All rise

Esquire (Malaysia) - - CONTENTS - Words by David Kun­sh­ner

The story of how an un­likely duo popped to the top on a Us­d3b-ayear in­dus­try—the Vi­a­gra.

Vi­a­gra It’s been 20 years since git the mar­ket, for­ever chang­ing men’s sex lives (and their part­ners’). But be­fore the lit­tle blue pill that could be­came a sta­ple of bed­side ta­bles and club-kids’ pock­ets, the drug had to over­come re­sis­tance from Wall Street, M.D.’S, Capi­tol Hill, and the Catholic church. Whose job was it to con­vince some of Amer­ica’s most pow­er­ful in­sti­tu­tions that all men de­served bon­ers? Two guys. This is the story of how an un­likely duo popped the top on a Usd$3-bil­liona-year in­dus­try.

Ac­cord­ing to the Chi­nese cal­en­dar, 2017 was the Year of the Cock. 2018 is the Year of the Dog. And, in Dog years, this is also the Year of the Cock Pill: Vi­a­gra. The rev­o­lu­tion­ary erec­tile-dys­func­tion drug is cel­e­brat­ing the twen­ti­eth an­niver­sary of its Brob­d­ing­na­gian launch in a most aus­pi­cious way: by fi­nally go­ing generic.

The ram­i­fi­ca­tions for generic silde­nafil (the sci­en­tific name) are huge for your pock­et­book and your health. Vi­a­gra’s high de­mand and cost (about sev­enty dol­lars a pill) have made it among the most boot­legged meds in the world, and one of the top sell­ers for In­ter­net phar­ma­cies. A study pre­sented at the World Meet­ing on Sex­ual Medicine found that 77 per­cent of Vi­a­gra sold on­line was fake. Coun­ter­feit Vi­a­gra and sim­i­lar im­pos­tors have been linked to liver dam­age, strokes, and death. Just a few years back, for­mer Los An­ge­les Lak­ers star La­mar Odom ended up face-planted in a Ne­vada brothel from coke and phony herbal fuck­le­ments. “He was tak­ing herbal Vi­a­gra,” brothel owner Den­nis Hof said at the time, “and a lot of it.” The avail­abil­ity of generic silde­nafil cuts the price of the pills in half and prom­ises greater as­sur­ance that the pill you pop won’t be your last.

But while Vi­a­gra is poised to go wider than ever be­fore, the inside story of its launch is not widely known. How did a group of odd­ball un­der­dogs in Amer­ica’s most con­ser­va­tive phar­ma­ceu­ti­cal con­glom­er­ate, Pfizer, bring it into ex­is­tence? At the time, the idea of sell­ing Vi­a­gra was con­sid­ered crazy at best and im­moral at worst.

In fact, it’s a mir­a­cle that it ever came to be at all. In ad­di­tion to the peo­ple within Pfizer who were in an up­roar over the “dick pill,” four ma­jor groups be­gan ral­ly­ing against it be­fore its launch: the Catholic church (which thought it was im­moral), med­i­cal ex­perts (who in­sisted pa­tients would be too em­bar­rassed to ask for the pill), busi­ness ex­ecs (who thought it would make Pfizer a laugh­ing­stock), and leg­is­la­tors (who lob­bied against the pill for the same rea­son as the church).

It was the job of two un­likely guys at Pfizer to over­come them all: Rooney Nel­son, a young Ja­maican mar­ket­ing whiz, and Sal “Dr. Sal” Gior­gianni, a crusty Ital­ian phar­ma­cist from Queens who be­came Vi­a­gra’s med­i­cal ex­pert. To­gether, Nel­son and Dr. Sal be­came the dy­namic duo of erec­tile dys­func­tion, woo­ing an­gry re­li­gious lead­ers, skit­tish politi- cians, and cyn­i­cal pharma nerds from all over.

Against all odds, they suc­ceeded, mak­ing Vi­a­gra one of the most suc­cess­ful and em­u­lated launches of all time, and the ba­sis for to­day’s Us­d3b-erec­tile-dys­func­tion in­dus­try. Now, on the drug’s twen­ti­eth birth­day, they’re shar­ing their story for the first time.

