Chapter One

Medicine in Transition

Caring for Patients at the Crossroads

The air was hot and muggy even by Amazon standards. It was the end of an exhausting but very satisfying day of doctoring indigenous people of all ages in a two-room school building temporarily transformed into clinic for this small medical mission. We were putting the medical equipment and records away, and I was thinking about how nice a cool shower was going to feel, when our interpreter approached me with a look of concern and asked if I would make a house call to a woman who was too sick to come to our makeshift clinic.

Several villagers led me across an open field and down a narrow dirt path to the sick woman's open cabin. As we approached, I could see her lying still in a hammock. Her husband was sitting nervously by her side and her four young children were darting playfully in and out of the cabin, pausing for just a moment to check on their sick mother. As I sat down next to her, I could tell from her detached, pained, and frightened look that she was seriously ill. Even the subtle facial expression she mustered to greet me seemed to cause her pain.

I was introduced to the sick woman and her husband by our interpreter, and learned that she had had a spontaneous miscarriage severel days before. The pain in her belly and vomiting had been getting worse for the past two days. I asked if I could examine her. She responded with a minimal nod and looked over to her husband to make sure that he agreed. Her temperature was now 103 degrees. Her abdomen was stiff and exquisitely tender to even the slightest touch. Most likely she had developed a uterine infection as a consequence of an incomplete miscarriage, and the infection had spread throughout her abdominal cavity, causing peritonitis. She needed to be hospitalized for intravenous antibiotics and fluids, and she needed dilatation and curettage of her uterus -- a D and C-to remove the infected tissue.

Her husband and several other villagers listened attentively as I explained my diagnosis. But their expressions changed from hope to despair when I told them that she needed to be treated in a hospital. They said that she couldn't go to the hospital because they did not have any money. I suggested that they take her there anyway and that someone would care for her. They said that wouldn't work, that she would be ignored, left to die on the hospital steps. I asked how much it would cost for her to get hospital care. They said $160. The two other Americans present and I glanced at one another and agreed, without a word being spoken, that we would get the money together. Fortunately, a boat soon came by, headed in the right direction, and off she went, accompanied by our capable interpreter, who could help her with travel and hospital arrangements. The woman returned to the village three days later, weak but much improved. Her look of fear was gone. Her husband and children stared in happy disbelief when they first saw her and realized she would recover.

When I got back home, I went to my office the Sunday before resuming my normal schedule to go through the paperwork that had accumulated while I was away. Among the several 3-foot-high stacks of patients' charts, test results, consultants' notes, medical journals, and junk mail was the latest issue of the Journal of the American Medical Association (JAMA), from November 24, 1999. I noticed an article about Celebrex and one about Vioxx, the latest drugs for arthritis pain. Each article presented the results of a study sponsored by the drug's manufacturer claiming that the drug was significantly safer than older anti-inflammatory medication, which was available in much less costly generic form.

The accompanying editorial -- these are typically included in medical journals to provide expert perspective on the most noteworthy articles published in each issue -- reported with unusual candor (especially since both authors had financial ties to at least one of the manufacturers of the new drugs) that neither of the new anti-inflammatory drugs provided better relief of symptoms than the older alternatives. The editorial also explained that the highly touted safety benefits of the new drugs appeared minimal in people who were not at high risk of developing serious gastrointestinal side effects. So minimal, the editorial said, that 500 such people would have to be treated for one full year with the new drugs instead of the older anti-inflammatory drugs to prevent just one serious but nonfatal stomach ulcer. Based on the difference in price between the new and older anti-inflammatory drugs, the editorial calculated that the cost of each serious ulcer thus prevented was $400,000.

Still moved by my experience in the Amazon, I wondered how many lives like that of the woman to whom I had made the house call might be saved for the cost of preventing a single nonfatal stomach ulcer by using Celebrex or Vioxx. I took out my calculator to see how many times $160 goes into $400,000. I could feel myself change when I saw the figure "2500" on the display and realized the injustice of that equation. Though I didn't realize it at the time, this book was conceived in that moment.

This incident sensitized me to the intense marketing of these two drugs. Advertisements for them suddenly popped up everywhere. At first the ads seemed inappropriate, but quickly they claimed their place as normal fixtures of the American cultural landscape. The implication of the ads was that the (unspecified) superiority of the new drugs allowed people to enjoy activities that they had previously been unable to enjoy because of arthritic pain-though no such superiority had been found in any of the major research.

The marketing campaigns were certainly successful ...

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Excerpted from Overdosed America: The Broken Promise of American Medicine by John Abramson
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