The future of drugs: Patients no longer - we are all customers now

IT HAS been an extraordinary few days in the drug world: first, the launch in America of Viagra, the small blue diamond-shaped pill which treats impotency, and now the possibility of a drug, or rather combination of two drugs, which might cure cancer by switching off the blood supply to tumours.

They represent two ends of the pharmaceutical spectrum. One is a drug with obvious consumer appeal - just the sort of market-driven product that people flock to buy and the big commercial drug companies love to create. The other represents our more traditional idea of the purpose of medicine: the thing you take to cure you of a grave illness. If it works, and there are inevitably considerable doubts, it will rank alongside vaccination or the first antibiotics as one of the giant breakthroughs in medicine.

It therefore illustrates a tension, which will become more evident, between the pressure on the giant pharmaceutical companies to produce drugs that meet consumer demand (for that is how they will make the most money for their shareholders) and the wider demand from humankind to find drugs that treat the mortal diseases.

Of course there is no hard and fast line between the two: any drug that can treat cancer successfully will have enormous commercial demand. But there is a chasm between, on the one hand, mood-changing drugs like Valium (which damps you down) or Prozac (which cheers you up), both of which have been great commercial successes, and on the other, treatments for diseases like malaria, which will be less profitable because they occur largely in poor countries.

Viagra is towards the Prozac end of the scale. There is tremendous demand for it for obvious reasons, but on purely medical grounds the case for its use is less compelling. Though it treats a distressing condition, some people might think of it almost as a recreational drug. As a result the Health Maintenance Organisations in America are refusing to fund its use. The control of the cost of private sector health care in the US is largely sub-contracted by employers to the HMOs, who therefore carry out a similar gate-keeping function as the NHS does in the UK. Presumably the NHS will take also a similarly sceptical view of its medical value when the product becomes available here.

Is it unfair to suggest that the drug companies are only interested in developing drugs that make profits? Maybe a little, but the hard fact remains that the balance of money spent on research is swinging away from the educational establishments and towards the giant drug companies. The financial markets recognise and indeed demand the focus on profits that the pharmaceutical giants deliver and have rerated their shares accordingly. Pharmaceuticals account for about 12 per cent of the value of the top 100 shares in London, give or take the odd percentage point, about as high as they have ever been. Meanwhile similar pressures are mounting on educational establishments, for as government funds are restricted they have to get sponsorship from commerce to help fund their research.

This shift of the supply of research from educational establishment to commercial company has been mirrored on the demand side by a shift in people's expectations of health care. In the old days drugs were things doctors prescribed to make you better: the consumer took what he or she was told to do. Now, gradually, there has been a shift, with people taking a much greater responsibility for their own health and expecting to have much more say in how they are treated. We are becoming customers rather than patients.

There is one enormously positive side of this: the emphasis on lifestyle as a determinant of health. You see this in all sorts of ways - the decline in smoking, the increasing proportion of people taking regular exercise, the efforts to improve diet and so on. The notion that the fastest way to improve the health of the nation is to encourage a shift in lifestyle is now accepted by the Government, hence the nannyish tone of both this one and its predecessor.

But there is also a less positive aspect. We will not always be the best judges of what is good for us. As the balance of power shifts from producer to consumer, from doctor to patient, some of us will end up living healthier lifestyles, but some will use the new freedom to take drugs that don't make us better but simply make us feel better - for a while.

That freedom will grow. It will grow because we are moving towards a global market for prescription drugs. At the moment what is available and not available is still controlled by national governments. But these governments have different standards: what is available one country is not available in another. Countries have different authorisation procedures, some believing that ultra-stringent testing is necessary before a drug is made generally available, others believing that the balance of advantage is in getting the drug to the consumer as quickly as is reasonably possible. Knowledge about drugs' properties and potential will become universally available through the Internet; drugs are light and easy to transport; and credit cards already provide a global payments mechanism.

At the moment we have a white market in prescription drugs and a black market in illegal ones. Expect a grey market to grow in drugs that are legal and available in some places but not in others. Expect consumers everywhere to regard themselves as the people who have the right to make these decisions, not the politicians in the country in which they happen to reside.

In the next months we are going to see some interesting tests. People here will want to test drive Viagra before it is commercially available. And people everywhere will be prepared to risk taking the cancer drugs long before they have gone through the normal screening procedures - and these are drugs which up to now have not been tested on humans, only mice.

Above all, marketing is going to become a vital component in drug development. Viagra is a good example. Great name that: a combination of virile and Niagara.