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Mar 0 4 2011 M.A PHARMACEUTICAL RELATIONSHIPS Intersections of Illness, Fantasy, and Capital in the Age of Direct-to-Consumer Marketing by MASSACHUSETTS 1NSTITUTE Nathan P. Greenslit MAR 0 4 2011 M.A. Cognitive Science Johns Hopkins University, 2000 LIBRARIES B.A. History of Science & Mathematics / Philosophy St. John's College, 1998 ARCHVES Submitted to the Program in Science, Technology and Society in Partial Fulfillment of the Requirements for the Degree of DOCTOR IN PHILOSOPHY IN THE HISTORY AND SOCIAL STUDY OF SCIENCE & TECHNOLOGY AT THE MASSACHUSETTS INSTITUTE OF TECHNOLOGY February 2007 © 2007 Nathan P. Greenslit. All Rights Reserved. The author hereby grants to MIT permission to reproduce and to distribute publicly paper and electronic copies of this thesis document in whole or in part in any medium now known or hereafter created. Signature of Author: Histor'Anthropology, and Science, Technology and Society January 19, 2007 C e rtifie d b y : J o s ep h _ _ _ _ Joseph Dumit Director of Science & Technology Studies Associate Professor, Anthropology University of California, Davis Thesis Supervisor Certified by: e Michael M.J. Fischer Y7 Professor of Anthropology and Science and Technology Studies Massachusetts Institute of Technology Thesis Conypittee Member Certified by: Sherry Turkle Abby Rockefeller Mauze Professor of the Social Studies of Science and Technology Massachusetts Institute of Tec logy Th is Comnftte ember i l / Accepted by: I iavitr m. incnae Dibner Professor of the History of Engineering and Manufacturing Professor of Engineering Systems Director, Program in Science, Technology and Society PHARMACEUTICAL RELATIONSHIPS Intersections of Illness, Fantasy, and Capital in the Age of Direct-to-Consumer Marketing By Nathan P. Greenslit Submitted to the Program in Science, Technology and Society on August 27, 2007 in Partial Fulfillment of the Requirements for the Degree of Doctor in Philosophy in History and Social Study of Science & Technology ABSTRACT This dissertation is a multi-sited ethnography among marketers, consumer-patients and psychiatrists in the U.S. It explores the recent history of styles of pharmaceutical advertising that have come about in response to FDA regulations and ethical issues raised by patients and the press about how the pharmaceutical industry shapes drug research. Specifically this dissertation explores the role of direct-to-consumer drug marketing (DTC) in the consumption and experience of antidepressants, including a cultural shift in the U.S. towards how the consumer negotiates new ethical injunctions to manage his or her own identity through pharmaceuticals. A key focus is how marketers carve out their own ethical niche from which they innovate on ways to persuade consumer audiences with scientific facts that double as public relations. This dissertation gives special attention to how individuals encounter and incorporate the putative neuroscience of DTC advertising of antidepressants to negotiate their personal knowledge of illness, and to manage their identity, everyday practices, and professional pursuits. From these ethnographic encounters I have identified "illness," "fantasy," and "capital" as three key themes for my analysis of DTC marketing. In turn I have combined the very different literatures on illness (which address patient advocacy movements and health care seeking and questions of how medical diagnoses can be deployed as social norms), fantasy (which address psychoanalytic conceptions of desire and self, as well as semiotic understandings of consumption), and capital (which address health care market competition, and negotiations with the FDA over truth in advertising). In sum, this dissertation offers a thick description of "ethical identity management" in the contemporary landscape of U.S. pharmaceutical consumption. Thesis Supervisor: Joseph Dumit Title: Associate Professor, Anthropology University of California, Davis PHARMACEUTICAL RELATIONSHIPS Intersections of Illness, Fantasy, and Capital in the Age of Direct-to-Consumer Marketing Introducing pharmaceutical relationships My interest in pharmaceutical marketing was piqued in 2001. It was during this year that Prozac-the quintessentially famous antidepressant-had just gone off patent. The drug was subsequently rebranded as "Sarafem," manufactured in a new pink-and-purple capsule, and marketed for the treatment of "premenstrual dysphoric disorder"-an illness that most of the public learned about, not through their doctors, but through the advertising campaigns for Sarafem. I will tell the story of Sarafem in greater detail in Chapter 4, but for the sake of introduction here is a quick topology of the issues that Sarafem had presented to me: 1. Professional boundaries and ethical interventions. Despite the fact that Prozac is one of the best-known drugs in history, the consumer-directed marketing for Sarafem never once mentioned Prozac. This was part of a deliberate strategy to disassociate the drug therapy of premenstrual symptoms frompsychiatric medicine (even though premenstrual dysphoric disorder was first introduced in the DSM-II-R-the American Psychiatric Association's diagnostic manual for mental disorders). Pharmaceutical industry representatives defended this move as an ethical decision to destigmatize the treatment of PMS as "medical," not "psychiatric." 