safety, is envisaged. The necessity of acknowledging a side effect that might restrict this use is not part of the plan. When a company is faced with defending a brand that is essential to its survival, commercial logic dictates that it will take any steps necessary to preempt the emergence of a hazard, including doctoring the evidence. This commercial logic led to a relentless marketing of Zyprexa that ultimately saw it being given to children as young as twelve months of age, its clinician prescribers seemingly unable to see the massive weight gain it produces, the diabetes it triggers, the raised lipids it leads to, and the premature deaths it causes.14
As the story of H-2 blockers and the treatment of ulcers suggests, drug companies have little interest in innovative treatments that would eradicate a condition for which they have on-patent drugs that manage it after some fashion. When ulcers vanished, after the introduction of antibiotics, companies like Astra-Zeneca with a new generation of gastric acid antagonists, such as Prilosec, turned to GERD (gastro esophageal reflux disease) to replace it. This disease, which now seems so widespread and crippling, was infrequently encountered when I was training, and as such it is difficult to believe it doesn’t stem at least in part from our increasingly unbalanced and artificial diets and lifestyles. While there are unquestionably severe cases that need urgent medical treatment, it also seems the case that a large number of digestive discomforts that might be better handled by changing lifestyles have now been medicalized and are managed with medication.
Quite extraordinarily GERD has even spread into infancy, incorporating colic, a disorder that lasts a few months and responds to care in the real sense. The first drug treatment for GERD in infants—Prepulsid (cisapride)—killed significant numbers of children where colic had never been known to kill children before.15 The shock of Prepulsid-induced deaths did not lead to a return to traditional medical care of colic— children instead are now getting Prilosec (omeprazole) and other successors of Zantac.
At the eighteenth annual Pharmaceutical Conference in Paris in June 1990, Christopher Adam, then the head of marketing at Glaxo told the meeting “we are moving into the mega-product age.”16 Right he was. Zantac had just become the first blockbuster. The next year all blockbusters combined only comprised 6 percent of the market, but by 1997, when SSRIs like Prozac were the darlings of the media, this had grown to 18 percent, and by 2001 to 45 percent, under the impact of Lipitor and the statins.17 There is no blockbuster that is a life-saving drug. They are all lifestyle or risk management drugs.
In 1990, market analysts perceived two threats to Glaxo’s position as the largest drug company in the world—the possible expiry of its patent on Zantac and the emergence of Prilosec, a new drug for ulcers. In fact the danger came from Barry Marshall’s research. Prilosec did displace Zantac but for the GERD rather than the ulcer market, forcing Glaxo into a series of mergers in order to sustain its position among the leading companies. In 1995, it merged with Burroughs Wellcome, at which time its chief executive, Richard Sykes, made it clear he still regarded the company as a serious research company that would have nothing to do with lifestyle drugs like Prozac. Five years later it merged with SmithKline Beecham, whose fortunes rode on Paxil, the company’s biggest earner since. By this time Sykes was gone. The market was changing the character of drug companies and in turn the shape of medicine.
THE FACE IN THE MIRROR
The idea that brands such as Lipitor, Paxil, and Fosamax might now have penetrated medical practice in a way that brands like Clark Stanley’s Snake Oil or Beecham’s Pills never did and that these modern brands might now play as big a part in medicine as Nike and Reebok do for running shoes and Lexus and BMW do for cars is not an idea that sits comfortably with the medical profession’s idea of itself.
In the world of medicine most doctors come from, drugs are good, though they are unfortunately sold by slick if rather sleazy salespeople to whom doctors might try to be polite but whom they otherwise try to avoid—unless “these people” are picking up the drinks tab. But in the new world of medicine, the person doing the selling is not the sleazy- looking suit standing by the exhibit. That person is there to distract attention from the fact that one by one doctors are having marketed back to them exactly what they say are the things that count for them. The industry needs a person out there whom the doctor can identify as a source of corruption, someone they can resist, the way they might resist an obvious honeypot. In this new world, if a group like No Free Lunch didn’t exist, the pharmaceutical industry would have to invent it.
In other industries, when companies manufacture a product they have to move it from factory to retail outlets where it competes with other products and they have to generate demand among consumers. The ideal arrangement is to have a dedicated showroom, such as automobile makers and Apple do, where purchases become almost inevitable as there are no competing brands in sight and, in the case of cars, nothing praising the virtues of walking, running, cycling, or any other means of transport. In the case of a branded drug, the task is to get on a hospital’s or managed care company’s list of approved drugs as well as into national guidelines and to have key articles placed in all the prominent journals. We shall see in chapters 4 and 5 how companies manage this and manage to eliminate competing influences, so that when the doctor gets to the point of purchase, the purchase is as inevitable as it is in a car showroom, but here let us focus on the doctor before he walks into the showroom.
He will likely think he is not particularly influenced by the ads for drugs he sees. And in this he is undoubtedly correct to a point—at least three-quarters of the ads for a drug are not aimed at him. He may even think that most ads make him less likely to prescribe rather than more likely. He will be unaware that just as marketers distinguish between women and men, or between those of us who want high-tech versus retro running shoes, so they also have learned to distinguish between “high-flyers,” “skeptical experimenters,” “rule bound,” and “silent majority” doctors.18 Few doctors have any idea how the marketers have pigeonholed them and as a result will not be able to pick out the ads aimed at them from the ones aimed at others that serve a secondary function of throwing any particular doctor off the scent.
High flyers are the doctors keen to try new things. They don’t want to hear what is in guidelines or what colleagues are doing. They are interested in the latest reports that promote a drug for something new, or in a different cocktail with other drugs, or in a higher dose than previously recommended. These are doctors that companies term “early uptakers” and they are important to getting a new product adopted. Skeptical experimenters are similar but more likely to temper their prescribing practices on the basis of experience.
In contrast to these two types, marketers identify most doctors as either rule bound or silent-majority conservatives. For the rule bound, regulatory approval of a drug means the drug should be used for the stated purpose and for that purpose only, and in accordance with the latest guidelines. The conservative majority want everything kept simple. They pick a drug and stick to it; they’re most interested in aspects such as whether the drug comes in a new formulation that might enhance compliance—a tablet that dissolves instantly in the mouth, for example, so that patients cannot but comply.
Where doctors, the media, and others see a salesperson visiting a physician with free pens and an offer of lunch, with a pitch based perhaps on the results of some recent clinical trial on a drug, the key exchange is of a different order: it is not what is handed over to the doctor but how he or she responds to various probes and what is then fed back to the company. After that, the pitch to a high flyer will be as different as the one to a rule-bound doctor just as a car salesman’s pitch is different to someone keen to buy a sports car compared to someone who wants to buy a family car.19 The ads and the patter directed at high flyers will show a doctor on a mission to tackle the scourge of disease, a mission that sometimes justifies extreme measures, where the ads to the rule bound may feature the latest authoritative guideline. The idea is to get the mood music right in the showroom, to get the brand speak in the right tone of voice.
Doctors won’t have to
