Changing conception of patienthood

Social science understanding of the making of the patient as a social process dates to the development of role theory and to specifi c discussions of the cultural construction of patienthood [1]. In its classic expression, the sick role involves four components (varying by illness severity and duration): 1) sick people are expected to give up some of their everyday activities and responsibilities, however, 2) they must want to recover as quickly as possible; and, as a result, 3) must seek care [2]. In the case of chronic diseases, patients must manage their condition by adhering to their treatment regime. As a consequence of care-seeking, an important aspect of sickness is the experience of being a patient, making the factors that influence the social construction of patienthood items of research concern [3-5].

Historic analyses stress that the making of the modern patient as an individualized, internally focused, and generally science-confi dent being awaited the ability of biomedicine to provide effi cacious treatment [6]. Overtime, argue Herzlich and Pierret [7], “sickness was transformed from a collective to an individual aff air, from a way of dying [e.g., sweeping lethal epidemics] into a way of living [e.g., the rise of chronic disease].” More recently, discussion has shift ed from a focus on a silent and trusting patient enfeebled by a paternalistic doctor- patient relationship to a distrustful and demanding consumerist patient demanding personal rights in the medical encounter [8,9].

In recent decades, the pharmaceutical industry has played an ever expanding role in defining patienthood as part of a wider pattern involving the pharmaceuticalization of illness [10,11]. Commodity advertisement, a practice the pharmaceutical industry helped to create, plays a critical part in this process. While modern pharmaceutical advertising through the mid-1990s primarily communicated understandings of patienthood to physicians, today advertisement on television, radio and in other electronic and print media also is pitched directly to the patient. What is a patient as communicated through these ads? What are the messages about how patients should feel and act embedded in DTC commercials? In this paper, we seek to answer these questions about what might be called the construction of pharmapatienthood based on an analysis of DTC advertisements in the electronic media.

Our approach is informed by Foucault’s concept of the “discursive regime,” which maintains that a discourse or codifi ed body of meaning about a topic (which is propagated through language, media images and other communication channels) is intimately related to power. In the health arena, the enactment of power can be seen in the worldwide development of a pharmaceutically-centered neoliberal model of public health that stresses access to medications over disease prevention or even clinical care [12]. Th e ability of pharmaceutical discourse to rise to dominance and masquerade as “truth” is rooted in the power of a $800 billion global industry to frame particular social understandings, expectations, and practices regarding patienthood. Pharmaceutical discourse, in short, seeks to shape the way that people know and act in the world [13]. As Park and Grow [14] found in their study of DTC antidepressant advertising, this mode of communication “may play a role in constructing [the] social reality of diseases and medicine.” Moreover, we argue here, the scripting of patienthood in DTC pharmaceutical advertising forms part of a discourse regime that can be read as containing meanings, communicated through sights and sounds that produce a subject, namely the modern patient.

The making of a discourse regime

On Oct. 10, 1962, the Kefauver Harris Amendments to the Food, Drug, and Cosmetic Act required pharmaceutical companies to provide detailed information about drug side eff ects, contradictions, and effi cacy in their advertisements, as well as present a “fair balance” between benefits and risks, and avoid false or misleading claims. In 1985, a year in which new drug approvals reached a 20-year high, the FDA lifted a moratorium on print media DTC advertisements for prescription products, signaling the beginning of a change in the role of the pharmaceutical industry in patient construction [15]. Even before this, in 1981, Merck, Sharp, and Dohme published a DTC ad for the prescription drug Pneumovax. At the time, this act was so novel it was reported on by The New York Times in an article that presciently stated “Physicians may suddenly find themselves assailed by a patient’s demands for drugs that doctors know little about, or drugs more scientifically controversial than the advertisement implies” [16].

The ability of the pharmaceutical industry to shape patient construction was radically accelerated in 1997 when the FDA, under pressure from the pharmaceutical lobby, issued relaxed guidelines for the DTC marketing of prescription drugs. Specifically, the FDA stopped requiring that ads provide comprehensive information about all possible side effects s, although this information still had to be provided on the inserts in prescription drug packaging. Unfortunately, it has been found, these are “often inconsistent, incomplete, and difficult for patients to read and understand” [17].

