Prescribing by Numbers: Drugs and the Definition of Disease

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

c h a p t e r t h r e e Finding the Hidden Diabetic Orinase Creates a New Market There are diabetics enough to go around.No doctor needs to lack for them. If he is not satisfied with the number of his cases, extra attention paid to those patients most susceptible to diabetes will disclose new instances previously overlooked. —elliot t p. joslin, 1931 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,Orinase: “The Upjohn Co. is now chalking up an annual volume of $30,000,000 in Orinase , the oral antidiabetic it introduced several years ago. Orinase was the first product of its kind. Previously, the principal therapy was insulin, a market dominated for many years by Eli Lilly and Company. Insulin sales have contracted —but not substantially. It would seem that Orinase’s introduction has expanded the total market by bringing under medical care diabetics who formerly were not treated.”1 Diuril and Orinase, Moskowitz argued, were two examples of a new form of pharmaceutical marketing that refused to accept the incidence of disease as a fixed market or a zero-sum game. Any disease was a potential market for a drug, but chronic diseases such as diabetes and hypertension were growth markets that could continue to expand—as long as the screening and diagnosis could be pushed further outward to uncover more hid- den patients among the apparently healthy. In the infinitely expandable universe of chronic conditions, in the logic of preventive pharmacology, Moskowitz saw unlimited growth capacity for the pharmaceutical industry. Like Diuril, Orinase catalyzed a shift in the basic conception of chronic disease from a model of inexorable degeneration to a model of surveillance and early detection.Both drugs fueled a movement to make the screening and treatment of“hidden patients,”or those unaware of their own pathology,into a public health priority. Both represented more palatable alternatives to inconvenient and painful therapeutics.And yet the story of Orinase’s relationship with diabetes constitutes a much different narrative from that of Diuril and hypertension . Unlike hypertension, which was largely a disease of the twentieth century , diabetes had been a stable category for centuries. When Orinase’s marketers tried to promote a product that promised to simplify the treatment of diabetes and extend the boundaries of the condition, they found themselves simultaneously aided and foiled by this historical inertia.And unlike the domain of hypertension, which expanded as a single numerical threshold was lowered, the definition of diabetes grew in concert with another condition, a flexibly de- fined precursor state known as prediabetes. We need to understand the relationship between diabetes and prediabetes, and the role of Orinase (tolbutamide ) at the interface between the two, to comprehend the pharmaceutical articulation of risk in contemporary therapeutics. But first, a brief history of diabetes as a symptomatic disease. A Disease in Motion Diabetes had become a site for theoretical debate over the arbitrary division of health and disease well before Orinase was developed. Claude Bernard singled out diabetes in his 1865 Introduction à la médicine expérimentale to illustrate how difficult it was to demonstrate any exact boundary between health and disease once the body was understood in terms of physiological chemistry .2 Fifteen years before the launch of Orinase, the philosopher of disease Georges Canguilhem used the example of diabetes to demonstrate that the value distinction between pathology and normality was fundamentally arbitrary .3 However,neither Bernard nor Canguilhem argued that the arbitrariness of the distinction in any way undermined the status of diabetes as a disease. Diabetes is one of the earliest named diseases in history. Symptomatically described in the Ebers Papyrus some thirty-five hundred years ago and men84 Orinase and Diabetes, 1960–1980 Finding the Hidden Diabetic 85 tioned in the subsequent writings of Galen and Celsus, diabetes was named after the Greek term for siphon—in reference to its most characteristic symptom of copious urination—by Arataeus of Cappadocia in the first century AD. It was not until the late seventeenth century that diabetes with sweet urine (diabetes mellitus) was formally differentiated...