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Launching Pfizer's Viagra

The Sunday Times

Sex drugs & rock 'n' roll

Viagra is the sex sensation of the century. Launched as a cure for impotence, it has now become the latest lifestyle accessory. But for some men it is useless, or much worse: the side-effects include death.

 

BRIAN DEER INVESTIGATES

 

The Sunday Times Magazine, September 6 1998.

The drug company's instructions are simple enough, but Dr Harin Padma-Nathan fears missing his engagement, and anxiously seeks advice. "Where's Chino?" he demands, via his hand-held cellphone, as we hammer through Los Angeles at 75mph in a dark blue BMW. "My passenger from England here tells me that the map you've given us runs out at Ponoma."

A voice reassures him: go the way you're told. He repeats this. I read the instructions. From his office at the Male Clinic in Santa Monica to the Chino Medical Group, 50 miles east, you follow I-10 onto California 60, shoot through Ponoma head south on Central Avenue, then left onto Walnut. Our destination is just past the hospital building. Street number 5475.

Pfizer's note actually says right onto Walnut - the wrong way - and one of its sales representatives, a dark-haired young man lurking in Padma-Nathan's parking garage, had earlier piled on extra stress by reckoning that we would be late. But at the frantic pace at which everyone is working, errors are bound to occur. We make one double-back, but look in good shape. We will reach our goal as planned.

It's a sweltering Thursday lunchtime, and the doctor is on assignment promoting Viagra: the selective phosphodiesterase inhibitor launched euphorically last March in America and now heading in Europe's direction. He's one of an elite core of paid Pfizer "consultants" who are hurtling through a punishing campaign of talks and media pronouncements. At Chino, a town of 48,000, he will lecture to a gathering of health professionals and offer a soundbite for network news.

In the light of the world-wide Viagra hysteria you wouldn't think he needed to bother. Not since the banning of Coke containing coke have people sweated so much for a drug. Even the launch ten years ago of Eli Lilly's selective seratonin reuptake inhibitor, Prozac, never saw a buzz like this. "Forget mind-altering drugs," Padma-Nathan tells me. "The new vogue is penis-altering drugs."

But today the doctor has a task on his hands that contradicts Viagra's image. There are signs of the frenzy spinning out of control, and the product's downside may be starting to show. Not only has it picked up the label "recreational drug", for which health insurers and governments are reluctant to pay, but potentially life-threatening side-effects have hit the news. So his goal, like that of Pfizer people all over the world, is to refocus the campaign on impotence.

Although paid by Pfizer, he's not a salesperson. The company has 15,000 of those. Rather, this 42-year-old Sri Lankan-born urologist is one of a new breed of doctor: a sort of freelance expert-entrepreneur, leasing their services and reputation. From his Male Clinic, which he set up for such purposes, he was the major contractor for Viagra's pivotal tests, submitted to the Food and Drug Administration. He advises the company. He makes company training videos. He travels at the company's expense. If you want to find a man to call "Dr Viagra", he's sitting at the wheel of this car.

His schedule is crazy, media pressure intense and I'm lucky to ride shotgun for the day. Pfizer itself says next to nothing on the record about its billion-dollar baby, leaving its hard-pressed consultants to feed the public's interest - so far with spectacular success. Padma-Nathan has recently done Newsweek (twice), Time, People Weekly, the New York Times, the Los Angeles Times, The Wall Street Journal, Nova, CBS News (six times) and NBC News (four times).

He asks my opinion about London-based press, which are also clamouring for interviews. With US Viagra consumption already down by one quarter from the peak of America's hysteria, the focus has now shifted to the upcoming European launch, especially in Germany, France and Britain. He has patients ready and waiting with testimonial anecdotes, and he wants to make the most of their material.

As we turn off the freeway, however, he's still grappling with the unremitting domestic appetite for the topic. He has a 43-frame slide show in his doctor's black briefcase, and there is the television appearance to psyche-up for. This morning, another Pfizer consultant, his friend Dr Irwin Goldstein from Boston, was quoted on the front of USA Today as prescribing the drug to women as well as men, and an NBC crew is driving from Burbank to Chino to record an item on this for tonight's news.

*****

Inside the two-story cream-and-pink Chino Medical Group building, a room is filling with 60 doctors and nurses who have come to hear Padma-Nathan. There's a Pfizer buffet behind them, a Pfizer promotions stand to the left and a grey-lettered white banner on the wall. "VIAGRA (sildenafil citrate) tablets," it announces, in case anyone forgot why they came.

