The Case of the Disappearing Patient
Bloodwork -- As an 'empowered' medical consumer, your life depends on choosing the proper drug. Do you want to make the decision based on which of the Norman Rockwell images rendered in television advertisements is most appealing?
It used to be that drug ads were directed only toward physicians, mostly in the dry pages of medical journals. And for good reason. Prescription drugs are complex things; each has risks and benefits. There is no such thing as a harmless medicinal drug. In Hebrew, the word for medicine is samim, or poison. Every drug is a poison. As Andrew Weill points out in one of his early books, Health and Healing (Houghton Mifflin Co, 1998), the notion of drugs having "side effects" is in itself a canard. (This is a reliably written well book, published before Weill became the alternative-medicine hawking pseudo-celebrity he is now.) Drugs have effects, some of which are wanted and some of which are unwanted. The fact that Zoloft, for example, can soothe one's anxiety is not categorically any different from the fact that it can also cause insomnia, dry mouth, and a marked reduction in sexual drive and performance. Zoloft does all these things to varying degrees in different people, and someone has to decide whether it is, on the whole, a worthwhile treatment for an individual.
Because prescription drugs are complex and powerful (and, let's not kid ourselves, often quite effective), it takes a reasonable amount of training and experience to weigh their risks and benefits as they apply to particular patients. Now, however, Madison Avenue is flush with spending on the category known as "direct-to-consumer" ads. According to a recent study of the Harvard School of Public Health, drug companies spend more than $2 billion a year to hawk their prescription goods direct to you via the telly.
You're likely to see these ads sandwiched in between segments of Peter Jennings or other evening news programs. That's when many Americans are settling onto sofas and easy chairs. It's at that vulnerable time of the day when they become aware, slowly, of the untended, or poorly attended to, creaks, gurgles, tugs and tremors that gnaw at their bodies like barnacles on a boat. There on the television, they are presented with images of hale-looking septuagenarians doing Yoga exercises on poppy-strewn hilltops. Or square-jawed granddads frolicking with their grandkids (let's hope they're the grandkids). Or middle-manager types on lunch break enjoying grease-dripping burgers with gastrointestinal impunity. My favorite is the 60-second soap opera featuring a very TriBeCa-looking gal wearing what looks like a black DKNY outfit while visiting the corn-poney farm of her new beau's family. Presumably thanks to the drug she's taking, she doesn't succumb to the dreaded curse of seasonal allergies.
These prescription drug ads are usually heavy on images and light on vocal description. Usually, these drug ads don't go for the typical hard sell. True, the name of the drug will flash across the screen at some point. A narrator might suggest you, "Ask your doctor if Vioxx (or whatever) is for you". But otherwise there is no explanation of what the drug being marketed in the ad is actually designed to do. There's a reason for this fuzziness that I'll get to in a moment. Even without the hard sell, the wholesome images presented to the viewer are so alluring, that it's tempting to conclude: "Who cares what the drug is for? I'll have whatever they're having."
I was having a conversation the other day with a new neighbor of ours; he's a drug scientist at one of the companies Wall Street refers to as "Big Pharma". He talked about the fact that drug companies are bleeding profits because the patents on many of the their most popular drugs are expiring. When a patent expires, the generics step in and sell analog versions of the brand name product for a fraction of the price. (Selling generic drugs, one analyst told the New York Times "is like printing money" (by Milt Freudenheim, 27 December, 2002). In Big Pharma, as with any industry, my neighbor said, "The bottom line rules. The big manufacturers have a small window in which to earn profits."
What that means, he said, is that once a drug has been developed and approved by the manufacturer's R&D people, the sales and marketing people step in and sell the hell out of it.²They have only 20-years to do so, 20 years during which their profits are protected by patent law. As a result, my neighbor said, drug companies don't want just "patients" to buy their drugs. They want everyone to buy their drugs. Which is why we've all become medical consumers. We're the ones being sold; we're the ones being persuaded. We're the ones who are being encouraged to go to our doctors and say, "Gimme".
