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Deterritorialized youthCHAPTER 2
Pharmaceutical Witnessing: Drugs
for Life in an Era of Direct-to-
Joseph Dumit People come into my office, throw down an ad and say, ‘That's me.' It's a disease that often has no symptoms. Advert for Peripheral Artery Disease
If you answered 7 or less for question 10, you probably aren't feeling like yourself. Website for Depression Awareness
As an anthropologist studying pharmaceuticals in the U.S., I am constantlytripped up by statements that seem to challenge my common sense, ones madeby pharmaceutical marketers, advertisers, doctors and patients. A life on drugsis not alien to me, nor to most readers of this article. We often are onprescriptions and we might be on them for life. But the easy emission of thesestatements points to a cultural inflection that I want to investigate here usingwhat Victor Turner called the method of processuralism in anthropology,attending to processes that we are involved in and to how actors perceive,mutate and communicate their embodied worlds (Turner and Turner 1992:172–73). All of the opening statements, I want to argue, share a relatively newgrammar of illness, risk, experience and treatment – one in which the body isinherently disordered and in which health is no longer the silence of the organs,but it is illness which is silent, often with no symptoms. In this article, I want to Pharmaceutical Witnessing interrogate this grammar, examining how it involves an image of health as riskreduction, and an image of information as full of partial facts. Together, theseimages underpin a logic of accumulation of pharmaceuticals in the U.S. suchthat it becomes natural and imperative to treat one's body with more and moredrugs for life. In fact, it is so commonsensical that even critics of thepharmaceutical industry and advocates of alternative medicine share in thislogical growth. This article is part of a larger, book-length study of ‘mass medicine' in the U.S.
Mass medicine refers to blockbuster pharmaceuticals whose yearly sales exceedone billion dollars and whose customers are measured in millions. My researchincluded analysing hundreds of pharmaceutical TV commercials, as well asmagazine ads and Internet sites; tracking patient discussion groups online; andinterviewing and holding workshops with pharmaceutical marketers, doctorsand patients groups. Here I examine advertisements for their grammar of factsand health. I also analyse the ‘grey literature' written by pharmaceuticalmarketers to each other to improve their practices. I aim to show how our waysof talking articulate with theirs such that we may get what we want, but it maynot be what we need. Pharmaceutical Executive (PE) is one journal thatconcentrates on marketing strategies towards doctors and the public. I trace akey shift in marketing towards what I call factual persuasion and what PE, in itsfirst branding seminar in April 2002, termed ‘Pharma's challenge to convertscience into marketing' (Shalo and Breitstein 2002: 84). Using tools from many disciplines, pharmaceutical marketers are building on a much longer tradition of public relations aimed at calibrating emotions formaximum effect in concert with the authoritative discourses of science andmedicine that dissociate viewers from their own bodies and experiences (Tye1998; Chomsky and Barsamian 2001; Herman and Chomsky 2002). I beginwith an early pharmaceutical commercial.
Remaking the Body at Risk
The following table shows a direct-to-consumer (DTC) televisioncommercial for a Depression Kit (manufactured by Lilly), which begins as achecklist in the form of an interrogation.
Table 2.1. Text of TV Advert for Lilly's Depression Kit
Have you stopped doing things you Sombre music playing over used to enjoy? Are you sleeping too black-and-white stills of much, are you sleeping too little? Have unhappy people.
Joseph Dumit you noticed a change in your appetite? Is it hard to concentrate? Do you feel sad almost every day? Do you sometimes feel that life may not be worth living? ‘Depression strikes These can be signs of clinical depression, a real illness, with real causes.
But there is hope, you can get your life back.
‘Get your life back' Treatment that has worked for millions is available from your doctor. pamphlets, phone number This is the number to call for a on screen, pictures of free confidential information kit, checklists and other including a personal symptoms information pieces.
checklist, that can make it easier Fade to logo for Lilly.
to talk with a doctor about how you're feeling. Make the call now, for yourself or someone you care about.
