Oldani - Thick Prescriptions

Thick Prescriptions: Toward an Interpretation of Pharmaceutical Sales Practices
Author(s): Michael J. Oldani

Source: Medical Anthropology Quarterly, Vol. 18, No. 3 (Sep., 2004), pp. 325-356
Published by: Wiley on behalf of the American Anthropological Association
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MICHAEL J. OLDANI
Department of Anthropology
Princeton University
Thick Prescriptions: Toward an Interpretation

of Pharmaceutical Sales Practices
Doctors aren't that corruptible.
The (drug) reps provide good information, and they are functioning
in a system where that is how you sell medicine.
The most comical thing is doctors' attitudes. You will never hear a
physician say, "This is influencing me." They are just so arrogant and
naive.1
Anthropologists of medicine and science are increasingly studying all

aspects of pharmaceutical industry practices-from research and devel-
opment to the marketing of prescription drugs. This article ethnograph-
ically explores one particular stage in the life cycle of pharmaceuti-
cals: sales and marketing. Drawing on a range of sources-investigative
journalism, medical ethics, and autoethnography-the author examines
the day-to-day activities of pharmaceutical salespersons, or drug reps,
during the 1990s. He describes in detail the pharmaceutical gift cycle,
a three-way exchange network between doctors, salespersons, and pa-
tients and how this process of exchange is currently in a state of involu-
tion. This gift economy exists to generate prescriptions (scripts) and can
mask and/or perpetuate risks and side effects for patients. With impli-
cations of pharmaceutical industry practices impacting everything from
the personal-psychological to the global political economy, medical an-
thropologists can play a lead role in the emerging scholarly discourse
concerned with critical pharmaceutical studies. [pharmaceuticals, gift
exchange, prescriptions, salespersons, North America]
Part I: Introduction
ritically engaged medical anthropologists have thus far told us very little
about the everyday world of pharmaceutical salespersons in the United
States and their interactions with health care providers. It is even more
striking that the first "detail man" appeared in America in 1850 (Smith 1968) and
Medical Anthropology Quarterly, Vol. 18, Issue 3, pp. 325-356, ISSN 0745-5194, online ISSN 1548
1387. ? 2004 by the American Anthropological Association. All rights reserved. Send requests fo
permission to reprint to: Rights and Permissions, University of California Press, Journals Division,
2000 Center Street, Suite 303, Berkeley, CA 94704-1223.
325
326 MEDICAL ANTHROPOLOGY QUARTERLY
that today there are an estimated 68,000 salespersons (Kirkpatrick 2000) promoting
products for pharmaceutical corporations in the United States. The historical depth
of this relationship requires a detailed ethnographic assessment of how the daily
interaction between "reps" and doctors not only translates into billions of dollars
of prescriptions annually but also how this constant commingling affects patient
care and modem health care in general.2
The central reason for the lack of anthropological literature on the drug rep
and the rep-doctor interaction is straightforward: anthropology has yet to ob-
tain regular access to the everyday world of drug reps.3 An examination of the
ethnographic literature on pharmaceutical sales practices in general reveals this
lack of access: there is a conspicuous gap concerning the day-to-day activity of
pharmaceutical salespersons. Nevertheless, other disciplines, such as investigative
journalism and the medical-ethics community, have provided early ethnographic
glimpses of pharmaceutical sales practices. Ethnographers of science and medicine
can build on these initial studies through long-term, critically based fieldwork and
present a more nuanced picture of sales representative activities. This article will
follow along these lines and provide an initial entrance into the everyday world of
pharmaceutical sales practices in the United States.
My access to the pharmaceutical sales environment is somewhat unique and
requires a brief explanation. I spent nine years working for a multinational drug
company (referred to as Company X in this article) as a pharmaceutical sales
representative, or what is more commonly used in the medical marketplace a
drug rep, or simply a rep, and occasionally what some still refer to as a "detail
man."4 Near the end of my selling career in pharmaceuticals, I returned to grad-
uate school, completed my Master's degree in anthropology, and have continued
on toward a doctoral degree in the anthropology of medicine and science. My
past circumstances have created an opportunity for me to autobiographically, or
autoethnographically (Moffatt 1992),5 explore pharmaceutical sales practices as
well as to develop and maintain contacts/informants throughout the drug industry
and medical community. Though much of what I present here can be characterized
as "memory ethnography," I did begin to take field notes late in my sales career
for just this type of ethnographic investigation.6 Perhaps one advantage I have
today is that I can speak from the perspective as a former "native," in the sense
that I understood and practiced the rules of the game (Bourdieu 1977), which
has been helpful for an anthropological understanding of the pharmaceutical rep-
doctor interaction as well as for ongoing work concerned with the health care
marketplace.
The major focus of this article describes what I call "the pharmaceutical gift
cycle" and how it operated throughout the 1990s at Company X and continues
to operate in a more general sense throughout U.S. health care, albeit in an al-
tered form. Much has been said about pharmaceutical gifts in both the media and
the medical literature. However, there has been little "thick description" (Geertz
1973) of these prescription-generating activities in the anthropological literature.
A modest goal of the descriptions below is to give readers a better idea of how
the social tools (and capital) of the pharmaceutical industry have impacted how
(and how often) prescriptions are generated for patients. Drawing from a variety of
sources, I focus specifically on the day-to-day activities of sales reps, who are the
key players (or brokers) within this exchange network. In particular, I concentrate
THICK PRESCRIPTIONS 327
on two key areas: the unique nature of the three-way gift cycle occurring in the
medical marketplace between reps, doctors, and patients and the ramifications of
the use of information technology (i.e., computer-based prescription tracking) and
accelerated gift exchanges for patients, or, as they are referred to throughout the
industry, consumers.
Situating the Rep
To date, the most comprehensive anthropological review regarding pharma-

ceuticals in general remains van der Geest et al.'s (1996) "The Anthropology
of Pharmaceuticals."7 Building from the work of Appadurai (1986) and Kopytoff
(1986), the authors take a novel and useful approach by creating a genealogy or "life
cycle" of a drug: production (research and development-R and D), marketing,
prescription (i.e., the generation of prescriptions or "scripts" by doctors), distribu-
tion, purchasing, consumption, and efficacy. Van der Geest et al. note that, "each
phase has its own particular context, actors, and transactions and is characterized
by different sets of values and ideas" (1996:153), which allows for anthropolo-
gists to ethnographically focus on each particular stage in the cycle. They focus
on the fact that sales reps have attracted very little attention from anthropologists
(1996:158). (However, see the following for sales rep activity "mentioned in pass-
ing": Ferguson 1981 [El Savador]; Nichter 1983 [South India]; van der Geest et al.
[1996:158]; Wolffers 1988 [Sri Lanka]; and, in more ethnographic detail, Kamat
and Nichter 1997, 1998 [Bombay].)
Part of the reason for this could be the previous models used for study-
ing pharmaceutical-related questions. For example, Kleinman (1980) realized
that a trend in medical anthropology was to focus on the "folk" and the "pop-
ular" sectors of health care versus focusing "primarily on the transaction of
pharmaceuticals within professional settings" (van der Geest et al. 1996:155).
Ethnographies looking at pharmaceutical "transactions" within the professional
setting (i.e., health clinics, hospitals, and pharmacies) have predominantly taken
place outside the United States (e.g., Sachs and Tomson 1994; Sacks 1989;
van der Geest 1982; Waddington and Enyimayew 1989/90). This conspicuous
gap concerning American pharmaceutical rep-doctor interactions in the ethno-
graphic literature should disturb the ethnographer, considering that although an-
thropologists have just begun to intensely study pharmaceutical sales(persons),
the industry has not failed to study us (van der Geest et al. 1996:158). The
consequences of this are quite ironic. By referring to anthropological studies
that show how non-Western peoples cherish vitamins, blood tonics, antidiarrhea
medicines, and hormonal preparations, the industry has been able to claim an
"openness" to local variations in cultural concepts of health, illness, and medicine.
In short, the "anthropological perspective is congenial to market research" (van
der Geest 1996:158). From a biomedical and critical anthropological perspec-
tive, pharmaceuticals may seem overused, and certain drugs may seem dubi-
ous, useless, or even dangerous. Yet, thanks to the ethnographic work of an-
thropologists (and their emphasis on "pharmaceutical relativism"), the industry
can claim that it is only providing for all of humankind what people welcome as
useful and effective medications for their own culturally specific treatments and
"cures."
The pharmaceutical industry, as well as sales reps and marketing departments,