Based on this policy change, pharmaceutical industry spending on DTC advertising grew to just under $5 billion by 2006. From the change in FDA policy through 2005, DTC advertising increased by 330 percent [18]. For every $1 invested by the industry in DTC advertising, the market produced a gain of $4.20 in increased sales. Between 1998 and 1999, the 25 most advertised drugs accounted for a $7.2 billion increase in spending on pharmaceutical products. Moreover, between 2000 and 2004, U.S. healthcare costs jumped by 9.6% annually, much of it the result of rising spending on pharmaceutical products [19]. Notably, Merck spent almost $100 million on DTC advertising for Vioxx, a fraction of what a study designed to test the drug’s deadly side effects would have cost [20,21].

How this jump in drug spending occurred is revealed by a survey conducted by the FDA which found that by 2002, 81% of respondents reported seeing or hearing an ad for a prescription drug [22,23]. Today, DTC pharmaceutical advertising is the most frequent type of health communication encountered by the public [24]. Regular television viewers in the U.S. see as many as 16 hours of prescription advertising a year in half to full minute doses [25].

As Consumer Reports [26] emphasizes, “Consumers are besieged daily by ads for prescription drugs, all beseeching you to ‘ask your doctor’ for a given brand-name drug for an ailment that you might, or might not, actually have. Moreover, a survey of 2,004 adults conducted by Consumer Reports National Research Center [27] found that 1/5 of survey respondents reported asking their doctor for a drug seen advertised on television or elsewhere. In most cases (70%), doctors comply with patient requests. As a result, demanding and receiving DTC drug prescriptions can be seen as a form of self-medication [28]. Notably, however, the most heavily advertised drugs are often not the most effective or safest treatments. They are, however, frequently the most expensive ones [27].

Prior analyses of DTC advertisements have focused on several issues including their contribution to patient health education [29-31]. Several studies have concluded the educational value of these advertisements is limited and that their primary impact is the creation of highly profitable consumer demand for specific prescription drugs [25,32]. Rather than expanding consumer understanding, according to Fisher and Ronald [33] and Hogle [34], DTC ads reflect medical neoliberalism and a shift toward consumer responsibility in the selection of treatment options.

This development marks a significant revision of patienthood. In light of the ubiquity of DTC pharmaceutical ads, we ask: what are the messages about patienthood expressed across a range of such advertisements and how are these messages communicated?

To analyze patient construction in DTC pharmaceutical advertising, we developed an observational framework to guide the content analysis of commercials. The framework guided the viewer to first record information about the drug being advertised, the health condition it was presented as treating, and the format of the advertisement (e.g., involving actors or cartoon figures). Next the observer recorded information about the patient, who generally played the central role in the advertisement, including perceived gender, age group, ethnicity, and social class (based on visual clues such as the patient’s clothing, home, possessions, and activities), other people present in the commercial (e.g., family members and friends of the patient, health care providers), the types of physical locations shown (e.g., inside people’s homes, in offices, out of doors), activities in which the patient and others are engaged, benefits that are shown or said to accrue to the patient through use of the drug, and the number and kinds of side effects associated with the advertised drug. Observers also recorded their impressions of the patient’s disposition (e.g., outdoorsy type, active vs. more homebound, carefree vs. controlled). All of this information was recorded on a data matrix which facilitated the identification of patterns peculiar to particular types of drugs (e.g., anti-depression medications) or found across drug types. The data matrix was revised several times to integrate new categories or patterns, so as to increase inter-coder reliability. The three authors individually carried out the advertisement observations in January and February 2012 and met regularly to compare observations and note patterns and emerging themes. Advertisements were either watched on television or on websites where ads shown on television could be seen.

