Irritability and (de)hydration

I GOT THE ABOVE IMAGE FROM HERE.

When you visit India, for social or business purpose, people talk of a 'quaint Indian custom' - people offer the visitor at home or business premise - first, a glass of water.  This is the first act by the host.  All business negotiations or social discussions begin subsequently.  Along with water, in some homes they offer jaggery or sugar to the visitor.  Many wonder why it is so.  In fact, in the traditional business zones like Gujarat, the hosts' stick to this tradition very firmly. Ever wondered why?

India is a tropical country.  One gets thirsty very fast.  Even if the thirst sensation has not yet occured in the individual (it is a physiological fact that a person gets thirsty only when mildly dehydrated) a person should drink water frequently before he gets thirsty - this helps in homeostasis (maintenance of balance in the body).  A person who is sufficiently hydrated is calm, mentally receptive, and of course healthy.

Imagine negotiating with a person who is dehydrated

An individual who is dehydrated, is basically IRRITABLE.  It is unusual to note that although medical science has recognized irritability as an important symptom of many ailments and diseases like anxiety, depression, diabetes, Parkinsonism etc (CLICK HERE), irritability, a very important and overt symptom of dehydration, is rarely mentioned as so in medical literature.  In fact, dehydration is also an underdiagnozed condition although it can cause many health problems like: chronic constipation, headache, visual disturbance, low back pain, chronic joint pain, renal problems, dry or sticky mouth,hypotension (low blood pressure), increased heart rate - respiratory rate - and pulse rate, fatigue, loss of appetite, indigestion, hyperacidity, heartburn, loss of facial and skin glow ....  Severe dehydration causes seizures, unconsciousness, and even death. 

Now that the summer months have just started, more and more people are susceptible to dehydration, due to heat stress.  The mistake that people do is that they wait for the THIRST SENSATION before hydrating themselves.  This is particularly true of children and the elderly. This can be dangerous, because thirst means mild dehydration has already set in.  A unique thing about the thirst sensation is that after a certain point of dehydration, the thirst sensation becomes dull.  This aggravates dehydration as the person does not feel thirsty.

In particular, the elderly and children are more susceptible to dehydration.  The elderly often suffer from weak sensations and loss of appetite, hence they consume less fluids.  Children have relatively more body water content than adults; hence, they are more susceptible to hypohydration or dehydration.   Many people, when thirsty, drink caffeinated beverages (coffee or tea or cola drinks) or alcoholic drinks, however, caffeine and alcohol are dehydrating rather than being hydrating!  In fact, it would be prudent to consume electrolyte energy drinks as an alternative to water rather than consuming alcoholic or caffeinated beverages.

SO THE MORAL OF THE STORY IS THAT ENSURE EVERY ONE (INCLUDING YOURSELF) IS WELL HYDRATED WHEN CONDUCTING BUSINESS OR SOCIAL TRANSACTIONS.  This will help improve the results of the transaction.  So before yelling at the kids or peers or subordinates - check! Are you hydrated and are the other people hydrated?!  Don't offer coffee or tea or cola drinks at first, offer water or electrolyte energy drinks to ensure hydration (remember children voluntarily drink more of flavored waters). 

Irritability and win-lose relationships

Each person while transacting (socially or in businesses) wants to ultimately establish win-win relationships.  Irritability is the enemy of win-win relationships.  TO ESTABLISH WIN-WIN RELATIONSHIPS (in business & social calls), THERE IS NO ROOM FOR IRRITABILITY - and this can be done by ensuring hydration!  That is why traditional business people of India, offer water first to visitors before business talk.  Before social discussions, Indian hosts offer water to guests and then begin the social talk.  It makes sense doesn't it?!

Dehydration, doctors, and medications

Many medications cause dehydration.  These include stimulants like amphetamines.  Many drugs cause loss of appetite and consequently thirst sensation is diminished, which aggravates dehydration & hence irritability.  

GAD (generalized anxiety disorder) which means excessive worrying, is a common diagnosis in general and psychiatric practice.  Irritability is one dimension of GAD.  While treating GAD, one should consider dehydration too since it aggravates irritability.

Dehydration and irritability: two big markets

Pharma and healthcare marketers have a robust opportunity in helping hydrate healthcare consumers and patients.  This requires a lot of 'education', in the first place, since mild dehydration is not seen by doctors as a serious symptom that needs to be treated,  only serious dehydration associated with vomiting, loss of blood or diarrhea, loss of fluids due to heat stress are taken seriously by-and-large by doctors.   However, mild dehydration too needs to be taken seriously (particularly in children, the elderly, and in patients on drugs that can aggravate dehydration).

The main products for hydration are water (Rs. 1800 crores is the packaged drinking water market in India), fruit juice based products, (the branded fruit juice market is reckoned to be Rs. 1200 crores) , and other hydrating fluids (including electrolyte energy drinks - non fruit juice and fruit juice based).  The prescription based hydrating market is around Rs. 125 crores per annum.  There is significant potential to grow the market for oral hydrating fluids through the OTX route (over-the-counter + prescription).

So this summer, offer hydrating fluids to yourself and your acquaintances.  The quaint Indian custom of offering water is very meaningful - ISN'T IT?!

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The Diabetes Syndrome

I got the above image of Romeo and Juliet from here.