are quite adept at this type of "spin selling" (or "spin doctoring"). Every objection
(by physicians, patients, and the general public) can be turned around to become
a positive selling point, something to be valued and sold for the patient's benefit.
In fact, this logic permeates every level of the industry, right down to the everyday
verbal exchanges between doctors and reps. For example, I would often be "hit"
with a quick objection by a doctor when "detailing" a heavily used hospital IV
antibiotic, usually planted by the competition: "Mike, your antibiotic X doesn't
cover pseudomonas and this is a nasty gram negative bug, especially when treating
diabetic foot infections." We were taught (by managers and corporate trainers) to
simply spin this into a positive sell:
Doctor, I completely understand where you are coming from (empathy is a key
component to the spin). And I am glad you brought this up because we recently did
a study that showed how most diabetic foot infections start in the community, and
as you are quite aware, pseudomonas is a nosocomial infection (hospital born).
So our antibiotic X is actually quite suited for diabetic foot infections. You don't
need to cover pseudomonas. In fact, if you use antibiotic Y (the competition) you
are actually covering "bugs" that are not present. And, as your infectious disease
colleagues have discussed with me, they would like to avoid the overuse of "big-
gun" nosocomial antibiotics that actually can "tease" up resistance to nasty bugs
like pseudomonas.
Now the "close," to complete the spin:
What's nice about our "targeted" antibiotic X is that it hits only what you want
and need to hit: community-acquired gram negative, gram positive, and anaer-
obic bacteria-it's the perfect spectrum for treating and defeating diabetic foot
infections. Now, can I count on you to write a "script" for antibiotic X the next
time you need targeting coverage of a diabetic foot infection?
Remember that the doctor's initial objection may have been part of the lan-
guage games of pharmaceutical sales. She or he may have just wanted to test my
knowledge of antibiotics (i.e., do I know my "bugs"?). Or was I, in turn, going to
be nasty toward the competition, usually not a good idea (the doctor and the com-
petition may be golfing partners). Regardless, the spin is an essential part of the
drug rep's tool kit and part of a dialogical relationship with health-care providers.8
By analyzing a critical everyday site of pharmaceutical transactions-the
doctor-drug rep interaction-we can begin to understand the logic of the phar-
maceutical industry in detail. Van der Geest et al. (1996) have established useful
ethnographic sites for detailed analysis for those interested in critical pharmaceu-
tical studies. Ethnographic work can also build on past research conducted by
nonanthropologists that have included discussions of pharmaceutical salesperson
activity. Silverman and Lee's (1974) Pills, Profits and Politics is a seminal as-
sessment of industry practices from a political economy perspective and discusses
detail men and industry practices at length (see especially chapter 3, Drug Promo-
tion). However, very little time is spent on the influence of gifts (1974:76) or other
exchanges.
Lexchin's (1984) The Real Pushers: A Critical Analysis of the Canadian Drug
Industry is another valuable addition to the literature of pharmaceutical practices, in
this case from a physician interested in medical ethics and public health. Chapter 8
includes a section addressing the activities of detail men. Although almost 20 years
old, it's worth noting that in 1984, about 46 percent of drug company budgets in
Canada were spent on detailing, which is about 15 percent of companies' total
revenues-the largest expenditure, more than raw materials to manufacture drugs
(Lexchin 1984:123). Lexchin's discussion on drug reps does not focus on gifts per
se, but his insights into how reps are trained to manipulate medical information
during the sales call are worth noting (1984:124-127).9 Starting from this initial
work, Lexchin has maintained an active research project concerned with pharma-
ceutical industry practices in North America, specifically the role of drug reps (see,
e.g., Lexchin 1989, 1990, 1993). Both Lexchin's and Silverman and Lee's work
remain valuable contributions to critical pharmaceutical studies, albeit at a more
macro level of analysis.
There are two main reasons to highlight the practice of pharmaceutical sales-
persons at a more micro, or everyday level. First, it's well known that billions of
dollars are used to generate (research and develop) new pharmaceuticals. However,
these tremendous R and D budgets and the entire flow of knowledge and informa-
tion used to discover new products rests on the ability of the industry to convince
those who can write a prescription, or a script (doctors, nurse practitioners, physi-
cian's assistants, etc.), to write that script for their particular product. In short, in
the United States, profit for the industry only begins to flows from scripts. Drug
reps are key players in this process and collectively can influence the generation
of millions of prescriptions and enormous product sales (on a daily basis).
One might argue that direct-to-consumer advertising has begun to erode the
role of the drug rep (see Belkin [2001 ] for a journalistic critique of TV advertising
and the growth of expensive, blockbuster drugs). I hope to show otherwise in
this article. Nonetheless, these ads work quite nicely with the sales strategies of
pharmaceutical reps. For instance, when a patient comes into a clinic and asks a
doctor about a drug he or she would like to take, the doctor is more than likely to
contact the local drug rep for product information and "free" samples (especially
if they have been embarrassed by their lack of knowledge in front of a patient).
More importantly, this allows the drug rep to be welcomed into the office by doing
the physician a favor (i.e., getting over there quickly, perhaps on the same day they
were contacted, with important product information).
What is most critical to this process is that the opportunity now arises for
the rep to talk about other products. The doctor, of course, is compelled to return
the favor and at least listen to the rep talk about these other products. Reps at
Company X were trained to respond to any request for product information by
always presenting the older/nonrequested products first. You were to hold out, if
you will, on the requested information because you had the upper hand and the
physician was forced to be a captive audience. Websites of multinational drug
companies now refer to advertising as part of their responsibility to "empower the
consumer" through information.10
Second, studying the activity of drug reps ethnographically is crucial because
they are part of a feedback loop of scientific and practical knowledge that is
essential for pharmaceutical companies to gauge product promotional strategies,
launch new drugs, and monitor sales (person) activity. A feedback loop at Company
X worked in the following manner: a marketing team at corporate headquarters
creates and implements a promotional strategy for the field force of salespersons
to implement during their everyday detailing of doctors. Many times, however,
the strategy needs to be altered, or even abandoned, if doctors didn't respond
to it. For example, Company X launched a new oral antibiotic that was a once-
a-day pill, required a short course of therapy, and was priced equal to its only
competitor within this new class of antibiotics (around $65 for the full course of
treatment).
Initially, reps tried to sell the product based on its superior "spectrum of
activity" and efficacy in clinical trials to doctors. However, the competition did an
excellent job of pointing out how much Company X's dug was per pill; because
of its once-a-day regimen, this amounted to around $10 per pill. Doctors were
outraged by this price per pill, their objections were hard to spin, and efficacy
became secondary (i.e., "I am not using that drug until you lower the price.").
Reps became convinced that they actually could not sell this drug until Company
X lowered the price. Initially, management hung on to the old adage that "cost
never sells, only efficacy sells." We were always trained to convince doctors that
our product was the best and once we had "buy-in," cost became a secondary factor
for doctors when writing a patient's prescription. This was normally the case but
not in this scenario.
The competition had taken a calculated risk and it was paying off. They also
knew that pharmaceutical companies rarely, if ever, lowered the price of a drug in
the United States.11 In fact, I don't recall this ever happening over my nine years
of employment. However, our new drug was not "moving," and this lack of sales
was a cause for company-wide concern. I remember writing about this cost issue
in my weekly report over e-mail to management, and other reps I worked with told
me they were doing the same thing. The e-mail and voice-mail barrage continued
until finally corporate headquarters lowered the price of our drug (to around $42
a script).
Doctors were extremely satisfied, but sales were still sluggish. We began to
get complaints that Antibiotic X, even though it had a short course of therapy and
(now) had a lower price, was too hard to dose. In other words, doctors had problems
writing a prescription.12 This antibiotic required a "loading dose" of double the
daily dosage for the drug to be pharmacokinetically effective over the full course of
therapy (i.e., it needed to be written as 400mg day 1, followed by 200mg x 4 days).
Again, and along with price concerns, reps would relay the complaints of doctors
through e-mail (weekly reports) and voice mail. The result of both doctor and field
demand was the eventual development of a full course of therapy for Antibiotic
X in an easy-to-write format (i.e., doctors simply could write a prescription as
follows: "Take Antibiotic X-pack as directed."). In the end, the combination of
reduced cost, user-friendly packaging, and "writability" led to the rapid increase
in sales of Antibiotic X, and today this antibiotic is selling well over $1 billion
annually.
This brief anecdote illustrates how ground-level exchanges between represen-
tatives and doctors can work to change marketing strategies at the corporate level
and prescription practices at the doctor-patient level. The pharmaceutical sales-
person played a central role in the negotiations and the eventual change of how a
pharmaceutical product is packaged, used, and thought about. And herein lies a
basic dilemma. Antibiotic X "caught fire." Clinics were "washing the walls with
it," as my first manager would have characterized this type of explosive product
growth. Everyone (doctors, nurses, and pharmacists) wanted this drug, especially
free samples of the Antibiotic X-pack-they asked for it by name. When I talked
to my friends and family during the cold and flu season, and they found out I sold
Antibiotic X, they wanted free samples. Doctors began to tell me that patients
would come in with a cold or flu and demand Antibiotic X. Most doctors would
oblige their patients-"even if it's viral." What was being missed, of course, in all
the hype was the increasing overuse of a broad-spectrum antibiotic for treatment
of, in many cases, nonbacterial (i.e., viral) infections.
The treatment of real bacterial infections, such as strep throat and community-
acquired pneumonia, had begun to change through the actions of drug reps. By
the time I left Company X, the concept of "step therapy" involving antibiotics had
evolved into a completely new form. Step therapy was no longer the judicious
use of older, narrower spectrum antibiotics for first-line therapy (usually generic
ampicillin/amoxicillin or erythromycin), with the gradual change to more broad-
spectrum agents if the initial treatment course had failed and/or depending on
microbiology lab reports. Now step therapy had become jumping between various
broad-spectrum, brand-name antibiotics to treat simple infections. Sample closets
were well stocked with easy-to-use (once-a-day), brand name "big guns" all doing
millions of dollars (some billions) in sales.13 Discussions concerning bacterial
resistance and how to follow proper medical protocols were left to occasional
chats with infectious disease specialists and academic doctors. Patient risk due
to infection with resistant "bugs" was not a problem for most high-volume script
writers because we all (reps and primary care doctors) agreed that industry R and
D would continue to develop better antibiotics.
In summary, the pharmaceutical salesperson is situated within a particular
medical-scientific and social milieu where both the present and the future prac-
tice of modem medicine takes place, where their actions have consequences far
beyond the simple exchange of scientific knowledge and prescribing information.
Pharmaceutical reps are part of a dynamic process where feedback loops can alter
prescription habits of doctors, product design, and patient treatment. The socially
intimate relationship between doctors and drug reps has a long history and these
interactions continue to shape the practices of one another.
Part II: Understanding the Logic of Pharmaceutical Gift Exchanges

The core of the pharmaceutical salesperson and prescription writing agent's
(e.g., doctors, nurse practitioners, and physician's assistants) relationship relies on
the exchange of gifts. Investigative journalists and the medical community have be-
gun to scrutinize the impact of these exchanges. For example, Wazana, a physician
concerned with medical ethics, compiled a comprehensive review of 29 medical
articles regarding the "regular contact" between pharmaceutical representatives
and physicians involving "gifts, free meals, travel subsidies, sponsored teachings,
and symposia," while seeking to identify the impact of representatives on the
"knowledge, attitudes, and behavior of physicians" (2000:373). He concludes that
the "present extent of physician-industry interactions appears to affect prescribing
and professional behavior and should be further addressed at the level of policy
and education" (2000:373). Twelve of the articles reviewed specifically addressed
"gifts," and authors of these studies concluded that receiving a gift (Sandberg
et al. 1997) and the number of gifts received (Hodges 1995) correlated with the
belief that "pharmaceutical representatives have no impact on prescribing behav-
ior" (Wazana 2000:375-376, emphasis added). In addition to this, a New Zealand
study (Thomson and Barham 1994) concluded that pharmaceutical gifting of "high
relevance" (i.e., stethoscopes, pen-lights, etc.) was associated with a "positive
attitude" toward drug reps (Thomson and Barham 1994).
What is important to note from Wazana's article as well as from the 29 ar-
ticles he reviewed regarding the activities of the pharmaceutical industry is the
separation and categorization of these pharmaceutical practices and tactics, all of
which increase sales. Wazana breaks down these activities into the following: gifts
(no examples are given, but from my experience this most likely would involve
things as mundane as a plastic pen to expensive bottles of wine); samples (free gifts
of medication for patients and personal use); industry-paid meals (gifts of food);
funding for travel to attend educational symposia (gifts of money and knowledge);
company-paid speakers (gifts of knowledge to doctors, residents, and medical stu-
dents); continuing medical education (CME) sponsorship (gifts to hospital grand
rounds and a possible gift of prestige to those associated with the educational
program if the CME program is a success); and honoraria, research funding, and
employment (gifts of money, status, security, and prestige).
The point of my parenthetical elaboration is to underscore how grouping
these data in a divergent fashion limits our ability to conceptualize the "totality"
(Mauss 1990) of everyday activities and gift exchanges between pharmaceutical
reps and health care providers. Pharmaceutical salespersons are involved in every
aspect of what Wazana astutely breaks down into separate categories to analyze and
develop statistical correlations. However, these activities are more complex and in-
terrelated, existing as part of the daily routine of drug reps, and are the social fabric
of doctor-industry exchanges. The interactions between doctors and reps resem-
ble more the complex web of kula exchanges occurring among the Trobrianders
than linear exchanges presented by breaking down gifting into categories. These
exchanges are socially embedded and evolve over time (often years, sometimes
decades). Pharmaceutical salespersons have multiple goals: establishing rapport
(i.e., trust), forging alliances, acquiring commitments through the "sharing" of in-
formation, the giving of oneself (time, money, pens, food, etc.), and the expectation
of returns (i.e., scripts). Actual "business" transactions per se are never conducted,
never witnessed.14 The actual everyday pharmaceutical economy is based on social
relationships that are forged and strengthened through repetitive and calculated
acts of giving.
From an ethnographic point of view, the everyday world of the pharmaceutical
salesperson requires the collection of convergent data. Geertz (1983) has provided
a valuable way for ethnographers to integrate and think about these two forms
of data. For Geertz, both convergent and divergent ways of looking at people
"have their uses" (1983:522), and for some purposes (in the case of gifting, in
particular), they complement one another. However, just as Geertz was concerned
with the sharp turn to divergent (sociological and economic) data in Java,15 I
want to stress the importance of convergent data here in the hopes of maintaining
the "adequacy of interpretations of the contemporary scene" (Geertz 1983:522)
concerning pharmaceutical salesperson activities. Yes, reps gift, but ethnographers
ultimately want to capture the "tone," the subtle nuances of the gift cycle itself,
and examine the implications of a gift economy for human health care.
Detailing the Gift Cycle
Kirkpatrick (2000) provides a detailed account of gifting and other activities

