From Paxil and Prozac to Ritalin and Viagra, Big Pharma is a multibillion-dollar global business. With a court battle that may result in Canada allowing drug companies to target ads directly at ¬consumers, how much of 'selling sickness' are we willing to swallow?
Out here on the fleece-clad West Coast, we like to think our active lifestyles keep us healthy. We exercise more than the rest of Canada, we don’t smoke as much and we live longer. But alongside those cheerful facts is a counterintuitive and alarming one: we are also consuming prescription drugs at an unprecedented rate. If we’re so healthy, why are we ¬popping so many pills? British Columbians are sophisticated when it comes to health issues. We’re widely read and up-to-date on the latest scientific news. We surf the Internet to discover the latest in natural remedies. But if drug company critics are to be believed, the reason we take so much medication is because – sophisticated or not – we are the victims of a major marketing conspiracy that has persuaded us to buy far more than we need. Through ¬vigorous marketing, these companies have convinced doctors that it’s in our best interests to prescribe these products. With targeted advertising, drug companies have drilled into our natural anxieties, convincing us we might be sick, scaring us into taking expensive medication for non-existent diseases.
These days, there’s an ill for every pill. Even being at risk of an illness has effectively been branded as having a disease ¬requiring preventive treatment. Hypertension and high ¬cholesterol, both physiological factors contributing to a higher risk of heart failure, are now indelibly branded in the public consciousness as diseases in their own right. Drugs designed to treat them are now the best-selling pills in the world. Health critics such as UBC researcher Barbara Mintzes and University of Victoria pharmaceutical researcher Alan Cassels say this is no ¬coincidence, pointing their fingers directly at aggressive drug company marketing strategies. Let’s face it: we’re bombarded daily with advertising and health information designed to make us anxious about our well-being. It seems to be effective, if statistics on skyrocketing drug use are anything to go by (see “Drugged Out?”). Is there anyone reading this who hasn’t wondered whether they should be getting their cholesterol or bone density checked? What about Ritalin for the kids? Hormone replacement therapy? Ever asked your doctor about antidepressants for anxiety or PMS? Who hasn’t seen an ad for Viagra? Prescription drug manufacturers say the concerns raised are nonsense. They’re in the business of making medicines that save many lives and improve the quality of millions of others. Yes, they supply information on their products to doctors. Yes, they try to raise awareness about disease. But consumers are discerning individuals who are entitled to be informed about the diseases they could have and the drugs available to treat them. And prescribing those drugs are doctors who are ostensibly independent medical experts and effective filters of any drug-company bias or propaganda. Victoria pharmacist Steven Dove also reminds us that it’s thanks to the drug industry that Canadians are living longer. “Pharma-ceutical companies have worked miracles in the last 50 years,” he says. Prescription drugs for cancer, HIV/AIDS, clinical depression and other life-threatening conditions are a boon. Gabriola Island physician Verne Smith makes that point emphatically with a single example: “When I started medicine [in 1958] everyone with Hodgkin’s disease died. Now they mostly don’t.” Given the breadth of access to health information, do concerns about the heavy-handed marketing of drugs really matter? On the one hand, we’re intelligent human beings who should have freedom of choice in our health care. We’re grown-ups who can make our own decisions, so advertise away; it’s only fair. Conversely, some argue that the state of our health is an emotional area in which we are highly vulnerable, and playing on that vulnerability with advertising that makes us think we’re sick is unethical and unfair. Only doctors should diagnose illness and prescribe treatment, goes the argument, and those doctors should not be subject to any form of influence by the drug companies. In the meantime, it’s the patient who is caught in the middle of the debate. Well-¬ informed or not, healthy or unhealthy, he or she simply isn’t in a position to contradict either the drug companies or the family physician. Noam Smith is a 65-year-old retired marketing executive. He and his wife Sylvia, 61, are well educated and are avid readers of magazines and Internet sites. (Their names have been changed to protect their privacy.) Neither likes the idea of taking drugs and both scorn the pop-a-pill-and-feel-better messages contained in drug advertising. Nonetheless, they are familiar with all the household-name pharmaceutical firms – the Merck Frossts, the Glaxos – and can reel off brand names such as Lipitor, Ritalin and Paxil without hesitation. Fifteen years ago the only prescription drug on this couple’s radar screen was the occasional dose of penicillin. Today they are painfully familiar with a wide range of medications. Everyone they know takes something. Many of their grandchildren’s friends are on Ritalin and a close friend of their son’s has been on Paxil for several years. Another friend saw an ad for Pfizer’s anti-inflammatory Celebrex in a magazine, touted in the media as a miracle drug in the treatment of arthritis. She tore it out, marched into her doctor’s office and