Pharmaceutical companies are intricately intertwined with every aspect of contemporary medical reality, and they increasingly drive the social process of medicalization in order to establish and dominate markets for their drugs and devices. In addition to funding the majority of clinical research, organizing it to generate an evidence base that favors their innovations, and in uencing the regulation of pharmaceutical drugs and devices, companies still spend substantial resources on direct attempts to shape the attitudes, dispositions, and prescribing behavior of physicians.
This article sheds new light on our picture of the relationship between the pharmaceutical industry and physicians by examining a novel form of physician-directed communication produced by one prominent corporation. An interpretive, thematic analysis of ORGYN e the unique, full-length magazine published by the Organon Corporation between 1990 and 2003 e reveals two overarching messages it communicated to physicians during that period.
First, it offered a compelling picture of the “good work” obstetricians and gynecologists do, which involves enabling women of reproductive age to control their fertility through contraception and infertility treatment, and providing symptom relief and preventive bene ts to older women by increasing compliance with hormone therapy regimes. Second, it included pharmaceutical technology in every aspect of the doctor’s work, portraying pharmaceutical corporations as the physician’s “natural partner”, and women patients as passive, disempowered objects of medical practice.
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Through these consistent messages, the print magazine ORGYN represented one important set of mechanisms by which a pharmaceutical corporation helped drive and sustain medicalization. The article ends with a consideration of the implications of ORGYN’s messages for companies, doctors, women patients, and the study of medicalization. O 2011 Elsevier Ltd. All rights reserved. Introduction Pharmaceutical companies are intricately intertwined with every aspect of contemporary medical reality.
From de ning diseases and funding clinical research to training physicians and guiding their prescribing habits, the pharmaceutical industry has thoroughly embedded itself in the science, regulation, and practice of modern medicine. And while medicalization e the de nition and treatment of life problems, processes, or deviance in medical terms (Zola, 1972) e was originally driven by health care professions and organizations, it is now increasingly driven by pro t-oriented corporations seeking to establish and dominate markets for their drugs and devices (Conrad, 2005).
Existing research documents several routes by which pharmaceutical companies drive the ongoing process of medicalization. Due in large part to recent regulatory changes that allow increased latitude for advertising pharmaceutical products (Moynihan & Cassels, 2005; Sismondo, * Tel. : ? 1 614 247 1974; fax: ? 1 614 292 6687. E-mail address: padamsee. edu. 0277-9536/$ e see front matter O 2011 Elsevier Ltd. All rights reserved. doi:10. 1016/j. socscimed. 2010. 10. 034 008; Tiefer, 2000), many companies now target print and television ads directly to consumers, ‘educating’ potential patients about medical conditions and available treatments, and effectively changing their self-perceptions to better t the drugs they offer (Arney & Rafalovich, 2007; Sismondo, 2004).
The industry also profoundly shapes the body of scienti c evidence on which medical practice is based, by: funding the majority of contemporary clinical trials (Bodenheimer, 2000); dominating linical research by using for-pro t institutional review boards and commercial research organizations to move more quickly than academic competitors (Washburn, 2001); carefully designing studies more likely to produce favorable results.
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Within this landscape of ubiquitous pharmaceutical involvement (Sismondo, 2004), the oldest strand e direct corporate attempts to in uence the attitudes, dispositions, and behavior of physicians e remains highly active. Doctors around the world are routinely visited by pharmaceutical representatives who bring them briefs or reprints of the latest research, teach them about the company’s products, and generally work to create positive feelings of reliability and trust by giving the company a friendly, helpful face (Lakoff, 2004).
Companies further entwine themselves with doctors’ professional lives by sponsoring the continuing medical education sessions physicians rely on to stay abreast of the constant stream of new medical developments (Relman, 2001).
And drug advertisements remain commonplace in the scienti c and professional journals doctors read.
These promotional activities have been shown to be highly effective, signi cantly in uencing physicians’ prescribing behaviors in favor of the companies who sponsor them (Marco, Moskop, Solomon, Geiderman, & Larkin, 2006; Sismondo, 2004; Wazana, 2000), and even inducing doctors to routinely write off-label prescriptions for their products (Hartley, 2003).
