Botox Nation

Changing the Face of America

Dana Berkowitz

• Publisher: NYU Press
• Year: 2017
• ISBN:
  9781479822911
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

One of NPR's Best Books of 2017 The first in-depth social investigation into the development and rising popularity of Botox The American Society for Aesthetic Plastic Surgery estimates there are about two-and-a-half million Botox procedures performed annually, and that number continues to increase. The procedure is used as a preventive measure against aging and a means by which bodies, particularly women’s, can be transformed and “improved” through the appearance of youth. But why is Botox so popular, and why is aging such a terrifying concept?
Botox Nation draws from engaging, in-depth interviews with Botox users and providers as well as Dana Berkowitz’s own experiences receiving the injections. The interviews reveal the personal motivations for using Botox and help unpack how anti-aging practices are conceived by, and resonate with, everyday people. Berkowitz is particularly interested in how Botox is now being targeted to younger women; since Botox is a procedure that must be continually administered to work, the strategic choice to market to younger women, Berkowitz argues, aims to create lifetime consumers. Berkowitz also analyzes magazine articles, advertisements, and even medical documents to consider how narratives of aging are depicted. She employs a critical feminist lens to consider the construction of feminine bodies and selves, and explores the impact of cosmetic medical interventions aimed at maintaining the desired appearance of youth, the culture of preventative medicine, the application of medical procedures to seemingly healthy bodies, and the growth and technological advancement to the anti-aging industry. A captivating and critical story, Botox Nation examines how norms about bodies, gender, and aging are constructed and reproduced on both cultural and individual levels.

1

Marketing Agelessness

The discovery of Botox—a purified and diluted form of the botulinum toxin, the world’s deadliest toxin—followed a series of accidents involving a batch of spoiled sausages, a band of musicians at a Belgian funeral, a pickled ham, and a married pair of Canadian doctors. The toxin is a naturally occurring by-product of the microorganism that causes botulism, a potentially lethal paralytic disease caused by eating contaminated preserved food.1 Although botulism has likely been around since ancient times, or at least as long as humans have been attempting to preserve and store food, the relationship between spoiled food consumption and the paralytic infection was not scientifically documented until the early nineteenth century.2

The first recorded instance of botulism dates back to 1820, when Justinus Kerner, a German poet and medical enthusiast, discovered that a substance in spoiled sausages, which he called Wurstgift (German for “sausage poison”), was responsible for a growing number of lethal food poisonings.3 Kerner, considered by his contemporaries to be an expert on sausage poisoning, published the first scientific descriptions of what physicians now recognize as the symptoms of foodborne botulism. The next important scientific step in the discovery of Botox came in 1885, when Emile Van Ermengem, a Belgian physician and professor of microbiology, was called in to investigate a massive outbreak of botulism that occurred after a band of musicians who had been playing at a funeral in Belgium became ill from eating pickled and smoked ham, many of whom later died. Through performing a clinical, toxicological, and bacteriologic analysis of the food and the victims, Van Ermengem was the first to successfully isolate the anaerobic bacterium causing the illness, which he appropriately named Bacillus botulinum, after botulus, the Latin word for sausage. Today we recognize the bacterium by the scientific name Clostridium botulinum.4

Both Kerner and Van Ermengem found that, even in small doses, the botulinum toxin could be lethal. Early symptoms of botulism, such as blurred vision and difficulty speaking and swallowing, typically appear within eighteen to thirty-six hours after eating contaminated food.5 Without treatment, the mortality rate ranges from 10 percent to 65 percent, and death usually occurs within a week.6 An excruciatingly painful experience, untreated botulism paralyzes victims’ bodies from the inside out: their bowels open, their autonomic nervous system fails, and eventually their lungs stop functioning, resulting in death by suffocation.

Only relatively recently has the medical world applied the botulinum toxin—in highly dilute form—for therapeutic purposes.7 In the 1970s Dr. Alan Scott, an ophthalmologist in San Francisco, began using a form of the toxin, botulinum toxin A, for the treatment of blepharospasm, a disorder of uncontrollable blinking. He branded the new drug with the less-threatening name “Oculinum.”8 Around the same time, the biochemist Edward Schantz started using the nerve toxin to treat strabismus, the condition more commonly known as “crossed eyes.” By the 1980s, the toxin was widely applied by both ophthalmologists and neurologists as a remedy for crossed eyes, uncontrollable blinking, and other facial, eyelid, and limb spasms.9

