I.
From Medic and Medical Center, ER and Chicago Hope, to General Hospital and "live" surgical procedures on the American Health Network and Animal Planet, a history of medicine and consumer culture may be traced through current print and televisual "direct-to-consumer" advertising campaigns. In the first six months of 1998, drug companies spent $306 million on TV advertising. Appearing most often during daily morning news programs like Today and Good Morning America and the nightly national news, these direct-to-consumer advertisements address consumers as potential patients. By encouraging individualized responses to healthcare ("take charge of your own health") these advertisements could be understood as calling into questions the taken-for-granted expertise of the physician.

As a result of the Food and Drug Administration's re-evaluation of prescription drug advertising guidelines, the world's leading pharmaceutical companies have widened their address to include audiences of both healthcare professionals and "lay persons." Indeed, as Jackie Stacey and others have argued, "[p]atients have traditionally been constructed as passive, compliant and obedient within biomedicine. The expert authority of the medical professional depends upon its exclusivity and its specialization." (Stacey, 1997, p. 205). Medical expertise relies upon keeping a particular domain of knowledge within a specific minority and away from the unenlightened majority. Stacey argues that "keeping patients 'ignorant' about their illnesses and treatments has long legitimated the wisdom of the medical profession." (p. 207) This partitioning of "knowledge" and the fairly absolute control of its dissemination to the "masses" is just one of the aspects of the patient-physician relationship which may be challenged by the shift of medical advertising's address from physician to patient-consumer. For instance, drug company discourse emphasizes the extent to which these ads "educate" both patient-consumer and healthcare professionals. "Education" is equated with, I would argue, brand recognition. Rather than an actual re-distribution of power and medical authority, what is made available through direct-to-consumer advertising is an opportunity for constructing new consumer categories based upon "niche-marketed" illnesses. Thus, patient-consumers are invited to diagnose themselves through discourses of symptom, illness, and a promise of a restoration of normality or return to the "routine."

The pharmaceutical corporations continue to produce distinct promotional campaigns for these ideal subject of address: physicians/healthcare professionals and consumers-as-patients. What this address to a non-professional audience also signifies, I would argue, is the extension of the corporate research laboratory into the domestic space. In other words, it is interesting to note that along with this proliferation of direct-to-consumer advertising on television, there has been a subsequent increase in commercials recruiting "test subjects" for experimental drug trials and other such projects (these are not only conducted by university teaching hospitals, but by for-profit or "independent" laboratories in various cities across the U.S.).

II.
Recognizing the need to critically analyze both the "power structure from which the drugs are created," (Erni, 1996) and the various circuits through which the drugs are produced, distributed and consumed, I want to endorse a dynamic approach to contemporary cultures and these life science industries. Specifically, how are we to account for such strategic and, presumably, mutually beneficial alignments between pharmaceutical giants and the non-profit AIDS service organizations or the relationship between the pharmaceutical corporation and the research university (sponsoring research, courses, entire programs or schools). These and other such examples of "corporate citizenship" cannot merely be read as some sort of public relations performance; they highlight the inadequacy of arguing in terms of either/or theoretical categories with regard to the global, corporate landscape and the defunding of federal and state programs for education and health care treatment/prevention. So, one begged question is: what series of events has enabled pharmaceutical corporations to claim such a "public advocacy" position, to represent themselves in these terms in the first place? While not a "legitimate" drug manufacturer, an example of a 19th century "quack" or "proprietary" medicine entrepreneur, Mrs. Lydia Pinkham, is instructive as a way of making sense of how today' pharmaceutical or "ethical" drug corporations have achieved such a contradictory status in the eyes of consumers.¹ I will use the term "quack" since this was the term most often used in media accounts of the struggles between proprietary and ethical drug manufacturers and their supporters/detractors.

One of the most celebrated examples of quack medicine manufacture and selling includes Lydia Pinkham -- the "Saviour of her Sex" -- and her "Vegetable Compound: A Medicine for woman. Invented by a woman. Prepared by a woman." (Donald Dale Jackson, Smithsonian, July 1984. p. 108) From the point of view of female consumers of Mrs. Pinkham's Compound and, no doubt for other consumers of various quack (or patent) medicines, this perception of availability of information and apparent concern about their questions was powerful. From the point of view of medical physicians, however, this "advice granting" "mimicked, distorted, derided, and undercut the authority of the profession." (Starr, 127) Indeed, Mrs. Pinkham's company profitably incorporated such female dissatisfaction and frustration with physicians in its response to perceived "female troubles" that her readers saw Mrs. Pinkham's tonic and advice service as part of a comforting, personal company. Mrs. Pinkham's Vegetable Compound manufacturing company actually appealed to genuine female concerns about physicians' disregard or lack of credibility with the public. It is equally significant that it was apparently easy to dismiss these letters written by Mrs. Pinkham's consumers were dismissed as the expressions of a duped and even hysterical female constituency.

