However hyped the risk of germs may be, it is at least real. Some corporations go so far as to conjure threats where there are none. A television ad for Brita, the German manufacturer of water-filtration systems, starts with a close-up of a glass of water on a kitchen table. The sound of a flushing toilet is heard. A woman opens a door, enters the kitchen, sits at the table, and drinks the water. The water in your toilet and the water in your faucet “come from the same source,” the commercial concludes. Sharp-eyed viewers will also see a disclaimer at the start of the ad printed in tiny white letters: MUNICIPAL WATER IS TREATED FOR CONSUMPTION. This is effectively an admission that the shared origin of the water in the glass and the toilet is irrelevant and so the commercial makes no sense—at least not on a rational level. As a pitch aimed at Gut, however, it makes perfect sense. The danger of contaminated drinking water is as old as humanity, and the worst contaminant has always been feces. Our hardwired defense against contamination is disgust, an emotion that drives us to keep our distance from the contaminant. By linking the toilet and the drinking glass, the commercial connects feces to our home’s drinking water and raises an ancient fear—a fear that can be eased with the purchase of one of the company’s many fine products.
Another, subtler form of fear marketing popped up in my doctor’s waiting room one day. A large poster on the wall entertained bored patients with “One Hundred Ways to Live to One Hundred.” Most of the one hundred items listed were printed in small, pale letters, and they were about as insightful and provocative as Mother’s Day cards. “Number 1: Enjoy yourself. ” “Number 73: Soak in the tub.” But seven items were printed in large, black letters that made them the visual focus of the poster. The first of these was “Number 22: Exercise regularly.” Hard to object to that. But then came “Number 44: Reduce the amount of cholesterol in your diet.” That’s a bit odd. Cholesterol isn’t inherently dangerous, so you may not need to reduce your cholesterol. It’s also hard to see why cholesterol would rank among the fundamentals of staying alive, along with exercise. It is not remotely as important as eating lots of fruits and vegetables, not smoking, and many other things that aren’t mentioned on the poster. So why does it get top billing over them?
Hints of an explanation appeared in the items that followed. “Number 56: Take your medicine as prescribed.” Then “Number 62: If you’ve had a heart attack or stroke and stopped taking your medication, speak to your doctor.” And “Number 88: Ask your doctor about new medications.” Finally, there was “Number 100: Listen to your doctor.”
Taken as a whole, the poster’s basic message is that pills are absolutely essential for a long life. That’s not a message you will hear from disinterested medical experts, but it is what you would expect to hear from a pharmaceutical company like the Bristol-Myers Squibb Pharmaceutical Group, identified as the maker of the poster in small print at the bottom left-hand corner. Bristol-Myers Squibb is also the maker of Pravachol, a cholesterol-reducing drug. According to the U.S. Food and Drug Administration, American sales of Pravachol earned Bristol-Myers Squibb $1.3 billion in 2005 alone, and that’s just a sliver of the market for cholesterol pills. Worldwide, Pfizer’s Lipitor racked up $12.2 billion in 2005.
This sort of camouflaged marketing is typical of the pharmaceutical industry, and it’s not limited to doctor’s offices. Health lobby groups, professional associations, and activists are routinely funded by pharmaceutical giants. Much of this is uncontroversial, but critics say Big Pharma deliberately blurs the line between disinterested advice and sales pitches. “Would the pharmaceutical companies spend billions of dollars a year if they didn’t think it was valuable? Of course not,” said Dr. Jerome Kassirer, a professor at the Tufts University School of Medicine and former editor in chief of the New England Journal of Medicine. That’s troubling enough, but more disturbing than Big Pharma’s marketing methods are its goals.
It is not in the economic interests of a corporation selling pills to unhealthy people for people to be healthy, or rather—to be more precise—for them to perceive themselves to be healthy. Their actual physical state is irrelevant. What matters is whether someone believes there is something wrong that can be cured with a pill. If so, the corporation has a potential customer. If not, no sale. It doesn’t take an MBA to figure out what pharmaceutical companies need to do to expand their markets and boost sales.
Critics call it “disease mongering.” Australians Roy Moynihan and David Henry, a journalist and a pharmacologist, respectively, wrote in the April 2006 edition of the journal Public Library of Science Medicine that “many of the so-called disease awareness campaigns that inform contemporary understanding of illness—whether as citizens, journalists, academics or policymakers—are underwritten by the marketing departments of large drug companies rather than by organizations with a primary interest in public health. And it is no secret that those same marketing depart- ments contract advertising agencies with expertise in ‘condition branding,’ whose skills include ‘fostering the creation’ of new medical disorders and dysfunctions.”
The evidence assembled by Moynihan and Henry in their book Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients is extensive. A good illustration of the general pattern is a confidential plan to market GlaxoSmithKline’s drug Lotronex in Australia by transforming the perception of irritable bowel syndrome. “IBS must be established in doctors’ minds as a significant and discrete disease state,” notes the plan, written by a medical marketing company. Patients “need to be convinced that IBS is a common and recognized medical disorder.” This would be accomplished by moving on several fronts simultaneously, including the creation of a panel of “key opinion leaders” who would advise the corporation on opinions in gastroenterology and “opportunities for shaping it,” drafting “best practice guidelines” for dealing with irritable bowel syndrome, launching a new newsletter to convince the “specialist market” that the condition is a “serious and credible disease,” and running ads targeting general practitioners, pharmacists, nurses, and patients. Another component of the plan is to involve a medical foundation that is described as having a “close relationship” with the plan’s drafters. The plan also calls for a comprehensive media strategy because “PR [public relations] and media activities are crucial to a well-rounded campaign—particularly in the area of consumer awareness.” It all came to naught, however. The U.S. Food and Drug Administration received reports that Lotronex caused serious and even fatal adverse reactions. The big push was abandoned, and the drug is now prescribed only to women with severe symptoms.
This is much bigger than advertising. It is about nothing less than shifting the line between healthy and diseased, both in consumers’ perceptions and in medical practice itself. Steven Woloshin and Lisa Schwartz, doctors and researchers at the Dartmouth Medical School, were among the first to analyze this process. In 1999, they published a paper examining proposals by various professional associations to change the thresholds for diagnosis of high blood pressure, diabetes, high cholesterol, and obesity. In every case, the new thresholds made it easier for people to be qualified as having these conditions. They then calculated that if all the new standards were put in place, 87.5 million otherwise healthy Americans would suddenly be deemed to have at least one chronic condition—and three-quarters of all Americans would be considered “diseased.”