In this famous Shakespearean play Juliet says:

What's it in a name? that which we call a rose
By any other name would smell as sweet;

BUT ALAS, LIFE IS NOT AS SIMPLE AS JULIET THE ROMANTIC LOVER OF ROMEO THINKS. Names are everything. Relationships are forged on names and surnames, employers provide employment based on names and surnames ... many things happen because of the name. Names have a lot of power and relevance in transactions - particularly in business. For example, there are many shoppers who buy any footwear that is branded as Bata - Bata by choice! People are convinced that a Bata product is a quality product and value-for-money buy. Similarly, many patients refuse to buy alternative pharma brands even though they are cheaper (with the same generic). There are patients who want to purchase brands prescribed by the doctor - they dislike substitutions made by the chemist (or pharmacist). In diagnosis, names have a lot of value - for example between diabetes insipidus and diabetes mellitus there is a difference in clinical presentation. Names carry a lot of value, trust, and import.

Do names change?

Oh! Yes!! In social, spiritual, and business life names change, and ownership of names also change hands. After marriage, most women change surnames with pride to show their new identity to society. It is a recognition that she has won a great new life partner. In spiritual life, name change is often resorted to, showing allegiance to a new faith. In business, names are protected with fervor. Brand names are built with passion and protected zealously. The TATA group has an entire department devoted to prevention of misuse of the TATA brand name. Thums Up is the leader cola brand of India. Although it was an Indian brand it has now changed hands - it is owned by The Coca Cola Company today. Names are so powerful that when they are deeply entrenched into the mass consciousness it is difficult to kill them - for example, even though Coca Cola is trying its best to kill or phase out the brand Thums Up, it still rules the cola market in India. The power of the THUMS UP brand name is such that as per this report, even though Thums Up sells in just 30% of the Indian market, it is the largest selling cola of India. As per the report, which cites A C Nielsen figures, Thums Up has 16.4% share of the cola market in India and is the largest selling cola brand of India. So the moral is that names have a lot of value in marketing - and in fact brand name potency is a source of sustainable competitive edge.

In disease management and medical sciences, name changes do take place


The most recent and popular example of name change is the change of IGT (Impaired Glucose Tolerance) to Prediabetes. IGT is a prediabetic state. 4.1 crore Americans are said to suffer from prediabetes. If the fasting blood glucose level is between 100 mg/100 ml of plasma to 125 mg/100 ml of plasma, the condition is defined as prediabetes. Patients of prediabetes are more susceptible to heart, blood vessel, and kidney disease. These patients are just a step away from becoming diabetic.

Why the name change from IGT TO PREDIABETES?

The name IGT was changed to prediabetes for the following reasons:

a) easy to pronounce
b) MORE IMPORTANTLY the new name BRINGS OUT THE RELATIONSHIP WITH DIABETES

In one way prediabetes is the first stage of diabetes. It is possible that the definition of diabetes may be changed to include prediabetes also in the future.

What is diabetes?

All contemporary medical literatures recognize the fact that diabetes (ie., diabetes mellitus) is a SYNDROME OF METABOLIC DISORDERS characterized by hyperglycemia, and defects in insulin production and/or impaired tolerance to insulin effect (ie., peripheral tissues show 'insulin resistance'.). Diabetes implies a group of metabolic diseases.

Diabetes is a disease characterized by hyperglycemia and increased susceptibility to accelerated atherosclerosis (thickening, hardening and loss of elasticity of blood vessel walls & narrowing of blood vessel), cardiomyopathy (disease of the heart), chronic kidney disease, neuropathy (disease of the nerves), angiopathy or vasculopathy (disease of blood vessels), and retinopathy (disease of the retina in the eye). In fact, this link states clearly that diabetes is a syndrome of disordered metabolism.

A syndrome is a set of signs and symptoms that tend to occur together and reflect the presence of a particular disease.

There is a term called METABOLIC SYNDROME. It does not mean diabetes. Metabolic syndrome or Syndrome X is a disorder characterized by high blood pressure, high LDL and cholesterol levels, abdominal obesity, and IGT (or prediabetes). There is increased risk of diabetes and cardiovascular disease in patients suffering from metabolic syndrome.

The bottomline is that diabetes is a syndrome

It is evident that diabetes is a syndrome where the patient has high blood sugar levels, increased thirst, hunger, urination, weight loss, lethargy, irritability, and mental confusion.

WHAT WOULD HAPPEN IF WE CALL DIABETES MELLITUS AS DIABETES SYNDROME?

Firstly, patients, healthcare providers and PHARMA MARKETERS will emphasize that diabetes is not just about lowering blood sugar - it is much more.

It means patients will talk about lowering blood lipids, lifestyle changes to avoid accelerated atherosclerosis, taking care of feet (foot problems are common in diabetics), avoiding and treating skin infections quickly, focusing on ensuring good wound healing, taking precautions to avoid worsening of infections (like respiratory infections) since immunity is weaker in diabetics, ensuring lifestyle practices that promote health of kidneys, taking medications that provide micronutrients to nerves (like methylcobalamin), testing the eyes regularly ....

Healthcare providers including doctors will treat the signs, symptoms, and susceptibilities of a diabetic patient FROM HEAD TO TOE. Normally, when diabetics are treated, the general focus is on normal blood sugar levels - but that is only one part of the treatment game.

FOR PHARMA AND HEALTHCARE MARKETERS this is a radical change in outlook as far as marketing communication and sales activities are concerned. Also it is about offering a bouquet of medications to prescribers which take care of the HEAD TO TOE signs, symptoms, and special susceptibilities of diabetic patients. The approach to sales and marketing management of diabetes will change if the focus of the marketers is on THE DIABETIC SYNDROME. (all signs, symptoms, and special susceptibilities of diabetics from HEAD TO TOE.).

