1. State of affairs: Pharma in the summer of 2021

If you look around the pharmaceutical industry in the summer of 2021, year two of the Corona crisis, you will find people in an unusually good mood. It is a mixture of cheerful relief and defiant self-affirmation with which people refer to the positive image of the industry. “Finally” is a word that is often heard. Because regardless of whether the incidence rates are falling or rising, the pharmaceutical industry’s contribution to combating the pandemic is generally looked at in a positive light. And this is music to the industry’s ears: finally people are recognising how good the sector is for people and society. That pharma saves lives. At last, even the evil media and the venomous trolls on social media understand that pharma companies are primarily concerned with one thing: that is, doing good. Finally.

The words of praise are balm for the souls of managers who have never felt sufficiently valued despite a sustained, decades-long economic success story. Or should we perhaps say, because of the economic success? It was above all the business model of patenting active ingredients and the billions in profits made in a short time from it that made the unquestionable social benefits of the drugs fade into the background and permanently damaged the image of Big Pharma. The fact that it was not least thanks to these companies that AIDS is no longer a fatal disease, that hepatitis C can be cured and that worldwide life expectancy is increasing was often forgotten in view of the profits gained from contributor-financed public health systems.

Things are different now. But will this phase of goodwill last? That depends largely on the companies themselves and their communication strategies. In order to extend the positive development of the industry’s reputation, they should analyse the causes of the improvement in image, draw the right conclusions and change the way they portray themselves accordingly.

2. Analysis: The image change during the pandemic

If you read the chorus of praise for the pharmaceutical industry during Corona times, you will find two basic narratives. The first describes the tireless spirit of research with which previously unknown scientists, far from the headquarters of large pharmaceutical companies and usually associated with academic institutions, worked tirelessly to translate groundbreaking successes in basic research into innovative therapies. The second narrative concerns a network of large pharmaceutical companies that, due to medical expertise, regulatory experience, global organisation, financial resources and existing production capacities, were either able to develop their own products in a very short time or push the research of start-ups (narrative 1) through the approval process, produce vaccines by the billions and distribute them worldwide.

Both achievements, of the start-ups as well as the corporations, have drawn admiration from even the harshest pharma critics. The communication departments of these companies should pay attention to one thing above all: what now elicits admiration are those qualities that companies have sought to hide out of embarrassment in the past. It has been size and money, internal and external research, production and sales experience that has ensured recognition.

This contradicts the narrative that pharmaceutical companies have cultivated for decades, especially in discourse with the general public, with lay media and in discussions with health policy stakeholders: if one believes this self-representation of research-based drug manufacturers outside of financial market and scientific communication, then they are largely guided by the interest of their patients, the “unmet medical need”, the provision of health care and, if even that is still too small, the “desire to serve mankind”. No other industry uses the word “ethics” more often, especially in connection with business practices, and no other is more convinced of its social value.

Those who regularly follow the presentations of pharmaceutical managers often hear of almost evangelical-like revival experiences; how the illness of a mother, a friend, or – perhaps more realistically – the misery of X-number of thousands of patients worldwide led to the realisation: we have to do something here! And that is why, the speaker reports with Ted Talk-worthy pathos, it fills them with joy and also a little pride that the research, tirelessly pursued with modest dedication over the years to develop active substance X or technology Y, has led to what ultimately gives millions of children or women or victims of the XY bacteria a clear view again in an otherwise gloomy future.

In summary, this account can be placed under the heading of the “patient narrative”. In this, the purpose and motivation of the company are identical. The focus is on patients, their suffering is the motivation and their therapy is the result of the company’s activities.

This is contrasted with an external perception that could not be more different. No other industry is as often accused of greed with reference to high profit margins. The business model is described as if illness and death were the main profit drivers. The list of accusations is long. It ranges from bribery of the medical profession to the distribution of drugs that are sometimes highly dangerous, sometimes completely ineffective, but in any case completely overpriced, to the shameless enrichment from the pots of contributor-financed public health systems.

This criticism is completely exaggerated, ideological and partly based on practices that have long since been discontinued. The fact that it can nevertheless hold its ground so successfully in public discourse is not least due to the “patient narrative”. With the constant emphasis on the patient, the industry creates the illusion of altruism, which, as in all other industries, does not exist and – more importantly for the image of the pharma industry – is not believed.

3. Digression: The history of the patient narrative

In order to understand why Big Pharma in particular (less so biotech start-ups) has for many years relied almost exclusively on the “patient-first” narrative described above, it is necessary to take a look at the recent history of discourse in the health care sector. It was the justified criticism of a long-established business model that prompted the industry to make a communicative U-turn about 25 years ago. The starting point was so-called “me-too products”, i.e. medicines that were based on new active ingredients and were therefore patent-protected, but whose effect was similar to that of existing therapies. The additional benefit for patients was low, but the price was high.

In view of increasingly empty coffers, the initially scientific debate was taken up with interest by politicians. The methods of pharmaceutical marketing, especially its proof of supposed innovation – for example, through scientifically questionable surrogate parameters – were now no longer the sole target of pharma-critical scientists, researchers or the media. Politicians joined in and demanded that from now on, the rules of evidence-based medicine should not only apply in the lecture halls of universities, but should also shape the regulation of the industry, especially in the approval and reimbursement of new medicines.

