May 8, 2012 |
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 countrieshave 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.
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 toldForbes 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."
Jim Hightower is a national radio commentator, writer, public speaker, and author of the new book, "
Swim Against the Current: Even a Dead Fish Can Go With the Flow." (Wiley, March 2008) He publishes the monthly "
Hightower Lowdown," co-edited by Phillip Frazer.
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