A total of 40 advertisements were viewed. These featured 37 different drugs promoted for the treatment of a wide range of health conditions or needs, including: depression (three ads reviewed), allergies (three ads), stroke and heart attack prevention (three ads), gastroesophageal reflex disorder, aka GERD (three ads), migraine headaches (two ads), erectile dysfunction (two ads), birth control (two ads), osteoporosis (two ads), weight loss (two ads); and one ad each for arthritic pain, rheumatoid arthritis, blood clot prevention, diabetes treatment, HPV vaccine, memory loss, neuropathic pain, overactive bladder, symptoms of Parkinson’s, psoriasis, schizophrenia/bipolar disorder, sleep aid and smoking cessation. Scussa [35] identified one hundred and three different drugs being advertised in DTC format (at the time of that research) -- our random sample of currently advertised/available DTC pharmaceuticals thus represents roughly forty percent of prescription drugs being advertised directly to consumers.

Our selection criteria was based on ease of access (we focused on advertisements that aired frequently on cable television and through online television sites like Hulu.com, or that are easily found on YouTube.com), and in part, on the type of conditions said to be successfully treated with the DTC drugs. Our sample included drugs for 24 different conditions, including many conditions that other research identifies as being the most commonly targeted for DTC advertising, namely “new drugs used to treat chronic conditions” [18]. We sought to analyze the content of a wide range of DTC ads for drugs to treat a broad range of chronic conditions or lifestyle ‘needs’ (e.g., birth control, weight loss), and thus consider our sample to be a fairly representative set of DTC ads. Our findings on pharmapatienthood as constructed in these advertisements are presented below.

Findings

One neoliberal message regularly if subtly expressed in the ads in our sample is that patients have a moral responsibility to play a pivotal role in their own treatment and recovery (or at least improvement) by speaking to their physicians about specific drugs they have seen advertised [36]. Commonly this message is stated directly by a narrator or by the patient him/herself. Additionally it is reinforced by the ways that patients are portrayed in the ads, the kinds of settings in which the actors are placed, and the handling of the complicated issue of drug side effects.

Patient characteristics

Not all of the ads in our sample employed actors, or only actors; 10% consisted of or included animated depictions of patients, symptoms, or biological mechanisms of the illness or treatment, while the other 90% were live-action mini-dramas featuring actors playing patients, their social network members, health care providers, and co-workers.

Animation (with verbal narrative) in DTC ads most commonly was used to express anatomical or biochemical processes that are complex or cannot easily be communicated using actors. Some of these ads, such as those for acid reflux disease or cholesterol medicines, use simple (and simplifying) animation to illustrate how cholesterol can build up inside of your arteries or how acid reflux develops in your digestive system. Other use of animation, such as the creation of an a pillow-like cartoon “blob” to represent a person suffering anxiety, depression or related conditions—as seen in DTC ads for the antidepressant Zoloft—appears motivated by an attempt to transform longstanding emotional suffering and anguish into a modest, solvable problems (in which “bouncing equals happiness”). Such ads feature fairytale narratives that offer comforting “elementary-school explanations of mental illness” that “make you want to buy the emotional world [they have] to sell” [37].

While the Zoloft blob is apparently ungendered, males were present in 48% and females in 58% of the enacted ads in our sample. Typically women shown in the ads were either the patient (e.g., for depression or sleep aid drugs) or near-silent but supportive partners of male patients. Rarely were the women particularly vocal nor did they appear to exhibit strong personalities. The exception to this pattern was older women, who were portrayed as more assertive about their treatment. Generally, women were portrayed as having fairly docile demeanors, quiet voices, and conservative clothing. Most seemed calm and pleasant but were never outspoken. Many played the role of mother or spouse in the ads; however some did appear to hold jobs outside of the home.

Men, by contrast, were shown as having a stronger presence in the ads. Often they were rendered as leading an outdoor-oriented lifestyle, seemed to be confident and proud, and displayed a generally “alpha-male” attitude (composed, optimistic, self-accepting, empowered, adventurous, passionate about life, and dominant but not aggressive). Most males appear to be the head of the household (except when in ads for depression or anxiety drugs). The trait that appears most often among males in the ads is that they know how to stay in control of their lives and their diseases.

