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Alexander Cockburn
NationofChange / Op-Ed
Published: Friday 27 April 2012
“The year after Vioxx was pulled from the market, The New York Times and other media outlets noted that American death rates had undergone a striking and completely unexpected decline.”

When Half a Million Americans Died and Nobody Noticed

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Are American lives cheaper than those of the Chinese? It's a question raised by Ron Unz, publisher of The American Conservative, who has just published a compelling comparison between the way the Chinese dealt with one of their drug scandals — melamine in baby formula — and how the U.S. handled the Vioxx disaster.

In September 2004, Merck, one of America's largest pharmaceutical companies, issued a sudden recall of Vioxx, its anti-pain medication widely used to treat arthritis-related ailments.

There was a fair amount of news coverage after the recall, but it was pretty slim considering the alleged 55,000 death toll. A big class-action lawsuit dragged its way through the courts for years, eventually being settled for $4.85 billion in 2007.

Senior FDA officials apologized for their lack of effective oversight and promised to do better in the future. The Vioxx scandal began to sink into the vast marsh of semi-forgotten international pharmaceutical scandals.

The year after Vioxx was pulled from the market, The New York Times and other media outlets ran minor news items, usually down column, noting that American death rates had undergone a striking and completely unexpected decline.

Typical was the headline on a short article that ran in the April 19, 2006, edition of USA Today: "USA Records Largest Drop in Annual Deaths in at Least 60 Years." During that one year, American deaths fell by 50,000 despite the growth in both the size and the age of the nation's population. Government health experts were quoted as being greatly "surprised" and "scratching (their) heads" over this strange anomaly, which was led by a sharp drop in fatal heart attacks.

For his melamine/Vioxx comparison, Unz went back to those 2005 stories. Quick scrutiny of the most recent 15 years worth of national mortality data provided on the U.S. government's Centers for Disease Control and Prevention website offered Unz some useful clues.

"We find the largest rise in American mortality rates occurred in 1999, the year Vioxx was introduced, while the largest drop occurred in 2004, the year it was withdrawn," says Unz.

"Vioxx was almost entirely marketed to the elderly, and these substantial changes in the national death-rate were completely concentrated within the 65-plus population.

"The FDA studies had proven that use of Vioxx led to deaths from cardiovascular diseases such as heart attacks and strokes, and these were exactly the factors driving the changes in national mortality rates."

"Patterns of cause and effect cannot easily be proven," Unz continues. "But if we hypothesize a direct connection between the recall of a class of very popular drugs proven to cause fatal heart attacks and other deadly illnesses with an immediate drop in the national rate of fatal heart attacks and other deadly illnesses, then the statistical implications are quite serious."

Unz makes the point that the users of Vioxx were almost all elderly, and it was not possible to determine whether a particular victim's heart attack had been caused by Vioxx or other factors. But he concludes: "Perhaps 500,000 or more premature American deaths may have resulted from Vioxx (emphasis added), a figure substantially larger than the 3,468 deaths of named individuals acknowledged by Merck during the settlement of its lawsuit. And almost no one among our political or media elites seems to know or care about this possibility."

I remarked to Unz that it seemed truly incredible that a greater than expected death rate of this dimension should scarcely have caused a ripple.

"I'm just as astonished," he said. "One might conjecture that the mainstream media and the government officials were all bribed or intimidated by Merck's lawyers, lobbyists and advertising budget into averting their eyes or holding their tongues. But from 2004 onwards, huge numbers of America's toughest trial lawyers were suing Merck for billions based on Vioxx casualties — didn't they notice the dramatic drop in the national death rate?

"The inescapable conclusion is that in today's world and in the opinion of our own media, American lives are quite cheap, unlike those in China."


