Ray Moynihan is an accomplished health journalist and author who has won several awards for his work. He is also an academic at Bond University and a documentary filmmaker. Moynihan’s research and writing focus on the healthcare industry, with an emphasis on how diseases are created, branded, and marketed to unsuspecting people.
He is known for his use of sharp humor, which can be seen in his mock documentary about a fictional illness called ‘Motivational Deficiency Disorder.’ He is also a founding member of the international conference Preventing Overdiagnosis and hosts the podcast The Recommended Dose.
Today, we will be discussing something that the speaker refers to as “an assault on being human” – the labeling of everyday life struggles as disorders and how patient advocacy groups, doctors, medical journalists, and respected academics are often manipulated by a powerful, corporatized healthcare system.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ayurdhi Dhar: Can you tell us what is disease marketing or disease branding?
Ray Moynihan: People are familiar with the way drugs are marketed. An equally important aspect of marketing is the way conditions and diseases are marketed. For the pharmaceutical industry, the bigger and wider those diseases, the more people who can be diagnosed, and the bigger your markets are.
The marketing of medical conditions has become a key plank of pharmaceutical industry marketing. The relationship between the medical profession, the pharmaceutical industry, and the patient movements has resulted in a harmful convergence of interests. This has led to the expansion of medical diseases, whereby more and more aspects of ordinary life are being defined as symptoms or signs of illness.
Dhar: Tell me about your reason for getting into disease marketing and branding.
Moynihan: It happened by accident. I was appointed as a national medical science reporter at a national TV current affairs program in Australia in the 1990s. I started getting all the press releases from the vested interests within the world of medicine and realized that there was sort of subterranean marketing going on.
Drug companies weren’t just selling pills. They were selling the diseases that would define the markets for those pills. I had a conversation with one of the most sophisticated drug company marketing people in Australia. She explicitly told me that what was very, very, very important was preparing the market before a new drug was launched. This applies in the mental illness world and everywhere in medicine. Helping widen the definitions of disease is a key part of marketing those pharmaceutical products.
Dhar: Is this what inspired you to create the “documentary” for ‘Motivational Deficiency Disorder’ and the April Fool piece in BMJ along with it? What was that about?
Moynihan: That’s exactly right. Because I was witnessing so much disease mongering—the creation and manufacturing of these broad new definitions of disease—and because I was talking to critics within the medical establishment as well, I started to write for the British Medical Journal.
We launched a campaign about the problem of ‘Too Much Medicine’ 20 years ago that’s continued. There was concern among many well-informed senior doctors, researchers, and scientists around the world, and among the public as well. It struck me and my colleagues as a fun thing to create our own disease using all those very obvious marketing strategies.
I can’t remember exactly what the prevalence was, but I think it was one in three or one in five. Whenever you hear “one in three or one in five people suffer from something,” you should feel skeptical because you’re dealing with marketing, not science. I should credit Alan Cassels, who I co-wrote Selling Sickness with this too. He came up with an early version of ‘Motivational Deficiency Disorder.’ I and other colleagues created this little video. It’s called ‘The New Epidemic,’ and it is quite funny.
We talked about laziness—“all my life, people have called me lazy, but now we know I was suffering from Motivational Deficiency Disorder.” We created a drug to treat it called Strival-PH, developed screening tests, and found that, of course, there were genetic markers for ‘Motivational Deficiency Disorder.’ We discovered that the prevalence just got larger and larger.
When we redefined it, we broadened the definition so that more people could benefit from the treatment. It was a fun thing to do, and we launched it in the British Medical Journal on April 1st, 2006.
Dhar: As hilarious as this is, the terrifying part is that I have seen this happen in real life. A recent real-life example of this kind of advertising was for binge-eating disorder, and Monica Seles was the celebrity they used. Did people believe the existence of this “disease,” motivational deficiency disorder?
Moynihan: When we launched it on April the 1st, we put out a press release. A lot of journalists around the world took it seriously. We got a call from the Wall Street Journal, but my colleague didn’t play along. He immediately admitted to the Wall Street Journal that this was a joke, so they never pursued it. It’s possible that the Wall Street Journal journalist knew it was a joke.
