Selling Tests, Selling Treatments: A Few Reflections on Medical Advertising
Posted by George Estreich, <i>Biopolitical Times</i> guest contributor December 18, 2013
Biopolitical Times
If you're interested in biopolitics, it's easy to feel off the radar. Prophets of climate change are at least vaguely familiar. They may often be dismissed, derided, or ignored, but at least they can assume that people acknowledge that there is such a thing as a climate, and have heard that it is changing. Notwithstanding writers like Margaret Atwood and Paolo Bacigalupi, whose visions of the future entwine catastrophic climate shifts and genetic engineering run wild, being interested in synthetic biology, or direct-to-consumer genetic tests, or the misrepresentation of disability in the age of prenatal prediction, can feel like being a prophet of the wrong disaster, on an abandoned street corner.
So it was with great interest that I read a piece in The New York Times a couple days ago, detailing the abuses of the pharmaceutical industry in selling treatments for attention deficit disorder – or, to be more precise, in quintupling the market for ADD drugs through a coordinated program of persuasion on every front, right down to shaping the science which is then cited as impartial support. The article interested me because the strategies it describes fit with what I've been seeing in the selling of prenatal tests. This, in turn, got me thinking about some of the concerns we may share with activists in other fields.
The parallels between the selling of ADD and the selling of prenatal screens are significant. Indeed, to say "parallels" may be misleading: both are phenomena of medical advertising, and both products are meant not to cure/prevent life-threatening conditions, but mainly or purely to address ability or achievement. Further, what's being sold is not only the product per se: it's also an idea of how to be, and in particular, what we want our children to be like. We want them, in short, to succeed.
I should say, in passing, that ADD is an actual thing. Though I think that the condition may be particularly noticeable in our achievement-oriented society, and in an educational system that emphasizes sitting, listening, and not disturbing the rest of the large (because largely underfunded) class, it is nonetheless true that ADD is real and the drugs are not placebos. Like antidepressants, they can help. The problem, as the article makes clear, is in the aggressive attempts to expand the market.
These attempts are, of course, precisely parallel to the vigorous marketing effort now underway with the new NIPS (noninvasive prenatal screen, a genetic test of very early fetuses based on a sample of the mother’s blood). As historian Alexandra Minna Stern pointed out recently at the Future Past conference, the market for these tests is vast: all women of childbearing age.
To convince people to adopt the test, you have to accomplish a number of things. You have to downplay any risk associated with the test itself. You have to establish the test as a "scientific" thing to do – hence the recommendations from professional organizations (some of which actually caution against misuse and overuse of the test, though the companies tend to ignore those passages), plus all the numbers, graphs, and general science-y feel of the websites. And you have to highlight the risk of not using the product. You establish a happy world on the product side, and a sad, anxious world on the not-product side, and then it's clear where the consumer should go.
Expanding a market is both a persuasive and an interpretive act. It involves a delicate balance between stigma and acceptance. If the condition is too stigmatized, people won't willingly admit they have it; conversely, if it's accepted as a normal part of being human, then people won't buy treatments for it. So, for example, you recruit a celebrity to be open and self-accepting about his ADD – and yet you portray children as hidden or obscured or weighed down by the condition. A delicate dance.
This balancing act is particularly important for a condition like ADD that is diagnosed on the basis of self-reported symptoms. In other words, absent an objective test, what people think they have shapes what they say about themselves to a doctor. Hence the importance, presumably, of self-administered questionnaires – which, as the Times reports, tend to indicate the possibility of ADD far above its actual occurrence in the population.
I was interested to read, too, that the selling of ADD drugs began with a bit of wordplay on the part of a pharmaceutical executive:
In the case of drugs like Adderall and Concerta, the interpretive act, the meaning-making achievement, is enabled by considerable financial muscle. Since corporations are people now, let’s call Shire (the company that sells Adderall) something friendlier, like Brad. Here’s what Brad can do: pay for research with a friendly conclusion; pay for doctors to be exposed to the research; cause millions of brochures to be written, printed, and distributed; take out state-of-the-art ads in mass-market, industry, and medical publications; sponsor parent advocacy groups; write and distribute comic books aimed at children; hire armies of sales representatives to pitch doctors directly; and hire Adam Levine (the frontman of Maroon 5, and celebrity judge on The Voice) to front your campaign.
The question that preoccupies me is this: How to respond? How does an actual person with an opinion – a person-person – respond to the sort-of person that is a corporation? When the sort-of person can spend millions not only to get a persuasive message out, but to alter the basis of fact from which we operate in the first place, how does a person-person respond?
Perhaps the first task would be to establish a taxonomy of error: to detail the standard abuses in the selling of new advances. Lots of work has been done on this, so I don’t expect to cover new ground here. But I would suggest, as a way of beginning the conversation, the following checklist, which could be used as a diagnostic tool when looking at advertising for a product.