Jean Carruthers, an ophthalmologist who was using Oculinum to treat crossed eyes and optimal spasms, was the first to discover the botulinum toxin’s cosmetic potential. During a routine procedure in 1987, one of her patients pointed to her brow and told her, “When you treat me there I get this beautiful, untroubled expression.” The next day Jean and her husband Alastair, a dermatological surgeon, decided to inject Oculinum in the forehead of their assistant, Cathy Bickerton Swann. Less than a week later, they observed that the lines on Swann’s brow that used to make her look angry and tired had completely vanished. From that day forward, Swann has been famously known as “patient zero” in the Botox trials.10

Even though the Carruthers “discovered” what we know now as Botox in 1987, it took another decade before people could be persuaded to use it.11 The idea that you could use a poison to paralyze and relax muscles to take away lines was foreign and bizarre, even for dermatologists to grasp. Word about the toxin traveled slowly but steadily; doctors would hear about it at a conference or through colleagues, they would try it on a patient, and then the patient would tell their friends about it. In 1991, Allergan bought Oculinum for about $9 million, rebranding it “Botox.”12 During the 1990s, as increasing numbers of dermatologists became convinced that the Carruthers had stumbled upon an extraordinary discovery, they persuaded more and more of their patients to give it a try, and Botox slowly became a beauty secret among insiders, celebrities, and socialites. By 2002, when the FDA finally approved the drug Botox for the cosmetic treatment of glabellar lines, word had already been widely circulated about the revolutionary drug.

By 2015 over eleven million people in the United States had used Botox, a derivative of the deadliest toxin on the planet, to smooth their facial wrinkles.13 As the journalist Alex Kuczynski notes, seemingly overnight Allergan was “transformed from a relatively small potatoes pharmaceutical company that sold acne products and eye drops to a hugely influential player on a billion-dollar global field.”14 So how did this happen? If we want to understand the roots of Allergan’s sudden transformation from a small pharmaceutical company into a multibillion-dollar giant, we have to go back forty years to the beginnings of the deregulation and commercialization of American medicine.15

America’s recent era of deregulation began in the 1970s when the Federal Trade Commission (FTC) filed an antitrust complaint against the American Medical Association’s (AMA) ban on direct advertising and patient solicitation. By 1978 the FTC declared that the AMA ban against soliciting business through advertising and marketing was a violation of the Sherman Antitrust Act, which made it illegal to prohibit certain business activities that reduced competition in the marketplace and restrained trade. In 1982, the Supreme Court upheld the FTC’s ruling. Then in 1992 Congress passed legislation that sanctioned reductions in the testing time of new drugs by the Food and Drug Administration (FDA), reducing drug approval times by close to 50 percent. As a result of the Federal Trade Commission’s rulings, the FDA’s ability to control the marketing and advertising of drugs has been significantly truncated. This deregulation was further accelerated in 1998, when pharmaceutical companies began to advertise in print media and television and on the Internet, opening the gate for Viagra ads during Monday Night Football and Botox commercials in between nightly reality TV programming.16

When the FDA approved Botox for cosmetic use in April 2002, Allergan spared no expense and wasted no time. The company began advertising the following month, committing a whopping fifty million dollars to its consumer ad campaign. By May 2002, Botox advertisements ran in twenty-four different magazines, including People, the New Yorker, Vogue, and In Style.17 By 2007, Botox had its first celebrity spokesperson, the actress Virginia Madsen, and in 2009, the actress, singer, and beauty queen Vanessa Williams became the second celebrity spokesperson for the product.18

But advertising alone does not account for Botox’s sudden rise in popularity. In addition to marketing in traditional ways, Allergan used other creative product placement strategies to ensure that Botox was promoted throughout the editorial pages of magazines. Even before Allergan committed to spending a single dollar on marketing, journalists, a group significantly more trusted by the public than advertising executives, functioned as ghost marketers in the public relations campaign for Botox. Nobody seriously trusts advertisements these days, but many of us still believe what we read in magazines. And it is this credibility on which Allergan’s public relations campaign banked.

By 2002, Allergan’s strategic marketing campaign was already skillfully woven throughout the editorial pages of national magazines. In 2002, Newsweek published a landmark article titled, “The Botox Boom.”19 Pegging it as “the miracle drug for Boomers,” Newsweek wrote that Botox was “helping to make trophy wives out of ordinary ones, turning character actresses back into ingénues, and erasing the stigma of failure from the brows of laid off technology executives.”20 Similarly, an article in Time said Botox was a “facelift in a bottle . . . a true miracle drug.”21 Another 2002 headline from Harper’s Bazaar read, “Imagine looking younger in an instant, with no surgery and no side effects.”22 Journalists raved that Botox was “easy, reliable and can be administered over a lunch break.”23 Word was out. We had finally found the fountain of youth, and its waters could be harnessed in a syringe.

