Dan Gardener 2009/10/16

[Preface]

We live in the healthiest and safest era in history, yet we are immersed in a "culture of fear." Fear is the dream tool of marketers and politicians. We are surrounded by carcinogens, avian flu, SARS, H1N1 swine flu, mad cow disease, chemical pesticides, nuclear waste, terrorist attacks, genetically modified foods, global warming crises, internet stalkers, child abductors, and economic panics—the list grows ever longer. Do we truly understand risk?

Is High Cholesterol Not a Disease? Big Pharma’s Clever Trick

"The rhetoric of disease-mongering makes it seem as though health is being promoted," wrote British physician Iona Heath in *PLoS Medicine*. "But in fact, the opposite is true. Much disease-mongering relies on portraying normal biological and social differences as diseases, and treating risk factors as if they were diseases themselves. The pharmaceutical industry is accustomed to managing risk factors, and thus this vicious cycle is established—because, by definition, those who take medication are patients."

The cholesterol warning on the wall of my doctor’s clinic is a perfect example. High cholesterol is not a disease; it is merely a risk factor for cardiovascular disease. There are many such risk factors, including lack of exercise, smoking, poor diet, high blood pressure, obesity, and diabetes. Most of these can be improved through simple lifestyle changes. However, cholesterol can be lowered with medication, so pharmaceutical companies singled it out and marketed it as if it were a disease itself.

In 2003, Pfizer launched a large-scale "consumer self-awareness" campaign, ostensibly to raise public awareness of heart disease and heart attacks in France and Canada. The ads were startlingly direct. The Canadian TV commercial showed a woman and two children crying in a hospital waiting room, followed by a doctor announcing her husband’s death. Then time reversed—the man was seen lying on a gurney being wheeled through the hospital, collapsing in an ambulance, and finally falling during a sunny picnic. The ad then told us it was cholesterol’s fault—even if you appear healthy, it can still kill you. So, get your cholesterol checked. The scene then shifted to the man and his children laughing, having escaped their grim fate.

Regarding Pfizer’s campaign in France, Jonathan Quick’s team from the World Health Organization’s Essential Medicines Policy wrote a strongly worded letter to *The Lancet*: "Of all known cardiovascular risk factors, only cholesterol is mentioned—this campaign does not achieve its stated purpose. The campaign does not mention any actual medical product, yet it coincidentally aligns with a study published in *The Lancet* on the use of atorvastatin to reduce major cardiovascular events." Atorvastatin is the generic name for Pfizer’s blockbuster cholesterol-lowering drug, Lipitor. "We believe this campaign may provoke anxiety in patients and encourage them to request statin prescriptions," Quick’s team added. "The information includes misleading statements and omissions that could lead to inappropriate medication use and heightened unnecessary risk." Thus, Quick concluded that the ad "violates several WHO ethical standards."

Barbara Mintzes, a professor of public health and infectious diseases at the University of British Columbia, was even sharper in her critique in *PLoS Medicine*. She wrote that Pfizer exploited "fear of death" to boost sales.

In most Western countries, public education campaigns require justification—only New Zealand and the U.S. allow direct-to-consumer drug advertising without restrictions.Even so, federal regulations in the United States still require advertisements to adhere to guidelines that serve the public interest, while the pharmaceutical industry insists their ads merely provide factual information and thus genuinely benefit the public. Many observers dismiss this as nonsense. Douglas Levy and former FDA Commissioner David Kessler, from the USC School of Medicine, pointed out in the *Annals of Family Medicine* that pharmaceutical companies' spending on U.S. television ads "doubled from $654 million in 2001 to a staggering $1.19 billion in 2005. Nearly a third of this was spent on one category: sleep medications. Yet no matter how disruptive sleep disorders may be, they pale in comparison to the leading causes of death in America—cardiovascular disease, cancer, and accidental injuries. Regardless of the industry's claims about the public health benefits of their ads, their heavy promotion of drugs for conditions of varying medical seriousness raises doubts about their true concern for the public interest."

In 2007, a research team led by Dominick Frosch from the University of California’s medical department published the first comprehensive analysis of the 30-minute drug ads aired annually in the U.S. in the *Annals of Family Medicine*: "Most ads (82%) included factual statements and rational arguments about product use, but few explained the underlying condition (26%), risk factors (26%), or disease prevalence (25%)." The researchers argued these omissions have serious consequences: "With unclear descriptions of who needs or could benefit from the product, (direct-to-consumer ads) implicitly encourage people to believe they may have numerous health issues that the advertised product could improve, while failing to clarify who might truly benefit from treatment."

Another overlooked aspect is lifestyle changes. Any doctor considering treatment for a health issue would first think about whether quitting smoking, improving diet, or exercising could help. Frosch's study found that 19% of ads mentioned lifestyle changes alongside medication, but none suggested lifestyle changes could replace drugs. In fact, nearly 19% of ads explicitly stated that lifestyle modifications were insufficient. The researchers noted: "Several cholesterol-lowering drug ads implied that non-drug approaches were hopeless."

Drug ads emphasize emotion. Frosch's study revealed that nearly all ads—95%—used positive emotional appeals, while 69% highlighted negative feelings. "Most ads featured protagonists whose lives were disrupted by health problems, with medication restoring their control. This loss of control extended beyond health issues, often including social, recreational, and work-related limitations. After using the product, the protagonists invariably regained full control and social approval from friends and family." This core message parallels home security ads or commercials featuring children playing near electric fences: you're in danger, but if you buy our product, life will be filled with laughter, sunshine, and rosy-cheeked kids at play.

"Disease-mongering exploits the deepest, most primal fears of suffering and death," wrote Iona Heath. It also taps into desires for happiness and social acceptance, achieving perfect emotional symmetry. Without our product, you’ll face fear, illness, rejection, death; with it, you’ll enjoy joy, vitality, acceptance, life. It’s hard to imagine a more effective way to trigger instinctive responses and open customers' wallets.An obvious question is whether pharmaceutical companies, security firms, and all other businesses that use fear and hope to market through psychological tactics learned these techniques through trial and error, or whether they drew from and applied scientific advancements over the past thirty years. There are many reasons to believe the latter is closer to the truth.

(This article is excerpted from Dan Gardner's new book *Risk: The Science and Politics of Fear*, Chinese translation published by Broadview Press.)

Source: http:/ / mag. udn. com/ mag/ world……_SUB_ID=4321& f_ART_ID=210773