Transcript for episode 2: Pharmaceutical Marketing

This is the transcript for the second episode of our series on the history of drug use in the 1950s and 1960s: Pharmaceutical Marketing.

References for this episode can be found here.

In 1986 psychiatrist Heinz Lehmann, one of the fathers of the Psychopharmacological Revolution, recorded his reflections on its impacts. Under the subheading “Business Explosion in Pychopharmaceutics” he wrote:

Psychopharmaceuticals, an industry of little economic consequence previously, quite suddenly mushroomed into a multibillion dollar business – world wide. The big companies all scrambled for part of the action and developed an endless list of me-too drugs, each variety claiming to be a little different and a little better than the other – although there was not much solid evidence for most of these competitive claims…

Drug advertising has become slick, almost hypnotically seductive, and for many physicians, unfortunately, the main source of pharmacological information.

And mushroom the industry certainly did. In 1957 the pharmaceutical industry, in general, was the most profitable industry out there, boasting a 20 per cent rate of return (which is the profit you earn on an investment). This was a full five per cent higher than its nearest rival. So how was the industry able to generate such massive profits? Was it just due to them producing a lot of excellent new and needed drugs? The fact that 1000 new pharmaceutical products hit the market between 52 and 60 may suggest that but a closer examination of the figures tellsa different story. Of those 1000 new products, only 118 were actually new chemicals. The rest were just branded and tweaked versions of old drugs, or combinations of old and new drugs. These new branded drugs were inevitably more expensive than the drugs they replaced, despite not necessarily containing any new ingredients; allowing companies to generate huge profits without much R and D investment.

To explain what’s going on here, think of branded painkillers like Advil in the US or Nurofen in the UK; both of these are essentially just ibuprofen, with a slightly different formulation. Yet check your supermarket shelves and you’ll find these branded products can be five times the priceof generic ibuprofen. So why does anyone buy the branded product? Well probably because of the brand’s marketing practices, which obfuscates links between their drug and generic versions, and also likely due to the power of brand recognition. For example, Nurofen recently got into trouble for releasing a line of products with titles like Nurofen Back Pain, Nurofen Period Pain, Nurofen Migraine Pain and Nurofen Tension Headache. And while you as a poor migraine riddled consumer squinting at the supermarket drug shelf, wishing they’d turn down those fluorescent lights, might think there was something special about Nurofen Migraine Pain; nope, its just ibuprofen. And to add insult to injury Nurofen charged double their normal high price for these products.

1950s pharmaceutical companies had astounding success promoting the use of their branded items. In general, the decade saw an explosive rise in marketing. This was the beginning of that mad men era of advertising and it seemed drug firmswere making good use of it. In 1947 patented drugs only made up 5 per cent of NHS prescriptions, by 1953 they made up 25 per cent, and accounted for 50 per cent of the drug bill. By 1957 branded medicines accounted for half of all prescriptions.

In this episode, we will examine the rise of pharmaceutical companies and the marketing tactics they used to achieve this success. As well as politician’s opinions of this advertising boom and reasons for government inaction.

Before we start I would like to give a shout out to our new sponsors:

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Ok before I get into trouble for advertising controlled substances, those obviously are not my sponsors; they are the British Medical Journal’s sponsors. These are some of the kinds of adds that populated its front pages during the 1950s. Each issue contained 30 to 50 pages of them.

And medical journals proved fertile ground for advertisers. Now depending on the classification of a drug, marketing it to the public may be illegal. But regardless, if you could persuade a person to take your drug, congratulations, you have one new customer. However, if you can persuade a doctor to prescribe your drug to his/her patients, you just gained dozens possibly hundreds of new customers. Plus doctors were extremely easy to market to. Advertisers could take a more direct approach by sending them mail or have representatives visit them. As journalist and historian Brian Inglis wrote in 65:

Promotion can concentrate on doctors. Their names, addresses and specialitiesare readily available to anyone who wishes to sell a product to them. And—what makes the market unique—doctors do not have to pay for what they order: the patient—in Britain, more usually the taxpayer—is the purchaser.

It is hard to think of any market in which the seller is better placed. Even where the patient has to pay,  it is not easy for him[sic] or his relatives to refuse a drug because it is expensive… It is not surprising that the profession has been subjected in recent years to the most powerful, sustained promotion campaign in history.

