Prologue

Selling sickness

by Ray Moynihan and Alan Cassels

Thirty years ago the head of one of the world’s best-known drug companies made some very candid comments. Close to retirement at the time, Merck’s aggressive chief executive Henry Gadsden told Fortune magazine of his distress that the company’s potential markets had been limited to sick people. Suggesting he’d rather Merck to be more like chewing gum maker Wrigley’s, Gadsen said it had long been his dream to make drugs for healthy people. Because then, Merck would be able to “sell to everyone.” 1 Three decades on, the late Henry Gadsden’s dream has come true.

The marketing strategies of the world’s biggest drug companies now aggressively target the healthy and the well. The ups and downs of daily life have become mental disorders, common complaints are transformed into frightening conditions, and more and more ordinary people are turned into patients. With promotional campaigns that exploit our deepest fears of death, decay, and disease, the $500 billion pharmaceutical industry is literally changing what it means to be human. Rightly rewarded for saving life and reducing suffering, the global drug giants are no longer content selling medicines only to the ill. Because as Wall Street knows well, there’s a lot of money to be made telling healthy people they’re sick.

At a time when many of us are leading longer, healthier, and more vital lives than our ancestors, saturation advertising and slick “awareness-raising” campaigns are turning the worried well into the worried sick. 2 Mild problems are painted as serious disease, so shyness becomes a sign of social anxiety disorder and premenstrual tension a mental illness called premenstrual dysphoric disorder. Everyday sexual difficulties are seen as sexual dysfunctions, the natural change of life is a disease of hormone deficiency called menopause, and distracted office workers now have adult ADD. Just being “at risk” of an illness has become a “disease” in its own right, so healthy middle-aged women now have a silent bone disease called osteoporosis, and fit middle-aged men a lifelong condition called high cholesterol.

With many health problems, there are people at the severe end of the spectrum suffering genuine illness, or at very high risk of it, who may benefit greatly from a medical label and a powerful medication. Yet for the relatively healthy people who are spread across the rest of the spectrum, a label and a drug may bring great inconvenience, enormous costs, and the very real danger of sometimes deadly side effects. This vast terrain has become the new global marketplace of potential patients – tens of millions of people – a key target of the drug industry’s multibillion-dollar promotional budgets.

The epicenter of this selling is of course the United States, home to many of the world’s largest pharmaceutical companies, and the stage on which most of the action in this book takes place. With less than 5 percent of the world’s population, the U.S. already makes up almost 50 percent of the global market in prescription drugs. 3 Yet spending in the U.S. continues to rise more rapidly than anywhere else, increasing by almost 100 percent in just six years – not only because of steep increases in the price of drugs, but because doctors are simply prescribing more and more of them. 4

Prescriptions for the most promoted categories, like heart medicines or antidepressants, have soared astronomically in the U.S., with the amount spent on these drugs doubling in less than five years. 5 In many other nations the trend is also up. Young Australians took ten times more antidepressants in 2000 than they did in 1990. 6 Canadian consumption of the new cholesterol-lowering drugs jumped by a staggering 300 percent over a similar time period. 7 Many of those prescriptions enhanced or extended life. But there is a growing sense that too many of them are driven by the unhealthy influences of misleading marketing rather than genuine need. And those marketing strategies, like the drug companies, are now well and truly global.

Working from his midtown Manhattan office in New York City, Vince Parry represents the cutting edge of that global marketing. An expert in advertising, Parry now specializes in the most sophisticated form of selling medicines: he works with drug companies to help create new diseases. In an astonishing article titled “The art of branding a condition,” Parry recently revealed the ways in which companies are involved in “fostering the creation” of medical disorders. 8 Sometimes a little-known condition is given renewed attention, sometimes an old disease is redefined and renamed, and sometimes a whole new dysfunction is created. Parry’s personal favorites include erectile dysfunction, adult attention deficit disorder, and premenstrual dysphoric disorder – a disorder so controversial some researchers say it doesn’t even exist.

With rare candor Parry has explained how pharmaceutical companies now take the lead, not just in branding their blockbuster pills like Prozac and Viagra, but also in branding the conditions that create the markets for those pills. Working under the leadership of the drug marketers, Madison Avenue gurus like Parry get together with medical experts to “create new ideas about illnesses and conditions.” 9 The goal, he says, is to give drug company customers around the world “a new way to think about things.” 10 The aim, always, is to make the link between the condition and your medicine, in order to maximize its sales.

