This is a final version submitted for publication. Minor editorial changes may have subsequently been made.
Abstract: The development of political agenda-setting through the use of sophisticated public relations techniques is threatening to undermine the delicate balance of representative democracy. This has important ramifications for policies aimed at providing mental health services and the implementation of mental health laws. The principal agenda setters in this area are pharmaceutical companies with commercial reasons to promote public policies that expand the sales of their products. They have manufactured highly effective advocacy coalitions that incorporate front groups in order to set the policy agenda for mental health. However, policies tailored to their commercial purpose are not necessarily beneficial either for patients or the society at large.
This paper uses the theory of agenda setting to examine how pharmaceutical companies are using public relations techniques to manipulate psychiatric thinking and public policy-making in the mental health field in the United States and Australia. Biologically-based theories for mental disorders, and the accompanying imperatives to use drugs in treatments, have come to be accepted by most of the major players in the mental health policy arena, including advocacy groups purporting to represent consumers.
Mental health policies have been extensively studied from the point of view of their effectiveness in achieving desirable mental health outcomes but the political basis of their formulation and adoptionthe agenda setting processhas been neglected.
The theory of agenda-setting is common to the academic fields of mass communications, policy studies and politics. The mass communications literature tends to concentrate on the role of the media in setting the public agenda while the political literature tends to concentrate more on how particular issues reach the governmental policy agenda. Of course, the two points of focus are interrelated since the public agenda affects the governmental policy agenda, and vice versa. In regard to the mental health policy arena, pubic relations companies have played a major role in both using the media to set the public agenda while at the same time directly lobbying to get particular policies onto the formal agenda. The formal agenda can be described as the set of items explicitly up for active and serious consideration of authoritative decision-makers (Cobb & Elder, 1983, p. 86).
Although policy setting in Australia and the US are very different (with a congressional and regionally based system in the US and a Westminster style of government in Australia), both countries have federal systems of government, and both countries make mental health policies at state and federal levels of government. Drug-based mental health policies have become dominant in both countries. In most cases US policy entrepreneurs have influenced Australian policies. However, in at least one area preventive drug treatment for schizophrenia it is Australian policy entrepreneurs who are influencing the development of US policy. (Gosden, 1999).
Most agenda setting theory encapsulates the idea of the need for advocates to expand interest in a particular issue or policy. This is usually done by policy-entrepreneurs (Kingdon, 1984) who build up advocacy coalitions (Sabatier, 1988) to push policies onto the agenda. What is unusual in the arena of mental health policy is the large role played by public relations in creating the relevant advocacy coalitions. These advocacy coalitions often have at their core purpose-built consumer groups that are little more that front groups for the psychiatric industry.
Front groups enable corporations, such as pharmaceutical companies, to take part in public debates and government hearings behind a cover of community concern. Corporations could do this openly and in their own names but it is far more effective to have a group of citizens or a group of expertspreferably a coalition of such groupswhich can publicly promote the outcomes desired by the corporation whilst claiming to represent the public interest. When such groups do not already exist, the modern corporation can pay a public relations firm to create them. (Beder, 1997, ch. 2)
The use of front groups to represent industry interests in the name of concerned citizens is a relatively recent phenomenon and one that pharmaceutical companies have heavily utilized. (See for example, O'Harrow, 2000; Picard, 2001; Menendez, 1998). Previously businesses lobbied governments directly and put out press releases in their own name or that of their trade associations. (Megalli & Friedman, 1991, p. 2). However the rise of citizen and public interest groups has been accompanied by a growing skepticism amongst the public about statements made by businesses:
Thus, if Burger King were to report that a Whopper is nutritious, informed consumers would probably shrug in disbelief...And if the Nutrasweet Company were to insist that the artificial sweetener aspartame has no side effects, consumers might not be inclined to believe them, either.
But if the American Council on Science and Health and its panel of 200 expert scientists reported that Whoppers were not so bad, consumers might actually listen... And if the Calorie Control Council reported that aspartame is not really dangerous, weight-conscious consumers might continue dumping the artificial sweetener in their coffee every morning without concern. (Megalli & Friedman, 1991, p. 3).
