If health care industry corruption and criminality were a city skyline, it would be booming, with tower cranes and half-built skyscrapers in every direction. Among the downtown giants at the center would stand Johnson & Johnson, an iconic U.S. company whose villainy receives a just and overdue accounting in Gardiner Harris’s No More Tears: The Dark Secrets of Johnson & Johnson.
The book is an investigative demolition job in the best tradition of muckraking exposés and should find a sizable and receptive audience at a moment when public sentiment toward our corporate health care system ranges between Ralph Nader and Luigi Mangione. Harris, a former reporter for The New York Times, spent years digging into the company’s past and conducted hundreds of interviews, but the most damning evidence in the book comes from internal documents that have surfaced during decades of lawsuits against the company’s long record of public endangerment.
This story begins with the firm’s flagship product and defining scandal. Introduced in 1894, Baby Powder marked Johnson & Johnson’s wildly successful venture beyond its origins as a maker of sterile cotton and gauze. For years, it had included tins of powdered talc in its bandage shipments to hospitals, but the company we know today resulted from the idea of selling them individually to consumers as a treatment for diaper rash. Long associated with war and surgery, Johnson & Johnson began calling itself “the baby company” and never looked back.
For more than a century, Baby Powder was the American infant’s first exposure to the insidiousness of modern marketing. Its singular scent was neither natural nor accidental but born of a laboratory effort combining more than 200 ingredients to produce “a sweet, vanilla-like base” with “overtones of jasmine, lilac, rose, musk, and citrus.” The company sold images of innocence to mothers while nurturing its next generation of customers in the crib. “Smells feed directly into the brain’s limbic system, the ancient seat of human emotion,” writes Harris. This insight formed the basis of a priceless association with birth and motherhood, and provided a durable “protective halo” even as the company’s innocence was revealed to be as fraudulent as its famous scent.
The first studies flagging possible dangers in the pediatric use of talcum powder, focusing on asphyxiation threats, appeared in 1922. They were followed by studies decades later noting high rates of talcosis, a fatal lung disease, among talc miners. Research then expanded to include asbestos, a fibrous mineral and common talc contaminant so loaded with potent microscopic crystalline needles that inhaling trace amounts damages lung tissue DNA and can cause cancer. By the early 1960s, researchers had linked asbestos exposure to rising rates of mesothelioma, an aggressive lung and abdominal cancer. This research gained a public profile only in 1968, when The New Yorker published an investigation containing data that suggested half of New Yorkers had asbestos in their lungs. One of the researchers profiled, Mount Sinai’s Dr. Irving J. Selikoff, was alarmed by higher rates of contamination among housewives. When he ran baby powders under an electron microscope, all contained asbestos.
The bad press shocked Johnson & Johnson, but the science did not.
The bad press shocked Johnson & Johnson, but the science did not. The company had known since 1958 that its bestselling product contained up to 3 percent asbestos. Six years later, it purchased a talc mine in Vermont, located three miles from the country’s biggest asbestos mine. “That colocation was no accident,” writes Harris. “Talc and asbestos are so chemically, geologically, and structurally similar that veins of one are often sandwiched between or ribboned with the other.” Just one year before the New Yorker story, the company had tested talc from the new mine and found two types of asbestos. Instead of warning the public and switching from talc to cornstarch, the company declared what Harris calls a “scorched-earth public relations campaign” on troublesome science. It leaned on Mount Sinai’s board to discredit its own research; devised a novel method for measuring contamination that was designed to fail; and turned to a Mengelean in-house researcher named Dr. Albert M. Kligman to conduct disturbing experiments that involved injecting talc and asbestos into the flesh of Black prisoners. Kligman’s reports to corporate confirmed the minerals caused extreme irritation when injected, but said nothing about cancer, because it was not a subject of study.
For another three-plus decades after the experiments, Johnson & Johnson successfully pressed the same strategy, with reputation unscathed, sales robust, and public trust intact. “We attribute this growing opinion,” read a self-satisfied internal company memo, to “favorable data from the various J&J sponsored studies that have been disseminated effectively to the scientific and medical communities in the U.K. and the U.S.” This was only possible, Harris notes, due to its parallel success “muddying the record on asbestos … and persuading [inconvenient researchers] to get out of the talc testing business altogether.”
