Pharmaceutical Branding: Identity, Individuality, and Illness
Sarafem® is one of the first pharmaceutical products to have been heavily promoted by direct-to-consumer (DTC) advertising, and is prescribed for a highly contested syndrome attributed to women, namely, premenstrual dysphoria disorder (PMDD). Sarafem is fluoxetine hydrochloride—the same chemical marketed as Prozac®. But whereas Prozac became famous as a gender-neutral green and white pill, Sarafem is produced in pink and purple, for women. The introduction and marketing of Sarafem have reawakened a number of debates, including those pertaining to the propriety of DTC advertising, the existence of PMDD, and the effects of branding the same pharmaceutical substance in more than one way.
Illness: A Social Phenomenon
Social scientists are increasingly interested in questions about illness as a social category, that is, about how individuals who find themselves confronted by diagnoses of disease—particularly those whose “realities” are contested—use the interrelated institutions that define disease and its treatment (i.e., medicine, psychiatry, pharmaceutical companies, and insurance providers) to instigate social and political changes. Some individuals fight to be recognized as ill [e.g., Vietnam veterans and post-traumatic stress disorder (1) ], or fight to be recognized as healthy [e.g., gays and homosexuality as a medical category(2) ], whereas others contest such declarations of disease and normality. As people encounter these fights, they forge collective identities. Now more than ever, the social identities that individuals construct for themselves in terms of disease are being complicated by their relationships with pharmaceutical products. In the case of Sarafem, for instance, people on either side of the fence take provocative stances:
Has anyone seen the commercial for Sarafem [pink flavored prozac ;-) ]? The commercial tries to pathologize the mood changes
often associated with menstruation: “Think you have PMS? Think again! You may have PMDD, Premenstrual Dysphoric Disorder,
a recognized medical condition.” Medical condition my ass, do the words “dysphoria” and “disorder” sound familiar to the community?
(3)
—From a listserv for transgendered people
And:
I’m so glad to hear the good Sarafem is doing. All I can say that it’s about time they’re treating PMS more seriously. (4)
—From an online discussion group on depression
In the first quote, Sarafem represents a medical/corporate intrusion into the gender politics that have formed around questions of premenstrual syndrome (PMS), pathology, and sexual identity; in the second quote, Sarafem represents a long-overdue recognition of a medical disease that is uniquely female. And between these two views sits a new factor: the pharmaceutical product’s identity . In this case, Sarafem and Prozac (both manufactured and marketed by Eli Lilly) are chemically equivalent, but consider the following public statement from a Lilly representative (5) :
We asked women and physicians, and they told us that they wanted a treatment with its own identity. Women do not look at their
symptoms as a depression, and PMDD is not depression but a separate clinical entity. Prozac is one of the more famous pharmaceutical
trademarks and is closely associated with depression.
Thus, pharmaceutical companies, as well as consumers, confront disease and its treatment by looking beyond mere pharmacology: it is only in the context of a set of explanations that our understanding of a drug and illness become crystallized. Here, a new logic arises from the drug’s (branded) identity, which acts to parse illness into separate, differently constructed and experienced diagnoses. Fluoxetine under the brand of Prozac is white and green, and was introduced as an antidepressant; under the brand Sarafem, it is pink and lavender, and is offered to women as a treatment for PMDD. Pharmaceutical products are taking on symbolic lives—“Sarafem ” is homophonic with “seraphim,” from the Hebrew word meaning “angel,” and targeted to fem ales—and represent a constellation of cultural messages regarding illness . At times, the new “social lives” (6) of drugs can generate new anxieties around what it means to be ill:
Last week, I saw 10 patients with PMS that had been prescribed Sarafem. Not one was told that she was taking Prozac. They
were shocked and angry. (7)
—Scottsdale physician Joshua Holland
In his best-selling Listening to Prozac , Peter Kramer implies that the varied and growing number of conditions that fluoxetine counteracts might really be part of the same thing. But here, in the separation of Prozac-remedied depression from Sarafem-treated PMDD, fluoxetine is taken up in a market logic that splits, rather than groups, illnesses. This splitting complicates the idea that a person’s relationship to a drug is really her/his body’s relationship to a chemical compound. There is, of course, a contemporary medical discourse in which people can speak comfortably about “chemical imbalances,” but this discourse is obfuscated as patients, physicians, the insurance and pharmaceutical industries concern themselves with the socioeconomic—that is, precisely not the chemical—aspects of drugs.
With the advent of direct-to-consumer (DTC) advertising, the symbolic meanings of drugs have become pervasive,. For instance, it wasn’t too long ago that all pills were white and round (8), but the language of Lilly’s Prozac Web site suggests that pharmaceutical companies face new struggles over how to represent pills as brands (9) :
Generic fluoxetine is not identical to brand name Prozac in appearance. The generic prescription you pick up at the pharmacy
won’t look like brand name Prozac. Receiving medication with a different color or shape may be unsettling or cause concern.
And Lilly is not unique in maintaining a concern for surface (i.e., color) as well as substance (i.e., drug). According to a professor of drug marketing, quoted in a Boston Globe article, “You wouldn’t make a pink Viagra…. Designers propose colors for a particular medicine and help make sure there are no symbolic mistakes.” (10) Today, pharmaceutical developers carefully consider the sociomedical meanings of what the French philosopher Jean Baudrillard critically referred to as the “inessentials” (e.g., color) of advertised commodities (11) .