The idea that drug companies help to create new illnesses may sound strange to many of us, but it is all too familiar to industry insiders. A recent Reuters Business Insight report designed for drug company executives argued that the ability to “create new disease markets” is bringing untold billions in soaring drug sales. 11 One of the chief selling strategies, said the report, is to change the way people think about their common ailments, to make “natural processes” into medical conditions. People must be able to be “convinced” that “problems they may previously have accepted as, perhaps, merely an inconvenience” – like baldness, wrinkles, and sexual difficulties – are now seen as “worthy of medical intervention.” 12 Celebrating the development of profitable new disease markets like “Female Sexual Dysfunction,” the report was upbeat about the financial future for the drug industry. “The coming years will bear greater witness to the corporate sponsored creation of disease.” 13 The unhealthy influence of the pharmaceutical industry has become a global scandal. That influence is fundamentally distorting medical science, corrupting the way medicine is practiced, and corroding the public’s trust in their doctors. 14

The burying of unfavorable research studies on children and antidepressants, the dangers of the anti-arthritis drugs and the investigations into the alleged bribing of physicians in Italy and the U.S. are just the latest in a string of embarrassments. 15 Exploding drug expenditures have helped produce double-digit increases in the costs of health insurance premiums, fueling further widespread anger towards the industry, particularly in the U.S. As a result, many doctors, scientists, health advocates, politicians, and medical journal editors are moving to try to wind back the industry’s influence over scientific research and doctors” prescribing habits. 16 The time is ripe to understand how that influence now extends right to the very definitions of disease.

Marketing executives don’t sit down and actually write the rules for how to diagnose illness, but they increasingly underwrite those who do. The industry now routinely sponsors key medical meetings where disease definitions are debated and updated. In some instances, as we will see, the medical experts writing the rules are at the same time taking money from the drug makers who stand to make billions, depending on how those rules are written. Many of the senior specialists deciding whether your sexual difficulties should be defined as sexual dysfunctions, whether your stomach complaints should be seen as serious medical conditions, and whether your everyday risks should be portrayed as deadly diseases, are on the payrolls of the companies seeking to sell you drugs. The payment of money doesn’t necessarily buy influence, but in the eyes of many observers, doctors and drug companies have simply become too close.

With many medical conditions, there is great uncertainty about where to draw the line that separates the healthy from the sick. The boundaries that separate “normal” and “abnormal” are often highly elastic, they may differ dramatically from country to country, and they can change over time. Clearly, the wider you draw the boundaries that define a disease, the wider the pool of potential patients, and the bigger the markets for those making drugs. The experts who sit down to draw those lines today are too often doing so with drug company pens in their hands, and they are drawing the boundaries wider and wider almost every time they meet.

According to these experts, 90 percent of the elderly in the U.S. will have a condition called high blood pressure, almost half of all women have a sexual dysfunction called FSD, and more than 40 million Americans should be taking drugs to lower their cholesterol. 17 With a little help from a headline-hungry media, the latest condition is routinely portrayed as widespread, severe and, above all, treatable with drugs. Alternative ways of understanding or treating health problems, and lower estimates of the numbers affected, are often swept away by a frenzy of drug company promotion.

While the boundaries defining disease are pushed out as widely as they can be, by contrast, the causes of these supposed epidemics are portrayed as narrowly as possible. In the world of drug marketing, a major public health problem like heart disease can sometimes be reduced to a narrow focus on a person’s cholesterol levels or blood pressure. Preventing hip fractures among the elderly becomes a narrow obsession with the bone density numbers of healthy middle-aged women. Personal distress is seen as being due largely to a chemical imbalance of serotonin in the brain, an explanation as narrow as it is outdated.

Like most everything else that happens in health care today, our ideas about sickness are being shaped in the long shadows cast by the global drug giants. Yet the narrowing of the focus is making it harder for us to see the bigger picture about health and disease, sometimes at great cost to the individual, and the community. To use a simple example, if an improvement in human health was our primary aim, some of the billions currently invested in expensive drugs to lower the cholesterol of the worried well might be far more efficiently spent on enhanced campaigns to reduce smoking, increase physical activity, and improve diet.

There are many different promotional strategies used in the selling of sickness, but the common factor among them all is the marketing of fear. The fear of heart attacks was used to sell women the idea that the menopause is a condition requiring hormone replacement. The fear of youth suicide is used to sell parents the idea that even mild depression must be treated with powerful drugs. The fear of an early death is used to sell high cholesterol as something automatically requiring a prescription.

Yet ironically, the much-hyped medicines sometimes cause the very harm they are supposed to prevent.

