_Prescribing by Numbers, Jeremy A. Greene

Subtitled: Drugs and the Definition of Disease

Greene covers the history of three drug categories (diuretics to reduce hypertension, antidiabetics and statins to lower cholesterol). He describes how these drugs were invented/discovered. He describes the arc of research used to motivate the creation of these drugs, justify the use of these drugs and to expand the market for these drugs. He includes occasions when unexpected research results led to the withdrawal of a drug -- and also when research results probably should have led to withdrawal of a drug but did not, and why.

Greene covers several threads of resistance to the increasing markets for these drugs. He avoids covering "scandals" because his point is that marketing and the market have a much bigger influence in the pharmaceuticals when their isn't a scandal than when there is. He asserts that paying too much attention to scandals distracts from the pervasive and unavoidable market influence in/on/of pharmaceuticals. Greene pays limited attention to the issue of negative effects on individuals who take drugs they may never personally experience any benefit from, and only mentions at the end the environmental impacts of pharmaceuticals, and the social injustice of crazy amounts of drugs for risk reduction in wealthy nations and nothing for people suffering from sleeping sickness and malaria.

This is a very wonky book. In addition to containing a lot of medical terminology, Greene assumes the reader has at least a passing awareness of basic ideas from statistics such as normal curves, standard deviations, one-tailed versus two-tailed tests. He assumes the reader is aware of scientific/medical conventions of research such as randomization, double-blind, case-controlled, cohort. He supplies limited details about things like thalidomide and the Framingham study, presumably assuming these are enough to aid the reader in recalling the rest of the story. He assumes the reader has the ability to make sense of words like nephritic (in medicine or anatomy) and deontological (in philosophy).

If you _do_ have the prerequisite background knowledge and vocabulary to make sense of Greene's language, I predict you will appreciate the clarity and conciseness of his presentation, the lean precision of his argumentation and his overall prose style. This is no chatty guy chasing down the experts and quizzing them; this is a scholar who is carefully rallying the evidence in the service of an unobvious but nevertheless extremely important thesis. Every once in a while, he lands a zinger -- like when he points out that by exhorting careful monitoring and treatment of prehypertension, public health folk are stuck pursuing an asymptomatic risk factor which leads to another asymptomatic risk factor, two steps away from any hard disease. But generally speaking, this isn't a funny or snarky book.

I really liked it. I'm planning on keeping my copy.

exercise, not smoking, and other important stuff

Reading Greene's book, I was struck once again about how people responded to the lessons of Framingham. Pharma made drugs to address the identified risk factors: high blood pressure, high cholesterol, smoking etc. All these drugs were intended for use _after_ dietary changes had failed to get the desired improvement. While quitting smoking is mentioned in some cases, the idea that quitting smoking would have a big effect on all the numbers seems to have been underemphasized or maybe not understood at all. Certainly everyone was shocked at the immediate and lasting drop in heart attacks in Massachusetts and elsewhere when smoking was banned in restaurants and bars, which is a strong indication that whatever the research said or didn't say, no one really viscerally understood what that would mean in practice. Chalk some of that up to the tobacco industry, but I'm betting there was a whole lot of something else going on, too.

The sheer lack of mention of exercise as the medical science developed hand-in-hand with the drugs is startling. Today, of course, I consistently feel that we pay too much attention to BMI and/or weight and not enough to waist circumference -- and we really don't pay hardly any attention to how adding even small amounts of low-intensity exercise can improve numbers.

I did a little googling, and once again, I'm annoyed at how little this has been researched. I know why -- there's no easy big money to be made out there by proving that the right kind and amount of exercise is as good as taking a statin -- but it is sad nonetheless.

It's particularly sad when you realize that everyone seems to be taking drugs for cholesterol and high blood pressure (sometimes in the same pill), and at least in some formulations, both of these increase the risk of problems in the liver and/or rhabdomyolosis. And on top of it, it's far from clear what the win is in these drugs for women anyway, in terms of hard outcomes.