of drug reps within the United States in a journalistic expose.16 He focuses on a
recently introduced drug called Celexa, a new player in the $6.3 billion market of
antidepressants. Celexa is a selective serotonin reuptake inhibitor (SSRI), similar
in its mechanism of activity to Prozac, Zoloft, and Paxil. Kirkpatrick started his in-
quiry wanting to know how a "me-too"17 drug like Celexa had captured 13 percent
of the SSRI market in just over a year and a half. His "short-term" ethnography is
striking in that it follows the biographical approach outlined (and discussed above)
by van der Geest et al. (1996). Through observation, interviewing, and historical
piecework, Kirkpatrick gives glimpses of the life cycle of Celexa, and in doing
so, uncovers the central role pharmaceutical salespersons have in giving life to an
otherwise me-too drug. A brief summary will help bring these issues to light.
Kirkpatrick (2000) initially describes the intensive training that pharmaceuti-
cal reps must endure. Forest, the company that promotes Celexa, runs a three-month
training program out of a "special campus on Long Island" (2000:38). Medical
training is hardly a prerequisite for employment,'8 and Kirkpatrick refers to the
"marketing powerhouse" of Sempter Pfizer (an industry nickname), because of its
known policy of recruiting former military personnel and teaching a "hard-sell"
mentality (Kirkpatrick 2000:38). Post-training there is a constant flow of informa-
tion to digest, including the growth of pharmaceutical-based computer technology
(a point I stress below). However, these training hurdles are offset by the incentives,
rewards, and high salaries-up to $140,000 a year, including bonuses.
Kirkpatrick's work helps uncover an important parallel that exists around the
practice of training. Pharmaceutical companies, such as Company X, incorporate
strategies that help build employee loyalty. Representatives learn first how to speak
medically,19 how to discuss complex disease states, and how to ultimately sell
specific products within these categories. The company, in return, showers reps
with gifts large and small: clothes, luggage, crystal bowls, social events, fine dining,
company parties, increases in salary, etc. Future sales reps learned the value of
gifting almost immediately (consciously or unconsciously) and, in return, sold
products by performing these same acts with doctors. We were indoctrinated almost
immediately into a corporate culture of gifting.
Similarly, Kirkpatrick (2000) correctly identifies a key site of pharmaceutical
industry indoctrination in the culture of gifting for doctors: initial training pro-
grams for residents. This is where the flood of small gifts, such as pens, coffee mugs,
stethoscopes, and penlights begins (2000:39) and where the gifting of the pharma-
ceutical industry is established as part of normal, routine medical life-common
sense. This gifting can evolve into expensive textbooks (Kirkpatrick 2000:39),20
and in my own experience, the payment of trips for chief residents to attend clinical
meetings with "opinion leaders" in the medical community.
The importance of developing loyalty through gifting cannot be overstated.
Successful reps within Company X were promoted to work at "influential training
centers." In other words, teaching hospitals have become the critical target for
pharmaceutical reps to gift and to detail their drugs. There are two clear reasons
for this. First is the already mentioned building of loyalty with future (prescribing)
doctors. The pharmaceutical industry is well aware that medical habits are devel-
oped at the teaching centers. Once doctors form these habits, it takes either a new
and improved class of medications or a lot of resources (expert speakers, money,
and more gifts) to change that habit.
Second, influential faculty members need to be continuously called on to
gain their support for products, or, at the very least, to attempt to neutralize their
opinions if they are opposed to a company's products. Important, as well, is the
ability of pharmaceutical salespersons to recruit doctors into a company's pool
of expert speakers, or "champions" in Company X jargon. Kirkpatrick (2000:40)
cites the well-publicized case of Dr. Martin Keller, a Brown University professor
of psychiatry and a member of Forest Pharmaceuticals' advisory board, who made
$556,000 of his $842,000 income in 1998 from consulting for drug companies-a
fact he failed to disclose when he published research about their drugs. From my
experience and on-going ethnographic work, this example remains an extreme case.
For instance, a microbiologist I have spoken with earned approximately $50,000
from one pharmaceutical company for talks he gave between 1999 and 2000 to
help introduce a new antibiotic to the market. (This equates to roughly 100 talks
in a year, at $500 a talk.) Dr. Keller appears to be on the high end of the pay scale.
Nevertheless, "speaker development" remains an integral part of pharmaceutical
marketing.
A key task of a pharmaceutical rep's job is to help transform influential
doctors into speakers and consultants who know the rules of the game and are
quite adept at negotiating a stipend and "working the crowd," in other words, to
sell without selling (see Oldani 2002). This can be a long process, often years in
the making. The process starts with small gifts (ranging from pens to pertinent
clinical articles) just to get in the door, which helps establish trust and rapport
over time, and eventually "developing" the doctor into a speaker for a company's
drugs. However, most rep activity at teaching institutions remains focused on the
day-to-day gift exchanges with residents.
For instance, Kirkpatrick correctly perceives "food as the reps' weapon of
choice" (2000:39). While working at Company X, it was not uncommon in one
week's time to have four to five lunches at clinics where the entire staff was fed,
two, or three "bagel rounds" before clinical conferences in the mornings, and one
or two dinner programs at more up-scale restaurants in the evenings. Regarding
the lunches and morning bagels, an older rep in my district increasingly felt we
were becoming nothing but "meals on wheels."2' Kirkpatrick also witnessed a rep-
resident exchange, where a $3 Starbucks coupon was given to the surgical resident
as a "thank you" for using his product. These types of thank-you exchanges (i.e.,
thank you for writing a script) were common during my tenure with Company X,
and drug reps are quite adept at using gourmet food and coffee as a strategy to
increase sales.
Using coffee to sell requires some elaboration. During one of my last years
with Company X, I was quite desperate to make "quota" (i.e., feeling managerial
pressure in form of performance reviews to match or exceed the previous year's
sales) for a hospital-based IV antibiotic, Antibiotic S. Hospital antibiotic business
is extremely competitive and usually involves a constant presence and "noise level"
(i.e., detailing) to effect business. An older representative at Company X had shared

