Big Bucks, Big Pharma
News One of the facts of American life these days is that many prescription drugs are now household names.

Marcia Angell: Both doctors, and the public want to reach for the newest prescription drug.

Gene Carbona: You can’t sit down to TV at night and not see a half dozen drug company commercials.
News Millions of Americans watch the ads, and then ask their doctor for prescriptions.

Katherine Greider: The reason we’re seeing so much consumer advertising is because it works.
News They do it by telling people “Ask your doctor.”

Larry Sasich: They can sell us almost anything.

Narrator: The companies that make up the pharmaceutical industry are among the largest corporations in the world. In 2004 their combined global sales were over half a trillion dollars, with Pfizer and Johnson & Johnson leading the pack. Together, these businesses have come to be known as “Big Pharma.” In the US, the core of Big Pharma’s immense profits is from sales of prescription medication. And since these drugs can only be prescribed by medical professionals, most of the industry’s promo- tional and marketing activities are directed at doctors, pharmacists and other health care providers. The companies of Big Pharma hope these campaigns will lead to new prescriptions for their brands. In recent years, Big Pharma has pushed its way into the traditional doctor/patient relationship and found a new way to increase sales - by targeting patients directly and independently, largely through television advertising.
ad Do you know about the purple pill called Nexium? -I know. -I know. You should know about it too.

Narrator: Between 1996 and 2004, industry spending on Direct to Consumer Advertising (or DTC) rose over 500 percent. Now, even before walking into their doctor’s offices, patients have already been exposed to millions of dollars worth of persuasive advertising that encourages them to ask their doctor how a particular brand of drug might help them.
ad Ask your doctor about adding Plavix.
ad Ask your doctor if Zelnorm is right for you.
ad Ask your doctor if a free sample of Viagra is right for you.
ad I asked my doctor about Lipitor. Have you?

Narrator: In this new landscape, the most vital question for American consumers is this: How might the influence of one of the most powerful for-profit industries in the world affect the way we think about our health and well-being?

BRANDING DRUGS
ad With Celebrex, I will play the long version. -Ask your doctor if Celebrex is right for you.

Elizabeth Preston: As these pharmaceutical companies move prescription drugs into the con- sumer arena, as they become consumer products, they advertise them quite differently. And what they do is rely on all the same practices of conventional product advertising.
ad -It’s so good to have my enthusiasm back. -I’m enjoying things again. -And its because of Enbrel.

Elizabeth Preston: They began trying to create brand identities for these products. And what branding is about is trying to create an emotional bond between a consumer and a product, which is a very different kind of relationship than we’ve ever had to our medications before.

Bob Goodman: Any doctor can tell you about patients that come in with a list of medications that they want that clearly all came from advertising that they see on TV. And if you watch the evening news, for example, it’s all advertisements for prescription drugs.
ad What does the weekend hold in store for you? Ask your doctor if a free sample of prescription Cialis is right for you.

Bob Goodman: And patients come in asking for things, they don’t even know what it’s for – women who are coming in asking for Cialis or Viagra, other things, and they don’t even know what they’re for.

Elizabeth Preston: So this becomes not a rational reason for taking the medication – this is not so much about the efficacy of the drug, but about our emotional response to the kinds of social meanings they have attached to that product.
ad Join the millions of people with asthma who have discovered Singulair. -I just want to play! -Play! -Play!

Katherine Greider: So you have these ads that are sort of ephemeral images unfolding before you. And to me they seem like perfume ads, they are something that’s all about image, that’s all about emotional impact.

Elizabeth Preston: Most of what you get in these ads are these incredibly compelling lifestyle portraits of people who are living healthy, vibrant lives, thanks to pharmaceuticals. You don’t really ever see the medical condition represented. You don’t ever see people suffering from the ailment that they supposedly suffer from. You see them restored to health after they’ve taken the chemical.

Narrator: The pleasing tones and images of these ads are often at odds with the less pleasur- able list of side effects that companies, by law, are required to recite.
ad Side effects include itching, rash, diarrhea, andbruising.
ad ...dry mouth, sweating, nausea...
ad ...headache, flu, runny nose, and ear infection.
ad If you take Wellbutrin-XL, there is a risk you may have a seizure.
ad Erections lasting longer than four hours, though rare, require immediate medical help.