When Rooney Nel­son ar­rived for his first day of work at Pfizer’s cor­po­rate of­fice in New York City af­ter com­plet­ing his MBA at Florida A&M, he thought it was any­thing but cool. Com­pared with Ja­maica, where he was born and raised, it seemed like an “ex­ceed­ingly con­ser­va­tive” com­pany, filled with thou­sands of somber em­ploy­ees, many of whom wouldn’t leave their desks without first putting on a suit coat. “It was not a hip kind of place,” he says with a laugh.

Pfizer had been around since 1849 and had made its name as the chief pro­ducer of peni­cillin dur­ing World War II. In re­cent years, how­ever, it had fallen be­hind larger phar­mas such as Merck and John­son & John­son. It was look­ing for a break. It came, as breaks of­ten do, when least ex­pected. Sci­en­tists at Pfizer’s lab in the small coastal town of Sand­wich, Eng­land, had made a strange dis­cov­ery while test­ing a drug that treated chest pain by ex­pand­ing blood ves­sels. When given the drug three times a day, vol­un­teers were re­port­ing mus­cle aches, headaches, and some dis­com­fort while swal­low­ing. Oh, and, as one in­ves­ti­ga­tor re­layed to Ian Oster­loh, the clin­i­cal re­searcher head­ing the study for Pfizer in 1991, some were get­ting hard-ons, too.

Treat­ing erec­tile dys­func­tion had long been con­sid­ered an ex­otic hack in­volv­ing pe­nile in­jec­tions and pumps. While Oster­loh was in­trigued by the re­port of in­creased erec­tions among the chest-pain-med­i­ca­tion vol­un­teers, it didn’t muster much of a re­ac­tion. Im­po­tence wasn’t ac­knowl­edged as a clin­i­cal prob­lem, he says, and if so, it was thought to be psy­cho­log­i­cal, not some­thing that could be fixed with a pill. “No­body at that time re­ally thought, Gosh, this is fan­tas­tic,” he re­calls.

But Oster­loh was among those who thought it mer­ited more study. He can still re­mem­ber his feel­ing of help­less­ness as a ju­nior doc­tor at the UK Na­tional Health Ser­vice when a forty-year-old man asked if he could be treated for im­po­tence. Oster­loh had gone to his boss to in­quire, only to be

“Some med­i­cal group felt that maybe we shouldn’t be mar­ket­ing such triv­ial medicine,” Dr. Sal says. “but as the old joke goes, it’s only triv­ial if you don’t have the prob­lem.”

told there was noth­ing they could do.

Pfizer agreed to what he calls a “low pri­or­ity” pi­lot study for twelve men to see if th­ese up­ris­ings were just an anom­aly. But when the sub­jects also ex­pe­ri­enced erec­tions, Oster­loh and the oth­ers re­al­ized that they had more than a cure for chest pains on their hands. They seemed to have stum­bled on a pill that could give guys erec­tions.

David Brink­ley, the head of Pfizer’s new product-plan­ning group, was en­ticed enough by the dis­cov­ery to see if it had the po­ten­tial to go to mar­ket. Gay and pro­gres­sive with a flair for mar­ket­ing, Brink­ley, like Nel­son, felt he was an out­lier within the staid com­pany. And it didn’t take long af­ter he be­gan dis­cussing the drug in-house to find that many didn’t share his opin­ion. “To have con­ver­sa­tions about sex­ual-func­tion drugs was dif­fi­cult for a lot of peo­ple,” Brink­ley says. “It was not con­sid­ered dig­ni­fied medicine.” The man­age­ment told him that it was not in the busi­ness of mar­ket­ing side ef­fects—erec­tions or oth­er­wise.

But af­ter enough vol­un­teers re­ported get­ting erec­tions from the drug, there was no doubt about it any­more: This was no side ef­fect; this was a di­rect re­sult. In 1996, Pfizer gave Brink­ley the green light to bring this pill to the pub­lic. It was named Vi­a­gra, a mean­ing­less word cho­sen, if any­thing, be­cause drugs that started with the let­ter V were con­sid­ered pow­er­ful-sound­ing.

Vi­a­gra would only work, Brink­ley knew, if he could over­come the big­gest—and for Pfizer, the riski­est—chal­lenge of all: be­ing taken se­ri­ously. It wasn’t just the out­side world that pre­sented a prob­lem; it was the vi­a­bil­ity within the com­pany it­self. When Nel­son first heard from Brink­ley about the “dick pill,” as they called it, he had the same re­ac­tion as just about ev­ery­one else there: He cracked up. “The early con­ver­sa­tion,” he re­calls, “was laugh­ter.”