The commercial features simple questions that are very general: are you sleeping too much or too little? But their seriousness is transmitted in thefollow-up: ‘These can be signs of clinical depression.' This conclusion converts the questions into a medical algorithm, a logical process of following a series of steps. But the grammar arrests: ‘these can besigns' is a peculiar phrase. It is retroactively transformative: aspects of one'slife are inscribed as symptoms. What you had previously thought of – if atall – as personal variations are brought into heightened awareness. The firstimplication is that you are, maybe, suffering from a serious disease and donot know it. Your body, in other words, is potentially deceptive, concealingits own decline. This is not a presymptomatic form of awareness. Unlike thesituation in Nelkin and Tancredi's Dangerous Diagnostics (1989), where abrainscan or genetic test reveals a disease before it manifests symptoms, hereyou find out that you have been suffering from symptoms without feelingthem.
The grammar of the phrase, ‘these can be signs of X' or ‘you could be suffering from X' are also not simple performatives. They do not assert thatyou have depression, they do not diagnose (Austin 1962; Kahn 1978). Forlegal, marketing, and health reasons, the grammar is explicitly modalized aspossibility: ‘these can be' ‘you could be' ‘you might be.' But they are givingyou a new possibility. Information about the possibility of pathology transforms modalization into mobilization (Halliday 1985). You cannot ignore the possibility morallybecause your status has changed (Sacks and Jefferson 1992). This can Pharmaceutical Witnessing produce a very strong duty to be healthy (now that you know you are not)and a rational ‘having to try' (since you know there is something you cando), that is as deeply moral as the imperative to be tested identified byNelkin and Tancredi (1989; see also Franklin 1997). You are now at risk, younow know that you have been at risk, you have to try to do something aboutit. Since treatments are available, ‘There is hope.' From a marketer's point of view, once you are aware of the disease in general, the question is how to get you to add depression, breast cancer,cholesterol to your lived anxieties, to your personal agenda, enough so thatyou attend to it, find out more information, and talk to your doctor about it.
This is what they term ‘personalization.' Their problem is how to get theirparticular facts into your head as facts that you come to depend on. Thispractice recalls and builds on an older generation of advertisements teachingyou that you might be suffering from bad breath or be overweight and notrealize it (Marchand 1986; Bordo 1993), but amplifying this personalizingeffect by passing it through tests and diagnostic algorithms.
For instance, another commercial begins with a scene of many middle- aged people on exercise bikes in a gym, working out but looking tired. Theonly sound is a ball rolling around and superimposed above them is aspinning set of numbers. Finally the ball is heard dropping into place; thenumber is 265. The cholesterol roulette is over. The text on the screen: ‘Likeyour odds? Get checked for cholesterol. Pfizer.' The challenge of thinking through how these commercials work dialogically lies in the fact that they aim for a retroactive status change.
Rather than illness punctuating ordinary life, the everyday conceals illness.
Once this is identified, once you identify with it, then your true, real life canbe returned to you. The process here is a counterpart to interpellation.
Althusser's process of interpellation involved the always, already self-recognition of the subject, where the teacher or policeman hails you or asksyou a question, and your response confirms the self evidence of your beinga subject: ‘I am I' (Pecheux 1982; Althusser 1984). Here your self-evidenceis directly assaulted. Your self-identity is called into question via thealgorithm. You are not who you think you are. Your body is not what youthink it is. Your feelings are not what you think they are. The algorithmoffers in turn to identify your objective self for you. So instead of theinterpellated response, ‘Yes, it's me', we instead say, ‘Oh! so that's who I am.' The challenge in studying pharmaceutical marketing is that the commercials do not usually work this easily. In fact they do not work well atall, but they do work well enough. Both the number of prescriptions and theamount of drugs per prescription are projected to continue to grow at 5–15per cent per year for almost all classes of drugs for chronic conditions(Express Scripts 2006). For marketers, some people responding some of thetime is all that they need: their processes of persuasion are designed to work Joseph Dumit in percentages, or market share. If they can get even a small per cent moreAmericans to consider the possibility that they might be depressed or havehigh cholesterol, and a small per cent of those people actually go to a doctorand request a prescription, the profits on these tens to hundreds of thousandsof additional patients are more than enough to cover advertising costs(Kaericher 2007). It does not matter whether those people ‘believe' that theyare sick, only that they act in accordance with that belief as delineated by themarketing campaigns. The studies that have been done on direct-to-consumer advertising suggest that these commercials are successful atgenerating concern and anxiety, and that they drive pharmaceutical salesjust enough to justify continuing to invest in them (Aikin 2002). Myethnographic challenge is therefore to account for this aggregate growth. Iam thinking of this as an ethnography of the aggregate. Thus I begin with astudy of how marketers imagine people to be manipulable enough.
