Prescribing by Numbers: Drugs and the Definition of Disease

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

c h a p t e r o n e Releasing the Flood Waters The Development and Promotion of Diuril Among newsmen, there’s a saying that there is only one thing colder than yesterday’s mashed potatoes, and that’s yesterday’s news. But when the subject is “diuril,” the newspaper never gets cold—because “diuril” makes news every day. The following reports provide additional evidence that “diuril” is still a “hot” news item, especially to the physician thinking about hypertension. —Diuril News Report 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 drug on clinical practice was equally profound.1 As late as World War II, a patient with high blood pressure and no symptoms was not likely to receive any treatment. A few decades later, hypertension had become a radically different entity, detected routinely in primary care screening and increasingly treated with specific pharmaceutical agents long before any symptoms had developed. The story of this transformation—and the faint but groundbreaking shift it marks in the definition of disease in the postwar era—is highly contingent upon the emergence of new therapeutic agents like Diuril and the promotional apparatus set in place to market them to physicians and patients across the country . To understand the interplay between drug and disease in late-twentieth- century therapeutics—and the contested positions of doctors, patients, researchers ,pharmaceutical executives,and others with a stake in the outcome— we must pay attention to the simultaneous interactions between the research, the clinical, and the market arenas in which pharmaceuticals operate. Hypertension became a different disease after Diuril. It is equally true, however , that Diuril became a different drug after it encountered hypertension. If we look at a pharmaceutical as both a clinical entity and a branded consumer product, the relationship between drug and disease emerges not as a story of design or serendipity, control or production, but rather as a narrative of cumulative negotiation and reciprocal definition. The history of Diuril and hypertension presented in this chapter illustrates the mutually constitutive processes of clinical research,clinical practice,and medical marketing in the postwar American pharmaceutical industry and traces the evolution of a set of hybrid structures that became central institutions of pharmaceutical promotion in the second half of the twentieth century. Antihypertensives amid the American “Drug Explosion” The American pharmaceutical industry in the two decades following World War II witnessed an increase in the scope and pace of therapeutic innovation unanticipated by physicians, consumers, or even the industry itself. Wartime infrastructural links between academic medicine, industry, and governmental institutions—overseen by the Office of Scientific Research and Development during the wartime effort—were swiftly adapted to yield a robust“pipeline”of novel and efficacious medicines that proved highly profitable for growing American drug concerns.2 Entirely new classes of therapeutic compounds were appearing almost every year, supported by a burgeoning research literature. By 1947 it was estimated that fifty cents of every dollar of pharmaceutical revenues came from products not available ten years earlier, and perhaps the most tangible example of this process was the growth of the antibiotic sector.3 Within fifteen years of the mass production of penicillin in 1943, the antibiotic market contained nearly twenty novel drugs and represented $270 million in annual sales.4 By 1958 the practicing clinician was faced with a promising but easily confusing set of novel antibiotics and branded combinations of agents to integrate into his or her practice. The same process took place with antihypertensives, a category of therapeutics similarly nonexistent a few decades earlier. Until the late 1940s, treat22 Diuril and Hypertension, 1957–1977 Releasing the Flood Waters 23 ment for hypertension was largely limited to sedatives,nitrates,or the complete surgical interruption of the sympathetic nerves running alongside the spinal cord. Over the ensuing decade, four entirely new classes of antihypertensive drugs—the ganglionic blockers, hydralazine, Rauwolfia derivatives, and Veratrum alkaloids—were combined and recombined in...