If Vi­a­gra was go­ing to be­come any­thing but a punch line, Brink­ley needed a launch team with the right mix of brash and style to han­dle it. And Pfizer had just the odd cou­ple for the job: Rooney Nel­son and Dr. Sal. “Have you ever seen that Arnold Sch­warzeneg­ger movie Twins?” Nel­son says with a laugh. “We were Twins. He’s sort of a short, chubby, Ital­ian, gre­gar­i­ous guy, and I’m this kind of tall, black, not-that-friendly guy that’s all about busi­ness.”

Nel­son, an up-and-com­ing mar­keter at Pfizer, not only had the right edge to launch Vi­a­gra; he also had the per­fect con­nec­tions. He’d spent the past cou­ple years work­ing on Car­dura, a treat­ment for the symp­toms of en­larged prostates, and had cul­ti­vated re­la­tion­ships with urol­o­gists around the coun­try, the ex­act group they needed to en­dorse and, ul­ti­mately, pre­scribe Vi­a­gra. It would be his job to con­vince them.

Dr. Sal was the ideal com­ple­ment to Nel­son. A wry mid­dle-aged clin­i­cal phar­ma­cist with five kids and two de­grees from Columbia, he was Pfizer’s di­rec­tor of ex­ter­nal re­la­tions, the med­i­cal ex­pert re­spon­si­ble for man­ag­ing the com­pany’s im­age and rep­u­ta­tion—two things that Vi­a­gra, more than any other drug he’d en­coun­tered in his eigh­teen years there, put at risk. “Pfizer then was

still a very, very con­ser­va­tive com­pany with very con­ser­va­tive roots,” he says, “and we were about to go off and sell a drug that was for sex.” With Dr. Sal’s med­i­cal ex­per­tise and Nel­son’s mar­ket­ing flair, it would be up to the two of them to sell the sex drug to the world.

What the hell is this? I don’t know what it’s do­ing to my brain.” The feed­back from the men in the early Vi­a­gra fo­cus groups went along th­ese lines. “They were hor­ri­fied,” as Nel­son puts it. “The first re­ac­tions were ‘You’re kid­ding, right?’ You know: ‘Where’s the cam­era? I’m on Can­did Cam­era.’ ”

The vol­un­teers in the clin­i­cal tri­als were also skep­ti­cal. Nel­son and Dr. Sal sat ea­gerly in a urol­o­gist’s of­fice one day as ten pa­tients anx­iously filed in. But the goal wasn’t just to make money. There was some­thing deeper that both of them rec­og­nized. Im­po­tence was a real prob­lem, one that, by be­ing over­looked, was con­demn­ing gen­er­a­tions, in­clud­ing the le­gions of baby boomers, to lives of frus­tra­tion.

The men had vol­un­teered to be part of one of Vi­a­gra’s early clin­i­cal tri­als, a first step to­ward bring­ing it to mar­ket. It was a dou­ble-blind, placebo-con­trolled, ran­dom­ized trial, which meant nei­ther the physi­cian nor the pa­tient knew who’d be get­ting a placebo. Af­ter tak­ing the drug, the pa­tient re­ceived what was called “vis­ual sex­ual stim­u­la­tion.” The VSS of choice: Deb­bie Does Dal­las. “I’d like you to watch it,” Nel­son would tell the pa­tient, “and I want to see if you get an erec­tion or not. If you get an erec­tion, there’s no cam­eras or any­thing, just so you know. If you have an erec­tion, you know, feel free to mas­tur­bate. Here’s a vial. When you’re done, could you put the ejac­u­late, the se­men, in that vial, close it up, and come back out?”

To de­ter­mine what, if any, im­pact Vi­a­gra had on ejac­u­la­tion, the team had to mea­sure the amount and con­sis­tency of the se­men. It was still so new that they had no idea what might hap­pen. “You don’t know what this drug is do­ing,” Nel­son says. What it was do­ing was some­thing they’d never an­tic­i­pated. Some pa­tients re­ported that they were hav­ing blue-tinted vi­sion, a con­di­tion known as cyanop­sia. It turned out that one of the en­zymes re­stricted by Vi­a­gra in or­der to cre­ate an erec­tion caused sen­si­tiv­ity in some rod cells in the eye, caus­ing some sub­jects to tem­po­rar­ily pick up more strands of blue light. A more last­ing symp­tom pre­sented in the vol­un­teers who re­ported not just erec­tions but four-hour ones—a tem­po­rary side ef­fect that many pa­tients didn’t mind. “Most peo­ple thought it was kind of cool,” Nel­son says.