Sadly, or perhaps fortuitously, one newspaper in New Zealand did take the thing seriously and put it on their front page, and so laziness was the sign of a medical condition called Motivational Deficiency Disorder in this big story. When they discovered that it was an April Fool’s Day joke, they were unhappy. I’m not sure they’ve ever reported on the BMJ ever again. Humor can be so powerful.
It’s important to say that when we’re talking about creating conditions, we’re not in any way trying to demean the genuine suffering of people. There are real conditions. There are real medications that offer enormous benefits for millions of people, but there is absolutely no doubt in the world that we have extended boundaries too much. We are treating people who don’t need treatment, and who won’t benefit from treatment, and we are promoting drugs that will ultimately cause more harm than good.
Dhar: This reminds me of Nick Haslam’s work on Concept Creep, how concepts in psychology have been broadening, from what constitutes bullying to abuse; it’s happening in popular discourse and then contributes to the broadening of diagnoses and then loops back into popular discourse.
Moynihan: That is fascinating—the other word that we use to describe this process is ‘diagnosis creep’— diagnoses just creeping outwards and getting broader.
Almost universally, whenever a body of experts gets together to review the definitions of a condition, as they do with high blood pressure, Type 2 Diabetes, depression, and social anxiety disorder, almost inevitably, they will widen the definitions.
I think this is a serious problem. It’s a serious assault on what it means to be human.
Dhar: ‘In Selling Sickness,’ you write that pharmaceutical companies influence people’s minds through fear. You give multiple strategies and examples, such as depression, ADHD, and female sexual dysfunction. One of these strategies is directly influencing doctors. How are diseases, not drugs, marketed to doctors?
Moynihan: It is this multi-layered marketing strategy that wraps medical and healthcare professionals in a world of marketing, from the cradle to the grave. Medical students are exposed to pharmaceutical marketing when they attend drug company-sponsored meetings, conferences, and parties. Then, the doctors graduate, and much of the continuing medical education they receive is sponsored by pharmaceutical interests.
Scientific conferences that doctors go to and journals that they read are predominantly funded by pharmaceutical companies. Some doctors are still seeing drug reps. In the age of the internet and social media, there are other numbers of ways.
It’s about framing human misery as the signs of mental illness, framing aging as a condition of disease.
I’ve stopped going to those scientific conferences because of the smell—metaphorically—that stench of corruption. The first few times I went to scientific conferences sponsored by drug companies where the audience was doctors, I could not believe what I saw. These professionals were acting like children. They were lining up to receive tiny shiny toys from drug company stands! The crassness, the crudity of some of these marketing strategies is phenomenal. This is where the prescribing doctor, the psychiatrists, get their information!
There was a psychiatric conference that absolutely astounded and horrified me. The sponsors were all the big global drug companies, Pfizer, Merck, Roche, etc. The guy speaking had organized the conference. When he gave a short talk about contemporary treatments for depression, he did the most extraordinary product placement I have ever seen. Every one of those sponsors got a moment where their latest antidepressant was given the limelight. This was dressed up as a scientific talk from a leading psychiatrist in Australia, and it was the most shocking, crude marketing I had ever seen.
Dhar: I have wondered the same—how can the clinicians not see it? They see all these pharma banners at a conference, the expensive lunches laid next to pharma talks. Eric Turner, who worked for the FDA, talked about that—why are we not skeptical?
Moynihan: A lot of clinicians believe that they are immune from that influence, but the evidence suggests otherwise. We have found that the impacts of pharmaceutical marketing are effective.
We know that doctors who attend sponsored meetings, subsequently prescribe more of those products. The problem here is not that people are prescribing drugs but that those drugs are being overprescribed. They carry a range of side effects, and for some people, those side effects outweigh the benefits.
A rational medical system would organize the education of their doctors differently. We are seeing that. There are many doctors and doctors’ groups that have acknowledged this as a problem and are moving away to seek independent information and forms of evidence.
