In the summer of 1746 London hospital provision for the poor with venereal disease entered a new phase. Surgeon William Bromfeild placed advertisements in the London Evening Post and the Daily Advertiser inviting donations for a new charitable hospital for impoverished patients suffering under the disease. Within six months his new charity had solicited enough support to launch the venture officially. The new London Lock Hospital opened its doors in January 1747. Unlike the royal hospitals supported by rents, or the workhouses supported by the public poor rates, the Lock was a private endeavor. That hospital would stand at the center of London, indeed of British hospital venereology for three centuries.

Why did Bromfeild open the Lock if there were already so many institutions treating the pox? If hospitals were not shunning venereal patients, as standard historical accounts have held for so long, then why did Bromfeild and his supporters embark on this endeavor? It was clearly not launched on a whim. The administration struggled mightily, but successfully, just to keep the hospital afloat during the difficult early decades. The hospital survived the turbulent eighteenth century and eventually found the stability to last all the way to 1952. This is an impressive record. We must ask what drove the founders? Why was this hospital, which seemed to offer services already offered by many other London institutions, considered necessary by the late 1740s? London charities were many and the competition for benefactions was stiff. How did the Lock Hospital convince English benefactors to support its mission? It is worth considering what was unique about the Lock Hospital and what niche it filled.

If it was not to provide care that was otherwise lacking, perhaps its mission was linked to a wider reforming agenda. Along with the idea that the Lock represented new tolerance, the idea that a reform program drove the charity has been one of the central assumptions of the scholarly work done on the Lock.

Many Londoners could not avail themselves of the services that the market provided. This posed a problem. What can be done, lamented surgeon Charles Peter in 1693, for “those poor unhappy wretches where the Pox and Poverty are complicated”? In a sense, that is the central question of the remainder of this book. Such folk were not entirely without options in the seventeenth century, as scholars have sometimes presumed. One of their main options lay in one of the two royal hospitals that offered venereal care, St. Bartholomew’s and St. Thomas’s. However, contemporaries did not always see these as a desirable choice. An anonymous commentator criticized hospital foul wards, claiming that “more rude Ignorance, and slighter Management in curing this disease, has not been heard of, than in these places.” He went on to claim that “some that have undergone their common unctions there, and come forth uncured, have protested they had rather chuse to dye, than to return thither again.” In 1696 a doctor named Wall similarly described the “Despised Hospitals and Lock Nursery” that represented the only resort for paupers who had been taken advantage of by ruthless quacks who took their meager pennies and sold them phony cures.

Wall’s depiction of seventeenth-century hospital VD care is notable for its lack of a clear opinion; it is a description that, though brief, captures well the tension and difficulty inherent in trying to sum up early modern hospital provision in simple terms. On the one hand, Wall offered rather little hope to the “captives” who resorted to the foul wards, where they might find themselves “reduc’d . . . to a dribling Condition” by the substandard care and “slack attendance” that characterized hospital therapeutics. Yet despite that grim picture he also acknowledged that the foul wards still “furnish[ed] out more Mercy to the Afflicted” than the dog-eat-dog market from which paupers were excluded. Wall’s depiction is generally accurate, exaggeration notwithstanding. There can be no question that hospital patients faced inferior care when compared on many counts to the care available to paying patients. However, before gauging that care we must first acknowledge the absolutely impressive scope of both hospitals’ provision for venereal patients, which has been largely unrecognized. The royal hospitals steered quite significant resources towards tackling the complicated problems of poverty and the pox, and saw venereal patients as worthy objects of that significant charity.