demanded a prescription. He was writing it out before she’d even finished speaking. The majority of their contemporaries, say Noam and Sylvia, take a daily cocktail of meds including beta-blockers for hypertension and cholesterol-lowering drugs. It isn’t necessarily a question of age. Noam’s father is 92 and he doesn’t take any of these drugs. [pagebreak] But Noam does. Four years after reluctantly consulting a doctor about dizzy spells, Noam finds himself trapped on a treadmill of medications for hypertension he wishes he wasn’t on, doesn’t know if he really needs, but is frightened to stop taking. Hypertension, or high blood pressure, features heavily in this debate. It’s easily modified with beta-blockers, a godsend to someone with dangerously high levels. The drugs reduce the risk of a heart attack, but other ways to lower risk include addressing lifestyle issues such as stress, lack of exercise and poor diet. Once you’ve been prescribed a beta-blocker, it can be difficult to wean yourself off. Withdrawal from the drug can cause the heart attack it was meant to prevent. North American guidelines for what constitutes a high level of blood pressure have also been revised downward repeatedly in the last 15 years, vastly enlarging the potential market. A systolic pressure of 160 was once considered acceptable for a 60-year-old. Now a systolic level of 140 for a 50-year-old is enough to trigger treatment. As the definition of high blood pressure changes, drug companies on a global scale have worked to heighten awareness of hypertension and promote the benefits of the drugs. By 2001, 17 million Canadians were seeing a doctor for treatment of high blood pressure, an increase of 30 per cent from 1997. Hyper-tension drugs are now a multi-billion-dollar industry. Smith’s dizzy spells have disappeared and his blood pressure is down to acceptable levels. Although he is all for managing the risk of a heart attack appropriately, he wonders if the drug regimen that became a permanent feature of his health care was really necessary. He questions the speed with which his doctors reached for their prescription pads. “No matter how well-educated or assertive you are, you still don’t question doctors,” says Sylvia Smith. “They’re on a pedestal. They are supposed to know best.” Noam nods in agreement. “Ironically, I also think I could have asked for any drug I wanted and they would have given it to me,” he adds. “I’ve got no doubt about that.” Behind the brand The branding of hypertension as a disease is just the tip of the illness- marketing iceberg. In 2005, Alan Cassels co-authored Selling Sickness: How the World’s Biggest Pharmaceutical Companies are Turning Us All into Patients. Much of his criticism is levied at American drug manufacturers, but he says the same practices are alive and well in Canada. Direct-to-consumer advertising is illegal in this country, but the fact remains that drug companies have been investing for years in marketing in Canada aimed both at doctors and the public. Part of the strategy is to give the normal ups and downs of everyday life medical legitimacy. Ordinary premenstrual tension has been turned into a mental illness called ¬premenstrual dysphoric disorder. It appears to have no base in empirical medicine, and yet following its categorization as a disorder, Eli Lilly successfully repatented Prozac in the United States under the name Sarafem for use in its treatment, earning millions in revenue. Likewise, clinical depression has been successfully parlayed into dozens of social disorders that can be medicated, including shyness, a sign of “social anxiety disorder.” The other tactic is fear-mongering advertising. Despite the ban on direct-to-consumer advertising in Canada, direct advertising and promotion of prescription medication to physicians is legal. So are advertisements to the public that focus on raising awareness of a disease, and ads that mention a brand name but not the specific use of a drug. These ads are directly aimed at raising public anxiety. Pfizer Canada ran an ad featuring the tagged toe of a corpse in a morgue over the question: “Would you rather have a cholesterol test or a final exam?” Pfizer makes a cholesterol drug that is widely sold in Canada. Similar ads featured a rhinoceros waiting around the corner for a strolling pedestrian who hadn’t been paying proper attention to his health. Ditto the shark lurking in the swimming pool. The message is clear: beware and be fearful. We’re easily convinced. In B.C., drug companies can trade on our Lotus Land eagerness for well-being. Steve Dove has been in the pharmacy business for 32 years. He says baby boomers aren’t a hard sell: “We’ve got this idea we want to live forever and we’ll spend whatever it takes to do it.” As a pharmacist, Dove doesn’t like the idea of companies adver¬tising directly to consumers. “It puts ideas in people’s heads that wouldn’t be there otherwise.” He raises cautions about the growing pressure to put decisions entirely into the hands of consumers. “Back in the ’60s, pharma¬cists couldn’t even put the name of the prescribed drug on the label. Now you’re legally required to discuss everything about the drug with the patient. It’s an age of full disclosure, of the consumer making the choice.” Unfortunately, no matter how well informed we are, in a field of such scientific complexity most of us, like Noam Smith, are not in a position to know where the line between medical fact and fiction falls. Doctors promise they have our best interests at heart and so do drug manufacturers. Regulating the physicians and the drug companies