The Norwegian Medical Association said that to receive ongoing professional medical education points, you can’t go to an industry-sponsored gathering. You will get them if you go to independent medical education.
Dhar: While writing about influencing doctors directly, you gave the example of depression, not selling antidepressants but selling this idea of depression as a simple chemical imbalance. You wrote that the serotonin hypothesis is debated, outdated, and simplistic. Tell us more.
Moynihan: In Selling Sickness, we wrote about a drug rep who spent his life just taking doughnuts to doctors. Part of what the drug reps are selling is that over-simplistic chemical imbalance narrative. I’m a journalist and researcher. I’m not a neurobiologist, so to really drill into that issue, you should talk to them. But that narrow explanation of depression is overly simplistic; it is outdated.
I’m sure for some people, those neurotransmitters have a role, of course. But everyone knows that there are so many factors that produce the distress we describe as these medical conditions. It is crucial for drug companies to shape the narrative about drug effectiveness by sponsoring medical education and scientific conferences featuring key opinion leaders funded by the companies.
Many prescribing doctors learn about the chemical imbalance theory from senior respected specialists who often are on the payroll of the company.
Dhar: In the U.S., before going to the doctor, I check the government database for how much pharma money they are receiving.
Moynihan: It’s called the OpenPayments website. It’s run by the federal government in the U.S. It’s well-funded, and it’s beautifully put together. It’s the result of the Sunshine Act—all the drug companies and device makers have to reveal exactly how much they paid to every single medical professional and their name.
In 2022, drug and device makers paid 20 billion Australian dollars to U.S. healthcare professionals! A lot was for industry-funded research. There are huge questions about industry-funded research. Part of those payments is to pay these key opinion leaders, these senior specialists, who then educate their peers and their colleagues. Some of that money is just close to bribery.
Dhar: Evidence suggests that industry-funded research tends to produce results that are pro-industry. You said that as a journalist, you don’t have the expertise to speak about neurobiology. But as a journalist, you do see patterns, and one interesting pattern for psychiatric disorders in your book was the prevalence rate changes going higher.
The other pattern across disorders was that any debate and controversy in the field is smoothed out by key opinion leaders, like the debates about the serotonin hypothesis of depression.
Moynihan: The more you learn about science, the more uncertain it becomes. If someone paints a picture of absolute certainty around healthcare decisions or treatment options, that is a red flag because medical science is incredibly uncertain.
We investigated social anxiety disorder. We were able to track almost in real time the launch and marketing of that relatively new condition. The PR companies that worked with the drug companies won awards for their work in helping to reposition that condition, reframing shyness as a symptom of a serious psychiatric condition that required drug treatment, an extraordinary coup for those companies.
Now, spilling forward 20 years, social anxiety disorder is an uncontroversial part of the medical establishment. But when you drill into the history, prevalence rates tend to get larger rather than smaller. There is this blurring of boundaries between ordinary life and medical conditions.
Dhar: Tell me about what is the most egregious or ridiculous passing of a drug by a regulatory body.
Moynihan: There are so many. It’s sad to watch those regulatory bodies become so captured by the very industries they are supposed to be regulating.
I think one of the most egregious examples was a drug called Flibanserin. It was a failed antidepressant that the pharmaceutical industry thought they could use as a drug to treat female sexual dysfunction, something called hypoactive sexual desire disorder. Both of these are incredibly controversial concepts anyway. The attempts to market female sexual dysfunction and desire disorders are one of the most egregious.
Dhar: You wrote a book about it.
Moynihan: It was called Sex, Lies & Pharmaceuticals. To say that one in two women suffer from female sexual dysfunction, it’s the grossest insult, but that is what many medical scientists did in alliance with drug companies. This attempt to medicalize what is obviously widespread sexual dissatisfaction driven by multiple factors that feminists have talked about, to use that distress and dissatisfaction, and turn it into a condition to sell drugs—it was again the most egregious example.
Getting back to the drug, Flibanserin, it kept getting rejected by the FDA because it didn’t work; it caused serious harm. Then, a very smart group of pharmaceutical marketers bought the right to this failed drug. They ran the most extraordinary campaign called Even the Score.
