Consider big pharma. In 2018, the world’s ten largest drug companies spent more than $76 billion on R&D—42 percent of the global total. Yet of the fifty-nine drugs that were approved that year, only 15 percent originated in the labs of the top-ten pharma giants. Pint-sized innovators with less than $1 billion in sales accounted for 63 percent of all new drug approvals.

Pedro Cuatrecasas, an industry veteran who brought more than forty medicines to market, blames bureaucracy for big pharma’s malaise:

[Drug companies felt] confident that they could manage and mandate results with discipline, order, formality, and efficiency. Unfortunately, many of these qualities are ones that suffocate creativity and innovation. Freedom, spontaneity, flexibility, nimbleness, tolerance, compassion, humor, and diversity were replaced by bulky and inflexible organizational structures characterized by regimentation, control, conformity, and excessive bureaucracy.

This is an important and underappreciated point: there is no shortage of ‘patient capital’ – institutions such as pension funds and university endowments are naturally looking for investments that may only pay off in the long term – but there is a shortage of patient individuals working in the finance sector, an industry remunerated almost entirely by transactions. The result is a constant flurry of financial activity engaging senior executives, investment professionals and advisers which rarely adds to, and often detracts from, the effectiveness and success of the underlying business. The financial pressures that motivated strategy at Merck and Valeant not only damaged the standing of the businesses and their products but also diminished the returns to their shareholders in the long run. In later chapters I will show that these are far from exceptional cases. The history of pharmaceuticals illustrates much that is right and wrong in the relationship between business and society. I have described four problem areas: the motivation and standards of behaviour of leaders of the industry; the interface between business and finance; the difficulty of constructing a regulatory regime that is relevant and effective; and the sometimes too tenuous relationships between prices, costs and values. None of these issues is unique to the pharmaceutical sector: similar questions arise in every kind of business, and the answers are necessarily specific to industry, time and place. But in this book – and another that will follow – I will illustrate principles and directions of travel.

Leslie Hannah, an eminent business historian, has shown how the ‘rationalisation’ of industry, which was favoured by the British Government (represented by the Bank of England), set the stage for the new ‘corporate economy’ which would characterise Britain for decades. The 1920s saw the creation by merger of ICI (chemicals), the Distillers Company (Scotch whisky) and Unilever (soap and margarine). A similar wave of mergers in Germany established IG Farben and Vereinigte Stahlwerke as the dominant chemical and steel producers respectively. (Both these companies were dissolved by the victorious Allies in 1945.)

In 2021 the newly formed investment fund Engine No. 1 secured the election of environmentalist Andy Karsner to the Exxon Mobil board. Sometimes corporate activists are active in both senses, as with Icahn’s attempts to engage with McDonald’s over animal welfare.

The nearest approximation I have found is Li Ka-shing, a refugee from China who is now Hong Kong’s richest man. Li left school at the age of fifteen and set up a small business manufacturing plastic flowers. From these modest beginnings he developed the massive Hutchison Whampoa group, of which Eversholt, another rail rolling stock leasing company, is a subsidiary. None of the, admittedly small, sample of railway employees I interviewed had ever heard of Li, far less experienced resentment at his oppression or exploitation. If they did express resentment, it was – appropriately – directed at the management of First-Group and most of all at the Department for Transport. Li is svelte, noted for his relatively modest habits and second only to Bill Gates for the scale of his global philanthropy.