These front groups lobby governments to legislate in the corporate interest, to oppose undesirable regulations and to introduce policies that enhance corporate profitability. Front groups also campaign to change public opinion so that the markets for corporate goods, for example psychiatric drugs, are not threatened and are even enhanced. Merrill Rose, executive vice president of the public relations firm Porter/Novelli, advises companies:
Put your words in someone elses mouth... There will be times when the position you advocate, no matter how well framed and supported, will not be accepted by the public simply because you are who you are. Any institution with a vested commercial interest in the outcome of an issue has a natural credibility barrier to overcome with the public, and often, with the media. (Rose, 1991, p. 28).
The public relations industry often refers to front groups euphemistically as "partners". Steve Rabin, a former executive vice president/general manager of Porter/Novelli, is an expert on the art of forming advocacy partnerships. According to Rabin advocacy partnerships are all about "the joining together of organizations commonly regarded as adversaries, the establishment of brand loyalty, the enhancement of product sales, the maintenance of a company's reputation and image in the community". (Rabin, 1992, p. 32). More recently Rabin has been applying his skills in partnership formation with the giant PR conglomerate Nelson Communications Worldwide. Nelsons client list includes Abbott Laboratories, AstraZeneca, Bayer, Bristol-Myers Squibb, Eli Lilly, Glaxo Wellcombe, Hoffman-La Roche, Janssen-Cilag,, Lundbeck, Novartis, Pfizer, SmithKline Beecham, Wyeth-Ayerst International, together with the National Alliance for the Mentally Ill (NAMI). (Nelson Communications Worldwide, 2001).
Some of NAMIs funding sources were recently exposed in a Mother Jones article. All of the pharmaceutical companies identified as funding NAMI, together with NAMI itself, are on the above client list of Nelson Communications.
According to internal documents obtained by Mother Jones, 18 drug firms gave NAMI a total of $11.72 million between 1996 and mid-1999. These include Janssen ($2.08 million), Novartis ($1.87 million), Pfizer ($1.3 million), Abbott Laboratories ($1.24 million), Wyeth-Ayerst Pharmaceuticals ($658,000), and Bristol-Myers Squibb ($613,505). NAMI's leading donor is Eli Lilly and Company, maker of Prozac, which gave $2.87 million during that period. In 1999 alone, Lilly will have delivered $1.1 million in quarterly installments, with the lion's share going to help fund NAMI's "Campaign to End Discrimination" against the mentally ill.
In the case of Lilly, at least, "funding" takes more than one form. Jerry Radke, a Lilly executive, is "on loan" to NAMI, working out of the organization's headquarters. (Silverstein, 1999)
The names of corporate front groups are carefully chosen to mask the real interests behind them but they can usually be identified by their funding sources, membership and who controls them. (Megalli & Friedman, 1991, p. 4). Some front groups are quite blatant, working out of the offices of public relations firms and having staff of those firms on their boards of directors. The best researched examples are in the environmental area. Here it has been observed that the Council for Solid Waste Solutions shares office space with the Society of the Plastic Industry, Inc and the Oregon Lands Coalition works out of the offices of the Association of Oregon Industries. (Stapleton, 1992, p. 35).
Corporate front groups have flourished in the United States. Several large companies donate money to more than one front group. For example in 1991 Dow Chemical was contributing to ten front groups including the Alliance to Keep Americans Working, the Alliance for Responsible CFC Policy, the American Council on Science and Health, Citizens for a Sound Economy and the Council for Solid Waste Solutions. According to Mark Megalli and Andy Friedman, in their report on corporate front groups in America, oil companies Chevron and Exxon were each contributing to nine such groups. Other companies which donate to multiple groups include Mobil, Du Pont, Amoco, Ford, Philip Morris, Pfizer, Monsanto and Proctor and Gamble. (Megalli & Friedman, 1991, pp. 184-5). These large corporations "stand to profit handsomely by linking their goals with what they hope to define as a grassroots populist movement." (Poole, 1992, p. 61).
Front groups are not the only way in which corporate interests can be portrayed as coinciding with a greater public interest. Public relations firms are becoming proficient at helping their corporate clients convince key politicians that there is wide public support for their policy agendas. Using specially tailored mailing lists, field officers, telephone banks and the latest in information technology, these firms are able to generate hundreds of telephone calls and/or thousands of pieces of mail to key politicians, creating the impression that there is wide public support for their clients position (Beder 1997, ch. 2).