With the tri­als show­ing pos­i­tive re­sults, they had to find the right al­lies to get be­hind Vi­a­gra. In phar­ma­ceu­ti­cal mar­ket­ing, just like in any other cul­ture or in­dus­try, there are the whales, the big shots whose vote of con­fi­dence is es­sen­tial to a new product’s suc­cess. The group con­sisted of the high-pow­ered, high-priced med­i­cal prac­ti­tion­ers: the heart sur­geons, neu­ro­sur­geons, and the like. At this time, the 1990s, pharma com­pa­nies had their own kind of le­git­imized pay­ola—spend­ing mil­lions to wine and dine doc­tors into en­dors­ing their meds.

To sell an erec­tion drug, how­ever, meant sway­ing the doc­tors who were way lower down the peck­ing or­der: the urol­o­gists. Com­pared with brain sur­geons and car­di­ol­o­gists, urol­o­gists were the Dun­der Mif­flin of the pharma world: nerdy, un­sexy, and un­ac­cus­tomed to the warm fuzz of mar­ket­ing crews. But that was about to change.

The mid-nineties were the hey­day for phar­ma­ceu­ti­cal jun­kets, but Vi­a­gra marked the first time that unglam­orous urol­o­gists were the ones be­ing se­duced. Pfizer would fly a dozen of them to an all-ex­penses-paid week­end at the

Break­ers in Palm Beach, Florida, and give them $2,500 each for their time. Pfizer could eas­ily spend $200,000 per trip to en­tice them. “Urol­o­gists, they had never re­ally been to places like that; they had never eaten like that; they had never drank like that,” Nel­son says. “So you had a re­ally primed group that was re­cep­tive to hear­ing your mes­sage.”

Over dirty mar­ti­nis and lol­lipop lamb chops, Nel­son would look out into the room and won­der how he was go­ing to en­er­gize them. He pitched them on how he was go­ing to make them as cool and de­sir­able as open-heart sur­geons. “This is an op­por­tu­nity for you to be at the cut­ting edge of what could be the most rev­o­lu­tion­ary product in a long time in medicine,” he said. But there was one prob­lem, they quickly told him: They never talked about sex with their pa­tients. There was no rea­son to dis­cuss im­po­tence, be­cause they had no rem­edy. “No physi­cian asks about things that they can’t treat,” as Nel­son puts it. “It was a wall of si­lence.”

The only way to suc­ceed was to break the wall. He and the team de­vel­oped what Dr. Sal called a se­ries of “door­knob con­ver­sa­tions,” named af­ter that mo­ment when men, of­ten on the way out of the doc­tor’s of­fice, would fi­nally find the courage to ask about a cure for im­po­tence. Their so­lu­tion: Be straight with them. “Why don’t we just make this real sim­ple and say, ‘If they think they have it, give them the medicine, tell them how to take it, set re­al­is­tic ex­pec­ta­tions, and let them go for it,’ ” Dr. Sal says the con­ver­sa­tion went. “And it’s ei­ther go­ing to work or it’s not go­ing to work.”

But while Dr. Sal and Nel­son were mak­ing head­way with urol­o­gists, they were en­coun­ter­ing mount­ing skep­ti­cism within Pfizer. “Some med­i­cal groups felt that maybe we shouldn’t be mar­ket­ing such triv­ial medicine,” Dr. Sal says. “But as

the old joke goes, it’s only triv­ial if you don’t have the prob­lem.”

Part of the is­sue, they re­al­ized, was se­man­tics. No guy wanted to tell his doc­tor he was im­po­tent. The word had too many neg­a­tive over­tones: weak­ness, help­less­ness, steril­ity. “In the early days,” says Brink­ley, “just talk­ing about im­po­tence was taboo. You couldn’t even say the word pe­nis.” They needed to come up with some­thing bet­ter than im­po­tence. Vi­a­gra’s med­i­cal team came back with just the fix: erec­tile dys­func­tion. It was per­fect, they thought. “Im­po­tence makes you feel like you did it to your­self,” as Nel­son puts it. “Erec­tile dys­func­tion feels like it’s hap­pen­ing to you.”