Extremely high incidence of the pox in the mid eighteenth century necessitated more ward space for London’s venereal poor. This may seem strange since the royal hospitals had large operations, and parishes treated an increasing number of patients within workhouses. By the 1740s there were more hospital beds for the city’s poxed poor than ever before, and thus the Lock’s emergence in that decade still confuses. Understanding the Lock’s original purpose ultimately rests on understanding how it related to the pre-existing network of medical institutions. When we consider the Lock within the wider context of the city’s medical welfare system, it becomes clear that its purpose was to fill a particular niche within that system. Despite the growing number of beds in London’s foul wards a particular portion of the city’s population remained neglected, and the Lock Hospital tried to fill the gap. It is only by considering the Lock in relation to the broader social welfare network that its unique character may be understood. Once understood, we can better compare the experiences of its patients to those we have already encountered.

The need for more hospital beds for venereal patients was acute in the early to mid eighteenth century. Demand continued to outstrip supply when it came to hospital beds for the pox. By the time William Bromfeild convened a meeting to found the Lock Charity, London had witnessed the establishment of yet two other major hospitals that cared for venereal patients, Guy’s Hospital in Southwark, and the London Hospital in the East End.

Guy’s Hospital, established in 1727 by famed benefactor Thomas Guy, originally intended to care for “incurables”—that is, those that other hospitals refused because their conditions seemed too desperate to cure successfully. Considering this original mission, it is surprising that foul wards came to house a significant portion of Guy’s patients. Unfortunately, the vast majority of Guy’s Hospital’s administrative records were not available for consultation at the time of this study.

In September 1992, Bill Clinton's presidential campaign organization asked if their candidate could deliver a major address at Merck's company headquarters in Rahway, New Jersey. Merck had never before hosted a presidential candidate there, and after some probing, we learned that Clinton's team had targeted Merck for the candidate's first important speech on healthcare reform.

Why Merck? I thought they'd chosen our company in part because of its reputation within the pharmaceutical industry. Although I hadn't been active in Democratic politics, I was a significant financial supporter of Bill Bradley and Frank Lautenberg, two Democrat senators from New Jersey. The other and more important reasons, I decided, were some of our company's recent activities. During the previous year, Merck had introduced its new policy on pricing, keying increases to changes in the Consumer Price Index. That innovation had received a great deal of favorable press as had our earlier decision to donate Mectizan to any program in the world capable of distributing the drug to people endangered by river blindness.

Merck was riding high, enjoying the kind of public acclaim for which every business and every CEO yearns. America's most admired corporation was an ideal platform for a major address on healthcare. Rather than announce their new proposals in a public health forum, we thought the Clinton team might want to use a corporate setting to suggest that their program had broad support, from business to organized labor, from conservatives to liberals.

By 1984, Diana and I knew exactly what we wanted my next job to be. We just didn't know where it would be. After acquiring some new responsibilities outside the laboratories during the last few years at Merck, I'd become intrigued by what made the company tick. And what might make it tick even better. Those experiences with on-the-job training whetted my appetite for an executive role somewhere. Neither my education nor my experiences before Merck had prepared me to become a “suit,” but that's what we decided my next job would be.

Fortunately, Diana and I were practiced at surviving these transitions together. In a sense, we repeatedly relived the NIH years, when I'd started with a textbook and launched my explorations in biochemistry and enzymology. I'd started at square one, with all its attendant doubts and insecurities. About ten years later, we made a less drastic turn into a university career. Add nine more years and we were headed to the Merck Research Laboratories to immerse ourselves in drug discovery in an unfamiliar corporate setting. Each time there'd been a few big problems and thousands of little problems for both of us to solve.

As I survey that trajectory, it seems evident that at each shift in direction we were captivated by the complexity of the problems and spurred by the results we hoped to achieve – results that would make a difference to a large number of people.

I'd barely settled into my new office when I made my first mistake, a global whopper. It was just what you might expect from a green CEO who didn't want to acknowledge that his organization wasn't ready to slug it out, toe-to-toe, with a heavyweight international competitor. The details, round by round, blow by blow, are engraved on my memory, but I'll try to gloss over the minutiae.

