuril represented the first palatable pill for hypertension, and although its story is less well known than the saga of antibiotics, the dramatic emergence of antipsychotic drugs, or the cultural hand-wringing surrounding the minor tranquilizers, the influence of this...

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2. Shrinking the Symptom, Growing the Disease: Hypertension after Diuril

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pp. 51-79

Physicians around the country were invited, in 1968, to mark Diuril’s tenth anniversary with a brief birthday celebration for the drug. A new desktop model of the Diuril Man was released in conjunction with a blitz of journal advertisements proclaiming, in glittering metallic ink, the historic role of chlorothiazide...

PART TWO: Orinase and Diabetes, 1960–1980

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3. Finding the Hidden Diabetic: Orinase Creates a New Market

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pp. 83-114

In 1961 Milton Moskowitz, the editor of Drug and Cosmetic Industry and a frequent commentator on developing practices in pharmaceutical marketing, prepared a feature article tracing the successes of Diuril, entitled “diuril Creates a New Market.” Searching for an example that illustrated the significance of Merck’s Diuril campaign, he settled on Upjohn’s new diabetes drug,...

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4. Risk and the Symptom: The Trials of Orinase

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pp. 115-147

Early in the afternoon of May 20, 1970, a report was leaked over the Dow Jones newswires that Orinase (tolbutamide),“a drug used to lower blood sugar in diabetic patients,”might be harmful. Orinase had been Upjohn’s showcase success and sales leader for nearly a decade, and news of its possible toxicity spelled disastrous things for the company and its investors. Before the New York Stock Exchange closed that afternoon, Upjohn’s stock had fallen in heavy...

PART THREE: Mevacor and Cholesterol, 1970–2000

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5. The Fall and Rise of a Risk Factor: Cholesterol and Its Remedies

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pp. 151-188

Cholesterol is a familiar figure in contemporary American life. Even if the average consumer is not conversant with the chemical structure of this five-ringed sterol or its role in the biosynthesis of bile acids, sex hormones, and gallstones, chances are that he or she knows cholesterol to be an agent of progressive disease of the heart and blood vessels, to be avoided in one’s diet and minimized in one’s bloodstream to prevent illness and promote longevity. High...

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6. Know Your Number: Cholesterol and the Threshold of Pathology

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pp. 189-219

What is your cholesterol? Odds are about even that you can answer this question with a number, or at least a value. Your cholesterol is 198. Your cholesterol is normal. Your cholesterol is 250. Your low-density lipoprotein (LDL) cholesterol fraction is above 130 milligrams per deciliter, or you have too much “bad” cholesterol, or, perhaps, you just “have cholesterol.” Regardless of how the results are defined, surveys indicate that between 50 and 75 percent of...

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Conclusion. The Therapeutic Transition

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pp. 221-240

In the spring of 2003, the medical public was advised to purchase several copies in advance of a particular issue of the British Medical Journal that was predicted to become a collector’s item. In surprisingly exhortative terms for the British publication, the editor proclaimed that the lead article might represent “the most important piece of medical news for the past 50...


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pp. 241-308


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pp. 309-318

E-ISBN-13: 9780801892097
E-ISBN-10: 0801892090
Print-ISBN-13: 9780801891007
Print-ISBN-10: 0801891000

Page Count: 336
Illustrations: 10 halftones, 3 line drawings
Publication Year: 2006