Elizabeth Preston: So I think one of the things that gets misrepresented by these ads is the safety of the drugs. While you get the major statement about risks, you get an incomplete picture of the drugs. These drugs are not as safe or effective as the ads suggest they are.
CBS News According to Otis Lee Elliot’s cardiologist, it’s not his high cholesterol that put him in the hospital, it’s the medicine he took to lower it.

Elizabeth Preston: Adverse drug reactions, reactions that happen even though the medica- tion has been properly prescribed, are the fifth leading cause of death in the United States.

Narrator: In fact, each year in the United States, adverse drug reactions cause an estimated 100,000 deaths and approximately 1.5 million hospitalizations. The withdrawal of the popular painkiller Vioxx from the market is a salient example of the magnitude of this problem.
ABC News Merck said today that data from a clinical trial found it increased risk of heart attack and stroke.
CBS News The arthritis drug may have caused 160,000 heart attacks and strokes...
NBC News -Twenty million Americans took Vioxx, -Vioxx relieves arthritis pain... -Often some say, unnecessarily, in response to advertising.

Bob Goodman: Vioxx is a superb example of what happens when you overpromote a drug. When doctors especially overprescribe a drug as a consequence of promotion, and they give it to people who it’s not indicated for, who they could have been giving very cheap, older drugs, which would have worked just as well. And then because the drug’s only out for a few years, you then discover when it’s used in lots and lots of people that it has side effects, some of which are fatal, that you didn’t know about.
ad Ask your doctor or pharmacist about Vioxx.

Bob Goodman: And in 2000, more money was spent promoting Vioxx than Anheiser-Busch spent promoting Budweiser, than Pepsi-Cola spent promoting Pepsi, I mean that’s a lot of money.
CBS News The industry group PhRMA defends direct-to-consumer drug ads, saying they educate the public and get patients to doctors for treatment.

Katherine Greider: I almost feel sorry for the people who try to defend the advertising as education because it’s so preposterous. I mean, come on. Is it education when Nike advertises its shoes? “Now you know how to cover up you feet and get from point A to point B.”

Marcia Angell: That is not what a thirty second television ad of beautiful people playing in the flowers does. Also, it’s self-evidently absurd to look to a company for impartial, critical, education about a product it sells.

Bob Goodman: The thing is we’re not talking about whether a patient is drinking one cola versus the other. And I think very few people would care if their grandmother drank Pepsi be- cause she was being deluded by the advertising, or they just had better commercials. And I think because we’re talking about patients’ health, it’s a very, very important issue.

Swimming in Pills
Narrator: Based on the sheer number of drug ads on television, it would be natural to assume that the industry is constantly creating new and improved drugs. But we might also ask: Are these new drugs really more effective?

Marcia Angell: When the drug companies test their drugs and submit their evidence to the FDA to get approval, they don’t have to compare the new drugs with old drugs to treat the same condition. They just have to compare their new drugs with the placebo, a sugar pill, which means that all they are really showing is that the new drug is better than nothing.

Narrator: Due to lax government regulation, prescription drugs end up flooding the market. A powerful example of this new market saturation is the exploding number of allergy medications.
ad Allergies used to take the fun out of games. Now, I’m Claritin Clear.

Narrator: The most successful new drug in this class was Claritin, a blockbuster that earned more than $3 billion in its best year. Other companies strongly pushed their own prescription antihistamines in order to garner a piece of this lucrative allergy market.
ad Yesterday, allergies took you out of it. Today, Allegra can help bring you back.
ad You know about Allegra. But you should know about Allegra-D. It just may be music to you ears.

Marcia Angell: I looked at the last seven years, 1998-2004, and during those years only 14% of newly approved drugs were actual new chemical compounds, classified as being likely to be bet- ter than drugs already sold. Most new drugs, ostensibly new drugs, were just old chemical com- pounds, not likely to be any better than anything on the market. These are called me-too drugs.

Gene Carbona: It’s not difficult to create a me-too drug, and it’s not expensive to create a me- too drug. It’s expensive to make novel compounds, because for every one drug, there are 2,000 drugs that fail, but for every one drug that’s a me-too, your batting 1,000 when you make a me- too drug.

Marcia Angell: What the drug companies are doing now is concentrating on lifestyle drugs that can be marketed to vast numbers of people and the market can be easily expanded.
ad When diet and exercise aren’t enough, adding Lipitor can help lower your bad cholesterol from 39 to 60 percent.

Marcia Angell: Let me give you an example. The top selling drug in the world now is Lipitor, Pfizer Lipitor. This is a drug of the statin type to lower cholesterol. But it’s a me-too drug, it’s the fourth of six very similar statin drugs now on the market.
ad I need to lower my choleterol. My doctor told me about Zocor.
ad Vytorin treats the two sources of my cholesterol.
ad Crestor, along with diet, can lower bad cholesterol by up to 52%.

Katherine Greider: There’s a lot of debates about whether we benefit as a public from having five different statins that the industry devotes a whole of money to promoting in order to com- pete with each other.

Marcia Angell: The marketing goes mainly to convince people that one me-too drug is better than another, despite the lack of any evidence on that score.

Katherine Greider: Once one company starts to advertise its product, and creates what’s called brand awareness of its product - its got the Campbell Soup, the Nike - another company that wants to promote its drug feels it can’t afford to stay on the sidelines. So it creates a sort of a vicious circle where everybody’s advertising.
ad - (song) We are the champions, my friend... -Ah, the feeling of asking your doctor about Viagra.

Katherine Greider: For example, the Viagras of the world in 1994, $265 million a year went to consumer advertising. In 2004, in the first 5 months of 2004, the same amount of money went to advertise erectile dysfunction drugs.
ad If a relaxing moment turns into the right moment, will you be ready? You can be with Cialis.
ad More and more men are making the move to Levitra. Maybe it’s time you discovered what all the excitement’s amount.

Katherine Greider: When we pay higher and higher prices for drugs, that’s a cost that we, in the United States, are paying for.

Marcia Angell: This marketing is the real name of the game, they’ve become vast marketing machines now. And if you could stop the me-too market, you would stop the promotional activi- ties to a large extent.
ad -Nexium. -Nexium. -Nexium -Nexium. People are asking their doctors about it. And if you call 1-800-4-Nexium, you’ll learn about a free trial offer. -Today’s purple pill is nexium.

Larry Sasich: Nexium, the “new purple pill” is probably the prime example of how the pharma- ceutical industry can sell anything. They can take an old drug and they can sell it as a new drug. Nexium is really the same thing as Prilosec.
ad It’s Prilosec time. Time to see you doctor about America’s most prescribed acid control medicine.

Narrator: In the early 1990s, Prilosec burst onto the scene as an innovative prescription drug to treat heartburn. When Prilosec’s maker faced the expiration of its patent, it knew it was about to lose its exclusive right to market the drug. Gene Carbona, a sales rep for Prilosec during this time, explains one way the company addressed this challenge.

Gene Carbona: We were going to lose $6 billion a year in revenue. And we knew that that was going to have a very strong effect on our company’s bottom line. And our company had to an- swer to the shareholders and the other members. So what they did is they licensed in a drug that was very, very similar, being Nexium.
ad Across America, doctors who specialize in acid reflux disease have switched more patients to the purple pill, Nexium, than to any other prescription of its kind.

Narrator: By 2004, the popular purple pill was available in three almost identical versions, but it priced at vastly different amounts, ranging from $24 a month over–the-counter Prilosec, to $171 for the new prescription drug Nexium.

Katherine Greider: No amount of cold hard facts about this drug could hold back its progress in the American marketplace. And it’s a good example of how broken and corrupt our market- place really is. Because it simply started advertising to the consumer, pushing this new drug to doctors, dropping samples. It became the most advertised drug product in the United States, and it’s hugely successful.

Katherine Greider: And the fact that there’s both an over-the-counter version of Prilosec and a generic version available makes no difference, because our system has no way of shedding light for the basic consumer.

Gene Carbona: It’s a classic campaign, very successful. And there are other manufacturers out there that know that their products are going off shelf life and promoting, not generics, but they’re promoting their new branded product, which is almost the same.

Larry Sasich: it’s remarkable what this industry is able to do, and how they’re able to create images of drugs as either being new or more effective or safer than older drugs, when all of the underlying information points totally in the opposite direction.

DISEASE MONGERING
CBS News Your blood pressure may have gone from normal to high over night. New government guidelines mean millions need a check-up. Do you?

Narrator: At the same time that drug advertising is pushing people to their doctors, experts are busy redefining what it means to be sick.

Marcia Angell: All you have to do is change the definition of high blood pressure, and you can increase that market by tens of millions of people. Or change the definition of high cholesterol.
CBS News -If you didn’t have a cholesterol problem yesterday, you may have one now. -The new guidelines call for a huge boost in use of cholesterol-lowering drugs known as statins. The new numbers mean that millions of Americans may be taking statin drugs for the rest of their lives.

Katherine Greider: In some cases it is a question of “hey, more people are getting treated for this and this is great,” and in some cases even more people should get treated probably. But what’s always muddying the waters here is that a major source of information, to consumers and to doctors alike, is the industry that stands to profit from these medicines.
CBS News The guidelines were written by nine experts on cholesterol. The National Institutes of Health, which sponsored the report, now says six of them have financial ties, such as speaking fees, research grants, or other funds with drug companies which make the most widely used medications.

Narrator: In recent years, Big Pharma has begun promoting more than just its treatments and products: drug companies now increasingly advertise health conditions themselves. As a result, Big Pharma normalized even the most obscure health disorders and presents them as common.
ad It’s frustrating. Just when you’re ready to relax, that’s when it happens. The urge to move, along with uncomfortable sensations in your legs. They’re hard to describe, but they can even keep you from getting to sleep. You feel the urgent need to get up and move, just to get some relief. There’s a name for it: Restless Legs Syndrome, and if you have it, you’re among the nearly 1 in 10 US Adults who do. Want to know more? Visit RestlessLegs.com or talk to your doctor.

Bob Goodman: Of all the things that industry does, this is probably the one thing that I think could be labeled as evil – that in order to make a profit, disease mongering - making a population, medicalizing something that is really a part of everyday life.
ad You often feel distracted, disorganized, restless, unable to finish things. Like the channel keeps changing in your mind and you can’t control the remote. If you’ve felt these symptoms your whole life, you may have Adult ADD.

Bob Goodman: So in other words, a person who is not yet a patient, who is actually feeling quite good, sits down to watch the evening news, and after seeing a few commercials says to him or herself, “ You know, I’m not quite as healthy as I thought.”
ad -I’ve got to remember that appointment tomorrow. Did I send the car payment? What made me volunteer for that assignment? -Introducing Lunesta: a sleep aid that can give you and your restless mind the sleep you need.

Katherine Greider: You have this huge phenomenon then, a huge increase in prescriptions and there’s this debate about what is this problem – has it always been around? Is it a problem of behavior? Is it really a biochemical problem?

Bob Goodman: And what’s happened now is you’ve taken a healthy person and medicalized something that was not medical and this person may very soon end up on a prescription medication.
ad -At work, I’m tense about stuff at home. At home, I’m tense about stuff at work. -If you’re one of the millions of people who live with uncomfortable worry, anxiety, and several of these symptoms for six months or more, you could be suffering from Generalized Anxiety Disorder.

Narrator: Because patent life can be extended if new indications are approved, companies are constantly searching for new diseases to treat with old drugs. Anti-depressants of the Prozac variety, or “SSRI’s”, are a good example of this practice. Originally approved for major depressive disorder, these drugs are now prescribed for a variety of mood and anxiety disorders. Each new indication approved promises increased profits, and must therefore be promoted heavily to the public. A striking example is how Paxil was revitalized as a treatment for Social Anxiety Disorder. Its company hired a public relations firm to frame this condition as a major and common medical problem, and the firm launched a multi-faceted campaign that moved beyond advertising to get stories about social anxiety disorder placed in print media and on television. [NBC Today Show] This morning we begin a special two-part series on Social Anxiety Disorder: Many of us have suffered from shyness or fear of social situations at some point in our lives. But for millions of Americans, their anxiety can be debilitating.

Narrator: Paxil’s award-winning product director was quoted as saying, “Every marketer’s dream is to find an unidentified or unknown market and develop it. That’s what we were able to do with Social Anxiety Disorder.”
ad What it is...What it feels like. What it is...What it feels like. What it is...What it feels like. We know what Social Anxiety can feel like, and Paxil can help.

Elizabeth Preston: When people begin to critique these advertisements and these cam- paigns, I think it’s a little easy to actually forget about the people who do suffer from Social Anxi- ety Disorder, who suffer from major depression, who suffer from post-traumatic stress disorders. There are people who suffer from these conditions and whose lives are radically transformed by the medications, and I think it’s actually important to remember that. That doesn’t mean that at the same time, we’re not sort of creating a culture of the worried. Well people, who might have this problem, are sort of suddenly concerned that they have this problem.
ad Over ten million Americans suffer. Do you?

Larry Sasich: If we take shyness, which is probably a part of the personality of most of us in some situations, it’s an appealing part of people, it’s part of their personality, and we turn it into a new entity, and we call it Social Anxiety Disorder. Now you’ve increased the size of the market and now you can go out and advertise Paxil for Social Anxiety Disorder, for somebody being shy.

Elizabeth Preston: The Paxil-CR ad reads to me a little bit like medicalizing normal experience.
ad If you are one of the many who suffer from overwhelming anxiety and intense fear of social situ- ations with unfamiliar people, now there’s Paxil-CR. Paxil-CR helps relieve symptoms of Social Anxiety Disorder all day, so the real you can come through.

Elizabeth Preston: You have people who look mostly comfortable, but they’re a little uncom- fortable in a social setting, and we’re turning that into a condition that needs significant treat- ment. The SSRI’s have a million side effects. They are not clean drugs, and to suggest that if you have a tough time going into a meeting and introducing yourself to people, then you should be on an SSRI, I think is problematic.
ABC News We are going to take a closer look tonight at the possible link between anti-depressants and suicide.

Larry Sasich: The other disturbing aspect of this class of anti-depressants was the fact that these drugs were being prescribed to a large number of children.
ABC News About one million children under eighteen take such drugs now, with doctors writing three times as many prescriptions as they did a decade ago.

Larry Sasich: And we don’t know if the drugs were being used appropriately – if they were being used in children with major depressive disorders, or they were being used on a 12 or 14 year old boy that didn’t make the football or basketball team and he felt sad.

Katherine Greider: So you have this kind of system that has no brain. It has profit as its goal, and it has no mind, and it just builds the market without thinking about: Are there other ways we can deal with this? Is this something we want to pathologize? Is it something we want to see as a sickness?
ad It’s that week before your period. The irritability, mood swings, bloating. Think it’s PMS? It could be PMDD: Premenstrual Dysphoric Disorder...

Marcia Angell: What Eli Lilly was very successful in doing to expand its market on Prozac, was to essentially recolor it, instead of a green capsule, made it pink, rename it Sarafem, and get ap- proval to market it for premenstrual tension, which it called Premenstrual Dysphoric Disorder.
ABC News Drug manufacturer Eli Lilly launched a $30 million marketing campaign to inform women about their new drug that promises relief.
ABC News Theproblemis,Sarafemisnotnew,andtheconditionit’sbeingadvertisedtotreatmay not even exist.

Larry Sasich: Prozac and Sarafem are exactly the same thing, it’s all a matter of image.
ad Sarafem:ThefirstandonlyprescriptionmedicationforPMDD.

Larry Sasich: Once again, the pharmaceutical industry, through its advertising ingenuity is able to sell us almost anything, even old drugs as new drugs.

Marcia Angell: A lot of women would really be outraged if they knew that they were just taking good old Prozac –same dose, same dose- but priced, at my drug store anyway, over three times as much as generic Prozac.
ABC News Fuelingthedebate,Sarafem’smarketingblitzstartedjustbeforeEliLillylostitsexclusive patent to sell Prozac, a drug that generates $2 billion in sales each year. With Sarafem, the company obtained a new patent, and for now, they are the only company that can market a treatment for PMDD.

Katherine Greider: This the whole process of creating disease awareness is controversial, and I think its sort of a question that we should decide as a society. And what bothers me about it is it's being promoted by an industry that has its own motivations, which have nothing to do with our culture or our physical well being, or really our health as a society.

Marcia Angell: I can’t help but think that there are millions of Americans who are taking drugs that they probably don’t need and may even be harmful. That they’re being convinced, and their doctors are being convinced that they should take life-long drugs that probably are of no net benefit and may be of net harm.

Bob Goodman: Clearly in our culture we tend to look for quick fix fixes in pills- whether we’re talking about obesity or any other health problems. Certainly the direct-to-consumer advertising feeds on this.

Elizabeth Preston: We don’t look at environmental problems that might be causing asthma or causing these allergies. We don’t look at lifestyle issues that might be causing indigestion and so forth, erectile dysfunction for that matter. Instead, we just sort of talk about it at the level of individual biology. And so that means we’re not looking at the social causes, it means we’re also then not looking for social solutions.

Marcia Angell: I think it's very important for patients, in a sense, to give their doctor permis- sion not to prescribe a drug...by saying to the doctor, you know, I don’t want a drug unless I really need a drug. And then if the doctor who will be taken aback by this says, well yes I really do think you need a drug, then it's up to the patient - or I think the patient should say - is there something, even though it’s a free sample and I may use this free sample until I run out - is there a drug for the same condition that’s cheaper? Or is there a generic?

Elizabeth Preston: You really need to be your own advocate. And you need to be educated. And that means spending a lot of time doing research about any medication that you’re going to take, any health care procedure that you’re going to undergo.

Larry Sasich: Consumers really need something to protect themselves. We look at our publica- tion, “Worst Pills, Best Pills,” as a source of information for prescription drug consumers. Not only do we do a book, a newsletter called “Worst Pills, Best Pills,” but we also have a website to give people objective comparative information so that they can decide for themselves, so that they have something to balance the advertising.

Narrator: Groups like Public Citizen have been working tirelessly to arm consumers with im- portant information. Also necessary, say advocates, are campaigns to tackle the industry’s mass targeting of our healthcare providers.

NO FREE LUNCH
Narrator: While direct-to-consumer advertising remains the most visible aspect of the drug industry’s overall marketing approach, the real story lies behind the television screens. Invisible to most consumers, the majority of pharmaceutical promotion is still directed at medical professionals. Increasingly, drug companies are pushing their brands at medical conferences and in medical journals. In addition, there are close to100,000 industry sales representatives who spend count- less hours visiting hospitals and physician’s offices and leaving behind branded items to remind both doctor and patient who they are and what they’re selling.

Bob Goodman: Anyone who’s been a patient or has ever set foot in a doctor’s office knows that their offices are just flooded with clocks, pens, coffee mugs, calendars, with branded drug names on them. In fact if you pulled over any medical resident or medical student who’s wearing a white coat - and there have been studies that have done this - almost all of the things in their pockets would be branded products, whether it's their pen, their stethoscope tag, compass, other things that they may use for medical purposes. And so the most obvious thing about that is doctors and students are walking advertisements, really saying these things are OK, advertising for these products, which is really the problem itself. And then of course, the other problem, which I con- sider the primary problem, is they’re receiving gifts from the companies and therefore developing relationships with the companies.

Gene Carbona: You get cases and cases of pens, and cases and cases of stethoscopes and things like that, that are all within the AMA and PHRMA guidelines. But you also have a budget, that pretty much, is unrestricted.

Marcia Angell: Doctors now, their morale is fairly low. Managed care is causing a lot of prob- lems, they’re being treated now as just one more vendor in some respects, and the drug company sales people treat them with terrific respect.

Larry Sasich: This starts out on the first day of medical school, and in many medical schools, even the incoming students who are two years away from seeing patients, will start to get gifts from the pharmaceutical industry. And as these students get farther along in their medical educa- tion, the interactions and the gifts escalate, to free lunches, to dinners, to trips.

Gene Carbona: No matter where you spend money, in pharmaceutical promotion - whether it's in sample distribution, educational programming, non-educational programming, champagne brunches, happy hours, NY Jets tickets - no matter where you spend the money, you make money. And my boss always told me, there will always be more funding, spend what you can. In fact, if I give you $100,000 to spend, Gene, I want you to spend $200,000.

Marcia Angell: Certain activities that would be illegal if they were called marketing, are not illegal if they are called education. There’s a safe harbor for them. For example, it’s illegal to give kickbacks to doctors, to prescribe your drug, but if you’re essentially paying them to educate other doctors or to be educated by other doctors, then it’s no longer a kickback.

Gene Carbona: You can hide anything under educational. You can hide eighteen holes of golf for fifty people under an educational event. And during those eighteen holes, you can give a case of scotch that costs $1,000 to each one of the recipients of this free golf round. You can give golf clubs to individuals, and it’s all under educational. So when the drug company says, “Oh no, we don’t spend money on those promotions anymore, it’s all educational,” I know for a fact that anybody who played golf with me got a $300 putter and my bosses never saw that on the expense form because it went under education.

Marcia Angell: All kinds of things with a sort of thin, educational veneer over them. That’s where I think the lion’s share of their marketing money goes. And they get what they pay for. I mean they're not charities. They track very carefully what doctors prescribe before and after they attend one of these events, and they know the prescriptions for the company drug go up.

Gene Carbona: Obviously, that drug company that I talked about, the powers-that-be, will say, “This is not the case, this is the exception and not the rule, this is the way it used to be.” Well, that’s baloney. Again, I’ve got very close contacts still in the industry and I’ll get phone calls about once a week: “Listen, I’ve got $35,000 to spend this month - how can I do it? Give me something that won’t look so bad, but I need to spend the money, I need to spend, spend, spend.”

Narrator: In addition to providing gifts and trips, perhaps the most potent weapon in the drug rep’s arsenal is free drug samples, usually accompanied by supporting literature. In 2004, the in- dustry gave away the retail equivalent of almost $16 billion worth of drugs, and these products are the chief enablers of the market machine.

Katherine Greider: On the one hand, you have the consumer advertising, so the consumer is prepared by having seen this on TV. On the other hand you have the doctor that’s been prepared by the rep, and you also have that sample. And those sort of things all meet together and the consumer goes in and says, “I have this problem, and I saw this ad,” and the doctor says, “Oh I have this study that somebody dropped off about this, and in fact, here’s the drug.” And that momen- tum is unbeatable, essentially, and it works. Even if there are people out there who are saying, “Hey, actually there was a federal agency that said that’s not the right drug to take! That’s actually not the most cost effective drug!” None of that stuff matters because that apparatus that I just described is so powerful.

Bob Goodman: And what it is, is a way of getting both patients and physicians hooked on their product, which is always the newest, most expensive product on the market.

Gene Carbona: You don’t see generic drug companies out there sampling generic drugs that cost $3 a month. In Anytown, USA, you walk into a physician’s office, and you walk into a room that’s usually a ten-by-ten room that’s full of hundreds of thousands of dollars of samples - they’re all the most expensive, branded drugs. These are drugs that cost upwards of 100-300 dollars a month, and the office is full of them.

Bob Goodman: A physician prescribing the appropriate medication is not necessarily what the industry needs. What the industry needs, or a particular company, is that a physician is prescrib- ing their medication. And this is the same issue that applies to the rep speaking with the doctor - the reps will say they’re educating doctors, but of course what they’re trying to do is promote their products and get the doctors to prescribe their products.

Gene Carbona: Physicians will say that the journal ads, and the television commercials, and the drug rep visits, and the lunches, and the pads, and the pizza have no effect on them whatsoever, and they’ll also say that although it has no effect on them, it most definitely has an effect on their colleagues. I knew, as an industry insider, that whatever I did affected my market share.

Bob Goodman: And all the literature that’s looked at this shows, again not surprisingly, that doctors are influenced by promotion, that the more they meet with reps, the more legitimate they think the information they’re getting from the reps, the more likely they’ll prescribe more expen- sive medication, for example, more inappropriate medication.

A HEALTHIER PRESCRIPTION
Narrator: Increasing numbers of physicians are now breaking the silence around these issues – they are refusing to meet with drug reps, and working to expose Big Pharma’s influence on the medical profession. [CNN Lou Dobbs] More and more doctors are becoming outraged at the ceaseless mass marketing by the drug companies. Doctors and medical students across the country today took a stand.

Narrator: Doctors, medical students, and even former industry insiders are raising public awareness through the media, while at the same time organizing within the medical community to challenge the industry’s promotional practices.

Gene Carbona: I’m working with AMSA, the American Medical Student Association. AMSA has 60,000 medical students from all over the country and what they’re working on is this big Pharm Free Campaign – pharmaceutical-free. And they believe that although drug companies are needed, drug reps are not needed.

Bob Goodman: One of the big problems has been that nobody was talking about it. The hidden curriculum was accepting these gifts, okay, because the teachers and everybody else was doing it, but there was no other message. And what we’ve been trying to do now is to get medical schools to explicitly and formally, in the curricula themselves in the medical schools, to talk to students about this and to discuss the ethical and professional issues involved.

Narrator: In 1999, Bob Goodman created the non-profit, No Free Lunch, to help educate health care providers, the public, and especially medical students about these issues.

Bob Goodmann: We have a pledge for physicians as well as other health care providers to take, which essentially says that they won’t accept gifts or other promotional material, that they’ll prac- tice on the basis of the scientific literature. And many patients do email me, asking me if there’s a physician in their area that has taken the pledge, so it is my hope that eventually one of the things when managed care organizations have their list of doctors and says whether they’re board certi- fied, and they speak English and Spanish, and have they taken the No Free Lunch pledge, there will be a yes or no for patients to choose them.

Narrator: Advocates for reform are also moving beyond this focus on individual physicians and patients, to argue for fundamental, systemic changes.