Trials and Tribulations

When I asked dermatologists to tell me how they felt when they first learned about Botox, every single one emphasized the drug’s extraordinary properties and wave-making consequences. I heard phrases like “revolutionary” and “transformational.” Ivan Camacho, a Latino dermatologist with a thriving practice in Miami whom I met at the American Academy of Dermatology meeting in 2014, told me, “It is really amazing how a toxin has created a generational change in how we have been able to intervene in the aging process.” And it has.

It has also proved useful for a range of other ailments, including cerebral palsy, carpal tunnel, tennis elbow, migraines, facial tics, incontinence, and chronic anal fissures. In fact, its applications are so versatile that medical authorities have begun comparing it to penicillin. Mitchell F. Brin, a neurologist and senior vice president of development at Allergan, pronounced, “Botox will transform the world the way penicillin has transformed infectious disease.”24 One German doctor even likened Botox’s significance to that of chemotherapy.25 If these analogies seem a bit hard to swallow, then how about those studies reporting that Botox could potentially cure depression? In 2013, Dr. Eric Finzi, a dermatologist lauded for his pioneering research on Botox and mental health, made international headlines when he found that more than half the people that he treated for depression with Botox shots showed significant improvement in their mood.26 A profusion of articles with titles like “Can You Really Botox the Blues Away?” and “Don’t Worry, Be Pretty” littered magazines, newspapers, and digital media that year, shaping a new cultural imaginary about the relationship between aesthetic enhancements and mental health.27

Botox has enjoyed some considerable publicity over the last decade and a half. Yet, despite riding high on an unprecedented period of success, there have also been a host of legal problems and public relations scandals with which Allergan has had to deal. Within only one year of Botox’s cosmetic approval, Allergan received a scorching letter from the FDA accusing the company of minimizing the drug’s side effects, for having advertisements that neglected to disclose facts about the product’s use, failing to present all of the serious risks associated with Botox, and omitting the duration and severity of such risks.28 This initial reprimand generated an outpouring of negative press coverage, stimulating early patient concern about the dangers of the drug.

However, it was not until a year later that the real publicity nightmare started—an acrimonious high-profile Hollywood lawsuit that instantly made media headlines. In a trial that could have easily been the subject of a theatrical melodrama, Irene Medavoy, a former model, actress, and wife of a high-powered Hollywood film executive, sued her dermatologist, Dr. Arnold Klein, after she fell gravely ill when he treated her migraine headaches with over 80 units of Botox.29 Medavoy had already been going to Klein, a celebrity dermatologist with A-listers like Michael Jackson and Elizabeth Taylor on his client roster, for her Botox Cosmetic injections. When Klein suggested she try Botox to relieve her debilitating migraine headaches, Medavoy saw it as a no-brainer. In addition to injecting her that day for her usual cosmetic routine, Klein injected Medavoy at the base of her skull, behind her neck, and behind each ear. Within one week of the procedure, Medavoy reported being incapacitated by headaches and had fever, blurred vision, ringing ears, respiratory problems, gastric distress, and difficulty swallowing. After her medical problems persisted for months, Medavoy sued Klein for unspecified damages, alleging that Klein committed malpractice by failing to get informed consent from her for use of Botox and its potential side effects, especially those arising from off-label uses such as her migraine treatment. She also sued Allergan for product liability, condemning Botox for being “an inherently dangerous product.”30 Medavoy sought reimbursement for both her medical bills and her lost wages from a proposed talk show. Throughout the trial, Medavoy was painted as a vain and frivolous opportunist and ultimately lost her case when the jury eventually sided with Allergan, nine to three. Despite the win for Allergan, the trial was not “without wrinkles for Botox,” and neither Allergan nor Klein left the courtroom looking innocent.31

One of the most crippling testimonies against Allergan came from Mitchell Brin, a senior vice president at Allergan and neurologist (the same man who compared Botox to penicillin), who confessed under cross-examination that the risks of Botox were unknown in dosages higher than 20 units and that the drug can spread to other parts of the body, affecting neuromuscular transmission. He also confessed that Allergan’s own clinical studies suggested that Botox might be associated with headaches, pain, sinusitis, flu-like symptoms, and respiratory problems. Medavoy’s own neurologist told journalists that he had conducted independent research demonstrating how Botox’s paralysis of facial muscles could potentially cause changes in other muscles around the body. He found that injecting Botox in a person’s forehead could cause changes in muscle function in the ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Introduction
• 1. Marketing Agelessness
• 2. The Turf War over Botox
• 3. Becoming the Botox User
• 4. Negotiating the Botoxed Self
• 5. Being in the Botoxed Body
• Conclusion: The Perils of an Enhanced Society
• Methodological Appendix
• Notes
• Bibliography
• Index
• About the Author