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ABOUT Alexander Cockburn

Alexander Cockburn is co-editor with Jeffrey St. Clair of the muckraking newsletter CounterPunch. He is also co-author of the new book "Dime's Worth of Difference: Beyond the Lesser of Two Evils," available through To find out more about Alexander Cockburn and read features by other columnists and cartoonists, visit the Creators Syndicate Web page at

All of the non-steroidal

All of the non-steroidal anti-inflammatory drugs (NSAIDs) except perhaps Naprosyn and low dose ibuprofen increase cardiac risk. Vioxx was not especially risky versus the risk for other NSAIDs but probably caused more deaths because of a pattern of sustained use in many elderly patients. This sustained use was a function of the decreased gastric irritation and decreased risk of gastrointestinal bleeding promoted with the Cox 2 inhibitors. Sustained use of the other non-steroidals causes a significant risk for gastrointestinal bleeding. NSAIDs cause many deaths in the elderly because of bleeding. I'm actually unhappy that they removed Vioxx from the market entirely because it was more effective with a longer duration of action, and less gastric irritation than most of the other NSAIDs. The appropriate use would be limited for acute injuries and illness (very good for a viral syndrome and has more efficacy for renal colic than any of the others except Toradol.

A few more notes 1. There

A few more notes

1. There were rumors that Vioxx was dangerous before the recall. Indeed the claims predate FDA approval (clearly another story). However, rumors aren’t numbers. There were 19.959 million Vioxx prescriptions in 2003 versus 13.994 million in 2004. That’s a fall of 5.965 million. However, the fall from 2004 to 2005 was 13.994 million. Yet, somehow raw (but not AA) death rates fell from 2003 to 2004 and rose from 2004 to 2005. 2004 Vioxx prescriptions were 70.11% of 2003. That’s only slightly below the 75% we would expect from the withdrawal date. In other words, physician avoidance (pre-recall) was quite modest at best.

2. Total COX-2 sales did not plummet in 2004. The IMS data shows that they were flat or down slightly. Let me quote from “IMS Health, National Sales PerspectivesTM, 2/2005″

“Despite the negative publicity and the voluntary withdrawal of Vioxx®, the COX-2 inhibitor class was flat for 2004 with sales of over $5.3 billion. Celebrex® remained the largest product with sales of $2.7 billion and Vioxx® achieved sales of $1.8 billion in the first nine months of the year before being withdrawn on September 29.” The link is

Other sources show Celebrex and Bexta sales peaking in 2004. Another report from IMS makes this point and suggests a decline in total COX-2 sales. See “Biotech Remains Industry Growth Engine, With 17 Percent Sales Growth”. The key quotes are

“Merck’s surprise, voluntary withdrawal of Vioxx® in September and potential safety concerns associated with other pain relief medications resulted in doctors switching patients away from Vioxx or starting them on other COX-2 products. Patient volume for the remaining COX-2s initially increased by more than 25 percent following the withdrawal, driven by a 15 percent increase in new therapy starts and a two-thirds share of all Vioxx switches.
“Over time, COX-2 usage has declined to below pre-Vioxx withdrawal levels, due in part to further safety concerns about this class of drugs,” said Lisa Morris, global director, IMS longitudinal services. “By year-end, the prescription COX-2 and NSAID market saw a 9 percent decline in total patients.” The link is The 9% decline may have been versus the third quarter of 2004 which means that total COX-2 prescriptions could have easily equaled 2003 (which appears to be the case).

See also “Sales rise for Celebrex and Bextra after Vioxx withdrawal” (

“Pfizer’s Celebrex gained a majority of sales for new-generation painkillers in the month after Merck & Co. yanked Vioxx due to safety concerns, according to IMS Health, a pharmaceutical information company.”

3. 2005 was a very different story. Vioxx sales were zero of course. Bexta went off the market on April 7th, 2005. Bextra did generate substantial revenues in the first quarter of 2005. However, the retail data (not the entire story) show Bextra growing from 2003 to 2004 (to over $250 million per quarter) and then falling to $148.370 million for all of 2005. Once again this is retail only data. Even though Celebrex stayed on the market with FDA approval, sales crashed in 2005. See “Sales plummet as cox-2 miasma vexes consumers” ( Quote

“According to IMS Health, sales of cox-2 inhibitors have plummeted 65 percent for the first five months of 2005, representing $1.5 billion in lost sales of Bextra, Celebrex and Vioxx. Of those three drugs, only Celebrex remains on the market. And now, two other cox-2 inhibitors that were in the drug development pipeline at the time of the Vioxx withdrawal are not expected to make it to market any time soon–if at all.”