This sort of operation was almost unheard of fifteen years ago, yet in the US today where "technology makes building volunteer organizations as simple as writing a check", it has become "one of the hottest trends in politics" and an $800 million industry. (Faucheux, 1995, p. 20). Grassroots campaigning became "the most popular political strategy in the 1990s." (Keim, 1996, p. 17) It is now a part of normal business for corporations and trade associations to employ one of the dozens of companies that specialize in these strategies, to run grassroots campaigns for them. Firms and associations utilizing such services include Philip Morris, Georgia Pacific, the Chemical Manufacturers Association, General Electric, American Forest & Paper Assoc., Chevron, Union Carbide, Procter & Gamble, American Chemical Society, American Plastics Association, Motor Vehicle Manufacturers Association, WMX Technologies, Browning Ferris Industries and the Nuclear Energy Institute. (Faucheux, 1995, pp.21, 26-30).
The public relations industry itself refers to artificially created grass roots coalitions as astroturf (after a synthetic grass product). Astroturf is a "grassroots program that involves the instant manufacturing of public support for a point of view in which either uninformed activists are recruited or means of deception are used to recruit them." (Quoted in, Stauber, & Rampton, 1995/96, p. 23). According to Consumer Reports magazine, those engaging in this sort of work can earn up to $500 "for every citizen they mobilize for a corporate clients cause." (Anon., 1994, p. 318).
Mario Cooper, senior vice president of PR firm Porter/Novelli, says that the challenge for a grassroots specialist is to create the impression that millions of people support their clients view of a particular issue so a politician cant ignore it and this means targeting potential supporters and targeting persuadable politicians. He advises: "Database management companies can provide you with incredibly detailed mailing lists segmented by almost any factor you can imagine." (Cooper, 1993/94, p. 14). Once identified potential supporters are persuaded to agree to endorse the corporate view being promoted.
Specialists in this form of organizing use opinion research data to "identify the kinds of themes most likely to arouse key constituent groups, then gear their telemarketing pitches around those themes." (Anon., 1994, p. 317). Telephone polls in particular enable rapid feedback so that the pitch can be refined: "With phones youre on the phones today, you analyze your results, you can change your script and try a new thing tomorrow. In a three-day program you can make four or five different changes, find out whats really working, what messages really motivate people, and improve your response rates." (Stauber & Rampton, 1995, p. 84). Focus groups also help with targeting messages. (Cooper, 1993/94, p. 15).
Demographic information, election results, polling results and lifestyle clusters can all be combined to identify potential supporters by giving information about peoples age, income, marital status, gender, ethnic background, the type of car they drive and the type of music they like. These techniques which were originally developed for marketing products to selected audiences, are now used to identify likely political attitudes and opinions. In this way the coalition builders dont have to waste their time on people who are unlikely to be persuaded and at the same time different arguments can be used for different types of people. (Grefe & Linsky, 1995, pp. 216-220).
When President Clinton attempted to impose price controls on pharmaceuticals, seven pharmaceutical giants hired PR firm Powell Tate to repair their public image and to counter public demands for price controls on pharmaceuticals
To counter public support for price controls on drugs, the firm drummed up "white hats"--citizens and respectable-sounding groups with no known ties to the industry--to "deliver the industry's message." Then, to create the appearance of broad-based support for the companies' agenda, Powell Tate undertook a "targeted grassroots effort to influence decisions of key lawmakers." A massive letter-writing campaign recruited probusiness citizens and eventually generated over 50,000 form letters and messages, sent to dozens of congresspersons. (Levine, 1993).
The pharmaceutical industry umbrella organization, the Pharmaceutical Research and Manufacturers of America, uses the specialized public relations services of Bonner & Associates. Bonner is thought to be one of the leading specialists in grassroots support for clients (Greider, 1993, p. 8) and boasts on its web site that it is variously the "pioneer", "guru" and "king of grassroots". (Bonner & Associates, 2001).