Doctors received mail from drug companies with astounding rapidity.  In 1957 an American doctor decided to calculate just how much promotional material was being sent out to the profession. He estimated the American pharmaceutical industry was sending doctors 80 tons (76,000 kg) of medical literature per day. As a colourful visualisation of this, he said if all the doctors lived in one city, it would take two railroad mail cars, 110 large mail trucks and 800 postmen to deliver the daily load of drug circulars and parcels to them. After being delivered, it would take 25 trash trucks to haul it away and burn it on a dump pile, the resulting blaze would be seen for fifty miles.

This scale seemed similarly extensive in the UK. As John Dent, the editor of the Journal for the Study of Addiction put it in 1958:

Every day doctors get advertisements of their virtues, these in glorious technicolour, in most expensive printing on most expensive paper, with strip cartoons of their effects on furrowed brows and agonised expressions of extreme pain and misery. With warnings of the dire effects of a sleepless night. Even intelligent and sincere doctors are swayed by these advertisements. They deplore the spate of cerebral sedative drugs demanded by their patients yet do very little to dam it.

And tranquillisers certainly formed a good chunk of this advertising. As we discussed last episode barbiturates were hugely popular; however, they were non-patented, so profit margins were slimmer. If a company could persuade doctors to use their patented tranquilliser instead they stood to make a fortune. However, the tactics companies used overstepped the bounds of what many doctors saw as ethical. In 57 pharmacologist D. Laurence announced to the British Medical Association that he was astonished by the “flimsy evidence” pharmaceutical companies were using to market their drugs. MacDonald, who we heard from last episode, announced Society for the Study of Addiction:

Manufacturers must, I suppose, advertise their goods in order to sell them, and no fish-wife calls her fish stinking. But some of the advertisements for these compounds are hard to swallow. Not all can be, as is claimed for a brand of meprobromate “superior to all other medicaments known at the present time for the effective symptomatic treatment of the neuroses and the restoration of repose...

After listing out some more tranquilliser and amphetamine marketing claims he concluded:

And so it is likely to go on and on. There are many other interesting drugs which are used to modify mood or which do so in the course of their other actions: opium and mescaline, ACTH and cortical hormones, chlorpromazine and LSD. But these have not been advertised in the same wide way.

That last bit highlights how in pushing their unneeded me too drugs, marketers were distracting doctors away from more effective and safe older drugs or new drugs which are seen as less profitable so were not marketed.

And in doing this the jewel in the pharmaceutical marketers crown were the reps or “detailmen”. These were employees who would visit GP’s or organisations to promote a drug in person and maybe hand out some free samples. In a 58 British Medical Journal article the Director of Bayer, Inch said of detailmen, “Of all the methods of propaganda the representative is the most effective”. Part of their success can be attributed to how useful doctors found them and still do. Hundreds of new products were coming out every year and it was very helpful for doctors to have someone come to your office or association and teach you about some of the new products entering the market. A 1962 poll found that while a third of doctors used marketing literature to keep up to date, half used reps. Inch, in his article, pointed out that it’s in the representative and firm’s interest that they are honest, as if they’re shown to be a liar it would reflect poorly on the company. However, while these marketing campaigns maybe didn’t lie explicitly, they certainly seemed to be skilled in the art of half-truths.

In 57 Tennessee Senator Kefauver set up hearings in the US to investigate the industry. He was suspicious of the pharmaceutical industry’s astounding profitability and suspected it may not be all above board. The hearings offer a rare insight into the practices of US pharmaceutical companies in this period. Many of these companies also operated in the UK or owned UK drug firms. On the subject of detailmen, one Doctor Console said, “There is a simple maxim which I learned from detailmen, which is known to most if not all the pharmaceutical industry: ‘If you can’t convince them, confuse them.’”

One of the main tactics of doing this, he called ‘blinding with science’. Console gave the example of a drug which the manufacturers said relieved anxiety, the claim was backed up by the fact that in rats the drug produced objectively measured changes in a particular area of the brain. However, in reality, there was no relation between the reaction in rats and human anxiety. The good and detailed science surrounding the drug causing certain areas of a rat brain to light up were visually displayed next to the claim that the drug relieved anxiety in the hope the doctor would assume the two were linked and there was some science backing up the marketing claim. Console would state:

The desired effect is achieved by encouraging false associations, and the frequency with which this approach is used is adequate evidence of its success.