Another aspect of patient portrayal in the ads is apparent ethnicity. Whites, who constitute 64% of the U.S. population [38], comprised 80% of the people shown in our DTC ads, 23% were Black (census: 12.6%), 5% were Latino (census: 16%), and 5% were Asian (census:4%). The total equals more than 100% because some ads showed multiple patients. As these data suggest, a significant majority of the patients shown were white, but Blacks and Asians patients also were over-represented in the ads in our sample, as compared to recent Census data.

Based on prevailing cultural images of middle class individuals, especially individuals in the upper sector of this class (e.g., nice, well-furnished suburban homes, sporty but casual clothes, newer cars, speech patterns of college educated individuals) [39], the majority of the ads depicted people who appeared to be middle class (83%), with only 10% of the ads showing upper class and 5% working class individuals. Fifty-five percent of the ads showed middle-aged patients, 23% showed older people, 20% depicted young adults, 3% showed teenagers and only two of the ads (5%) contained a child as a patient.

Finally, the patients portrayed in the DTC ads in our sample trusted the doctor to prescribe the right drug (75%); were pro-active (53%), had a positive life attitude (48%); were socially oriented (58%), had a preference for active lifestyles (70%); were outdoorsy (58%); were committed to maintaining control of their illness and symptoms (65%), and were shown as determined and courageous (e.g., not being deterred by possibly significant side effects, willing to raise questions with their doctor about significant diseases, not held back by illness) in their zeal to be healthy (75% of ads). These attributes are important constituents of pharmapatienthood.

Setting: Pharmaceuticals in the forest

It is well-known to anthropology that space is never empty and always meaningful [40]. Shields has used the term “social spatialization” to refer to the process of “social construction of the spatial which is a formation of both discursive and nondiscursive elements, practices, and processes.” Here we introduce the term “pharmaceutical spatialization” to refer to the way salient spatial images are developed and used in DTC advertisements in the service of constructing patients and selling drugs. In our analyses, for example, we found that 60% of the ads in our sample included outdoor, nature and/or recreational/athletic scenes. Thus, in a Lipitor advertisement, a man who reports that he had a heart attack at age 57 because he didn’t “do enough for his high cholesterol” is shown unloading his bicycle from the roof of his SUV, which is parked in a grassy forested area next to a river. He and his wife and son (presumably) are then shown riding leisurely through the forest to a quiet picnic spot among the trees. The scene closes with the man and women, arms wrapped around each other, mesmerized by the river as a warming sun sets over the hills. Similarly, in an ad about the use of Humira for the treatment of chronic plaque psoriasis, a woman is shown inside a house looking out the window in frustration at her family and friends sit talking on a dock on a lake. A dog is in the water retrieving a tossed Frisbee. The woman thinks out loud about “once again having to deal with embarrassing, flakey, painful red patches” on her skin that keep her inside instead of outdoors with her friends and family. As the woman begins talking about the benefits of Humira, she emerges from the house walking towards her friends; with each step she takes the severity of her psoriasis lessens (portrayed as disappearing pink circles over her clothing), until she is sitting among them with clear skin and a huge smile.

Ads that did not show a patient out-of-doors were for specific kinds of drugs, especially some anti-depressants, acid reflux and indigestion medications, osteoporosis preventatives, sleep-aid medications, weight-loss drug, prescriptions to control symptoms of rheumatoid arthritis or Alzheimer’s, an insulin delivery device for diabetes management, and a birth control pill. What this seeming laundry list of medications has in common is that they are intended to treat conditions that do not affect mobility, may affect someone indoors more so than when they are out and about (e.g., sleep aids), that would be difficult to portray visually in outdoor settings (e.g., osteoporosis, Alzheimer’s, birth control, high cholesterol), or that interfere with indoor activities like lying still, relaxing, and sleeping (e.g., restless leg syndrome, insomnia).