As businessmen, pharmaceutical marketers know exactly what their endpoint is: profit in the form of ongoing mass pharmaceutical consumption.
This profit ultimately boils down to prescription maximization which can beachieved through growing the absolute number of new prescriptions,extending the time a patient stays on a prescription, or shortening the timebetween having a condition and getting a prescription for it (Bolling 2003).
Most pharmaceutical marketing overviews start with the product cycle. A pharmaceutical in the U.S. must go through an extensive regulatory processin order to be approved for use. This process includes testing the drug forsafety, first in animals, then in humans. Its potential efficacy is then assessed,and finally its actual efficacy is tested in a clinical population for a specificillness through clinical trials. When all of these have been successfullyaccomplished, the pharmaceutical company applies to the FDA forapproval. If granted, the company gains a number of years of exclusive rightto market that drug to doctors and public for that illness. Marketers thereforedivide their strategies into stages: pre-launch, launch, market exclusivity, andtransition to generic competition. Embedded in their articles aboutdirect–to-consumer marketing, however, is also a complex theory of themass market as potential patients who do not know that they are ill, andmust be led, step by step, toward a prescription. I opened this article with a close grammatical reading of how some DTC commercials are constructed, arguing in effect that we as viewers arevulnerable to redescriptions or reclassifications of our everyday variabilityinto symptoms, and that we can be led to identify with the possibility ofdisease and treatment through rhetorical persuasion. I will now continue toattend to the logics and grammars of pharmaceutical marketing as they arecirculated, and analyse these in accordance with these explicit strategiesoutlined by marketers. Marketers have a highly developed language forarticulating the steps of conversion through which non-patients come to see Pharmaceutical Witnessing themselves as undiagnosed patients, then actively visit and persuade theirdoctor to give them a prescription. Using their terms, but focusing on howmarketers approach a person as someone who does not even know that theyrequire a drug, I have mapped their implicit strategy onto five distinct steps.
They are: 1. Awareness through Education2. Personalizing the Risk3. Motivation to Self-diagnose4. Seeing and Convincing a Doctor5. Branded Compliance Most DTC commercials are aimed broadly at addressing people in any step, at reinforcing this step-wise progression as logical and natural, and athelping people move onto the next step. This process involves much morethan just advertisements, it includes the design of clinical trials, arrangingscreening programmes, constructing databases, and monitoring compliance.
As we, patients and potential patients, try to learn facts about our risks andillnesses and come to incorporate these into our identities and bodies, almostevery aspect of the medical world we encounter is being modulated (notconstructed, but adjusted) in accordance with profit motives. That iscapitalism, you might say, but it is also an opportunity to understand how, inour capitalist culture, facts, risks and illnesses work in and on us,transforming how we experience, understand and measure health.
Awareness through Education
So companies realize that an effective way to reach commercial goals is tocultivate long-term patients through education, rather than acquiring newconsumers through brand-awareness advertising. (Hone and Benson 2004: 98) Medical sociologists have recognized how the neutrality of health information can be manipulated through selection and amplification,privileging one form of explanation over others. The idea that informationempowers can be turned into a structured or controlled empowerment, whatDixon Woods has called ‘information for compliance' in contrast to‘information for choice' (Dixon-Woods 2001, cited in Henwood et al. 2003:591). One key strategy for producing a market is direct education of bothdoctors and the public. Even before the launch of a new drug, time is spentcrafting messages about the disease that shape it towards market ends. In theU.S., advertorials are a technical term for this process: quasi-educationalspots that function to teach about specific disease symptoms and mechanism.
