PLoS Medicine | www.plosmedicine.org 0445
Essay
April 2006 | Volume 3 | Issue 4 | e189
I
t is often said that leading drug
companies now spend more
on marketing than on research
and development [1]. While such
contemporary pharmaceutical
marketing practices are sometimes
believed to be a modern phenomenon,
they are in fact a direct continuation
of 19th-century patent medicine
advertising. “Nostrum-mongers,” as the
novelist Henry James dubbed them,
are noted in the history of advertising
as having been the leading spenders
on, and foremost originators of,
advertising technique [2,3]. Nostrum
sellers pioneered print advertising,
use of trademarks and distinctive
packaging, “pull” or demand-
stimulation strategies, and even the
design and commissioning of medical
almanacs that functioned as vehicles for
promotion of disease awareness. Henry
James’s psychologist brother, William
James, was so exasperated by “the
medical advertisement abomination”
that in 1894 he declared that “the
authors of these advertisements should
be treated as public enemies and have
no mercy shown” (see page 235 in [4]).
There is no doubt that drug
company discoveries have profoundly
improved upon our capacity to treat
illness. But pharmaceutical marketing
is more closely aligned with consumer
marketing in other industries
than with medicine, for which the
consequences are not trivial. Once we
view pharmaceutical industry activities
in this light, we can disentangle
industry’s infl uence on contemporary
medicine. Because we believe that
we owe corporations our wealth and
well-being, we tend not to question
corporations’ fundamental practices,
and they become invisible to us. What
follows is an attempt to demystify some
of the assumptions at work in the
“culture of marketing,” toward the goal
of explaining contemporary disease
mongering.
Beliefs about the Free Market
There are three beliefs commonly
associated with the “free market.” The
fi rst is that human beings are creatures
of limitless but insatiable needs, wants,
and discomforts. The second is that
the free market is a place where these
needs might be satisfi ed through the
exercise of free choice. The last of
these beliefs is that the surest avenue
to innovation in all industries is
unfettered competition in the market.
Insatiable needs. The anthropologist
Marshall Sahlins theorizes that the
belief in unlimited wants is unique in
the West, and stems from the Christian
notion of “fallen man” as sufferer.
This results, says Sahlins, in a peculiar
idea of the person “as an imperfect
creature of need and desire, whose
whole earthly existence can be reduced
to the pursuit of bodily pleasure and
the avoidance of pain” [5]. A historical
and philosophical examination of
professional marketing shows that an
assumption of boundless needs and
wants is also at the heart of marketing
theory. In this sense, marketing can
be regarded as the institutionalization
of this view of human nature. The
marketer’s challenge is to translate
those limitless needs into profi ts.
Sahlins also points out that “in
the world’s richest societies, the
subjective experience of lack increases
in proportion to the objective output
of wealth” [6]. In other words, the
richer we get, the more we want.
One explanation of this paradox lies
in the way marketing activities are
instrumental in getting us to think
more about what we lack. Marketers
and advertisers project and refl ect back
to us our discontent with the status
quo. Americans are said to spend,
on average, three years of their lives
watching television advertisements, and
the effect is that they are conditioned
to want more and more. According
to the advertisements, the viewer’s
personal anxieties and dissatisfactions
are best addressed by consumption.
This same message lies at the heart of
much pharmaceutical advertising.
Lifestyle choices. In a consumer
society, when individuals make choices
toward the satisfaction of their needs
and wants, they experience this as
constructing their own individuality
Pharmaceutical Marketing and the Invention
of the Medical Consumer
Kalman Applbaum
Funding: The author received no specifi c funding for
this article.
Competing Interests: The author has declared that
no competing interests exist.
Citation: Applbaum K (2006) Pharmaceutical
marketing and the invention of the medical
consumer. PLoS Med 3(4): e189.
DOI: 10.1371/journal.pmed.0030189
Copyright: © 2006 Kalman Applbaum. This is an
open-access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Kalman Applbaum teaches medical anthropology at
the University of Wisconsin Milwaukee, Milwaukee,
Wisconsin, United States of America. KA is the author
of The Marketing Era: From Professional Practice
to Global Provisioning (Routledge 2004). E-mail:
applbaum@uwm.edu
The Essay section contains opinion pieces on topics
of broad interest to a general medical audience.
