A recent paper (thanks yet again to Marilyn Mann) by Kalman Applbaum, of the Department of Anthropology, University of Wisconsin-Milwaukee, sent me scurrying back to an earlier paper of his that I had missed. The two offer an interesting perspective on how the drug industry achieves its aims in today's society.
Applbaum focuses much of his research on company documents revealed as a result of litigation against Eli Lilly over Zyprexa. In the earlier paper he reviewed these documents, supplemented with interviews. In his more recent paper he focuses on one part of the Zyprexa story--the decision by the Japanese health ministry in 2002 to require a warning label and to send a "dear doctor" letter about side effects. Lilly was concerned that the warning letter would exert global influence and so sought to counter its impact aggressively. In what follows I select threads from both articles in order to identify what I take to be Applbaum's key lessons.
Applbaum begins by teaching us marketing neophytes about "channels." Marketing drugs is highly complicated because there's no direct pipeline from the manufacturer to the end-user. Lots of folks control and manipulate the pathway that delivers the drug eventually to the mouth or body of the patient--most notably the physician who has to write the prescription, but also insurance companies, government regulators, managers of hospital formularies, and numerous other players. The key to selling drugs successfully today is first, to be able to control the channel: "Pharmaceutical manufacturers, like other marketing-driven enterprises, have realized that it is less in the product, the brand or even the patent where their fortunes lie, but in the stream, the marketing channel. Once you control the channel, you can insert any product you like into it, no matter how useless or dangerous."
But, if Rule One is control the channel, Rule Two is not to appear obviously to do so. Modern marketing lingo is full of words about "synergy" and so forth. The basic idea is to figure out ways to bend other parties to do what you want them to, by appealing in each case to their own interests, so that you never appear to be using power over them but always with and alongside them. It is in pursuit of this goal that pharmaceutical companies patiently and painstakingly unleash so many different measures at so many different levels, at such a high expense, as part of their strategy to market any given drug. Applbaum summarizes all the elements, for example, that went into marketing the SSRI antidepressants: "combined marketing and R&D divisions created and publicized research to demonstrate the efficacy of the drug; obtained academic 'key opinion leader' (KOL) endorsements for professional audiences (people whose careers and pocketbooks improved simultaneously); aired celebrity spokespeople and advertising to educate the lay public about the disease; lavishly funded antistigma campaigns; promoted among family doctors the use of abridged depression questionnaires and educated, and thus empowered, these dotors (and eventually their non-MD assistants) to look for telltale signs of depression and treat it; enrolled (in some cases, also bankrolled) the support of patient advocacy groups and solicited testimonials from among them; generated certified guidelines formulated and endorsed by psychiatrists in the employ of industry, to be adopted by hospital formularies and public insurance programs; took a lead role in determining the curriculum and scientific programs at continuing medical education programs and professional congresses; designed Web sites with diagnostic self-tests encouraging consumers along the path from self-diagnosis to the request of medication at the doctor's office.... The result was a phenomenal increase in the diagnosis of conditions for which a prescription of an SSRI ensued."
The way the company conducts this complex orchestra "results in the ability to pull all those disparate strings so that it looks like there is a consensus firming up from multiple locations, and hence it is not manipulated, cannot possibly be manipulated. One of the reasons the manipulation is obscure to us is that it seems as if they are not supervising the process at every step, because their hands are off the process so much of the time--And how, anyway, could they control the entire system?"
Turning next to the specific Japanese context, Applbaum claims that Eli Lilly managed to turn aside the threat to Zyprexa sales essentially by " a strategy of creating a shadow science to drown out noncompany-sponsored (and competitors') research reports on the side effects of the drug." The way in which this strategy is most at odds with the drug industry's self-image, and propaganda image presented to the medical profession, of its partnership in the pursuit of hard scientific evidence, is that, "the company treated the medical concerns associated with their drug as a relative and fungible truth--in short, as a brand truth that they had the right and the resources to control. The Zyprexa documents show how Lilly sought to deceive physicians in the United States about the severity of of the side effects, using the physicians' own incomplete knowledge against them." Thus, "An initial estimate is that about three quarters of the 5506 pges of Zyprexa documents are devoted to what Sergio Sismondo (2007) calls the 'ghost management' of science, and much of that to the side effects issue. Research is manipulated into sales fodder. Each claim in the doctor's office should be supported by research, and research is 'ordered,' as though from a shop, accordingly."
One footnote to the Zyprexa story in Japan is that the Japanese apparenly had no idea of how patient advocacy groups could be set up effectively to market drugs, so Lilly arranged for a selected group of patient family advocates to travel to Chicago to attend the annual meeting of the U.S. National Alliance of Mentally Ill (NAMI).
Applbaum notes the importance of understanding "channel marketing" as a way of understanding general issues that extend beyond the drug industry: "The master of synergistic power does not sell the channel outright. Instead, through manipulating partial truths and through capturing majority shares of heart, mind and voice, the disappearing synergist creates the context in which many social actors can move in a single direction even when they have competing interests. It is social process itself that is being pushed down the channel, while corporations collect only tolls." (Applbaum adds in a footnote that it is precisely because so many physician KOLs don't understand this, or don't wish to understand this, that they imagine that they somehow remain independent of the pharmaceutical industry because they consult with several competing companies rather than only with one.)
In HOOKED, I spent some time reviewing the Dichter study of pharmaceutical sales from the 1950s, one of the first documents to lay out the drug rep's strategy of being able to guide and manipulate the physician's prescribing precisely by appearing never to intend or to be able to influence his prescribing--strategies that the writings of Michael Oldani and Shahram Ahari have more recently brought up to date. I find it intriguing that Applbaum has painted a picture of the drug company's action in manipulating the marketing channels that almost exactly mirrors, at the social level, the individual psychological techniques long used by (and taught to) reps.
Applbaum K. Getting to yes: corporate power and the creation of a psychopharmaceutical blockbuster. Culture, Medicine and Psychiatry 33:185-215, 2009.
Applbaum K. Shadow science: Zyprexa, Eli Lilly and the globalization of pharmaceutical damage control. BioSocieties 5:236-255, 2010.