Another source gives a 48% fall in Celebrex sales in 2005. See “Pfizer to resume airing ads for Celebrex” ( Quote

“The return of Celebrex to TV follows its financial comeback. Celebrex sales hit $3.3 billion in 2004 then dropped 48% in the year after Vioxx’s withdrawal. Last year, Celebrex sales were $2 billion. Still, it ranks behind ibuprofen and naproxen in arthritis prescriptions, according to market tracker Verispan. Before the Vioxx recall, Celebrex was ahead of naproxen but behind ibuprofen.”

Let’s recap for a moment. COX-2 volumes were flat from 2003 to 2004 and death rates fell. COX-2 volumes crashed in 2005 and death rates rose. This is not the correlation the TAC is suggesting.

4. Drug companies do give away samples that could impact total consumption in 1999. However, volumes appear to be low compared to prescriptions. In 2007, drug companies spent $8.4 billion giving out samples. See “Pharma scales back drug samples to physician offices” ( Total prescription sales were $286.5 billion (IMS Health).

The notion that Vioxx early adopters were more at risk is conceivable, but lacking in any substantiation. Why would doctors single out patients with the greatest CVD risk, as the first users of Vioxx? To make such a claim, the TAC needs facts or at least a mechanism (in my opinion). If Vioxx had been the first COX-2 drug on the market this would be a stronger thesis. A person could argue that the sickest patients (in general), with the most pain, were the first users. However, Celebrex was approved on December 31, 1998.

5. TAC's use of overall and 65+ death rates suffers from several large problems. The biggest problem is that Vioxx apparently caused heart problems (all of Vioxx’s critics agree on this point). However, there is nothing in the heart disease data to support the TAC thesis. Online data shows that the CVD death rate fell from 1998 to 1999. To be precise the CDC has two sets of data from 1998. The standard data shows a fall for all age groups except for the 85+ group. Overall the rate falls from 268.2 to 265.9. Row 44 (the modified data) shows a slight rise overall (from 264.4 to 265.9) and big falls for the 65-75 group and the 75-84 group. The 85+ group rises as well. Any hint of a spike is absent. The 1999 versus 2000 CVD data show CVD death rates falling for everyone (as Vioxx sales quadrupled).

Let’s look at this another way. An incremental 100,00 deaths per year is roughly 33 per hundred thousand for the entire population. No shifts of that magnitude show up in the CVD data.

The NVSS (National Vital Statistics System) data makes the same point. The Major cardiovascular death rate fell from 1998 to 1999 (and kept falling in 2000) for all groups except for the 85+ cohort as Vioxx sales soared. Even the 85+ cohort is below 1998 levels in 2000. There is a big fall from 2003 to 2004. However, that should have occurred in 2005. The data has other big falls as well (1988 to 1989, 1989 to 1990, 2000 to 2001, and 2005 to 2006).

The subcategories (Heart disease, Heart attack, Chronic ischemic heart disease, Atherosclerotic cardiovascular disease, Heart failure, and Stroke) show the same pattern. Most fall from 1998 to 1999 and 2000. Heart failure and Stroke rise slightly. If Vioxx was nearly deadly as TAC's assert s , it would show up in the NVSS CVD data. It doesn’t.

As a check, I graphed CVD mortality from 1998 to 2007. The Vioxx effect is not apparent. The expected spike from 1999 to 2000 and crash from 2004 to 2005 are clearly absent.

Thank you

Peter Schaeffer

P.S. David Graham estimates that Vioxx might have caused 88,000 to 139,000 additional heart attacks / strokes with a 30-40% mortality rate. That’s certainly plausible and not contradicted by the CVD data. Of course, total COX-2 mortality must have been higher because of the side effects of Bextra / Celebrex. As everyone knows, Celebrex remains on the market.

A few more notes. 1. If Vioxx

A few more notes.

1. If Vioxx had anything approaching the impact TAC (The American Conservative) is suggesting, it would have shown up in the CVD death statistics first and foremost. It doesn’t.

2. Vioxx was withdrawn on September 30th, 2004. Many folks probably continued to take their pills for a few weeks longer. If Vioxx was really so deadly that removing it from the market for the last 3 months of 2004 had a material effect, then much larger increased in death rates should have shown up sooner. Indeed, since it was still on the market for most of 2004, the largest impact on death rates should have been from 2004 to 2005. In fact, the crude death rate rose from 2004 to 2005. Evidently, removing Vioxx raised death rates.