The central thrust of agenda setting in mental health policy-making over the last 20 years in both the United States and Australia has resulted in the triumph of biological interpretations of mental disorders together with drug-based treatment regimes over theories and policies associated with forms of "talking therapy" like psychotherapy and family therapy. This dramatic shift of policy has largely come about as the result of pharmaceutical industry-funded public relations activity which has provided policy entrepreneurs and organized advocacy coalitions to promote drug treatments for what are often claimed to be imbalances in brain chemistry.
Various pharmaceutical companies, which manufacture drugs used for treating mental disorders, are located at the top of the flow-chart. These are mostly powerful transnational corporations. Agenda setting lines flow from these individual companies to pharmaceutical industry organizations. The industry organizations are set up and funded by the pharmaceutical industry for the specific purpose of lobbying governments and setting agendas. In the United States the main industry representative body is the Pharmaceutical Research and Manufacturers of America (PhRMA). In Australia it is Australian Pharmaceutical Manufacturers Association (APMA).
Downstream from the industry organizations are public relations and advertising consultants, on the one hand, and the psychiatric profession and psychiatric researchers, on the other. The commissioning of agenda setting activity can reach these two entities directly from individual companies or through the industry organizations. Individual companies retain public relations and advertising consultants and they also fund the psychiatric professional bodies by advertising in their journals. Pharmaceutical companies also set the agenda by selectively funding psychiatric research aimed at propagating the belief that mental disorders are caused by brain defects. The propagation of brain-based theories provides the necessary foundation for claims that drugs are suitable forms of treatment. A good example of this strategy at work in Australia is the funding of the prestigious Neuroscience Institute of Schizophrenia and Allied Disorders (NISAD) by six drug companies, all of which manufacture new schizophrenia drugs: Janssen Cilag, Eli Lilly, Pfizer, Novartis, Lundbeck, AstraZeneca. (Neuroscience Institute of Schizophrenia and Allied Disorders, 2001).
Similarly the pharmaceutical industry organizations often front for sections of the pharmaceutical industry by retaining public relations consultants and sometimes by coordinating the funding of psychiatric research. An important line of agenda setting communication is via a two-way exchange between PR/advertising and the psychiatric profession/researchers. Public relations firms are often used to disguise the sources of drug company funding for psychiatric research and there is also a constant barrage of drug company advertising in psychiatric journals aimed at persuading psychiatrists to use specific drugs. The reverse flow, from psychiatry to PR, involves the utilization of psychiatric research, and psychiatric expertise, in public relations campaigning.
Figure 1: Flow of Pharmaceutical Agenda Setting
At the bottom of the flow-chart is the sphere of democratic policy-making processes. These democratic policy-making processes largely involve a two-way circular flow of opinion/information/power between three entities: the public, the media, and the government. As in the game of paper, stone, scissors, each of these entities sometimes has power over the other two, depending on the sequence in a chain of events. The public can have power over specific media outlets by exercising consumer choices. It can also have power over government by exercising electoral choices. At the same time, the media can have power over the public by controlling the type and quality of information it receives. The media can also have power over the government by manipulating public opinion and electoral choices. The government, on the other hand, can have power over the media through regulation and the selective release of information. The government can also exercise power over the public through legislation and law enforcement.
The whole key to agenda setting in this democratic policy arena is to insinuate the right idea, at the right point in the chain, and have it flow around the circle in the right direction. Mastery of this skill is what public relations is all about. Although there are agenda setting lines flowing into the sphere of policy-making from other entities, in regard to setting the agenda in mental health policy, it is the input coming from public relations consultants that is most relevant.
Public relations campaigns aimed at influencing mental health policy can target all three of the policy-making entities. A common strategy in a PR campaign is to use elements of the public as an entry point for a spin going in one direction and the media as an entry point for a spin going in the opposite direction. The purpose is to catch the government in a pincer movement and make it the focal point for complimentary imperatives spinning in opposite directions. This creates a sense of urgency in government circles and makes mental health bureaucrats and politicians vulnerable to direct and indirect approaches by pharmaceutical industry-sponsored consultants offering policy solutions
An extended campaign to set the policy making agenda in regard to schizophrenia offers a particularly good illustration of how these tactics work. All of the pharmaceutical companies involved in this agenda setting campaign have introduced new, atypical neuroleptic drugs for schizophrenia treatment onto the market over the past decade. These new drugs had been developed for two main reasons: 1) patents for the older generation of drugs were expiring and cheap generics were coming onto the market; and 2) the older generation of schizophrenia drugs had fallen into disrepute for being both ineffective and dangerous. However, in introducing the new drugs the pharmaceutical companies were confronted by two difficult public relations problems: (a) the new drugs are many times more expensive than the older drugs and, (b) according to critics, they are not any more effective or safer than the old drugs they replace. (Breggin and Cohen, 1999, pp. 76-82).
