The companies that develop, study, manufacture and distribute prescription medicines have mounted some of the most effective marketing campaigns in human history. For example, AstraZeneca has been able to convince doctors to order Nexium®, the newest, most expensive version of a heartburn medicine whose virtually identical older sibling, Prilosec®, costs about one-tenth as much and is just as effective.
Big Pharma regularly develops and markets drugs which are no better than medicines already on the market and available at much lower cost. The new drug may actually be inferior to established drugs in terms of effectiveness and side effects. No matter. Send those detailers out to the doctor’s offices with smiles, smarts, samples and warm chocolate chip cookies, and Big Pharma laughs all the way to the bank.
But more than products, Big Pharma sells conceptual models, frameworks for how we come to view the biological phenomena we call illness. These models come to define how we, as physicians and our patients understand illness and health. Of course, these models are also intimately entwined with pharmaceutical development and marketing.
The “cholesterol” model of cardiovascular disease, which labels LDL cholesterol “bad” and HDL cholesterol “good,” is a prime example. It is also the most successful pharmaceutical marketing strategy in history. To this day, marketing executives at Pfizer, Merck and others must shake their heads in wonder at our collective naiveté. We all bought it. You never see or hear the word “cholesterol” mentioned anywhere without the modifier “good” or “bad” in front of it. That marketing strategy has paid off big time. Annual profits for statins are in the billions of dollars.
This is what I tell my patients about cholesterol: “LDL is a protein made in the liver, whose job it is to carry cholesterol (also made in the liver), out into all the tissues. There, it is used to construct every cell in the body. And it plays an important role in the production of a number of hormones, like testosterone for example. No cholesterol means no sex life. Is that bad or good?”
“LDL is the delivery truck, and cholesterol molecules are the bricks. One medium sized organ especially rich in cholesterol is up there between your ears. Do you really think the cholesterol that makes up most of your brain is bad?”
“HDL is the garbage truck that picks up used or useless cholesterol and takes it back to the liver to be recycled. Cholesterol attached to this protein carrier, like the cholesterol carried by the LDL protein carrier, is neither good nor bad.
If your LDL cholesterol is too high, the only thing bad is your diet and lifestyle! And don’t blame it on your genes. That’s just more creative marketing, bent on selling Vytorin®. (“Your high cholesterol is due to too many frankfurters and your Uncle Frank,” gushes a popular TV ad.)
We have the same genes, more or less, as our Paleolithic ancestors from 10,000 years ago. They were hunter-gatherers who encountered very little salt and fat in their food. None of the flesh they ate came from animals that had been fattened up with corn. They were very physically active and obesity would have been unknown among them. Such a diet and lifestyle would assure that the balance between LDL and HDL cholesterol would have been optimal.
All of their diet was unrefined, and contained large amounts of minerals (not sodium) which would be expected to keep their blood pressures low and their bowels regular. They had no high fructose corn syrup. At times they faced scarcity, sometimes quite severe. Many died young, from infection, trauma, cold exposure, childbirth, warfare, etc. This was a harsh environment at times, and those who survived were strong, resourceful and very capable of dealing with adversity, including long periods of scarcity, punctuated by occasional short periods of plenty.
Our problem now is that most of us face long, uninterrupted periods of plenty, even excess. In most of the developed world, and even in much of the developing world, you can get very excessive calories and lots of salt, fat, sugar and refined carbs for very little money (and thus energy expenditure). Thus we have a pandemic of obesity and diabetes, now nick-named “diabesity”. Most peoples of developed nations have hypertension and high cholesterol as well. The combination of these four, called the Metabolic Syndrome, is now a world-wide pandemic.
Having spent the last 12 years as a convalescent “Hospitalist,” I saw too many patients with these problems. Besides having more heart attacks and strokes, they end up with senile dementia and kidney failure, requiring dialysis in a nursing home. Oh yes, and they’re likely blind, with one leg amputated too. This is every senior citizen’s worst nightmare. And 23% of adults have the metabolic syndrome right now. That’s almost one in four Americans. Many don’t even know they have it. It is even more common in Blacks, Native Americans, Native Hawaiians and Hispanics.