This is blas­phemy! This is im­moral!” Nel­son and Dr. Sal lis­tened pa­tiently inside a con­fer­ence room at the Helm­s­ley ho­tel, over­look­ing Cen­tral Park, as an­other re­li­gious ad­vo­cate told them what Pfizer could ex­pect if Vi­a­gra ever got re­leased. They’d as­sem­bled a roundtable of dea­cons, pas­tors, rab­bis, and oth­ers to gauge their re­ac­tions to the boner pill. It was part of their due dili­gence for this un­charted ter­ri­tory, an im­por­tant lit­mus test for what kind of re­sis­tance they’d meet by re­leas­ing the drug.

“There was con­cern that there might be re­li­gious ob­jec­tion,” says Brink­ley, who’d had feel­ers out all the way up to the Vat­i­can for a re­sponse. At this roundtable, it was al­ready go­ing south. “Why would you even do this?” one cler­gy­man asked in dis­may. “If that type of product ever comes on the mar­ket, I will or­ga­nize protests against it.”

It seemed like a very real pos­si­bil­ity that the launch could trig­ger a kind of “sex panic,” Brink­ley says, from the moral ma­jor­ity. “They don’t want in­sur­ance or tax dol­lars pay­ing for peo­ple’s bon­ers.” It seemed they were also pre­pared to sen­sa­tion­al­ize Vi­a­gra, al­leg­ing that it would give men erec­tions and also drive them to sex-crazed sprees that would spread AIDS. “As a gay man,” Brink­ley says, “there was a fair amount of eye rolling that went on be­hind closed doors.”

They were also get­ting flak from inside. As word spread through­out Pfizer, Nel­son and Dr. Sal be­gan hear­ing more and more jokes and deri­sive com­ments from co­work­ers they passed in the halls. “We’re go­ing to be a laugh­ing­stock,” one per­son would say. “Are we go­ing to have Play­boy Bun­nies in the lobby?” joked an­other. Oth­ers were more pointed. “Are you guys crazy?” they’d ask. In Nel­son’s es­ti­ma­tion, the cards were stack­ing against them. “Fifty per­cent of the peo­ple within the com­pany that knew what was go­ing on thought it would never launch and never should launch,” he says.

Nor­mally, when launch­ing a new drug, a com­pany would take pains to me­thod­i­cally in­tro­duce it to the world in ad­vance, prep­ping the mar­ket, do­ing press, and so on. But Vi­a­gra was too volatile to leave vul­ner­a­ble to th­ese el­e­ments. So the team made a coun­ter­in­tu­itive—if not seem­ingly hare­brained— decision: They would launch com­pletely in stealth, go­ing pub­lic with it only twenty-four hours later if and when it was ap­proved. “I had an epiphany, a eu­reka mo­ment,” Nel­son says. “The less we talk about this, even in­ter­nally, the bet­ter we are.”

Dis­creetly, the team refined this strat­egy in thou­sands of fo­cus groups. They nar­rowed it down to three pos­si­ble ways—or “product pro­files”—to present Vi­a­gra to the world. The first op­tion was the most di­rect: It’s a drug that can cause erec­tions and en­able men who have lost their abil­ity to have sex. The sec­ond was more sci­en­tific: Vi­a­gra can treat a dis­ease called erec­tile dys­func­tion and al­low men to re­turn to nor­mal phys­i­o­log­i­cal ca­pac­ity. The third took a dif­fer­ent ap­proach com­pletely, skirt­ing the de­tails of the drug and fo­cus­ing in­stead on its de­liv­ery sys­tem: For the first time, there’s a pill that can be used to treat a con­di­tion that has al­ways been treated by in­va­sive surg­eries.

Af­ter thou­sands of fo­cus groups, they ar­rived at the an­swer: op­tion num­ber three. Vi­a­gra is a pill—safe, cheap, and easy. A guy would merely get a sam­ple, pop it into his mouth, and see how it worked. This was the per­fect way to get men to look at the drug. As Nel­son puts it, “I’ll try it! And if it doesn’t work, who gives a fuck?”

