It's enough to make you sick. In 2000, the average patient visit to a physician lasted a scant 18 minutes, according to the U.S. Department of Health and Human Services. (Less doctor-friendly sources give current durations as low as five minutes.) With 25% of Americans enrolled in HMOs, a 2002 Gallup survey ranked HMO manager as the second most untrustworthy occupation, just behind car dealers. And 40 million Americans have no health insurance at all. In short, the general public feels neglected by doctors and wary of profit-hungry insurance companies; of late, even the federal government has let them down. They should feel a little better, however, with how book publishers are treating them.

R.R. Bowker reports that 7,382 medical and health books were published last year and 7,483 in 2003, representing a spike over the five preceding years. The last time similar levels were reached was in 1996—the same year President Clinton signed federal legislation to stop the "drive-through deliveries" insurance companies were pushing to boost earnings. Managed care exploded in the '90s, and that growth has changed the physician-patient relationship, forcing health-care consumers to widen their search for information and advice. "The current health-care environment—in which MBAs run the system—promotes a more impersonal and superficial relationship between the doctor and patient," says Linda Greenspan Regan, executive editor of Prometheus Books, which this month is publishing W. Grant Thompson's The Placebo Effect and Health: Combining Science & Compassionate Care.

People are worried, and worry and stress is not good for anyone's health. According to Marc Siegel (see sidebar below), an internist and professor at the New York University School of Medicine, that anxiety has been magnified by the sense of dread that has hung over Americans since 9/11. Siegel writes in False Alarm: The Truth About the Epidemic of Fear(Wiley, Aug.), "Fear is looming larger in our lives." In It's Not All in Your Head (Guilford, May), authors Steven Taylor and Gordon J.G. Asmundson estimate that one in five people "worry[s] too much about being sick." (The current debate about a possible link between autism and mercury-based vaccines produced by Eli Lilly and other companies, a debate to a great extent sparked by David Kirby's Evidence of Harm [St. Martin's], is doing nothing to bolster consumer confidence in drug companies or, for that matter, the U.S. Congress. [See sidebar, p. 36.])

It's not exactly "patient, heal thyself," but health-care consumers are well advised to educate themselves about health and disease, just as they might expect to gather information before buying a car.

"It used to be that you'd go to a doctor and sit there and wait for the needle stick. Now the consumer is being asked to do some discerning," says Jim Nageotte, senior editor of Guilford Publications.

Books aren't the only sources of such information, of course. The Internet is a strong player in this category: nine-year-old medical Web site WebMD ( welcomes more than 22 million unique visitors monthly, and a 2005 Pew survey showed that eight out of 10 Internet users have sought health information online at some point.

"We're becoming cognizant that we need to be responsible for and manage our own health," says Sydny Miner, a senior editor at Simon & Schuster. "People are becoming their own advocates, and they're turning to books [over the Internet] as reliable sources of information with easy presentation. This is why God created indexes."

You Is Leading the Way

The need for laypeople to grasp basic body mechanics is at least partly behind the success of You: The Owner's Manual (HarperResource) by Michael F. Roizen and Mehmet C. Oz, which had one million copies in print one month after its publication on May 3—the same day the authors appeared on TheOprah Winfrey Show.

There's no denying the Oprah effect at play here, but this book has also tapped into something in the zeitgeist by supplying accessible, easy-to-absorb health information presented in a way that those of us without M.D.'s can understand.

You is moving quickly at Transitions Bookplace in Chicago. But while owner Gayle Seminara Mandel believes "Oprah played a big part," she thinks the inverse is true as well, meaning that because Winfrey "has her finger on the pulse of America," she unerringly selects books that speak to what many Americans—especially baby boomers—are already experiencing.

Books don't get much more nontechnical, either. While Roizen and Oz are physicians, they eschew jargon. Instead of plastic-overlay organ diagrams, You offers pen-and-ink drawings populated by elves, such as one of the male reproductive system titled "The Male Dipstick."

In fact, there was concern in-house that the frat boy—style approach evident in You's cartoony drawings and jokes—like referring to gas as "the form of bad breath that comes from your body's basement"—might render it "too lowbrow." And in an environment in which, according to S&S's Miner, we can "parse health care more finely," the appeal of its wide span of topics was unpredictable.

