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Logo of bmjThis ArticleThe BMJ
BMJ. 2003 May 31; 326(7400): 1205–1207.
PMCID: PMC1126058

Unhealthy spin

Bob Burton, freelance journalist1 and Andy Rowell, freelance journalist2

Short abstract

Public relations companies are experts at “third party technique”—helping the drug industry separate the message from what could be seen as a self interested messenger. But most journalists have a sketchy idea about how the public relations industry works, and thereby are vulnerable to uncritically accepting the disguised messages of the drug industry

Few doctors have heard of the world's leading medical public relations companies—Edelman, Ruder Finn, Noonan/Russo Presence, the Shire Health Group, and Medical Action Communications, among others. Yet barely a day passes without most doctors or their patients being exposed to messages that have been carefully crafted by these public relations companies, aimed at boosting sales of their clients' drugs.drugs.

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According to the public relations industry's trade press, the top five companies in “healthcare PR” raked in over $300m (£186m, ##260m) last year for everything from planning pre-launch media coverage of new drugs and cultivating doctors to publishing medical journals and wooing patients' groups.

Business tactics

At the heart of most public relations strategies is what is referred to as the “third party technique.” Edelman's associate director health in London, Paul Keirnan, explained the technique as separating the message from what could be seen as a self interested messenger. A pharmaceutical company defending a controversial product, he said, “would have much less credibility than if an opinion leader or a prescriber said it. It is not putting words in the mouths of opinion leaders. It is basically using a third party to put forward what are the facts without it being seen to be spun if you like by the pharmaceutical company.”

Summary points

In the “third party technique,” instead of using a company representative from the drug company (who would have low credibility) as spokesperson, an apparently independent messenger with a higher credibility rating in the eyes of the target audience is used

A lack of proactive disclosure by third party messengers is often reinforced by the failure of doctors, patients, and journalists to demand that potential conflicts of interests be revealed

“Healthcare” public relations has traditionally focused on influencing prescribing decisions, but now attention is increasingly directed to potential patients

Patient groups are increasingly being sponsored by drug companies, and this is fuelling debate about standards of disclosure by non-profit groups

Expert reporting on the public relations industry is lacking, allowing tactics aimed at shaping important decisions on health care to flourish

The director of the Australian public interest health group Healthy Scepticism, general practitioner Peter Mansfield, argues that as a result most medical public relations is advertising dressed up to look as though it is from an independent source “so that it comes in under the radar of critical appraisal.”

In the world of healthcare public relations, a critical element of the “medical education” plan is the recruitment and training of “key opinion leaders” to speak on behalf of the sponsoring pharmaceutical company. Their role at conferences, for example, can span everything from presenting papers to fielding questions in open conference sessions.

The director of the Surrey based medical communications company Ethical Strategies Limited, Peter Hansen, agrees that relationships between drug companies and doctors and patients' groups should be disclosed in all communications. However, Hansen's support for disclosure comes with what he describes as a big caveat: “In the public eye there is a misperception that for some reason medicine is somewhat different to other businesses, and the fact is, it is not,” he said. Physicians and patients' groups need funding, and “at the end of the day the pharmaceutical industry is the most significant sponsor of it [medical communication]. The general public needs to realise that medicine is a business.”

Medical publications

Although the most prevalent influence on doctors' prescribing patterns is visits by drug companies' sales representatives, medical publications have a crucial role in buttressing their sales spiel. “Even when a study does not support a particular key message the introduction and discussion sections still provide an excellent platform for message delivery,” Harry Cook from ICC Europe candidly wrote in one trade publication.1 “Reprints [of journal articles] can be a very powerful selling tool, as they are perceived as being independent and authoritative,” he noted.

In another guide to medical publishing the authors highlighted that a number of titles can be exploited: “There is a spectrum of titles out there. These range from the high readership/high budget titles who are less willing to prostitute their editorial standards, to the low readership/low budget titles which have lower editorial standards and do not have either the time or the staff to edit puff pieces.”2

A less well publicised role of some public relations companies is to hire freelance journalists to cover events such as major conferences with news stories to be placed in medical publications. Upbeat reports of preliminary results of research can raise unrealistic expectations of doctors and patients of medical “breakthroughs” that never eventuate.

Hansen agrees that the use of freelance journalists in this way is common. “I think it does happen quite a bit... if an article is going to be written and placed in a journal I think it would be appropriate to actually state that this journalist was supported by so and so company,” he said.

Consumers and patients

Increasingly, public relations companies are turning their attention to direct to consumer (DTC) marketing and patients' groups. “Consumers of prescription medicines in the past have usually taken the doctor's advice as being gospel, but there are far more information sources for consumers now than ever before,” Keirnan said. “Pharmaceutical companies can't simply rely on the tried and trusted methods of advertising: sales force and direct mail.”

On its website the medical communications company Mednet Media argues that by concentrating largely on physicians in chronic illness areas pharmaceutical companies are missing out on the “empowered” patient who is influencing brand prescribing. Although doctors and consumer groups back bans on DTC advertising, pharmaceutical companies are being urged to use the internet to influence potential patients without breaching the advertising restrictions. “E-DTC,” Mednet Media calls it.

Equally importantly for the drug companies is the development of relationships—including funding— with patients' groups. These offer the prospect of being able to mobilise grassroots lobbying muscle to influence policy makers.

The funding of advocacy organisations by pharmaceutical companies is prompting a reaction from non-profit groups that reject corporate patronage. The executive director of the San Francisco based Breast Cancer Action, Barbara Brenner, believes that disclosure of funding ties should apply to non-profit groups too. “People from advocacy organisations rarely, if ever, disclose their funding sources, not in an active way,” she said.

Crisis management

A critical role for public relations companies is also keeping their clients out of the news with well honed defensive crisis management strategies. Many general practitioners first hear about adverse effects of a drug in the mainstream media.

When a public relations crisis emerges, companies seek to turn third party “partners” into corporate shields. A key task in a crisis is to “deploy third parties to advance your cause,” explained Maxine Taylor, the director of corporate affairs at Lilly UK. Third parties should be called on, she said, “to share the spotlight if possible, or indeed to divert the spotlight of media attention from you.”3

Edelman's Keirnan agrees. “If it is the pharmaceutical industry that responds to the journalist or the media, it has very little credibility because everyone would say, `Well the industry would say that, wouldn't they',” he said.

For general practitioners such as Peter Mansfield, the drug industry's sophisticated public relations campaigns create a crisis of confidence: “Either you are not aware that this is going on—in which case you trust everything and then people are harmed by prescribing medicine that has damaging side effects. Or, if we are aware of it then we don't know who we can trust. This can lead to us being too sceptical so we don't prescribe good new drugs as soon as we should. Either way its a no win situation for patients and GPs,” he said.

Balancing act

If the invisible ties between pharmaceutical companies and their public relations companies are what underpins the power of the “third party technique,” what can be done to allow doctors and citizens to make informed decisions? How can the imbalance between the growing marketing and public relations budgets of the pharmaceutical industry and disparate doctors, consumers, citizens, and journalists be made more equal?

Much of the success of the “third party technique” relies on the lack of a requirement for medical opinion leaders, non-profit groups, or journalists with financial ties to drug companies to proactively disclose them. Most journalists have, at best, a sketchy idea about how the public relations industry works, and by failing to ask the people they interview to disclose funding sources or potential conflicts of interest they reinforce the effectiveness of the third party technique.

Worse still is the invisibility of the public relations industry in mainstream media reporting. Outside of the public relations industry's trade press, we know of no mainstream journalist in the English speaking world who is dedicated to covering the public relations industry.

Nor do the self regulatory codes of ethics of the public relations industry offer much hope. At best they require passive disclosure of who their clients are: they must be asked before they need to disclose the information. Even then, there are few grounds for optimism. The most recent iteration of the code of ethics of the Public Relations Society of America—the country where half the global drug sales are made—has abandoned any enforcement role for the professions' peak body.

In a media age of fewer journalists and shrinking budgets, a reliance on good journalism alone as an antidote to spin doctoring would be misplaced. Heightened awareness of the strategies of the public relations industry is essential but is, at best, one strand in a multilayered defence against spin.

Peter Mansfield argues that the Achilles' heel of the medical public relations sector is the money trail paved by taxpayers and insurance companies: “We give them rewards for increasing the sales of more expensive new drugs regardless of the impact on health care. So we shouldn't be surprised if they do whatever works to fulfil the objectives that we are currently paying them for.”


Competing interests: None declared.


1. Cook H. Practical guide to medical education. Pharmaceutical Marketing 2001;6: 15.
2. Grey A, ed. Practical guide to medical publishing. Pharmaceutical Marketing 2000. Nov:4.
3. Taylor, M. A look at what to do in a crisis apart from panic. Pharmaceutical Marketing 2002. (accessed 29 Apr 2003).

Articles from The BMJ are provided here courtesy of BMJ Publishing Group