This paper sheds new light on the relationship between the pharmaceutical industry and physicians by examining a unique form of physician-directed communication produced by one prominent corporation between 1990 and 2003. Starting in 1990, Organon International leaped beyond buying individual advertising pages to publishing its own full-length magazine.
For 14 years, the company published quarterly issues of ORGYN, and distributed them free of charge to 120,000 obstetricians and gynecologists around the world. Resembling a photojournalism magazine such as National Geographic or Life, ORGYN published feature articles, research reports, and general interest pieces that would be informative to physicians working in the eld of women’s health. As such, ORGYN was a truly novel form of pharmaceutical communication. It was not an advertisement: ads are concise one or two page entries in scienti c or professional journals that densely construct and/or re ect cultural meanings intended to in uence physicians’ prescribing choices (Hutcheon & Hutcheon, 1987).
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By contrast, ORGYN was a full-length magazine that enabled its parent company to articulate such meanings more extensively, to present deeper and more varied messages to physicians, and to deliver core ideas repeatedly. Indeed, ORGYN likely facilitated communication with doctors precisely by not resembling an ad, and by containing very few discernible ads. But neither was it lled with the type of formal research articles pharmaceutical companies meticulously plan in order to dominate a body of clinical evidence (Sismondo, 2009).
Instead, ORGYN was somewhat lighter fare, presenting information useful to practicing physicians, but in a format that was attractive to view and easy to read.
The publication nevertheless carried the conferred expertise necessary to draw physician readers, covering many of the same scienti c breakthroughs as peer-reviewed medical journals, and including many pieces written by or about respected clinicians and researchers. ORGYN thus offered Organon an exceptionally large canvas on which to construct an image of doctors’ work, their female patients, and its own activities and products. Given the importance of communicating directly to doctors and this ample space in which to do so, then, what ideas did Organon choose to convey? This inductive and interpretive analysis reveals two overarching messages ORGYN communicated to physicians. First, it offered a compelling picture of the “good work” obstetricians and gynecologists do in managing women’s reproductive and post-reproductive lives.
This “good work” involved enabling women of reproductive age to control their fertility through contraception and infertility treatment, and providing symptom relief and preventive bene ts to aging women by increasing compliance with hormone therapy regimes. Second, it showed pharmaceutical technology entwined with every aspect of these medical practices, portraying the corporation as the physician’s indispensable partner in good work. Together, these messages de ned women’s life issues as medical problems; reinforced the expectation that medical experts can provide much-needed solutions; and positioned pharmaceutical companies among these necessary experts. ORGYN thus offers a powerful case study of the mechanisms by which a pharmaceutical corporation can help drive and sustain medicalization.
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Data and methods The core of this study consisted of a two-stage interpretive analysis of 49 of the 50 print issues of ORGYN that were published between 1990 and 2003 e the full run of the magazine (the missing issue e 1991, #2 e is not available in any American, Canadian, or Organon corporate archive).
The rst stage of analysis involved a categorical coding method that organized ORGYN’s contents according to topics and subtopics (Corbin & Strauss, 1990; Swanson, 1986).
I entered this inductive work with no preconceived ideas about ORGYN’s topics or themes; a physician acquaintance had suggested only that I examine a unique publication he had been receiving. I began the analysis by breaking down the text of each article into the smallest possible units of meaning e usually the sentence or paragraph level e as the foundation for understanding the magazine’s contents.
I re-read these units several times, generating an exhaustive list of all the ideas and arguments represented in each article. I then sorted each item on these lists into as many categories as appropriate e for instance, a sentence-long assertion might be coded as both “treatment for menopausal symptoms” and “bene ts of hormone replacement therapy. ” This yielded a long list of categories, most of which could be organized as subsets of the ve dominant ORGYN topics (see Table 1).
To check Table 1 Frequency of Occurrence of Dominant Topics in ORGYN. Dominant Topics in the Text Infertility Menopause.