But HarperResource senior editor Kathy Huck posits that the book has sold precisely because of its general nature. She says, "It's not about eight weeks or 12 weeks or 30 pounds—every page is the take-away." A low $24.95 price tag hasn't hurt, either.

At Avery, publisher Megan Newman rejects the idea of rushing out a copycat general health title, despite You's success. Instead, Newman claims, the success of a general book causes a paradigm shift. She says, "Just the way Eats, Shoots & Leaves [Gotham, 2004] opened the market to more intelligent grammar books, the fact that something so seemingly pedestrian could become such a huge mainstream success forces you to look at the marketplace in a different way, from a packaging standpoint and an overarching editorial concept."

Personal Best

Voice and individuality are turning out to be key to books aiming to fill the void left by absent doctors. In this confessional age, in which personal slant is all, a new type of health book—call it the illness memoir, insider's edition—is establishing itself.

These aren't memoirs purely of falling sick, like Brooke Shields's Down Came the Rain (Hyperion),about her postpartum depression, or Marisa Acocella Marchetto's graphic novel Cancer Vixen. Instead, in these titles, sufferers of illnesses who often are already experts in related fields meld their own it-happened-to-me tales with here's-what-to-do practical advice.

One such hybrid is Paula Kamen's All in My Head: An Epic Quest to Cure an Unrelenting, Totally Unreasonable, and Only Slightly Enlightening Headache (Da Capo, Feb.). Kamen, a journalist and the author of two nonfiction titles, has had a chronic daily headache for close to 15 years; in the book she both limns her search for a cure—ranging from traditional drugs to acupuncture to beyond weird (fig tea and a vibrating hat, for starters)—and offers advice for other chronic pain sufferers.

"Books by doctors are often pure self-help with bulleted easy answers," says Kamen. "You see books by some kind of guru of either alternative medicine or Western medicine who says, 'Follow my plan, you'll be cured.' I wanted to provide more realistic information."

Kamen points to the emergence of informative titles from the patient's point of view as a sign that the old doctor-patient relationship—with the former acting like a parent to the latter as child—is evaporating.

Stephen Schneider, the winner of a 1992 MacArthur "genius" grant for his work in climatology, survived mantle cell lymphoma to write The Patient from Hell: Getting the Best That Modern Medicine Can Offer (Da Capo/Merloyd Lawrence, Oct.) Although the title opens with the statement "This book is not anti-doctor," Schneider does go on to encourage patients to buck the system, in which "most physicians—and patients—act as if the patient's role is simply to take orders and be cooperative."

Indeed, where once it was solely the M.D. imprimatur that qualified many health book authors, today personal involvement counts. Carolyn M. Kaelin, author of Living Through Breast Cancer, is not only a breast cancer surgeon and an assistant professor of surgery at Harvard but is herself a breast cancer survivor. Because of the added impact of her personal experience, Kaelin's February title was plucked from the Harvard Medical School series that McGraw-Hill is publishing in trade paperback and put into hardcover as a stand-alone.

Judith McCarthy, publisher of the consumer group at McGraw-Hill, notes that people who want the hard facts and clinical information that was once the province of medical and health books "now go to WebMD."

Just Say No

Overscheduled doctors, HMOs that value profit over care: reading the medical news today may have you reaching for a Valium. Or maybe not. Impotence drug Viagra may cause blindness. Painkiller Vioxx may cause heart problems. The hormone replacement therapy once trumpeted as a godsend for menopausal women increases the risk of breast cancer, stroke and heart attack. Antidepressant Paxil may cause suicidal thoughts in young people. Just last month, medical device manufacturer Guidant revealed that it knew its defibrillators could cause sudden death, yet continued to market them anyway. The perception that the FDA is not protecting consumers reached new heights in late 2004, when the Journal of the American Medical Associationcalled for a separate agency to monitor the safety of pharmaceuticals.

As Square One publisher Rudy Shur puts it, "It's not a good thing to be told that your blood pressure is high, be put on meds that you think are safe, watch your blood pressure drop, then drop dead."

"Last year alone there were three books about drug companies, all by physicians, that said, 'Sit up and look at what is going on here,' " says Avery's Newman. Despite the apparent crowding, Avery will publish J. Douglas Brenner's Before You Take That Pill in 2006, based on one of "a ton" of proposals Newman has seen.

