May 2012, Volume 14, Number 5
Edited by Jim Hightower and Phillip Frazer
Sales over science, profit over people, greed over need
The great American medicine show, a spectacle of deceit, manipulation, and flimflammery
Butterflies waft across a beautiful field of spring flowers. A delightful young family bicycles joyously down a country lane. A couple on a park bench leans sensually into each other. A 40-something woman's face radiates with both perfect beauty and internal happiness. "All's right with the world," is the message... as long as you've taken your dosages of Lunesta, Celebrex, Cialis, and Botox.
Welcome to medicated America, where the fix for every problem--from incontinence to erectile dysfunction, stiff joints to mood swings, weight gain to wrinkles-- is just a prescription away. Thus the beautiful images, stirring music, attractive actors, and soothing words in the omnipresent, multibillion-dollar kaleidoscope of drug advertising by Pfizer, Merck, Eli Lilly, Johnson & Johnson, and other giants of Big Pharma--all pitching their particular brand-name nostrum directly at us hoi polloi (the industry spends a fourth of its income on ads and other promotions, nearly double its expenditures on research and development). The corporate come-ons typically conclude with a phrase that has achieved cliche status in America's vernacular: "Ask your doctor if 'Suprema Wundercure' is right for you."
The better question, though, is one that cartoonist Dan Piraro expressed in one of his "Bizarro" panels: "Ask your doctor if playing into the hands of the pharmaceutical industry is right for you."
One would assume that in a rich, medically advanced, health-conscious nation like ours, dicey decisions about whether to allow a particular pharmaceutical product into our bodies would be among the most rational we make--as determined by (1) the best science available, (2) the strict moral duty of medical purveyors to "First, do no harm," (3) good government regulation, and (4) the profession's fear of public reproach and legal punishment. One would, however, be wrong on all counts:
- Science has been supplanted by rank hucksterism
- The strictest "moral duty" of corporate executives has been reduced to maximizing profits
- A "good" regulation is one that's good for profit seekers
- Public reproach is just a momentary embarrassment to be covered over by corporate image makers
- Legal "punishment" never includes jail time, but only a fine that's easily absorbed as a necessary cost of doing business by these immensely profitable entities.
In the past three decades, America's healthcare system has radically metamorphosed from a public service network (largely run by independent physicians and nonprofit hospitals) into a corporate profit machine--one that Dr. Arnold Relman, the renowned former editor of the New England Journal of Medicine, calls the Medical-Industrial Complex. Drugmakers have been among the most ambitious, in-your-face pushers of this transmutation of medicine into just another commodity to be sold by hook or crook. In this system, the concept of "care" has been reduced to "caveat emptor," with the shareholders' interest in monetary gain overriding all other interests.
The DTC contagion
A fast-moving, systemic epidemic called DTC has swept across America, endangering public health, jacking up our costs, and weakening the curative connection between health professionals and patients. DTC stands for "Direct-to-Consumer" drug advertising. It's a plague of marketing, empowering profiteering corporations to short-circuit the judgment of doctors by using all of the tricks of Madison Avenue (including lies) to convince viewers and readers that (first) they're suffering from a particular malady, (second) the advertiser's brand-name medicine is the very best cure, and (finally) they must go to their doctors pronto to insist on getting a prescription for that specific drug. The essence of this marketing scheme is to turn consumers into sales representatives for drug peddlers. Brilliant.
Prescribing medicine through the television, radio, print, and internet ads of corporations (whose sole motive is to sell more pills) is so crass, so awash in conflicts of interest, and so inherently dangerous that only two countries have ever legalized it: New Zealand in 1981 and the USA in 1997.
In our country, the corporate-friendly government of Ronald Reagan first okayed DTC drug ads in 1985, but his Food and Drug Administration ruled that pages-long consumer warnings about health risks had to be included, so there were few takers. Then came Bill Clinton's corporate-friendly government, which issued a revised FDA rule in 1997 allowing drugmakers to dodge the full disclosure provision--as long as their ads met an "adequate" standard for informing consumers about risks.