It was my first deal. ICI, the giant British chemical company, had approached Merck because they needed a modern cardiovascular drug to boost their sagging product line and were focusing on the ACE inhibitors. Merck had an excellent candidate coming along in the clinic, lisinopril, our follow-on therapy to Vasotec. Our early clinical results were very positive. Lisinopril reduced blood pressure, was a bit more potent than Vasotec, and appeared to have a slightly longer duration of action. On the basis of these results and our experience in the field, we were confident that our new product would be a success. ICI agreed and proposed that we both market the drug worldwide at the same time, competing against each other and using different brand names for the same therapy.

The negotiations, which lasted for weeks, were intense. Corporate Licensing handled Merck's side of the deal while ICI's CEO and I stayed on the sidelines. In exchange for lisinopril, ICI offered one of their compounds, an aldose reductase inhibitor designed to stop the long-term ravages of diabetes.

We went to France by ship in the summer of 1962 and immediately started looking for an apartment in Paris. Both Diana and I thought we knew enough French to figure out the Parisian real estate market on our own, and besides, we enjoyed feeling self-reliant. Since I had been spoiled by living within walking distance of the NIH laboratory, we concentrated on locations close to the Pasteur Institute. At first we were disturbed to learn that all apartments in Paris had two prices: the official, legal, taxable price, which was very low, and the unofficial, illegal, cash price, which was higher. But even the cash prices were reasonable, and we decided not to buck the system. If French apartment owners wanted to avoid taxes – apparently a national tradition – we would just have to play by their rules.

Once we made that decision, we were surprised at how easily we found just what we wanted: a modest apartment within reach of our very limited budget on the right bank of the River Seine near Montmartre. The location was attractive, close to the great museums and restaurants, and I would be only a short distance from the Institute.

The next day I went to the laboratory to meet Jacques Monod. Knocking, I heard him answer, “Entrez!” Primed to continue practicing my French, I walked into his tiny office and said, “Bonjour, Monsieur.” Monod glanced up and said, “Hi, Roy.” Monod was completely fluent in both languages.

As the retired chief executive officer of a major U.S. multinational firm, Roy Vagelos has already received a lifetime allotment of public attention. Whether it was standing before financial community experts to explain the past, present, and (I hoped) future of Merck & Co., Inc.; or testifying before a congressional committee in defense of the National Institutes of Health budget; or announcing Merck's gift of a new drug with the potential to eradicate river blindness – I spent years in the media limelight, receiving more than my share of newsprint, magazine pages, and TV coverage. Now, however, almost a decade after that highly visible life ended, I have collaborated with Lou Galambos on a book that has allowed us to reflect on all three of my careers: in medicine, science, and business. Along the way, we have tried to provide a balanced perspective on two important professions and on an industry, pharmaceuticals, that has aroused a tidal wave of controversy in recent years.

When Lou suggested that we collaborate on this book, I initially resisted. I was then in my last year on the job at Merck and didn't have time to reexamine the past – especially what seemed at the time to be the distant past of my family, my education, and my first two professional careers. But I was finally convinced that we could do the job expeditiously if, following recorded discussions concerning the events of my career, Lou drafted chapters and I edited them.

In 1994, my retirement from Merck was celebrated in the lavish style characteristic of today's successful American corporations. There was the magnificent dinner complete with a small band and huge floral centerpieces. And, of course, the made-to-order video with shots of my friends, family, and colleagues from around the world saying nice things about me and what we had accomplished in the past nine years. The outdoor phase of the retirement ceremonies was held on a sunny October day in Rahway. Dr. Bruce Alberts, President of the National Academy of Sciences, lauded my scientific and academic accomplishments. New Jersey Governor Christie Todd Whitman helped dedicate Merck's Rahway site as the “P. Roy Vagelos Research and Development Center.” I appreciated their kindness, but I could hardly stand any of this praise. I couldn't wait to leave and jumpstart the next phase of my life.

It was of course comforting to know that Merck was in good shape. The Clintons’ bashing had caused the stock price of Merck and all the major pharmaceutical companies to drop. Merck slid from $54 to $29 a share, but it was slowly recovering – as we knew it would. Merck's core business was fundamentally very strong. Perhaps the best news accompanying my retirement was our progress in developing an effective treatment for HIV infection and AIDS, the kind of achievement that makes work in the pharmaceutical industry unusually rewarding.