Joseph Dumit Advertorials are ads ‘designed to deliver the experience of reading an article'(Prounis 2004: 152). They are used increasingly in the U.S. to build diseaseawareness, to ‘create an urgency to treat diseases earlier and moreaggressively', and to draw attention to underserved populations.
The logical premise of education as patient cultivation is that the public, doctors and medical institutions are ignorant. The status quo is harmingpeople in a most dangerous way because they are not even aware of theharm they are doing to themselves.
Ilyssa Levins, chairman of GCI Healthcare Public Relations, underscoredhow public relations supports the ‘science and marketing connection' bycreating a receptive climate through advocacy and issue-oriented mediarelations. She said PR can facilitate awareness and adoption amongregulators, payers, medical influencers, and patients alike by conditioningthe market for acceptance of new concepts such as overactive bladder.
(Shalo and Breitstein 2002) Being ignorant of medical issues justifies an emergency public health response: explicit manipulation or ‘facilitated awareness'. There are twomain approaches to awareness through education: preparing the market andhealth literacy. At different levels of generality, each aims at changing thestatus quo of common knowledge through critical presentation: redefiningwhat health is, what treatment is, what a smart person does to be healthy,and so on. They aim, in other words, to reframe how we see the worldworking and what we take for granted. In this manner, fact-based marketingcreates a receptive climate.
The premise of health literacy is that a large segment of the population cannot handle complicated information. They must be managed likechildren: ‘Limit the content. Make it easy to read. Make it look easy to read.
Select visuals that clarify and motivate' (Kelly 2003). With this kind ofhandholding, medical information is streamlined so that it becomes moreefficient in producing more prescriptions.
The aims of health-literacy campaigns as envisioned by marketers are to cement this relationship between knowing and doing. Targeting a sixth-grade reading level allows imagining a market of 110 million people whocould be addressed with health information. The health-aware individual isthus presented as one who can and will act on medical facts. While facts aretypically seen as descriptive, health education is only seen as meaningful andsuccessful if its knowledge induces action. Non-compliance with facts is thusframed as a problem of literacy. Health literacy grammatically frames thepublic as well-intentioned but ignorant, illiterate, uneducated anddisempowered.
Pharmaceutical Witnessing When health information is offered, people cannot understand or actupon it. When that happens, [often] low health literacy may be at fault.
Health literacy is defined as the ability to read, understand, and act onhealth information, and it becomes more important as patients are askedto take a more active role in their own healthcare. (Kelly 2003) The moral grammar of ‘health information' is that facts will of course be acted upon. This grammar precludes resistance: if you do not act on whatyou know, you must be doing so for psychological reasons. You areconfused, embarrassed, intimidated or ignorant. Each of these reasons offersan opportunity for strategic intervention to fix the problem of people whohave encountered the information but are not acting on it.
In Europe, this challenge is acute because brand-name pharmaceutical advertising to consumers is not allowed. Sandoz (Novartis), with anantifungal agent Lamisil to promote, needed to find another way ‘toencourage patients to talk with their doctors about onychomycosis and itstreatment options. So the company renamed the condition the moreconsumer-friendly ‘fungal infection' and took out newspaper ads askingreaders to call or write to ‘"Step Wise" for a free brochure on foot care'(Hone and Benson 2004: 96). Besides capturing future patients through theinformational relationship, the phrase ‘fungal infection' became an indirectbrand, an illness fused with Lamisil as its treatment. The challenge forpharmaceutical companies is managing education that is not directlybranded without giving too much away to competitors. Their goals are to‘employ prelaunch promotion to prepare potential customers for futureproduct use, without generating new prescriptions for the competition'(Bolling 2003: 112). Mechanisms include quasi-branded cues that will laterbe branded explicitly when the drug that works on just that mechanism islaunched. Even the colour schemes and typography are tied into this processof managing awareness in anticipation of a future market (Prounis 2004).
Personalizing the Risk
When its efforts to market to physicians had reached the saturation point,the manufacturer of a prescription health product for women decided tolaunch a DTC campaign to expand product sales. The company's goalwas to pull through new prescriptions by increasing the target audience'sawareness of the need for treatment to prevent the onset of osteoporosis.
The first communication objective was to get patients to ‘personalize' therisk so they regarded the disease state as important enough to warranttaking further action. If the company introduced the brand too early in therelationship, before the target woman considered herself to be at risk for Joseph Dumit the disease state, she would quickly dismiss the therapy as not appropriatefor her. (Bolling 2003) Once a prospect is aware of a risk and accepts that it is possible, he or she must then be made to personalize the risk. Having been introduced to a fact,one needs to enter into a relationship with it. Personalizing involves havingthe risk become part of an existing internal and external dialogue. It has tobecome part of my story, how I talk about and represent myself to myselfand others. Personalizing requires that the possibility of risk in general nowbecomes my possible risk. What is needed is that I worry about thispossibility, that it go from being an object of my attention (awareness) tobecoming an object of my concern.
Medicalization is a term used by sociologists to describe the historical process through which conditions, complaints, normal variation and sociallyundesirable traits are turned into medical conditions and interventions(Conrad 1992; Klawiter 2002; Lock 2002; Clarke et al. 2003). Analysed aspower conflicts, medicalization can be a coercive force making people intopatients in order to control and manage them. Alternately, medicalizationcan be a tactic by sufferers to become objects of attention and care throughbecoming patients (Dumit 2006). Within DTC, these problems of ‘my status'and ‘my bodily state' are ‘offered' to me as explanations for what I am andshould now be concerned about. It appears non-coercive, even empowering.
I am offered a gift to evaluate freely. However, as Ronald Frankenberg hasnoted, characterizing this process of medicalization is fraught with narrativeand conceptual difficulties for everyone involved (Frankenberg 1993).
How does medical identification happen? How can we ethnographically describe an encounter with an advertisement that is effective as documentedin increased prescription demands, yet does not reduce the viewer to ajudgemental dupe, to use a phrase from Garfinkel (1967), someone who ispassively manipulated by the media. In order to investigate processes ofidentification, I will make a detour into the anthropology of religion andpersonhood, and draw on the work of Susan Harding, who studied ChristianFundamentalist followers of Jerry Falwell (Harding 2000). She analysed thetechniques of evangelical witnessing, the explicit process of attempting toconvert non-believers into believers through speech and dialogue. Her studyoffers a framework for understanding the active, participatory process ofidentification and persuasion that is going on in pharmaceutical advertising.
Harding approaches conversion and status change from the inside, so to speak, as one who is involved in the situation, in the dialogue, struggling tounderstand. Harding notices this when driving home after interviewing aminister. She almost gets into an accident. In that moment of danger, shefinds herself asking, ‘What is the holy spirit trying to tell me?' Finding herselfasking this question begins a key insight. She found herself beginning ‘to Pharmaceutical Witnessing appropriate in her inner speech the evangelical language and its attendant viewof the world'. Her modes of attention, cognitive and emotional, were drawn tothe near accident as a gap in the ordinary, an event within the everyday where‘the seams split' (Harding 2000: 58–59).
Harding argues that one moves from being an unbeliever to believer through a ‘process of acquiring a specifically religious language … If you are seriouslywilling to listen, and struggle to understand, you are susceptible to conversion'(2000: 57) It is the unwitting, basic desire to understand that aids this process.
It is specifically not a ritual in that there is no social sanctioning that bridges thetwo worlds. Rather, the listener gets ‘caught up in certain kinds of stories' inwhich the personal referents, the pronouns, ‘Christ died for you', slip up, andslip into one's own language. Her description is deeply processual: the listenerstruggles to make sense of stories with uncertain references, stories that forceattention onto events, past, present and future, which disrupt the normal flowof life, leaving those disruptions open and vulnerable, and making sense ofthem only through a religious grammar.
Harding shows that the worlds of the believers and the unbelievers regarding fundamentalism are each clear and logical, but that evangelicals want toconvert or save others. While it appears that from either position there is nomiddle ground, that you either believe or you do not, Harding insists that thereis a substantial in-between position, which evangelicals describe as ‘being underconviction'. Harding describes ‘coming under conviction' as a kind ofindividualized dialogic approach to status change.
Similarly, the suggestion: ‘These may be signs of a serious illness' and the question, ‘Is this a symptom?' can be thought of as part of coming under abiomedical conviction. This ‘inner rite of passage', Harding suggests, works‘subliminally' in that she and others who are witnessed to often have no ideawhat is happening. They are not changing status with a culture, however that isto be defined, but are instead switching cultures or worldviews.1 Finding oneselfasking the question, ‘Is my cholesterol too high?' is already such a switch. Onehas begun acquiring a specifically pharmaceutical language and worldview.
In pharmaceutical marketing, this switch often turns on some sort of bodily hook. This is a facilitated recognition in which I come to understandthat what I had previously taken for granted or overlooked in my body is infact an object of concern. In this manner, my attention to a risk possibilityand my self-concern become linked, and the temporal fact that I hadoverlooked this before adds an emotional surprise and worry to the mix.
The archetypal form of this identification is the ‘ouch test' as described byvirtual contributing editor Vern Realto in Pharmaceutical Executive:2 Of course, in the world of DTC, it helps to have a product indication inwhich patients can point to a spot on their bodies and say, ‘Ouch!' Prilosec[for acid indigestion] has such luck. And its DTC creative makes full use Joseph Dumit of the fact. Patient self-selection is the point. For a heartburn sufferer,looking at the campaign's ever-present cartoon figures is like looking inthe mirror. Does it hurt? Yes. Would you like 24-hour relief with a singlepill? Yes! (Realto 1998: 14) The grammar of this concise description conceals the interpellation at work. ‘Patient self-selection' is the retroactive effect of the campaign when itis successful. A person who does not consider herself a patient or evennecessarily a sufferer comes to recognize a complaint as suffering and astreatable and therefore recognizes herself as a patient. Althusser called thisprocess of coming to see oneself as having already been a patient a ‘subjecteffect'. I call this process, when it happens through a scientific fact, ‘objectiveself-fashioning' because one's new identity appears to have been verified asone's real and objectively true identity (Dumit 2004).
This retroactive effect can also happen at a bodily level, within a subject's body, when an ache or complaint is reframed as a symptom. In the followingdescription, by patient compliance expert Dorothy L. Smith, the headacheis always already a symptom that the unaware consumer has mistakenlyignored.
DTC ads can make consumers aware that symptoms they have tried toignore, believing that nothing could be done, are actually the result of atreatable condition. For instance, a person who suffers from frequentheadaches may learn from a DTC ad that those may be the symptoms of amigraine and that there is treatment available. Those ads can give us hope.
They can help us identify positive steps to take. They can motivate us totalk with the doctor about subjects we find embarrassing. (Smith 1998) Furthermore, one recognizes that a third-party expert enabled this objective redescription of one's ‘symptom' as the truth of one's experience.
In addition to a subject-effect here, there is also a truth-effect. At this pointin the DTC process, the target is common sense. First, in the awareness step,I recognize that heartburn is a treatable medical condition and also that Ishould have known this. As a fact, it should have been part of my taken-for-granted background against which I examine the world. ‘If we think there isno treatment available for our symptoms, we may decide it's not worthspending the money on an office visit' (Smith 1998). Now, withpersonalization, I see that I may be suffering from this treatable medicalcondition. I may be a patient. What I now know is that I am a possible patient.
Realto's account of Prilosec (above) notes that it is ‘lucky' to have this built-in auto-identification ‘ouch' test. Then, the problem is only one ofmedicalizing a portion of experience. The bigger challenge for marketers isproducing identification with an asymptomatic condition, ‘making patients Pharmaceutical Witnessing recognizing themselves' despite feeling healthy. Medical sociologists andanthropologists have long used a distinction between illness as livedexperience framed by lay notions of suffering and disease as biomedicalknowledge (cf. Kroll-Smith et al. 2000). The aim of risk and symptompersonalization is precisely to fuse these understandings of illness anddisease together so that one talks in terms of medical facts, risk factors andbiomarkers, so that one literally experiences risk factors as symptoms.
