Pharma: Greed, Lies, and the Poisoning of America
Author: Gerald Posner
Publisher: Avid Reader Press, 2020. 816 pages
Reviewer: Megan Aiken ǀ November 2021
Is the opioid crisis due to a single atom? No, this isn’t a hypothetical question to intrigue the reader. Rather, Posner’s expert, detailed text on the history of pharmaceutical corporations often asks readers to consider the magnitude of a single atom.
Had it not been for a single atomic difference between Terramycin (by Pfizer) and Aureomycin (by Lederle), Pfizer may not have been the pharmaceutical giant it is today as one of the top pharma giants and, next to OxyContin developer and Sackler-owned Purdue, a leader in ‘most lawsuits gained’ during the opioid crisis. Gerald Posner’s in-depth and ground-breaking Pharma uncovers the interconnectedness of medical research, advertising, and American economic development throughout the 20th century to uncover the plethora of ripple effects contributing to a crisis ravaging the United States and beyond.
In some ways, Pharma is not a novel text. In recent years there have been many incredible studies on the opioid epidemic in America, such as Dopesick by Beth Macy, Dreamland by Sam Quinones, Fentanyl, Inc by Ben Westhoff, and of course Barry Meier’s Pain Killer, along with others that choose to tell the story of one piece of an incredibly complex and historically-constructed problem. These stories draw readers to consider the hurt and struggle of those affected by a problem that is not receiving attention in a meaningful way by decision-makers. None of the aforementioned texts, however, historically situate themselves in the manner that Pharma does.
Despite its immediate appearances, Pharma is less of a book about the opioid epidemic than it is a medical history of what led to the crisis: corporate greed, hubris, bureaucracy, and the quest for an idyllic healthy population. This is exactly where this book’s novelty lies. Posner expertly and uniquely draws connections from the politics and policy of 20th-century American development, presenting a kind of butterfly effect tale of not only the marketing tactics that led to OxyContin overprescription and the resulting crisis (in Pain Killer fashion), but the political motivations and social forces that, over time, enabled it. Pharma tells the story of the interlocking mechanisms of regulation, advertisement, and capital accumulation that led “A Jewish Kid from Brooklyn” (Arthur Sackler) to have his family name become synonymous with an enduring legacy of overprescription and overdose that has ravaged America, and beyond, for two decades.
Prestige is one Hell of a Drug
Posner’s work is not solely about opioids or even just the Sackler family, for that matter. Pharma couches the advent of wonder drugs, like OxyContin and Valium which came before it, in a longer history of America’s intimate relationship with drug use – good and bad. The earliest part of this text begins with the construction of good versus bad drug regulation in the early 20th century, and how early pharmaceutical companies grew from having a negative to positive public image. Posner manifests a sort of anxiety throughout the text, from pharmaceutical corporations, as if they are constantly grasping to remain in a positively-viewed light, normally by building a home in the grey area between legal and illegal marketing and manufacturing.
From the stigma of early pharmaceutical corporations’ wartime pushing of cocaine, alcohol, and painkillers like morphine, the author guides readers through the advent of sulfa-products, penicillin and the antibiotic boom, barbiturates, oral contraceptives, tranquillizers, benzodiazepines, antidepressants, and so on. Pharma weaves a tale of how America grew addicted to pharmaceutical drugs through aggressive, (usually) legal pushing. In doing so, Posner describes the subtlety and creep of addiction beyond medication — the addiction to greed, power, and material possessions that can seemingly deteriorate one’s own ideology, ethics, and moral compass.
As a Marxist during his undergraduate education and an alleged communist during McCarthyism, it seems almost antithetical that Arthur Sackler would go on to discreetly position himself, his work, and his knowledge, as the voice of guaranteed pharmaceutical profit. Posner describes Sackler’s humble yet ambitious beginnings, yet, by the 1960s, Arthur Sackler was at the center of a network of advertisers, academics, and (sometimes imaginary) medical practitioners who were often able to skirt political actors like Senator Estes Kefauver and FDA Commissioner James Goddard, ensuring corporate interests were realized. Posner illustrates how Sackler (or a close colleague) is consistently behind the curtain when pharmaceutical interests are at stake.
Catch Me If You Can
Pharma reads with the tone of immediacy reminiscent of a kind of cat and mouse action movie. Throughout the text, Posner consistently reminds us of two things: that the writing of an opioid crisis has been on the wall for a long time, and that just when the villain looks to be done for, something gets in the way of the good guys.
Posner opens Pharma writing about the current opioid crisis, and one of the hallmark details of this text is that it is, in my opinion, one of the best illustrations to date of the writing on the wall. The crisis that began in the 1990s is not so much a new crisis, but one that had been ebbing and flowing for decades. Repeated attempts at the perfect cocktail of substance, regulation, and advertising had yet to be successfully profitable and long-lasting, until OxyContin. Prior to the 1990s, the reader can pick out this cycle of aggressive marketing, non-addictive claims, and addictive consequences, at least two other times: morphine in the latter 19th century (pre-regulation, and pre-research into addiction) and Narphen (a synthetic opioid) in 1960. Beyond opiates, Posner highlights drugs like Valium and Premarin that had their extreme side-effects understated for purposes of the profit margin and public image. This marketing-claim-consequence cycle primed the medical world for OxyContin, especially amidst the growing pain reevaluation movement that attempted to reconsider chronic pain and addiction (or pseudoaddiction). This movement has been the hallmark justification for opioid manufacturers for the past 40 years.