is the federal government. But since policy-makers and regulatory agencies are not medical experts, how are these bureaucrats supposed to question the validity of medical decisions, or tell health professionals and drug research scientists that they are wrong? Barbara Mintzes says one of the problems is the way conditions are characterized: “Diseases get misrepresented and it’s very difficult for patients to tease that apart. For example, osteoporosis has been successfully redefined by the drug manufacturers as a disease in terms of bone density. But osteoporosis is really just a stage on a continuum of aging.” Promotional campaigns that began in the mid-1990s in Canada urged preventive treatment in relatively young women. Drug companies began subsidizing the cost of bone density testing apparatus and sponsoring screening clinics. Heavy lobbying efforts were made to have private insurers and public funders include the cost of tests in their plans. In Alberta, the number of women tested in 1994 totalled 2,500; in 2000, the total was 90,000. It’s worth pondering how many of those tested ended up with scripts for Fosamax or Actonel in addition to or instead of receiving the standard advice on adding calcium and vitamin D to their diets. Are British Columbians putting undue pressure on their family doctors to prescribe medications such as Fosamax that the drug companies are trying to convince us we need? Michael Golbey is a family physician in Kelowna and president of the B.C. Medical Association. He says the BCMA doesn’t support direct advertising to consumers because most people simply are not in a position to under¬stand the use of drugs. “That’s a matter between doctors and patients, not 50 seconds of advertising and patients. That’s just silly.” Gabriola Island family physician Verne Smith adds that while there is likely a subliminal effect from advertising of prescription drugs, he can’t say he’s ever found himself under pressure from a patient to prescribe a drug he isn’t comfortable with. Warren Bell, who has practised medicine in Salmon Arm for 27 years, says his experience is different: “People come to my office every day asking for pills they don’t need.” [pagebreak] Bell let loose his frustration in a late-night email typed out after a long day of seeing patients: “There’s a relatively recent phenomenon, unprecedented in scale and scope, of disease identification being driven exclusively by public relations departments of large multinational corporations. This option [used to be] held in check by lack of [direct-to-consumer advertising], which meant that the rabid PR job of industry had to be tailored to the conservative and somewhat informed psyche of the physician. Now that drug corporations have direct access to the public consciousness, they are unleashing their full-metal-jacket assault on what is or is not a disease. Baldness, impotence, shyness: there’s no end to it. The only limits are the imaginative scope of the drug industry PR wonks on the one hand and, on the other, the willingness of society and governments to tolerate such behaviour.” In January of this year, the Health Council of Canada released a report on the public health implications of drug company advertising authored by Barbara Mintzes. Countering claims that television commercials and print ads educate patients and give them more autonomy, Mintzes found, after analyzing the impact of ads in the U.S. and New Zealand, that they contained nowhere near enough information to adequately inform patients. A majority of doctors in New Zealand felt pressured by patients to prescribe advertised medicines. When it comes to influence on doctors by the manufacturers, Verne Smith says he’s going to do what is medically correct, not what a drug company tells him. “I think we doctors are a cynical bunch. I was taught in medical school to be very questioning of drugs. I still am.” Smith believes doctors in B.C. don’t fall prey to hard-selling by drug companies. Ottawa-based Pharmaceutical Advertising Advisory Board (PAAB) commissioner Ray Chepesiuk is more direct. Drug companies do exert influence on doctors, and it’s a two-way street, he says: “We all know if you pay some doctors enough they’ll be on your side, at least for a while.” The PAAB was founded in 1976 as an independent agency for the purpose of vetting the advertising of prescription drugs in Canada. Health Canada remains the ultimate authority, but PAAB reviews and pre-clears drug advertising. Such pre-clearance isn’t legally required, but it’s heavily recommended by PAAB. According to Chepesiuk, advertising standards “are much higher than they were 15 or 20 years ago. Both doctors and the public are much more aware. There are some stupid marketing practices here – trying to disguise marketing trials as clinical trials, for example – but there are also very good ones.” Transgressions of the rules continue. Pharmaceutical companies offer financial support to health professionals to attend sponsored conferences, and still distribute promotional products plastered with brand names. They start marketing before a product has been fully cleared. Rx&D, a national association to which many of Canada’s pharmaceutical companies belong (see “The Toothless Watchdog,” p. 107) and which works closely with PAAB, has its own code of ethics regarding advertising and promotions. It deals with more than a dozen breaches of the code by its members annually. But Chepesiuk says marketing transgressions by drug companies aren’t widespread and that criticisms of American practices simply don’t apply in Canada. He cites good marketing