Out of Ammo: The End of “Silver Bullet” Medicine

 Carol Cofone

Carol Cofone / Strategy

From The Checklist Manifesto by Atul Gawande, MacArthur Fellow, a general surgeon at the Brigham and Women’s Hospital in Boston, and assistant professor at Harvard Medical School and the Harvard School of Public Health:

…we have been fooled about what we can expect from medicine—fooled, one could say, by penicillin. Alexander Fleming’s 1928 discovery held out a beguiling vision of health care and how it would treat illness or injury in the future: a simple pill or injection would be capable of curing not just one condition but perhaps many. Penicillin, after all, seemed to be effective against an astonishing variety of previously untreatable infectious diseases. So why not a similar cure-all for the different kinds of cancer? And why not something equally simple to melt away skin burns or to reverse cardiovascular disease and strokes?

Medicine didn’t turn out this way, though. After a century of incredible discovery, most diseases have proved to be far more particular and difficult to treat. This is true even for the infections doctors once treated with penicillin: not all bacterial strains were susceptible and those that were soon developed resistance. Infections today require highly individualized treatment, sometimes with multiple therapies, based on a given strain’s pattern of anti biotic susceptibility, the condition of the patient, and which organ systems are affected. The model of medicine in the modern age … has become the art of managing extreme complexity— and a test of whether such complexity can, in fact, be humanly mastered.

When Eli Lilly launched Evista (raloxifene) in the 1990s, they foresaw the end of the era of “silver bullet” medicine. They saw the incredible complexity of bone remodeling, the pan systemic impact of postmenopausal hormonal changes and the patterns of morbidity and mortality associated with hip fracture as the context for a management process. Lilly’s investigators, medical directors, and marketers understood that the way this process unfolded for an individual patient would be critical to her postmenopausal health and that it could make the difference to her quality of life, and even to the length of her life.

Today, the complexity of osteoporosis is widely perceived and presents significant management challenges to clinicians. In a recent interview with an obstetrician/gynecologist on the subject of osteopenia, he wondered about the meaning of a BMD value. “How am I to know if this number truly represents a pathology? What if that is a normal value for an individual, and otherwise healthy, woman? If this is not an indicator of a disease state, why should I consider treating it?”

Clearly, osteoporosis today (like the other complex endocrine condition of diabetes) has come to be seen as a shape-shifting adversary. With a natural history that plays out differently for different patients, physicians are less likely to accept a traditional disease model for its management. Additionally, as the practice of medicine heads into the accountable care future, with utilization providing the context for pay for performance models of reimbursement, there will be even less willingness to accept disease models in chronic conditions with no clear-cut therapeutic definition of “cure.”

Therefore, even though Lilly undertook advanced strategic work to define diagnostic differences in the disease state to illuminate unique therapeutic contexts for Evista as well as Forteo, a need exists today to more fully address the health status of postmenopausal women, and the potential of its portfolio.

This makes it an especially opportune time for Evista to reinforce its equities and assert its brand leadership. With the power of its clinical credibility and deep understanding of the processes of bone remodeling, pan systemic postmenopausal hormonal change, and hip fracture—it can redefine the concept of health itself. It can reshape its proposition, as neither treatment nor prevention, but rather as a process of personal health maintenance, which is the right and responsibility of each individual woman, working with the support of her physician.

Big Arrow Group, a full service brand consultancy, sees the potential in this proposition clearly. Our long history of experience in endocrine medicine, including brand and communication strategy, and global creative development and execution for Lilly’s Evista, Humalog and insulin delivery devices, and our current experience in insulin pumps gives us a deep and vital understanding of the category as it has come to be. That combined with ongoing work with Genzyme’s portfolio of rare disease therapies and with Aetna’s ActiveHealth Management gives us insight into where it can lead.

As responsibility shifts more and more to patients, and as our understanding of healthcare evolves in the face of ever-increasing complexity, there will be a need to empower patients to pursue their rights and live up to their responsibilities within the process of personal health maintenance. This, however, will require communications with ever greater specificity and ever greater efficiency.

Big Arrow has already laid the foundation for this increasingly segmented communication. Through our work for clients in rare disease categories, we have come to see that in the future, across categories, all patients will have something in common with those who suffer from rare diseases. They will all be embarking on individually unique journeys, each with its own particular series of turns and its own specific destination.

We have already created the communication tools and processes that can help patients, and the pharmaceutical marketers who wish to reach them, negotiate the exceedingly complex clinical landscape. We have re-imagined the patient journey, activating it as the organizing principle for the development and deployment of a digitized storehouse of information.

Because these tools are responsive to the needs of each, single, unique patient, they are responsive to the needs of all patients. By extension they are responsive to the needs of important pharmaceutical brands that wish to leverage their full leadership potential in the “post silver bullet” healthcare marketplace.


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