Johnson & Johnson continued its disinformation campaign as further dangers came to light. In 1982, the journal Cancer published data showing that regular use of talcum powder on female genitals nearly doubled the risk of ovarian cancer. Even as nine subsequent studies confirmed the link—with most reporting higher risk—the company stuck to its playbook. For Johnson & Johnson, switching to cornstarch would amount to admitting error and risk cracking the cornerstone of its corporate mythology. A slide from an internal presentation describes the company’s claims on “both the mother-infant bond and mother’s touch” as the company’s “Golden Egg.” Another depicts a piggy bank receiving coins next to the words “mother-baby bond.”
As the first lawsuits loomed in the late 1990s, Johnson & Johnson attempted to shift its Baby Powder liabilities onto a shell company with limited funds. Only when a judge blocked this Hail Mary did the full story emerge. Between 2010 and 2021, the company spent $25 billion fighting lawsuits representing hundreds of thousands of people, the largest of which produced bounties in incriminating evidence in discovery. Among the worst defeats was a 2018 suit in which a jury awarded 22 women with ovarian cancer $25 million each and ordered the company to pay $4.14 billion in punitive damages. In 2020, a bruised Johnson & Johnson finally discontinued domestic sales of the talc-based powder that Roberta Ness, former president of the American Epidemiological Society, estimates is a factor in 2,500 cancer diagnoses and 1,500 cancer deaths every year. The company continued selling the product abroad until 2023.
Harris could have written an entire book about the story of Baby Powder, and No More Tears would still warrant an honorable mention among notable recent narrative investigations at the intersection of corporate perfidy and public health, such as Bartow J. Elmore’s 2021 history of Monsanto, Seed Money. Alas, Johnson & Johnson’s original sin was nowhere near its last.
Tylenol is Johnson & Johnson’s second-most iconic product. And like Baby Powder, its ubiquity obscures decades of deceitful and ultimately deadly marketing.
When Johnson & Johnson purchased McNeil Laboratories in 1959, it acquired the firm’s new acetaminophen-based painkiller called Tylenol. Years after the blockbuster’s over-the-counter release, research revealed the drug’s toxic effects on the liver. When the company applied for an “Extra Strength” version in 1975—upping the recommended dose by about a third, to 500 milligrams—The Lancet declared acetaminophen “one of the commonest causes” of liver failure in Britain, and editorialized that if it “were discovered today it would not be approved.” With Extra Strength’s approval by the Food and Drug Administration in 1976, the drug’s slim margin of error between recommended and dangerous doses all but disappeared. Documents show that Johnson & Johnson was aware of this, and knew that adding even small amounts to recommended doses on top of moderate drinking could cause “catastrophic liver damage.” Once again, it fought tooth and nail to protect the illusion of Tylenol’s safety, resisting even updated warning labels until 1994. Harris writes that this was especially baleful for pediatric versions of the product, including an infant formula. Between 2000 and 2009, the FDA estimates that at least 20 children died from overdoses. As with Baby Powder, this legacy persists in the (at least) 150 Americans who die and the 30,000 hospitalized every year from overdosing on acetaminophen. For many years, the company maintained that all acetaminophen-related adult deaths were intentional suicides.
Harris ably covers the famous tampering scandal of 1982, in which several people in Illinois died after consuming Tylenol deliberately contaminated with cyanide. While the company’s response is still taught in business schools as a textbook case of responsible corporate crisis management—in which the company leveled with the public and helped initiate the age of tamper-proof packaging—the real story is predictably sordid. Far from serving as a model of accountability, the company covered up extensive evidence that the poisonings resulted from soft spots in its distribution system, and not from a “madman in retail,” as the public was led to believe. A company whistleblower later told investigators that the company knew the killer worked for its contractor, but “kept that knowledge not only from the public but from investigators.”
From the perspective of Johnson & Johnson’s executives and investors, the cyanide scare was dwarfed by another crisis: generic competition. The Hatch-Waxman Act of 1984—which lowered barriers for smaller drug companies to introduce nonbrand versions of drugs whose patents had expired—was negotiated just as bigs like Johnson & Johnson were facing a generational “patent cliff.” The perfect storm required they get creative if they were to preserve their extraordinary margins and profits. Like their peers, Johnson & Johnson responded, not by investing more into R&D, but by raising prices and expanding markets by inventing and pushing new use cases for patented drugs. To accomplish this, the company hired a national sales force—D1 cheerleaders and West Point grads were favored—and spent enormous sums systemically bribing the nation’s doctors and medical thought leaders. Like previous gambits, it was a spectacular success. “Every dollar given to doctors led to between $3.50 and $5 in additional drug sales,” writes Harris.
