by Bob Burton and Andy Rowell

The bulk of the world's drug deals are not done secretively in dark alleyways or noisy nightclubs but involve government-approved drugs prescribed by doctors or bought over the counter in pharmacies and supermarkets.

The global pharmaceutical industry--which generated revenues of more than $364 billion in 2001--is the world's most profitable stock market sector. According to IMS Health, the leading drug industry market analyst, half the global drug sales are in the US alone, with Europe and Japan accounting for another 37%.

While the common image of the legal drug industry is of workers in white lab coats, the reality is that public relations, marketing and administration commonly absorb twice the amount spent on drug research and development. During 2000 more than $13.2 billion was spent on pharmaceutical marketing in the US alone.

Driving the annual double-digit growth in the legal drug supply are a band of specialist "healthcare" PR companies working for behemoths such as Pfizer, GlaxoSmithKline, Merck and Astra Zeneca. Heading the healthcare PR league table are Edelman, Ruder Finn and Chandler Chicco Agency in the US and Medical Action Communications, Shire Health Group and Meditech Media in the UK.

"Medical education" includes cultivating and deploying sponsored "key opinion leaders" such as doctors. Patient groups too can be created or wooed to assist with "disease awareness campaigns" or provide emotionally charged testimony in favor of speedy regulatory approval of new drugs.

Other lucrative revenue streams for healthcare PR companies can include organizing events such as medical conferences that provide a platform for well-trained "product champions" to announce promising results of drug research. Such results can be reported by medical journalists--who can be hired by PR firms--in medical journals that they can create for their clients.

PR companies also undertake conventional lobbying strategies such as opposing restrictions on "direct to consumer" (DTC) advertising--currently allowed in the US and New Zealand--that sells drugs using the same techniques used to sell products like toothpaste.

Add to the mix the usual grab bag of tricks in issue management for dealing with dissenting scientists or journalists and you have the world of healthcare PR.

Buzz for Drugs

According to Bob Chandler and Gianfranco Chicco, former staffers at the PR firm of Burson-Marsteller the key to promoting drugs is creating "buzz." In 1997 Chandler and Chicco teamed up to found the Chandler Chicco Agency (CCA), which now boasts offices in New York and London and is ranked among the top healthcare PR companies.

CCA has plenty of experience creating "buzz," having launched Pfizer's $1 billion-a-year impotence drug, Viagra and the arthritis drug Celebrex for Pharmacia and Pfizer, which last year turned over $3.1 billion.

In a contributed article to the trade magazine PharmaVoice, Chandler and Chicco explained that "while buzz should always appear to be spontaneous, it should, in fact, be scientifically crafted and controlled as tightly as advertising in the New England Journal of Medicine."

One of the reasons for Viagra's success, they explained, was "Pfizer's sensitive and responsible approach" to encouraging potential patients to talk openly about impotence. To create "disease awareness," they hired celebrities and public officials to talk publicly about "erectile dysfunction," their preferred terminology.

"The buzz spread through the media, virtually eliminating the taboo word 'impotence,'" they wrote. In the US, they hired former Vice President Bob Dole to endorse the product, turning Viagra into "success beyond a marketer's wildest dreams."

Impotence Australia (IA), Pfizer's front group down under, launched an advertising campaign with PR support from Hill & Knowlton. The campaign hit a snag, however, when its undisclosed ties to Pfizer were detailed in separate articles in Australian Doctor and the Australian Financial Review. Ray Moynihan, the author of the AFR story, revealed that Pfizer had bankrolled Impotence Australia to the tune of $200,000 Australian dollars (US $121,000). In an interview with Moynihan, IA Executive Officer Brett McCann admitted, "I could understand that people may have a feeling that this is a front for Pfizer."

A later Impotence Australia advertising campaign featured Pele, the Brazilian soccer legend. "Erection problems are a common medical condition but they can be successfully treated. So talk to your doctor today . . . I would," Pele advised.

What Women Want

While some PR firms work to gain media profile for their clients, others work hosing down bad publicity. In January 2003, for example, pharmaceutical companies were caught with their pants down when the British Medical Journal featured an article by Moynihan challenging the use of exaggerated statistics by corporate-sponsored scientists seeking to create a new medical "syndrome" called "female sexual dysfunction."

Moynihan's article was picked up by hundreds of other publications around the world, prompting a hasty response by Michelle Lerner of the bio-technology and pharmaceutical PR company HCC DeFacto. Lerner, a former business reporter for Miami Today, scrambled to mobilize "third party" allies. She dispatched an email to a number of women's health groups.

"We think it's important to counter [Moynihan] and get another voice on the record," the email stated. "I was wondering whether you or someone from your organisation may be willing to work with us to generate articles in Canada countering the point of view raised in the BMJ. This would involve speaking with select reporters about [female sexual dysfunction], its causes and treatments," she wrote.