Such squishy words (slipped into regulations by industry lobbyists) are a corporate wet dream. Thanks to the adequacy loophole, fluffy-puffy, no-worries prescription drug ads quickly mushroomed. In 1997, spending on DTC ads was only $220 million; by 2002, it was $2.8 billion; and it has kept a steady pace of roughly $3 billion a year ever since.
A real reform
What if drug marketers had to tell us the details of every under-the-table payment (aka bribes) that they make to doctors? Well, here's good news... [read more]
Corporations don't spend that kind of money to dramatize the severity of their products' nasty side effects. As two ad execs giddily put it in a 1998 report to the industry, "The ultimate goal of DTC advertising is to stimulate consumers to ask their doctors about the advertised drug and then, hopefully, get the prescription." Obviously, to "get the prescription," corporate ads don't stress such unpleasant outcomes as these (taken from the small print of full-page ads for just a half dozen heavily advertised drugs): very high fevers, confusion, uncontrollable bowel movements, trouble swallowing, lower sperm count, prostate cancer, loss of vision, suicidal thoughts... and, of course, death.
Side effects do have to be addressed, but not conspicuously--for example, it's "adequate" for an off-camera announcer to buzz through them with a muted, fast-paced delivery (usually while cartoon butterflies flutter playfully on-screen to distract viewer attention). It's a disgusting, dishonorable way to generate sales--but it works. In 2008, the House Commerce Committee found that every $1,000 spent on drug ads produces 24 new patients, and a 2003 research report found that prescription rates for drugs promoted with DTC ads were nearly seven times greater than those without such promos. Ethics aside, these consumer hustles have proven to be profit bonanzas:
- From 2000 through 2004, Merck & Co. poured more than $500 million into adverts promoting Vioxx, turning the pain pill into one of the "Top 100 Megabrands" listed by Advertising Age. The drug was meant for the relatively few people who can't stomach aspirin, but the PR push touted it to all arthritis patients, a much larger marketing pool. The campaign promised "everyday victories" over pain and immobility, featuring former Olympic skating champ Dorothy Hamill spinning effortlessly (and pain-free) on the ice. Merck's ads sold some 20 million Vioxx prescriptions, including to people who paid the ultimate price for buying the hype--a 2005 research report in The Lancet, the prestigious British medical journal, attributed as many as 140,000 sudden cardiac "events" in America to the use of Vioxx. In September of 2004, Merck took the pill off the market over "safety concerns." As an expert pharmacy consultant told Forbes magazine in 2006, "Vioxx wasn't a bad drug for everyone, it was a bad drug for certain patients. Unfortunately, people saw the ads and started demanding the drug from their doctors." That's the deadly power of mass advertising for drugs.
- Some ads are simply frauds, including one that Pfizer ran on TV until 2006, hailing the prowess of the company's cholesterol-lowering drug, Lipitor. The star of the spot was Robert Jarvik, who was described as the well-known "physician" who was the "inventor" of the artificial heart. In a picturesque outdoorsy setting, he was shown vigorously rowing a boat across a lake--visual "proof" that his own heart was in robust condition thanks to his use of Lipitor. His tagline was: "You don't have to be a doctor to appreciate that." Good, because he doesn't practice medicine, and while he worked on the artificial heart, he did not invent it. Oh, he also wasn't rowing the boat--a double played that role. Embarrassed, Pfizer had to yank the ad--but it continues to merchandize Lipitor with some $250 million a year in commercials, generating about $11 billion a year in sales, more than any other pharmaceutical in history.
- Bear in mind that these pitches are being made to consumers who cannot just go purchase the product--only licensed medical professionals can diagnose and prescribe. But, again, the promotions work, as an industry spokesman happily affirmed: "There's a strong correlation between the amount of money pharmaceutical companies spend on DTC advertising and what drug patients are most often requesting from physicians." He also noted that the trumpeting of brand-name pills "is definitely driving patients to the doctor's office." No surprise, then, that prescription drug use has soared in the past decade, during which spending (by consumers, private health plans, and governments) more than doubled. A 2010 survey by the National Center for Health Statistics not only found that about 35 percent of Americans over 60 take five or more prescription medicines a day (more than twice the intake in 1999), but even 22 percent of children under age 12 are on at least one Rx regimen. "People may be taking too many drugs," deadpanned the NCHS leader. And in recent years, a whole new market has opened up for DTC hucksters: Medical devices. In 2007, Johnson & Johnson launched the first mass-audience TV commercials for highly specialized, complex therapeutic devices. This is beyond odd; it is dangerous. Only expert practitioners have the knowledge and experience to judge whether one brand-name medical gizmo is superior to another. Yet, here was J&J doing a pitch to us clueless consumers for "Cypher," a drug-coated coronary stent for opening closed arteries. I'm all for consumers getting more say in health care, but--come on!--how would I know enough about the efficacy of various stents to instruct my doctor to "Make mine Cyphers"?
