In March of this year, Hollywood legend Lauren Bacall appeared on NBC’s Today show, telling host Matt Lauer about a good friend who had gone blind from an eye disease called macular degeneration and urging members of the audience to see their doctors to get tested for it. Then she mentioned a new drug called Visudyne, marketed by Novartis—which had hired Bacall as a spokesperson for the drug because of her appeal to the target audience of elderly consumers.
There is nothing particularly new about the use of celebrities in marketing programs for all manner of products—including pharmaceuticals—but for some reason Bacall’s appearance sparked a new wave of criticism, and prompted several news departments to review their policies about letting viewers know when a guest is a paid spokesperson for a product or company.
Disturbingly—though not, perhaps surprisingly—much of the news coverage suggested that public relations people for the pharmaceutical companies were misleading reporters. The New York Times reported that, “After learning that some celebrities who talked on its news programs about their health problems were being paid by drug companies, CNN has issued a new policy and will tell viewers about the stars’ financial ties to corporations.”
The implication was that Novartis and other pharmaceutical companies were sneaking celebrities onto news programs without alerting reporters to the connection between the stars and the companies they were representing. But producers at NBC were informed in advance about Bacall’s relationship. It would be highly unusual—and probably counterproductive—for a public relations person to fail to inform a media outlet about the true agenda of one of its guests.
Still, Dr. Joseph Turow, a professor at the Annenberg School for Communication at the University of Pennsylvania, called the use of celebrities in promoting pharmaceutical products “highly problematic and maybe even unethical.” The fact remains that neither Bacall nor Lauer mentioned the fact that she was a paid spokeswoman for Novartis. Says Turow, “People should be clear about the reasons [celebrities] are making certain recommendations.”
Leaving aside Turow’s assumption that he is clear about the reason Bacall was making the pitch for Visudyne—the fact that she was being paid does not preclude the possibility that she is genuinely concerned—the big question is whether responsibility for informing the public lies with the company or with the individual reporter.
“This topic first came to light in the 80s when Mickey Mantle was a spokesperson for Voltaren,” says Ame Wadler, who heads the healthcare practice at international public relations firm Burson-Marsteller. She is referring to a case in which the baseball great made claims that went far beyond the approved labeling for Ciba-Geigy’s arthritis drug. “I have been with three large agencies since then and involved in numerous celebrity campaigns—all of which fully disclosed the corporate sponsor. It’s routinely on press releases and disclosed on any DTC materials.”
Burson-Marsteller was involved in another case earlier this year, in which actress Kathleen Turner appeared on ABC’s Good Morning America to talk about her battle with rheumatoid arthritis. The audience was not told that the star—appearing on Broadway in The Graduate—was being paid by Wyeth and Immunex (now part of Amgen), which co-market Enbrel, a new treatment. Turner did not mention the product by name, but did tell Diane Sawyer that there were “new medications” that were “extraordinarily effective” without unpleasant side effects, and referred viewers to a website maintained by the companies.
Says Wadler, “There is absolutely nothing inappropriate about a celebrity offering his or her personal experience to help the general public learn more about a health condition, as long as the disclosure takes place.”
CNN, she says, had materials in advance of its interview with Kathleen Turner that fully disclosed the Wyeth/Immunex sponsorship.
“Public relations has long been regarded by the FDA as an extension of product labeling,” says Ilyssa Levins, who heads GCI Healthcare. “As a result, PR professionals and their clients must adhere to the package insert when making claims to the media on behalf of their pharmaceutical clients. This includes clearly identifying celebrity spokespeople’s endorsement of drugs, as a paid spokesperson.”
As far as Levins—and most of her colleagues—are concerned, a pharmaceutical company has fulfilled its obligation once it has informed the media of the relationship.