a recent sales success story for this same antibiotic involving free cups of coffee.
He had begun to hang around a gourmet coffee cart in the lobby of his hospital
in the mornings buying coffee and getting some "face time" with his doctors. The
logic here is to promote.your antibiotic as doctors start their morning rounds. As I
often observed during my tenure, a successful sales strategy, when actually shared
with colleagues, is built on and altered by other reps.
I decided to use coffee as my gift of choice and targeted a hospital where I
had established good rapport (i.e., I could walk the halls without being kicked out).
I made arrangements to have coffee cards made, giving ten free cups of coffee to
any person presenting them at the coffee cart at my teaching institution. They were
identified with an Antibiotic S sticker on the back. I first targeted the residents who
admitted most of the patients to the hospital and generated the most prescriptions of
antibiotics. I made "gift packets" with file cards (dosing information on Antibiotic
S), a clinical reprint showing the efficacy of Antibiotic S, and a coffee card attached
to this information with a brief letter explaining how the card worked.
Within a month, I was clearly in demand for my coffee cards. I was receiving
phone calls from residents and staff doctors for cards. I began carrying just the
cards in the hospital, no other detailing materials. Handing them out to surgeons,
infectious disease doctors (IDs), or anyone who could write a prescription of
Antibiotic S. Several weeks into the program, I received a call from the hospital
PharmD, who was friendly to Company X (a paid speaker), but quite upset about
not receiving a coffee card. I realize now that if I was giving them to surgeons
and IDDs, my PharmD was probably offended that I left her out of the loop. With
the pharmacy neutralized through coffee, sales far exceeded my expectations and
I achieved my quota.22
Giving the gift of coffee had become institutionalized within my institution.23
I am sure my competition was at a loss. They may have increased the "counter-
detailing" of their products, yet having to compete with a novel gift cycle was
difficult to overcome clinically. They would have to think of their own novel
ways to increase sales. The competition couldn't provide a similar gift, because it
wouldn't work in the same way. I achieved my goal, which was to maintain my
monthly "numbers" and make quota for the year through increased prescription
generation. Eventually, residents whom I had developed relationships with left this
institution and doctors tired of whipped-cream mochas, but the pharmaceutical gift
cycle had been effective when implemented correctly.
Effective gifting allows the pharmaceutical salesperson (and the industry in
general) the ability to sell and market me-too products. My first manager liked to
quip, "All things being equal, how are you going to sell your products?" Selling
novel, new products (i.e., first in class, first to market)24 is not a problem for the
industry. What becomes essential to successfully selling older and newer me-toos
is the ability to differentiate your product from the competition and this can be
achieved through constant levels of strategic gifting. Sahlins (1972), in a rereading
of Mauss's classic essay, emphasized two key aspects of the gift cycle: (1) hau,
the Maori term for "spirit of things" given, and (2) the importance of a third party.
Finding the hau in gifts to be given is an essential part of a representative's
gifting acumen: the novelty of gourmet coffee, free and completely accessible for
tired and weary hospital physicians and residents; "hot ticket(s)" for a professional
sports team; a romantic dinner for two at the newest chic restaurant in town. Even
the plastic pen, the essential component to the salesperson's tool kit, contains a little
hau. My company, for example, in what now seems to be a brilliant promotional
strategy, created a metal pen for a new anti-infective product in which the entire pen
was a color photo of a microscopic scene. The scene involved the destruction of
microbials (post-treatment with our anti-infective) by white blood cells in vibrant
colors. This became the pen to acquire. Doctors asked for it by name, which led to
the ultimate goal: a discussion of our product, another valued gift exchange, and
product prescriptions.
Hau as "kitsch value" also cannot be understated. The coffee mug with dis-
appearing bacteria,25 the enlarged plastic dust mite paperweight for allergy meds,
and, the stuffed animal mascot for pediatric products26 all have had their respective
moments (spirit generating and magical qualities) within the gift cycle. The gift
can take many expensive and bizarre forms, however the simple plastic pen exem-
plifies both the practical and symbolic effect of Sahlin's (1972) "ideal gift cycle":
a rep constantly passes on a pen to a doctor (with inscribed dosing information on
the body of the pen) during sales calls; over time, the doctor finally commits to
writing a script for the next appropriate patient; the script is given to the patient
(frequently with free samples); the patient fills the script at a pharmacy; the phar-
macy enters this information into a computer; a third party buys this information
and sells it to a pharmaceutical company, which compiles this "script tracking"
information for both sales reports and physician surveillance. The drug rep finally
receives confirmation of prescription generation a month or two later, both in the
form of sales reports (prescriptions converted into actual dollars) as well as these
script-tracking reports.27
Successful reps who make quota on a yearly basis are given a range of gifts
from the corporation. These include monetary rewards (e.g., product bonuses,
increases in salary, etc.) as well as merchandise. For example, Company X incor-
porated a points accumulation system of rewards, which were redeemed through a
merchandise catalogue. Representatives could acquire gifts ranging from TVs and
VCRs to all-expense-paid family vacations. Managers could also hand out points
for special accomplishments such as getting formulary approval for Company X
products at hospitals or HMOs. The most prestigious gifts at Company X were
reserved for those salespersons who ended the sales year in the top 10 percent of
their peer group.
The "circle of excellence" provided successful representatives with increased
bonus, extra points, award trips, opportunities for promotion, and, most of all,
status. "Get your name up in lights," as managers would say, and "keep me from
riding with you" (in your car on sales calls)-personal freedom being a valued gift.
We all knew the names of the "top performers." At large company gatherings, these
representatives had a slight celebrity status (e.g., "there goes Jean Lane, circle of
excellence seven years running").
There is a dark side to this corporate gift economy for reps. Failure to make
quota led to tremendous managerial pressure to increase sales and could easily
lead to job loss. However, during the 1990s, Company X's expansion mirrored
the industry in general, and many reps who were doing poorly simply left to
work for other pharmaceutical corporations or new biotech companies looking
for sales force expansion. In fact, one would rarely hear that a colleague was
fired, more often they "moved on" to other companies or other opportunities.28
Nevertheless, when reps were successful at generating scripts, they became part of
a total system of gift exchanges. This system is the pharmaceutical gift cycle, which
begins with exchanges between reps and doctors, is followed by the movement of
pharmaceuticals through patients, and concludes with a bounty of returns to the
multinational pharmaceutical corporation and the rep.
Critical to the pharmaceutical gift cycle, as well as Sahlin's reinterpretation
of gift exchanges among the Maori, is the third party: the hau-generating patient.29
The actual patient is never present during doctor-rep exchange and most often
exists in the abstract as a medical type. He or she is the "patient with diabetes," or
less referential to a human being: "When you see a community-acquired pneumo-
nia, don't forget to write for Antibiotic X"; "This once-a-day medication will be
perfect for the noncompliant patient." Patients still remain the crucial vector within
this gift cycle in North America, not because they can be relieved of an illness but
rather for their value in generating prescriptions. Patients contain a kind of hau
within themselves because their bodies contain endless sites for potential phar-
maceutical cures. Ultimately, this potential translates into "the yield on the gift"
(regardless of cure) in various forms of profit (Sahlins 1972:160) for the com-
pany (and the rep). The logic of pharmaceutical sales practices is based on the
logic of the three-way gift cycle illustrated here. The rational world of medicine
has intersected with (and is often usurped by) the "rationales" of the market-
place to create a socially rich gift economy of exchanges that has persisted over
time.
What is at stake and often concealed within this calculated medical industry
gift economy is the risk for drug-induced side effects for patients, from the mun-
dane (e.g., nausea, headaches, etc.) to the more extreme (e.g., drug interactions,
organ damage, and death). For example, when Company X aggressively intro-
duced a new antibiotic (Antibiotic Q), indicated for "everything"-from sinusitis
to nosocomial infections-tremendous growth was achieved in the marketplace
with the newest "big-gun" in a very short period of time. However, Antibiotic Q
was restricted shortly after its introduction by the FDA because of its association
with liver toxicity, and, in severe cases, patient death. There was a tremendous
amount of gifting involved as part of the hype for this product, which was tar-
geted as a blockbuster for Company X. Gifts included pens, clocks, free dinners,
symposia with expert speakers, and post-marketing clinical grants, all of which
went toward accelerating prescription growth and eventually led to severe side
effects.
Antibiotic Q was at play in the medical marketplace, which often can lead to
unwanted (and unforeseen) consequences with new products. Some of this push
for successful product launches has been determined by the demand by Wall Street
investors for blockbuster drugs. In other words, products and stock performance
hinge on a good introduction to the medical marketplace. (Part of Celexa's growth
was due to a strategic launch, as discussed by Kirkpatrick [2000].) The problem
today is that the industry has perhaps become too successful at launching new
products (i.e., crafting blockbuster markets). The clinical trials used to predict
safety and tolerance aren't designed to predict the hyper-growth of new products.
For example, let's say severe side effects occur at the rate of 1 out of every 10,000
patients treated by a drug during pre-market trials. After a successful introduction
to the market, a rapid rise in prescriptions may see 100,000 people using the drug
within the first month. If the pre-market clinical trial side-effect rate holds up, this
will be an incredible number of possible deaths.
This scenario appeared to play out with Company X's Antibiotic Q. In fact,
liver toxicity was extensively tested pre-market, because of its history in this par-
ticular class of antibiotics and appeared to be a nonfactor. However, hyper-use
of this antibiotic across patient types with concomitant illnesses and infections
can lead to unpredicted side effects and even death. Viagra also had a spike in
the number of post-launch deaths due to another consequence of pharmaceutical
hype. Viagra generated so much interest from doctors and the public at large that
health-care providers simply wrote the drug without getting all the safety infor-
mation, either through conversations with reps or directly from the FDA-approved
product package insert. This can easily happen. Patient/public demand for Viagra
was intense (drug rep phones were "ringing off the hook"), so doctors took all the
samples they could get and wrote prescriptions, not realizing the risks involved
for patients with heart disease (i.e., they didn't read the package insert closely).
Another phenomenon Viagra introduced was the ability to obtain scripts via the
Internet (with or without an actual written prescription). Patients simply found
nontraditional ways to get the drug, while putting themselves at risk for unwanted
side effects.30
These examples highlight how hyping blockbuster markets can lead to seri-
ous risk for patients, even death. However, the industry is also very focused on
maintaining product markets once they are established. The day-to-day activities
of pharmaceutical sales representatives and constant levels of gift exchange are
central to preserving these markets. The pharmaceutical industry relies on "mainte-
nance medications" to remain profitable. Maintenance meds are potentially lifetime
medications taken daily: antihypertensive, anti-type II diabetes, anti-ulcer, anti-
arthritis medications, etc. The 1990s saw the explosion of brain drugs as well (e.g.,
antidepressants, atypical antipsychotics, etc.), and Company X promoted a very
successful SSRI.
In 1998 when I left Company X, managers asked reps to promote the idea that
if depressed patients had a relapse or two, the doctor should start to talk to their
patients about "indefinite treatment" (i.e., for one's lifetime). This is the major
role of patient bodies within the three-way pharmaceutical gift cycle: the body
remains a site, which (collectively) through the consumption of prescriptions,
generates billions of dollars annually for the industry. Nevertheless, pharmaceu-
tical companies are quick to promote to doctors (and to the general public) that
the patient's best interest is always being served with the introduction of new
medications.
Most annual reports by multinational pharmaceutical corporations are satu-
rated with powerful patient "success stories" for each product in the company's
portfolio, which are no doubt true for these particular patients. What I have tried
to convey here, however, is that the pharmaceutical gift cycle, which remains at
the very center of medical-pharmaceutical social life-a "continuous presence"
(Sahlins 1972:182)-can present unforeseen risks for patients. A key outcome of
these exchanges remains side effects, in the form of both industry profit and bodily
side effects for patients. The latter will continue to emerge once new drugs are
introduced to the medical marketplace.3'
Part III: Pharmaceutical Involution
Principles of Pharmaceutical Marketing
In an astute and illuminating study in 1975, Mickey C. Smith put togeth