The branding and the social coding of drugs is situated within medical contexts: PMDD is different from depression and therefore Sarafem “belongs” to it more than Prozac does. But the attempt to make brands stick to diseases invites a whole new set of tensions among pharmaceutical companies, health care providers, and insurance companies. Now that generic fluoxetine is commercially available, HMOs, for whom “therapeutic equivalence” and not brand name is key, typically refuse to cover the cost of Sarafem (12, 13) . Thus, within different institutional settings, the patient/consumer encounters quite different ideas of how disease, bodies, and drugs go together.
Markets, Molecules, and Meanings
Public concepts of disease are increasingly formed on the bases of DTC marketing of pharmaceutical products. Accordingly, there is a new political economy of health care. The Web site for Sarafem, for instance, disperses information to physicians differently from how it presents information to patients (13, 14).
Physicians are informed that:
Fluoxetine was initially developed and marketed as an antidepressant (Prozac®, fluoxetine hydrochloride).
Patients, on the other hand, read:
What is the active ingredient in Sarafem? Sarafem contains fluoxetine hydrochloride, the same active ingredient found in Prozac®.
Both statements are technically true, but socially, they produce very different meanings. The differences in these descriptions are not those of technical expertise; the patient-directed description is not “simpler” than the physician-directed one, but the differences are nonetheless stark. For physicians, the first statement allows that Sarafem and Prozac are the same drug , with different packages. The second statement, for patients, conveys that they are different drugs , with the same ingredient. And as patient advocacy is increasingly overlapping with consumer advocacy, these differences are not trivial: As the above quotes suggested, we live in a world where some people will be “shocked and angry” that their prescription for PMDD is chemically identical to an antidepressant, whereas others welcome alternative branding as a gesture of personalized care.
Sarafem’s large print and broadcast campaign represented one of the first times a pharmaceutical company had spent more on DTC than physician-directed advertising in the first months of a drug’s release. The campaign quickly exemplified how advertising was becoming a new space where people encountered ideas about health, disease, drugs, and selves, and DTC in particular became a new site for social movements to instigate health care reforms [see, for example, (15) ]. The pharmaceutical industry has countered critics of DTC by arguing that DTC “empowers” consumers to participate in their own health care, “[r]ather than remaining uninformed and relying entirely on health care professionals.” (16) The controversy around DTC and the fact that social movements are insinuating themselves into health care policy debates suggest that a new form of medical citizenry is emerging, one in which patients must be savvy consumers, and that these new kinds of medical citizens are appearing at the same time that sites for health care reform are shifting.
Conclusions
It goes without saying that in terms of economic theory the direction in which goods can be profitably produced by profit-making
enterprises is determined by the marginal utilities for the last consumers … But from a sociological point of view it should
not be forgotten that, to a large extent, in a capitalistic economy (a) new wants are created and others allowed to disappear
and (b) capitalistic enterprises, through their aggressive advertising policies, exercise an important function on consumers.
Indeed, these are essential traits of a capitalistic economy. (17)
—Max Weber
There is an important sense in which the appearance of Sarafem was a purely economic move, exemplifying new pressures in the U.S. to extend the patent lives on drugs by rebranding and marketing them for different illnesses. As soon as generic fluoxetine became available, it was covered by 91% of managed care formularies, half of which immediately dropped their coverage of brand-name Prozac (18) , and within a month Prozac lost two-thirds of its prescription volume, a collapse in market share that represented “an all-time speed record” for the pharmaceutical industry (19) . Marketing journals at the time spoke of Sarafem as part of an attempt by Lilly to minimize losses from Prozac’s patent expiration, and IMS-Health (a large market intelligence firm for pharmaceutical and healthcare industries) also anticipated the appearance of Sarafem as a tactic to “combat generic erosion:” (20)
To sustain growth and market share… [companies] are looking for ways to extend the life of their patents; to receive FDA approval
for new indications of existing products; and to create new, improved versions of existing products. (21)
The fact that the appearance of Sarafem has particular social coherence as a commodity in a marketplace suggests a rather complicated picture of illness in the twenty-first century: In what sense does the appearance of illnesses depend on pressures in the pharmaceutical marketplace?
Medical anthropologists in the twenty-first century will have to confront these complicated questions about the relationships between the experience of illness and the production of its treatments. Indeed, as DTC advertising demonstrates, the question of how we experience illness through social institutions must simultaneously be a question of how we encounter ideas about illness and drugs in the first place (22) . It’s in these contexts that prescription drugs are taking on new “social lives,” and we need to account for how this might be changing how people experience illness and identify with diagnoses. Patient identity is in an important sense becoming branded identity, and it’s important to see the ways in which encounters with medicines are complicated by such knowledge. DTC advertising, gender politics, and the pressures on pharmaceutical companies to capitalize on patents ultimately function to diffuse the authority once centered in pharmacological science. The more that biomedical scientists appreciate the social lives of drugs, the better prepared they will be to advise, learn, and generally negotiate the modern power structures that inform social understandings of illness .
Nathan Greenslit is a student in the Program in Science, Technology, and Society at the Massachusetts Institute of Technology. E-mail npg{at}mit.edu ; fax 617-258-8118.
- © American Society for Pharmacology and Experimental Theraputics 2002
