Dr. Abramson doesn't spare the pharmaceutical companies any criticism. Our system of drug-financed medical reasearch and medical centers, corporate-sponsored professional organizations and medical education, and consumer advertising corrupts the decision making process of doctors, patients, and expert panels. The evidence central to evidence-based medicine can't be trusted because it's financed by drug companies. The practice guidelines that expert panels such as the American Heart Association publish which are supposed to guarantee we all practice high quality medicine can't be trusted because they're funded by drug companies. But that's only part of the problem. As Dr. Abramson says at one point in his book - "we have met the enemy and they are us."

The problem can be traced back to the late 1980's and early 1990's when Medicare, Medicaid, and the baby boom population reached maturity. There was much hand-wringing at the time about the "crisis in American medicine," just as there is now. Then, as now, the crisis was the cost. The solution, which enjoyed wide support from all sectors of society - from the public, the medical profession, and politicians on both sides of the aisle - was the adoption of managed care, or HMO's. The public loved it because it meant they no longer had to pay for healthcare, at least not directly. For a minimum co-pay, and the price of their monthly insurance premiums, they would get unlimited access to their doctors and all the preventive care they needed - pap smears, mammograms, immunizations, and yearly physical exams, and drugs. The medical profession loved it because they believed passionately in the power of prevention and they also believed that by providing unlimited preventive care they could conquer disease. The insurance companies loved it because it shifted the inherent risk of their business to the medical profession. Politicians loved it because it meant that once Medicare and Medicaid beneficiaries were shifted to managed care programs, someone else would make the painful and unpopular decisions about rationing that are inevitably needed to rein in costs. It was win-win all around.

Except it didn't quite turn out that way. The gatekeeping nature of HMO's turned out to be immensely unpopular - so much so that the insurance companies pretty much gave up on limiting benefits, lest they be accused of corporate malfeascence. Instead, they just raised premiums. The emphasis on prevention, and the willingness to pay for it, encouraged doctors and the public to accept expanded definitions of health and disease. Doctors could promote with impunity the necessity of having bone densitometry tests or fasting lipid panels done - and the necessity of treating values outside the defined norm - without giving much scrutiny to the actual benefit. And the public could accept it without much thought, since they didn't have to pay for it directly. Add to this mix the expansion of pharmaceutical advertising directly to the patient - who no longer had to worry about the cost of the product they were consuming, and you've got a recipe for unlimited demand, and unlimited spending. (The drug industry marketing departments knew a golden opportunity when they saw it. What other product has the luxury of advertising directly to a consumer who doesn't have to pay for it?)