a comprehensive study describing the Principles of Pharmaceutical Marketin
where one of his goals was to lay out "the intricacies involved in the marketin
pharmaceutical products" (p. v). In his chapter on "Detailing and Other Forms
Promotion," Smith provides a litmus test of sorts for us to begin to understand h
the principles of physicians and detail men have changed over the last 25 yea
In 1975, it was well known that the most expensive component in the life cy
of a pharmaceutical product is supporting the detailing efforts of salespersons
physicians (Smith 1975:300).
Kirkpatrick (2000:38) allowed us to see how this spending has escalated t
where $9 billion of the $10 billion spent annually on drug promotion is direct
toward marketing specifically to doctors, with the major cost attributed to ph
maceutical salespersons. When asked why all this money was spent on detailin
Smith answers that it is because it is the most effective form of selling products.
ensuing discussion regarding this effectiveness supports my entire position t
far. In Smith's terms, the pharmaceutical industry pays for human contact with
physician by establishing two-way communication (p. 301). Smith has tapped
the essence of why billions of dollars today are spent on salespersons-to cre
and maintain a space of social contact. It is here that the gift cycle and var
forms of "knowledge exchanges" (Oldani 2002) take place.
In the British medical literature several years later (where in Great Brita
about half of the industry's promotional budget was spent on salespersons), r
resentatives are described in a positive light operating in a social milieu tha
mutually constructed:
You can expect him to be highly competent on his product, and to give a good,
clear presentation. He should also be knowledgeable on his own firm's other
products and, within limitations, on matters relating to clinical pharmacology
and therapeutics generally. He should be frank about cost. He will convey back
to his firm any information, queries, or reports of adverse drug reactions. In fact,
this is a valuable source of such information for industry.
What you cannot expect the representative to be is disinterested. He is
obviously going to present his products-whatever it is-in the best possible
light. No one is completely unbiased (even medical teachers cannot support all the
statements the make) so don't expect him to say anything that is directly contrary
to the firm's interest-such as recommending someone else's product.... On the
whole, I think that representatives do a conscientious job to the best of their ability
in a system that is open to a great deal of abuse.... As I once said in a letter to the
Lancet, the (medical) profession gets the (pharmaceutical) industry it deserves.
[Binns and Smith 1979:1134-1135]
In the late 1960s and throughout the 1970s, there was a sense of medica
respect around the detail man, whose role is medically important and underst
to be one of promoting products to the best of his or her ability within a sys
cocreated by medicine and industry. My first two years with Company X touc
on the end of these "good old days," as they were described to me by older m
reps. Past times were recalled fondly by these detail men. These were times when
mostly male reps called on mostly male doctors, became personal friends with
many of their "clients," and discussed how a "piece of the pie" could be had by
everyone.32
When Smith (1975:309-310) discusses "the future of the detail man," he
sees two potential reasons for their demise. The first is that physicians who see
reps as a way of keeping up with the literature will eventually require better,
noncommercial sources for continuing education. Second, he cites Weiss (1967)
who was willing to predict that "advancing techniques of communication" will
spell trouble for communication through the relatively old fashioned medium of
person-to-person confrontation. Smith notes that Weiss's view has been challenged
by industry spokespersons, who consistently claim that there is no substitute for
such contact. Weiss's insight seems well thought out, considering the pharmaceuti-
cal industry emphasis today on advertising through various media and information
technologies.
Still, the number of drug reps continues to grow in the face of these new tech-
niques of communication (one for every 11 doctors [Kirkpatrick 2000])-Pfizer
Inc., now the second largest company in the United States, currently has 11,000
sales representatives (Harris 2003). And Smith's own concern with continuing
medical education has taken the reverse turn. When I left Company X in 1998, I
was intimately involved (i.e., providing funds and speakers) with CME programs,
grand rounds (at private and teaching hospitals), telenets (i.e., lunch teleconfer-
ences over speaker-phones with groups of health care providers), and other aspects
of medical and pharmacy education.33 What has held true is the industry's sus-
tained belief and practice that there is no substitute for creating and maintaining
the social space of doctor-rep interactions. This space has only become more in-
tensified through increases in gifting, which are being fostered by a synergy with
information technology. As risks for patients increase, the function of this space
has retained its original form or purpose-the generation of prescriptions.
Accelerated Gifting
Michael, thanks for lunch.... Now, what I wanted to talk to you about
was my music. I love playing music, and I am adding a music room
onto my house.... That sounds great.... Now, I like your drugs too,
especially that antidepressant, but I am building this room and its going
to be expensive.... Yeah?... So I was wondering, if you guys are
giving any grants to doctors who want to use your products, because
that would be useful for me at this time? Ah... well, I definitely can
look into that.
(Recollection, ca. 1992)
Dr. Remi, hello.... Thanks for the time, it's Michael.... I came by
today just to follow-up on that grant we talked about. What grant?
You know the grant to get you some experience with that drug for
hypertension. Really? Let me see the check.... A thousand dollars?
Yes you just need to get 25 patients started on the drug, and I have a
chart for you to mark their progress and then we can talk about them
every couple of weeks. Remember what we discussed? Ok, give the

check to my secretary.
(Recollection, ca. 1996)
These are my two strongest recollections of how the doctor-rep interaction

began to alter itself before I left Company X in 1998. A crack was revealed in the
time-honored gift cycle. In both cases-doctor and drug rep-we decided to cut
to the chase and, as a result, the other person was caught off guard. In Bourdieu's
(1977:6) words, we both revealed "the truth of our practice."34 A doctor, looking for
extra money, and a drug rep, looking for extra business, were willing to compromise
their integrity through the lure of scripts. In both cases, prescription generation
never occurred. I never followed up with this musically inclined doctor. I told my
manager about the event and he laughed. We both knew he had "low potential" as
a "high prescriber," and I simply never called on him again. (However, if he was
a high prescriber, we may have made some arrangements.) Dr. Remi, a true high
prescriber, always saw me for a brief chat after the check was given, but I never
made quota on that antihypertensive. He never "got onboard" to become a steady
script writer.
Nonetheless, these events are significant, because they are part of a larger
process I describe as a "pharmaceutical involution" that began in the mid-1990s
and is operating today. This involution involves all the key ingredients of the old
way of doing business-gifts, knowledge exchanges, social interaction-with one
key ingredient added-information technology. This technology has created the
high prescriber, while compressing the essential social time needed for something
like gift exchanges to effectively occur and for patient risk to be minimized. The
increasingly rapid and complex pace of pharmaceutical transactions has created
unforeseen consequences for both doctors and patients.
Recall how Geertz described involution as "cultural patterns, which, after
having reached what would seem to be a definitive form, nonetheless fail either
to stabilize or transform themselves into a new pattern but rather continue to
develop by becoming internally more complicated" (1963:80-81). Quoting the
anthropologist Goldenweiser (1936), Geertz elaborates on the notion of involu-
tion: "The pattern precludes the use of another unit or units, but it is not inimical
to play within the unit or units. The inevitable result is progressive complica-
tion, a variety within uniformity, virtuosity within monotony. This is involution"
(Goldenweiser 1936:81). When the fundamental cultural pattern of pharmaceuti-
cal sales-doctor-rep interaction through gift exchanges-began to reveal itself to
me ethnographically, I simultaneously realized that this pattern had changed over
the course of my tenure with Company X-involution was occurring.
Part of being a rep in 1989 included a bit of covert research regarding who
wrote what products and how much.35 This was done by infiltrating local phar-
macies and forming alliances with nursing staff and receptionists.36 Usually after
several months, you would get a picture of who the key doctors were to call on
at a particular hospital or clinic-the high writers of certain products. This took a
certain level of social skill, and certain representatives were more adept at handling
this than others. This knowledge became a valuable secret to keep and quite ad-
vantageous to use during the sales call (i.e., to know what a doctor writes gives the
rep the upper hand in mentally preparing responses to objections and for crafting
presentations in general). Nonetheless, this process took time and it was part of
developing rapport and played nicely with how gift exchanges worked.
However, the 1990s saw the pharmaceutical industry tap into information
technology and pay companies (third parties) that could provide "script tracking"
information. Computers allowed for prescribing data to be collected from pharma-
cies, tabulated, and eventually sent directly to reps to see what their doctors had
actually been writing. What we found out many times confirmed our suspicions:
doctors lied to us or at best wrote scripts for most products within the same class
in equal amounts (i.e., no clear pharmaceutical favorite). But now we had the data
and reps could focus on continuously gifting these high prescribers to gain more
"face time" to detail products in order to pressure a change in prescribing habits.
And herein lies the involution. Every representative (from all the major compa-
nies) by the late 1990s had this information. High prescribers were swarmed by
representatives and gifts. Effective gifts needed to become more novel, more in-
teresting. Mundane gifts, like cookies, were now being baked by representatives.
Donuts needed to be personally inscribed with product names. Lunches need to be
specialized to set you apart ("no pizza, no chicken please"). Sub sandwiches were
replaced by Thai, Chinese, Vietnamese, and Middle Eastern cuisine. You could
never be empty handed going into a clinic-everyone was gifting.
Elaborate and expensive gifts became the norm. Getting high prescribers
out for wine tastings, cigar parties, dinner cruises, and golf outings (at the most
exclusive course) was essential. If you could mix a little education into these
events with an expert (a company-sponsored speaker who also was entertaining),
you might have an edge on the competition. However, it was more than likely
that they were attending a ballet program the day after your theater-night with
your toughest competition. If doctors had children? No problem. Representatives
began to hold Saturday morning matinees at local movie houses, where a company
promotional film was played before a children's film. If you had success taking
residents to a baseball game (where, of course, you gave out "Company X bucks"
for beers and bratwurst), you would soon find out your competition had taken
them to another game, but rented a corporate suite and had food catered in from
a gourmet deli. There truly was "virtuosity within monotony." Certain doctors
began to react against the constant state of gifting (i.e., "Quit inviting me out, and
instead lower the price of your drugs.") and to script-tracking techniques in general
(i.e., "I know you know what I write and I don't care!").37 Kirkpatrick (2000:43)
has documented the more extreme case of a grassroots effort to resists gifts and
representatives altogether.38
Regardless of growing resistance, pharmaceutical corporations continue to
pour billions of dollars into a gift economy. The fundamental reason for this is
that these practices remain efficacious in two important ways. First, as illustrated
above, gifts can and do generate scripts for products. My ethnographic experiences
and Wazana's (2000) review of the medical literature as well as doctor testimonies
confirm that over time, prescription generation is influenced by gift exchanges.39
Second, and again borrowing insights from Bourdieu (1977), we can see how
the current intensification of the pharmaceutical gift cycle exposes two different
economies at play in the medical-pharmaceutical marketplace.
Using Bourdieu's (1977:172-173) terms, we have an older, goodfaith and
archaic economy, a gift-exchange economy that is "forced to devote as much time
(and money) concealing the reality of economic acts as it expends carrying them
out." The more calculated the gift exchange becomes (as was the case with my
recollections mentioned above), the more this economy "exposes the objective
workings of the other economy." In other words, pharmaceutical involution at
times exposes the true nature of pharmaceutical-medical transactions: monetary
profit through the use of patient bodies. Furthermore, and perhaps more impor-
tantly, on a very mundane level, the everyday function of the pharmaceutical gift
economy (e.g., the plastic pen transactions, the free lunch, etc.) works by "lim-
iting and disguising the play of economic interest and calculation" that exists at
every level of pharmaceutical product promotion. The industry works very hard
to maintain afeel-good economy for doctors and reps to coexist, where decisions
for prescriptions can be based on other criteria.40 Thus, a paradoxical health-care
economy has been created, one that is all about the patient, while simultaneously
not about the patient at all.
And these economies continue to expand. The statistics are staggering. In
2000, there were 2.9 billion prescriptions written in the United States (10.4 per
American). The total cost of prescriptions in 2000 is a whopping $132 billion
dollars. This was a 19 percent increase from the year before and represents the fifth
year in a row of double-digit increases in consumer spending on pharmaceuticals.
Fauber and Manning (2001), summarizing the report from the National Institute
for Health Care Management Research and Educational Foundation, describe how
this increase is the "latest evidence yet of two trends: a shift in the demand to
new higher-priced and heavily promoted drugs; and an increase in the age of the
American population, with a corresponding demand for more drugs" (2001:1).
Unfortunately, the use of the word "demand" indicates a one-sided affair, where
consumers are presented as demanding high-priced drugs.41 I have tried here to
balance this type of research and to show the complex web of activity between
pharmaceutical representatives and the medical community, all of which helps
create demand and pressure (i.e., "I use their product so the reps will leave me
alone") to generate more prescriptions through the bodies of consumers.42
The report discusses many of the themes covered in this paper. In particular,
the drugs that accounted for half of the rise in cost (over $10 billion dollars)
are maintenance medications indicated for arthritis, high cholesterol, diabetes,
depression, and ulcers-the chronic diseases of Western modernization. These are
heavily promoted blockbuster drugs, however, as the report goes on to say-their
efficacy is a matter of debate. Findlay, the author of the report, is quoted as saying
that many of the new drugs are "worth it (the price), and some of them may not be"
(Fauber and Manning 2001:4), indicating that me-too drugs are driving much of the
growth and involution, which has become a larger phenomenon that is represented
at the local level through hyper-pharmaceutical promotion and gifting.
Finally, the report discusses the increase from the industry point of view
and brings into focus another spin tactic of the industry that is often used at the
local level of pharmaceutical sales practice. A spokesperson for the Pharmaceutical
Research and Manufacturers of America (the industry's main lobbying association)
is quoted as saying "medicines can keep people out of the hospital." She was excited
to report that more than 1,000 new drugs are in company pipelines and that we
are "going to continue to see innovation in the pharmaceutical industry."43 "We
have entered the golden age of pharmaceuticals" (Fauber and Manning 2001:3).
The spin at the local level was always to talk about how new medications keep
people out of the hospital (i.e., "Doctor, does your patient want to spend $90.00
a month on medication or $1,000 a day on hospital bills?"). Yet, according to
Fauber and Manning (2001:4), some managed-care organizations are reporting
that there is no reduction in overall hospital utilization because of prescription
drug increase. The debate seems to be gaining strength on both sides, which often
confuses the critical issues at hand. However, what is becoming clearer and in
need of ethnographic investigation is that pharmaceutical-related questions such
as innovation or involution are closely related.
Conclusion
The pharmaceutical industry exists at the nexus of what Michael Fischer

