hat a strange, uniquely illusive figure the doctor is. The art of medicine is so manifestly a higher purpose – the safeguarding of human life itself – that its practitioners enjoy a kind of immaculate moral authority. Yet these doctors are also the frontline vendors in an industrial complex, which includes hospitals, equipment-makers, insurance companies and drug firms, their eyes all fastened on their profit margins. The industry relies on the doctor’s unimpeachable image, on the patient’s worried willingness to accept anything that is prescribed. In the US, in particular, the gap between saviour and salesman is a chance to make money off the most captive of markets: the sick hoping to get well again. One of the people to have recognised this most clearly was Arthur Sackler, the patriarch of a pharmaceutical dynasty that is the subject of Empire of Pain. The Sacklers ran Purdue Pharma, which sold OxyContin, the pain medication that ignited a blaze of drug abuse across the US. At least half a million people have died from overdosing on opioids such as OxyContin; the tablet became a way into heroin use. Patrick Radden Keefe first wrote about the Sacklers four years ago in the New Yorker, just as Americans were getting angry about how the family that sold OxyContin was also celebrated for its philanthropy. Its name adorned the sites of cultural cachet that it had purchased: the Sackler Wings at the Louvre in Paris and New York’s Metropolitan Museum of Art; the Serpentine Sackler Gallery in London; buildings at Harvard, Oxford and other universities. Keefe brings to the Sacklers the same unflagging energy for research that lit up his previous book, Say Nothing, about a murder in Northern Ireland. Empire of Pain is an attentive history of the family, and gathers up evidence of how the Sacklers were aware of the ways in which OxyContin drove the opioid-abuse epidemic – how, in fact, they even marketed the drug to capitalise on it. Arthur Sackler, the restless eldest son of European Jewish immigrants, was a qualified psychiatrist, but his fortune rose from his marketing skills. With his two brothers he took over an advertising agency that marketed drugs to physicians, mostly through a free medical newspaper that he published himself. He hawked Valium and other tranquilisers so effectively, Keefe writes, that “patients had started going to their doctors and requesting each new wonder drug by name”. Sackler hid his connection to his journals, so when his partners in the publications were accused of bribing a government official – of even writing a speech for him, to improve the prospects of a new Pfizer antibiotic – Sackler stayed off camera. Then the brothers bought a small, humdrum drug company named Purdue Frederick, a manufacturer of earwax remover, antiseptic and constipation pills. Under Sackler, Purdue developed and sold MS Contin, a slow-release morphine tablet, without even waiting for regulatory approval. Sackler died in 1987, and his heirs sold their share of the business to his brothers, but those members of the next generation of the family who took over the company inherited his disregard for ethics and the law and used it to flog their flagship slow-release opioid: OxyContin The things they knew! They knew that OxyContin was more potent than morphine, and they exploited the fact that doctors thought the reverse to be true. (“It is important that we be careful not to change the perception of physicians,” a Purdue official advised.) They claimed OxyContin posed little risk of addiction, even though Purdue had carried out no tests to that effect at all. They knew they were using flimsy literature to reassure physicians about OxyContin’s safety: “not a peer-reviewed study,” Keefe writes, “but a five-sentence letter to the editor by two doctors at Boston University”. They knew the drug could be injected, but they didn’t let on. They argued that OxyContin’s slow-release mechanism was a barrier to abuse, but they knew they also owned another company that made immediate-release oxycodone. Studying their sales data, they maintained a secret list of doctors who overprescribed OxyContin – and did little to alert the authorities to these pill mills, preferring to grow rich off the proceeds instead. Purdue Pharma earned at least $35bn from OxyContin. With it, the Sacklers bought their reputation as genteel cultural benefactors, along with mansions all over Europe and the US. A second-generation Sackler, Mortimer, purchased a resort home in Turks and Caicos, and he flew in yoga instructors from the US to guide him towards inner peace. “If the sand on the beach got too hot in the noonday sun, staffers would spray it with water so that guests could stroll where they wanted without fear of burning