practices in this country, such as the support clinics and toll-free telephone numbers companies operate to provide patient education on their products. “Who knows more about the drug than the company itself, after all?” he asks. Indeed. Barbara Mintzes says the low incidence of formal transgressions just means the standards and their enforcement are not rigorous enough. She cites billboard ads for prescription acne medication in eastern Canada that feature impossibly beautiful young men and women, and she accuses the drug manufacturers of playing on a vulnerable, youthful audience. Fighting back Members of the Better Pharmacare Coalition (BPC), an association of most of the major B.C. patient groups, are aligned in pushing for greater patient access to medications through wider Pharmacare coverage. BPC coordinator Brian Battison says its members are very careful about not being perceived as influenced by industry when they are advocating the use of drugs. “There’s no undue influence. And you could ask, who’s using who? We’re reliant on the money to do our work. If we can use their money to benefit our patients, then that’s a legitimate and honourable undertaking.” Battison also says people deserve credit for being able to think for themselves. “We make benefit/risk decisions 100 times a day. Shall we cross the road or not? Shall we eat salad or fries? If we have factual, accurate information, then human beings can make their own decisions.” Public exposure to drug advertising is growing. Pfizer, Merck Frosst, Bristol-Myers Squibb and GlaxoSmithKline are all household names in Canada, thanks to massive advertising budgets. Their products are touted on websites and they fund their own scientific reports on groundbreaking drugs, the results of which appear daily in the newspapers. Drug advertising can be seen on American television channels, and it is prolific in the U.S. print media, particularly in glossy life-style magazines. Some have argued that direct-to-consumer drug ads are inevitable in Canada. Case in point: CanWest MediaWorks Inc., a subsidiary of media giant CanWest Global Communications Corp., has launched a legal action in the Ontario Superior Court of Justice, challenging the federal government on its prohibition of direct-to-consumer advertising. Although the premise of the lawsuit is freedom of expression under the Canadian Charter of Rights and Freedoms, in press releases CanWest describes the current restrictions as unfair and discriminatory, the implication being that CanWest is suffering from an unfair competitive disadvantage since its media neighbours south of the ¬border are allowed to sell expensive airtime and print-ad space to drug companies. If its case proves successful, CanWest can expect to enjoy a significant boost in ad revenue. The Canadian arm of Merck Frosst, once the bad-boy poster child of the industry, thanks to the fatal side effects and subsequent recall of its anti-inflammatory wonder drug Vioxx, is a member of Rx&D. Vincent Lamoureux, manager of public affairs at Merck Frosst Canada, says Merck “subscribes religiously” to the Rx&D code of ethics, which is highly prescriptive in terms of advertising. Merck’s four top-selling products include two hypertension drugs and an anti-cholesterol drug. Lamoureux stands firmly behind his company’s products, saying it isn’t putting pressure on physicians and it certainly isn’t over-selling unnecessary drugs. “The evidence is clear that high blood pressure and cholesterol contribute to heart disease, and it’s a good thing to treat them,” he says. Like it or not, through our generous access to U.S. television, print media and the Internet, British Columbians will continue to soak up the Merck message and similarly well-crafted messages circulated by Merck’s competitors. We can turn to our family doctors for advice, but what or whom we choose to rely upon is our call. “It’s all very well having all that information, but I apply the buyer-beware principle to everything I get told now,” says Noam Smith. “I mean, what am I supposed to believe?” Local pharmas weigh in Most, if not all of B.C.’s drug firms are relatively small biotech companies still in their start-up phase, concentrating on research. But they all agree that marketing savvy goes hand in hand with promising lab results. Gordon McCauley is the CEO of Allon Therapeutics in Vancouver, which is currently developing drugs aimed at neurodegenerative conditions such as Alzheimer’s. He says there’s no question about the benefits of direct-to-consumer advertising, noting that “it helps the sales process,” he says, pointing out that “the starting position is that these are commercial organizations answering to shareholders, developing very expensive products, and marketing is to be expected. In Canada, the regulation of that is tight.” He expects that, like other small biotechs in the province, Allon will eventually strike a partnership with a larger company that can put its marketing expertise to work for the company. Aspreva Pharmaceuticals Corp. in Victoria is one of only a handful of biotech companies actually making a profit in B.C., and in 2005 it posted revenues of $76.5 million. The company takes existing drugs and assesses their use for treating less common diseases. Last year its marketing expenditure exceeded $20 million. President and co-founder Noel Hall sees patients as informed consumers who have a right to choose. “There’s a strong push for direct-to-consumer advertising to happen in Canada,” he notes. “Effectively, I think it’s already here because so much American ¬advertising comes here.”