“Once the pharmaceutical company has clearly disclosed in the press kit and pitch letter that the celebrity is a paid spokesperson, it has completed its obligations. It’s possible that that the celebrity will forget to mention that they are there on behalf of a specific company, and the reporter doesn’t ask. But once the pharma company discloses this information in the press materials that were originally sent to that media gatekeeper—it actually becomes the responsibility of the media to ensure that this fact is clarified to its
viewers or listeners or readers.”
Says Paul McDade, who heads the global healthcare practice at Hill & Knowlton, “Disclosure should be the guiding principle. Any celebrity spokesperson should be comfortable informing media about his or her financial ties to a pharmaceutical company. Celebrities have been paid to represent companies for many years; many media understand this and are interested in speaking with celebrity spokespeople nonetheless.”
Most public relations professionals make the point that attempting to hide corporate-celebrity relationships is a waste of time.
“Lack of disclosure on the part of celebrities, corporate sponsors and thought leader spokespeople is nonsensical,” says Belsito. “There is absolutely no need for backroom cloak and dagger antics. If an agency doesn’t believe enough in the integrity of its clients, the products they represent or the people with whom they want to work to achieve their business goals, then what’s the point of the marriage? I believe public relations firms with healthcare expertise would be far wiser to speak the truth—always—and allow the journalists to decide how to disclose information to their readers or viewers.”
“I would always advocate letting the news outlet know that the celebrity is being sponsored by XYZ company,” says Michael Durand, who heads the healthcare practice at Porter Novelli. “If he or she has a compelling story, the news outlet will still conduct the interview. I have no problem with CNN requiring the identification of company-sponsored celebrities. My beef is that recommending celebrities seems to be the default tactic when agencies can’t come up with any more creative public relations strategies. Sometimes they work fine, but often companies are wasting hundreds of thousands of dollars on celebrity programs that have no impact on marketing.”
Belsito says her firm does not pitch a story without full disclosure. “If we have viable news, why on earth would we disguise the interests of the people we hope can communicate it best? Yes, we have a policy. It’s not very complicated. It’s called telling the truth.”
Is there a downside to disclosure? Probably not. “It’s hard to know whether we have lost more than we have won because of disclosure, but we wouldn’t have it any other way,” says Belsito. “Why? Because telling the truth works.” For that reason, most PR pros are not opposed to CNN’s new policy—although they do question the mock outrage that came through in the network’s statements about celebrity interviews. “CNN’s guidelines are not just right; they are necessary,” says Belsito. “I hope every news outlet follows suit.”
Others agree. “I believe the sourcing of celebrities in the news media is a good thing,” says Ken Rabin, a veteran healthcare communicator and executive vice president at Ruder Finn. “The public has a right to know.”
Choosing the right celebrity is important, however.
“Agencies and clients must be vigilant in recommending highly qualified celebrity candidates, those that are passionate about the cause because of a personal connection,” says Levins. “There is nothing wrong with being paid for time spent sharing your personal experience to advance the nation’s health. We just need to be confident that the celebrity messenger is motivated by the cause more than financial gain.”
Several people, for example, questioned the use of actor Noah Wylie, who plays a doctor on the hit television series ER. Wylie has worked with several pharmaceutical companies.
After an episode of the show featured Wylie’s character finding skin cancer on a patient, for example, Schering-Plough hired the actor for campaign to raise awareness of the disease. Schering markets Intron A, used to treat melanoma. Pfizer, meanwhile, hired Wyle to raise awareness of post-traumatic stress disorder after a storyline in which his character was dealing with psychological trauma as he recovered from a stabbing. Some of the questions asked by Matt Lauer seemed to assume that Wylie was a real doctor rather than an actor who plays one on TV.
“I understand why they thought he was a good spokesman,” says one healthcare PR expert. “But if you think about it, he didn’t have anything to bring in terms of his personal experience, just the fact that he plays a doctor on TV. You have to wonder whether the companies involved thought consumers were stupid enough to think he was a real doctor.”
Clearly, there is a need for companies to be more judicious, and more transparent, but the use of celebrities is not going to go away anytime soon.
