The strange temptations of phoney medicine

22nd July, 2021

We puny humans just can’t seem to deal with the idea of a disease for which there is no treatment. We’ll always find something to believe in, no matter how tenuous. Since the Sars-Cov-2 virus was discovered, people have been circulating “cures”, from avoiding iced drinks (nope) to using special red soap (soap is good, its colour irrelevant).

Some speculative treatments have been pushed by politicians. The UK’s former Brexit supremo David Davis has urged the use of high-dose vitamin D supplements, while Donald Trump advocated hydroxychloroquine. Alas, a high-quality randomised trial has shown that hydroxychloroquine is not an effective treatment. Low-dose vitamin D is a useful supplement to take in winter, but there is no good evidence that high doses can treat Covid-19.

Then there is the pure quackery: inhaling hydrogen peroxide, using a USB flash drive as a “bioshield”, or drinking a suspension of silver particles in water. There is a lot of money to be made by selling snake oil to the fearful or desperate.

Phoney treatments are not new. Indeed, their enduring popularity is a puzzle. In 2010, the economist Werner Troesken published a study of the US market for unproven concoctions — “patent medicines” — in the 19th and early 20th centuries. He concluded that, even after adjusting for inflation, people spent more than a hundred times as much on such medicines in 1939 as they had back in 1810. This growth outpaced overall spending twenty times over, and the market for patent medicines eventually rivalled major industries such as fertilisers or paints.

So why the demand? Steven Johnson, in his new book Extra Life, points to two powerful forces helping to make useless treatments look good: the immune system and the placebo effect. The human immune system is a wonder: most people who are sick recover.

Now stir in the placebo effect, the well-known but poorly understood tendency of people to benefit simply from the belief they are being treated. Troesken notes that many quack medicines included ingredients such as chilli, alcohol and opium, producing plausible highs, lows and tingles. If you happen to recover from sore knees after applying petroleum oil seasoned with chilli pepper, turpentine and camphor — Clark Stanley’s Snake Oil Liniment — then you might well give Stanley the benefit of the doubt.

Chronically sick people rarely expected miracles, but were willing to give these treatments a try. What did they have to lose? The emergence of a few genuinely effective medical treatments did nothing to damp demand: it enhanced the plausibility of true and false medicines alike. So people hopped from potion to potion, more in hope than expectation. If these treatments had worked, writes Troesken, “people would have been cured . . . and spending would have been curtailed”. The fact that they did not cure much was, ironically, part of the reason they were in demand.

And where were the regulators? Johnson describes an irony: they finally took an interest because of a product that was not a quack medicine but a genuine antibiotic, sulphanilamide. Because it was not soluble in water or alcohol it was delivered as a chunky pill, difficult for children to swallow.

In 1937 a child-friendly version was marketed by a new drugs company, SE Massengill. It was a raspberry-flavoured syrup with the sulphanilamide dissolved in diethylene glycol. Too few people knew then that the glycol was toxic and there was no legal requirement to check. More than a hundred people, 34 of them children, died of kidney failure before the US Food and Drug Administration figured out the problem and tracked down the last poisonous bottle. Harold Watkins, who originally produced the deadly syrup, killed himself.

The FDA’s main role had been to ensure that the syrup did, as advertised, taste of raspberries. In 1938, President Franklin D Roosevelt signed a new law mandating that the FDA could also check for toxicity. And Frances Oldham Kelsey, the young chemist who identified the toxin in Massengill’s “Elixir”, went on to a senior role at the FDA, where she later refused to approve the use of the deadly drug thalidomide.

We consumers need help. We cannot distinguish tricks from treatments without high quality information. That information can come from public, profit-seeking or non-profit sources, and regulators are well placed to require the expensive checks needed.

Yet it is not easy to draw the line on what to regulate and how. The FDA, understandably, wants to avoid approving future child-killing drugs, but there is a price to be paid for caution. The FDA was slow to approve Covid tests in early 2020. It has seemed sceptical of the Oxford/AstraZeneca vaccine approved by British and European regulators and in use in more than 160 countries around the world. There is a risk in hasty approval but also a risk in delay.

I cannot help but draw a broader political lesson from the long history of demand for quackery. When we feel that things are not going well and that experts have been unable to help, we seek more speculative remedies, even if we do not expect much. When those remedies fail, we become more desperate, and we keep searching. There is always another charlatan around the corner.

Troesken underlines the puzzle, writing “one does not normally expect strong consumer demand for products that routinely fail to deliver”. Not strong voter demand, either. And yet here we are.

Written for and first published in the Financial Times on 27 June 2021.

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