By this name changing exercise, society will stand to benefit. The stakeholders like doctors, healthcare providers, pharmacists, patients, and healthcare/pharmaceutical marketers will of course gain because of the buzz. Hence, the powers-to-be and global healthcare authorities should now focus on a NAME CHANGING EXERCISE, from diabetes to THE DIABETES SYNDROME just as IGT was changed to prediabetes (to signify the importance of the diagnosis). In fact, if a new definition of THE DIABETES SYNDROME is made, prediabetes can also be included under this umbrella term. This will help the cause of global diabetes syndrome management.

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THE KSA FACTOR

I GOT THE ABOVE IMAGE FROM HERE.

The basic purpose of business organizations is SALES AND PROFITS. When these two are not there, the identity and verily the existence of the business organization ceases. It is very evident in these times of recession! The above two are the basics of any business organization.

Needs, wants, desires, GREED, and FEAR drive the consumption of goods and services. It is human nature to continuously upgrade (his/her) requirements. A family that purchases a two bedroom flat, after a short time of satiety, starts dreaming of upgrading to a three bedroom one... and so on. When a marketer fills the information search void of a such a prospect who is seeking answers for his requirements, the marketer gets a 'sales kill'.

The above reflections are true of healthcare and pharmaceutical business too.

Where there are buyers and sellers there are people

Business is about transactions between buyers and sellers, generating profits and customer delight. People make up an organization. And where there are people, there is 'PEOPLE MANAGEMENT'. The key dimensions of people are their KNOWLEDGE, SKILLS, AND ATTITUDE. Training implies processes and activities that enhance knowledge, skills, and attitude of people to improve job efficiency & effectiveness, and business results.

For eg., when a company plans to launch a biosimilar product, there should be knowledge of this concept among the field personnel. The skill to talk about the biosimilar brand is an important trait, and the attitude is also very vital.

Let us say, there is an excellent MR, with a good grounding of knowledge, and above average detailing and negotiating skills; however, if this guy just does not move about in the target market - the issue obviously here is about attitude. All the three aspects are important for business results.

So the question here is HOW TO DEVELOP THE KSA OF A FIELD PERSON?

Here obviously, KSA refers to Knowledge, Skills, and Attitude.

Dribbling the ball

How did Pele become a living legend footballer? The answer is practice - dribbling the ball in practice sessions, simulation training, and strategic activities. The learner is at the centre of the training universe in sports. The trainees do not sit and listen to long lectures or captivating presentations, they are, for most of the time, practicing with the ball. Such practice sessions are arduous, however, they are effective in producing Peles or sales champions.

In pharmaceutical training it is more often than not trainer centred sessions. The trainer puts in a lot of effort to provide captivating presentations, in a bid to motivate the trainees AND BUILD CONFIDENCE. The trainer gives exhaustive lectures on the complexities of the product too. While these are valuable inputs, putting the emphasis on dribbling the ball too is important. It is only when the person practices with concentration that real training gets done.

Modeling

Being a role model is very vital for effective training. When a trainer demonstrates the use of a detailing aid or implementation of a strategy, a lot of learning is imparted to the trainee.

I remember a MR who reported to me when I was a first line manager. This guy was quite experienced and full of zeal. However, during my first joint field working I found a quaint habit - after every few words of detailing he would make a funny PSSST sound. Probably the doctors had got used to this so no eyebrows were raised. I understood that this was a habit to seek sympathy and time. I did not comment. During subsequent doctor calls I requested him to permit me to detail - and I did it for all the remaining calls and remaining days of joint field working.

He used to keenly observe my detailing style in the clinic. Actually, detailing with a visual aid is tricky - one has to modulate the content and extent of detailing depending on the doctor's profile and his mood.

The next month I was in for a pleasant surprise. This guy would detail in every clinic in the same style that I would and his PSSST sound was no more there! I was happy.

Whenever any new visual aid would be given, he would wait for me to use it during the field working, and during the next joint field working he would handle the detailing himself, having picked up the delicate points during my demonstration.

Today, it is good to know he is a second line manager in a good company.

The moral is that MODELING IS USEFUL FOR A TRAINER.

ULTIMATELY BUSINESS RESULTS DEPEND ON THE KSA LEVELS OF THE FIELD PERSONNEL. The KSA levels are developed through continuous training inputs - through mailers, classroom training sessions, meetings, and other formats & tools.

KSA of an organization is very important. The result of the sum of the individual KSAs of employees is greater than the additive sum. That is there is a synergistic effect. 1 + 1 > 2.

KSA is developed in line with the organizational culture and objectives through three techniques:
1) REPITITION
2) PERSUASION
3) DISSONANCE.

One has to repeat, persuade, coax, and sometimes even cause tactful dissonance so that KSA levels are in line with company requirements. This ultimately creates sales, profits, and a sustainable competitive edge in the marketplace.

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Competition for patients:Participatory Medicine

I GOT THE ABOVE ATTRACTIVE IMAGE FROM HERE.

The foundation of the pharma and healthcare industry is the PATIENT. He or she is the person who is in suffering and requires medical attention. The patient or the healthcare consumer, is the basis of the pharma and healthcare industry.

How does one become a patient?

At the root of it, an individual becomes a patient when he or she is in suffering. At the practical level, an individual becomes a patient based on SIGNS AND SYMPTOMS. Examples of signs and symptoms include pain, discomfort, fever and the not-so-overt signs and symptoms like decrease in BMD (bone mineral density), raised blood lipid level, raised creatinine levels etc. IN the case of preventive healthcare products like functional foods, nutritional supplements, and vaccines, the patient is not in suffering - yet he or she is a patient.

Blood: the lifeline of the healthcare industry

Blood - the liquid connective tissue - is described as the lifeline of the human body. And this amazing fluid is also the lifeline of the pharma and healthcare industry! Almost every disease involves measurements related to blood - eg., blood lipid levels, RA factor (rheumatoid factor) test etc. Many diseases are insidious, and can be discovered through routine tests. For eg., for many, diabetes is discovered through routine blood tests rather than through assessment of overt signs and symptoms. So the importance of blood tests and other clinical tests in apparently normal individuals is very high.