(1999) recently described as the "third industrial revolution." All the key player
are present: electronic media and information technology as well as molecular bio
ogy (1999:458), with the implications of pharmaceutical practice ranging from th
personal-psychological to the global political economy (1999:457). A challenge
of ethnographic practice becomes getting at the "unequally inflected discourse
competing for hegemonic control," while realizing anthropology itself is part of
stream of these representations and mediations fighting for authority (1999:455)
Fischer specifically points to other genres of writing as a way to juxtapose, com-
plement, and/or supplement critical forms of ethnography. Included in his list ar
various genres discussed and used above: investigative journalists, historians, au-
tobiography, and science writers. All of these have helped create the "working
image" of pharmaceutical sales rep practice presented here.
I have used a variety of means to situate the pharmaceutical salesperson more
anthropologically in hopes of stimulating further inquiry into this secret world-to
begin to fill in the conspicuous gaps. My empirical tools have been fragments of
past life memories and ongoing work with current and former sales representatives
I have tried to highlight a few of the inner workings of the pharmaceutical industry
in everyday practice, namely, how pharmaceutical representatives are intimately
involved with physicians in generating billions of dollars of prescriptions throug
a particular mode of exchange: a three-way gift economy.
My focus has been on exchange and its relationship to pharmaceutical sales
practices. This work is part of a growing literature of cross-cultural pharmaceutical
studies as well as a more general interest within science studies focusing on ex-
change. For example, Warwick Anderson's recent work on science and exchang
in New Guinea looked at the various "exchange regimes" that developed around
"kuru transactions" between the Fore and other local groups, between medical sci
entists and research subjects, between anthropologists and informants and betwee
groups of scientists and anthropologists (2000:714). He convincingly shows the
importance of gift giving within the domain of moder science (and academia).
And, in particular, he points our attention to how the gift cycle (or "gift relation-
ship") can take on elements of calculation and competition (Anderson 2000:716).4
These elements also operate within the pharmaceutical gift cycle I have describe
here.
Perhaps there is no better example of science at play within the market-
place than the multinational pharmaceutical industry. Fortunately, there exists an
established literature, albeit in a non-Western context, that examines the shifting

exchange networks operating within emerging pharmaceutical markets. A seminal
article on this subject is Kamat and Nichter's (1998) work in India, mentioned at
the outset of this article. Kamat and Nichter examine the reciprocal relationships
between pharmacy owners, medicine wholesalers, and pharmaceutical sales rep-
resentatives ("medreps") and how they influence pharmacy staff (1998:779). In
India, as in many non-Western countries, most pharmaceutical products are avail-
able over the counter, which is also a growing trend in North America. This creates
a need to study "the profit motives of different players located on the drug sales
continuum" (1998:779), especially the growing role of consumers in generating
their own prescriptions.
The involution of the gift cycle can be seen as emblematic of larger involution
processes at work in the bodies and minds of patients filling their pharmaceutical
prescriptions.45 Simply put, in this unprecedented era of health-care innovation,
new illnesses continue to emerge, according to pharmaceutical industry statistics.
These corporations are quite adept at uncovering "silent" or "hidden" epidemics.
New pharmaceutically treatable psychiatric "disorders" such as Pre-Menstrual
Disphoric Disorder (PMDD), social phobia, and Attention Deficit/Hyperactivity
Disorder (ADHD) continue to be defined as medical illnesses and new medical
markets.46 Medical anthropology must continue to ask pertinent questions such
as: Who are the key players defining heath(care) in this current medical-industrial
climate? How do certain bodies (social, corporate, human, etc.), coexisting in
complicated exchange networks, profit (or do not profit) from this moder era of
patient health and pharmaceutical prescribing?
The job of all pharmaceutical salespersons has only one goal: to generate
scripts or "moving drug," as it was called at Company X. These drugs move in a
particular direction: through patient bodies. We are not simply all just potential
patients. Today, we are increasingly all potential consumers of pharmaceuticals,
the consequences of which we have only begun to investigate anthropologically
(and medically). If we have entered the "golden age of pharmaceuticals," the task
remains for critical ethnographers "to plunge into the midst of them," as Geertz
(1973:30) has put it, and to anthropologically examine the emerging side effects for
human health in a society increasingly reliant on, and governed by, multinational
pharmaceutical corporations.
NOTES
Acknowledgments. My research and writing has been generously supported by the

Graduate School at Princeton University as well as other university organizations, including
The Center for Health and Wellbeing, The Princeton Institute for International and Regional
Studies, and the Canadian Studies Program. This article began through my conversations
with Emily Martin and Rena Lederman who enthusiastically encouraged me to pursue
the concept of thick prescriptions ethnographically. I also am indebted to my cohort of
Eugene Raikhel and Natasha Zeretsky, who always gave me the time to talk about all
things pharmaceutical. I would like to thank the following people as well for their time
spent reviewing previous drafts of this article, all of which aided in its development: Carol
Greenhouse, Vincanne Adams, Ian Whitmarsh, three anonymous reviewers, and the editorial
staff at MAQ. In particular, I owe special thanks to Joao Biehl for his critical remarks on
earlier drafts of this article and for the opportunity to explore these ideas during his seminar
Science, Culture, and Power held in the spring of 2001 at Princeton University. Last, but
certainly not least, one of Jim Boon's gifts to me (and many other graduate students) was
The Gift, and our discussions in "Prosem" were instrumental in helping me think about the
pharmaceutical industry anthropologically.
1. Three different physicians commenting on the relationship between pharmaceutical
sales representatives and doctors; quoted from Kirkpatrick (2000:42-3).
2. Interestingly, many of the early pharmaceutical reps were doctors and were later
replaced by pharmacists (Smith 1968:299). Until the 1970s, some physicians were hired
as "part-time detail men," which Silverman and Lee (1974:76) classify under "The Gift
Gambit" in their chapter on drug promotion.
3. Ethnographic access to industry practices is improving. Anthropologists such as Cal
Appelbaum (Japan), Andrew Lakoff (Argentina), and Emily Martin (United States) have
ongoing ethnographic projects that focus on the sales and marketing practices of multi-
national pharmaceutical companies, including the activities of sales representatives. My
current ethnographic projects related to the pharmaceutical industry include interviewing
both past and current representatives as well as pharmacists and doctors who receive funding
(e.g., stipends, speaker honoraria, etc.) from the industry. Nevertheless, due to the propri-
etary nature of the drug industry, the day-to-day activities of the sales rep remain elusive.
4. My past employer will be called Company X, and both the names of individuals and
products will be given pseudonyms. There are many reasons for this, including protecting
current and former employees who are discussed in this ethnography. Also noteworthy
are the possible legal ramifications that could result from identifying a pharmaceutical
company by name. I have no binding agreement forbidding disclosure of my past activities,
however I do see an inherent risk of exposing the highly secretive and protective world of
pharmaceuticals. Native terms and phrases appear in quotations.
The term detail man is a reference to the past, when the majority of reps were male (and
called on mostly male doctors) as well as to the nature of the actual sales presentation. Sales
reps present "details" of a product to physicians (often called "detailing"), usually with the
help of visual aids kept in a "detail book" and stored in the "detail bag." When I left Company
X in 1998, the term detail man was still used occasionally for male reps by older male doctors
and their staff. Today, the field forces of most major pharmaceutical companies appear to
be split 50-50, women to men. Kirkpatrick (2000), discussed in this article, describes the
typical rep today as "female and attractive"-a point worthy of ethnographic exploration.
5. Moffatt (1992:207) uses the term autoethnographic when reviewing the various
ways ethnography on American culture has been conducted. He specifically sites the work
of Carroll (1987), Curran (1989), and Hayano (1982) as autoethnographic as well as Weston
(1991) and Sacks (1988) as using their "native" experiences to inform their anthropological
projects. None of these examples deal with corporations, however Ho (2003) spent one
year working as a Wall Street investment banker and used that experience to both develop
contacts and produce an illuminating account of the effects of downsizing in the investment
banking community.
6. I completed my first ethnographic project during my last year of Master's study at
the University of Wisconsin at Milwaukee. That initial project has evolved into a separate
account (and companion paper) of "off-label" promotion of pharmaceutical products within
my sales district (and Company X in general) as well as the abrupt ending of my drug rep ca-
reer because of these types of activities. I will refer to it often in this article (see Oldani 2002).
7. Building on this initial work, Reynolds Whyte et al. (2002) have more recently
produced the Social Lives of Medicine, which, in part, is a synthesis of the literature and
a cross-cultural look at the global commodification of health at an everyday level. Phar-
maceuticals again play a prominent role in their discussion ("the medicines with the most
active social lives in the world today") as does the sociocultural interaction of these drugs
with other non-Western forms of "material medica" (2002:3).
A version of this section was previously published in the Kroeber Anthropological

