What’s more, despite advances, the pipeline of new drugs has slowed to a crawl, as one promising candidate after another has petered out in the last phases of development. "The low-hanging fruit has been picked," says Derek Lowe, PhD, a drug discovery chemist and industry pundit. William Haseltine, PhD, a former researcher at Harvard Medical School and the founder of Human Genome Sciences and eight other biotechnology companies, notes that fewer than 1 in 100 new ideas reaches clinical trials and fewer than 10 percent of these are approved for sale.

This high failure rate means that the few drugs that do get through the gauntlet of clinical trials and FDA approval become must-win propositions. A company must pull out all the stops to sell the drug, which means marketing.

The drug industry’s intense marketing to physicians has been well covered. But it’s worth noting here that some marketing is designed to push out perfectly worthwhile older treatments (whose patent protection has often expired and can therefore be sold as cheap generics) in order to advance newer treatments (which are under patent protection, and therefore are more expensive).

But are the new drugs really better? The FDA doesn’t require comparative clinical trials, only proof that the drug beats a placebo. So unless somebody were to compare drugs head to head, it’s almost impossible to say. That was the premise behind a landmark study by the name of ALLHAT (short for Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), begun in 1994. Various treatments for high blood pressure were compared side by side in order to see, once and for all, which treatment was really best. At the time the study began, the use of diuretics and beta-blockers was in decline, while three newer treatments—calcium channel blockers, angiotensin-converting enzyme inhibitors (known as ACE inhibitors), and alpha-adrenergic blockers—were on the rise. But since these newer drugs had only been compared to placebo when working their way to FDA approval, there was no way to know which treatment was most effective.

The study, which recruited 42,000 individuals with elevated blood pressure, was one of the most ambitious ever carried out for the condition. The subjects were divided into four groups and given one of four treatments: a diuretic, an ACE inhibitor, a calcium channel blocker, or an alpha blocker. Within a few years, the alpha blocker arm of the trial was stopped: Patients were showing a 25 percent increased risk of heart disease. The other 30,000 patients continued their protocols for 5 years, and then the results were analyzed.

Published in 2002 and elaborated upon in 2006, the results were a disaster for the drug industry. Not only was the alpha blocker deemed too suspect to use, but the calcium antagonist and the ACE inhibitor both fell short of the cheap, common, and old-fashioned diuretic in lowering blood pressure and reducing the risk of heart disease. Patients on the newer, patented drugs had higher rates of stroke and heart failure.