So it was with great interest that I read a piece in The New York Times a couple days ago, detailing the abuses of the pharmaceutical industry in selling treatments for attention deficit disorder – or, to be more precise, in quintupling the market for ADD drugs through a coordinated program of persuasion on every front, right down to shaping the science which is then cited as impartial support. The article interested me because the strategies it describes fit with what I've been seeing in the selling of prenatal tests. This, in turn, got me thinking about some of the concerns we may share with activists in other fields.
The parallels between the selling of ADD and the selling of prenatal screens are significant. Indeed, to say "parallels" may be misleading: both are phenomena of medical advertising, and both products are meant not to cure/prevent life-threatening conditions, but mainly or purely to address ability or achievement. Further, what's being sold is not only the product per se: it's also an idea of how to be, and in particular, what we want our children to be like. We want them, in short, to succeed.
I should say, in passing, that ADD is an actual thing. Though I think that the condition may be particularly noticeable in our achievement-oriented society, and in an educational system that emphasizes sitting, listening, and not disturbing the rest of the large (because largely underfunded) class, it is nonetheless true that ADD is real and the drugs are not placebos. Like antidepressants, they can help. The problem, as the article makes clear, is in the aggressive attempts to expand the market.
These attempts are, of course, precisely parallel to the vigorous marketing effort now underway with the new NIPS (noninvasive prenatal screen, a genetic test of very early fetuses based on a sample of the mother’s blood). As historian Alexandra Minna Stern pointed out recently at the Future Past conference, the market for these tests is vast: all women of childbearing age.
To convince people to adopt the test, you have to accomplish a number of things. You have to downplay any risk associated with the test itself. You have to establish the test as a "scientific" thing to do – hence the recommendations from professional organizations (some of which actually caution against misuse and overuse of the test, though the companies tend to ignore those passages), plus all the numbers, graphs, and general science-y feel of the websites. And you have to highlight the risk of not using the product. You establish a happy world on the product side, and a sad, anxious world on the not-product side, and then it's clear where the consumer should go.
Expanding a market is both a persuasive and an interpretive act. It involves a delicate balance between stigma and acceptance. If the condition is too stigmatized, people won't willingly admit they have it; conversely, if it's accepted as a normal part of being human, then people won't buy treatments for it. So, for example, you recruit a celebrity to be open and self-accepting about his ADD – and yet you portray children as hidden or obscured or weighed down by the condition. A delicate dance.
This balancing act is particularly important for a condition like ADD that is diagnosed on the basis of self-reported symptoms. In other words, absent an objective test, what people think they have shapes what they say about themselves to a doctor. Hence the importance, presumably, of self-administered questionnaires – which, as the Times reports, tend to indicate the possibility of ADD far above its actual occurrence in the population.
I was interested to read, too, that the selling of ADD drugs began with a bit of wordplay on the part of a pharmaceutical executive:
All.“A.D.D. for All” may be Pharma’s wishful thinking – but “ADD for many” is what they’ve managed to achieve. According to the article, “sales of prescription stimulants have more than quintupled since 2002.”
For A.D.D.
A.D.D. for All.
Adderall.
In the case of drugs like Adderall and Concerta, the interpretive act, the meaning-making achievement, is enabled by considerable financial muscle. Since corporations are people now, let’s call Shire (the company that sells Adderall) something friendlier, like Brad. Here’s what Brad can do: pay for research with a friendly conclusion; pay for doctors to be exposed to the research; cause millions of brochures to be written, printed, and distributed; take out state-of-the-art ads in mass-market, industry, and medical publications; sponsor parent advocacy groups; write and distribute comic books aimed at children; hire armies of sales representatives to pitch doctors directly; and hire Adam Levine (the frontman of Maroon 5, and celebrity judge on The Voice) to front your campaign.
The question that preoccupies me is this: How to respond? How does an actual person with an opinion – a person-person – respond to the sort-of person that is a corporation? When the sort-of person can spend millions not only to get a persuasive message out, but to alter the basis of fact from which we operate in the first place, how does a person-person respond?
Perhaps the first task would be to establish a taxonomy of error: to detail the standard abuses in the selling of new advances. Lots of work has been done on this, so I don’t expect to cover new ground here. But I would suggest, as a way of beginning the conversation, the following checklist, which could be used as a diagnostic tool when looking at advertising for a product.
- Is persuasion being presented as information?
- Are deep, irreducible human qualities being reduced to diagnostic categories? Are ways of being formerly thought to be part of life being pathologized? In what ways are the limits of “health” being expanded?
- What would the world look like if everyone who possibly could use the product did use it?
- In what ways is risk being portrayed? In what ways does the product on offer promise to reduce or eliminate risk?
- In what ways are the risks of the product itself being minimized?
- In the advertisement, is there anything that seems an absolute, inarguable good, like “a healthy child?” If so, what – or whom – does this good exclude? Or, to put it another way, with what other absolute, inarguable goods does the first good conflict?
Perhaps questions like these offer a partial solution to our lonely-prophet problem. To be interested in the effects of new human biotechnologies is at least in part to be interested in the way those technologies are sold.
Previously on Biopolitical Times: