Mr Peter Mansell
23 November 2000
4th Asia Pacific regional Conference of WSMI
Never before have we been subject to so many different kinds of media. Security cameras
track our progress through shops and town centres. Wedding receptions, holidays, even
births are sealed for posterity on video. Television images flash across national borders
and the global sprawl of the Internet has created a new form of democracy, with all the
freedom and chaos, opportunities and risks that implies.
We live in an era of intense self-consciousness, endlessly processing reflections of
ourselves. Recently a television series shown in the UK marked a new frontier in this
game of watching and being watched. The programme, ‘Big Brother’, put a group of
young people in a closed environment and, like laboratory rats, observed them over the
course of several weeks. Yet it was difficult to feel any sympathy for these human guinea
pigs, all of whom ended the series with lucrative contracts as models, TV presenters,
newspaper columnists or personalities for hire. Once their time was up, they were
absorbed into the very media that gave them life.
Many of you will recognise the concept of ‘Big Brother’ from George Orwell’s classic
novel, “1984”. The irony is that, in this new context, Orwell’s dystopian vision of being
endlessly scrutinised became entirely benign: the protagonists welcomed it, the public
watched avidly and the news media chewed over the social and ethical implications.
Everybody had something to gain.
With the growth of the Internet and other global communications channels, the last few
years have also seen the power and presence of the news media taken to unprecedented
levels. They are everywhere in our lives, like a virus. And everyone is far more mediasmart. Whereas in the past people would turn to family or friends in times of crisis,
nowadays they are just as likely to consult a public relations adviser.
Political strategy has also taken the media to its heart, so policy decisions are sometimes
as much about sending out the right message as doing the right thing. Similarly, as
businesses multiply, globalise and diversify, corporate images are constantly groomed
and refined. On a broader scale, the ubiquity of news channels such as CNN means that
global catastrophes are filtered, graded and reshaped for public consumption. So
technologically advanced was the coverage of the Gulf War that post-modern theorist
Jean Baudrillard was draw to suggest that perhaps the conflict never really happened.
At the crux of all this is the need for control. And the more control people take over the
images they deliver to the outside world, the harder the news media may work to subvert
those images. Yet in some situations – the Gulf War being a case in point – the media are
now accused of ‘playing the game’ too much, of becoming the desk-bound lackeys of
public relations and ‘spin’. Hard news is sacrificed to a tedious round of lifestyle pieces
in which journalists do little more than write about themselves and their friends.
Specialists are ousted by self-perpetuating brand names with a licence to pronounce on
anything that happens in the world – today a raspberry coulis, tomorrow the Arab-Israeli
conflict.
This kind of complacency has two quite different consequences. On one level it makes
for a more compliant response to the news, whether real or manufactured. On another, it
creates a competitive stalemate in which journalists have to go out on a limb to say
something their competitors haven’t said already. That may mean better journalism or a
wilful disregard for the facts in the service of the story.
More and more, relationships between the media and the outside world that feeds them
appear symbiotic: parallel agendas that sometimes skid off into conflict. Journalists may
complain about relentless spin-doctoring, but when were the media ever truly objective?
As the journalist and film-maker John Pilger wrote in his book ‘Distant Voices’: “The
majority of humanity are not news, merely mute and incompetent stick figures that flit
across our television screen”.
So where do self-medication and the over-the-counter medicines industry fit into this hall
of mirrors? I hardly need remind you that information, and empowerment through
information, sit at the heart of the self-medication concept. The Internet and direct-toconsumer advertising may have narrowed the gap between prescription medicines and the
people who take them, but the doctor – the ‘learned intermediary’ – is still there to tie the
strands together and make a final decision on treatment. The field of influence on OTC
product choice is far wider: family and friends; advertising through any number of
channels; product labelling and packaging; pharmacists, doctors and media both new and
old.
Given that people need information to self-medicate, it should follow that the OTC
industry enjoys a close and mutually satisfying relationship with the press and other
media. And there is undoubtedly a huge appetite for information on health in general. In
most industrialised countries our lives are getting longer and we want to know how to
make the most of them. A recent survey published in Prevention magazine found that
60% of adult Americans would rather read or hear about dietary supplements than stories
on business or sports.
Yet there is something of a dichotomy in the media representation of the OTC sector.
Outside the specialist press, the health pages of newspapers and magazines – of which
there are many – carry plenty of largely unreflecting snippets about new OTC products.