The strat­egy suc­ceeded. In the later fo­cus groups, the pill hit big. By Fe­bru­ary 1998, Pfizer was ready to launch the drug. But there was one im­por­tant hur­dle re­main­ing: ap­proval by the Food and Drug Ad­min­is­tra­tion. Pfizer had spent nearly $100M on Vi­a­gra up to that point, and there was no guar­an­tee that the world’s first erec­tion pill wouldn’t go limp.

On March 27, 1998, Nel­son, Dr. Sal, Brink­ley, and the dozen oth­ers on Vi­a­gra’s core team gath­ered around a fax ma­chine in a con­fer­ence room in Pfizer’s New York head­quar­ters. They were await­ing a mes­sage from the FDA re­gard­ing whether their eigh­teen months of ef­forts had fi­nally paid off. Shortly be­fore noon, the an­swer spooled out. A lawyer ran her eyes over the page and read it aloud: “The FDA has ap­proved silde­nafil cit­rate for the use of erec­tile dys­func­tion in men.”

Nel­son shouted, “Oh my God! Fuck me! Yeah!” He fell on the floor in relief, joined by the oth­ers. But they couldn’t cel­e­brate for long. The FDA ap­proval meant it was time to launch a drug that still had yet to be an­nounced to the world.

Right on the heels of the ap­proval, there was a more press­ing mat­ter: the side ef­fects re­quired to be listed on the la­bel. The reg­u­la­tory board had hit them with a black-box warn­ing about tak­ing Vi­a­gra with ni­trates—a com­bi­na­tion that could re­sult in a heart at­tack. Most com­pa­nies would try to bury the black box as much as pos­si­ble. But Brink­ley sur­prised his team. He told the group to lead with it. “We’re go­ing to en­cour­age peo­ple that if you’re on a ni­trate, do not take Vi­a­gra,” he said. “That’s go­ing to be the first thing we’re go­ing to say.”

Nel­son thought Brink­ley was “bat­shit crazy.” There was no prece­dent for such a ma­neu­ver. But Brink­ley, Nel­son re­calls, held firm. “Rooney,” he said, “you have to trust me on this.” His rea­son­ing was that Vi­a­gra was go­ing to be such a hit that they didn’t need to risk hid­ing any­thing about it, even if it meant equat­ing sex with death.

With ev­ery­thing ready to go, the team booked a massive launch meet­ing at the World Cen­ter Mar­riott in Or­lando, Florida, to in­tro­duce Vi­a­gra to Pfizer’s three thou­sand sales rep­re­sen­ta­tives. The av­er­age sales rep was a good-look­ing twenty-five-year-old—“the guy looked like a quar­ter­back, and the girl looked like freak­ing Candy the cheer­leader,” Nel­son says—but that didn’t make the chal­lenge any eas­ier. “We needed to make them com­fort­able with talk­ing about sex,” he says. They did this by get­ting ev­ery­one used to say­ing all the right words. They went around the room and had ev­ery­body say erec­tion five times. “Erec­tion! Erec­tion! Erec­tion! Erec­tion! Erec­tion!”

They had to get the gen­eral pub­lic talk­ing, too. They needed some­one who could de­liver the mes­sage soberly and cred­i­bly. Dur­ing the clin­i­cal tri­als, they learned from a urol­o­gist at Wal­ter Reed that for­mer se­na­tor and pres­i­den­tial can­di­date Bob Dole was in­ter­ested in par­tic­i­pat­ing. Dole had been par­tially par­a­lyzed dur­ing World War II and was him­self suf­fer­ing from erec­tile dys­func­tion. Af­ter try­ing Vi­a­gra suc­cess­fully, he was more than ready to speak out on be­half of the drug to help oth­ers. It was just what the team needed. “The im­por­tant thing was to nor­mal­ize the med­i­cal con­di­tion,” Brink­ley says, and Dole proved to be the ideal mes­sen­ger.