Marcia Angell: Well, in a sense, you can’t blame the drug companies for doing what they’re doing, these are after all, investor-owned business, whose fiduciary responsibility is to maximize the value of their shareholders stock, that is to increase profits any way they can. I think my great- est criticism would come for the institutions that have allowed themselves to be corrupted by the drug companies.

Katherine Greider: Sadly, it appears that our federal government has been really extensively co-opted by the industry and I’m really not a person given to sort of cynicism or conspiracy theo- ries about this sort of thing, but many people in Congress have said, “They’ve got a stranglehold on us.”

Gene Carbona: They get in to all the capitol hills in every state in the country and in Washing- ton DC, and they’re spending billions of dollars, trying to create legislation that’s either going to protect the industry or to help promote the industry.

Marcia Angell: That’s one of the things that the industry does with its vast wealth, it buys influence and it also uses its wealth to co-opt any institution that might be expected to stand in the way of its drive for profits. So it co-opts, first of all the US Congress, it gives generously to political campaigns, it has the largest lobby in Washington. Nothing goes through Congress that it hasn’t approved. So it begins with US Congress and then through the US Congress and the Ad- ministration, it controls to a remarkable extent, the FDA.

Larry Sasich: We need the FDA. The basic structure and idea behind the Food and Drug Ad- ministration was in the public’s interest, and I think the framework is there. What’s missing is that there has been no oversight, and Congress has allowed the industry to become the FDA’s partner in the development of new drugs.
NBC News - Some Senators say the FDA shares the blame. -One of my concerns is that the FDA has a relationship with drug companies that is far too cozy.

Larry Sasich: The incentives that we have in our healthcare system, and kind of, healthcare as a business, are really kind of perverse in the sense of how we should be thinking about the public’s health.

Marcia Angell: I think the public is becoming very disillusioned, they’re no longer believing that this is a miracle industry in the sense that they may once have believed that. So in a sense I think that it’s just a matter of the public starting to put this all together and put pressure on Con- gress.

Katherine Greider: The influence of the industry on American medicine is far too extensive. And we’ve been naïve about it, and we need to separate them and be clear-eyed about what the motives of industry are, and what our goals are as a people for our public health.

Producer: RONIT RIDBERG
Editor: RONIT RIDBERG
Written by: RONIT RIDBERG | LORETTA ALPER | JEREMY EARP | SUT JHALLY
Executive Producer: SUT JHALLY
Associate Producers: LORETTA ALPER | JEREMY EARP
Narrator: AMY GOODMAN
Camera: DAVID RABINOVITZ
Motion Graphics: DAVID EELLS
Audio Engineer: ZEKE FIDDLER
Original Music: ANDREW KILLOY | PETER BRANDOLI
Media Research Coordinator: ANDREW KILLOY
Production Assistants: JENN HACKWORTH | BLAKE MAYBECK | SILAS LOWE | SARAH DAGGETT | DAMARIS SANTOS PALMER | AMY HINDLEY | DANNY KIM | DAN MONICO | BRIANNA SPOONER | LEIGH WHITING-JONES
On Location Assistance: CRAIG LEMOULT (Columbia University Medical Center) | HELENA MARTINS (Dept. of Social Medicine, Harvard) | VALERIE COLLINS (Public Citizen Staff of The Medical Letter) Additional Footage Graciously Provided by: MONICA MEHTA | SARAH DAGGETT | CYNDY SCHEIBE(CRETV)
Location Audio: JEREMY SMITH | DAVID RABINOVITZ
Graphic Design (Print): SHANNON MCKENNA
DVD Author: RONIT RIDBERG
DVD Menu Design: SHANNON MCKENNA
Transcription & Subtitles: RONIT RIDBERG

Featuring Interviews With:
DR. MARCIA ANGELL (Dept. of Social Medicine, Harvard Medical School; Former Editor New England Journal of Medicine)
DR. BOB GOODMAN (Columbia University Medical Center; Founder, No Free Lunch)
GENE CARBONA (Former Pharmaceutical Industry Insider and Current Executive Director of Sales, The Medical Letter)
KATHARINE GREIDER (Journalist; Author, The Big Fix: How the Pharmaceutical Industry Rips Off American Consumers)
DR. ELIZABETH PRESTON (Dept. of Communication, Westfield State College) DR. LARRY SASICH (Public Citizen Health Research Group).