There are many complaints about half-truths and omitted information in the UK too. A Dr Myerson described an event where he confronted a rep who was promoting the use of dexamphetamine - the amphetamine from that fat people die first add. After double-checking the sales pitch, Myerson found that the drug has only been proved to reduce appetite for 6 weeks, not long term. In response, the rep demonstrated the characteristic flexibility of a salesman, changed his story and recommended the drug as a good way to start a diet.

A Dr Wilkins wrote in to complain that a drug was being advertised as being ‘placed high among the androgens listed’ in a British Medical Journal article. Turned out the drug only held this lofty position because the list was alphabetical and the drug began with A.

Another doctor wrote in to complain that after using an expensive new drug on a patient, it didn’t help the condition and led to some serious side effects.

I understand from the consultant that the drug at that time was being widely used all over the country where this condition was treated, but he admitted that opinions of its value varied enormously. In fact it was being used before controlled tests had been carried out. Now, apart from suffering and the delayed diagnosis of serious side-effects, this waste of public money is enormous.

And the use of drugs before they had been properly tested was not as rare as one would hope. During this period governments had very little oversight of drug firms, the UK didn’t even have something like the FDA to review drugs before they came to market.

It is hard to find accounts from the marketer's point of view, but there are a couple. In 1961 a rep wrote into the Lancet to complain about all the bad press his profession had been getting of late. He objected to being painted in a villainous way by medical articles, stating the GP is not some simpleton that can easily be swayed to prescribe useless drugs. Continuing:

Providing we are always completely honest, the doctor is likely to try products for the recommended conditions. In this way sales materialise and our employers are satisfied, but first and foremost, representatives of my acquaintance are always true to themselves.

Although he may be right that pharma reps shouldn't be seen conniving Machiavellian figures swindling poor doctors, the fact that doctors are likely to try the drugs they recommend does demonstrate their power over the profession.

Another British detailman, Ted Whitehead, described how after masquerading as a patient in his usual way the doctor greeted Whitehead by describing him as “a menace to the health of the nation.” After this Whitehead had a change of heart and went on to become a teacher. In 1964 he wrote in a New Statesman article:

but I cant help often thinking of those silver-tongued detailmen flying from surgery to surgery in search of disease, lurking among the running noses with a pocketful of panaceas. As they say, they provide some useful information to the medical profession. But for their sake (and for mine and yours) I hope that the Ministry of Health won’t wait too long before appointing itself sole purveyor of full, unbiased, unselected “details” of all drugs, new and old.

Of course, the Ministry of Health never did appoint itself the sole purveyor of drug information, to the best of my knowledge no country has done this. And there is a difficulty in replacing the service the industry provides. Governments already struggle with funding the education they do provide, I am doubtful there would be much enthusiasm to pay for pharmacologists to go around informing the profession about new drugs.

Another method companies used to push their products and confuse doctors was in nomenclature; how the drug companies named their products. As a doctor explained in 1953:

The question of the name of a compound plays more part than is imagined in prescribing. A practitioner will remember an easy catch-name much more readily than a long chemical formula, and in a busy practice will prescribe it as a matter of habit and merely because it is quicker to write down.

When I first read this, honestly I was a bit dismissive of this angle. It seemed a bit far-fetched to me that doctors were prescribing one drug over another because of the catchiness of its name. However, I hadn’t fully appreciated the scale of what doctors faced. Brian Inglis, who we heard from earlier, wrote:

The multiplicity of names for products in the drug industry exceeds the bounds of human imagination. First there is the chemical name which attempts to spell out the structural make-up of the drug; and here a variety of forms of expression is possible. Next is the generic name… [which also has multiple expressions]. Finally, a drug usually has a host of individual trade names used by various companies engaged in the promotion of the product. In consequence, a single drug product is represented in the market by such a complex body of nomenclature as to intimidate even initiates in the field. And if one can visualise this situation for a single drug multiplied by the thousands of drugs currently marketed, he can get some impression of the chaos existing in the area of drug nomenclature.

In order to make use of this chaos, drug companies pushed their trade names hard and made little reference to generic names. This not only helped build brand recognition but also kept the marketing claims surrounding a trade name separate from the actual science surrounding the chemical or generic name. As GP Leon Shirlaw would complain at a symposium on tranquillisers:

My attitude is one of complete confusion. Whenever I hear a lecture or read an article about them, I encounter the official names. On the other hand, psychiatrists in their letters, when they recommend me to prescribe them to patients, and medical representatives, who praise the virtues of products of their own firms, use the trade names and I find it impossible to correlate the two.