Marketing of pharmaceuticals and healthcare goods is challenging

Pharmaceutical and healthcare goods are meant for consumption by the patient. For this to happen, firstly an individual should get converted to the status of a patient, second, his healthcare provider (mainly a doctor) should recommend or administer the pharmaceutical or healthcare item. Third, in certain countries, the third party payer should agree to pay for the medication or healthcare item. Fourth, the patient should be motivated enough to consume the same (ie., there should be patient compliance). In case the medication or healthcare item is to be consumed for longer periods, it is even more challenging for the healthcare marketer to ensure patient compliance.

This is the reason why there is, today, a focus on the account management approach to marketing of pharmaceuticals and other healthcare goods. When the aspect of product consumption is considered, the physician alone is not the influencer. The payers, hospital authorities who recommend the availability of a product in the pharmacy, pharmacist (or chemist - who has the powers to push the product), and the empowered patient himself are important. Hence, it becomes imperative to manage relationships and engage in fruitful communication between all these important agents of product consumption.

This participatory environment in the practice of medicine with an empowered patient is creating a new ecosystem of healthcare: PARTICIPATORY MEDICINE.

It is a model of medicare where the role of the patient is emphasized. The patient is no more a passive recipient of medical care. The patient is an empowered entity and he or she can influence or control the course of treatment. Powerful healthcare authorities like the NIH are helping craft the environment of participatory medicine. This is because, blogs, internet, message boards and other web 2.0 tools are creating a social media for participatory medicine.

One of the change agents of society catalyzing participatory medicine is obviously the INTERNET. The cyberzone has created a new avatar of the patient: the e-patient. The e-patient is the informed patient who plays a key role in therapy. A classic example of the e-patient is the famous blogger Amy Tenderich of Diabetes Mine.

Pharma marketing some 20 years back was at its simplest: all you had to do was contact the doctor, and get a whole load of prescriptions. The physician was the sole PATRON OF PHARMA PRODUCTS. Then, the pharmacist became important as more and more me-too brands competed for the limited shelf space. And now the payers, authorities with recommendation powers (particularly in hospitals), and slowly but surely the PATIENT himself are becoming important for the consumption of pharmaceutical & healthcare goods. THE ERA OF THE EMPOWERED PATIENT IS NEARING!

Obviously the trend of participatory medicine has enormous impact on marketing and communication efforts of healthcare and pharmaceutical companies. Patient information leaflets, and other communication material to patients will also gain importance - however, they need to be designed in such a way, that the doctor is not offended. The communication should look like supportive to the physician's role as a healer.

An idea particularly for chronic care pharmaceuticals like antiasthmatics and antidiabetics is to have PATIENT EDUCATION WEBSITES hosted by the brand marketer. When the doctor recommends - say an antidiabetic medicine, he can also prescribe a visit to the website to the patient. The patient will in-turn learn about the medicine, importance of blood sugar control, dangers of diabetic complications (like gangrene, neuropathy etc) from the website. He can also register for e-mail product/disease updates on this website. He can also probably enroll for new drug clinical trials (e-recruitment), or the patient can sign in for sms reminders for taking the antidiabetic medicine on time (for eg., every 2.00 pm he can request for sms reminder for taking the dose). (Note: When the patient registers on the product website, the patient needs to mention the doctor who recommended the website to him. In turn, the website can send a thank you e-note to the doctor.).

The fact is that participatory medicine will increase. How to enlarge this trend harmoniously? This is the question: the answer - is to involve the physician community and make the doctor community a channel for empowerment of patients. For eg., doctors can be engaged for speaker sessions wherein doctors will talk to a group of patients (who take a particular brand) on diabetes and medication. Till now, we have opinion builder doctors who talk about therapy to their colleagues (speaking engagements). The next step in a participatory medicine environment is to have opinion builder doctors talk to groups of patients.

The participatory medicine environment opens up new doors for pharma and healthcare marketers. There are two options - either close the eyes and say this is a fad and not a trend. Or two understand the market fluxes and judiciously participate in the participatory medicine environment.

IN ESSENCE, IF THE PHARMA OR HEALTHCARE ITEM SHOULD EXPERIENCE CONTINUED MARKET SUCCESS, THE PATIENT POPULATION FOR THE BRAND OR PRODUCT SHOULD INCREASE CONSTANTLY. Even if the prescriber base for the pharmaceutical does not enlarge significantly, yet, if the patient population goes on increasing, the product will continue to experience good market success.

There are two ways of increasing patient population (or user base) for a product:

a) communicate with more and more prescribers or influencers and ensure they recommend the product to more and more of their patients.
b) empower the individual or patient with education and communication. Encourage word-of-mouth.

The second approach is tricky, since there are regulatory challenges, and the communication should not substitute the doctor's advice. One cannot build sales of a pharmaceutical or healthcare product without doctor support. Thus, a blend of above two approaches needs to be adopted as the trend of participatory medicine is on! Thus, it is wise to focus on both: doctor conversion and patient conversion.

So it is obvious that with the globalization of healthcare and pharmaceuticals, participatory medicine will gain traction.

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THE CYCLE OF TRUST

I GOT THE ABOVE IMAGE RELATING TO BIOSIMILARS FROM HERE.