Look,” Dr. Illingworth said, “high cholesterol is killing people.” Roger Illingworth of Portland, Oregon, was a prominent heart specialist. He and two fellow cardiologists from Dallas were visiting Merck in 1982 as consultants to give us an outside perspective on our programs at the laboratories. In their clinical practices all three were treating patients with serious artery diseases, their coronary arteries narrowed by plaques of cholesterol and fat. Not coincidentally, these patients also had elevated cholesterol levels that hadn't responded to any of the available treatments. The three clinicians were in complete agreement: “Mevacor was doing a helluva job in the clinic,” Scott Grundy said. “Why don't you let us try it in some high-risk patients?” Illingworth, Grundy, and his colleague David Bilheimer were eager to restart limited clinical trials because the outlook for their patients was dire.

Having spent several years caring for such patients on the wards of the National Heart Institute, I knew they were right. As the head of Merck's research labs, I was tempted but hesitant. The evidence these and other medical researchers had uncovered pointed to elevated cholesterol levels (hypercholesterolemia) as a major cause of heart disease, and I knew that the high-risk patients Grundy, Bilheimer, and Illingworth were treating had been unable to bring their cholesterol levels down to a safe range either through diets or drugs. In many such cases, badly clogged arteries left the patients facing almost certain encounters with life-threatening heart attacks.

Roy, don't you know you'll be selling toothbrushes and combs?” Phil Majerus crowed. I played it straight: “Phil, I don't think Merck sells those products.” But the truth was, when I accepted the company's offer to head basic research for a year and then become president of the Merck Research Laboratories, I didn't know everything Merck was doing. In 1975 the company had several subsidiaries, and so it was possible that one of them did make toothbrushes or combs. But if so, I would never admit it to Phil.

What I did know about Merck & Co., Inc., consisted of an impressionistic blend of Rahway memories, family lore, and recent personal encounters. From my days jerking sodas at Estelle's Luncheonette, I had a good feeling about the technical people who worked for the company. Not only were they smart and excited about their work, but they were also fun. They played tennis and touch football, they read interesting books, they were on top of current events. I wanted to be like them. I also knew many Rahway families in which two or three people were employed at Merck. I thought of it as a benevolent, paternalistic organization that took good care of its employees. My sister's husband, Robert Currie, had been a process chemist in Merck Research for years, and so stories about the company, mostly positive, had always floated around our family gatherings.

One of the executive perks at Merck Research Laboratories was a limo for company business. On a beautiful September day in 1980, in my fifth year as head of the laboratories, the limo picked me up at home after lunch. We drove down through the Pine Barrens to the Seaview Resort at Absecon, New Jersey, where all of Merck's senior scientists were gathering for their four-day annual meeting to survey their accomplishments and plan our program for the next year. I left early because I'd arranged a singles match with my colleague Stan Fidelman. There'd be neither time nor space on the tennis courts for singles once the entire group arrived, so a few of us always tried to get together early for some intense competition before the work began. It was also a good occasion to have some private time with Stan, who was a close friend and a very special person in our organization.

As the car headed into southern New Jersey, my mind drifted a bit as I admired the beauty of the landscape and thought about the history of that area. I'd recently read John McPhee's book on the Pine Barrens, which rekindled my interest in seeing them again. But I quickly stopped musing, dug into my pile of reports, one from each of our laboratories, and became completely engrossed in the strategic reviews.

My life is in many ways the classic American dream: poor immigrants come to the United States and work very hard; their children receive an excellent education and lead a better life. I was born just before the start of the Great Depression, in October 1929, in Westfield, New Jersey, where my Greek father and one of his brothers owned a shop that sold candy, ice cream, and snacks. In the next few years, times were hard for all of us, but we were cushioned from the worst effects of the economic crisis by our family. Children now grow up in a society less supportive than mine was even in the harshest days of the 1930s.

