The Big Fix: How the pharmaceutical industry rips off American consumers by Katharine Greider, PublicAffairs, $14, ISBN 1586481851
Measuring the Gains from Medical Research: An economic approach edited by Kevin M. Murphy and Robert H. Topel, University of Chicago Press, $27.50, ISBN 0226551784
What Price Better Health? Hazards of the research imperative by Daniel Callahan, University of California Press, $29.95, ISBN 0520227719 Reviewed by Charles Medawar
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YEARS ago 鈥� I believe when pleading for a monumental loan 鈥� President Emilio Medici summed up the state of his nation: 鈥淏razil is doing well, but the people are not.鈥� The same dilemma once haunted surgeons: 鈥淭he operation was a great success. Unfortunately, the patient died.鈥� The reckoning of risks, benefits and costs so often depends on perspective, and on who鈥檚 counting.
These three books underline this dilemma in American medicine today. Health expenditure accounts for a massive 13 per cent of US national income 鈥� roughly twice the average for the European Union 鈥� but with nothing like the health benefits to match. The best of US medicine is superb, yet 40 million Americans are uninsured and a personal health crisis would bankrupt as many again.
The pharmaceutical interests that control the medicine agenda of the European Commission, meanwhile look to the US with envy and alarm, pointing to its dominant influence in the world pharmaceutical market. The EC鈥檚 Enterprise Directorate sees Europe lagging behind: it invests much less in research and development, therefore innovates less and earns lower returns.
Katherine Greider鈥檚 book, The Big Fix, gives earthy evidence of the point the Eurocrats have missed. There is a global crisis in drug innovation, with increasingly less quality or quantity to show for the ever-greater spend on research and development. The US economic boom in the pharmaceuticals sector is overwhelmingly the result of increased marketing expenditure. The turning point came in 1997 with deregulation that permitted what has since become saturation advertising of prescription drugs in the mass media. Greider illustrates the point that double-digit growth in investment returns translates into unaffordable drugs. Middle America, especially its elderly, is angry and up in arms.
None of this would seem of much concern to the nine contributors (mostly economists) to Measuring the Gains from Medical Research, whose tables, graphs and formulae demonstrate the gains made from medical research. One of them even comes up with 鈥渁 first approximation鈥�, from 1970-1990 data, which proposes that 鈥渢he social rate of return to pharmaceutical innovation is about 68 per cent鈥�. Say no more.
Daniel Callahan鈥檚 thoughtful appraisal in What Price Better Health? comes closest to the mark of all three books: hang on to baby, but drain the bathwater that stands for unfettered market forces and short-term political gains.
None of these books suggests that the US is anywhere near the realisation that rugged individuality is also an obstacle to health. Personal health is overwhelmingly predicted by the health and well-being of others 鈥� including their example, attitudes and behaviour 鈥� quite apart from technological gain and professional intervention.