Most industries have moved toward the realization that the most profitable resource to be extracted even from poor countries is not raw materials or labor, but the readiness to consume. To capitalize on this potential, firms take two allied approaches. First, they seek to influence exchange environments (distribution channels, treatment guidelines, reimbursement policies) to enhance the flow and profitability of their drugs. Second, they invest in doctor and consumer awareness campaigns, referred to as “education,” to stimulate demand directly. Here I’ll point out a few features of demand stimulation in pharmaceuticals.
Medicines were traditionally thought to be “inelastic goods”, meaning that promotion (or lowering prices) wouldn’t lead to an appreciable expansion of consumption. No one who doesn’t have high blood pressure, for instance, will start taking antihypertensive medicine because of a billboard advertisement, nor will people who already take it increase their dosage. Doctors prescribe these drugs to patients who require it, and we assume that doctors are informed by scientific studies, not advertisements.
Regrettably, this is often not true. Each link on the entire medical information chain—from research funding, to scientific journal publications, to FDA approval, to public health therapy guidelines, to product labeling, to the scientific programming at medical conferences, to medical education in medical schools and in the clinic—is the focus of concerted persuasion campaigns. If this sounds improbable, consider such representative datum as that there is a full-time drug rep for every seven doctors in the US or that the marketing budget for Pfizer’s Lipitor in 2002 alone was $1.3 billion—roughly the equivalent of the National Institute of Health (NIH) budget for research into Alzheimer’s disease, arthritis, autism, epilepsy, influenza, multiple sclerosis, sickle cell disease, and spinal chord injury combined.
Drug reps and advertisements are only the proverbial tip of the iceberg. The money spent to hire prominent academic doctors (“key opinion leaders”) to publicize the results of corporate-ghostwritten research at medical schools and in sponsored “satellite symposia” at professional conferences may, at 20% of pharmaceutical marketing costs, take up the largest share. By comparison, 14% is spent on advertising. Some areas of medicine, such as psychiatry, have proven more vulnerable to marketing encroachment than others, but all of medicine has been deeply affected.
What this all means is that, unbeknownst to most of us, physicians rather than laypeople are the principal targets of pharmaceutical propaganda. The average physician has neither the training nor the time to evaluate the merits (much less the veracity) of scientific researches and the claims of key opinion leaders. The industry exploits this ignorance to our collective detriment. In the meantime, the practice persists partly because most doctors refuse to entertain the possibility that they are not masters of their own field of knowledge and practice.
Without necessarily understanding all the ways in which private interests (including those of HMOs and insurance companies) impact medicine in the US, the public has lost much trust in doctors. Many polls show this trend. Ironically, this presents an opportunity for the drug industry to develop a direct relationship with consumers, who increasingly turn to sources other than their doctors for information about their health. But if doctors can’t tell the difference between advertisements and bona fide science, how can the rest of us?
In other parts of the world, the dismantling of public health services in favor of a dependency on pharmaceutical solutions achieves the same result: a shift in the information source away from experts and into the waiting arms of pharmaceutical sales agents. Drug companies devote untold resources to shaping the information you see on the internet when you search for symptoms or the name of a medical condition on Google. Wikipedia is a favorite site of pharmaceutical company manipulation. The result is that many patients visit their physicians with a request for specific medicines and diagnostic tests already on their lips. At risk of estranging these patients, who in a privatized medical world are valued customers, even reluctant physicians acquiesce.
Aiding the trend towards self-diagnosis and medication is the prevalence of drugs developed to treat invisible disorders (i.e., those for which we have no symptoms) such as hypercholesterolemia or “pre-diabetes”, producing what Jeremy Greene describes in his book Prescribing by Numbers as “the modern predicament of the subjectively healthy but highly medicated individual” (2007:viii).
Greene is not suggesting that the drugs and the risks they are used to manage are fictitious. However, the continued expansion of their use depends on the ability of pharmaceutical companies to set the threshold for what is considered risk of disease. Should 140/90 be diagnosed as hypertension, or 130/80? The difference may appear negligible as regards a given individual, but for the pharmaceutical industry the difference is worth many billions of dollars. As Greene puts it, “The diagnostic process is now as much a negotiation between the pharmaceutical industry and guideline-setting committees as it is a negotiation between doctor and patient” (2007:219).
The industry, in short, builds its expansion platform on partial truths that are then packaged and promoted to doctors and the public as whole truths. Ray Moynihan, Alan Cassels and others have called this practice “disease mongering,” described as:
“…the effort by pharmaceutical companies (or others with similar financial interests) to enlarge the market for a treatment by convincing people that they are sick and need medical intervention. Typically, the disease is vague, with nonspecific symptoms spanning a broad spectrum of severity—from everyday experiences many people would not even call “symptoms,” to profound suffering. The market for treatment gets enlarged in two ways: by narrowing the definition of health so normal experiences get labeled as pathologic, and by expanding the definition of disease to include earlier, milder, and presymptomatic forms (e.g., regarding a risk factor such as high cholesterol as a disease in itself)” (Woloshin and Schwartz 2006).
Medical anthropologists generally use the expression “medicalization” to describe when previously non-medical phenomena come to be classified in terms of disorders or potential disorders, and thereby come under the purview of medical treatment. Disease mongering points up the strategic side of medicalization. If we liken strategic medicalization to commoditization (or commodification) in Marxist economic terms, we will begin to perceive the managerial conditions, motivations, and practices that exert the greatest force over healthcare today.
Much more can be said about how medical scientific and clinical values are converted into commercial value, since this is not a simple translation. I leave this to a future post.
I conclude with the speculation that for the bridge between marketing efficiencies, consumer perceptions and motivations for purchase to be completed, the abstract realm of symbolic production must be linked to powerful, expandable emotions. Fear and its antidote—risk reduction behavior—has proven an ideal marketing vehicle because it permits the conversion of seemingly healthy, symptomless people into sick ones, in need of medication and constant measurement. Risk management has come to stand in for prevention, though the two are not the same. Both the risk management and lifestyle models of pharmaceutical use call for long-term therapy. This is the basis for blockbuster drugs, which have successfully competed against the pursuit of cures and strategies of prevention.
Greene, Jeremy. Prescribing by Numbers: Drugs and the Definition of Disease. Johns Hopkins University Press, 2007.
Moynihan Ray and Alan Cassels. Selling Sickness. How the world’s biggest pharmaceutical companies are turning us all into patients. New York: Nation Books, 2005.
Woloshin, Steven and Lisa M. Schwartz. “Giving Legs to Restless Legs: A Case Study of How the Media Helps Make People Sick” PLoS Medicine 3(4): e170 (2006). Available at: doi:10.1371/journal.pmed.0030170
- The Colonization of Pharmaceutical Science by Marketing
- Pharmaceutical Marketing, Capitalism, and Medicine: A Primer (Part I/III)
- Pharmaceutical Marketing, Capitalism, and Medicine: A Primer (Part III/III)
- Cases for Overhauling Pharmaceutical Governance
- Warning Label Spin: Further Reflections on What the FDA is Up Against