The Influence of Marketing
Marketing is most effective when the potential customer hears the same message from multiple, reinforcing sources. The ideal launch of a new drug might go something like this: The physician, attending a meeting of her specialist society, hears an exciting talk about a new drug nearing approval by the Food and Drug Administration (FDA) but not yet on the market. Within months, ads in widely read medical journals announce that the drug is finally available. Then, the company’s rep visits the office and leaves a stack of glossy reprints extolling the drug’s virtues as well as a supply of samples. Now a patient walks into the office asking for that drug by name, based on a television ad he had seen. It is hard to imagine this physician not getting the powerful message that this new drug is important and useful and that failing to prescribe it to patients would be poor medical practice.
K. Applbaum, a medical anthropologist, described the aim of drug companies’ marketing as “controlling the channels” (Applbaum 2009, 2010). Chemicals that might serve as drugs follow a complex route, from discovery, scientific testing, and approval for marketing to manufacture, prescription by a physician, and actual consumption by a patient. Along this route, many sorts of people serve as gatekeepers, who can facilitate or impede the drug’s flow along the route. These gatekeepers include scientists, government regulators, insurers, pharmacy benefit managers, and many others besides physicians and patients. These various gatekeepers have disparate interests, many at odds with one another.
According to Applbaum, the drug firm has two strategic aims. The first is to control the channel. The gates have to be configured so that the drug can flow smoothly all along the route. Applbaum notes that when a firm, or the industry as a whole, effectively controls the channel, it hardly matters what specific drug is put into it or whether the drug is helpful or harmful; the drug will be prescribed and taken and the companies will profit.
The second strategic aim is not to appear to be controlling the channel at all. Many of the gatekeepers are more likely to cooperate with the company’s aims precisely to the degree that they believe that they are acting autonomously and are free from industry manipulation. Smoothly controlling the channel requires that each gatekeeper believes that he is acting independently in his own interests. The very complexity of the channel serves this strategic aim well; it simply does not seem possible to the average onlooker that any single actor could possibly exert so much control, at so many places, simultaneously. (Of course, when one has $57 billion to spend, many things become possible.)
Applbaum studied in depth one of the case examples I will refer to later, the newer classes of antidepressant drugs. An example he gives of “controlling the channels” is the creation of simple-to-administer questionnaires designed to allow primary care physicians to determine whether a patient is sufficiently depressed to warrant drug therapy. From the standpoint of the physician, the questionnaire seems a valuable aid. It saves time and increases the efficiency of an office visit. Psychiatrists commonly criticize primary physicians for missing the diagnosis of depression, so this instrument reassures the physician that she is being appropriately thorough. Also, since the diagnosis of a treatable depression can now be made (or so it appears) in the office, there is less need to refer patients out of the practice either to psychiatrists or to other mental health professionals.
From the standpoint of the drug company, things look a bit different. If psychiatrists prescribe a new antidepressant, then the potential market is a certain size. If primary care physicians as well as psychiatrists can be persuaded to prescribe the drugs, the potential market increases greatly. If primary care physicians can also be persuaded that a patient who in former days would have been viewed as simply reacting to bad life circumstances, or going through a bad spell, can be reclassified as having a depression that deserves drug treatment, the market is further expanded. If the questionnaire is designed to set the threshold for diagnosing depression lower than is strictly warranted, it is unlikely that the primary physician will have the expertise to challenge this.
For such a questionnaire to have the desired effect, other aspects of the channel have to be favorable. The physician, for example, must be persuaded that whereas older antidepressants were somewhat dangerous to administer, the newer classes of drugs are considerably safer and so can be prescribed with relative impunity. In this way, the various aspects of the overall marketing campaign all fall into place.
The twin strategies of controlling the channels, and not appearing to be controlling the channels, have important implications for other parties along the pathway, especially physicians and patients. The role of the pharmaceutical industry becomes inherently less trustworthy. Even if, in any specific instance, a drug firm is communicating candidly, other actors must remain suspicious that some level of subterfuge is intended to conceal an effort to exert control over other parties’ behavior. Another important implication, which I will develop more below, is that one highly efficient way to control a channel is to change the way both physicians and patients think about a medical condition. If these other actors can be persuaded to think about a disease in a drug-prescribing-friendly fashion, the industry can be assured of sales, even while other actors fondly believe that they are doing nothing more than acting in accord with their own self-interests (or professional responsibilities) and are not a party to marketing manipulation at all.
The case studies of antidepressant drugs and drug therapy for type 2 diabetes illustrate how what at first seems to be the desirable “patient-centered care,” or even the less desirable “disease-centered care,” can easily be rechanneled into drug- centered “care.”