DOI: 10.1371/journal.pmed.0030189.g001
Pills are often marketed as a solution to
human anxieties and dissatisfactions
PLoS Medicine | www.plosmedicine.org 0446
and identity. This special consumer
identity is what people refer to when
they use the word lifestyle, though
they may not realize the consumerist
implications of the word. Marketing
claims to provide a solution to the
problem of unlimited needs and wants,
while simultaneously enhancing free
choice and the construction of lifestyle.
In pharmaceuticals specifi cally,
“lifestyle drug” marketing techniques
were honed in the 1980s and 1990s for
cosmetic and sexual enhancements
[7,8]. These techniques have been
broadened to include other areas
of medicine. The campaigns used
to market cosmetic and sexual
enhancements were focused on
expanding perceived need for these
products, and in this respect were
a simple extension of customary
marketing conduct that had existed
for over half a century. The crossover
to curative medicine occurred with
psychotropic drugs, which have a very
wide range of active properties, thus
granting the marketer latitude in
reinterpreting their value back to the
consumer. For example, one class of
antidepressants, the specifi c serotonin
reuptake inhibitors, is marketed for
eight distinct psychiatric conditions,
ranging from social anxiety disorder
to obsessive-compulsive disorder to
premenstrual dysphoric disorder.
And “lifestyle marketing” has now
extended to the promotion of many
of the blockbuster “maintenance
drugs” intended for daily, lifelong
consumption, such as drugs for
allergies, insomnia, and acid refl ux.
As a result of this sequence of
events, industry opened the treatment
of the inside of the body—the fi nal
frontier—to the same logic that
governs all other marketing. Whether,
in the antidepressant market, the
“distribution channel captain,” as
marketers refer to the predominant
competitor, ends up sailing the
serotonin reuptake channel (the
serotonin reuptake inhibitors) or the
norepinephrine reuptake channel (the
challenger, serotonin–norepinephrine
reuptake inhibitors) may yet be
determined by marketing rather than
by medical jockeying.
Competition among drug companies
yields innovation. It is an article of
faith among free market devotees
that breakthroughs spring not from
paternalistic expert systems such
as medicine but from industrial
competition. As long as fi rms are
committed to producing medications
to treat diseases—as they are
classifi ed by medical science—this
argument has some authority. But
once a fi rm becomes principally
driven by marketing—the case for
most companies in most industries
since the 1980s—then innovation
comes to mean an elaboration of
meaningless differences among
a fi eld of comparable “me too”
products. “If marketing is seminally
about anything,” said Theodore
Levitt, one of the towering fi gures
of marketing and former editor of
the Harvard Business Review , “ it is
about achieving customer-getting
distinction by differentiating what you
do and how you operate” [9]. More
harmfully, expanding and altering
the consumer’s perception of disease
is just as effective, and evidently a lot
easier, than fi nding new cures.
From Patients to Medical
Consumers
Since, in a consumer society, we
see ourselves as individuals and
as free agents when we exercise
consumer choice, it is not diffi cult for
pharmaceutical companies and other
privatized health-care deliverers to
convince us that it is empowering to
think of ourselves not as patients but
as consumers. This conversion from
patient to consumer also paves the way
for the erosion of the doctor’s role as
expert. A startling report of this was
described in a recent New York Times
article: “For a sizable group of people
in their 20’s and 30’s, deciding on their
own what drugs to take—in particular,
stimulants, antidepressants and other
psychiatric medications—is becoming
the norm. Confi dent of their abilities
and often skeptical of psychiatrist’s
expertise, they choose to rely on
their own research and each other’s
experience in treating problems like
depression….A medical degree, in
their view, is useful but not essential”
[10]. This phenomenon, the article
suggested, is “driven by familiarity”
with the drugs. The emergence of
this potentially dangerous situation
demonstrates an unchecked expansion
of the drug industry into an already
accepted mode of thought—that “every
minor mood fl uctuation,” as the article
reported, can and should be remedied.