One of the post-Hatch-Waxman “blockbusters” to result from this strategy was a protein called Erythropoietin that increased red blood cell counts. It was initially developed to help dialysis patients avoid transfusions, but in the run-up to its 1989 debut under the trade name Procrit, the company decided that market was too limited. Instead, Johnson & Johnson targeted the much larger (and untested) cancer market by selling Procrit as a treatment for anemic chemotherapy patients. Wall Street thought the strategy inspired; Fortune named Procrit 1989’s “Product of the Year.”
There was just one problem. Independent researchers quickly discovered that the drug not only posed heart-attack risks, but also supercharged the growth of tumors. Some tumors, it turned out, even had Erythropoietin receptors. As the evidence solidified, the chief medical officer of the American Cancer Society dubbed the product “Miracle-Gro for tumors.” But rather than pull Procrit from the cancer market, the company dusted off its Baby Powder script and sought to bury and discredit the science linking Procrit to tumor growth. A company researcher later testified to overhearing one Johnson & Johnson employee tell another, “We have to kill this work.” That they did. Johnson & Johnson hired doctors, writes Harris,
to undertake scientifically dubious clinical trials, contracted with ghostwriting firms to write up the results in deceptive ways, and then paid the purported authors to exaggerate or lie about the trials at medical conferences in lectures many doctors were required to attend.
A few years after launch, Procrit had made the company more money than any other drug in its history, accounting for 10 percent of its drug sales and its fattest margins. The company charged $1,000 per dose—of which oncologists pocketed nearly one-third. Harris estimates that oncologists participating in Johnson’s deadly fraud doubled their salaries, on average, from $300,000 to $600,000. The company could not claim ignorance. It was later revealed that Johnson & Johnson shut down several in-house studies to test hemoglobin levels because cancer patients who got the drug showed accelerated tumor growth and died at much higher rates than the placebo group. Harris mentions one epidemiologist who estimates Procrit’s death toll in the hundreds of thousands and counting.
In 2016, more than a decade after an investigation by The New York Times broke the scandal, Johnson & Johnson finally released internal data from one study showing that women with breast cancer who took Procrit were twice as likely to suffer stroke or pulmonary embolism and were at a higher risk of dying. Also in 2016, Johnson & Johnson sold $1 billion worth of Procrit on the cancer market, mostly to provincial doctors who likely did not have subscriptions to the Times or leading medical journals.
It may seem impossible that Procrit could have a rival for Johnson & Johnson’s most depraved scandal of the ’90s. But Harris presents a candidate. Risperdal was an antipsychotic hatched in the laboratories of Johnson & Johnson’s biggest drug subsidiary, Janssen Pharmaceuticals. It was released in 1993 to replace Haldol, a similar drug sold by Johnson & Johnson whose patent had just expired. It was always going to be a tricky transition. Not only were “chemical straitjackets” passing out of style, there was evidence that the pricey new drug was no more effective, and more dangerous, than Haldol, now available as a cheap generic.
Of course, the company was never interested in proving Risperdal’s therapeutic advantage. Since the FDA did not require comparison trials, none were conducted. As with Procrit, the company focused on persuading doctors to prescribe the heavy tranquilizer to as many people, and for as many conditions, as possible. Harris quotes a sales plan draft from early in the process in which one executive observes, since the schizophrenic market is limited, “Aggressive expansion of Risperdal use in other indications is therefore necessary.” Here we are properly introduced to one of the book’s recurring villains, Alex Gorsky, the sales rep turned division chief tasked with creating markets for Risperdal. The strategy he devised, at once immoral and illegal, centered on telling psychiatrists that, because the drug was approved for schizophrenics, it could be prescribed for any and all conditions associated with schizophrenia. Gorsky focused on two demographic extremes. He established an “ElderCare” sales force to hype the drug’s benefits for “aggressive” dementia patients—despite the company’s own trials showing the drug caused high blood pressure, strokes, and higher rates of death among elderly patients—and another focused on pediatric psychiatrists, who were given samples and pamphlets that touted Risperdal as a broad-spectrum treatment for bipolar disorder and any “aggressive behaviors that annoy others.”