“Working with a celebrity makes as much sense as ever,” says John Seng, president of Spectrum Science Public Relations. “Americans are hooked on celebrities. We can’t get enough of them. Reporters are human beings with human curiosities. They know their audiences and are keenly aware of the kind of stories that appeal to mass readership and viewership. A personal, shared experience of a personality who connects with viewers and readers definitely encourages audiences to learn more about a condition or a therapy. What’s so wrong with that?”
Seng makes the point that underpins many of the arguments for giving pharmaceutical companies wide latitude in terms of communicating with consumers—through public relations and direct-to-consumer advertising: physicians remain the ultimate decision-makers. So information empowers patients, who may identify symptoms earlier, or visit their physicians more often, or make suggestions about possible courses of treatment. But ultimately, drugs cannot be dispensed without a professional physician making the same kind of decision he or she has always made.
The use of celebrities is not the only area of pharmaceutical marketing that has come under fire in recent months. Mother Jones recently published an article, Disorders Made to Order, that looked at the increasingly popular technique of promoting diseases—particularly little known diseases, and particularly mental health disorders. The article, by Brendan Koerner, has been reprinted in The Guardian in the U.K. and most recently in the Toronto Globe & Mail.
Koerner cites a campaign conducted by Cohn & Wolfe on behalf of GlaxoSmithKline, after its blockbuster antidepressant Paxil was approved for generalized anxiety disorder, a condition described by mental health advocates as “the forgotten illness.”
The author has several issues with the Cohn & Wolfe campaign: the condition itself was ill defined, and estimates of the number of sufferers varied dramatically; the physician spokesperson for the campaign, Dr. Jack Gorman, an esteemed psychiatrist at Columbia University, was in the pay of the company; and an apparently independent patient group, called Freedom From Fear, was in fact being run by Cohn & Wolfe.
Says Koerner, “Typically, a corporate-sponsored ‘disease awareness’ campaign focuses on a mild psychiatric condition with a large pool of potential sufferers. Companies fund studies that prove the drug’s efficacy in treating the affliction, a necessary step in obtaining FDA approval for a new use, or indication. Prominent doctors are enlisted to publicly affirm the malady’s ubiquity. Public relations firms launch campaigns to promote the new disease, using dramatic statistics from corporate-sponsored studies.
“Finally, patient groups are recruited to serve as the ‘public face’ for the condition, supplying quotes and compelling human stories for the media; many of the groups are heavily subsidized by drug makers, and some operate directly out of the offices of drug companies’ PR firms.”
The reaction of the public relations community to the article was almost universal rejection of its not so subtle subtext, which is that PR firms were creating imaginary illnesses for which their clients have found the “cure.”
“The article should be used as a case example of biased reporting,” says Marybeth Belsito. “It is outlandish to suggest that pharmaceutical companies define what qualifies as a mental disorder or who will benefit from treatment.” Pointing to the campaign’s success in helping people understand that there was a treatment for what was wrong with them, she adds: “Cohn & Wolfe deserves to be celebrated—not chastised.”
Others detected a bias against mental illness in the suggestion that general anxiety disorder is not a “real” disease.
Says one PR agency executive, “Physicians and patients have worked hard in recent years to remove the stigma from mental health problems, to dispel the myth that ‘it’s all in your head.’ Then along comes an article like this that denies the legitimacy of a disease that is listed in the Diagnostic & Statistical Manual of Mental Disorders. It’s not the first time Mother Jones has attacked pharmaceutical companies for their work in this area.”
Another wondered out loud whether either the magazine or the author might have a connection to the Church of Scientology, which is openly hostile to both psychiatry and mental health drugs.
But Koerner argues that the Diagnostic & Statistical Manual of Mental Disorders, published by the American Psychiatric Association has “no formal safeguards to prevent researchers with drug-company ties from participating in decisions of interest to their sponsors.”