The DTD contagion
In addition to getting you and me to push particular products on our doctors, the drug and device industry runs a massive, sophisticated, and relentless "Direct-to-Doctor" sales program that skates on the thinnest ethical ice and frequently plunges all the way into illegality. While these efforts, costing more than $6 billion a year, occasionally pretend to be "educational," they are in fact an elaborate exercise in medical flimflammery--nothing but a door-to-door ploy by each of the major makers to hoodwink your doctor into prescribing their brand-name pill, rather than a competitor's brand or a generic.
To do this, the biggest of Big Pharma deploy an astonishingly large force of "sales reps" all across the country--90,000 of them! That's roughly one for every nine physicians, and they swarm non-stop into doctors' offices--one Virginia physician says his office had to set a quota of three visits in the morning and three visits in the afternoon in order to get any doctoring done. They are highly trained in persuasive arts, motivated to make the sale at all costs, and alarmingly successful (a 2003 Blue Cross survey found that more than half of "high-prescribing" doctors relied on the reps as their main source of information about new drugs).
INTRIGUING QUESTION: What occupational sub-group of Americans are, by far, the most heavily recruited to take jobs as drug reps? You might think pharmacists, marketing consultants, or even used car salesmen. All wrong. THE SURPRISING ANSWER: College cheerleaders.
Hey, the point is to "make the sale," to entice this mostly male profession to switch from A to B. Solid scientific evidence is one thing, but winks apparently work, too--and who's twinklier, prettier, more buffed, peppier, or more gregarious than cheerleaders? The University of Kentucky, which boasts champion-level cheerleading squads, has been one of the premier movers of talent from pompoms to Pharma. A UK "cheering advisor" notes that his perky collegians are naturals for sales rep positions: "Exaggerated motions, exaggerated smiles, exaggerated enthusiasm--they learn those things, and they can get people to do what they want." He says he routinely receives calls from drugmakers seeking to hire his graduates. "They don't ask what the major is," he says.
The demand is so high that an executive of a business that runs cheerleading camps set up a specialized employment firm in 2004 called "Spirited Sales Leaders." Based in Memphis, it funnels hundreds of former cheerleaders into drug sales.
"There's a lot of sizzle" in being a sales rep, he explains, and these experienced sizzle-generators can earn six figures a year, counting bonuses, for pep-talking doctors into writing more prescriptions for their companies' medicines.
Not that these upstanding corporate citizens would stoop to hiring salespeople based on their sex appeal. No, no, explained a top executive of Bristol-Myers Squibb: "[It] has nothing to do with looks, it's the personality."
Sex appeal or not, the essence of the job is manipulation, and reps are highly trained and well armed to ingratiate themselves with each individual on their list of doctor-clients. Adriane Fugh-Berman, a doctor and professor at the Georgetown University Medical Center, is a drug company watchdog who has studied the doctor-sales rep relationship. In a 2007 article, she reported that the salespeople play to a doctor's feeling of being overworked and underappreciated: "Cheerful and charming, bearing food and gifts, drug reps provide respite and sympathy; they appreciate how hard doctors' lives are and seem only to want to ease their burdens. But every word, every courtesy, every gift, and every piece of information provided is carefully crafted, not to assist doctors or patients, but to increase market share for targeted drugs." Here are key elements of the DTD operation:
The file. Each doctor is a mark, and drug reps are trained intelligence gatherers who build and constantly update a computerized corporate file on the doc's personality, preferences, interests, and any personal tidbits that might help them change his or her prescribing habits. The strategic goal of good reps is to become each doctor's trusted "friend"--not unlike the relationship that lobbyists try to cultivate with lawmakers.