Will the same approach work for a cholesterol-lowering medicine? No.
But if a way exists to make patients recognize themselves through anyDTC communication, therein lies the first lesson in consumer heath caremarketing. You can take it to the bank. (Realto 1998) The lived body must be reframed as no longer giving forth symptoms, but instead as naturally concealing them. One's body itself, as marked or measured,then takes the place of a bodily symptom. Even a basic demographic attributelike sex, race or age can become the basis for risk personalization and marketing.
In a commercial for the osteoporosis-prevention drug Fosamax, women areurged to recognize themselves first positively as healthy, active, successful andempowered, and therefore as at risk. It presents a number of such vibrant womensaying, ‘I'm not taking any chances. I'm not putting it off any longer. A quickand painless bone density test can tell if your bones are thinning. If they are, thisis the age of Fosomax.' The commercial concludes with multiple female voices: Bone density test?Bone density test.
Sounds like a good idea to me.
Ask your doctor about a bone density test and if Fosamax is right for you. For a viewer, identifying as a positive, healthy woman becomes identifying with the risk, which must be tested since it cannot beexperienced. A successful advertising encounter is one which accepts andinternalizes this uncertainty under a biomedical conviction: that one mightneed Fosamax, and only the bone density test can tell.
Targeting a slightly older demographic, a series of commercials for Zocor feature grandmothers and grandfathers, including the famous football coachDan Reeves, discussing how much they enjoy their time but how much theywant to see the future, their grandchildren's graduations, etc. They narratehaving had a heart attack and how diet and exercise were not enough tolower their cholesterol: I could dance all night back there. So I was thrilled when my grandsonwanted to follow in my footsteps. But before our first lesson, I had a heart Joseph Dumit attack. I needed to lower my cholesterol. How will you take care of yourhigh cholesterol and heart disease? Their doctor's information about Zocor gives them a salvationary solution: ‘Be good to yourself. It's your future. BE THERE.' This mode ofstorytelling provides an image of a responsible rational actor who uponhearing a new fact incorporates it through concern and then action. The veryact of reciting this tale repeats this process, passing on the informationalpossibility of risk to the listener, and the personalized possibility of taking itup responsibly.
Rhetorically repeating a tale about a fact is a mode of passing on the grammar through witnessing. The tale is told in the exact words that theviewer can in turn state for themselves, to others, and to their doctor.
‘Because I want to be there.' At the same time, the risk information istranslated from an ‘odds' sense of possibility to a powerfully imperative oneof probability. If you too are a woman or middle aged, how can you not ‘beready', ‘get checked'' and so on. Putting these tactics together requires aprecise effort at timing the market – coordinating public relations campaignsincluding mass media articles and doctor awareness so that biomedicalidentification and pharmaceutical conviction successfully take place.
Motivation to Informing Self-diagnosis
The goal during this pre-launch stage is not to motivate patients to seetheir doctors but to motivate them to respond for more information.
(Bolling 2003) Once identification has taken place and the person accepts a possible risk as their own, marketers see the next step as converting the possible intoactual risk, or in the case of symptoms, getting the patient to self-diagnose.
The next step of motivation then confirms this personal possibility as aprobability through some kind of objective self-assessment: a self-diagnosisthrough a checklist or another external tool. Self-help is promoted as a ‘free'activity, it does not cost anything to ‘see' if you fit the criteria. You do notrisk anything, you just take this simple quiz. Ambiguities of language in adsand teaser articles aim to induce curiosity and concern about one'sapparently neutral and healthy status.
Checklists and risk-factor charts are provided in DTC commercials, ads, news articles, on websites and in direct-mail pieces. The personalized patientis still a patient-in-potential, and these self-help techniques aim to createempowered self-identified patients whose next task will be visiting andconvincing their doctors of their condition and need for treatment.