Public relations executives are quick to refute suggestions that their clients manufacture mental health problems.
“It takes more than $800 million to develop a drug,” says McDade. “With these stakes on the line, pharmaceutical companies have a very strong vested interest in targeting drug development only toward legitimate disease states—ones that have been validated across the board by patient need, scientific inquiry, and clinical research. Doing otherwise would raise ethical issues, and it would also be bad business to make such a huge up-front investment in a dubious market—both important reasons why this rarely happens.”
As for the strategy of marketing diseases rather than specific products—a technique that drives patients to their physicians’ offices but does not require them to discuss the side effects of their products—public relations people believe it has played an important and beneficial role in getting consumers more involved in their own healthcare.
“Public relations plays an essential role in educating patients and health care professionals about diseases and their treatments,” says McDade. “Of course, some diseases—even debilitating ones—aren’t as well-known as others, and their severity isn’t fully appreciated by the public at large; public relations can help to remedy this kind of situation. But any healthcare public relations campaign that is successful over the long term needs to build upon a solid foundation of legitimate need.
“These basic principles apply regardless of whether a drug is for a mental health condition, cardiovascular problem, cancer, diabetes or any other disease. As for ‘scare’ tactics, it’s counterproductive to send messages that get in the way of reasoned, well-informed decision-making by a patient or healthcare professional—people are better-educated about their health than ever, and often resent the assumption that the fastest way to get them to act is via alarmist tactics rather than clear, calm presentation of facts.”
Michael Durand agrees. “There probably have been some isolated cases of companies whipping up public hysteria,” he says, citing suggestions that AIDS activists, for example, had exaggerated the risk to heterosexuals in order to generate wider coverage of HIV. “But the strategy of building disease awareness is always carefully reviewed by not only marketing executives, but also medical and regulatory people.”
The reality is that many people still do not seek help with serious—and treatable—mental health conditions because of the stigma associated with mental illness.
“Mental health remains one of the least respected areas in terms of understanding the types of disorders and their impact on individual’s lives,” says Seng. “The stigma associated with schizophrenia and even depression still keeps too many people from seeking effective treatment. Raising awareness of mental disorders, however uncomfortable or ‘gray’ these areas may seem, is a legitimate endeavor undertaken by many hardworking health care providers and patient advocates.
“If audiences are appropriately alarmed or concerned after being made aware of warning signs and risk factors, then the PR outreach is working as it should.” Again, PR professionals make the point that patients cannot simply go out and buy the medication being promoted. They have to visit a physician first, and that’s rarely a bad thing.
“In my experience, disease awareness programs are developed to help people identify risks and symptoms in order to get help,” says Ame Wadler. “The fact is that there are hundreds and thousands of people who have been helped through these programs, either because they were able to recognize symptoms that required treatment or, because through such initiatives, they realized that they were not alone, that their symptoms are not their ‘fault,’ so that they were more comfortable seeking physician.”
One example is the Campaign for Clinical Depression, which began 15 years ago and helped destigmatize a disease so that sufferers could more effectively seek help.
But one aspect of the Paxil campaign that does raise concern is the use of the patient advocacy group, Freedom From Fear. On the day the drug received FDA approval for generalized anxiety disorder, the group released the results of a telephone survey claiming that “people with GAD spend nearly 40 hours per week, or a ‘full-time job,’ worrying.” The survey mentioned neither GlaxoSmithKline nor Paxil, but the media contact listed was an account executive at Cohn & Wolfe.
Similarly, an outdoor ad campaign, “Imagine Being Allergic to People,” made no mention of either Paxil or SmithKline. They were identified as the work of a group called the Social Anxiety Disorder Coalition and its three non-profit members, the American Psychiatric Association, the Anxiety Disorders Association of America, and Freedom From Fear. Says Koerner, “The coalition was no grassroots alliance of patients in search of a cure. It had been cobbled together by SmithKline Beecham and Cohn & Wolfe handled all media inquiries on behalf of the group.”
