It is often said that leading drug companies now spend more on marketing than on research and development [1]. While such contemporary pharmaceutical marketing practices are sometimes believed to be a modern phenomenon, they are in fact a direct continuation of 19th-century patent medicine advertising. “Nostrum-mongers,” as the novelist Henry James dubbed them, are noted in the history of advertising as having been the leading spenders on, and foremost originators of, advertising technique [2, 3]. Nostrum sellers pioneered print advertising, use of trademarks and distinctive packaging, “pull” or demand-stimulation strategies, and even the design and commissioning of medical almanacs that functioned as vehicles for promotion of disease awareness. Henry James's psychologist brother, William James, was so exasperated by “the medical advertisement abomination” that in 1894 he declared that “the authors of these advertisements should be treated as public enemies and have no mercy shown” (see page 235 in [4]).

There is no doubt that drug company discoveries have profoundly improved upon our capacity to treat illness. But pharmaceutical marketing is more closely aligned with consumer marketing in other industries than with medicine, for which the consequences are not trivial. Once we view pharmaceutical industry activities in this light, we can disentangle industry's influence on contemporary medicine. Because we believe that we owe corporations our wealth and well-being, we tend not to question corporations' fundamental practices, and they become invisible to us. What follows is an attempt to demystify some of the assumptions at work in the “culture of marketing,” toward the goal of explaining contemporary disease mongering.

Beliefs about the Free Market

There are three beliefs commonly associated with the “free market.” The first is that human beings are creatures of limitless but insatiable needs, wants, and discomforts. The second is that the free market is a place where these needs might be satisfied through the exercise of free choice. The last of these beliefs is that the surest avenue to innovation in all industries is unfettered competition in the market.

Insatiable needs

The anthropologist Marshall Sahlins theorizes that the belief in unlimited wants is unique in the West, and stems from the Christian notion of “fallen man” as sufferer. This results, says Sahlins, in a peculiar idea of the person “as an imperfect creature of need and desire, whose whole earthly existence can be reduced to the pursuit of bodily pleasure and the avoidance of pain” [5]. A historical and philosophical examination of professional marketing shows that an assumption of boundless needs and wants is also at the heart of marketing theory. In this sense, marketing can be regarded as the institutionalization of this view of human nature. The marketer's challenge is to translate those limitless needs into profits.

Sahlins also points out that “in the world's richest societies, the subjective experience of lack increases in proportion to the objective output of wealth” [6]. In other words, the richer we get, the more we want. One explanation of this paradox lies in the way marketing activities are instrumental in getting us to think more about what we lack. Marketers and advertisers project and reflect back to us our discontent with the status quo. Americans are said to spend, on average, three years of their lives watching television advertisements, and the effect is that they are conditioned to want more and more. According to the advertisements, the viewer's personal anxieties and dissatisfactions are best addressed by consumption. This same message lies at the heart of much pharmaceutical advertising.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Pills are often marketed as a solution to human anxieties and dissatisfactions

https://doi.org/10.1371/journal.pmed.0030189.g001

From Patients to Medical Consumers

Since, in a consumer society, we see ourselves as individuals and as free agents when we exercise consumer choice, it is not difficult for pharmaceutical companies and other privatized health-care deliverers to convince us that it is empowering to think of ourselves not as patients but as consumers. This conversion from patient to consumer also paves the way for the erosion of the doctor's role as expert. A startling report of this was described in a recent New York Times article: “For a sizable group of people in their 20's and 30's, deciding on their own what drugs to take—in particular, stimulants, antidepressants and other psychiatric medications—is becoming the norm. Confident of their abilities and often skeptical of psychiatrist's expertise, they choose to rely on their own research and each other's experience in treating problems like depression….A medical degree, in their view, is useful but not essential” [10]. This phenomenon, the article suggested, is “driven by familiarity” with the drugs. The emergence of this potentially dangerous situation demonstrates an unchecked expansion of the drug industry into an already accepted mode of thought—that “every minor mood fluctuation,” as the article reported, can and should be remedied.

Promoting consumer familiarity with drugs is one example of the very broad influence of the pharmaceutical industry. This influence extends to clinical trial administration, research publication, regulatory lobbying, physician and patient education, drug pricing, advertising and point-of-use promotion, pharmacy distribution, drug compliance, and the legal and ethical norms by which company practices themselves are to be evaluated. Actors traditionally found outside the “distribution channel” of the market are now incorporated into it as active proponents of exchange. Physicians, academic opinion leaders, patient advocacy groups and other grass roots movements, nongovernmental organizations, public health bodies, and even ethics overseers, through one means or another, have one by one been enlisted as vehicles in the distribution chain. The inclusion of patients in the distribution chain fundamentally changes their role from recipients of medical care to active consumers of the latest pharmaceuticals, a role which surely helps to support industry profits.

Ethical Justification for Marketing

Because illness is one of the most tangible forms of suffering, the pharmaceutical industry, more than other industries, can link its marketing activities to ethical objectives. The result is a marriage of the profit-seeking scheme in which disease is regarded as “an opportunity” to the ethical view that mankind's health hangs in the balance. Marketers and consumers in the West to some extent share a common vision of needs and the terms of their satisfaction. This apparent complicity helps even the most aggressive marketers trust that they are performing a public service. Pharmaceutical company managers that I speak to signal this when they characterize their engagement with the public as “doing good while doing well.”

These managers also see nothing wrong with integrating doctors, patients, and other players into the drug distribution channel. On the contrary, they say, this is state-of-the-art management, making it professionally principled and tactically astute. Marketers also regard the incorporation of consumers into the channel as ethical because then people's needs can best be determined and satisfied, conferring upon them the power of self-determination through choice.

But this choice is an illusion. For in our pursuit of a near-utopian promise of perfect health, we have, without realizing it, given corporate marketers free reign to take control of the true instruments of our freedom: objectivity in science, ethics and fairness in health care, and the privilege to endow medicine with the autonomy to fulfill its oath to work for the benefit of the sick.