When Vi­a­gra fi­nally hit the mar­ket, for eight to twelve dol­lars a pill, it was an in­stant phe­nom­e­non. As ex­pected, it also be­came the butt of late-nighttalk-show jokes and pro­voked the ire of the moral ma­jor­ity. But it sold wildly. Phar­ma­cists re­ported fill­ing ten thou­sand pre­scrip­tions a day, which eas­ily out­paced scripts for the launches of top drugs such as Prozac and Ro­gaine. Vi­a­gra sales would reach $1B in its first year. “It’s the fastest take­off of a new drug that I’ve ever seen,” Michael Podgurski, then the di­rec­tor of phar­macy for Rite-aid, gushed to Time. Newsweek called it “the hottest new drug in his­tory.”

For the team be­hind the scenes who launched Vi­a­gra, the suc­cess gave them a deeper sat­is­fac­tion, too. Dr. Sal was eat­ing at a steak­house in Mon­roe, Louisiana, with his wife when he over­heard some men at a nearby ta­ble talk­ing about erec­tile dys­func­tion. It filled him with pride. “My God,” he said. “We’ve ac­com­plished one of our goals, which is to talk about this as a real med­i­cal prob­lem, not as a sex­u­ally dirty kind of thing, and take away some of the stigma as­so­ci­ated with older per­sons hav­ing in­ti­macy.”

Nel­son learned four rules for launch­ing some­thing that’s never been done be­fore. “Num­ber one, ex­pect to be laughed at if you’re do­ing some­thing that’s go­ing to be a break­through,” he says. “Num­ber two, be real wary of ex­perts; they’re go­ing to tell you all the rea­sons why that thing’s not go­ing to work. The third thing: Have peo­ple on the team who re­ally un­der­stand the busi­ness you’re in.” And, fi­nally, he says, be pre­pared to be hated. “If you ex­pect to change the world, you’re go­ing to get a lot of love, but you’re go­ing to get a lot of hate. You got to run the math. The hate’s prob­a­bly go­ing to be a frac­tion of the love.”

And as Dr. Sal learned, there was plenty of love to go around. Not long af­ter Vi­a­gra came out, his fa­ther asked him if he could hook him up. “Hey, can you get me some sam­ples?” his dad asked. “Ab­so­lutely not!” his mother replied sar­don­ically. “Don’t even think about it, Sal.”

To­day, twenty years af­ter Vi­a­gra’s launch, it’s never been eas­ier to get the lit­tle blue pill. Pfizer just re­leased its non­pre­scrip­tion ver­sion, dubbed Vi­a­gra Con­nect, in Bri­tain, the first coun­try to ap­prove over­the-counter sales of Vi­a­gra.

Though the patent on Vi­a­gra doesn’t ex­pire un­til 2020, Pfizer ne­go­ti­ated a deal that al­lowed Teva Phar­ma­ceu­ti­cals to be­gin sell­ing a generic ver­sion last De­cem­ber. Not only is the pill con­sid­er­ably less ex­pen­sive; it’s now all the more ac­ces­si­ble. Ro­man, a new start-up, is an app that screens men for erec­tile dys­func­tion and gets a pre­scrip­tion de­liv­ered right to their door.

While Vi­a­gra is go­ing main­stream like never be­fore, there’s more op­por­tu­nity on the hori­zon for treat­ing other such mal­adies. “There are still a lot of sex­ual dys­func­tions where we don’t have treat­ment,” Oster­loh says, “such as lack of sex­ual de­sire in men and women.” An es­ti­mated twelve mil­lion women suf­fer from sex­ual de­sire dis­or­der. The lead­ing con­tender for treat­ment is breme­lan­otide, which is be­ing de­vel­oped by AMAG Phar­ma­ceu­ti­cals and Palatin Tech­nolo­gies. They have com­pleted suc­cess­ful tri­als and hope to have it avail­able by 2019.

When asked what’s com­ing next for men, Nel­son, who has since left Pfizer to run his own mar­ket­ing firm, cracks a devil­ish grin. “You re­ally want the dark-web ver­sion of this?” he asks. The fu­ture, he goes on, will fea­ture ar­ti­fi­cially in­tel­li­gent sexbots and drugs that will en­hance the ex­pe­ri­ence fur­ther. “There’s go­ing to be a pill that in­creases not only erec­tions but plea­sure,” Nel­son says. “That’s go­ing to be the co­caine of sex. It’s the ul­ti­mate pill.”

Left: The very first Vi­a­gra print ad. It ap­peared in Esquire US in Au­gust 1998. Above: Bob Dole’s erec­tile dys­func­tion-aware­ness cam­paign.

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