Notably in light of an earlier era in American history in which health was closely associated with ability to work, only 11% of ads depicted patients at work. Primarily these ads were for medications to control or prevent blood clots, weight gain, diabetes, and osteoporosis–all medications that could be construed as helping patients to stay on the job and avoid missing work due to health problems.

Side effects

Across all the ads in our sample, more than sixty separate side effects were mentioned or shown in small print on the screen. There were an average of four side effects per ad, but fully 40% of ads neither mentioned nor showed a single side effect. More than 10% of ads listed or mentioned ten or more side effects. The maximum number of side effects in an ad was 14. The most frequently mentioned side effects included: fatigue/tiredness (five ads), digestive problems (five ads), joint or muscle pain/weakness (five ads), headaches (four ads), and allergic reactions (three ads). More than 55 other side effects were presented in our ad sample.

The drug ads that listed the greatest number of side effects (ten or more) were for treating insomnia, depression, and a quit-smoking aid. In general, side effects were introduced near the end of ads, after many images of content, much-improved patients had been shown, and side effects were often merely shown scrolling in small print across the bottom screen while a voice-over narration continued to extol the virtues of the drug being advertised, background music built to a loud crescendo or otherwise became more central (and distracting), and/or while images of an ideal patient continued to be shown enjoying outdoor activities, peacefully sleeping, or otherwise exhibiting the benefiting of DTC drug use. For example, in a Lipitor ad, the patient is shown riding a bike in the woods with his family, smiling and enjoying himself, while the side effects are quietly mentioned by the narrator. In an Advair ad, patients are shown holding their inhalers and smiling confidently, while the narrator describes the increased risk of death associated with the use of this potent drug. Similarly, a myriad of risks mentioned for the Gardasil vaccine are verbally listed by the narrator while full-screen images of lively, healthy, active teenage girls are shown laughing and smiling, exercising, and hanging out with friends and family.

The core plot of most of the ads we viewed was a simple deliverance tale composed of four components: 1) loss (of a pain-free life, mobility or other capacities, enjoyment, or social interaction); 2) longing (often expressed as a focus on “getting your life back” or “regaining control”); 3) action (talking to one’s doctor, use of the advertised drug); and 4) deliverance (restoration of lost capacity, control, and enjoyment) [25]. Part of what some patients appear to restore is their pre-illness identity. Illness, especially chronic illness, constitutes a threat to identity, and, as a result, promises of identity restoration, it has been observed, are common in DTC advertisements [41].

To achieve their intended goals, DTC advertisements work hard to create an emotional connection with their target audiences, allowing the viewer to identify with the visual, personality or sociodemographic characteristics of a featured patient and their plight. However, as Woloshin, Schwartz and Welch [42] observe, “DTC ads provide limited information on how well the drug works.” Further, the issue of failure is never addressed by the ads. This is notable in light of the admission of Allen Roses, vice-president of genetics of GlaxoSmithKline, who reported “The vast majority of drugs—more than 90 percent—only work in 30 or 50 percent of people.” [43].

While other studies have produced findings parallel to ours on the highly gendered nature of DTC portrayals, less research has explored other sociodemographic characteristics of patients. From the perspective of Social Identity Theory, based on the selection of actor ethnicity patterns found in DTC ads, pharmaceutical companies would appear to be primarily targeting white consumers. This interpretation is based on the fact that viewers’ identification with the apparent ethnicity of actors in an advertisement has been found to have a positive effect on their intentions to purchase an advertised brand [44].

Of note, research on DTC ad exposure by ethnicity indicates that Blacks are exposed to about one-third more advertisements than whites, reflecting “consumers’ television-watching [patterns] and [pharmaceutical] firms’ advertisement-placement decisions” [45] For example, Nielsen Media data for the Fall of 2004 show that Black households watched 40% more television than non-Black households. Consequently, even with fewer ads targeted to Blacks, this sizeable market segment may still be heavily reached with ethnically targeted DTC advertisements. In light of significant growth in the Latino population, their general absence from these ads remains unclear.