3. The age-adjusted death rates tell a more useful story. The age-adjusted (AA) death rate plunged from 2003 (832.7) to 2004 (800.8). From 2004 (800.8) to 2005 (798.5) it was almost flat. Removing Vioxx from the market stopped (for a while) progress in reducing death rates.

4. The introduction of Vioxx provides even stronger evidence. Vioxx was introduced on May 20th of 1999. However, sales were slow at first. Only 4.845 million prescriptions were written in 1999. The number of prescriptions rose to 20.630 million in 2000 and 25.406 million in 2001 (the peak year). The crude death rate rose from 847.3 in 1998 to 857.0 in 1999. However, it fell to 854.0 in 2000, and 848.5. Evidently an extra 15 million Vioxx prescriptions in 2000 reduced the death rate as did another 5 million in 2001.

5. The AA death rates tell an even better story. The AA death rate rose from 870.6 in 1998 to 875.6 in 1999. However, the extra 15 million Vioxx prescriptions reduced it to 869.0 in 2000 and another 5 million Vioxx prescriptions reduced it to 854.5 in 2001. As mentioned above, the AA death rate falls from 832.7 in 2003 to 800.8 in 2004 (with Vioxx still on the market for most of the year). It then essentially flat lines in 2005 (798.8).

6. The use of crude death rates is ultimately misleading. The American population is obviously aging. AA death rates make considerably more sense. In a few years, the baby boomers will start dying off in large numbers. The crude death might even rise. What does that demonstrate other than the pig coming out the other end of the Python?

7. Obviously everyone will die eventually and that 500,000 is an estimate of premature deaths. Premature by how much? A year? A month? One second? If the reduction is material it should show up in death rates (AA and crude). It doesn’t.

8. Death rates rise and fall for reasons clearly unrelated to Vioxx. The crude death rate rose from 1994 (866.1) to 1995 (868.3) and from 816.5 in 2004 to 825.9 in 2005.

9. See Table 8 for a comparison of 1998 versus 1999 death rates. The overall death rate fell in the 65-74 cohort while rising 75-84 cohort and the 85+ cohort. CVD fell in both the 65-74 cohort and the 75-84 cohort from 1998 to 1999. The CVD death rate rose for the 85+ cohort from 1998 to 1999.

See also Table 9 in for a 1999 to 2000 comparison. As Vioxx prescriptions soared (quadrupling to 20 million) all 65+ death rates fell. The CVD 65+ death rate also fell.

10. In the last pre-Vioxx year the overall death rate was 847.3. In 2003 with Vioxx going strong, it was 841.9. In 2004 (14 million Vioxx prescriptions) it was 816.5. Of course, the age-adjusted data show that Vioxx “saved” even more lives. The 1998 AA rate was 870.6. The 2003 rate 832.7. The 2004 rate was 800.8.

11. The crude death rate was essentially flat from 2004 to 2005 when it should have fallen the most. The 65+ data is more dramatic. Table 9 of shows 65+ mortality rates fell every year from 1999 to 2008. So did the CVD death rates.

12. Any alleged linkage between Vioxx going off the market in 2004 and mortality statistics suffer from a basic flaw. Vioxx was recalled on September 30. September 30th isn’t Jan 1.

Thank you

Peter Schaeffer

P.S. I am not claiming that Vioxx was harmless. NSAIDs are (apparently) intrinsically dangerous. However, the incremental deaths were too few to show up in the overall mortality statistics and more decisively, too few to show up in the CVD mortality statistics.

The TAC needs to do some fact

The TAC needs to do some fact checking before publishing something like this. If Vioxx actually resulted in 500,000 premature deaths it would have shown up in the overall death rate. It didn’t. See “National Vital Statistics Reports” ( The overall and age-adjusted death rates fell from 1999 to 2005. Indeed, the age-adjusted death rate fell faster after 1999 than it did before.

