MegaPharm has seen the serial consolidation of thousands of competing pharmaceutical firms into a couple of handfuls of huge, rich, multinational conglomerates with turnover greater than most countries [there are 228 countries]. Ireland ranks 35th with a revenue of $93billion, but is disconcertingly pwned by the pharmaceutical industry with thousands of voter's wages dependent on pharma production lines across the country.
GSK Started small in 1830 as Smith & Gilbert . . . & Kline  & French & Richards  & Nathan  & Horlicks  & Beecham  & Glaxo Burroughs Wellcome . There are, of course, economies of scale: big facilities are more efficient than small. But those big facilities demand more sales so that the [capital intensive] production lines are never idle. MegaCorp can reduce the wage bill on the manufacturing side by off-shoring production to Indonesia or Ireland but the herds of "detail-men" coursing about the country talking to prescribers in their surgeries are mostly white, mostly men and all on delivery bonus. Their salaries, and those copy-editting in the advertising department, are part of the reason for the handsome retail mark-up over production costs.
The other reason is the claim that developing novel therapies is intrinsically expensive . . . because novel - so many bright ideas scattered on the floor of Reality Station: failed at one of the many stages where the creative spark is walked up the hill to a safe drug that actually works to alleviate suffering. Doesn't work in a Petri dish; doesn't work in mice; doesn't work women; does work in some women but kills a disconcerting number of other women. Not to worry about that though, if the FDA prevents sales in the USA, there is a vast market in South & Central America.
It didn't have to be like this. Posner's thesis is that the growth and development of the American Pharmaceutical industry went in a particular direction because of Arthur Sackler: a charmer who had a way with words and a relentless entrepreneurialism: so many companies, so many wholly-owned subsidiaries so many inter-dependencies. Posner had to become a forensic accountant to shovel through a mountain of documentation to determine that Sackler (or his brothers or his wives or his cronies) was the beneficial owner a named $$$ company with a registered address somewhere in America or Europe. He realised that doctors were the key nexus in the distribution of drugs: if you could get your product front-and-centre with a GP then there were potentially hundreds of sales to the doctor's patients. Direct mailing of promotional copy, often masquerading as objective impartial science, helped as did free samples to try on vulnerable patients. Side-effects? Contra-indications? there was nothing to be gained by emphasising those! And the detail-men who appeared, all smiles, in person: they were trained more in empathy than in evidence.
The competitive marketing which Sackler started and was taken up by everyone else in the industry - except The Losers - meant that far more scripts were filled than was strictly necessary. This worked serially for
- A for antibiotics - penicillin, tetracyclin, etc. each in turn developed anti-biotic resistant strains like MRSA and CRE. As we blame the Chinese for Covid-19, so we should blame the USA as the breeding ground of untreatable pathogens through the 1950s and 1960s
- 80% of US antibiotic pharma goes to farmers! 140,000 tonnes annually mostly as growth promoters and/or prophylaxis against overcrowding in feedlots
- Psychotropics: Valium, Librium, Adderall, Prozac, Xanax . . . 600 million scripts in the USA in 2018 costing $30 billion. That's only $50 a pop: huge numbers of sales means the price is low for each. Contrast with orphan diseases with only a few punters: Vimizim costs 10,000x more per dose.
- Oral contraceptives and hormone analogs. Diethylstilbestrol was widely prescribed for a variety of real and imaginary ailments. Alan Turing was chemically castrated with this estrogen-like chemical before he committed suicide. Estrogens have a wide variety of physiological functions beyond regulating the menstrual cycle and the side-effects of oral contraceptives indicate the extent of that empire: blood-clots, cancer, stroke. It didn't help that decades of women were give 10x more estrogen than was needed for preventing pregnancy.
- Orphan drugs - meant to help folks suffering from minority diseases - is being flim-flammed into an excuse to charge $whatever+50% because The feds will pick up the tab