Global Pharmaceutical Markets and Corporate Citizenship: The Case of Novartis’ Anti-cancer Drug Glivec
I. Chronology of Novartis v. Government of India (p. 167-169)
1972 – Indian patent law protects process of drug creation but not the active ingredients. Generic companies can reverse engineer ingredients to create low priced alternatives.
1995 – India joins WTO and must transition its patent legislation: Section 3(d) states that significant improvement must exist in drug to obtain a secondary patent so that any pre-existing product could not be re-patented to prevent generic competition.
2003 – Novartis receives 5 year exclusive marketing rights for Glivec. The nine companies producing imatinib mesylate decrease to three.
2006 – Secondary Indian patent for Glivec denied because it did not satisfy Section 3(d). Novartis seeks equal protection under the law with Article 14 of Indian Constitution.
2007 –Indian courts toss out lawsuit because the state has ‘constitutional obligations to provide good health care’. If Novartis succeeded in eliminating Section 3(d), they could exploit prices and further eliminate competition.
II. Pharmaceutical Citizens for and against Novartis (p. 169-175)
Lobbying against Novartis, pharmaceutical citizens were concerned with rights violations that product patents entailed. Corporations were not the rightful owners of drugs; citizens had primary right to drugs because of constitutional rights to good health care. As many relied on India’s pre-1995 patent laws to provide affordable generics, Novartis’ bid to enforce product patent laws would take away citizen rights to access lifesaving care.
Conversely, Novartis was indebting citizens by gifting Glivec to those in need. These groups were in favor of product patent laws for they provided incentive for corporate investment in R&D. Despite losing the lawsuit, Novartis won the loyalty of pharmaceutical citizens through self-congratulatory displays of gifting: Novartis was no longer taking drugs away from people with their fight for product patent protection, it was fighting for patent law so it could continue saving lives with Glivec.
IV. Self-interested exchanges, non-interested gift giving, and hybrid gift-commodities
What supporters of Novartis failed to acknowledge were the profit motives behind its gift giving. Why give Glivec away for free when a profit could be made by charging the same price as the generic competition? As Glivec was an upcoming blockbuster, Novartis could not risk a price drop when developed countries, the largest market share, learned of the low prices Glivec sold for in developing markets such as India, the smallest market share. The best option was to ‘gift’ Glivec because it created a positive corporate image while maintaining high pricing levels and profit margins in Novartis’ primary markets. By masking economic self-interest as interest-free gifting, Novartis created hybrid gift-commodities (167). As Ecks suggests, “attempts to clearly separate between pure commodities and pure gifts is more ethical than to advocate hybrid gift-commodities – especially if seemingly pure gifts in one domain distract from big profits made elsewhere” (167). With Glivec, Novartis should have avoided the ‘good citizen’ rhetoric in order to be clear about their profit motives in the gifting of Glivec.
Getting to Yes: Power and the Creation of a Psychopharmaceutical Blockbuster
Applbaum’s article articulates how strategic marketing campaigns expand antipsychotic market by coordinating the interests of those within the marketing distribution channel and concludes with a discussion of this new synergistic, cultural expression of corporate power.
I. The Distribution Channel (p. 185-190)
Distribution channel members are intermediaries in the drug development and marketing process: physicians, hospitals, regulators, insurers, payers, pharmacists, and codependent choice makers such as family and case workers are all members in but not of the pharmaceutical marketing channel. Members have no contractual obligation to uphold the interests of the firm yet are necessary for it to achieve success. To align the members’ competing interests with corporate objectives, pharmaceutical marketing must be a social process which changes the consciousness and habits of professionals and patients alike.
II. Bringing Products to Market (p. 190-197)
Psychoactives are brought to market through the distribution channel in three ways: educating PCPs to empower them to change their prescribing habits (prescribing for depression instead of referring patients to psychiatrists), hiring expert opinion leaders to legitimize this new prescribing culture, and capitalizing on market entry points such as relaxed FDA rules concerning DTC advertising. Here, PCPs were educated to recognize and prescribe based on subtle symptoms, becoming participants in Eli Lilly’s distribution channel by their own volition.
III. Evolution and Expansion of Primary Markets (p. 197-205)
Eli Lilly was able to revolutionize and expand their target market of Zyprexa in two ways. First, disease state prioritization (‘let’s just trial everything and see what happens’) uncovered new applications of Zyprexa. This provided a competitive advantage because it satisfied doctor’s unmet needs for treating comorbid symptoms such as pain associated with depression, expanded the target patient population, and extended Zyprexa’s patent. The awareness of Bipolar Disorder expanded the spectrum of the disease itself: Zyprexa, originally approved and prescribed for Bipolar Disorder I, quickly became prescribed for a range of spectrum disorders such as Bipolar II and Cyclothamia while also becoming applicable in pediatric and geriatric populations.