If the 500,000 statistic was correct, there should have been at least 100,000 incremental deaths in the peak year from Vioxx. That’s 33 per 100,000 for the entire U.S. See any blips in the data of the magnitude? They don’t stand out…

Of course, the incremental deaths should really show up in the CVD (cardiovascular disease) mortality statistics. They don’t. See “US Death Rates 1975-2009″ ( Also see some Arizona specific data (“Trends in Age-Adjusted Mortality Rates of Deaths due to Cardiovascular Disease, Arizona and US, 1980-2004″ – The Arizona data is not by itself particularly important (state level death rate variations are huge). However, the Arizona data exactly tracks the U.S. overall data.

Is it possible that Vioxx resulted in 50,000 deaths over the period in question? Sure. I don’t have anything approaching the background to evaluate such a claim. I wouldn’t be surprised either way as to the truth. For the record, I do have opinions on topics like this. I spent years deflating Thiomersal / autism claims…

However, there is a larger issue here. NSAIDs (Celebrex, Vioxx, Bextra, etc.) are all associated with incremental mortality. Indeed, even Naproxen (also a COX-2 NSAID) has been linked to higher death rates. However, these drugs are simply too valuable to give up. Ask the people who take them, if anyone has any doubts. For many, NSAIDs are the difference between a normal life and ongoing, severe pain.

This is why the FDA panel voted 31-1 to keep Celebrex on the market. The same panel also voted 17-15 to keep Vioxx for sale. Even excluding panelists with industry ties, the vote was 8-14 (losing) to approve Vioxx. If Vioxx was really as bad as some allege, why did 8 panelists (with no industry ties) favor its continued sale? Why was the vote in favor of Celebrex (which is also linked to CVD) almost unanimous? See “10 on FDA Vioxx panel had ties to companies ” (

Thank you

Peter Schaeffer

P.S. I have no ties to the drug industry (other than as a customer). I was once prescribed Naproxen many years ago. It was astonishingly helpful even though I only took it for a week or two. I have taken Aleve (OTC Naproxen) from time to time.

We can't reduce human beings,

We can't reduce human beings, whether American, Chinese or anyone else, to economic engines. EVERY human life is of inestimable worth, and none is more valuable than any other.

I Live in Michigan and drug

I Live in Michigan and drug companies have been granted immunity from recourse by our legislature. Of course we still have to watch the commercials. What has happened to those who went off Vioxx in 2004? My brother was on it, now he's getting chemo for a blood cancer.

Perhaps drug advertising

Perhaps drug advertising should be removed from TV, magazines,

A very good idea. Since I

A very good idea. Since I watch a few daytime TV shows, over the years I've seen more than one new wonder drug go from "ask your Dr. about...", to mention in ads for personal injury law firms urging everyone who's taken that same medication to get in on the class action suit.

The author of the article has

The author of the article has it all wrong. It is still about worth. And American lives are OF COURSE more valuable than those of chinese. But you must differentiate between used and brand new. Economically a 60 year old person is considered a burden whereas a baby is seen as a future asset. If there had been the same thing in the US as in China with poisened baby milk powder, the company would have been sued into oblivion and the managers sent to prison or put on death row.

After the thalidomide horror

After the thalidomide horror of the 1960's the pharmaceutical industry mounted lobbying efforts to buff images and gain influence. Results of the lobbying have included virtual capture of the FDA along with a cadre of congressmen relied upon for favors to the industry. Advertising of pharmaceuticals has created a healthy revenue source for the media with its news presentations increasingly reluctant to risk offending the feeding hand with any criticism of its products.

Cardiac problems and risks were expressed about Vioxx with serious concerns by eminent medical authorities at institutions such as the Cleveland Clinic. The FDA warned Merck in 2001. The company's marketing and advertising campaigns continued along with efforts to debunk incoming warnings. The honest altenative, at this point, would have been to mount a well designed (and expensive) study to address the criticisms. Instead the company mounted a PR campaign to deny, debunk and confuse the issue. The FDA and the media were faced with the possibility of losing credibility revenue and reprimand. So 55, 000 people had to die prematurely before the drug was withdrawn in 2004. Responsibility lies with those who corrupt government for their own monetary gain.

So when are those who were

So when are those who were responsible going to be stood against the wall and shot and the bill for the ammunition sent to the closest kin?