In elementary school I was a cutup who entertained the other students – but not of course the teachers. They were interested in teaching Pindaros Roy Vagelos (they wouldn't use my nickname, Pindo) to read and write in English, goals that seemed formidable to a first-grader who spoke only Greek at home. I was a slow learner. I wasn't interested in learning. It was much more fun to fool around and tease the other kids. Besides, I had recurrent ear infections that made it difficult for me to hear. Since my last name begins with a “V,” I sat in the back of the class, where it was hard to hear even when I was healthy.

One of the important factors in the improvement in human health across the globe during the last half-century was the growth of basic research at the National Institutes of Health (NIH), a large government-funded organization headquartered in Bethesda, Maryland, just outside of Washington, DC. My assignment at NIH included the care of heart disease patients – a task for which my experience at Massachusetts General Hospital had prepared me very well. But I was also going to engage in basic research, and the search for fundamental scientific knowledge was another thing entirely. I was curious but a bit uncertain about what I could accomplish. My new mentor was also uncertain.

“I've never taken on an M.D. as a postdoctoral fellow,” Earl Stadtman said during my interview at the National Heart Institute. All the scientists working with him had completed graduate training in biochemistry and, like Earl, they had Ph.D.'s. I was just a novice in biochemistry, having had only a single course in medical school. Up to this point in my career, my experiences with pure research hadn't particularly excited me. Stadtman let me know at our first meeting that he had some serious doubts about my interest in the kind of research he was doing. Nevertheless, he took the time to explain carefully and quietly the several projects under way in his laboratories at the National Heart Institute (one of NIH's eight institutes). He was so soft-spoken that I found myself leaning forward, trying to catch every word.

Back on a familiar path at NIH, I quickly settled in with my growing team as we pressed on with the research on biosynthesis. Al Alberts and Peter Goldman were now joined by Phil Majerus, a scientist of enormous intellectual capacity. Phil, who was one of the smartest people I had ever met, was able to understand new concepts and master new techniques faster than almost everyone else. When he joined our laboratory, we had determined some of the characteristics of the acyl carrier protein (ACP), which is linked to various biochemical intermediates in fatty acid synthesis. Phil, Al, and I were now able to isolate a pure form of ACP and to establish that all the intermediates involved in fatty acid synthesis are bound to this single protein.

Majerus next wrestled with defining the structure of ACP, which would give us additional clues as to how it functions in fatty acid synthesis. We knew we had a protein to which all of the biosynthetic intermediates were attached, but we couldn't be certain of its function until we clearly established its composition and structure. All the while we were looking nervously over our shoulders, fearful that Harvard's Konrad Bloch or some other giant was going to beat us to the solution.

For a time, second best seemed a likely outcome after Phil, Al, and I embarrassed ourselves in front of what seemed like a million talented scientists.

The 1980s provided every reason to think all business was corrupt. The newspapers were full of insider trading and Wall Street scandals. The most upsetting news was about the gross profits made by people widely described as financial parasites, who sucked off billions of dollars through complex schemes that most people had difficulty understanding. There were junk bond crazes and hostile takeovers by financiers who broke up organizations instead of building them. Much the same picture appeared on television, in local movie theaters, and in popular magazines. Fiction, nonfiction, it was all the same: People in business are not like you. They are fundamentally immoral, and the richest are making no positive contributions to our society.

Recently we have had another burst of business scandals. In the last few years some of the country's largest firms have collapsed as a result of corruption, leaving their shareholders, former employees, and entire communities in deep distress. This time some of the leading firms in the accounting profession have been caught up in the scandal for abandoning their watchdog role and approving the illegal practices of their corporate clients. Once again, men in powerful positions lined their own pockets while presiding over a devastating slide into bankruptcy.

During the nation's previous bout with business scandal in the 1980s, it was especially easy to believe that business was corrupt because millions of lives were changing in dramatic, often devastating ways as a result of changes in corporate America.