Dr Meyerson would also complain that several times he had not been aware that the drug he was talking about with a representative was dexamphetamine until he later read up on it.

Of course, this all played into that tactic of confusing doctors. If a the doctor really wanted to know what they were prescribing, they were going to have to work for it.

During this period the industry even gave itself a different name. They were no longer to be referred to as drug firms, now they were pharmaceutical companies. They no longer made drugs, now they made pharmaceuticals. This was done in order to distance themselves from the bad press of narcotics. Ironically, the industry was responsible for first commercialising many of these narcotics like heroin and cocaine.

So while we have heard a lot about criticisms from the medical profession, how did they translate to the press? Well to be put simply they weren’t. Apart from the odd article reporting on other's complaints, the press showed barely any interest in drug advertising. And when they did report on it independently, it wasn’t too critical. For example when the Mirror reported that a drug company had started sending doctors LP records with a talk about a new tranquilliser on one side and opera on the other, the article simply concluded, “I wonder which side puts them to sleep first?”

And while the press did not seem too bothered about criticising drug marketing, they did publish a steady stream of articles promoting a drug’s use. This apparently inspired patients to demand that doctors use these new, sometimes barely tested, drugs rather than ones that the doctor had more experience with. In the US there is a large body of evidence of the drug manufacturers supporting this practice directly. During the Kefauver Committee’s investigations, they were told drug companies were planting articles in newspapers. When the committee investigated the claim they found an organisation in New York which acted as a liaison between drug companies and newspapers and radio and TV stations. The organisation even produced feature to promote their clients’ products called Spotlight on Health, which gave the impression it was a newspaper column. Spotlight on Health was sent out to 2000 US daily newspapers.

Alton Blakeslee, a prestigious science writer for the Associated Press, said he was once approached to write a story about a new drug for a magazine. The liaison offered Blakeslee 1,500 to 2000$ to write an article for a drug firm and all he had to do was mention the firm's drug by trade name twice and never mention any other product. In addition to this fee, Blakeslee was promised a further 5,000$ under the table, and if the article got reprinted by a certain outlet the company would offer him a further 10,000$. In all Blakeslee was being offered the potential to make 17,000$ by planting a drug ad in the national press. A huge amount by today’s standards, an astronomical amount for the time.

I have seen no evidence that this sort of thing happened in the UK, but Fleet Street did show enthusiasm for boasting the potential of new barely tested drugs. Wonder Drug was a favourite label for substances they wished to sensationalise. Whether the reasons for these articles were honest or not, they were still playing the role of the drug company’s unofficial marketer. And sometimes these drugs could be dangerous. For example in 1953 the Daily Mail ran the headline ‘Wonder Drug Kills Pain after Operation’, promoting the use of new anaesthetic Efocaine. The article claimed, “Efocaine has been tested by British doctors in a series of experimental operations and has been proved to be successful and safe”. Now the only test I found by British doctors came out a month before in the British Medical Journal and was based on just 14 patients.

The rest of the story of Efocaine shouldn’t surprise any of you by this point. The day after the test was published the marketing train started up with a full-page ad in the BMJ. However, fairly soon side effects started being reported. These started with letters about discomfort and pain but quickly escalated to more serious side effects. Out of America came reports of serious neurological symptoms and permanent paralysis, even a death. Similar reports started appearing in the UK.

The particularly damaging aspect of this was that hospitals were already able to produce an anaesthetic for this purpose which didn’t carry these horrific side effects and was cheaper. By 55, two years after the Mail hailed it as a new Wonder Drug, a definitive study on Efocaine stated the drug’s clinical use was no longer justifiable. And the epoch is littered with 'therapeutic misadventures' like these, highlighting how there were severe consequences of unethical marketing beyond costs going up.