The young adult and middle-aged demographics, the most commonly featured age brackets in the ads, are also the most likely to be working and have the best health insurance. Moreover these age groups, trained by a life-time of television watching to be consumers, are prepared to make requests of their physicians as they begin to suffer the kinds of chronic health problems most frequently targeted by DTC commercials. Research suggests tha, people in young adult and middle age brackets are less likely to accept pain or the aging process and are willing to spend a considerable amount of money on better health [46].

As well, with an aging population suffering multiple diseases, the post-work phase of contemporary life has created a significant market for pharmaceutical companies. However, companies face rising competition from generic drugs, as well as policy changes intended to restrict healthcare spending or to respond to public concern about drug safety [23]. A significant segment of DTC advertisement helps promote demand for specific brand names targeting an aging population.

The preponderance of DTC ads depicting middle class patients reflects what has been consistently been found in class identification research, namely that the majority of Americans identify with the middle class whatever their income [47]. However, patients in the ads are not depicted as battling the contemporary challenges facing the middle class, including rising health care costs [48]. Rather, they recall an earlier time when middle class families experienced a greater sense of economic security, suggesting that DTC ads help sell drugs directly based on their ability to offer relief from burdensome symptoms, but also indirectly through their ability to offer sanctuary from contemporary economic woes.

The two drugs in our sample that included working class patients were Seroquel (for schizophrenia and bipolar disorder) and Advair (for asthma control). Various markers of lower socioeconomic status have long been known to be risk factors for asthma, and to differentially affect the severity of asthma [40], so it is understandable that the working class might be included as a target audience for an asthma medication. More troubling, perhaps, is the suggestive message in the Seroquel ad that working class people are the social group that suffers from mental illness, particularly a stigmatizing disease like schizophrenia [49]. Yet mental health research has not found a correlation between social class at birth and the risk of developing schizophrenia, although a connection has been identified between older age at diagnosis and/or beginning of treatment for people of lower socioeconomic status with schizophrenia [50].

On the other end of the income spectrum, upper class or wealthy individuals were depicted in in ads for Boniva (osteoporosis), Xenical (weight loss), and FlexPen (diabetes). The Boniva ad featured a successful actress as the drug’s spokeswoman, explaining the upper class status coding for this drug. The reason for the depiction of an upper class woman in the Xenical ad may lie in recent findings [51] indicating that thinner women have greater earning potential in the United States – people in higher income brackets may in fact be better positioned to be able to maintain a smaller body size, or to lose weight, in order to preserve the social status associated with thinness. The diabetes ad showing an upper class individual is more difficult to explain, as people in poverty are actually the most likely, statistically, to suffer from diabetes [52]. However, more educated (and thus, potentially higher-earning) individuals are more likely to try new medical technologies, especially new pharmaceuticals [53], and the FlexPen is a new delivery system for insulin injections. This discussion suggests that the issue of class portrayal in DTC pharmaceutical advertising remains unclear and would probably benefit from a study design in which multiple advertisements for the same set of medicines are compared for clues about patient social class.

The frequent use of outdoor scenes in DTC ads is noteworthy in that the National Time Use Survey (2010) on people’ daily activities in the United States found that the average working person spends slightly less than 6.5% of their time outdoors. The ads, in short, rather than directly reflecting the actual lived-experience of patients, vastly over-represent one small (if highly idealized) facet of American life (Leech et al. 2002). Repeated watching of DTC advertisements suggests that the significant emphasis on showing patients outdoors (especially during the presentation of side effects of advertised pharmaceuticals), and, commonly, in enjoyable social and recreational activities, appears intended to associate pharmaceutical commodities with activity, freedom of the physical and social burden of symptoms, and an optimistic sense of well-being and sociability. The patient not on pharmaceuticals is restricted, housebound, and withdrawn, while on pharmaceuticals she/he walks symbolically through her/his front door and becomes a mobile individual living the good life as that is understood in the contemporary American imaginary. Indeed, it is of note that a body of research suggests that exposure to “nature” is in fact associated with improved health, outlook, and sense of comfort (Kaplan 2001; Kuo and Sullivan 2001; Van den Berg et al. 2003), a link that DTC advertisers expropriate as a motivator for getting your doctor to write the desired script.