A lot of children have early stages of these problems now. Fast foods and sugared drinks, widespread closure of phys-ed classes in school, and more sedentary activities such as TV, computer games and the internet have spawned an epidemic of childhood obesity and risk factors for heart disease. Some kids are even developing Type 2 diabetes. I tell their parents that this is the type of diabetes kids get when they have worn out their pancreases eating a diet recommended by the TV ads they watch all the time instead of playing outside. Pediatricians are ill-trained and equipped to deal with the onslaught of childhood Type 2 diabetes.
Teenagers who become diabetic could be on kidney dialysis as early as their 30’s or even late 20’s. Young adults on dialysis have the life expectancy of sickly 80-year-olds. There aren’t enough dialysis units and nephrologists right now to deal with all the 40- and 50-year-olds and above with diabetic kidney failure.
Diabetics are poor candidates for kidney transplantation. Even if they were good candidates, there aren’t enough organs to go around. In 2006, there were about 29,000 solid-organ transplantations; as of June 2007, there were about 97,000 people on waiting lists for organ transplantation. The cost of transplantation in 2005 averaged $210,000 for a single kidney. Dialysis for end-stage kidney failure costs about $70,000 per year. Those costs are not going to go down.
What’s to be done? In 2007 all the politicians are promoting universal health insurance to cover those who aren’t covered already by employment based plans, Medicare, Medicaid, the Military and VA systems, and the patchwork system of city, county and even state hospitals. We can’t afford all of these right now and it’s going to get a lot worse.
Over the next 20 years some 78 million baby boomers will go on the public dole, i.e. Medicare and Social Security. That breaks the bank, according to the Comptroller General, David Walker. There are not enough workers in the next generation to cover the skyrocketing medical expenses of their parents. Walker has calculated that in 20 years, there will be no funds for anything other than health care and interest on the national debt. Everything else has to shut down, that’s even including the Pentagon’s overseas (mis)adventures.
Our only hope is to get real about what’s causing conditions like diabetes, obesity and cardiovascular disease, Centering our health care system on questionable hypotheses like the idea that heart attacks are “caused” by high LDL and that they’re “cured” or prevented by taking drugs that lower LDL, may be good business for the pharmaceutical industry, but simply will not help us out of the health care crisis.
Simply put, all of us need to take better care of ourselves by eating in a healthful and conscious manner, engaging in some kind of weight-bearing exercise nearly daily and practicing relaxation several times daily. I did this myself when I turned 40. I quit smoking (pack a day, since my teens), went on a very healthy, low fat (Pritikin) diet and dropped my cholesterol from 240 to 140, and that’s without any pharmaceutical assistance. It is interesting to consider that, faced with someone with a cholesterol of 240, any doctor in 2007 would insist that I take a statin.
I started jogging, and finished 2 marathons (26.2 miles!) when I turned 50. Now 20+ years later, I still take long walks with my dogs twice daily, 7 days per week, and work out at Gold’s Gym three times weekly. I look, act, and feel like I did in my 40’s, and most importantly, my brain still works perfectly. That’s because my blood pressure has been low all these years.
If I can do it, so can you. If you can do it, so can your patients.
Cleaves M. Bennett, MD, is clinical professor of medicine at Harbor/UCLA Medical Center. He received his MD with honors from University of Rochester in 1960, and was one of the nation’s first board-certified nephrologists. His longstanding interest in preventive medicine, and frustration at seeing the end-stage complications of obesity, diabetes, hypertension and cardiovascular disease prompted his founding of the No More Medicines Foundation, a non-profit group aimed at helping people prevent chronic disease without reliance on prescription pharmaceuticals. He is also author of, You Can Control Your High Blood Pressure Without Drugs (2006). For more information, visit: www.nomoremedicines.com.