As often happens in today's wired world, a copy of Lerner's email was forwarded to Moynihan. He contacted Lerner, who refused to disclose the identity of her client, stating that doing so would "violate ethical guidelines." When we contacted Lerner ourselves, she declined further comment and suggested that we interview HCC DeFacto Director Richard Cripps. All he would tell us, however, is that "I don't want to get into the specifics at this stage."

We also interviewed Moynihan, who expressed disgust with HCC DeFacto's crude campaign. "The participation of the corporate sector in that debate [on female sexual dysfunction] is extremely welcome if it is open. If they are going to try and get their message out there via small community groups without their fingerprints on it, that is just pathetic," he said.

Kathleen O'Grady, the editor of A Friend Indeed, a newsletter for Canadian women in menopause and midlife, was one of the recipients of Lerner's email. She told us that she was "surprised, and then very angry . . . They wanted to use our credibility to bolster their public relations. Under no circumstances would we ever agree to such an arrangement."

Disease Awareness

Writing for the British Medical Journal, Moynihan joined physicians David Henry and Iona Heath in warning that drug company marketing campaigns over-emphasize the benefits of medication. "Alternative approaches--emphasising the self-limiting or relatively benign natural history of a problem, or the importance of personal coping strategies--are played down or ignored," they wrote.

Conventional wisdom says that drugs are developed in response to disease. Often, however, the power of pharma PR creates the reverse phenomenon, in which new diseases are defined by companies seeking to create a market to match their drug.

A decade ago, the late journalist Lynn Payer wrote a book titled Disease Mongering, in which she described the confluence of interests of doctors, drug companies and media in exaggerating the severity of illness and the ability of drugs to "cure" them. "Since disease is such a fluid and political concept, the providers can essentially create their own demand by broadening the definitions of diseases in such a way as to include the greatest number of people, and by spinning out new diseases," she wrote.

Pharma PR practitioners are sometimes quite candid as they discuss the art of creating a need for a new product. "Once the need has been established and created, then the product can be introduced to satisfy that need/desire," states Harry Cook in the "Practical Guide to Medical Education," published by the UK-based Pharmaceutical Marketing magazine.

Sometimes patient groups are created out of whole cloth to boost a new drug that is about to emerge from a drug company's "pipeline." Most of the time, however, drug companies woo existing non-profit patient groups. "Partnering with advocacy groups and thought leaders at major research institutions helps to defuse industry critics by delivering positive messages about the healthcare contributions of pharma companies,"explains Teri Cox from Cox Communication Partners, New Jersey, in a September 2002 commentary in Pharma Executive.Corporate-sponsored "disease awareness campaigns" typically urge potential consumers to consult their doctor for advice on specific medications. This advice works in tandem with corporate efforts to influence doctors, the final gatekeepers for prescription drugs.

According to Julia Cook of the Surrey-based Lowe Fusion Healthcare, potential "product champions" and "opinion leaders" in the medical fraternity are critical to influencing doctors' thinking. "The key is to evaluate their views and influence potential, to recruit them to specially designed relationship building activities and then provide them with a programme of appropriate communications platforms," Cook wrote in the "Practical Guide to Medical Education."

Recruiting potential supporters to an advisory committee, she says, allows time to develop a closer relationship and evaluation of how they can "best be used." However, a delicate touch is required. "Credibility can also be undermined by overuse," Cook warned. "If you front the same people to speak at your symposia, write publications, etc., they will be inevitably be seen as being in your pocket."

Obtaining favorable coverage in medical journals is also an important element in pharmaceutical marketing. An investigation by the Journal of the American Medical Association article found that it was a commonplace practice for articles to be "ghostwritten" for well-respected medical researchers.

Based in Oxford, England, 4D Communications is one of the PR firms that helps, in the words of its web site, to "mix experienced scientists with marketers and creatives to create memorable educational and commercial programmes." According to Emma Sergeant, 4D's managing director, PR companies can help with the "creation of authoritative journals." Indeed, drug company-sponsored publications are so lucrative that in 1995 Edelman established a subsidiary company, BioScience Communications, to "meet the education needs of major pharmaceutical firms."

Journals, though, can achieve far more than touting the benefits of a new drug. Publications can be used to create a market "by creating dissatisfaction with existing products and creating the need for something new," wrote Harry Cook from ICC Europe in a medical publishing guide. "Reprints [of journal articles] can be a very powerful selling tool, as they are perceived as being independent and authoritative." Indeed, this perception of independence and authority is precisely what healthcare PR uses to keep the public from realizing that much of what they see, hear and read about drugs originates from sources beset with conflicts of interest.

In creating or co-opting patient groups, hiring "product champions" and cultivating doctors, PR companies make it harder for citizens to obtain accurate, genuinely independent information to enable informed health decisions. While healthcare PR campaigns are undoubtedly effective in selling more drugs, they don't necessarily make for a healthy population.