Developing Contraception Healthy Nations Pregnancies Major Mentiona # of issuesc 43 % of issuesd 87. 8% Minor Mentionb # of issues 4 % of issues 8. % Totale # of issues % of issues 47 95. 9% 35 71. 4% 10 20. 4% 45 91. 8% 36 73. 5% 2 4. 1% 38 77. 6% 25 51. 0% 6 12. 2% 31 63. 3% 26 53. 1% 3 6. 1% 29 59. 2% a Issues coded as “major mention” include at least one full-length feature article or at least four short articles on the topic. b Issues coded as “minor mention” do not include any full-length feature articles, but do include three or fewer short articles on the topic. c Out of a total of 49 ORGYN issues coded. d # as percent of 49 ORGYN issues coded. e Total issues coded as containing a major or minor mention of the theme. 1344 T. J. Padamsee / Social Science & Medicine 72 (2011) 1342e1350 he reliability of the categorical coding, I asked a second analyst to code one randomly selected issue using a deductive rubric that captured my inductively-developed topics and subtopics; our independent coding of the 24 articles in this issue yielded agreement on the major topic for 96% (23) of the articles and on the presence/absence of all ve dominant topics for 88% (21).
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This categorical analysis allowed me to gain a thorough understanding of the explicit messages ORGYN presented to its readers. The second stage of analysis involved interpretive exploration of the implicit themes present in the magazine (Glaser, 1978).
Rereading the text associated with each categorical code allowed me to draw out themes that uni ed ORGYN ‘s coverage of a topic (e. g. : various contraception-related subtopics were contextualized by a notion of empowering women).
Comparing text across codes illuminated some similarities in their implicit messages (e. g. : both helping n infertile woman conceive and alleviating a menopausal woman’s urinary problems were presented as noble efforts that relieve signi cant suffering), as well as some distinctions (e. g. : infertility treatment was presented in a language of rights and choices, whereas menopause treatment was presented in a language of responsibility).
Searching for consistencies and inconsistencies across the content of all categorical codes revealed themes of “good work” and “natural partners” woven throughout. These two themes are discussed in detail below. ORGYN articles are analyzed here as the product of a single authorial voice because Organon controlled their content even though they were written by a variety of people.
Some ORGYN articles were composed by staff writers employed to produce speci c content. Others were selectively pared down versions of work previously published in scienti c journals. A third set was written by researchers and prominent physicians commissioned to report on speci c aspects of their work. ORGYN’s editors changed over the years, but its central topics and themes remained the same with one only exception: a shift in the coverage of hormone replacement therapy (discussed below).
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As the effective editor of all ORGYN’s messages during the period analyzed, Organon not only accepted and rejected contributions but also shaped their content.
In addition to the contents of ORGYN itself, my analysis also draws on three forms of supplementary data. First, I consulted contemporaneous Organon websites for context in the form of company mission statements, descriptions of research activities and products in development, and marketing information. Second, I extended my exploration of menopause-related themes beyond ORGYN’s publication years, because major research ndings signi cantly changed the medical environment for menopause care in 2002 e just before the print version of ORGYN was replaced by an online version. In order to understand how Organon responded to the 2002 ndings, my analysis includes all menopause-related articles from the online ORGYN between July 2002 and January 2006.
To contextualize this coverage, I also analyzed all articles about hormone replacement therapy (HRT) published in The New York Times and The Washington Post between June and December 2002, and in Newsweek, Newsweek International, U. S. News and World Report, Journal of the American Medical Association, The Lancet, and New England Journal of Medicine from June 2002 through September 2003 (total ? 94 non-ORGYN articles).
Third, I conducted semi-structured, hour-long interviews with two members of ORGYN’s target audience of obstetricians and gynecologists for background information about how the magazine was assembled and how it was received by physicians.
Both interviewees have extensive expertise as clinicians, researchers, and department chairpersons at major teaching hospitals, and one also wrote commissioned pieces for ORGYN. Organon was acquired by Schering-Plough in late 2007, which subsequently merged with Merck. They have continued publishing an online version of ORGYN but the content of that website has not been reviewed for, and is not commented on in, this paper. Organon and ORGYN Founded in the Netherlands in 1923, Organon grew to be one of the world’s leading research-based, multi-national pharmaceutical corporations. By 2006, Organon employed about 14,000 people in more than 60 nations, had active markets in more than 100 countries, and had achieved annual sales of €2. 61 billion Euro (approximately $3. 81 billion U. S. dollars).