Meanwhile, author Angell, a senior lecturer in social medicine at Harvard Medical School, cites even more titles on drug companies, but says her book, The Truth About the Drug Companies,and others like it haven't put a dent in these corporations—yet. She notes, "The industry continues to be so wealthy and so powerful that it can co-opt any institution that we might expect to stand in its way, starting with the U.S. Congress, the FDA and the medical profession itself. But there is an increasing disenchantment on the part of the public."

At Houghton Mifflin, senior editor Deanne Urmy believes she's got the title that will do for meds what Eric Schlosser's Fast Food Nation (Houghton, 2001) did for hamburgers. (Not to mention what it did for Houghton, which was to spend more than a year on the New York Timesbestseller list.) Generation Rx by Greg Critser began life as a cover article in Harper's and will have a 75,000-copy first printing in October. It reports on the companies themselves, but also looks at how eagerness for a quick fix leaves Americans vulnerable.

Benefiting from this pharmaphobia even more than muckraking exposés are reference guides to pharmaceuticals and their side effects, like Pocket's Worst Pills, Best Pills: A Consumer's Guide to Avoiding Drug-Induced Death or Illness from a Public Citizen's Health Research Group team headed by Sidney W. Wolfe, who has appeared on Good Morning America to discuss recent revelations about dangerous drugs. A new version out in January of this year already has 115,000 copies in print, compared to the 180,000 copies in print of the previous edition, published in 1999.

In December, Pocket will publish the seventh edition of the PDR Pocket Guide to Prescription Drugs. Senior editor Kevin Smith notes that sales have decreased slightly with each edition, which he sees as "like a movie—each time you do a sequel, fewer people come," but without any substantial drop-off in sales. The sixth edition, published in 2003, has more than 400,000 copies in print. At 1,760 pages, it's a brick, but because of the mass market format, Pocket has been able to place the title on CVS counters and in Wal-Mart.

There are more to come, too. When Heather Jackson, executive editor, moved from St. Martin's to Rodale in 2003, she brought along People's Pharmacy series authors Joe and Teresa Graedon, who host a syndicated radio show and write a syndicated newspaper column. In winter 2007, Rodale will publish the first of two titles by the Graedons—a compendium of all types of medicine, from generic drugs to home remedies to homeopathic treatments, and their efficacy and side effects.

Square One publisher Shur is focusing on alternatives to traditional pharmaceuticals with titles like Carol Simontacchi's Natural Alternatives to Vioxx, Celebrex & Other Anti-Inflammatory Prescription Drugs(Apr.) and Jay S. Cohen's What You Must Know About Statin Drugs & Their Natural Alternatives(May), both paperback. A 10,000-copy first printing for the former sold through in four weeks, and the latter has shipped more than 10,000 copies as well. A 2004 government survey revealed that 36% of adults in the U.S. use some form of alternative medicine.

That 36% figure is no surprise to Wiley executive editor Tom Miller. When Miller was brought on board eight years ago and assigned to construct a consumer health list, his market research showed that alternative and natural health had "exploded," yet there were few books providing information on such topics. Now the mainstream and the alternative have met in the middle, Miller reports. In 2004, when Wiley published the fourth edition of the American Medical Association Family Medical Guide,it included sections on alternative medicine.

For their part, health book publishers are certainly not predicting that doctors are becoming obsolete, and they maintain conservative standards regarding credentials and research. Avery's Newman advises against letting skepticism push too far in the other direction, despite the fact that "cranks can sell books—piles of them."

And Miller offers a cautionary tale about disillusionment with the establishment that he witnessed when he arrived at Wiley. "Back then, some people were so mistrustful they went with energy modalities and Reiki and Bach floral remedies, and didn't go to doctors at all." The results, he warns, were "catastrophic."

"We do well to be extremely skeptical of both the health insurance industry and the pharmaceutical industry," says Angell, "but the answer isn't to stop going to doctors or to stop taking drugs. It's to stop treating health care and drugs as a market commodity instead of as a social good."