their feet,” Keefe writes. It is the kind of magnificent story he unearths regularly. (Here’s another: when Mortimer’s back ached, he’d order a couple of butlers to prop him up as “human crutches” as he hobbled around.) Keefe’s book ends in 2020, and right until the final pages – well after the truth of their lies emerged, well after the opioid epidemic touched off a wave of heroin abuse – the Sacklers refuse to concede their role in this calamity. In a Congressional hearing in December – at a time, mind, when the Trumps were just beginning to box up their belongings to move out of the White House – one legislator told two Sacklers: “I’m not sure I know of any family in America that is more evil than yours.” Keefe’s narrative is so lush with details that only in the chinks do we spot the story behind the story: the rotting structure of American healthcare that almost wills disasters into being. Some failures are born of lethargy or neglect. A federal government official once told me that if states had simply transitioned faster to reporting their health statistics electronically, someone might have caught a pattern: “all the drug overdose deaths, the suicides, the medical examiner events” that advertised the opioid crisis. But other failures are the results of a system maintained at a level of designed corruption. So, for instance, an officer at the Food and Drug Administration (FDA) granted OxyContin its approvals in an astonishingly short time – 11 months – and then quit the agency. A year later, he was working at Purdue, earning $400,000 a year. A federal prosecutor, in a meeting with Purdue executives, got them to admit that a 160mg tablet of OxyContin could kill a child; he also left his post to become a paid consultant for Purdue. In 2010, the FDA let Purdue “evergreen” its patent on OxyContin, extending its life on the basis of a ramshackle excuse: that the company had a new, uncrushable version of the pill, which made it difficult to abuse. A decade later, the agency admitted that, while fewer people were probably snorting or injecting the reformulated drug, “evidence was not robust that [it] caused a meaningful reduction in overall OxyContin abuse”. You could still swallow the pills, after all; either that, or you switched to heroin. In a courthouse in Virginia, in 2007, Purdue pleaded guilty to lying about OxyContin’s potential for addiction, ponied up $600m in fines, and then went on peddling the drug as it had always done. The standard rogues of capitalism assisted: corporate lawyers, lobbyists, McKinsey consultants. (The moment the Sacklers began toppling from grace, a McKinsey consultant warned a colleague that it was time to start “eliminating all our documents and emails,” Keefe finds.) When the Sacklers faced their stiffest legal challenge, two years ago, they cashed out their stakes in Purdue, moved most of their money overseas and had Purdue file for bankruptcy; once that was done, no court could claw damages out of their personal funds. For a while, in 2019-20, it seemed possible that Sackler family members and company executives would face criminal charges. Then the Trump administration engineered their reprieve. Keefe set out to be a chronicler of the Sackler family, so it’s unfair to complain that he spends too little time interrogating the nexus of money and government. Nevertheless, that nexus is clearly the source of so much dysfunction in American healthcare – to the extent that to read Empire of Pain is to wonder if even the Sacklers are just a distraction from the real problems. Purdue may not be around any more, but the system that abetted it survives unchallenged. In the past half-year, the seasoned sceptics among us have been advised to unfurrow our brows and soften our hearts – to celebrate the marvel of vaccines developed on the fly, in the teeth of a crisis. These vaccines are brandished as proof of the essential soundness of the medical industry: its patent regimes, its sense of ethics, the might of its corporations, the operations of its markets. None of these champions hangs around very long to listen to the argument that, while the vaccines may bear out the march of science, their distribution suffers from many of the industry’s mercenary habits. The rich prevail over the poor. Taxpayers fund research, only for large firms to cling to intellectual property rights and the revenues they will bring – and for governments to back this opportunism even during a global pandemic. Companies publish dubious data. And those members of the Sackler family who were involved have endured nothing more distressing than a social downfall. Only in a deranged world can the erasure of their names from museum galleries be considered punishment enough for OxyContin.