Organon was known primarily for its hormonal products, and 16 of its 26 drugs on the world market at about that time were primarily for obstetric or gynecologic use: eight contraceptives, four fertility treatments, and four hormone therapies for aging women (Organon, 2008).
During its fourteen year print run, ORGYN was published quarterly in English, Spanish, French, German, and Brazilian Portuguese. Its stated purpose was to provide practitioners with up-to-date information on clinical and research issues, interesting interviews, conference overviews, book reviews, and cultural articles from an international perspective (Organon, 1999).
ORGYN was unique in the world of medical publications.
Medical publications can generally be classi ed into three types: scienti c society journals, professional society journals, and the so-called ‘throw-away’- or ‘controlled-circulation’-periodicals, which are highly pro table, dominated by advertisements from a variety of companies, and nanced entirely by these ads (Rennie & Bero, 1990; Silverman & Lee, 1974).
ORGYN t most closely within this nal category: it was distributed free, was not peer-reviewed, and was owned by a pro t-driven corporate entity. But it was also distinct in several ways: its pages were dominated by feature stories instead of advertisements; the very few ads it did contain marketed the products of only one company; and it included articles on a broad range of clinical, scienti c, and general-interest topics. ORGYN’s appearance was also quite different from that of other controlledcirculation periodicals.
Printed in full color on thick, glossy paper instead of thin newsprint, ORGYN looked distinctive and expensive. Its much higher production value was evident in the rich, close-up nature image (e. g. , the opening petals of a ower) that spanned the front and back cover of each issue, and the original commissioned artwork and photography that adorned the inside pages. The bulk of each ORGYN issue was composed of short articles or longer features written speci cally for ORGYN or adapted from other sources. Of the 56 pages in each issue, only four (plus inside front and back covers) consisted of advertisements. Analysis of these ads con rms the ndings of earlier studies of pharmaceutical marketing.
Some focused on Organon itself, constructing the company as trustworthy, innovative, useful, and reliable. Others marketed speci c Organon products using catchy headlines, illustrations that would have appealed to the physician-as-consumer, and detailed text that presented rational information to the physician-as-scientist (Smith & Visconti, 1968).
What is unique about ORGYN, however, is that it provided Organon with an entire magazine worth of articles and accompanying artwork through which to address doctors, and it is the messages conveyed by this large body of text and images I explore here. Five topics dominated ORGYN’s contents: infertility, menopause, developing nations, contraception, and healthy pregnancies (see Table 1).
Each of these topics appeared in more than half the issues and recurred throughout ORGYN’s lifespan; together they took up most of the magazine’s page space. Infertility and menopause were each featured prominently in more than 90 percent of ORGYN issues. Articles on these topics framed them as medical problems, explored possible treatments, pro led leading clinics and practitioners, detailed cutting-edge research, and more. Feature articles T. J. Padamsee / Social Science & Medicine 72 (2011) 1342e1350 1345 about the developing world appeared in three quarters of the issues.
Complementing the magazine’s main focus on professional activities in the af ent nations where readers worked, these pieces added images of “family planning” or “population control” activities to ORGYN’s picture of the benevolent work of obstetricians and gynecologists. Contraception in the developed world was discussed as a separate topic in almost two thirds of issues, and nearly 60 percent explored ways to ensure healthy pregnancies, mothers, and babies. Coverage of these dominant topics was supplemented by general interest pieces that would have engaged readers’ attention and rounded out the magazine, including clinical advice on other topics (e. g. “Gynecological Oncology”, Fall 2002), general scienti c reports (e. g. Advances in Understanding the Mitochondrion”, Fall 2002), and articles about the humanities (e. g. “Hemophilia in European Royal Families”, 1993, #4) or sports (“Scuba Diving and the Menstrual Cycle” 1992 #2).
Cutting across coverage of all the magazine’s topics were ORGYN’s two core themes: the “good work” physicians do in managing women’s health, and the role of pharmaceutical companies as physician’s “natural partners” in this work. Both themes were inherently medicalizing messages, through which ORGYN portrayed comprehensive notions of the relationships between doctors, pharmaceuticals, and female patients. The next two sections explore these themes by examining ORGYN’s top two topics e infertility and menopause e in detail.