The data. How can pill peddlers know which ones your doctor is prescribing--isn't that a private matter? Not in today's bluntly intrusive world of commercial data mining. A majority of pharmacies sell their records of every single prescription written by doctors doing business with them. This vast trove of computerized info is bought by such data hawkers as IMS Health, which procures prescriptions from about 70 percent of US pharmacies. While the names of patients are deleted, the name of the doctor who wrote each prescription is easily discernible, so pharmaceutical giants pay millions a year to buy, slice, and dice the electronic data on exactly which medicines each doctor has ordered and in what quantities. This is regularly fed to the laptops, iPads, and even smartphones of the sales reps on the ground--allowing them to target their daily pitches, and to precisely and carefully track the slightest of changes in a doctor's prescribing habits.
The gift. Reps don't go to a physician's office empty-handed. Gourmet donuts and lunch treats for the entire staff are daily routines, and doctors and key staffers are treated to dinners at fine restaurants, holiday gift baskets, tickets to a game or show, and such nice personal presents as a silk tie or a monogrammed golf bag. A New York Times report in January of this year says that two-thirds of doctors accept such goodies. For the heavy prescribers of a drugmaker's concoctions, the gifts grow ever-larger--a ski trip to Aspen, an invitation to make weekly paid "lunch and learn" presentations in other doctors' offices, an honorarium to make brief comments at a conference in some five-star resort (complete with an "educational grant" to cover the bar tabs and other incidentals), big-buck "consulting" contracts that require practically no work, and outright cash payments for prescribing particular drugs. The Times' January report found "that about a quarter of doctors take cash payments" and "that they are more willing to prescribe drugs in risky and unapproved ways."
The hoax. Few doctors are experts in the chemistry and biological impacts of particular medicines, so they rely on honest studies and tests (as reported in credible medical journals) to give them an un-hyped, non-sales-rep picture of the pluses and minuses of the drugs they choose to prescribe to you and me. Unfortunately, this process, too, has been corrupted--drugmakers have regularly paid doctors and researchers to conduct studies and publish results without revealing their financial ties. Pfizer, however, sank this sales-over-science approach to new lows when it launched its antidepressant, Zoloft, in the 1990s. It hired an advertising firm to fabricate "studies," write them up as salutary reports about the drug, pay some big-name psychiatrists a couple of thousand bucks each to put their names on the reports, and convince major journals (read by thousands of doctors) to publish the ghostwritten "findings." About half of the medical articles about Zoloft at that time were ad agency fakes. Journal editors, embarrassed by being scammed, have since imposed safeguards, but many doctors and observers say that up to 20 percent of major journal articles are still being ghosted.
We can do better
DTC and DTD are just two surging branches of the central stream running through America's healthcare industry--an out-of-control stream that should be labeled DTP--"Direct-to-Profit." The very fact that healthcare, an essential human need, has been twisted into an "industry"--a commercial activity for the purpose of maximizing profits--is a damning measure of its moral bankruptcy.
As avaricious and monopolistic drug corporations have demonstrated again and again, "care" is treated, at best, as an externality to their real work of making money--and at worst as an impediment to that corporate imperative. Thus, top executives and boards of directors constantly seek ever more sophisticated forms of deception and manipulation to, at all costs, make the sale. In this ethos, such loathsome products as blatant price gouging, artificial shortages of vital medicines, deliberate promotion of pills that kill, falsification of medical research, and routine corruption of doctors are not merely tolerated, but expected and accepted as normal.
Is this the best that this great, super-rich country can do? Of course not--we Americans can, must, and will create a system that puts public need over private greed. This month's "Do Something" features some groups leading the way. I'll give the final word to Dr. Relman, the thoughtful, insistent, and unflagging voice for an ethical and sensible system of care built around the concept of "Medicare for all." A decade ago, he wrote that "our health policies have failed to meet national needs because they have been heavily influenced by the delusion that medical care is essentially a business... A different kind of approach could solve our problems, but it would mean major reform of the entire system... Since such a reform would threaten the financial interests of investors... the short-term political prospects for such reform are not very good. But I am convinced that a complete overhaul is inevitable, because in the long run nothing else is likely to work."