who must assimilate the essential knowledge and learn how to prescribe them effectively and safely, rationally rather than routinely. This together with drug promotion and advertising, far more forceful than the comparative ignorance about them warrants, will lead just as inevitably to chaos, more insidiously perhaps than if all available new drugs were thrown on the market at one time, but the same chaos nonetheless.

If the therapeutic morbidity continues to rise, as it must under present conditions, it is clear that something will have to be done about it and this will be necessary if, as it gives every indication of doing, the pharmaceutical industry continues along its present lines. There is every reason to believe that the government will step in in the interests of public health unless some better and effective program is established first.

Is governmental control the only answer? Is it naive to hope that, as a few industries have in the past, the pharmaceutical industry would undertake to control its own practices? It seems to me that such an unusual procedure is justified because the pharmaceutical industry is an unique industry and it cannot operate in the same way or with the same attitude to its consumer public as other industries to. It must be concerned with the welfare of its public, of the public in general. It must have a high moral standard.

It makes little difference if, under the impression that it is the best, a housewife buys the next best detergent. But you may not fool any of the people any of the time about drugs! For even the slightest deviation from fact may be vital; if, under the misapprehension that it is the best, a doctor prescribes something less than the best, it may be the difference between life and death. Unlike the housewife and her detergent, it is clearly immoral if the physician is even slightly misled by claims made for the drugs he is importuned to use on the sick. It matters to him, it certainly matters to the patient, and it should matter

to the pharmaceutical industry. There is the very real ethical question of whether the pharmaceutical industry has the right to sell all the drugs it creates and whether it does not have the moral obligation to select only the elite of its creations for use in man. There is no room for presumption or supposition. The catalog of the drug industry must be a "blue ribbon" list. If industry takes the view that as a purveyor of chemicals it can put all of its products on the open market, it should act as proper chemical manufacturers do and should remove itself from the field of drug promotion, certainly from a biased program of medical education.

I do not believe that the pharmaceutical industry is Public Enemy Number One or that its collective attitude is après moi le déluge. The industry has done many wor derful things for medicine and for mankind. It is to be hoped that it will continue to do so. But insofar as its operations are intimately connected with the life and health of the community, it has a moral obligation to the community which is in no wise lessened by its contributions of the past; perhaps the responsibility is even increased because of the precedents it has set. Unless it recognizes and acts on this aspect of its established function, does it not now stand in serious danger of having to give over its initiative as well as its controls to the government?

What can the pharmaceutical industry do? It seems to me that it can do a great deal. And it seems to me that it can do it more efficiently through its own devices than through any other agency, academic or governmental. Industry should undertake to control its practices. This would not be quixotic but, in my opinion, genuinely practical, really realistic. It should plan broadly for the effective screening of the drugs it synthesizes and terminate the current practice of the hurried introduction of new drugs in order to establish a foothold on the market while leaving the real testing of drugs in the hands of practicing physicians with patients as unwitting sub

jects. Industry should undertake to limit the number of congeners of a single drug on the drug market to some practical number, to the two or three or four shown to be the best in industry's own grand clinical trials. Such a system would ensure a uniform high standard of preliminary investigation of new drugs.

While today most companies conduct careful and thorough explorations of new drug actions and toxicity in the laboratory as well as careful preliminary trials in the hands of experts before the drugs are marketed or even distributed for trial in the hands of clinicians, there are a few who, at a considerable saving in dollars and, often more important to them, a saving in time, put new drugs into circulation with the flimsiest minimum of preparatory work in order to inch in quickly on markets established by others. This inequity and immorality would be ended. To do this fairly as well as effectively, industry must arrange for cross-licensing so that companies which are not the patent holders of the drugs selected for general use can also distribute them and, therefore, will not lose all if their congeners are not chosen.

If clinical trials were carried out on a grand scale with an entire group of drugs examined in a coordinated program at one time instead of the present short-sighted system in which closely related drugs are examined separately and are not adequately compared, the truth about the group as a whole as well as the relative merits of its members would emerge much more promptly. Not only would the therapeutic morbidity rate fall but, perhaps even more important, since only the best drugs in each group would be available, patients would not be deprived of the best drug for their illnesses. A half dozen well chosen antihistamines would serve everyone's needs far better than the present twentyfive. The market would not be cluttered with near duplications for which the most conflicting claims are made. There would be more knowledge and more knowledgeable medical discussion and far less huck

sterish mumbo jumbo about drugs. The Tower of Babel of drug names would collapse.