The key word in economic transactions is TRUST

CONSUMPTION depends on TRUST. When a person buys a strip of a pain reliever like Crocin or Dart, there is a factor of trust involved in the transaction. The customer trusts that the product will meet a certain level of performance – ie., will relieve his headache (also known as cephalgia). When a person purchases a financial product like say an insurance product, the customer trusts that the product will meet a certain performance level in terms of services and money-back. When the performance claims are not authentic – when untruths are promised, and/or the promises are reneged, the cycle of trust is broken, and consumption comes down.

There are many factors affecting consumption – purchasing capacity, credit availability and support, need for the product or service, price of product or service etc. However, the root of all the reasons for consumption is TRUST. The basic trust – HERE – is that the product or service will fulfill the consumer’s need or want or desire. The trusted product should deliver the expected value or make the customer FEEL GOOD. If a customer is going to feel conned and feel bad about a transaction –ie., he does not trust the transaction, the consumption will not take place. The core of marketing is increasing consumption of the marketed product or service. Thus, it is logical to conclude, that the root job of marketers is constantly building trust between target audience and the brand.

Recession

When the economy becomes sluggish, ie., when consumption comes down, demand stifles, and production stagnates… recession sets in. There are a lot of triggers for recessionary forces to gain speed; however, the major catalyst is MISTRUST, lack of faith. The cycle of trust gets broken down – consumption comes down, consumption growth retards and recession sets in. And every one runs for cover. Spending habits become conservative because you do not know what is waiting round the corner, and there is a negative cycle of mistrust.

Just like trust can be infectious, mistrust too has a butterfly effect. After all economic behavior of people is basically human behavior, and is guided by emotions and not logic alone. When the housing mortgage crisis started in US, it generated a lot of mistrust - about the actual demand - consumption patterns in society. And when people realized one cannot trust situations, financial figures and statements, and CXOs - stock markets started melting and economic recession gained speed.

The rofecoxib story & mistrust

When rofecoxib 'failed' (in terms of safety) causing a huge financial loss to Merck, the reverberations were felt in the entire pharma field. Managements and US FDA became conservative with respect to 'go-to-market' decisions on new drugs.

Mind you, introducing a new drug is not easy. It requires the new chemical entity (NCE) to go through a battery of preclinical and clinical tests before getting commercialized.

It is rare for a NCE in modern times to fail on the grounds of safety. The reason is the clinical trial process. Any promising NCE cannot enter the human clinical trials unless safety is established in the pre-clinical animal testing stage. In the US and EU, clinical testing in humans is given a high level of importance.

In Phase 1 clinical trial stage, of 1 to 3 years duration, the drug's safety profile is mainly vetted on about 100 patients.

In phase 2, which is of 2 years duration, the safety of the drug is established in a larger pool of patients (about 100 to 300) suffering the disease targeted by the drug. In phase 2 clinical trials, the efficacy of the drug is also checked if it is statistically significant.

In phase 3, which is of 3 to 4 years duration, not only is the effectiveness checked for the target indications, the safety profile is continuously built and the side effects monitored. Phase 3 studies involve several hundred to several thousands patients. Two pivotal trials are required to be positive in this phase, for the drug to get marketing approval.

When in phase 4, the marketing of the drug can be taken up, however, post marketing surveillance studies are continuously done to check for the safety and efficacy of the drug. It is at this stage that rofecoxib's cardiovascular side effects became public. And caused the burial of the drug.

IT IS AMAZING THAT DESPITE A ROBUST CLINICAL TESTING PROCEDURE, AS DESCRIBED ABOVE, ROFECOXIB BECAME A COMMERCIAL FAILURE. The root cause for such failures resulting in a massive loss of trust on pharma R & D, is that managements' are forever on the hunt for patented blockbusters. This means one can make a lot of money by ruling a LARGE market. Each blockbuster product launch should fetch at least 500 million USD with 70% net margin - that is the game plan.

Why is pharma said to be relatively recession proof?

The main reason is that one needs medicines come what may - recession or no recession. But it also indicates that there is a lot of trust on those medicines - physicians trust them, patients trust them and the society trusts the pharma products. If this trust was not there, during a period of recession, when money is scarce, people would think twice to spend on medicines too. If pharma in any country feels a big pinch during recession, it is indicative that people there do not believe the medicines are value for money and they are waiting for alternatives.

Trust: the reason for Baba Ramdev's success

Baba Ramdev's Yoga, healthcare, functional food and Ayurvedic pharmaceutical strategies are successful, because his programs and story telling are authentic - they are winning the trust and word-of-mouth of people. Trust is the foundation of his success.

Biosimilars and trust

Biosimilars is the buzzword of the pharma industry, today. This amazing field is seeing a lot of trust and hope. Pharma CXOs trust that a lot of growth in sales and profits is possible through launch of biosimilars. Merck and Pfizer are getting deeper in to the biosimilars and biopharma game. However, if any company has to succeed here, again it is TRUST that needs to be won. Biosimilars is a premium game in the pharma business today. Any biosimilar should prove itself as worthy as the innovator brand - and it requires a lot of robust clinical trials - or the brand will lose trust - even if a small side effect occurs that does not occur with the innovator brand. While the financial pot of gold is alluring to the biosimilar entrepreneur, there are a lot of risks that can cause the initiative to go bust. IN A RECESSIONARY WORLD, WHERE MISTRUST REIGNS SUPREME, WINNING TRUST IS THE KEY. In the case of biosimilar marketing, the mindset of the marketer needs to be different, as compared to marketing of chemical generics.