Second, ‘share of voice’ allowed Eli Lilly to further expand Zyprexa’s target market: using DTC advertising and publication planning strategies, it was able to compete with psychiatrists and academics over who represents Bipolar Disorder. Once corporate objectives are voiced by non-contractual participants in the distribution channel, commercial interest becomes invisible. This expands product markets as it changes the social consciousness; the change in prescribing attitudes looks cultural instead of corporate-driven. In the case of Zyprexa, a cultural discourse of ‘health as prevention’ was developed by strategic marketers at Eli Lilly.
III. Power, Culture, and Agency (p. 206-212)
Strategic marketing coordinates divergent interests by creating social expressions of power: power that is participatory, inclusive, and empowering for medical professionals and patients alike, bringing potential whistle-blowers into the distribution channel by their own volition. This synergistic power, as Applbaum articulates, is a “whole that multiplies the value of the parts” (180). Under the guise of full agency, intermediaries are not aware they are being manipulated when they change prescribing habits or internalize risk factors promoted in DTC advertising. This is dangerous, Ecks states, because “once [corporations] control the channel, [they] can insert any product…no matter how useless” (210). Not only is this “structurally violent” (210), but represents a perverse violation of human agency through guiding socio-cultural processes in favor of corporate objectives. When R&D and marketing combine from the onset to develop a drug, bring it to market, and expand the target population, corporations have the power to legitimize new social attitudes.
Pharmaceutical Witnessing: Drugs for Life in an Era of Direct-to-consumer Advertising
Dumit illustrates how DTC advertising uses “grammars of illness, risk, and experience” (37) in order to change personal identities and perceptions so that a culture of ‘drugs for life’ is normalized.
I. Awareness Through Education (p. 42-44)
Marketers choose information in their advertisements that highlights the public’s ignorance of their own health. In this case, health information appears as unbiased fact but is selected to develop a grammar which is highly manipulative, invoking a sense of urgency that necessitates action: if one is unaffected by the new information that DTC advertisements present, they “…are confused, embarrassed, intimidated, or ignorant” (44). For example, Novartis marketed to associate their product, Lamisil, with fungal infection. Here the primary marketing message was not the Lamisil brand, but the naiveté of the public in their inability to recognize the need for Lamasil in their own lives.
II. Personalizing Risk (p. 44-49)
This is the process of internalizing possible risks in the target consumer and having such risks projected outward as a new self-identity. In responding to DTC advertisements, “I am sleeping too much! Maybe I have do have depression!”, one enters a dialogue with medicalized rhetoric and their orientation changes from being in attunement with their body to being deceived by their body. This is effective even with asymptomatic risks as Dumit illustrates with Fosomax: marketers advertised their product using fit and healthy women discussing bone density tests. Target audiences, being active women themselves, saw their healthy lifestyles as being associated with populations at risk for osteoporosis. ‘No one is safe from osteoporosis, especially those who believe they are healthy!’ Personalization of risk progresses into a rhetoric of ‘health as preventative action’ instead of ‘health as freedom from illness’.
III. Motivation to Self-Diagnose (p. 49-54).
Once potential patients internalize risks, marketers push them to self-diagnose through free tools to further educate and empower. These tools are often ‘scientific’ and tangible to lend credibility to patient concerns. In using questionnaires like the one Zoloft provided in their advertising (Table 2.2), audiences are able to regain a sense of personal agency and take the steps necessary to return to their former, healthy self.
IV. Seeing and Convincing a Doctor (p. 55-57)
“Pass through persuasion” (55) is the process of patients visiting their doctors armed with the necessary facts and language to get what they want to solve the problem they are convinced they have. Patients have symptoms verified through DTC tests, tests which are more credible and tangible than physicians’ often disinterested perception of emotional distress. Physician emplotment is achieved by DTC campaigns by, in the case of Effexor XR, giving patients a highly specific vocabulary needed to achieve and maintain control of the conversion. How dare a doctor refuse a patient who has taken the time to educate, test, and empower themselves?!
V. Branded Compliance (p. 58-59)
The last step is to develop a loyalty to a brand. This process “integrates the pharmaceutical into the everyday and reinforces a notion of dependent normality” (58). ‘Drugs for life’ becomes a positive identity: long term prescriptions are associated with the rhetoric of health, prevention, and empowerment instead of illness, self-alienation, and lack of agency.
Dumit illustrates how marketing rhetoric is able to turn one’s body against them, concealing information and illness instead of aiding and empowering. With DTC advertising, non-disease states are no longer just risk factors for disease; they are examples of how our body alienates us and prevents us from knowing we are unhealthy, making us “not ourselves”. To solve the problem, long term drugs are needed to regain empowerment. One cannot be cured without adopting a new identity that normalizes lifelong prescriptions.
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