A friend of mine who frequently travels about China buying chemicals, was traveling on a local airline about 10 years ago. He noted that the staff on the aircraft were very grumpy. He asked the stewardess what was going on. Most of the passengers were company people going to headquarters. There had been a crash and a group of engineers had been identified as at fault. So all of the airlines staff was being gathered at headquarters to watch the executions on the next day.

Accountability ??? What is effective. The story above is what I would have expected from the epoch where the famous quote re "let them eat cake" came from. Has the USA gone back to that?

Up the 99%!!

"One might conjecture that

"One might conjecture that the mainstream media and the government officials were all bribed or intimidated by Merck's lawyers, lobbyists and advertising budget into averting their eyes or holding their tongues."

No. This is no conspiracy. It's simply that the nature of investigative journalism has fundamentally changed as a result of media consolidation. Instead of independent minds dodging flak in search of truth from all different points of view, we have a hive mind that rarely reports more than what is handed to it, gift-wrapped and hog-tied. I dare say that PR and marketing firms have never had more influence over what appears in our various media outlets. A carefully crafted press release about some frivolous well-funded nothing, designed to be plagiarized, will show up in the public discourse virtually unchanged (unquestioned, unchecked, unverified). Meanwhile, a story of great public import (but without a media liaison, and therefore without the stamp of legitimacy) can completely escape attention. The unwitting implication is, if no one's already trying to draw attention to it, it can't be all that important, can it?

Maybe the indictment here

Maybe the indictment here should be against the FDA. After all, isn’t it the FDA that spends so much time and money in the drug approval process in order to assure (or is it appear to assure?) that no one will die from taking it?

Maybe this is just another example of how government bureaucracies are rarely capable of providing the protection they promise.

Maybe it’s time to allow the free market more leeway in exchange for a greater cost of being wrong. With two major changes to the drug industry, I think more life-saving drugs can get to market faster, safer, and less expensively. First, why not require fairly large deposits (include the majority of senior officer salaries) into some kind of escrow account for the benefit of claimants (i.e. the people harmed by a drug) that can only be paid out over a very long period of time (decades, that is), but only if no one is harmed by the drug?

Second, why not a congressional act that opens the door to greater personal liability for negligence (and even criminal prosecution) for company officers who take their responsibilities too casually and cause harm to patients? (This should, of course, not be limited solely to the pharmaceutical industry.)

I am a libertarian capitalist, but I would expect most Occupy Wall-Streeters to agree that eliminating the bogus protection of the corporate veil and holding people (individual people, that is, as opposed to corporations) responsible for negligence and wrong-doing would be a sure step in the direction of fairness. Now the only problem is how to pry large corporate America and greedy bureaucrats from their passionate, entangled embrace long enough to get something like this passed …

Once it was individual PHARMA

Once it was individual PHARMA executives who feared "perp walks" and bad publicity and responded with money and guile to corrupt the regulatory agency to eliminate and possibility of personal exposure while ensuring uninterrupted flow of ill-gotten gains. Believe me, I once witnessed this fear and their reaction in some of the " greedy great ones." When this phenomenon takes place neither free markets or capitalism are functioning.

what did you say, Lori?

what did you say, Lori?

I am think it's mostly not

I am think it's mostly not the difference in nations but ages. The Chinese problem was babies dying. Ours is our elderly, seeing anyone's life cut short is tragedy we are especially sensitive when it happens to our young.

Every American is in mortal

Every American is in mortal danger for their lives from a major conspiracy to protect corporations and save face for the government. An american life really is not worth the profit of a corporation. I get so mad reading about cover-up again and again. I believe we have become a fascist state.

Every American is in mortal

Every American is in mortal danger for their lives from a major conspiracy to protect corporations and save face for the government. An american life really is not worth the profit of a corporation. I get so mad reading about cover-up again and again. I believe we have become a fascist state.

Every American is in mortal

Every American is in mortal danger for their lives from a major conspiracy to protect corporations and save face for the government. An american life really is not worth the profit of a corporation. I get so mad reading about cover-up again and again. I believe we have become a fascist state.

Every American is in mortal

Every American is in mortal danger for their lives from a major conspiracy to protect corporations and save face for the government. An american life really is not worth the profit of a corporation. I get so mad reading about cover-up again and again. I believe we have become a fascist state.

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