But the political, economic or regulatory context in which these products are offered
rarely warrants a mention. In fact, it is questionable whether self-medication in its purest
sense – the independent consumer purchase of non-prescription medicines over the
counter – is really understood by some of the mainstream press.
Even the august Financial Times, in a brief note on Merck & Co.’s withdrawal from its
OTC joint venture with Chugai in Japan, said the alliance was predicated on expectations
of an increase in ‘self-prescription’ – not self-medication – in that country. Perhaps these
misconceptions are not so surprising when, in countries such as France or Germany, the
non-prescription market is still so tangled up with considerations such as prescribing and
reimbursement.
So we have an industry whose products are splashed all over the television and billboards,
yet whose profile as an industry is still somewhat muted. Compare this with the ethical
pharmaceutical industry, which has largely shaken off its adversarial relationship with the
press and now attracts a good deal of fairly sober financial- and scientific-based coverage.
There is a high level of interest in state-of-the-art technologies such as genomics or the
political implications of governments refusing to pay for expensive new treatments and
so-called ‘lifestyle’ drugs. On its front page recently, the Sunday Times Magazine
reduced the painful debate about drug rationing in the UK to a picture of a medicine
bottle labelled “Blair’s Pharmacy. Dose: Suffer or die because we can’t afford to fill this
bottle with the tablets that you need” (Blair being Tony Blair, the British prime minister).
Which is not to say that all the coverage is now favourable. Medicines continue to have
side-effects and these are inevitably picked up by the media – sometimes with very good
reason. On the other hand, sloppy, knee-jerk reporting on pharmaceuticals is still very
much with us. Only a few weeks ago the Sunday Express published a piece about the
long-term side-effects of a leading benzodiazepine tranquilliser. While the drawbacks of
the benzodiazepines are hardly news, the case histories used in the story were
undoubtedly alarming. What capsized the report, however, was illustrating it with a large
photograph of Paula Yates, the British television presenter who died of an overdose the
month before. The only palpable connection between Paula Yates and the tranquilliser in
question was that she had once taken it. Nowhere was it suggested that she had overdosed
with the drug, or even suffered any side-effects from it.
Not that OTC medicines are free from these negative connotations. The pack size
restrictions on paracetamol in the UK; the measures to prevent diversion of ephedrine and
pseudoephedrine in the US or the Czech Republic; the recommendation by an FDA
advisory committee that phenylpropanolamine should be removed from the OTC market:
whatever the arguments for or against these actions, they send out the message that
medicines available without a prescription can be dangerous, even lethal.
Inevitably this will put industry on the defensive. No-one wants a panic reaction that will
kill off sales. On the other hand there may, perverse as it seems, be a longer-term benefit
in having these issues aired. One of the problems, I would suggest, with OTC medicines,
is an essential ambivalence: they are serious medicines that have jumped through all the
regulatory hoops, yet often their profile is that of fast-moving consumer goods (FMCGs).
The industry relies heavily on advertising, branding and mass marketing, yet it is
understandably sensitive to the implication – particularly from some healthcare
professionals – that this condemns its products to ‘second-class’ status. It does not help
when efficacy judgments are used to lever non-prescription medicines off reimbursement
lists.
Although some of the aforementioned techniques are now beginning to creep into the
prescription sector, the overlap between medicinal status and FMCG marketing arguably
has the potential to confuse or misled consumers. The draft final report from Australia’s
National Competition Policy Review of Drugs, Poisons & Controlled Substances
Legislation refers to a “misconception that OTC medicines may be inherently safe
compared to prescribed medicines”. In a qualitative study commissioned in 1990 by the
Department of Community Services and Health, the report notes, consumers “thought
dosage could be less precise than recommended on the label for OTC medicines or those
bought from the supermarket”.
Nor is the issue confined to how people use or misuse OTC medicines. OTC product
abuse may look like a drop in the ocean compared with the percentage of consumers who
self-medicate sensibly and in accordance with labelling instructions. But be sure that if it
happens, the media will be onto it. A recent example was a story in The Observer
newspaper claiming that more than 20,000 people in the UK are addicted to over-thecounter drugs. It cited the case of actor Mel Smith, who confessed to nearly dying from a
seven-year addiction to a well-known painkiller brand. “It’s frightening how easily I
became hooked on a drug freely sold over the counter,” Mr Smith was quoted as saying.
“I swallowed the pills like Smarties. Swallowing 50 tablets in one day was tantamount to
committing suicide.”