Aside from the obvious harm caused by putting hyperactive children on heavy tranquilizers, Johnson & Johnson concealed the extent to which Risperdal impacted the endocrine system by raising prolactin levels in hormone-secreting glands. In other words, the drug caused young males to gain weight, grow breasts, and lactate. Before Johnson & Johnson’s marketing campaign, pediatric bipolar diagnoses were extremely rare; the disorder’s very existence was a subject of debate. But that was before one-third of the nation’s psychiatrists started working as part-time sales reps for drug companies. After the rollout of Risperdal, diagnoses surged, growing fortyfold between 1994 and 2003. The key figure in what Harris calls the company’s “sophisticated disinformation scheme” was Harvard University’s Joseph Biederman, who received millions to legitimize the notion that very young children could be diagnosed as bipolar and prescribed antipsychotics. He was worth every penny the company paid him. In 1997, Risperdal sales reached $600 million.
In 2000, an independent study showed 13 percent of children on the drug had grown permanent breasts, more than a hundred times the rate on the warning label. Harris estimates, conservatively, that “twelve thousand boys were disfigured in that year alone.” Three years later, Johnson & Johnson rolled out a “back to school” campaign around a new dissolving tab form of Risperdal, replete with sales reps throwing “ice cream and popcorn parties” at child psychiatry offices across the country. As part of the campaign, the company distributed a branded chart, called “DART: Depression, Agitation, and Racing Thoughts,” to lower the prescription threshold to include more moderate behavioral issues.
This chart may remind you of the infamous frowny-face Wong-Baker FACES Pain Rating Scale that Purdue Pharma promoted during the same period. It should. Among No More Tears’ contributions is filling in the role Johnson & Johnson played in prepping and exploiting America’s opioid epidemic.
In 1990, six years before Purdue’s OxyContin hit the market, the FDA’s painkiller chief Curtis Wright approved a “timed release” 72-hour fentanyl patch produced by Johnson & Johnson, called Duragesic. The patch had the same conceptual design flaw as Purdue’s more famous pill: Where Oxies could be crushed to immediately access the full dose, Duragesic could be chewed. Even when it was used as directed, patients received, on average, 150 percent of target dose in the first day. After 52 people died in their sleep hours after putting the patch on their bodies, the FDA ordered Johnson & Johnson to add a black box label.
But the company refused to give up on the patch or the related project of normalizing opioids for common pain. Leading the charge once again was Gorsky, who activated the American Pain Society—founded with a grant from Johnson & Johnson in 1977—and compiled maps with the locations the country’s most “pain-sensitive” doctors, i.e., pill mills. These efforts expanded apace with OxyContin’s massive success into the late ’90s, as openly envious Johnson & Johnson executives explored a partnership with Purdue to co-promote their opioids as treatments for moderate pain. To help them catch up with Purdue, Johnson & Johnson executives in 2002 hired a group of McKinsey consultants who encouraged the company to market Duragesic for chronic back pain and “target high abuse-risk patients (e.g., males under 40)” for extended treatment periods. “Both strategies ensured soaring addiction and death rates,” writes Harris, who dryly observes that Gorsky would later be named Humanitarian of the Year by the Community Anti-Drug Coalitions of America.
Space does not allow for a full summary of the systemic criminality recounted in No More Tears, the first draft of which, Harris notes, was twice as long. Other outrageous examples he documents include a metal hip replacement with a high fail rate in trials that the company tried to fix by making last-minute design changes not included in its FDA application; a vaginal mesh that the company continued selling even after it painfully ruined the sex lives of tens of thousands of women; and the Ortho Evra birth control patch, which delivered spikes of estrogen that caused unwanted pregnancy, stroke, and death. The story of Propulsid, meanwhile, is practically a footnote. The drug was known to cause arrhythmias and pose a high risk for infants. Johnson & Johnson “quietly underwrote a marketing campaign that succeeded in getting one in five premature infants in the country to be given this dangerous and useless medicine,” writes Harris. The company pulled the product in 2000, once again only as the first lawsuits came into view. Harris ends with the company’s scandal-plagued single-shot Covid-19 vaccine, for which the FDA revoked authorization in 2023 after investigating a rare and severe type of cerebral blood clotting and more than 100 suspected cases of Guillain-Barré syndrome among those who had received the vaccine.
Throughout this history, the question presents itself: Where the hell was the FDA?