Promoting consumer familiarity
with drugs is one example of the very
broad infl uence of the pharmaceutical
industry. This infl uence extends to
clinical trial administration, research
publication, regulatory lobbying,
physician and patient education, drug
pricing, advertising and point-of-use
promotion, pharmacy distribution,
drug compliance, and the legal and
ethical norms by which company
practices themselves are to be
evaluated. Actors traditionally found
outside the “distribution channel” of
the market are now incorporated into
it as active proponents of exchange.
Physicians, academic opinion
leaders, patient advocacy groups
and other grass roots movements,
nongovernmental organizations,
public health bodies, and even
ethics overseers, through one means
or another, have one by one been
enlisted as vehicles in the distribution
chain. The inclusion of patients in
the distribution chain fundamentally
changes their role from recipients
of medical care to active consumers
of the latest pharmaceuticals, a role
which surely helps to support industry
profi ts.
Ethical Justifi cation for Marketing
Because illness is one of the most
tangible forms of suffering, the
pharmaceutical industry, more than
other industries, can link its marketing
activities to ethical objectives. The
result is a marriage of the profi t-
seeking scheme in which disease is
regarded as “an opportunity” to the
ethical view that mankind’s health
hangs in the balance. Marketers and
consumers in the West to some extent
share a common vision of needs and
the terms of their satisfaction. This
apparent complicity helps even the
most aggressive marketers trust that
they are performing a public service.
Pharmaceutical company managers
that I speak to signal this when they
characterize their engagement with
the public as “doing good while doing
well.”
An assumption of
boundless needs and
wants is at the heart of
marketing theory.
April 2006 | Volume 3 | Issue 4 | e189
PLoS Medicine | www.plosmedicine.org 0447
These managers also see nothing
wrong with integrating doctors,
patients, and other players into
the drug distribution channel. On
the contrary, they say, this is state-
of-the-art management, making it
professionally principled and tactically
astute. Marketers also regard the
incorporation of consumers into
the channel as ethical because then
people’s needs can best be determined
and satisfi ed, conferring upon them the
power of self-determination through
choice.
But this choice is an illusion. For in
our pursuit of a near-utopian promise
of perfect health, we have, without
realizing it, given corporate marketers
free reign to take control of the true
instruments of our freedom: objectivity
in science, ethics and fairness in health
care, and the privilege to endow
medicine with the autonomy to fulfi ll
its oath to work for the benefi t of the
sick.
References
1. Angell M (2004) Over and above: Excess in the
pharmaceutical industry CMAJ 171: 1451.
2. Young JH (1961) The toadstool millionaires: A
social history of patent medicines in America
before federal regulation. Princeton (New
Jersey): Princeton University Press. 282 p.
3. Lears J (1994) Fables of abundance: A cultural
history of advertising in America. New York:
Basic Books. 512 p.
4. Laird PW (1998) Advertising progress:
American business and the rise of consumer
marketing. Baltimore (Maryland): Johns
Hopkins University Press. 480 p.
5. Sahlins M (1994) Cosmologies of capitalism:
The trans-pacifi c sector of “The World System.”
In: Eley G, Dirks NB, Ortner SB, eds. Culture/
power/history: Reader in contemporary social
theory. Princeton (New Jersey): Princeton
University Press. pp. 412–456.
6. Sahlins M (1996) The sadness of sweetness:
The native anthropology of Western
cosmology. Curr Anthropol 37: 395–428.
7. Lexchin J (2006) Bigger and better: How Pfi zer
redefi ned erectile dysfunction. PLoS Med 3:
e132. DOI: 10.1371/journal.pmed.0030132
8. Tiefer L (2006) Female sexual dysfunction: A
case study of disease mongering and activist
resistance. PLoS Med 3: e178. DOI: 10.1371/
journal.pmed.0030178
9. Levitt T (1986) The marketing imagination.
New York: Free Press. 238 p.
10. Harmon A (2005 November 16) Young,
assured and playing pharmacist to friends. New
York Times. Available: http:⁄⁄www.nytimes.
com/2005/11/16/health/16patient.html?ex=
1289797200&en=ecbeab25b58126c4&ei=
5088&partner=rssnyt&emc=rss. Accessed 6
March 2006.
April 2006 | Volume 3 | Issue 4 | e189