Now you may ask what Mr Smith was doing taking 50 tablets a day at all, particularly
when the product label would have told him very clearly not to. Ironically, around the
same time an OTC cough medicine from the same manufacturer appeared in another
story published by The Observer’s sister newspaper, The Guardian. This poked fun at the
long and intimidating list of warnings included on the product’s packaging.
In this instance the manufacturer was able to point out that the product was a medicine
containing three active ingredients, and any potential side-effects had to be listed for each
of them. The concerns about OTC addiction are a little more complex: whose fault is it?
You may well argue that an addictive personality will find any way to satisfy that
addiction. One OTC manufacturer had to withdraw a sleep aid formulation from the UK
market because heroin addicts in Glasgow were melting down the capsules and injecting
them. Yet a standard citerion for non-prescription status is that the medicine should not
have any significant potential for abuse.
Ultimately, I believe, there has to be some element of shared responsibility in these
situations – although it may be that the fear of legal action makes that impossible. As I
suggested before, perhaps in the long run it is not so bad if people are reminded that OTC
medicines come with a risk-benefit equation attached. One of the less welcome legacies
of the consumer revolution and the accompanying growth in litigation has been an
increasingly risk-averse society. If people can understand that taking any medicine
involves some kind of risk-benefit evaluation, they may feel more comfortable with the
less familiar ingredients and more ambitious indications that have switched over the
counter in recent years.
In my view, the question of how the OTC industry really wants to be seen by the media
and general public – medicines or consumer products, serious or not so serious – will take
on increasing urgency as the industry widens the parameters of self-medication to
encompass products such as dietary and herbal supplements, or even functional foods.
Both WSMI and ASMI have acknowledged this trend by changing their name and, to
some extent, their identity – as have a number of other national or regional OTC
associations.
There is an emerging body of evidence about the benefits of dietary supplements and
other foodstuffs in promoting well-being or even reducing the risk of specific diseases. At
the same time, an undeniable question mark hangs over the quality, safety and efficacy of
some of the products currently sold under food law, often with very lenient pre-approval
requirements. And as you will all be aware, the issue of health claims in these categories
is an explosive one. Clearly it is in the interests of the mainstream OTC industry to bring
an aura of science-based professionalism and responsibility to these markets.
In one sense, these emerging sectors typify the independent will to self-medicate that has
sometimes been lacking from the conventional OTC sector. Yet there is a real danger that
the whole industry will end up being tarred with the same brush. Remember also that the
media can be fickle. Canada is one country where the press have fallen out of love with
what are now classed as ‘natural health products’ or NHPs. Early this year, the Toronto
Star published a series of articles under the heading, “Blind Trust: An Investigation into
Alternative Medicine”. They attacked the looser efficacy requirements proposed for
NHPs and claimed the creation of a new regulatory framework for these products had
been “highjacked” by the herbal products industry.
Industry’s management of these issues will be critical in determining whether the broader
conception of self-medication either enhances or dilutes its credibility. The same could be
said of the increasing tendency for OTC medicines to spread from their traditional base in
pharmacies to general retail outlets and other mass-market outlets. Will a more liberal
distribution profile bring these products closer to ordinary items of commerce, subject –
as in the US – to discounting, three-for-two offers and every other tool of the retail trade.
And does this actually matter, or is it something that will have to be remedied through
better labelling or public education?
If the OTC industry needs to think hard about how it wants to be perceived by the
spectrum of government, regulators, healthcare professionals, consumers and the media,
there is one area where the industry is well placed to improve its standing. That is as a
public health asset.
It is easy enough to argue that self-medication can relieve the pressure on national drug
budgets, but that is not the whole story – nor should it be. In fact, any pharmacoeconomic
case for OTC medicines must take into account the wide differences between countries in
healthcare systems, reimbursement and insurance provisions, medical and consumer
culture, remuneration of doctors and distribution channels. What is more, presenting selfmedication as a tool to reduce healthcare expenditure – even if the money saved can be
put to better use – is both politically sensitive and risks a rebound effect.
In the UK the talk is now about “managing demand” rather than cutting costs. The New
Labour party came to power on an astute platform of linking rights and responsibilities in
areas of state provision. Yet even this policy has its limits. As far as the National Health
Service is concerned, people pay their taxes and expect something in return when they
get sick. To be told it is the public’s fault that the NHS is overstretched is ultimately
counterproductive.