Throughout this history, the question presents itself: Where the hell was the FDA? Harris, to his great credit, never lets this question out of sight. His story only makes sense if braided into the concurrent corruption and capture of the only agency standing between the public and the Alex Gorskys of the world. This is not the lesser aspect of the story, but is arguably the more enraging. We know corporations are sociopathic institutions; the government exists to protect us from their sociopathy. And as Harris puts it, “No major government agency has failed as fully, frequently, or consistently as the FDA.” The result is a health care system “riddled with criminality” and responsible for deaths “in the millions—more than the combined American toll from every war since the birth of the United States.”
The period covered by No More Tears spans the FDA’s infancy, perceived golden age, and neoliberal gutting, charting its devolution into the corrupted husk of an agency we know today—one that is dependent on industry funding and staffed by a combination of demoralized idealists waiting to transfer out, and salivating industry lackeys waiting to enter the gilded revolving door. A key event in Harris’s narrative of decline is the appointment of Arthur Hayes Jr. as FDA chief in 1981, recommended by Donald Rumsfeld to ensure a green light for aspartame, the possibly carcinogenic sweetener developed by his employer, the drug company G.D. Searle. A decade of enervating funding cuts followed, leaving the agency ripe for a full neoliberal makeover under Bill Clinton, who oversaw the transition to a new regime of five-year deals through which industry provides much of the agency’s budget. The 1997 legislation was the knockout blow: It green-lit direct marketing of prescription drugs, reduced the number of clinical trials from two to one, and authorized drug companies to give doctors reprints of “studies” urging unapproved off-label uses. Soon after, regional offices lost the authority to launch criminal investigations, giving the power to a headquarters overseen by cautious aspiring drug company consultants and future white-shoe corporate lawyers. Thereafter, writes Harris,
Approvals [of investigations] became almost impossible to get…. Financially dependent on the drug industry after 1992, the FDA would never again … visit the homes of top Big Pharma executives unannounced, and never again delay the approval of a new drug while an investigation continued…. Getting tough on drugmakers is simply not part of the agency’s mandate anymore.
It isn’t just the FDA that’s been captured. The Johnson & Johnson story is one of broad and deep elite corruption. “Again and again and again, Johnson & Johnson sold dangerous products and hid the risks from patients and regulators, all while being widely praised for a high standard of ethics,” writes Harris. “That praise most often emanated from a professional class—doctors, lawyers, and academics—that J&J sponsored with huge payments.”
Despite occasionally playing a heroic role, the fourth estate does not escape censure. Harris opens the book with an embarrassing mea culpa about his own erstwhile naïveté. It was only in 2004, after five years covering Johnson & Johnson and the drug industry for The New York Times and The Wall Street Journal, that he “began to suspect that the company’s culture and its apple-pie image might be entirely at odds.” Left unstated is the possibility that Harris’s protracted innocence helped produce that image. (Here, he is not alone in the halls of elite journalism: Just as Johnson & Johnson prefers West Point grads who follow orders, business editors like reporters who believe in capitalist fairy tales.)
Given the depths of his disillusionment, Harris ends on a confused note that suggests his education remains incomplete. To explain Johnson & Johnson’s “ruthless, sociopathic indifference,” he resorts to the “corporate deviance” model of organizational theory—a sociologist’s explanation for why good people and good companies do bad things. But this cannot explain the endemic criminality across a health care sector that accounts for nearly one-fifth of the U.S. economy. Johnson & Johnson is paradigmatic of a more fundamental corruption. But rather than extend the implications of his reporting to a system critique, Harris closes with a bizarre attempt at evenhandedness that lauds Johnson & Johnson for developing Bedaquiline, a tuberculosis drug. As Harris should know, Bedaquiline, like nearly every other drug in the modern pharmacopeia, was developed largely in publicly funded labs, with the government heavily underwriting every step of the process, beginning with basic research. Johnson & Johnson’s main achievement was to claim the patents and proceed to charge scandalous sums.
Far from an argument in favor of Johnson & Johnson’s existence, Bedaquiline is a testament to the need for a fully public bench-to-bedside drug pipeline. If the government conducted trials of the drugs it spends hundreds of billions of dollars developing, and maintained an active, if not dominant, role through to distribution, many of the episodes recounted so powerfully in No More Tears could have been avoided. Harris not only shrinks from this conclusion, but includes in his list of Johnson & Johnson’s accomplishments the fact that its “financial success has made hundreds of thousands of shareholders and employees richer and happier.”
No More Tears illustrates why these profits do not belong in a win column. Indeed, they are the very root of the problem.
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