Most healthcare public relations professionals agree that when a pharmaceutical company funds a patient advocacy group—in whole or in part—the link should be disclosed.
“If the pharma company is funding that group, this sponsorship should be included in all promotional materials,” says Levins. “But sponsorship can take many forms: If the company is sponsoring the group via an unrestricted grant, and it plans to have little input on the new group’s direction, then the credibility factor is very high. But even if grant is restricted, or there is no grant and funding is outright, it is the caliber of the board and the mission of the group that actually is the benchmark for credibility.
“In these cases, the group’s executive director should be one of the pre-eminent experts in the field with a very high profile board. Without that, it is less likely in today’s highly questioning environment where pharmaceutical industry distrust is at its highest that the media will give the group a lot of air time.”
There’s nothing wrong with pharmaceutical companies giving money to patient groups, as long as there is full disclosure.
“I can tell you that dozens of non-profits would not be around, would not be able to educate the public or help patients without the support of the pharma companies,” says Durand. “The critical issue is transparency. I have no problem with these strategies, but public relations agencies and clients must identify their funding of these programs at the outset. There is absolutely no downside to this that I am aware of, and a gigantic downside to failing to do so.”
McDade agrees: “Again, disclosure should be the guiding principle,” he says. “Patient advocacy groups should be comfortable identifying the source of their funding. Many groups depend on corporate funding for some portion of their activity. These groups often also have systems and controls in place to ensure they can pursue their missions on behalf of patients in a non-biased way regardless of the source of funding.”
There are practical reasons for erring on the side of caution. Says McDade, “Credibility is such an important and irreplaceable asset for most patient advocacy groups that they are extremely vigilant about protecting it.”
And again, the downside of hiding the link between corporate interests and advocacy groups far outweighs any benefit. Experts point to a campaign conducted in 1998 by Glaxo Wellcome, after the FDA proposed a ban on CFC-based inhalers—known as metered-dose inhalers or MDIs—used by asthmatics, because the cholorflourocarbons they emit. The company founded The Emergency Committee to Save MDIs and mailed letters to asthma patients claiming the government was on the verge of banning their inhalers, prompting hundreds of letters of protest to the FDA.
But when asthma patients were told that Glaxo was behind the campaign, they felt they had been manipulated. The company’s decision to hide behind a front group, rather than going to patients directly and explaining its position, may have helped it win the immediate battle, but only at the cost of long-term relationships and trust.
Says Wadler, “I think the pharmaceutical industry tends to apologize too much for the fact that in addition to saving lives, it is also a business. There’s a concern that any activity that serves a commercial interest is suspect. But I don’t think the industry has anything to apologize for. I think it’s important to be up front about the fact that you are doing it for health reasons and for business reasons.”
“The problem is not that group receive money from private sources, but the cynical age in which we live,” says Seng. “Unfortunately, there is such demonization of the pharmaceutical industry that cynics will always consider unrestricted grant money from them as tainted.”
There is more of a problem with groups that are created and sustained by a single corporate sponsor, however. If the intention is to confer credibility on a company’s message, it’s clear the intention is to mislead.
“I am not categorically opposed to a pharmaceutical company helping start or sustain a struggling patient advocacy group in a disease area that is essentially underserved and in need of such support,” says Rabin. “Where I start to have a problem is when the advocacy groups that a company or industry funds are nothing more than front groups or shell organizations without a true and enduring constituency. Advocacy development that matters in the long run must be done the ‘old fashioned way.’ Third-party support cannot be rented for short-term purposes, we need to earn it for the long haul.”
And on a pragmatic level, It’s unlikely that an advocacy group with no roots in the patient community will deliver much credibility. Says Wadler, “A third party organization with a single sponsor is an oxymoron. We counsel our clients that it is best to partner with an existing, credible organization and try to find shared objectives with that organization even if there are areas of disagreement.”