Striking the right chord

Obama is proving to be a leader of high mettle, he has directed the US govt to find out about the monies lying in Swiss banks. His intention is to get the idle cash in to the system in USA - this will certain build confidence and TRUST. IMAGINE IF THE INDIAN GOVT. DOES THIS - IT IS ESTIMATED THAT INDIANS HAVE STASHED RS. 50 LAKH CRORES OF RUPEES IN SWISS BANKS. THE CENTRAL ANNUAL BUDGET IS RS. 20 LAKH CRORE RUPEES ONLY! IF ALL THIS MONEY FROM THE SWISS BANKS GETS IN TO INDIA, IT WILL CREATE AN ECONOMIC AND HEALTHCARE MIRACLE OVERNIGHT BECAUSE THE TRUST ON THE ECONOMIC SITUATION WILL INCREASE, THE PURCHASING CAPACITY AND DEVELOPMENT WILL ALSO RADICALLY INCREASE!

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THE MELTING POT PRODUCT PORTFOLIO STRATEGY

The above image is that of Indian sweets. Variety is not only the spice of life, Indian sweets are also available in a rich variety! (I got this image from here). If a customer visits an Indian sweet stall, he will be so impressed by the variety, a sort of melting pot of sweets, he or she is bound to purchase something - a prospect will get converted in to a customer because of the variety, and a customer will purchase at least one item. The wide variety is responsible for the success of the sweet shop. The ability to cater to a wide variety of tastes and different customers is important. We pharma marketers can learn from this concept!

When we were kids we used to read a lot of Asterix and Obelix comics. There was this interesting character, Getafix – the druid in these comics. This wise old man used to create potions in his cauldron – a melting pot – with diverse herbs. One of his unique products was the magic potion that gave the drinker immeasurable strength. Today pharma giants are in search of such a potion that can give immeasurable strength to their product portfolio!

John Mack, the pharma consultant and blogger from America, has written about this product portfolio dilemma in a humorous way where he brings to focus the drying product pipeline of big pharma companies.

Product portfolio challenges

Products are the bread and butter of companies. Products are the identities of a company in the market. It is through the product range that a prospect or customer gets to know the company – the products are a point of contact between the target audience and the company. So product portfolio management is a most critical task of any company as all revenues are hinged on it.

With respect to new products, traditional pharma has been single minded: Identify a molecular target, synthesize/extract and screen a new drug candidate to modify the molecular target for patient benefits; establish the safety and efficacy of the new molecule through clinical trials. That is, see if the new molecule can be established as more effective and safer than contemporary medicines, patent the product, and market it. Basically, the new product should have projected annual sales (from the first year) of at least 500 million US dollars and fetch at least 70% net margin. This was the well trodden R & D path, which cost the pharma company for new product R & D (including clinical testing costs) at least 880 million dollars and the time- to- market being about 14.7 years. Traditionally pharma companies either invent the new molecule, or license it from innovator pharma companies or buy up the innovator company or outright purchase the technology. This traditional approach has been based on molecular biology and understanding the biochemistry of the disease process. True, this approach provides fodder for the new product cannon.

However – rofecoxib changed this product pipeline strategy forever. Rofecoxib was touted by Merck as the revolutionary highly selective Cox 2 inhibitor, which was very effective for pain relief; it was promoted as a drug that did not have any side effects on the tummy (ie. creating hyperacidity) or on the respiratory tract (ie. causing broncho spasm). But the celebrations were short lived. Phase 4 clinical trials established that rofecoxib caused deaths due to adverse effects on the cardiovascular system. Rofecoxib was withdrawn. Perhaps after the thalidomide tragedy no other pharma event has shaken the pharma industry to its very roots.

The rofecoxib product market tragedy was followed by the 800 million USD torcetrapib failure AND Exubera – the world’s first inhalable insulin was also withdrawn from the market. No new blockbusters were visible on the new product horizon. (The benchmark for any new product introduction is that it should have a minimum annual sales projection of 500 million USD from the first year. And there were no products fitting this criterion. ) Risks were too too high. The product pipeline strategy of many a company was at peril.

The biopharmaceutical product pipeline

However, biopharma companies like Amgen and Genentech are in a better shape. These companies have new introduction products that generate annual sales of at least 300 million USD. So a glimmer of hope has come from the biopharma segment. Hence, Merck is betting big on its vaccines range and Pfizer is reinventing itself as a biopharmaceutical company. In fact, the acquisition of Wyeth has been on these grounds.

Remember, Pfizer is a symbol of America. If it had not purchased Wyeth, one more icon of America would have weakened. So the purchase of Wyeth gives Pfizer a new hope.

The latest fad of product pipeline strategy is to have a set of biopharma products

Biopharma has gained traction due to an interdisciplinary approach to new drug R & D. New biopharma products have a connection to the field of genomics (identifying, understanding, and functional characterization of genes), proteomics (study of proteins in the body) and in turn computational biology (applying IT in biology - the leader company here is IBM).

The biopharma game started with the Human Genome Project (2001). This project and Celera (a private company) characterized the 30000 genes in the human body. Thus, it was now possible to identify defective genes and create new therapies that correct the genetic problem. Genes also contain coded information for protein synthesis. Proteins are ubiquitous and are made up of amino acids. Enzymes, antibodies, and most hormones are proteins. Proteins are involved in the structure of cell, inter-cell communication and functioning of cells. Proteins also undergo a process called protein folding which is important and is considered while creating therapeutic proteins. Biotech companies reseach and manfacture therapeutic proteins that correct disease processes. For instance, lack of erythropoietin (which is synthesized by the kidneys) is responsible for anemia in kidney failure patients. Amgen launched a biotech product - alpha erythropoietin. This is now a blockbuster pharma brand.

This goes to show biopharma products are important for a robust product pipeline and product portfolio.