They created a fake grassroots campaign that looked like a feminist campaign to even the score—the FDA had approved sexual dysfunction drugs for men but none for women, so this was not fair. The trouble was the drug didn’t work and had adverse effects. This campaign was successful, they recruited senior feminist organizations, but it was hugely controversial. Other feminist groups were outraged by this. It came before an advisory committee that passed it.
That drug is so awful that even the best marketers were unable to create large sales. That is a credit to the women of the U.S. who were able to see through the marketing of both the condition and the drug.
Dhar: It was marketed as female Viagra, but unlike Viagra, you have to take it every day, and you can’t drink, among other restrictions. When they were trying to study the effects of the drug with alcohol, they tested it on only men!
This brings us to patient advocacy groups, which look so good on paper. They are ground-level movements, but often these groups that inform patients and say they advocate for patients, are funded massively by drug and device manufacturing companies. They tend to provide information that puts these companies in a positive light.
Can you tell us more, especially using the case of ADHD which you wrote about in the book?
Moynihan: This is a huge problem. Drug company marketing has broadened from just targeting doctors to also targeting patient groups. A study looked at patient advocacy groups in a certain country and found that 60% of them received some form of pharmaceutical company funding.
With ADHD, there was a big patient group called CHADD. It was central to the early marketing of ADD as a widespread condition. There is enough evidence that ADHD and ADD are being diagnosed in people with very mild problems. There’s strong evidence from large observational studies that if you are the youngest child in a classroom, you are more likely to be diagnosed. That is a classic red flag for over-diagnosis.
The patient groups form alliances with the drug companies and relevant doctor groups to form these powerful coalitions of interest that say that the prevalence of this condition is as big as possible.
The consumer groups, the advocacy groups that don’t take industry money, have a more evidence-informed and reliable approach. In the U.S., you have a non-industry-funded mega-consumer group called Consumer Reports. They don’t take a cent of drug company money. You can also look at the Cochrane Reviews of the evidence about drugs. I wouldn’t look at industry-funded patient group websites because the chances are I’m going to be misled.
Dhar: Coming to journalism, what is your most memorable interview?
Moynihan: When I met that marketing expert 20 years ago and she told me that it’s not just about marketing drugs; it’s about preparing the field, developing awareness of the condition.
The other interview was at the beginning of my career. I sat with a young doctor who had just diagnosed a four-year-old with ADHD and had prescribed amphetamines. We were making a TV documentary at the time about ADHD. That doctor said, “Well yeah, I did diagnose, I did prescribe, but that kid’s not the best example of someone with ADHD; it’s probably quite borderline. I’m not even sure that he really needed the diagnosis or the drug.”
He told me, but not the parent or the child, that. The obscenity of that situation where that child’s narrative was changed forever, possibly unnecessarily, stays with me.
But I’ve also been so encouraged by how much interest there is in this problem within the medical establishment. I helped set up an organization called Preventing Overdiagnosis, which is a global collaboration of scientists, researchers, clinicians, and consumers.
Dhar: We’ve talked about the crimes of medicine, psychiatry in particular. What are the crimes of journalism here? You write that patient advocacy groups would supply the perfect patient for media interviews. What is the responsibility of media and journalism in this whole story?
Moynihan: Does the media have a responsibility here? Absolutely. I’ve worked with colleagues in the media to increase awareness to report better. My first study in NEJM was how media buys drug companies to exaggerate benefits and downplay harm.
There is an enormous receptivity among journalists. But sadly, there are still high-profile journalists directly accepting money from pharma companies in the same way that many senior doctors do. It’s a huge conflict of interest. Too many awards for medical journalism are funded by pharmaceutical companies.
But things are changing. People are developing a healthy skepticism. Until we have corporations in the medical space, we are going to need strong, well-informed civil society and regulatory structures to try and keep the marketing campaigns in check.
MIA Reports are supported, in part, by a grant from The Thomas Jobe Fund.