In 1996, Madison Avenue was spending $600 million annually on direct-to-consumer television ads. A year later, the FDA created guidelines governing what the companies could or could not say in those ads. But all that did was open the floodgates and give the practice of direct-to consumer advertising a greater veneer of respectability. In 1997, after the regulations were drafted, the consumer TV ad budget for drug companies doubled (according to media analyst Competitive Media Reporting). Which in itself is not insidious. After all, the business of America is business and corporations have a right (read: obligation) to maximize their profits.
But here's the rub: What happens when you've spent billions in developing a drug and it's not the best drug to use in some cases? Or in most cases? Or at all?
Traditionally, physicians were the ones to make those sorts of decisions in behalf of their patients. Maybe they didn't always do it well or efficiently, but it made sense that they ought to be the ones to do it. Think, for example, what you would do if you were suffering from uncontrollable high cholesterol (familial hypercholesterolemia). You could take one of the seven new statin drugs, such as Lipitor, Baycor or Zocor. Your life depends on choosing the proper drug. Do you want to make the decision based on which of the Norman Rockwell images rendered in television advertisements is most appealing?
I wouldn't. Especially considering what's at stake for the companies who are doing the persuading: a $16 billion market (according to The Scientist magazine, 11 April, 2001). Considering those odds, I'd want my doctor to make the decision. Or consider this: What if a drug company's profit motive ends up requiring you to take a treatment?
Sound Orwellian? That's exactly what happened when drug manufacturer Merck released its chicken pox vaccine in 1995. According to the Akron Beacon-Journal (16 April 2000) Arthur Lavin, M.D., a proponent of childhood immunizations, was opposed to the chicken pox vaccine. Like many pediatricians, Lavin, the Beacon-Journal said, was reluctant to administer the vaccine to small children because he knew the reality was that chicken pox is not only a self-limiting disease in children, but it also confers lifelong immunity. "There's been a greater and greater move toward redefining chickenpox as a dangerous disease," he said. My neighbor agrees. "It's insane from the perspective of medicine," he said. "From the perspective of business, though, it makes absolute sense."
Incidentally, those FDA guidelines governing direct-to-consumer marketing that I alluded to earlier require that television ads have "fair balance". What that means is that if a drug company is going to make a heavy claim about its drug in a television commercial, then it will need to include an equally sobering dose of information about the drug's unwanted effects and risks. Occasionally, companies take the gamble. The TV ads for Valtrex, for example, an anti-viral used in the treatment of genital herpes, touts the drug's purported benefits while including the litany of risks and side effects associated with the medication.
But in the vast majority of cases, the companies prefer to steer clear of the whole matter of side effects which is why the ads rarely state the drug's benefits: No stated claim means no dealing with the issue of fair balance. Which is why you see lots of Yoga being performed in ads for Vioxx, and hear very little about what Vioxx is actually for (osteoarthritis, in case you're interested, and want more than to just improve your Yoga practice).
In Madison Avenue-speak, these fuzzy drug ads fall into two categories: They are either known as help-seeking ads ("Life without gastrointestinal reflux it is now possible. See your doctor"); or reminder ads (you see the brand name and the happy, smiling people, but nothing at all is said about the treatment or condition).
Is all of this bad? Not entirely. There is some notion of empowerment that goes along with being a medical consumer rather than a mere patient. Sure, drug companies are trying to persuade you, but that in itself means they are investing you with the power of decision-making. It means you are being emboldened to discuss alternatives with your doctor without being concerned that you will be patronized, as patients routinely were in the Marcus Welby era. But with empowerment comes increased responsibility. How many people have the insight or time to look at the published research before confronting their doctors with what they think is the drug they ought to be taking?
One doctor told me he's gotten tired of arguing with those of his patients who insist on an inferior or inappropriate drug because they liked the advertisement. "I don't make a case for or against individual treatments anymore," he said, "no matter how much I may disagree, It takes away time I need to deal with other patients. I just flat out give my opinion, and they can take it or leave it. But considering that I'm the one with the M.D., if I were the patient, I'd listen up."
Are there benefits to having a more informed patient base? "Informed is a loaded word," this doctor said, "Informed about what? The ads usually end off by saying, 'Ask your doctor,' but the message they¹re really conveying is, 'Tell your doctor.'"
Recent news on prescription drugs: "FDA wants easier-to-read warnings on drug ads" CNN.com 4 February 2004.