Ranbaxy is acquired by Daiichi Sankyo

The Ranbaxy purchase by Daiichi Sankyo is a marriage of convenience to both parties. The challenge of having a robust product portfolio can be met by having a strong generic portfolio. This is the bet by Daichii Sankyo. Many companies buy competitors to strip off their resources and weaken them. However, this Ranbaxy purchase appears to be an important synergistic acquisition for Daichii Sankyo. On the other hand, Ranbaxy's promoters were having some debt and the company did not have any promising blockbuster molecule(s) that would take it to greater heights. Hence, the marriage took place. And mind you this integration is a very strategic one. There are no sobs of job cuts - pure harmonius synergy - like a Japanese poem - HAIKU!

Having a generic drug portfolio is important to have a melting pot product portfolio that can withstand technological stresses.

Wellness product portfolio is an evergreen one

A product portfolio that is evergreen - is one that can seemingly sell forever without the fear of technological obsolescence. There are such lucky products. For eg., Ayurvedic brands belong to this class. Liv 52 (#5 in the Indian pharma market ) a decade back was about Rs. 18 crores sales per annum, and now it is about Rs. 100 crores sales per annum. Revital - a nutritional supplement from Ranbaxy with its OTX (prescription plus over-the-counter) product promotion is such an evergreen product. Becosules Z a vitamin brand from Pfizer is also an evergreen wellness brand - and is a constant topper brand of Indian pharma market.

The moral: a strong wellness product portfolio is a must to strengthen pharma companies. This is one reason that pharma biggies in India like Merck, Piramal Healthcare, and Mankind are having electrolyte energy drinks with patient value in their product portfolio.

P & G has an interesting product portfolio

Procter and Gamble is one interesting company that does not believe in gambling in the product marketing game! They have put their eggs in many baskets!! This interesting company has detergents, personal care, fast moving health goods like Vicks, fast moving consumer goods - soaps etc, and even PRESCRIPTION PRODUCTS in its product portfolio. Yes - they address the exciting chronic orthopaedic prescription markets like osteoporosis and osteopenia through its brand Actonel (risedronate). Actonel is positioned to increase BMD in postmenopausal women (even with a once-a-month therapy - that is something that no woman would grumble about and surely one can convince a woman to buy it!). There are lots of lots of things to learn from P & G's product portfolio game. It has products from FMCG point to FMHG point and even a prescription range. Talk of bulletproofing! Johnson and Johnson is a similar company. Some companies that come close to P & G in their business approach is the Ayurvedic major of India, Himalaya; Zydus Cadila - of course has some products in its FMHG segment and many in the prescription segment. Mankind is trying to grow and gain market share in the Ayurvedic and FMHG segment - it is already strong in the prescription segment.

By the way, the herbal and Ayurvedic pharma market is now catching the attention of pharma marketers. One reason is Patanjali Chikitsalaya and its success. This institution created by Swami Ramdev has about 800 doctors all over India, and they see some 50000 patients every day (all over India). Their sales turnover even though the products are very economical is near abouts Rs. 20 crores plus per annum and growing steadily (not bad for a new company).

Pharma marketing is tricky

Let us say you have Rs. 100 to spend on pharma marketing. Now, how will you divide and where will you focus these monies? On which product and which strategy? This is the question that constantly grapples pharma marketers. On which product will you bet on - so you get the best ROI? That question haunts many a pharma marketer. One guide is to have a MELTING POT PRODUCT PORTFOLIO STRATEGY for best bulletproofing from unfavorable market conditions.

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HOT BUTTONS OF A CONVERSATION: the e-imbroglio

TRY CONVERSING WITH A GROUP OF DOCTORS! IT IS TOUGH CUTTING THROUGH THE CONVERSATIONAL CLUTTER!! THE ABOVE IMAGE COMES FROM HERE. The fact is, we are in the age of conversations - enhanced by social media and the internet. Both the - loud and whispered conversations - are defining our attitude, emotions, and activities.

I was waiting to meet a dermatologist, some time back with a MR colleague, at a hospital. We overheard a conversation between two doctors:

Doc 1: So how is patient Ankita doing?

Doc 2: She is better, no doubt it was mainly a exacerbated hypersensitivity of the skin...

Doc 1: OK, but don't forget to put her on Augmentin ... there is always a possibility of secondary infection!

This is a conversation - and it reflects the word-of-mouth popularity of Augmentin. There are thousands of such conversations going on in target prospect or customer segments. The point is how can pharma and healthcare marketers benefit from conversations?

One to one conversations

Pharma marketing is characterized by highly personalized relationships between pharma company medical representatives and physicians. This is one reason pharma has not been fast in embracing digital marketing concepts (as fast as other industries).

During one-to-one conversations between a doctor and a MR, knowing the profile of the doctor with all the fine details helps in discovering the hot buttons to engage in a fruitful conversation:

Dr. Manohar MD, a bearded Malyali gentleman, practicing in Marathhally, Bangalore was one of my favorite calls during my independent field work days. While talking to him I realized he had a fond hobby - he loved aeroplanes. In fact, his knowledge was so vast, he knew the wing span and horse power of various military and commercial airplanes.

With this background knowledge, I happened to meet him at his clinic for a call one day. I wanted to launch a new product - SUPERGESIC CREAM - to him.

As an ice breaker, I started talking about aeroplanes and the Aero show (for which Bangalore has now become famous - in fact, this year's aero show is to start in a week's time). After some talk about planes, I took out the launch visual aid, and started, "Dr., planes are known for their swiftness, and here I am pleased to launch a new SWIFT ACTING, topical approach to pain management, introducing, (pause) Supergesic cream... "

The call went on well. During my next visit after 15 days, a pleasant surprise awaited me from the chemist - he said, Dr. Manohar was prescribing good quantities of Supergesic cream, at least 3 to 6 tubes a day!!