These sorts of events started to inspire open calls for regulation from some sections of the medical profession. Which is the reason the Director Beyer addressed them with an article in the British Medical Journal telling them it's not that bad and to simmer down. So what if anything did the government do about this. Publicly the issue was mostly picked up by the Labour party. Some Labour MPs did adopt medical arguments into their worries surrounding an expanding advertising market. Between 1950 and 1958 the total expenditure on advertising exploded from £180 million to £364 million and some MP’s were worried about the effect it was having on society. However, being incorporated into this larger issue meant the problems surrounding pharmaceutical advertising were not given special attention. For example, Labour MP F. Noel-Baker presented medical concerns in a 1958 House of Commons debate on advertising, stating:

A great deal of such advertising is dangerous because, in the opinion of many doctors, the health of the nation is being endangered by wildly dishonest claims made by the manufacturers of these products...

This is an important national issue. We are in danger of having in this country the situation which has developed in the United States of America. Do we want to become a nation of people who are boosted by drugs in the morning, soothed by tranquillisers in the afternoon and put to sleep by hypnotics at night? If not, there is a strong case for looking into the advertising aspects of the problem and, secondly, for tightening up the relative legislation.

However, he spent much more time discussing how the populace was being persuaded to buy needless detergents and toothpaste.

It is perfectly true that it is a good thing to clean one’s teeth. It is perfectly true that it is a waste of good money to do it with toothpaste. By far the most effective and cheapest way, which I recommend, to any thrifty and intelligent housewife and which I am trying to enforce in my own house – as from today – is to clean one’s teeth after each meal with ordinary kitchen salt. I am proposing not to use any more toothpaste for the rest of my life.

But in making this a general argument, replies from the government were general too. The conservative government were not going to curb marketing because it was good for growth and the economy and made life more colourful.

Labour’s most vocal campaigner was Baroness Dr Summerskill, who throughout the late 1950s and early 60s, repeatedly pointed out the government was being ripped off to the detriment of the nations health by pharmaceutical companies.

It would be wrong to say the Conservative government was doing nothing, the doubling of the drug budget over the decade obviously concerned them. Conservative Minister of Health Macleod would say pharmaceutical products caused him more concern than any other item, including hospitals. To combat it the government was consistently trying to remind doctors to prescribe generic medicines instead of expensive trade names. As historian Stuart Anderson put it, “The decade up to the mid-1960s witnessed a struggle between the industry and the government for the ears of the medical profession.” You probably do not need to be told which side was winning that struggle, decisively.

The government stood no chance of competing with the millions of pounds marketers were spending on doctors, if they wanted to reduce this they would have to implement substantial measures and controls. However, there were a few things that meant it would be hard for the Conservative government to do this. First of all, you had political ideology, regulations and control were seen as the thin end of a socialistic wedge, leading to nationalisation. And if you think that is a bit of a stretch of a slippery slope argument, let me give you Beyer director Inch’s own words:

It seems likely that unless the pharmaceutical industry becomes State-controlled, which has already occurred in some of the "Iron Curtain" countries with most unfortunate results on therapeutic progress, advertising by the pharmaceutical industry to the doctor must continue. There would appear to be no simple solution, and the medical profession should try to adopt a tolerant attitude to what, at worst, is a relatively minor nuisance.

You can hear there Inch’s aim in trying to get the profession to complain less. This argument, that for the sake of survival marketing is needed, was repeated in the press. And Inch is right about what was going on in communist Europe. While the West was pumping out pharmaceutical discovery after discovery, the East had little to show for themselves. This comparison was a large part of drug companies’ argument for their continuation free from regulation.

And you must not forget the period we are talking about is the height of the cold war. An ideological war was taking place over whether free enterprise or state control was a better way of organising ourselves. In these scenarios, it is easy for things to become black and white. Also, the pharmaceutical industry was a star in showing how great free enterprise was. In its war for hearts and minds, the US government was putting it front and centre. ‘The Communists might be able to send a man to space but we can cure your ailments and make your life less miserable.’ Drug firms, of course, did their best to encourage this. The Pharmaceutical Manufacturers Association chairman, William Graham announced in 1960, "Probably through no other industry can the superiority of our American competitive system be demonstrated so impressively”.

Plus the industry was getting results. Even if most new products were unneeded the industry was still making useful discoveries. In the last episode I showed how drugs revolutionised the treatment of depression, but this only makes up a small part of the industries products. They were producing new antibiotics new vaccines, which were saving people’s lives. In the face of all this, why would you move against the industry?

To return to Inch’s article, which is likely somewhat representative of the industries lobbying another point he made was that due to their intelligence doctors shouldn’t need protection from marketing.