2. Surplus health' and feminist pharmacology. Criticism of Sarafem often took the form of accusing the pharmaceutical industry of medicalizing (and therefore capitalizing on) female experiences, and of looking to a science of the body to reify gender inequalities. At the same time, other voices welcomed Sarafem as a long-overdue recognition of suffering that is uniquely female, and lauded the scientific legitimation of that suffering. 3. Material-semiotics2 and identity fashioning. One MIT psychiatrist told me a story of how she had decided that one of her patients-a depressed male undergraduate student-should be put on Prozac. The psychiatrist wanted to get the student started on his medication right away, and she looked in her stash of drug samples to see if there was any Prozac. There was no Prozac, although there were samples of Sarafem-its chemical equivalent. But the student refused to take Sarafem. As the psychiatrist put it, there was just no way he could ingest a drug designed to treat PMS. She added that this student was not particularly macho in his refusal; on the contrary, he was apologetic in his acknowledgment of his own irrationality (I know it's the same thing, but ...) Marketing is terrain of this topology. Sarafem was one of the first pharmaceuticals to be marketed "direct-to-consumer" (DTC) and, in the wake of its television and print advertising campaigns I have been witness to a set of local reactions on the part of doctors, patients, consumers, drug regulators and marketers. I wished to explore these 'A phrase coined by Joseph Dumit. 2 A phrase coined by Donna Haraway to denote how symbolic relationships and material relationships can be mapped onto each other. See: Donna J. Haraway, Modest Witness@Second Millennium.Femaleman(C)Meets Oncomouse(Tm) : Feminism and Technoscience (New York: Routledge, 1997). reactions, to understand their implications for the changing doctor-patient relationship and specific uses of antidepressants in the broader context of American health care. I have identified the themes of "illness," "fantasy," and "capital" as three key intersecting technologies for my analysis of DTC marketing. The social and cultural problematics of pharmaceutical branding have enabled me to combine the very different literatures on illness (which address patient advocacy movements and health care seeking and questions of how medical diagnoses can be deployed as social norms), fantasy (which address psychoanalytic conceptions of desire and self, as well as semiotic understandings of consumption), and capital (which address health care market competition, and negotiations with the FDA over truth in advertising). In this dissertation I disaggregate what often gets lumped as marketing (i.e. simultaneously capital, desire, health care seeking), to show more clearly the historical and cultural sites of intersection where decision-making about illness and treatment occurs. Throughout I offer and explore individual experiences as ethnographic foils to these historical and cultural loci, in order to suggest some of the social and psychological contingencies in this complex terrain: "Pharmaceutical relationships" names the ways in which individuals (whether they are patients, physicians, or marketers) encounter and create experiences with medications that have assumed specific social lives as heavily marketed and advertised commodities. Pharmaceuticals are manufactured to have effects but they are marketed to have meanings, which often starts with brand loyalty. One marketing industry source, commenting on Prozac's patent loss, noted: "[T]he news in August 2000 that Prozac had lost a patent fight and might face generic competition two years sooner than expected sent Eli Lilly's stock down 30% in one day ... This may have been a dramatic overreaction, but it demonstrated that pharmaceutical companies-like Coca-Cola, IBM and Ford-increasingly are their brands." 3 Pharmaceutical companies increasingly are their brands, and the pharmaceutical industry is perhaps the central force within American health care. Indeed, the very scale of pharmaceuticals in the U.S. is unprecedented, and staggering: In 2005, over three-and-a- half billion prescriptions
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