As a result, health systems worldwide flipped the switch. Only those drugs that were demonstrably more beneficial than existing therapies were paid for. This benefit had to be proven by studies that followed the rules of evidence-based medicine. The change in state reimbursement (e.g. in Germany through the AMNOG, Arzneimittelmarktneuordnungsgesetz) and the establishment of so-called HTA institutions (Health Technology Assessment, in Germany IQWIG, Institute for Quality and Efficiency in Health Care) are evidence of the policy shift.

After initial resistance, the companies not only complied with their regulatory orientation, the changed study design and pricing. They also changed their communication. In essence, it was about the principle of evidence-based medicine, that the value of approval studies must always be based on proof of the concrete benefit for patients. Accordingly, patients and their diseases now also came to the fore in the external presentation of pharmaceutical companies. For about the past 20 years now, patients and the benefits provided to them have been presented as the almost exclusive drivers of entrepreneurial activity.

At first glance, this all seems rather credible. Are patients not in fact the centre of the business model? Is it not legitimate to present previously untreatable diseases as the driving force of entrepreneurial action? If only “real innovation” is paid for, is not the search for cures for underserved diseases the core of the pharmaceutical value chain? And accordingly, are not all the pharmaceutical managers correct when they put patient suffering at the start of their external public relations efforts?

No, they are not.

Anyone who analyses the pharmaceutical business model, especially research and development, knows that it is not oriented towards the benefit of people who are at risk of or affected by a disease, but towards the goal of translating scientific knowledge into products. If there is no possibility of this, a pharmaceutical company will not get involved in a given indication, no matter how great the suffering of patients may be. And conversely, their “medical need” only ever comes to the fore in communication when a new active ingredient moves forward in the pipeline, i.e. when the market launch of a new product is imminent.

Only if knowledge can be translated into products can the industry serve patients. Its motivation does not arise primarily from a medical need, but from medical research. If economics distinguishes between supply and demand theory, then the pharmaceutical industry is certainly not driven by patient demand, but by the supply it finds in its own laboratories, with partners in start-ups or in the academic environment.

It can be assumed that pharmaceutical companies, with their prayer-like patient narrative, wanted to ensure that their positioning was compatible with the political environment. Since then, their storyline has been fatally similar to that of politics, research and the medical profession. But here, too, it is by no means the same when two different actors do – or say – the same thing.

Ultimately, compatibility does not mean talking the talk of the other party, in this case the political sphere and the public. Those who seek compatibility want to be heard. But those who are heard should also appear credible. And that is exactly what pharmaceutical companies have not been successful in doing with the patient narrative. If politics is oriented towards the interests of patients and contributors, this is credible because they have given it the mandate. When the pharmaceutical industry does this, it is not. Because it is not true. And because everyone knows that.

4. Recommendation: A narrative about research and business

The self-portrayal of a sector does not have to justify its own actions solely on the basis of their benefits, that for direct customers (in this case patients, doctors) and that for society (in this case, the health system). This is important, but not sufficient on its own. It is at least as important to add an entrepreneurial context, a description of the intrinsic motivation. That companies act so completely without self-interest, that they orient themselves exclusively to the needs of others, seems neither particularly credible nor meaningful. It also seems all the more contradictory when an industry has for decades been accused of charging excessive prices for its products and burdening public coffers. Against this backdrop, it seems all the more necessary to point to one’s own expertise as an entrepreneurial motivation in addition to admitting to the motive of profit (why is that actually so difficult?). The social value of pharmaceutical companies arises from the very expertise they have demonstrated during the pandemic: they have the medical knowledge (and organisations of corresponding size) to scour the global research landscape and integrate their innovations into their own research and/or roll them out globally as products. The character of Big Pharma is largely determined by its focus on medical research (now also data analysis), not on the well-being of patients.

The more truthful (and therefore more believable) story is that research drives the product portfolio. The product portfolio defines the “medical need” addressed by the company – and not the other way round. It is not the needs of patients that define the portfolio. It is the portfolio from which the treatment of patients’ needs emerges. Patients are at the end of the process. This does not make them any less valued, but they are not the driver of innovation.

Pharma can do what basic researchers, doctors and the state cannot: design studies, go through phases 1 and 2 and 3, manage approval processes, set up production to meet EMA and FDA requirements, organise distribution. More importantly, it is not just pharma that understands research; researchers do as well. Pharma also understands the potential of research (which researchers do not always do). Discovering research, practising research, monetising research. That is pharma – for the benefit of patients.

It should not be forgotten that a more credible narrative is urgently needed, especially during times when data is taking on increasing importance. The storyline “We are doing all this for you” is all the more implausible when the patients addressed in this way are no longer just beneficiaries of research and development, but also its partners. Their data is becoming increasingly important for those who want to advance medicine, also and especially for companies.

Of course, companies are aware of the importance of research and use it when portraying themselves externally. However, as a driver of their own actions, it falls short. Big Pharma’s communication strategy needs a stronger – and above all more prominently placed – research narrative. This is the only way to reduce the discrepancy between self-perception and external perception.

Above all, investors and politicians will appreciate the openness. And the public will come to realise – even if slowly – that the pharmaceutical industry is not better or nobler than other industries, but it does much more good than most companies can claim.

picture credits:
©Tim Freiwald
Window At Night, 2019,
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