Back in May, historians Jeremy A. Greene and David Herzberg published a paper reviewing drug advertising in the 20th century (subscription required). One of the problems that I encountered when writing HOOKED was the relative lack of good books and articles on the history of pharmaceutical marketing during that period. Jeremy Greene, MD, PhD wrote a couple of excellent papers on this subject while still completing his graduate studies, as I was pleased to credit in HOOKED. He's now affiliated with the Division of Pharmacoepidemiology and Pharmacoeconomics at Harvard where he's been doing his residency.
Basically the article recounts how at the start of the 20th century, the granddaddies of the big drug firms of today had to make a choice--"patent" medicines, which were characterized by secret ingredients and exaggerated advertising claims of cure, or "ethical" medicines (so-called from the AMA Code of Ethics), which were openly labeled drugs listed in the official U.S. Pharmacopoeia and advertised to physicians rather than to the general public. Obviously there was a lot of short-term profit in the patent medicine trade, but the companies looking at the big picture realized how they could carve a market niche on the "ethical" side, using the "ethical" label itself as a signal of corporate integrity. While "ethical" in the AMA's view meant advertising only to docs, the companies started pushing the envelope right off. They began with ads that named no specific medicines, but that were aimed at getting consumers to associate their name with quality and reliability. They effectively derailed any protests from the AMA by including in the ads a lot of reminders that consumers should seek medical advice from their physician before taking any drugs, so that the ads were as much ads for "go see your doctor" as for "buy our medicines." As the century wore on, the companies pushed the envelope a bit more. For instance, Parke, Davis initially had the patent on Benadryl, as one of the first truly effective antihistamines. A 1960 full-color magazine ad pictures Ward Cleaver and his family (OK, maybe not them exactly, but an equally idealized middle American family) enjoying a picnic and barbecue in their back yard, despite (as the text explains) a serious allergy problem they all share. The title runs: "This is what we work for at Parke, Davis." The text is ostensibly not about recommending any drug (Benadryl is never named) but simply using the development of a new antihistamine as just one example of the general benefits the drug industry provides for society. Yet it would not take much thinking to infer from the ad that if you have allergies and want to enjoy your back yard in the summer, you should go ask your doctor pronto for this new drug made by Parke, Davis.
A perhaps even cleverer use of an apparently innocuous "general information" ad to implicitly peddle a specific drug occured when Roerig, a division of Pfizer, introduced Atarax, its minor tranquilizer (which happens to be a pharmacological relative of Benadryl). In a 1957 newsreel, a know-it-all wife is informing her idiot (but anxious) husband about the physiology of stress. The film segues to a narrator who takes the viewer inside a drug laboratory to describe the latest developments in the fight against this dread affliction. He mentions in passing that a state of peaceful bliss could also be termed "ataraxia" and that therefore a new drug to achieve this state might be called "ataraxic." Of course, any relation to the brand name Atarax is strictly coincidental.
After updating the story to the modern era of direct-to-consumer ads, Greene and Herzberg make several points. One of their main points is one that I emphasized in HOOKED--that if you look at only one level or one channel of pharmaceutical industry influence over physicians or the public (or both), you seldom see what is really going on, as the industry is a master at using multiple levels and channels in synchrony to get their marketing message out. The present article shows that this expertise is not something that the industry arrived at yesterday, but rather is a skill honed over many decades. Federal regulation of drug ads, by contrast, almost always focuses on a single channel of communication, and thus is fated always to be two steps behind the pharmaceutical companies. The authors call for understanding that marketing of the sort they describe will probably always be with us, making it essential that we develop better ways of preventing truly harmful advertising--while at the same time they admit how hard that is. The whole point of their previous discussion, after all, has been that whatever is going on in drug company advertising is seldom what meets the eye.
Another important point is contained in: "The popular promotion of pharmaceuticals, in short, needs to be understood as a longstanding--if often covert--dimension of prescription drug marketing... This should come as no surprise given the industry's location within a resolutely commercial--and consumerist--medical system." It has been easy, when we try our best to focus on ethics, to portray medicine as fundamentally a profession which is supposed to be dedicated to the patient's well-being ahead of profit. This appropriate goal risks, however, ignoring the actual history of American medicine, especially when we are reminded that the AMA was for so much of the 20th century the public face of that enterprise. And the AMA, from its founding (but especially in the middle of the 20th century), has been ambivalent over its ethical identity. When it suited, the organization trumpeted its deep commitmnt to ethics and professionalism. But the AMA also resolutely insisted that the only appropriate model for medical practice in the US was the entrepreneurial physician, the doc as small businessman. My teachers in medical school could recall the days when you could be kicked out of the county medical society for joining an early form of HMO, or even, for that matter, a group practice, instead of the solo practice valorized by the AMA. When the organization that spoke for American medicine could not get it straight between a patient-centered ethic and a profit-centered business model, how could we expect any other part of the health care system to do better?
Greene JA, Herzberg D. Hidden in plain sight: marketing prescription drugs to consumers in the Twentieth Century. American Journal of Public Health 100:793-803, May 2010.