A study by Kaphingst et al. [54], and affirmed by our observations, revealed another strategy used to undercut patient understanding of side effect. These researchers compared the “fact density” (i.e., the number of facts given about a drug’s benefits and risks within a unit of time) in DTC ads. They found that the 23 ads in their sample provided a mean of six facts about drug benefits (with a range between 2–12 facts) that were communicated in a mean time of 10 seconds (with a range between 4–27 seconds). These ads presented a mean of 10 risk facts (with a range of 2–19) in an average time of 14 seconds (with a range between 3–23 seconds). Based on these data, they conclude that “on average, viewers had more time to absorb benefit facts than risk facts” [54].

Moreover, side effects are listed verbally or in writing, but, unlike drug benefits, they are not actually shown in patient suffering and distress. Also of note, the narrator’s catalog of side effects is timed to begin at the exact moment when the patient is first shown in seemingly full, often quite exhilarating recovery: “The eye trumps the ear as the words ‘sexual side effects, diarrhea and nausea,’ among other unpleasantries, are drowned out by the visual satisfaction of a transformed, sunny-looking [patient]” [37].

The variation in the number of side effects included begs the question of why some drugs are marketed directly to consumers without any mention of side effects at all. In our sample, the latter category included drugs for erectile dysfunction (E.D.), high cholesterol, weight loss, and osteoporosis. What is it about these drugs that exempt them from any acknowledgement of side effects in DTC advertising? One explanation is that pharmaceutical companies know that when it recognizes that an ad is in violation of its guidelines the first action of the FDA is to ask the manufacturer to withdraw the violative ad voluntarily. If this is not effective, the FDA can send what is called an “untitled letter” warning that the ad in question, by minimizing the risks of the drug, is in violation and should be withdrawn immediately. The FDA also may send a “Warning Letter” if the violation is egregious. Warning Letters may require that not only must the violative ad be pulled, the company must take some corrective actions by disseminating accurate information to various audiences (e.g., patients, physicians, pharmacists). In other words, during the time it takes to the FDA to spot a violative ad (which requires monitoring by an agency with a limited budget) and until a Warning Letter is used (or, if that too fails, the issuance of an injunction by the Department of Justice), a considerable amount of time (as much as several months) may pass during which the problematic ad is regularly broadcast to sufferers. Consequently, ads may run for a period of time and then be withdrawn without any penalty being imposed, which, indeed, is the most common pattern [55].

A related issue is the role DTC ads may have in creating worry about minor or ambiguous symptoms, transforming risk factors for disease into disease, or even the social construction of new diseases (e.g., restless leg syndrome, irritable bowel syndrome), all of which might be seen as side effects of DTC advertised drugs. Elliott [56], a physician and professor of bioethics, observes that the advertising of Paxil helped to bring into existence “social anxiety disorder” in an effort to expand drug sales. He, as well as a growing number of other researchers, argue that many drugs advertised directly to lay audiences promote such newly constructed diseases, rather than seek to improve public health [57,58].

It is estimated by researchers [59] that the pharmaceutical industry, which regularly tops surveys of the most profitable corporate segment, spends about twice as much on advertisement as it does on research (contrary to industry claims). As a result, by the time an American reaches the age of 65, he/she will have viewed an estimated two million television commercials, many of them for pharmaceutical drugs [60]. As argues, advertising represents as significant shift in Western culture from a 19^th century emphasis on moderation and self-denial to a 20^th century in which commodities are highly valued, readily possessed, and symbolically imbued “with the power to transform the consumer into a more desirable person.” This transformation has been advanced in an individualist direction through the rise of neoliberal philosophy and its emphasis on personal accountability in all areas of life, including health, and its celebration of the market as the solution to all problems, social and personal . As Fjellman stresses, the hegemonic metamessage of our time is that “the commodity form is natural and inescapable. Our lives can only be well lived (or lived at all) through the purchases of particular commodities.” In this way, “Well-being [itself] is recast as a commodity and as a distinct personal achievement” [11].