Society Papers (Oldani 2002).
8. A reviewer of this article wondered about the level of deception as it relates to the
day-to-day activities of pharmaceutical sales representatives. Spinning is actually a subtle
form of deception. In this article, I have chosen not to discuss deception per se, but it remains
a key part of pharmaceutical sales and varies in degree from rep to rep and from manager
to manager. I have discussed this more ethnographically in Oldani (2002). In that paper,
I specifically discuss the various types of "knowledge games" reps incorporate into their
details and compare pharmaceutical sales reps to the trickster because of their boundary
crossing between health care and the market and their superior use of "language." Although
rare in my experiences, there are examples of blatant manipulation of product efficacy and
safety data (see the example in Oldani 2002:159, note 22).
9. It is also worth noting Lexchin's (1984:206-225) discussion in chapter 13, entitled
"Medicalization: The Ideology of Drug Use." In this chapter, he outlines how the industry
is most successful at treating specific diseases that are most prevalent in modem capitalist
countries, such as hypertension, Attention Deficit Disorder (ADD), and anxiety disorders
that require minor tranquilizers such as Valium (see chapter 1). His main concern is the
growing trend to medicalize "social problems" (i.e., most hypertension is stress related and
can be controlled by diet and life-style changes, yet we continue to overmedicate). In the
last 20 years, one could argue that the trend is to "pharmaceuticalize" the most common
social disorders in Western countries.
10. Vuckovic and Nichter (1997) have done research on drug advertising in the United
States and their work showed that patients who do not receive requested pharmaceuticals
will find a doctor who will satisfy their needs (cited from Reynolds Whyte et al. 2002:141).
Mintzes et al. (2003), using patient and doctor survey databases in Vancouver, British
Columbia, and Sacramento, California, concluded that patients who requested direct-to-
consumer advertised drugs were "much more likely to receive 1 or more new prescriptions
for requested drugs or alternatives than those [patients] who did not request DTCA drugs"
(2003:405).
11. A reviewer of this article pointed out that pharmaceutical companies have low-
ered the price of some HIV/AIDS drug treatments outside of the United States. This
is true. However, aside from lowering the price of AZT in the United States due to
pressure from AIDS activists, pharmaceutical manufacturers rarely lower the price of
a U.S.-marketed prescription drug. The U.S. market remains the major source of rev-
enue for most companies. The current border war between multinationals and Canadian
Internet pharmacies shows the lengths to which pharmaceutical companies are willing
to protect the U.S. market (i.e., threatening to cut off the supply of popular drugs to
an entire country). Investigative journalist Merrill Goozner (2004) also makes it very
clear in his book The $800 Million Pill that the growth of the U.S. market is main-
tained by using billions of dollars for clinical studies for drugs already on the market
and to support the growth of "me too" product markets (see especially chapters 9 and
10 in Goozner's book). ("Me too" is a catch-all phrase for the plethora of new drugs
that will saturate an existing market with no clear advantage in efficacy; see above as
well.)
12. Again, how much of this was truly a doctor complaint or a complaint started by our
competition is hard to evaluate. Part of our sales strategy was to constantly manufacture and
make doctors aware of "weaknesses" in our competitor's products. For example, Antibiotic
Y (the competition) mentioned above could cause a metallic aftertaste for patients. I would
mention this when discussing my Antibiotic X: "And doctor, remember, with our drug there
is no metallic aftertaste." The goal was to get the physician to bring the complaint up to the
competition (even if the physician never heard of it from one of his or her patients), thus
getting the competition on the defensive.
13. I will not discuss the issue of drug samples in depth here. However, the subject
is central to pharmaceutical practice. For instance, the actual placement of samples within
a "sample closet" could influence prescription-writing practices of doctors. In many cases,
you needed to place your samples at "eye level," especially if your product was one of
other medications in a similar class of drugs. Reps would engage in "sample wars," that is,
moving competitors' samples to the back of the closet or out of sight in order to have the
doctor or nurse focus their gaze only on our product. Samples were the only visual indicator
if a product was "moving" or not. If your samples were gone, it most likely indicated the
doctor had given them to patients and wrote a script (a prescription). A classic technique
was to get your samples placed on the doctor's desk as a reminder of his or her commitment
to using (writing for) your product.
14. In ideal economic terms, a drug rep should present a product to a doctor, get the
commitment for a prescription, have the doctor call the patient into the examination room
(with the rep present), and write a prescription of the rep's product for the patient. Then
the patient should give the script to the drug rep who reaches in his or her bag and gives
the patient the drug, who, in return, gives the rep $50 for the drug. The rep then sends the
money to his or her company and is paid a commission. Of course, this is not the nature of
exchange in the medical market place. The generation of prescriptions is mediated through
a variety of different interests-medical, legal, governmental, personal, and financial.
15. Geertz was organizing his thoughts around convergent and divergent data in hopes
of answering his critics (and supporters) regarding the "involution" question of Javanese
(economic) development.
16. Hawthorne (2003), an investigative journalist, has recently published her inside
account of the Merck pharmaceutical corporation. Chapter 5, "The Freebie Circuit," is
a well-researched discussion of gifting by the industry mainly through the activities of
drug representatives. She discusses the "hierarchy" of gifts (2003:126-133) (e.g., from
plastic pens to Broadway tickets) as well as important topics such as sales quotas, sales
rep territory structure, and how the industry tracks prescriptions written by physicians
through information technology (also discussed above). Although not part of the scope
of her project, there seems to be a lack of discussion of the risks that arise for patients
through the "freebie circuit." This is something that is essential when addressing the industry
anthropologically.
17. Me-too drugs are drugs usually within the same chemical class that show equal
efficacy and side effects in clinical trials. Kirkpatrick cites The Medical Letter, a nonprofit
newsletter that evaluates new drugs to enter the market, as characterizing Celexa as a me-too
(i.e., no benefit over other SSRIs). His article essentially speaks to this larger question, which
is how the pharmaceutical industry continues to saturate most markets (antidepressant,
antihypertensive, antibiotic, etc.) with a variety of me-too products. One could argue that
the goal then becomes one of simply expanding markets versus improving the quality of
care of patients.
For an accurate account of the strategies used by the pharmaceutical industry to
promote me-too psychotropic drugs, see Valenstein (1998:165-201).
18. When hired by Company X, I became part of an "experiment" to hire people with
biology and chemistry experience (I was trained in a pre-med undergraduate program.). By
the time I left, most people hired were again coming from business and marketing as well
as the military (both retired and in the reserves). A general critique my first district manager
would often invoke was that many of us, especially me, talked "too much science" and that
we needed to detail and to sell. Perhaps this type of sales philosophy is what ended the
experiment.
19. The first thing I received in the mail after being hired by Company X was a small
book of medical terms and definitions. Our first test during training was based on knowing
this new "language." I failed and took the test again until I passed.
20. I would often hold textbook raffles during lunches with residents and medical
students. I would normally set up lunch, put out small gifts (pens), and then give a brief
product presentation. To enter the raffle, I would have doctors write a pretend script for
one of my products. The textbook would be displayed so all could see it. (These books
were quite expensive, usually over $100 and far exceeding the AMA guidelines of $50
gifts for physicians.) On more than one occasion, I was quite shocked to find that during
my presentation the textbook had been taken. Residents would reassure me that somebody
probably just thought it was a free give-away.
21. A strategy at Company X was to have young reps work with older reps during the
first year of training. You really learn to sell pharmaceuticals by watching other people. This
older rep, who I completely respected in terms of professionalism (read here as honesty),
and I had a lunch appointment where we brought in sandwiches from a deli and everyone
was quite satisfied with lunch at the clinic except the doctor. She was a vegetarian. We
quickly got in our car and raced over to another deli for a non-meat lunch, (all the while,
the senior rep complained about running around for food) brought it back and saw the
doctor. She was quite thrilled about our effort and gave us extra time to chat about our
products. This, of course, taught me a valuable lesson: flexibility and appropriate gifts can
pay dividends.
22. Pharmacy represents a critical site for drug rep interactions. In this case, the
PharmD had the influence and authority to affect what went on the hospital formulary, and
more importantly, could influence the prescription writing on a day-to-day basis. In other
words, if I had failed to give her the coffee card, I could have potentially lost business by
her changing doctor orders back to a competitor's product. At this hospital, however, the
PharmD was a complete ally (I had recruited her to speak for Company X-part of the
neutralization process) and actually was an advocate for Antibiotic S before the coffee card
program. I simply hurt her feelings by not giving her a card and probably made her feel less
equal to the physicians she worked with. (I am quite sure she got two cards immediately.)
23. My "nickname" at another institution is an example of how gifting can become
institutionalized. I was called "Larry III" by the pharmacist, who was also the head of
purchasing. Larry I, the real Larry, had actually helped hire me and had previously worked
at this hospital, and his eventual replacement was called Larry II by this same pharmacist.
I subsequently replaced Larry II and received the new name of Larry III. During my rep
days, the nickname was funny and always a point of conversation, so I never thought much
of it. However, in retrospect I realize how interchangeable we all were in the eyes of this
pharmacist. The "Larrys" did one thing well for this pharmacist. We supplied him with
gifts: lunches for his staff, CME programs, grants, checks for pharmacy fund-raisers, raffle
items for give-aways at these same fund-raisers. Ultimately, we made him look good. He
rewarded me with huge purchases when it counted most-when I need a "bump" to put me
over quota for the year.
24. Celebrex, a new COX2 inhibitor, and Viagra are cases in point. They both were
sequentially the most successfully launched products ever. This was the case for Viagra for
a variety of reasons, including newness. Celebrex, however, entered the highly competitive
anti-inflammatory market, and is a twice-a-day medication. Yet being first to market almost
guaranteed a successful introduction.
25. The idea here is creating a gift that ties into the efficacy and the sales pitch of the
product. If you have an antibiotic that kills pseudomonas, you put a picture of this bug on
the mug, and with heat (i.e., coffee) "the bug disappears, just like in your patients infection
doctor!" By the time I left, this hau had been used up by several companies.
26. Company X introduced an animal mascot with its very successful pediatric an-
tibiotic. It was represented at every level of promotion and advertisement-file cards, pens,
sample boxes. We also were instructed after the first year of product introduction to throw
a "birthday party" for the mascot at a big pediatric clinic of our choice. We were given all
sorts of party favors and birthday gifts to give to doctors and staff and were instructed to
buy a birthday cake (better if it coincided with the birthday of a key pediatrician). Many
reps reported success with this party in weekly reports and district meetings.
27. This information is now downloaded daily into the databases of reps' laptop
computers.
28. I have chronicled my own ending as a representative, which was partially due
to managerial pressure to promote products "off label" (Oldani 2002). Two sales reps I
worked with in the 1990s illustrate how the failure "to make your numbers" can lead to a
long-term managerial commitment to see a representative leave the company with mixed
results. Robert, for example, had a physical handicap and failed to make quota for several
years running. Over the years, different managers tried numerous tactics to get him to retire
early, including embarrassing him at meetings in front of his peers (his "numbers" were
always low). Robert fought this and often rallied his doctors to support him when making
sales calls with his managers. One ER doctor I knew, who treated Robert when he fell, which
was often, was appalled that Company X would not provide Robert with a more accessible
vehicle to work with (he often struggled getting in and out of his company car). Robert is
now on medical retirement, which he managed to secure after years of negotiations. The
other representative, Dianna, managed to hang on to her job for years despite having poor
quota numbers. During my tenure, at least three different managers tried to get her to quit
(often asking me to talk to her because we were close). However, she knew how to play
the system. This system had evolved from "gentleman agreements" in the late 1980s (i.e.,
managers would sit down and have a "heart to heart" with reps and they would both agree
it was time to "move on") to an intensive corporate/managerial review system for reps (i.e.,
"paper trail") that recorded in detail sales goals/quota and either a reps failure or success to
meet these goals. Getting fired became more concrete procedure (e.g., three poor quarters
led to probation, followed by reviews by regional managers, and then possible termination).
Dianna often managed to have a good quarter, which would start the whole process over
again. She finally left Company X in 2001 and now sells software.
29. It is not my purpose here to enter in the "third-person debate" of gift exchange
theory that Sahlins (1972) sets in motion as he discusses Mauss, Best, Levi-Strauss, Firth,
and Johansen. Rather, I use Sahlins's critique to simply highlight the importance of under-
standing the role of third parties (patients) in the pharmaceutical gift cycle, which I feel is
unique unto itself.
30. For an interesting give and take with an ex-FDA physician regarding the risks of
new drugs, see his interview in the New York Times with Grady (2001).
31. Most recently, the selective serotonin reuptake inhibitor class of antidepressants
have come under FDA scrutiny because of possible links to suicidal behavior, in particular
for children prescribed Paxil (Harris 2004). Readers may recall that in the early 1990s,
Prozac was linked to suicide as well. Company X took advantage of this negative press
with Prozac when introducing its own SSRI in mid-1990s and saw tremendous growth with
its own antidepressant. Prozac reps eventually spun the negative into a positive during the
selling presentation (i.e., the negative side effect of agitation was transformed verbally to an
"uplifting" property). Doctors were told to use Prozac in depressed patients who appear very
sluggish, and other SSRIs should be prescribed in the agitated/anxious depressed patient.
Spinning helps bury side effects until they reemerge, in this case, for the entire class of drugs.
It now appears that side effects are also buried on a larger scale by "ghost writers" who
sign off on company-sponsored clinical trials after corporation has compiled its own study
from the raw clinical data (see counterpunch.org/ giombettipaxil.html; this information was
also presented by industry critic Dr. David Healy at the 2003 American Anthropological
Association meeting).
32. On one of my first days on the job in 1989, I ran into an older rep from Smith Kline
French (now after several mergers: Glaxo-Smith Kline). In his late 50s, he approached me,
the young, hyper, and ready-to-go get business new rep, and talked to me for about ten or
15 minutes in front of my open car trunk. He introduced me to the old mentality of "piece of
the pie." He told me there was enough business to go around and to take my time not to be
too pushy with doctors-they don't like that. I listened attentively and after the exchange I
never saw him again. The area I worked, northern Wisconsin, was rapidly changing in rep
demographics. By the time I left in 1992, most of the major companies were represented
by young aggressive salespersons.
33. With nine years' experience, I was often asked to come in and present a new product
to a hospital pharmacy and doctor's clinics using all the tools of expert speakers-slides,
literature, even a laser pointer.
34. Everything takes place as if agents' practice, and in particular their manip-
ulations of time, were organized exclusively with a view to concealing from
themselves and from others the truth of their practice, which the anthropologist
and his models bring to light simply by substituting the timeless model for a
scheme which works itself out only in and through time. [1977:6]
The doctor realized this and wanted to exploit "the timeless model" he was part of. In
doing so, he undermined and revealed what I was after-scripts. A truth that, when blatantly
revealed to me, was quite repugnant at that specific moment.
35. Military metaphors are part of the everyday language of Company X. We were
taught The Art of War by Sun Tzu (1981) (e.g., full frontal assaults vs. changing the bat-
tlefield) and had a two-day workshop in "Targeted Account Selling" (i.e., how to identify
who the power players are in your hospitals who will get your drug on formulary).
36. Dealing with the "gatekeepers" in the clinics was characterized as "drug rep 101"
by my first manager. To elaborate on this would require another article. They are key players
in the entire scheme of things and often required special gifts and favors for information
and admittance into the clinic or hospital floor.
37. Several physicians (who had become personal friends) and I at one point discussed
script tracking over drinks. Most realized that I knew what they wrote, but several kept
asking: "You really, really know what I write?" One doctor became distressed and was
concerned with his "lying" to drug reps whom he considered friends (like me) and was
confused why they wouldn't bring this up with him. They simply acted like they believed
that he was writing their products. I told him our policy at Company X was never to discuss
this information. In fact, reps who did discuss this information, or who had actually brought
the paperwork to a sales call to show a doctor that he was in fact not writing a prescription,
were reprimanded by the company. The doctor was not satisfied with my answer and asked
aloud, "How can they expect me to write a BID (twice-a-day) drug when their competition
is QID (once-a-day)? I still will use their other products, but not that BID drug."
38. A New York doctor recently created the Web page www.nofreelunch.org with in-
formation regarding how pharmaceutical companies influence medicine. He also countered
the gifts of drug reps with coffee mugs and T-shirts labeled: NO FREE LUNCH: JUST
SAY NO TO DRUG REPS.
39. An essay in the New York Times describes nicely how the social machine
the pharmaceutical industry can erode a doctor's decision-making process, one that i
perceived to be governed by evidenced-based medicine and science. The author de
how his friend deplores the pharmaceutical industry's influence on medical practic
amuses himself by taking advantage of everything the drug companies have to offe
free pens to all-expense-paid trips. To "learn" about a new treatment for AIDS, his
took advantage of all the company perks-drug rep presentations to company paid
The author concludes his essay by noting how surprised his doctor friend was w
needed to switch patients off of this new HIV medication that presented unforeseen
for patients post-introduction to the market. His friend said, "It turns out I had an
lot of people on that silly drug.... I honestly can't imagine how that happened" (Zuger
2004:D5).
40. A pharmaceutical salesperson can be seen as an altered version ofBourdieu's "man
of good faith." For the most part, reps practice no exchanges involving money (although
"grants" are given in the form of checks) and work tirelessly to create a pharmaceutical
"genealogy" of social relationships in order to keep distributing gifts to these same "friends
and neighbors." The tighter the personal relationships between reps and doctors, the more
informal the transactions become (i.e., reps can simply talk directly to doctors about products
without showing clinical proof of efficacy, side effects, etc.). In other words, the relationship
can evolve into one of "total confidence" (Bourdieu 1977:173).
41. Often consumers resist pharmaceuticals themselves. As one might expect, I have
become a reservoir of pharmaceutical stories and anecdotes for friends and family members
to pass on. Recently, a friend has kept me informed of a pattern emerging with her primary
care doctor. The last several times she has gone to visit her, my friend has mentioned she has
been "stressed out" but this young doctor never has taken a complete history of this patient,
asking questions like "Why do you think you are stressed," or "Tell me about your work,
family, etc." Instead, she keeps offering my friend a drug to take to "ease her stress." Twice
my friend has returned home and realized the drug is an antidepressant and has refused to
fill her script. My friend also is outraged because the doctor continues to remind her that the
side effect of the drug is weight loss (my friend is slightly overweight), however the doctor
never discusses other ways to lose weight or relieve stress. The doctor is also spinning side
effects into benefits for the patient, a key method of selling pharmaceuticals (discussed in
Part I).
42. Obviously, the consumer is playing an expanded role in the prescription process,
especially with the advent of direct-to-consumer advertising. This is stressed in the article
by Fauber and Manning (2001) as a key part of the increase in pharmaceutical demand and
price. My current ethnographic work in Canada includes narratives of patient demand for
pharmaceuticals.
43. A year later, however, Pollack (2002) reports in the New York Times that many
of the new product pipelines within the industry remain "far from full" (Cl). The feeling
on Wall Street is that with drugs not coming fast enough to sustain double-digit growth,
more companies might merge, may increase revenues by raising prices of existing drugs,
advertising heavily to consumers, and scrambling to extend their patents (C7). My most
recent discussion with representatives also indicates that pressure has increased in the
field to generate more prescriptions of products already on the market. This often involves
accelerated gifting as well as off-label promotion of drugs (i.e., promoting a product that is
not indicated for a particular disease) in order to expand the market, which is also against
FDA policy (see also Oldani 2002).
44. He is specifically referring to the competition and calculation Bourdieu (1977)
described among the Kabyle. He cites numerous authors who have examined science and ex-
change theory, including Biagioli (1993) and Galison (1997); also see Anderson (2000:715-
717).
45. The involution process appears to be at work within the federal government and
industry's ongoing debate of pharmaceutical pricing. Pear and Oppel's (2002) article in the
New York Times is a revealing look into a recent "strategic planning retreat" by top industry
leaders and their lobbyists-the Pharmaceutical Manufacturers of America. The industry
is pleased these days because of recent wins by Republicans in the House and Senate. The
journalists also discuss the amount of money given to politicians from both parties, up to
$200,000 for one Republican through various channels. To sell politicians, the industry has
hired a lobbying field force of 600 persons, which outnumbers the members of the House and
Senate combined. Another interesting part of this retreat is the industry's strategy with the
AARP. The executive director of the AARP (which is pushing for prescription price controls
for seniors) was a dinner speaker at this gathering. This tactic-inviting the competition to
speak for you or to you-was often used by reps when trying to "soften" or "neutralize" a
doctor who had contrary views regarding your medicine. Sometimes it worked, sometimes
it didn't.
46. For a thorough study on how history, culture, politics, economics, and other forces
(including the pharmaceutical industry) converge to construct a medical market and a social
category of illness, see Chrisler and Caplan's (2002) work on PMS and PMDD.
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Oldani - Thick Prescriptions