This writing on the wall is not solely limited to cycles of drug innovation, but is also about the relationship between industry and government: from the swine flu epidemic to the overprescription of opioids, Posner demonstrates that past government administrations have essentially been held hostage by political capital when national crises due to regulatory negligence end up causing (or nearly causing) significant harm to the population. In these times, where a clear problem stems from the industry and can only be solved by the industry, Pharma illustrates very well the dance among marketers, researchers, bureaucrats, and politicians. None of this is ever limited to a single corporation. While Posner is able to generally tie most elements back to the Sackler family network (which became even more confusing after the death of Arthur Sackler), what he ultimately describes is a structural force deeply engrained and simultaneously at odds with governing Americans, fuelled by little more than the rationale of prestige and accumulation.
By the time the scene of Pharma is set and the main characters are introduced, the reader has been subjected to plot twist after plot twist. There arise times where it seems as though one of Pharma’s many villains’ plans will surely be foiled. Oftentimes, what seems to ultimately allow villains to persist is waning public attention. For example, the 1963 JFK assassination immediately overshadowed the damning report about the dangers of addictive pharmaceutical drugs, in particular Librum, that could have sidelined Sackler’s vastly prestigious and profitable marketing network. A decade later, the just-as-damning Drug Efficacy Study Implementation (DESI) task force found that nearly 2,000 drugs on the market were possibly ineffective, despite FDA approval. This potentially pathbreaking indictment was curtailed by a combination of overambition and a slow bureaucracy. In the 1990s, when FDA Commissioner David Kessler attempted to tighten regulations around harmful pharmaceuticals, his efforts were cut short by personal affairs; yet his efforts ignited the entire pharmaceutical industry to increase lobbying efforts in the aftermath of his 1997 resignation.
Ultimately, one might assume a natural conclusion to Pharma would be policy recommendations or insights for how the U.S. and other countries can recover after decades of largely corporate-induced, out-of-control addiction and overdoses now made worse by a global pandemic. But as stated previously, this is not a book about the current crisis as much as it is a cautionary tale about the writing on the wall, about the ways in which the villains continue to come out on top. For those who may think Posner does not leave the reader with nuggets of where to go from here, I ask those people to consider history. The book details a number of times where the Overton window reveals the potential for change, times where we can look to, now, to see if the past will repeat itself, or if a new, healthier course will be charted. We need to be vigilant when these times arise — public attention must be maintained, the veil of advertising must be lifted, and government interests must fixate on accountability and oversight, even if it risks material gain.
While it is undoubtedly a welcome addition to the growing literature on pharmaceuticals in America, Pharma is not without its shortcomings, particularly with regard to how Posner balances depth and breadth. In terms of depth, as the book navigates toward the current moment it becomes clear that there is an overarching colorblindness that downplays the discriminatory nature of how opioid addiction has been handled. While this undoubtedly allows the material to hit home for a more privileged population that may oftentimes see themselves situated at a distance from the opioid crisis, the particular racial discrimination involving medicating, however defined, is an unfortunate omission here. This is likely a reflection of writing style or tone rather than a deliberate omission, as Posner otherwise effectively writes with little personal voice. Instead, his voice is that of those who came before, from government, corporate, and media reports. The omission of any discussion of the role of race is not entirely just on the part of Posner, then, but rather a classic omission that archival sources would have adopted. This reflection of archival source voicing can be observed in Chapter 21: Targeting Women, which is the first time Posner’s source material constructs separate medicating profiles for men (“executive neurosis”) and women (“neurosis, hysteria, anxiety, and depression”); this was, of course, for the express purpose of targeted advertising (pg. 204).
With regard to breadth, Pharma is a long text, and at times Posner perhaps deviates too far from the path ahead of him. At times, the overarching point, or narrative, is momentarily lost down an intriguing side-path that may or may not be important for later narratives. At the same time, there is a meta-narrative to the text that, through these rare diversions, allows readers to feel and experience the complexity of the problem. In this regard, readers who wanted to work through this book over time would have benefited from some high-level indication of the meta-narrative, overarching themes, especially so that these segues, though eventually valuable to the narrative, make greater sense at the time.
Pharma a challenging read, but Posner writes in language plain enough to be accessible for many, and effectively describes and contextualizes many things that could easily be otherwise inaccessible for readers. Well suited for anyone interested in, affected by, or participating in U.S. pharmaceuticals and regulatory politics, Pharma is a much-needed foray into the potential ripple effects of a single atomic difference, and the springboard of greed, capitalism, regulation, and policy failure. Pharma ought to serve as a cautionary tale, as the world moves from public health crisis to public health crisis, that human connections and prestige endure these crises and, in fact, may profit from them. While Posner himself does not offer an explicit solution, I think one seems clear: we must recognize the warnings, and the public agenda must not be allowed to dismiss this epidemic.
Megan Aiken is a Ph.D. Candidate at the University of Alberta