Erectile dysfunction, female sexual dysfunction, hair loss, osteoporosis, restless leg syndrome, shyness: These are just a few of the conditions whose seriousness and prevalence have been systematically inflated by drug companies seeking bigger markets. Language is one of the most basic means of medicalizing a problem, the critical first step in getting people to ask their doctors for a pill. So “impotence” becomes “erectile dysfunction,” an impressively medical-y phrase that pushes away consideration of factors like stress and anxiety as causes of impotence that can be cured without a pill. Numbers are also key. People will be more likely to conclude they have a condition if they think it’s common, and so drug companies push statistics like “more than half of all men over forty have difficulties getting or maintaining an erection”—a number that is grossly misleading because it comes from a study not taken seriously by experts in the field.
“The rhetoric surrounding disease mongering suggests that it will promote health,” writes Iona Heath, a British physician, in the Public Library of Science Medicine, “but the effect is in fact the opposite. Much disease mongering relies on the pathologizing of normal biological and social variation and on the portrayal of the presence of risk factors for disease as a disease state in itself. When pharmaceuticals are used to treat risk factors, the vicious circle is completed because anyone who takes medicine is by definition a patient.”
There’s no better example of this than the warning about cholesterol on my doctor’s wall. High cholesterol is not a disease, merely a risk factor for cardiovascular disease. There are many such risk factors, including lack of exercise, smoking, an unbalanced diet, high blood pressure, obesity, and diabetes. Most of these can be improved with simple lifestyle changes. Cholesterol, however, can be reduced with pills. And so drug companies singled out cholesterol and promoted it as if it were a disease in itself. In 2003, Pfizer led a major “public awareness” campaign, ostensibly to raise awareness of heart disease and heart attack in France and Canada. The ads were shockingly blunt. On Canadian television, a woman with two young children weeps in a hospital waiting room. A doctor emerges and says her husband is dead. Then time reverses. We see the man wheeled down the hospital hall, in the ambulance, and collapsing at a sunny picnic. It’s high cholesterol, we are told. Even if you seem healthy, it can kill you. Get tested. Then the man and his kids are shown smiling and laughing—their grim fate has been averted.
Responding to the French version of Pfizer’s campaign, Jonathan Quick and colleagues in the Department of Essential Drugs and Medicines Policy of the World Health Organization wrote a stinging letter to the British medical journal The Lancet. “Of all the major factors accepted as cardiovascular disease risks, only cholesterol is addressed—the campaign’s stated aim is not pursued. No mention is made of an actual medical product, but the campaign coincided with publication, in The Lancet, of [a study] showing reductions in major cardiovascular events after use of atorvastatin.” Atorvastatin is the proper name of Lipitor, Pfizer’s lucrative anticholesterol drug. “We believe the campaign could have worried patients, encouraging them to request a prescription for statins.” Quick and his colleagues added that the “information used contained misleading statements and omissions likely to induce medically unjustifiable drug use or to give rise to undue risks.” For that reason, Quick concluded, the ads “did not respect several of WHO’s ethical criteria.” Barbara Mintzes, a professor of health care and epidemiology at the University of British Columbia, was more pointed in an article in the Public Library of Science Medicine: Pfizer, she wrote, is using the “fear of death” to promote sales.
The subterfuge of public information campaigns is necessary in most Western countries because only New Zealand and the United States allow full, direct-to-consumer advertising of pharmaceuticals. But even in the United States, federal regulations require ads to follow public-interest guidelines, and the pharmaceutical industry insists that its advertising simply provides solid information and is therefore in the public interest. Many observers think this is nonsense. Writing in the Annals of Family Medicine, Douglas Levy of the University of Southern California School of Medicine and David Kessler, the former head of the U.S. Food and Drug Administration, noted that drug company spending on TV ads in the United States “doubled from $654 million in 2001 to a staggering $1.19 billion in 2005. Nearly one-third of the 2005 spending was only one category: sleep medicines. Yet sleep disorders, however problematic and serious they may be, are almost inconsequential when compared to the major causes of death in the United States: cardiovascular disease, cancer and unintentional injuries. No matter how much the industry claims its advertising provides public health benefits, the amount spent promoting drugs for conditions of varying severity begs the question of whether the industry truly is acting for the public benefit.”
In 2007, a team led by Dominick Frosch at the University of California Department of Medicine published (in the Annals of Family Medicine) the first comprehensive analysis of the content of the thirty hours of drug ads the average American sees on TV each year. “Most ads (82 percent) made some factual claims and made rational arguments (86 percent) for product use, but few described condition causes (26 percent), risk factors (26 percent) , or prevalence (25 percent).” The researchers feel these omissions have an important consequence. “By ambiguously defining who might need or benefit from the products, [direct-to-consumer-advertising] implicitly focuses on convincing people that they may be at risk for a wide array of health conditions that product consumption might ameliorate, rather than providing education about who may truly benefit from treatment.”
Another matter that gets short shrift is lifestyle change. The first thing any physician will do when considering how to treat a condition is ask whether lifestyle changes—stop smoking, eat better, exercise—can do the job by themselves. In the Frosch study, 19 percent of ads mentioned that lifestyle changes could be made in conjunction with taking pills. But not one ad mentioned that lifestyle changes were a potential alternative to popping pills. In fact, almost 19 percent of ads went so far as to explicitly state that lifestyle changes were not enough. “Several ads for cholesterol-lowering drugs appeared to suggest that non-pharmacological approaches were almost futile,” the researchers wrote.
What drug ads emphasize is emotion. The Frosch study found that almost all ads—95 percent—contained a positive emotional appeal, while 69 percent played up negative feelings. “Most ads showed characters who lost control of their lives as a result of conditions and used medication to regain control. This loss of control extended beyond specific medical problems and often included an inability to participate in social, leisure or work activities. Characters typically regained complete control over their lives after using the product, whereupon they also received social approval from friends and family.” The fundamental message, then, is little different than that of home security ads and the image of the little boy playing soccer beside an electrified fence: You are in danger, but if you buy our product your life will be filled with smiles, sunshine, and pink-cheeked children at play.