The pharmaceutical companies wanted to maximize their profits in what appeared to be a potentially critical environment and a tight market. They decided the best approach would be to find ways to expand the size of the market. Hitherto the market for schizophrenia drugs had been restricted by diagnostic conventions, on the one hand, and civil liberties protections on the other. Until recently diagnostic conventions generally limited the recognition of schizophrenia, and therefore the application of neuroleptic drug treatment, to symptoms which indicate psychosis. The agenda setters determined to expand the market by breaking this convention and promoting the concept of an additional pre-psychotic phase of schizophrenia which requires preventive treatment with their new drugs. To further expand the market they also decided to wage campaigns to weaken civil liberties protections and thereby increase the number of people who could be treated involuntarily.
The overall solution was the development of a two-fold public relations campaign that is still in progress. The first part involves harnessing support groups for relatives of people suffering from schizophrenia as the driving force for an advocacy coalition. This has been achieved by carefully focussed funding of these organizations. (Gosden, 2001, pp. 94-97). Once they were made dependent on drug company sponsorship they could then be used as public relations front-groups to assist with planting stories in the media about the efficacy and safety of the new drugs and about claims that schizophrenia has supposedly been scientifically proven to be a brain disease requiring urgent drug treatment at the earliest signs. A ready example of this practice can found at schizophrenia.com (schizophrenia.com, 2001a) which purports to be "A Not-for-Profit Information, Support and Education Center" representing consumers. However, schizophrenia.com acknowledges on its web site that it is funded by Janssen Pharmaceuticals. (Schizophrenia.com, 2001b). The slant on schizophrenia being promoted by drug company-funded organisations like schizophrenia.com is intended to impact on governments as expressions of public interest advocacy and to position the new drugs as preferred methods of treatment by government mental health services.
An aspect of the campaign involves funding selected psychiatric researchers to promote the doubtful belief that schizophrenia must be detected and treated in a pre-psychotic stage to avoid brain deterioration. (Gosden, 2001, pp. 224-247). This line of argument has the potential to vastly expand the market for schizophrenia drugs and has already led to the development in Australia of government-sponsored preventive treatment programs for schizophrenia, which utilize the new drugs.
A key element of the PR strategy involves funding from the drug company Eli Lilly being channeled through both the World Psychiatric Association (Rosen et al. 2000) and NAMI (Silverstein, 1999; Oaks, 2000, p. 14) to mount an anti-stigma campaign. The thrust of the anti-stigma campaign is to advocate for the elimination of discrimination against people diagnosed with schizophrenia, so long as they are taking medication.
Meanwhile, in what appears to be a coordinated strategy, the Treatment Advocacy Center (TAC), which was originally established as branch of NAMI, has been feeding a very different, but complimentary, line to the media and the public about the dangerousness of untreated schizophrenia. This line involves associating untreated schizophrenia with news stories about violent behavior (Torrey & Zdanowicz, 1999, p. 27A) and promoting wild hyperbole about the murderous intentions of untreated schizophrenics: "Violent episodes by individuals with untreated schizophrenia and bipolar disorder have risen dramatically, now accounting for an estimated 1,000 homicides annually in the United States" (Treatment Advocacy Center, 2001a). This approach is intended to send an agenda setting spin in the opposite direction by scaring the public and impacting on governments as a law and order imperative. The policy intention with this counter spin is to weaken civil liberties protections in mental health laws in order to increase the number of people eligible for involuntary treatment.