Read a Book and Call Me in the Morning Last September, the giant drug company Merck announced that it was pulling its popular arthritis drug, Vioxx, off the market, even though it racked up $2.5 billion a year in sales. This happened on the heels of the publication of three separate books dealing with drugs and health care. As doubts about the issues of prescription drug safety, the efficacy of the Food and Drug Administration and the ethics of drug companies arose, these books' three authors (Marcia Angell, author of The Truth About the Drug Companies [Random House]; John Abramson, Overdosed America [Perennial]; and Jerry Avorn, Powerful Medicines [Knopf]) became familiar faces on cable television, as news producers scrambled to help inform a rattled public. Following the Vioxx removal, concerns surfaced about the related drugs Celebrex and Bextra. This time, Pfizer was under fire, and these three physician-authors were once again getting face time, and deservedly so.
Both Drs. Abramson and Angell had warned that, because of overzealous drug company promotion, Americans were taking way too many drugs for exaggerated conditions. They also argued that drugs like Celebrex had taken the place of cheaper yet equally effective treatments. Dr. Avorn, chief of two pharmacology divisions at Harvard, argued in Powerful Medicines that the information vacuum about prescription drugs is too often filled by drug company—provided information rather than by empiric data. Who, then, can health consumers trust?
Not, apparently, the federal government. Since 1962, the FDA has had the authority to make sure that pharmaceutical products are proven to work before they can be marketed. But authority does not equal effectiveness. Preapproval trials are still quite limited, and it's not until a drug is already on the market that observational studies of large populations are completed. The harm is long done by the time the FDA encounters some unforeseen side effect that limits the usefulness of a drug or even forces it from the market. Notorious cases such as the unrestrained use of hormone replacement therapy being linked to breast cancer, or the popular use of the diet pill fen-phen in the U.S. even after it was known to cause pulmonary hypertension and was removed from the shelves in Europe, have done little to change the system for ensuring drug safety.
Many articles have recently been written about the weak role the FDA plays in ensuring drug safety. The public is concerned: If the drug companies are in bed with the federal agency overseeing their business, who can be trusted? No doubt, the public will turn to books, just as they did a year ago, and as they are doing now with David Kirby's book, Evidence of Harm, on the autism/vaccine connection [see sidebar, p. 36]. The links between power brokers, government, public health and the public itself are infinitely complex; understanding them is crucial. Among the many resources a health consumer can go to, well-published books from reputable sources with no axe to grind are perhaps the most valuable. The best defense against the spread of anxiety about drug safety is a well-informed consumer. —Marc Siegel, M.D.
Book Stirs Autism Debate Since 1991, when the Center for Disease Control (CDC) and the Food & Drug Administration (FDA) recommended that vaccines laced with a mercury-based preservative—thimerosal—be given to infants, cases of autism in the United States have increased fifteenfold. Today, one in 166 children is diagnosed with the disease. Both the federal agencies involved and the drug manufacturers deny any correlation. Case closed.
Not quite.
The June 16 online magazine Salonpublished a piece by Robert F. Kennedy Jr. called "Deadly Immunity," an exposé about thimerosal, government cover-up and the root causes of autism. Soon radio and MSNBC gadfly Don Imus was on the case—interviewing Kennedy, berating pundit Chris Matthews and Meet the Press moderator Tim Russert for being asleep at the journalistic switch, and bringing author David Kirby and his book about autism to the forefront of the battle.
Evidence of Harm was published by St. Martin's in April to a starred review from PW. Two months and six printings later there are 57,000 copies in print and appearances on the New York Timesand the Discovermagazine bestseller lists. But it has not been an easy journey for Kirby. Before landing with St. Martin's, just getting published was hard work. "There was a similar pattern in dealing with the publishers as I have seen in dealing with the media," he says. "That is, the person, either the producer or the editor who gets the story, loves it. Wants to do it. Calls us up, excited. It goes up the corporate ladder and it eventually gets killed. Some people got back to us and said, 'You know, we're owned by a company that owns media' or 'we publish pharmaceutical publications.' They were pretty upfront about it."
Except for his three appearances on the Imus radio program, Kirby claims he has been ignored by the national media, but for a very brief appearance on The Today Show: "Three seconds. Literally, I timed it," he says.
A Web search on the topic of thimerosal shows that there is plenty of skepticism about the vaccine-autism link, especially from parents of autistic children whose experiences suggest other causes. There are also at least two studies that have found no association between mercury-based vaccines and autism. Still, what Kirby and Robert Kennedy ask for is further study and more candor from the CDC.
About the media's cold shoulder, Kirby is sanguine: "If I had a multimillion dollar ad budget," he states, "and I was spending a good chunk of that on a program and that program was going to have on someone who was going to attack a product that I made and possibly subject me to litigation, I'd try to send a message too." —Dermot McEvoy