Can there be any doubt that under such a system the public and the medical profession would benefit? What about the pharmaceutical industry and its stockholders? If the medical profession merely continues to use drugs when they are needed, it will obviously not prescribe less after the inauguration of such a system than it does now. It is possible that it might prescribe even more because it would feel more secure; physicians might exploit drugs more fully, using more effective dosage. There might well be fewer token prescriptions given because of patient demands for the latest in drug development. If the industry manufactures larger amounts of smaller numbers of stable drugs, production costs should fall. Furthermore, if there are fewer drugs, more brands of the same drugs rather than more different drug entities, the very costly system of detail men and the enormously expensive and elaborate brochures which routinely stuff our mail boxes and monotonously extol the virtues of their principals should take no more of the pharmaceutical manufacturer's dollar than they are really worth.

Would not the discovery of new drugs pay off even better than now, since new drugs would be more firmly established by this system? Since their effective lives would be longer, their use through crosslicensing would be more extensive and the income to the discoverer through royalties should be greater. Would not the savings in drug production and distribution be enormous in such a system? Would there not be greater profits to industry as well as lower cost to the consumer? In this connection, it is suggestive that even now, of all the leaders in the field of pharmaceutical manufacture, one of the most successful (if not the most successful) of all American pharmaceutical companies from the point of view of gross profits introduces the smallest number of new drugs for a company of its magnitude and indulges in

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virtually no molecule manipulation as the means of encroaching on markets established through the original research of other manufacturers. Those who follow such a system may therefore have larger profits as well as clearer corporate consciences. In addition, "the most ethical of the ethical companies" will not be forced by competition, as the New England Journal of Medicine points out they now are, to "meet the tactics of the least ethical."

It seems to me that the only segment of industry which may not wish to participate in an arrangement along the lines proposed because it cannot possibly profit by it is that small marginal portion which (1) has nothing to contribute to a cross-licensing system and (2) is interested only in seeing that its own product, rather than the best medication for the patient, is used in each instance. Since the organized industry will have gained such a high order of confidence of the medical profession and the public at large, should any firms refuse to participate, would they be able to compete with those who do? This system would serve to separate and distinguish in the ethical drug industry the ethical and the really ethical.

Because of coordination and increase in efficiency, the trials on humans could be more carefully and safely conducted. Because there would be far less waste of that invaluable commodity, the human subject, the clinical investigator would have much less trouble getting adequate clinical material for his needs and would be able to conduct more satisfactory clinical trials. Because this arrangement would eliminate much duplication and overlapping, that even rarer commodity, the expert clinical investigator, would be better able to deal with the heavy load provided for him by the new drugs. Finally, because clinical trials would be planned on a broad base, far less time and money should be wasted in preliminary trials before new drugs could be safely and properly marketed, and as a result there should be less delay in the safe use of new drugs.

It seems to me that advertising wou continue at its present pace but would have to change from product promotion to inst tution promotion. Brand names would tak on much more meaning because drg would at once be identified with their d tributor. The type of competition the would engender should lead to the highe standards in drug manufacture. It woul no longer be essential for industry to ea cate (sic) the physician about drugs. P graduate medical education would retur where it properly belongs, to the aegis a academic institutions, accredited med journals, and medical societies.

Research in industry would continue its present pace; new drugs will always b needed. But under such a system, thos drugs which reach the market would b used without reluctance and cynicism be cause faith in industry's claims for drag would be re-established. Since structure roulette would be restricted to the searc for better drugs and not used to circumvent patent rights, research in industry wou become far more meaningful than it pre ently is.

There can be no question: the medic profession's gain would be enormous. Be cause there would be fewer drugs in ust there would be a much larger over-all a perience with each and more informatic about the unusual as well as the mort common drug actions, about hypersensity ity, toxicity, synergism, incompatibilit and treatment of poisoning, of tolerance and addiction, and of use in refractor cases. Because the drug companies woul be selling the same drugs, there would be few conflicting claims about their action and effects, thus far less confusion. As the result of more knowledge and greater cor fidence, the physician would use his mec caments with greater assurance and explo drugs to the greater good of his patients

Will the patient benefit? How can the patient fail to benefit? Only the best drug would be available. This is, of course, th most important consideration, but there ar ancillary benefits as well. Because the phy

sician would understand the drugs better and use them more effectively and with greater confidence, the patients would get better results from them. Certainly there would be far less iatrogenic disease. Finally, it seems likely that because the manufacturers of the best drugs would not be in terror of having them displaced through structural roulette or more effective pro

motion, they would not need to recoup their costs quite so quickly and could depend on a stable and prolonged market. And because there would be honest competition in the true American sense of the word, while drugs would cost the patient less, the profits of the manufacturer should also increase.

It could happen here.

Walter Modell, M.D.