Involuntary treatment is an essential part of the market for schizophrenia drugs. Without involuntary treatment there would be virtually no market at all because most people diagnosed with schizophrenia initially have to be force-treated with neuroleptic drugs. A central objective of this hyper-stigmatising, law and order part of the campaign is the introduction of community treatment orders, or outpatients commitment. Outpatients commitment involves a court order which allows the forced treatment of people living in their own homes. Until the introduction of outpatients commitment people could only be force-treated if they were in-patients in hospitals. This limited the number of involuntary patients at any one time to the number of beds available. However, considering the doubtful nature of diagnostic methods used for identifying schizophrenia, outpatients commitment promises to provide an open-ended expansion of the market for the new schizophrenia drugs. Outpatients commitment is already well established in most states of Australia and is being progressively introduced, state by state, in the United States.
As an off-shoot of NAMI the Treatment Advocacy Center is dedicated to playing its complimentary role of associating schizophrenia with violence and the urgent need for forced treatment, which they euphemistically call "assisted treatment".
Assisted treatment (also known as involuntary outpatient commitment, substituted judgement, or guardianship) must be provided before individuals become a danger to themselves or others, particularly for individuals who lack awareness of their illness-a common side-effect of these devastating disorders.
Current federal and state policies hinder treatment for psychiatrically ill individuals. The Center is working on the national, state, and local levels to educate civic, legal, criminal justice, and legislative communities on the benefits of assisted treatment legislation.
The Treatment Advocacy Center serves as a catalyst to achieve proper balance in judicial, legislative and policy decisions that affect the lives of individuals with serious brain disorders, such as schizophrenia and manic-depressive illness. (Treatment Advocacy Center, 2001b).
In the middle 1990s, as a number of the new schizophrenia drugs were passing through their final stages of approval, and these public relations campaigns were gaining momentum, one analyst of the pharmaceutical market argued that the $1 billion a year US market for schizophrenia drugs could be expanded to $4.5 billion a year. Annual sales of Eli Lillys drug Zyprex alone were projected "at $1 billion after five years on the market". But the analyst argued that the market expansion depended on the removal of two barriers. The first barrier was that currently only half of the 2.5 million Americans with schizophrenic symptoms were then receiving treatment. The implication was that ways would have to be found to ensure treatment reached this other half of the schizophrenic population. The second barrier was that a cheap generic drug was then dominating the market. (Reuter Information Service, 1996).
As things have turned out this analyst under-estimated of the potential for a PR-driven expansion of the market for schizophrenia drugs. A recent Wall Street Journal report in May 2001 describes the market for schizophrenia drugs as a "fast-growing, $5 billion-a-year market" in which Eli Lillys Zyprexa has already gained a $2.35 billion share and is "on course to surpass $2.5 billion this year". (Hensley and Burton, 2001).
Cobb et al (1976) propose three models of agenda building; an outside-initiative model where citizens groups gain broad public support and get an issue onto the formal agenda; a second model where the issues are initiatives that come from government and may need to be placed on the public agenda for successful implementation; and an inside-access model where the policy proposals come from policy communities with easy access to government, usually with support from particular interest groups, but little public involvement.
It is clear that the types of campaigns that have been run by public relations consultants to set the mental health agenda for the pharmaceutical industry utilize all three of these models. They run coordinated campaigns that involve funding consumer advocacy groups to simulate outside-initiatives; they plant stories in the media that are designed to gain public acceptance of policies that are already on the government agenda; and they use the insider-access model when they utilize pharmaceutical industry lobbying organizations to gain easy access to government. This access is facilitated by the millions of dollars pharmaceuticals companies and associations donate to politicians and political parties. (See for example, Mintz, 2000, p. A26; Public Citizen, 2000).
The use of sophisticated public relations techniques for setting political agendas has become a standard practice in most advanced democracies. The consequences are slowly becoming apparent. The system of representative democracy is being reshaped into a new kind of "managed corporatocracy" in which public opinion and government policy are custom-made products that can be shaped, packaged and sold by skilled public relations experts.
The cynical way in which this shaping, packaging and selling has been carried out in regard to mental health policy-making over the last couple of decades should serve as a warning to anyone who believes that the public good should come before corporate profits. Policies tailored to this commercial purpose are not necessarily beneficial either for patients or the society at large The acute vulnerability of mental patients to exploitation, and the existence of mental health laws which provide for involuntary detention and treatment of certain classes of mentally disordered people, create conditions that require vigilant protection of civil liberties and human rights
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