Direct-to-consumer pharmaceutical advertising, which as we have argued constitutes a discursive regime composed of words, music, and image, embraces, mobilizes, and promotes these newer cultural themes, including themes about patienthood, in the interest of ever expanded profit. Included in the process is the making of new health worries and new diseases, or what has been called “disease mongering” [36,58].

One product of the discursive regime is the making of new understandings of patienthood affirming the flexible ability of capitalism to continually bring into being new and redefine old cultural arenas as pathways to revenue in an ever evolving if continually fraught political economy. Along the way, lives and livelihoods, worldviews and values, and cares and concerns may be swept aside without people fully realizing the source of their frustrations. As noted by Applbaum [61], “Because we believe that we owe corporations our wealth and well-being, we tend not to question corporations’ fundamental practices, and they become invisible to us.” Ironically, the continual remaking of culture in the service of profit may be a force that helps create the very suffering that the pharmaceutical industry claims to relieve.

Our analysis found that DTC ads construct the ideal patient as someone who is assertive, intolerant of any suffering or sign of aging, self-directed, and motivated to talk to his/her doctor about gaining access to prescription medications they believe will allow them to lead full, happy, productive, and social lives. Achieving these goals commonly is expressed in the ads (although varying by the disease of concern) through actors playing the role of patients who are visibly engaging in fulfilling and active outdoor lifestyles, with affectionate interactions with (heterosexual) partners, and often with children and trusted and fun-loving friends. Noting that patient education is the common industry justification of DTC advertising, a frequent message in the ads is: patients recognize the importance of proactively taking charge of their illnesses and not letting them or their symptoms hold them back (from the many things they want to do with their lives); they should also, when not in the woods hiking, biking or canoeing, or playing with their kids, work productively in their chosen middle class professions, without needing to miss work to manage their illnesses.

There are, however, several problematic social structural aspects of the DTC pharmaceutical advertising (not the least of which being their veracity and the damage done to people’s health from taking powerful drugs that often are ineffective but may have significant iatrogenic side effects and/or are taken for industry mongered diseases). First, they assume that all ad viewers have a doctor to go to when seeking a specific prescription drug even though 16.3% of Americans are uninsured and the number who receive insurance through their employment has continued to have plummeted, going from 64.1% in 2000 to 55.3% in 2010. Second, they overlook the fact in an era in which 8.2% of Americans (12.5 million people) officially are unemployed [38], and the actual number is believed to be higher, that viewers have a job to go to where they can be productive. Thirdly, not all T.V. viewers are in romantic relationships—as Baby Boomers are less likely than their parents to ever marry, nor are all heterosexual or live in traditional nuclear families. Fourthly, there is the emphasis in the ads that the responsibility is on the patient to have the wherewithal and motivation to identify, request, and consistently take the miraculous pharmaceutical drugs that will allow them to be outdoorsy, active, productive, and social, and not be held back by their symptoms.

Rather than acknowledging the larger economic, gendered, ethnic, class, and structural forces and social determinants of health that shape the likelihood that an individual will suffer from a particular illness, DTC ads tell viewers that it is their job to seek out and benefit from the particular commodity that will best enrich their lives. Not only are viewers told they must buy things to be truly happy and healthy, but also that it is their responsibility to identify the right commodity that will most effectively aid them in being an ideal patient, and a superlative person. And thanks to the DTC and over-the-counter drug advertisements, there is no shortage of such medicinal commodities to choose from.

This paper was original presented at the 2012 Society for Applied Anthropology meeting in Baltimore, MD in the session entitled “Medical Anthropology and its View of the Patient,” organized by J. Bryan Page. The comments of other presenters and attendees is gratefully acknowledged.