So the hot button here was the aeroplane talk, this was effective in having a productive conversation and good storytelling on Supergesic cream to Dr. Manohar MD. This incident is still fresh and vivid in my memory, thanks to the success.

Thus, the point is that one has to discover the hot buttons of a person and strike a conversation based on the likes and dislikes.

In fact, I had learnt this point from my dad - Late Suresh G Chiplunkar, a PSR with Wyeth. He would share with me (when I was still going to college), how based on the tastes of a doctor, like say, films, one has to start the doctor call with that point.

Mr. Vivek Balse, a good family friend and an exceptionally gifted PSO with Pfizer, would share with me his experiences too. I believe Pfizer called this approach of effective conversations with doctors as SOCIAL STYLE SELLING TECHNIQUE. The technique was to basically align the in - clinic activity with the personal interests of the doctor and finally put across the product message.

Digital marketing and pharma

Digital marketing and pharma have a sort of love-hate relationship. On one hand, all pharma marketers agree to the immense potential of the internet and digital media for marketing activities. However, all wonder why the adoption of these digital technologies is not as swift as it could be.

One reason is that pharma marketers still swear by the conversations (including story telling & messaging) between the field force and the doctors - as the foundation of pharma sales. Pharma marketing does not envision any other form of effective conversations with the target doctor community. There is an important reason for this belief. The reason is: EFFECTIVE PHARMA SELLING IS A HI-TOUCH EXPERIENCE. There is an intimacy between the MR and the doctor, which is in fact responsible for prescription generation. Digital marketing on the other hand, is not personalized. It is standoffish and there is a thinking that digital marketing may not result in better sales. Hence, pharma marketers feel it is better to play with the time- tested & trusted winning business model - and that is invest on MRs (more and more of them), and more on in-clinic activities between doctors and MRs - to ensure prescription generation.

Is there a way out of this e-imbroglio?

E-imbroglio is a pharma marketing phenomenon characterized by inertia to adopting digital marketing concepts and techniques.

The main reason for the e-imbroglio in pharma marketing is that digital marketing avenues are not positioned as effective for conversations that can result in doctor conversions and enhanced prescription generation. Digital marketing is visualized as a costly add-on to traditional sales and marketing through MRs. The ROI from digital marketing campaigns is anybody's guess - hence, pharma marketers continue to invest in the MR based pharma product promotional formats.

The best way out to increase adoption of digital media for effective sales and marketing is to use a HI TOUCH-HI TECH approach.

THE HI TOUCH - HI TECH APPROACH

Hi-touch refers to the human touch of marketing, represented by MRs. Hi-tech refers to use of high tech gadgets and techniques to enhance sales and marketing activities. In the Hi-touch and Hi-tech approach the MRs, field personnel and Head Office personnel use digital media in a co-ordinated way to have enhanced conversations with doctors.

Example 1: Background: India has one of the world's highest mobile phone penetrations. In fact, every doctor has a mobile phone. Every MR has a mobile phone.

Let us say we want to create a campaign for electrolyte energy drinks in prescribing practice.

Step 1: Provide a mobile phone to each MR with which one can record a doctor's medical opinion with some clinical patient photos on how electrolyte energy drinks have delivered patient value.

Step 2: MR sends the same to Head Office, through email, and this is posted on the product portal.

Step 3: MR informs his doctors about the posts, and the doctor community visits the product portal to view and understand the medical opinions of other doctors.

Step 4: A poll is conducted to find out which are the most interesting clinical videos and the most voted one is given a good gift. The doctors can also discuss issues relating to the videos on message boards available in the portal. They can also be enticed to listen to e-detailing.

Example 2: Background: The pneumococcal vaccine is sometimes in a bind - some pediatricians feel it is not a very valuable vaccine as it provides protection from invasive pneumococcal disease only - and not from the common types of clinical pneumonia.

The pharma marketer's problem here is to enhance consumption of this vaccine. This can be done by reiterating that this is a necessary protection to some susceptible groups (to begin with).

The marketer launches a mobile phone based case study photographing campaign of invasive pneumococcal disease in diabetics. The case studies are collected by MRs in collaboration with the doctors on whom they call.

These medical opinion case study videos are uploaded on the product portal and doctors are informed of the same. These doctors will not only see their video but will engage in conversations on the website message boards and they can view the videos of their colleagues too.

Such doctors can also be encouraged to listen to e-detailing podcasts on the importance of pneumococcal vaccine in diabetics. They can also order for samples or purchase vaccines at discounted prices or print out a discount voucher for gifting to patients who opt to get vaccinated.

The above approaches can be used for any campaign - like liver disease case study campaign, antibiotic resistance clinical study campaign, etc.

THROUGH THE ABOVE E-CAMPAIGN BASED DIGITAL APPROACHES, THE PHARMA MARKETER GETS THE DOCTORS HOOKED ON TO THE NET, CREATES AN EXCITEMENT AMONG MEDICAL LIAISON FIELD PERSONNEL, AND MEDICAL REPRESENTATIVES. The end result is that there is an INTEGRATED MARKETING COMMUNICATION APPROACH, with out dismantling or altering the traditional MR based approach to doctors in clinical settings.

When such e-CRM (customer relationship management) approaches are adopted not only will pharma marketers get out of the e-imbroglio, they will also see enhanced product adoption. Besides, patients and doctors too will get to enjoy the benefits of the digital revolution leading to better patient care and healing.

The digital medium is a great enabler for pharma marketers to create a selling environment, to the patients it is an empowering medium, and for doctors the digital medium facilitates instant and real-time communication. The digital medium helps overcome geographical barriers.

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