Long-term hormone replacement therapy increases the risk of heart attacks for women, while antidepressants appear to increase the risk of suicidal thinking among the young. At least one of the blockbuster cholesterol-lowering drugs has been withdrawn from the market because it was implicated in causing deaths. In one of the most horrific cases of all, a drug sold as helping with common bowel problems led to constipation so severe for some people, they simply died. Yet in this case, as in so many others, the official government regulators somehow seemed more interested in protecting drug company profits than the public’s health. 18

The pharmaceutical industry and its supporters defend their marketing campaigns as raising awareness about misunderstood diseases, and providing quality information about the latest medicines. Company executives talk of empowering consumers with advertising, and their paid celebrities are said to educate the public about health conditions via glossy magazine articles and on TV talk shows. Certainly there are some valuable examples of industry-sponsored efforts to destigmatize a health problem or stimulate much-needed action, as has occurred in the area of HIV-AIDS. Yet in other cases these campaigns are not education at all, but plain old promotion: skewing our understanding of the causes of human illness and distorting our knowledge of the remedies, playing up the benefits of drugs and playing down their harms and costs.

A loosening of advertising regulations in the late 1990s in the U.S. has delivered an unprecedented onslaught of drug marketing targeted at ordinary people, who now watch an average of ten or more of these advertisements every day. Likewise, viewers in New Zealand are subject to this sort of promotion. Elsewhere in the world the industry is fighting relentlessly for similar deregulation. For the supporters, this marketing is a valuable service; for the critics, it is putting disease at the center of human life. It is pushing the genuinely ill towards a limited range of the most expensive drug solutions, and making tens of millions of the healthy start to fear that their bodies are broken, dysfunctional, deficient, and decaying. This disease-mongering is an assault on our collective soul by those seeking to profit from our fear. It is no dark conspiracy, simply daylight robbery.

Selling Sickness unmasks the latest marketing techniques from the drug industry’s multi-layered campaigns. Technique by technique, condition by condition, a pattern emerges, a formula for changing the way we think about illness in order to expand markets for drugs. The diseases explored here are not the only ones being oversold; they are, though, among the most dramatic, compelling, and freshest examples we have. Once you become familiar with the formula, and start to recognize the tricks of the trade, you’ll begin to see the black magic of disease marketing at work everywhere.

Some of the promotional strategies may already be familiar, but the dirty tricks and covert operations are likely to shock and anger many readers. The aim of Selling Sickness is not to further discredit a much maligned drug industry, or its many valuable products. Nor is the goal to denigrate the many fine and principled people who work inside these giant corporations and who are motivated, like many hardworking medical scientists outside, to discover and develop safe and effective new therapies. Rather, the plan is to expose the way in which the industry’s promotional machinery is turning too much ordinary life into medical illness, in order to expand markets for medications.

Over three decades ago a maverick thinker called Ivan Illich raised alarms that an expanding medical establishment was “medicalizing” life itself, undermining the human capacity to cope with the reality of suffering and death, and making too many ordinary people into patients. 19 He criticized a medical system “that claims authority over people who are not yet ill, people who cannot reasonably expect to get well, and those for whom doctors have no more effective treatment than that which could be offered by their uncles or aunts.” 20 A decade ago medical writer Lynn Payer described a process she called “disease-mongering”: doctors and drug companies unnecessarily widening the boundaries of illness in order to see more patients and sell more drugs. 21 In the years since, these writings have become ever more relevant, as the industry’s marketing roar has grown louder and its grip on the health care system much stronger.

Soaring sales have made drug companies the most profitable corporations on the planet during particular years of the past decade. 22 But the flip side of healthy returns for shareholders is an unsustainable increase in costs for those funding the health system, whether they are governments or private insurers. It is no surprise that the industry’s unhealthy influence has become part of the political debate in many nations, which exploded in Australia during negotiations over the recent free trade deal with the U.S. As the public learns more about industry’s influence over the definitions of disorders and dysfunctions, and its methods for creating “new disease markets,” the selling of sickness will likely move closer to the center of those debates.

Like the best of scientific inquiry this work of journalism is offered as part of an ongoing conversation, to be continued with friends, families, and physicians, with other health care providers, work colleagues, health officials, and elected representatives: a conversation that questions the corporate-sponsored selling of sickness, and explores new ways to define and understand disease. It is a conversation that could ideally benefit from the energy and enthusiasm of a whole new global collaboration of independent researchers and health advocates, whose primary aim is to promote a more rational and informed public debate about human health, rather than simply selling fear in order to sell pharmaceuticals.

Note: Unless otherwise indicated, all monetary amounts in this book refer to U.S. dollars.