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i n t r o d u c t i o n The Pharmacopoeia of Risk Reduction By means of his oracles, a Zande can discover the mystical forces which hang over a man and doom him in advance, and having discovered them he can counteract them or alter his plans to avoid the doom which awaits him in any particular venture. Hence a man’s future health and happiness depend on future conditions that are already in existence and can be exposed by the oracles and altered. — e. e. evans-pritchard, 1937 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 industry. In the decade or so since the end of World War II, pharmaceutical manufacturers had seen the scope of their business expand dramatically, the structure of their firms grow outward, and the pace of their new-product development accelerate at an impressive rate. The industry was progressive and forward-leaning, and the audience assembled to hear the address given by Charles Mottley—Pfizer’s chief of operations planning—was keen to hear what he had to say about the pharmaceutical future. Mottley asked his audience to consider the paradoxical long-term influence that antibiotics—at that time the most lucrative sector within the pharmaceutical market—were beginning to exert upon broader health statistics. Antibiotics had effectively reduced the frequency and severity of infectious disease, but they had also effectively reduced their own potential market.“There seems to be an important lesson here for the drug industry,”he continued.“As the industry does a good job of producing efficacious drugs and helps to win a given campaign . . . the net result is to limit the potential market.”If the industry was to have a viable future, it would be necessary to grasp the nature of this irony and work to invert it. Drugs needed to grow their markets, not shrink them. Mottley told his audience that the expanding prevalence of chronic disease already evident by the late 1950s offered the perfect opportunity to redesign the drug-disease relationship. “Trends are developing in the cause of death statistics ,” he concluded, “which indicate that ‘tomorrow’ greater proportions of people are likely to suffer fatal accidents or be afflicted with diseases, such as cancer and cardiovascular involvements, for which there are, as yet, no really effective drugs.”1 As chronic diseases gained in importance from the 1950s onward , Mottley suggested, and as a chronic pharmacopoeia developed alongside them, new concepts of disease and treatment could be explored to maximize the long-term growth potential of pharmaceuticals. Conditions that patients would necessarily have for the rest of their lives—coupled with treatments that could be taken every day for an indefinite period—had the makings of a market that could result in sustainable growth. The same year that Mottley addressed the crowd at Boca Raton, medical journals carried the early results of the Framingham Study, the first major effort of the recently established National Heart Institute and the American Heart Association in their joint endeavor to better understand the “modern epidemic” of coronary heart disease.2 In the wake of receding morbidity and mortality of infectious diseases, heart disease had emerged as the foremost killer of modern times, and the search for a cure, or at least a cause, of this epidemic had gained widespread popular attention.3 As the Framingham investigators followed the cardiovascular history of some six thousand residents of this small Massachusetts city,they began to single out the predictive“prepathological ” categories that would eventually become known as coronary risk factors . Some of the categories were apparently immutable demographic characteristics of an individual: age, sex, and family history. Others, such as cigarette smoking, were potentially modifiable behaviors. The central risk factors, however , were physiological variants believed to be mechanistically connected to heart disease: hypertension (high blood pressure), hypercholesterolemia (high blood cholesterol),and,later,diabetes (uncontrolled elevation of blood sugar).4 Implicit in the initial Framingham publications, then, was a tantalizing new 2 Prescribing by Numbers [3.143.244.83] Project MUSE (2024-04-19 23:34...

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