They are followed by an interpretive analysis of the cast of characters and telling silences in ORGYN’s discourse. The “good work” of obstetricians and gynecologists ORGYN’s rst core theme offered a compelling picture of the “good work” readers and their professional colleagues do: ensuring women’s capacity to become pregnant if and when they want to, have healthy pregnancies, deliver healthy babies, and remain healthy long after the end of their reproductive years. Consistently re ected in articles on all ve dominant topics, the good work theme portrayed an image of obstetricians and gynecologists engaging in a benevolent, meaningful, and noble calling by comprehensively managing women’s reproductive and postreproductive lives.
Re ecting a long-standing tendency in the broader world of medicine (Bell, 1987; Conrad, 2007; Vertinsky, 1998), ORGYN supported the medicalization of an entire range of women’s issues by presenting them as problems that could e and should e be named, understood, and managed by physicians and the treatments they provide. Treating infertility as noble pursuit ORGYN’s infertility narratives were present in almost every issue. Most set the stage by pointing out that rates of assisted reproductive technology (ART) usage were rising in af uent nations. ORGYN articles presumed that this growth trend re ected a straightforward increase in the proportion of infertile couples. They explained that, for a variety of reasons, more and more women (and men) found themselves unable to conceive a child when they chose to do so, and therefore sought medical help. Dr. Arthur F.
Haney, past president of the American Society for Reproductive Medicine, expressed the dominant logic of increasing infertility: When women reproduce later in life, or when they just have a longer interval between children, they have a greater probability of having gynaecological disease and thus have a greater probability of being unable to have children. (ORGYN 1998 #3, p. 7) In motivating the discussions of infertility treatment to come, then, ORGYN relied on two rhetorical moves. First, it framed the simple fact that fertility declines with age as a disease, thereby suggesting a medical solution. Second, it situated advances in ART as a logical response to contemporary increases in infertility rates, even though there was little statistical evidence that those rates had actually risen in recent years.
It might in fact have been more accurate to say that both the perceived epidemic of infertility and the steadily growing usage of ART were products of changing dynamics in the social construction of reproduction and fertility (Scritch eld, 1995), and that one of these dynamics was the ongoing medicalization of infertility (Becker & Nachtigall, 1992).
ORGYN was an active agent of this medicalization process, consistently presenting infertility as “a very serious personal and social problem” (ORGYN 1993 #3, p. 10) that touches “the very core” (ORGYN 1993 #2, p. 11) of people’s lives, disrupting their expected reproductive life narrative (Jenkins & Inhorn, 2003).
“Most couples take their ability to have a child for granted. Yet one in six worldwide fail to achieve this goal. They are confronted with the painful and often lonely experience of infertility” (ORGYN 1998 #2, p. 43).
According to ORGYN, the eld of assisted reproductive technology existed to alleviate this pain.
As one of the originators of in-vitro fertilization (IVF) put it, “I have bothered with infertility for most of my working life because I see it as a cause of great and lasting human sadness. It demands treatment” (ORGYN 1992 #3, p. 5).
Infertility, then, was not presented as just a personal trouble e it was conceptualized as a medical problem to be xed through new medical advances. These interventions were portrayed as part of the profession’s good work, and as offering profound promise. A feature story on the history and life of Louise Brown, the rst baby to result from IVF, exempli es the nobility of purpose expressed across ORGYN’s coverage of infertility. To all her friends back home, even to her mother, father and little sister Natalie, she’s just Louise, a teenager like any other.
But to millions of infertile couples around the world, she’s Louise Brown, the world’s rst “test-tube baby”, and still, 16 years after her birth, a symbol of hope and ful llment for them all. To these people, Louise Brown holds celebrity status. It’s not hard to understand why. For what the Brown family represents to physicians involved in assisted reproduction is the embodiment of what infertility treatment can achieve e just mom, dad and the kids, enjoying a normal family life. (ORGYN 1994 #3, p. 16) Beyond de ning infertility as a medical problem and describing medical treatments, ORGYN further bolstered the medicalization of infertility and contributed to the expanding usage of ART by making a case for the right of women (and occasionally men) to be treated for their infertility problems.