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Thick Prescriptions: Toward an Interpretation of Pharmaceutical Sales Practices

Author(s): Michael J. Oldani

American Anthropological Association, Wiley are collaborating with JSTOR to digitize,

Thick Prescriptions: Toward an Interpretation

Doctors aren't that corruptible.

Anthropologists of medicine and science are increasingly studying all

Situating the Rep

To date, the most comprehensive anthropological review regarding pharma-

The pharmaceutical industry, as well as sales reps and marketing departments,

Now the "close," to complete the spin:

Part II: Understanding the Logic of Pharmaceutical Gift Exchanges

Detailing the Gift Cycle

Kirkpatrick (2000) provides a detailed account of gifting and other activities

(i.e., detailing) to effect business. An older representative at Company X had shared

Part III: Pharmaceutical Involution

Principles of Pharmaceutical Marketing

In an astute and illuminating study in 1975, Mickey C. Smith put togeth

every couple of weeks. Remember what we discussed? Ok, give the

These are my two strongest recollections of how the doctor-rep interaction

The pharmaceutical industry exists at the nexus of what Michael Fischer

established literature, albeit in a non-Western context, that examines the shifting

Acknowledgments. My research and writing has been generously supported by the

A version of this section was previously published in the Kroeber Anthropological

1998 Pharmacies, Self Medication and Pharmaceutical Marketing in Bombay, India

1989 Doctors and Detailers: Therapeutic Education or Pharmaceutical Promotion? In-

2003 How Does Direct-to-Consumer Advertising (DTCA) Affect Prescribing? A Sur-

van der Geest, S.

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