On the surface, of course, advising people to self-medicate rather than bothering the GP
with a minor ailment makes good sense. For some, though, OTC medicines are simply
not affordable; others, particularly the elderly, may want to visit a doctor because they are
lonely or scared. We cannot just ignore these impulses, particularly in a society where
older people no longer have the support of extended families.
So the OTC industry needs to tread carefully in this area. One common failing is to talk
about the confident, self-reliant, self-medicating consumer as though this description
applies across the board. In fact, it may very well depend on class, age, education and a
number of other variables. In the same way, if we listened to some of the generalisations
about the Internet, we would believe the whole world was plugged in.
These caveats aside, there are indications that governments are beginning to take selfmedication more seriously as a public health resource. It is interesting that when the
Australian authorities decided in 1998 to permit consumer advertising of schedule 3 or
pharmacist-only medicines on a case-by-case basis, this was conditional on being able to
show a public health benefit from that advertising. In the UK the government has taken a
number of initiatives, such as the NHS Direct telephone helpline, that explicitly recognise
self-medication and, in the broader sense, self-care as an intrinsic feature of the primary
care network.
The UK government’s national plan for modernising the health service declared that the
“frontline in healthcare is the home … The NHS will become a resource which people
routinely use every day to help look after themselves”. Other European countries such as
France and Italy are, after a long period of apparent indifference, starting to formulate an
active self-medication agenda. WSMI, of course, is no stranger to these policy
considerations, through its relationship with the World Health Organization. Speaking
last year at WSMI’s 13th general assembly in Berlin, WHO Director-General Dr Gro
Harlem Brundtland said: “In entrusting communities and individuals with more
responsibilities for their own healthcare, be it through self-medication, cost-sharing for
services or health services management, we are not ‘offloading’ responsibility but merely
recognising the reality that empowered individuals can have the capacity to direct their
own health in positive directions”.
One thing that is helping to embed self-medication in the public health equation is
prescription-to-OTC switching, particularly for indications that were previously
considered off-limits for OTC products. Three examples in particular come to mind.
Perhaps the most compelling is smoking cessation, about which you will be hearing more
from David Graham later today. There is no doubt that nicotine replacement therapies,
now available widely and in many different forms without prescription, have the potential
to help save lives on a massive scale. The WHO has forecast an annual tally of 10 million
deaths from smoking related diseases by the third decade of this century. Moreover, it has
acknowledged the importance of nicotine replacement therapy as an instrument to
improve public health outcomes through its partnerships with industry in the framework
of the Tobacco Free Initiative.
Smoking cessation is one area where there is a clear public health argument for
improving access to therapy through deregulation. The same logic was applied, although
inevitably somewhat more contentiously, by the French government when it allowed an
emergency contraceptive or ‘morning-after pill’ to be sold as a non-prescription medicine
last year. The number of unwanted pregnancies among teenage women in France was
running at around 10,000 a year, out of which 6,700 were voluntarily terminated.
The third example is one for the future, and again it would situate self-medication in
potentially life-saving territory. This is cholesterol management, an indication that once
again proved too much for advisers to the Food and Drug Administration when they
turned down two ‘statin’ treatments as prescription-to-OTC switches last July.
Nonetheless, industry in the US is confident that at least one of the switches will go
through. A notable feature of these applications was that they were both targeted at
people with average to moderately elevated cholesterol, who are below the recommended
entry level for prescribed cholesterol-lowering treatments. This untreated population is
said to account for nearly one in three heart attacks in the US.
How, then, can the OTC industry usefully sell itself to the outside world on a public
health platform? One way might be to put more money into unbranded public service
advertising, along the lines of the regular campaigns run by the industry-supported
Consumer Health Information Centre in the UK. In the long term, that may do more for
the image and development of self-medication than endlessly stoking the competitive
fires with huge advertising investments just to maintain brand share. And when these
investments are fuelling slanging matches about relative safety profiles, as has happened
with analgesics in the US, then ultimately is not self-medication that suffers?
In conclusion, let us return to smoking cessation. In China, the country with the world’s
largest population of smokers – around 320 million in all – up to 70% of the adult
population are tobacco users and already smoking is blamed for an estimated 75,000
deaths per year. That is not just a public health issue, it is a public health catastrophe. The
first nicotine gums and patches went on sale in Chinese pharmacies last November. Who
knows what they might achieve. That is self-medication and that, I would argue, is
something worth shouting about.
Thank you for listening.