This right extended broadly, to married and single women, lesbian couples, and women older than 40; in the European context the right to use ART also became a case for using public funds to pay for treatment. In ORGYN, infertility was always viewed through the medical gaze: the reasons it exists, methods of avoiding it, and solutions to it were all constructed through medical and scienti c language. Selected experiences of women patients were carefully recounted in the voices of physicians and researchers, teaching readers how painful infertility is and how miraculous treatment can be in stories that revolved around doctors and technologies. Women’s own perspectives remained obscured; their own voices unheard.
Missing, too, was any mention of the high failure rates and negative experiences patients of infertility treatments often endure (Becker & Nachtigall, 1992; Greil, Slauson-Blevins, & McQuillan, 2010).
ORGYN’s retelling process represented the mechanisms of medicalization at work, sustaining professional jurisdiction over infertility by presenting it solely as a medical problem, and xing it as the doctor’s noble purpose e part of the “good work” of ORGYN’s physician audience. 1346 T. J. Padamsee / Social Science & Medicine 72 (2011) 1342e1350 Menopause management as enhancing quality of life Although most of the profession’s activities revolve around fertility, contraception, and childbirth, ORGYN stressed that the gynecologist’s good work did not end at the close of his or her patients’ reproductive lives.
Almost every issue devoted extensive coverage to the care of menopausal and aging women. During the 1990s, ORGYN was actively engaged in the medicalization of menopause, in line with a contemporaneous cultural consolidation around understandings of menopause that some analysts termed the “menoboom” (Gullette, 1994).
Re ecting similar themes as the histories of social anxiety disorder (Conrad, 2005), female sexual dysfunction (Tiefer, 2006), and other recently medicalized illnesses, the medicalization of menopause involved raising awareness of a common and previously taken-for-granted phenomenon, naming that phenomenon as a medical problem, and articulating distinct medical solutions for it (Bell, 1987; McCrea, 1983).
ORGYN’s early articles often opened by drawing menopause into the conceptual realm of medicine (Conrad & Schneider, 1980): “Scientists now commonly agree that the climacteric represents a true ovarian endocrinopathy that adversely affects a woman’s health” (ORGYN 1993 #1, p. 52).
Such assertions of medical de nition would have helped readers organize their diagnostic thinking and laid the groundwork for medical intervention. Today oestrogen de ciency e viewed by some as a de ciency state comparable to diabetes or myxoedema e is still “grossly undertreated”, says the British Journal The Practitioner. Yet the appropriate therapy, it adds, can achieve a great deal. approach echoed the dominant medical and social understanding of its time: that menopause was a de ciency disease (Coupland & Williams, 2002).
The de ciency concept had long been used to set the stage for treatments that ‘replace’ missing hormones (Ballard, Huk, & Wadsworth, 2001), and had roots as far back as the 1930s (Bell, 1987).
Decades later, Robert Wilson’s in uential Feminine Forever (1968) popularized the notion of menopause as a dramatic de ciency problem, the view of estrogen replacement as a miracle cure, and the sense that physicians should offer therapy to help not only women, but also the men who had to live with them (McCrea, 1983).
Soon after, feminists began ghting back, critiquing the de ciency disease discourse and offering alternate, less medicalized, interpretations of the menopause experience (Foster, 1995; Worcester & Whatley, 1992).
By the time ORGYN came on the scene, these challenges had been well disseminated. The magazine eventually took account of them, often quoting medical experts on the idea that “menopause is not a disease” (ORGYN 1997 #2, p. 19).
But this overt shift away from the disease model did not constitute a de-medicalization of menopause. To the contrary, ORGYN continued to use its professional authorial voice to advance a more nuanced medicalized discourse about menopause e one that relied on a concept of treatment without disease.
Menopause is a normal event, and I think women are lucky to have it because it signals the time to make important preventive healthcare decisions that affect the rest of their lives. (ORGYN 2002 #2, p. 46) We must not look at life extension but rather at the enhancement of quality of life. The focus should be on menopause not as a disease but as a marker in life beyond which some of the things that can go wrong can be prevented. (ORGYN 1997 #2, p. 19) In this new construction, physicians still bore a responsibility to care for women’s health not only by treating symptoms but also by helping them make the right decisions to prevent future illness and disability.
