Editor’s note: This is the second of two opinion pieces by Dr. Steele about the American pharmaceutical industry, its power and the growing number of challenges to it.

In the playgrounds of my youth there was always a bad boy we loved to hate. When he finally got his comeuppance at the hands of someone bigger or a coalition of the smaller, the moment left a sweet taste to be savored for weeks.

The bad boy of the American health care system is its pharmaceutical industry, and after a long run as the playground bully, this well-heeled coalition of huge companies is finally taking some well-earned licks of its own. Why it got the reputation, the licks it is taking, and what happens when the beatings stop, all have implications for the medicines we take and how much we pay to take them.

If the pharmaceutical industry currently looks like a deer with a bull’s-eye tattooed on its forehead that just walked into a gun show, it got there because it has seemed willing to do anything for a buck. Some practices in the pursuit of profit have been predatory enough to make a pirate pale. Among them:

. widespread manipulation of the results of “scientific” studies to support drug sales;

. some marketing practices so questionable as to perhaps be illegal. Two months ago Abbott Laboratories paid $622 million in fines to settle an investigation into its marketing practices. It and other companies have paid more than a billion dollars in such fines in the last four years;

. makers of AIDS-fighting drugs vigorously fought the manufacture of cheaper, generic versions of these drugs for AIDS-ravaged, poverty- ridden Africa;

. promoting new uses of drugs as a way to expand sales;

. many pharmaceutical manufacturers have routinely fought entry of generic drugs onto the U.S. market in order to protect their profits on brand-name drugs, sometimes suing over pill coatings and package colors as of patent infringement. As a result, American patients have paid billions of extra dollars for their medicines, billions which have gone unnecessarily to the most profitable industry in the country;

. pharmaceutical costs have been among the fastest rising health care costs, and Americans pay more for their prescription drugs than patients in any other Western country;

. as a result of these and other issues, the American pharmaceutical industry is now under siege on virtually all fronts. Big business, state governments, even the traditionally friendly Republican Party, and President George W. Bush, have joined the slugfest.

A few examples:

. 22 state governments beat back drug industry objections and now force physicians to prescribe less costly drugs to Medicaid patients, up from three states just three years ago;

. President Bush recently an-nounced new federal rules that would limit the ability of brand-name drug manufacturers to slow the flow of generic drugs to the market by repeatedly suing generic drug manufacturers. He said the new rules would allow Americans faster access to cheaper generic drugs, saving patients $3.5 billion annually;

. smelling blood in the water, two pharmaceutical companies turned on one of their own, Astra-Zeneca, and announced they would rush a generic version of Astra-Zeneca’s blockbuster Prilosec to the over-the-counter market this fall. The move could cost Astra-Zeneca billions, and represented the first time a brand-name manufacturer had been so vigorously attacked by one of its own;

. the idea of a Medicare prescription drug benefit, which the industry has successfully fought for years, is still alive in Congress. Some of the country’s biggest businesses are lined up against the pharmaceutical industry in this debate. The industry’s failure to kill the proposed benefit is but one of several legislative issues which have failed to go its way recently, and suggests a significant loss of clout in Washington, the home of pharmaceutical industry clout.

Things have gotten so bad that industry lobbyist PhRMA, recently referred to as “a multi-armed octopus” by one Republican congressman because of its lobbying practices on Capitol Hill, boosted its lobbying budget for 2003 by 23 percent, to $150 million, according to The New York Times. Saying the industry was “on the defensive, facing a ‘perfect storm'” of resistance, PhRMA reportedly earmarked additional millions to lobby the Food and Drug Administration, state governments, Congress and to fight Canadian drug imports. According to a PhRMA document reported by The Times, $1 million will reportedly go to developing “a standing network of economists and thought leaders to speak against federal price control regulations” in op-ed pieces, articles and testimony. (They have not yet contacted me as a thought leader, however – I must be thinking too clearly.)

As America’s big businesses, health insurance companies and politicians take their shots at the pharmaceutical industry, care must be taken not to kill the industry with its well-deserved comeuppance. We are now dependent for our future health on an industry that, while it has demonstrated little interest in our health, is the only pharmaceutical industry we have. Ours is a free enterprise model of pharmaceutical manufacturing and marketing and profit is its heart. Reducing industry profits too much in order to reduce prescription drug costs risks killing the goose that keeps laying golden miracle drugs. As the industry is forced to function more like a corporate citizen motivated by patient interests and less like a ticket scalper, it may lose some of its ability to make the next great drug. We are potentially cursed by the remedy to the curse of high drug costs.

The real answer to this dilemma is for the pharmaceutical industry to reinvent itself in an economically viable model of social responsibility. It needs to prove that our prescription drug care can safely be left to an industry run for the principal purpose of making profit and improving stock prices. It needs a corporate conscience. Otherwise it runs the risk of being dismembered by its growing number of desperate and infuriated enemies. Our future is in its hands; if it continues to run socially and economically amok we will all keep taking our pieces out of the industry’s financial hide, its profits will dry up, and the dollar drive to invent new wonder drugs will be lost. Then who will make our prescription drugs for us? The Department of Defense, perhaps?

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.