For a paid consultant, his performance is impressive. Committed and yet subtly detached. "I am not a stockholder in Pfizer or anything," he declares at the outset, pacing back and forth in black suit-trousers, grey shirt and yellow tie. "I have no financial interest in Pfizer, Viagra or any of the products I'm going to mention."

It's the kind of lecture that the company's consultants are putting on everywhere. It redefines impotence as "erectile dysfunction", then cuts to a cover of Newsweek. Then to a list of obsolete therapies that were the options before the new product. Vacuum devices. Penile implants. Injections. Urethral pellets.

"1998 is a wonder year for this area of medicine," he announces. "At last, erectile dysfunction is starting to come out into the open and to be talked about."

Slides five and six give another angle on the change: an upward revision of numbers. Using bar charts in primary colours, there are estimates of erectile dysfunction incidence which have, apparently, soared in recent years. Post-war studies from the famous Kinsey Institute reckoned that 15% of men in their 50s were impotent. In 1986, a study of ageing in Baltimore said 8% at age 45. But according to a May research paper co-authored by Padma-Nathan, with Goldstein, in the prestigious New England Journal of Medicine, the incidence is very much higher. "The disorder is age-associated," his paper declares, "with estimated prevalence rates of 39% percent among men 40 years old."

This figure seems extraordinary, but the slides move on. Numbers nine through 12 zoom in on the penis: firstly in cross section then microscopically, to reveal how Viagra works. Here are the corpora cavernosa - the two spongy tubes, one either side of the urethra, that are pumped with blood during erections. Here are the smooth muscles that become relaxed to permit this flow. Then come more technical slides. Viagra alters the balance of nitric oxide, which is produced in response to sexual stimulation and which activates an enzyme called guanylate cyclase, which in turn gets on with the job. More specifically, the drug inhibits yet another enzyme, called phosphodiesterase type 5, which degrades yet another, called cyclic guanosine monophosphate, which is otherwise inclined to suppress nitric oxide and throw all this into reverse. Phew.

He speaks for precisely 30 mins, takes questions and hurries downstairs. The NBC crew have set up their lights and are anxious to get back to Burbank. They're working on segment called "The Clamour for Viagra", apparently triggered by Goldstein's remarks.

Padma-Nathan sits stiffly with his fingers clasped and subtly contradicts his friend. He's not against prescribing to women in principle, but argues that more work is needed. "It's irrational for Viagra to be used in women without any safety data," he says. "It's irrational to use a drug that is being used off-label without clinical research."

Nathan's clip is in the can. The lights go out. We scurry to the car.

Back in Santa Monica, he hits the phones to square me a testimonial anecdote. A Santa Barbara couple had initially looked good, but were so freaked out by the BBC that they grumpily went to ground. "They wanted to film us on the beach," the patient's wife berated me. "It was something more like an entertainment."

While he calls on my behalf, I poke around the clinic, starting with the doctor's office. On the walls by his desk are 18 framed certificates which proclaim his various achievements. They look nice enough, but there's nothing very startling. A British doctor would put them in a drawer. The industry usually calls on full professors, department chairmen and medical school deans. But my Dr Viagra looks like a middle-rank urologist: more successful than distinguished, I'd say.

On a cherrywood sideboard are a pile of reprints of the May New England Journal of Medicine paper with the dramatic impotence statistics. There are six authors named, including Nathan and Goldstein. Five of them are Pfizer consultants. It mostly describes two Viagra trials, the results of which were vital for its license. One involved 532 volunteers, the other 329. A Dr Ian Osterloh, of Pfizer's British research centre, at Sandwich, Kent, helped to design the tests.

The 2000-square-foot Male Clinic has nine rooms, in shades of grey, and since opening in October 1996, Padma-Nathan and his staff have used them intensively to test 11 impotence remedies. On shelves and in cupboards, everywhere you look, are the accumulated patient data: more than 700 3-inch spines labelled "Pfizer", "Zonagen", "Schwarz", "Eli Lilly". Padma-Nathan, it seems, isn't only Dr Viagra, he's Dr Impotence Product in General.

But today, and tomorrow, he's on the road for Pfizer, with his biggest impact tonight. From my room at the Century Courtyard hotel, I watch Tom Brokaw anchor NBC News with the latest update on the product. He trails it teasingly across three commercial breaks. I wonder how much that helps the ratings? "It's the drug that has changed the lives of millions of American men," he begins the item, "restoring the sexual potency they thought they'd lost forever."

Launching Pfizer's Viagra
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This report is copyright, Brian Deer. No portion of this article on the launch of Pfizer's erectile dysfunction drug Viagra in 1998 may be copied, retransmitted, reposted, duplicated or otherwise used without the express permission of the author. Responses, information and other feedback are appreciated