Some doctors complain about the type and content of the actual advertisements, and it must be admitted that some of the less ethical manufacturers do overstate their claims. This is quite indefensible, but at the same time the righteous indignation of doctors should be tempered some what by the knowledge that all of them, even the least qualified, have had at least six years' scientific training, and they should be better able to assess in a critical way the claims made by the pharmaceutical manufacturers than, for example, the general public is able to assess the claims made by manufacturers of soap or toothpaste.

In other words, these are doctors, men and women of science, sure a couple bad eggs are behaving inappropriately but their intelligent audience should be able to see through these. This point was also replicated in the press. Under this line of thinking, the medical profession should not need the same protections against advertisers as the general public.

However other pharmaceutical workers seemed to disagree. C O’Brien, an ex-employee of drug company Cyanamid wrote in a 1964 New Statesman article:

Doctors may rant and roar about the amount of “rubbish” poured through their letterboxes but they fall just as heavily as any housewife buying her 3d-off packet of soap. The drug companies know this and churn out their blotters, their natty books and coloured folders with anguished pictures. And the doctor, indoctrinated like a good housewife, forms an attachment to a brand, the sign of quality, the sign of whatever it is.

Perhaps this supposed difference between the susceptibility of the profession and the general populace wasn’t all it was cracked up to be. If doctors bought into this idea that they were better insulated against falling for marketing tactics, the astronomic rise of Branded Medicine throughout the 50s and early 60s suggests they probably weren’t. Interestingly it is still a problem relevant to this day.

A 2000 American Medical Association article found that most doctors do not believe they were affected by pharma advertising. A survey of German physicians found that about half of them thought they were rarely or never influenced by pharma reps. That said they were nowhere near as confident about their colleges. The survey found that doctors thought their peers were 3 times more likely to be influenced by reps. And in our era, greater vigilance is perhaps needed as advertising can be more subtle. Over the past decade, pharmaceutical firms have started marketing on social media, breaking direct to consumer rules on several occasions.

The Press too can still act as an official and unsolicited marketer for the industry. In August 2018 the Guardian, Telegraph, Independent, Mail, and Times all ran articles claiming Ritalin was the best treatment for ADHD and that hundreds of thousands of more children needed to take it. They were reporting on a very impressive study published in the Lancet. However, the press’ claims exceeded the scope of the study. As the NHS would complain on their website:

Some of the UK media provided a distorted summary of the results of the study.

For example, The Independent tells us: "ADHD treatment may be needed by hundreds of thousands more children, experts suggest".

This would appear to be based on the reported opinion of one of the authors of the study.

But the study itself never looked at whether ADHD was being underdiagnosed.

Similarly, The Times' headline, "Drugs are the best way to treat children's ADHD", is also misleading.

Drug treatments weren't compared with alternatives such as behavioural treatments in this study, so it's inaccurate to say this.

Just to be clear, I do not think this represents some link between the industry and the press, its just that opinions are more interesting to report on than the science. I mean of course the telegraph is going to get more clicks from the headline, “Drugs denied to hundreds of thousands of children with ADHD, experts say”, than something like “Study finds the most effective stimulant for the treatment of ADHD is Ritalin for children and amphetamine for adults”. Doesn’t have the same ring to it does it.

Over the past decades regulations have been put into place all around the world, but the broad stroke problems still exist. Patented medicines still inflate the NHS budget and every few years the government still tries to combat it by educating doctors. That a 2018 British Medical Journal article on drug marketing opened its analysis with the inflammatory statement, “Drug promotion is reducing, not improving, health by contributing to mistreatment, overtreatment, and under treatment”, might not fill you with confidence about our current policies, but at least some protections do currently exist.

The drug marketing explosion of the 1950s with no legal constraints led to a situation where doctors  were bombarded with advertisements of largely unneeded, sometimes dangerous products. Advertising tactics could be specifically geared to mislead or confuse the prescribers, ballooning medical costs. However these costs were not enough to inspire a reaction from the conservative government which politically found regulation hard to justify. As I have touched on the costs weren’t just monetary, and this libertarian stance toward the industry was soon leading to one of the worlds worst pharmacological disasters. One with effects so terrible that when a Belgian mother who killed her affected baby was found not guilty of murder, the crowd cheered. So terrible that it forced governments world wide to put the industry under stricter control. This will be the subject of the next episode.