Since the company stood to gain from letterwriters' continued consumption of the "Compound," I would maintain that it is unproductive to regard these exchanges simply in terms of the promotion of a type of willful disregard for the patient-consumer's well-being. The company's reply to these letters is enabled by certain assumptions about (1) the communication dynamic between male physician and female patient and (2) fears regarding practices of invasive surgery in the late nineteenth century.

Thus, central to the regulation of quack medicine and the distinction between legitimate and illegitimate medicine was the question of authority: in whose hands would medical authority rest? This question resonated profoundly with the American Medical Association. Almost from its inception in 1847 the AMA considered the propietary medicine business to be at odds with its purposes and goals. However, the medical journals and newspapers continued to accept such advertising as a large base for their revenue. Only in 1905 did the AMA stop accepting propietary or quack medicine advertising in JAMA. In conjunction with this closure, the AMA established an internal review board, the Council on Pharmacy and Chemistry, to "set standards for drugs, evaluate them, and lead the battle against nostrums." (Starr, 131) In this noble endeavor, the AMA received some help from muckraking journalists who published in Ladies Home Journal and Collier's Weekly, respectively, and "discredited the claims of the patent medicine companies to provide personal medical advice." (Starr, 130, ital. mine) The important point informing journalists' articles was that commercial interest as such could be dangerous to your health (that proprietary medicine makers and sellers were only in the business of making money) and that consumers should put their trust and faith in the professional physician.

This, of course, enabled the AMA and "ethical" medicine to launch more of an audible and "credible" appeal to its public. And, in turn, the proprietary medicine makers and sellers bowed to this burgeoning authority as well. Thus, the drug companies found it much more prudent to advertise and direct their other more central promotion efforts such as personal selling to physicians -- to the medical professional -- rather than the lay consumer. In order to advertise to physicians, however, the AMA demanded that these same drug companies withdraw advertising from the public. This withholding of advertising (information, etc.) from the public and rechanneling it through the physician signified a major structural and industrial change in the economics of health and constitutes the backdrop for current discourses about direct-to-consumer prescription drug advertising. If patent medicine manufacturers and sellers were once seen as undercutting the authority of the legitimate physician, then today's medical advertisements now emphasize the importance of the physician-patient relation -- and even tend to "authorize" the power of the physician (i.e., "ask your doctor about...").

In the way that Lydia Pinkham's propietary medicine company encouraged its consumers to write to them for advice, today's pharmaceutical giants hope to construct a similar relationship with their consumers. As a type of virtual "Dear Abby," corporations like Glaxo Wellcome, Ltd. and others encourage their potential consumers to write to them or to visit their websites for further information. By directing the patient-consumer (viewer or reader) to these other sites, the pharmaceutical corporations hope to guide the circulation of information and potential perceptions of the advertised product. Moreover, this appeal to individualized response aids in establishing a perception of an intimate or "caring" relationship between the corporation and consumer. Re-directing what may appear to be a cold, clinical, sterile pharmaceutical corporation with scientists in white lab coats and gloves into a vision of concerned personal health consultants, these advertisements encourage consumers to articulate their health questions.

III.
The advertisements for the protease inhibitor Crixivan® by Merck featured in both OUT Extra's Winter 1998 supplement, A Consumer's Guide to HIV Care, and JAMA's July 1, 1998 volume -- their annual AIDS special issue ("A Cover Without Art") -- represent different ways of constituting consumer and professional markets for the distribution and consumption of HIV/AIDS prescription drugs. In both contexts, however, what is striking is the extent to which this and other advertisements are part of an expanding cultural project in the reconstruction of HIV/AIDS from a so-called death sentence to a chronic, manageable illness. (Here, I only have space to address the direct-to-consumer portion of this dual campaign). As part of this "normalization" or re-visualization of illness (which needs to be historicized in relation to the stigma usually associated with HIV/AIDS), these HIV/AIDS drug advertisements might be undertsood as responding, even if at a problematic and reductive level, to the critiques made by AIDS activists in the late 1980s. As responses to ACT UP's demand, "drugs into bodies," these advertisements of the mid-1990s would appear to reverse the dominant cultural repertoire of HIV/AIDS imagery usually concentrating upon image of the person living with HIV/AIDS as melancholic, alone, and passive. However, these advertisements featuring various forms of activity, from rockclimbing to running to cycling amidst visions of "diverse" communities, replace one normalized, naturalized vision with another: that of the preferred image of a person living with HIV/AIDS that is made possible through the described drug. In fact, what is being advertised is not necessarily the product itself but the promise or image associated with consumption of the product. What is being sold, then, is a normative or preferred vision of "health" and/or a restoration of the "productive" body through the consumption of the drug.

The discourses that are consistent throughout these advertisements are those of individual empowerment, restoration of previous states of health and mobility, conquering fear, and possibilities of a future (Merck's Crixivan® slogan: "Focus on the rest of your life."). The advertisements use basic conventions from the personalized testimony of "ordinary" and "real-life" people living with HIV/AIDS to de-personalized sci-fi computer images of the virus being attacked by a particular drug.

Significantly and in contrast to other regular issues of OUT and the "niche-marketed HIV/AIDS publication" POZ, no advertisements for viatical companies were published. I am interested in accounting for this apparent shift and in understanding how this revision of living with HIV/AIDS serves many different sets of interests -- particularly in terms of queer entrepreneurism and HIV/AIDS empowerment through the public sphere of visible consumerism.

A Consumer's Guide to HIV Care includes an HIV/AIDS advertisement for one of the most prescribed HIV/AIDS drugs, Merck's Crixivan.® This ad which appears as a double-page spread, usually features an individual white male or a group of people of different races and genders in various stages of rockclimbing. One side of the advertisement depicts the climber's struggle with the other side of the page offering an image of the climber having made it to the top. The words accompanying and cutting across the images are "In the battle against HIV, there's a change in outlook." Then, at the bottom right corner appearing with the brand name (and generic), "Remember to ask your doctor about CRIXIVAN. Focus on the rest of your life." In other words, fighting against HIV now consists of changing your way of seeing the virus with the change provided by Crixivan®. And, the battle now is waged through prescription drugs and individual effort or action (i.e., the patient-consumer exercising his/her "choice" in the HIV/AIDS marketplace).

The bulk of the written text directly addresses the person living with HIV and sets the affective terms for the reader's feelings about HIV and his/her life: "If you're HIV+, you know the feeling. Everything's at stake -- your health, your peace of mind, and your expectations for the future." This description suggests that there is some normative response to being HIV+ and that by taking Crixivan, this "outlook" can be altered. Later, the ad states, "Everyday is an opportunity to fight back," further enforcing the linkages between taking this prescription drug and some new form of "activism" (as in the AIDS Coalition to Unleash Power's late 1980s chant: ACT UP! Fight Back! Fight AIDS!). This analysis is not meant to posit one "true" form of activism, but to ask how the language of, in this case, ACT UP gets incorporated into an advertisement for a prescription HIV/AIDS drug. While it is the case that many of the advances in drug-testing and development can be directly traced to the work of ACT UP, it is disquieting but not unbelievable to see this language of coalition struggle incorporated into an individualized appeal to an HIV/AIDS consumer.

From an economic perspective, direct-to-consumer HIV/AIDS advertising has had an obvious impact upon the revenue of key pharmaceutical corporations such as Merck. As figures published in the corporation's annual Form 10-K filed with the Securities and Exchange Commission on March 25, 1998 make abundantly clear, the largest boost in corporate sales can be attributed most notably to the introduction and movement of Merck's Crixivan® (indinavir sulfate). Launched in the U.S. in March, 1996 after being granted an "accelerated approval" by the Food and Drug Administration, the revenues garnered through the sale of this single HIV protease inhibitor represent the largest increase of any of Merck's other classes of drugs.

The sales of the protease inhibitor Crixivan® represent the most significant single increase in Merck's revenue in a drug category with the second highest increase attributed to the osteoporosis drug Fosamax® (alendronate sodium) for the treatment and prevention of bone density deterioration in postmenopausal women. In addition to highlighting how significant the marketing of HIV drugs to consumers is in relation to generating revenue for prescription drug companies, this economic aspect of direct-to-consumer advertising underscores how HIV treatment has come to constitute a type of industrial dependency, facilitating more than ever the problematic reinscription of HIV as a virus that we can, apparently, live with, as a biomedical crisis that can be managed through, consumer culture and the corporate citizenship of drug makers and sellers.

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Note

1. When I use the term "quack" or "patent" or "proprietary" medicines to describe those remedies, cure-alls, elixirs marketed to consumers and at odds with physician organizations such as the AMA, I do not mean to suggest that they are interchangable. Though these compounds have been referred to as "patent" medicines and contrasted with "ethical" preparations of known compounds advertised only to the profession (healthcare professionals), this term "patent" is actually a misnomer. Most "patent" medicines were not patented at all since in order to receive a patent, the formula had to be disclosed; technically they were "proprietary" drugs whose trademarks were protected by copyright. [back]

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References

Erni, John. (1994). Unstable Frontiers: Technomedicine and the Cultural Politics of "Curing" AIDS. Minneapolis: University of Minnesota Press.

Jackson, Donald D. (1984). "If Women Needed a Quick Pick-Me-Up, Lydia Provided One." Smithsonian, July, 107-119.

Stacey, Jackie. (1997). Teratologies: A Cultural Study of Cancer. London: Routledge.

Starr, Paul. (1982). The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books.