Pharmaceutical Witnessing Checklists empower and disempower at the same time. The paradox ofchecklists is that while they appear to be a form of self-help they take thequestion of diagnosis, ‘Am I sick?', out of the subject's hands. Even if feelingsand experience are used to fill out the checklist, the algorithm then decideswhether or not these count as objective symptoms. The score one receivesthus takes the place of a lived experience of illness, the score can evenbecome its own experience. In this manner, one comes to verify that indeedthe possible risk or symptom is a true risk or symptom. One has gained notjust a fact about oneself but also a vocabulary, rationale and moraljudgement about the unfinished process.
Checklists thus function as a kind of rite of passage. Anthropologist Victor Turner described rites of passage as liminal processes in which a person issocially unmade and then remade into a different person – a boy into a man.
Within DTC campaigns, nominally healthy persons (prospects) becomesecretly sick persons – patients in waiting (Sunder Rajan 2007) – who areoriented towards becoming healthy again. In the DTC rite of passage, onegives up one's sense of self and health — the body becomes a silent traitorthat has concealed its condition. One then submits to the ritual of questionsin order to discover that the body really is disordered. If one is sick, thepromise is that one will then be treated and reunited with one's true self andtrue community. This process is enacted explicitly in many DTCcommercials. Figure 2.1 shows the visual images that accompany thecommercial for Zoloft reproduced in Table 2.2.
Figure 2.1. Zoloft Liminality (screen shot from TV) Joseph Dumit Table 2.2. Zoloft TV Commercial You know when you're not Drawing of fuzzy egg feeling like yourself.
(or neuron?) with sad face.
You're tired all the time.
You may feel sad, hopeless, and lose Egg cries. A ladybug interest in things you once loved.
approaches egg and egg loses interest, sighing.
You may feel anxious, can't even Nighttime, a crescent moon sleep. Your daily activities and comes out and egg starts relationships suffer. You KNOW when you just don't feel right.
Now here's something you may Text at bottom of screen: not know: These are some symptoms ‘Symptoms persist every day of depression. A serious medical for at least two weeks' condition affecting over twenty-million Egg looks surprised, then then sad again.
While the cause is unknown, depression Shifts to picture labelled may be related to an imbalance of ‘Chemical Imbalance', with naturally occurring chemicals between ‘nerve A' and ‘nerve B' with nerve cells in the brain.
little balls going from A to B. Text at bottom: ‘Dramatization'.
Zoloft, a prescription medicine, works Zoloft symbol appears as to correct this imbalance.
‘chemical imbalance' words fade, and black boxes appear on ‘nerve A' When you know more about what's Birds chirping, shift back to wrong, you can help make it right.
egg, who is happy and has grass growing near it.
Only your doctor can diagnose depression.
Butterfly comes and eggsmiles at it, then chases it.
Text at bottom: ‘Depression is a serious medical condition'.
Pharmaceutical Witnessing Zoloft is not for everyone. People taking Egg bounces past large Zoloft medicines called MAOIs shouldn't take logo, chasing butterfly. Text Zoloft. Side-effects may include dry at bottom: ‘Zoloft is mouth, insomnia, sexual side-effects, approved for adults 18 and diarrhoea, nausea and sleepiness. Zoloft older' then ‘See our ad in is not habit-forming. Talk to your doctor People magazine' then about Zoloft – the number one prescribed brand of its kind.
Zoloft. When you know more about Text says same thing with egg what's wrong, you can help make it right.
bouncing along. Then text atbottom: ‘1-800-6-ZOLOFT' The story in the Zoloft commercial mimics a Van Gennepian rite of passage as delineated by Turner. The subject, ‘you', begins separated,alienated by a series of descriptions that are aligned into accusations. Thebiomedical facts are then introduced in a reflexive, subjunctive voice, thevoice of liminality. These may not be your fault, they may be symptoms ofa biology. ‘You' at this point in the story is in the liminal state of being boththis and that, both mental and physical, accused and sick. You "know" youdon't feel right, but you need the commercial to tell you that the feeling is areal symptom. And the grammatical voice, as Turner observed, can thenshift form the subjunctive to the optative, from hypothesis and possibilityinto emotion, wish and desire (Turner 1982). ‘There is hope' a narratorexplains, ‘treatments are available'. The conclusion of the story is of coursere-aggregation, a return to society with a new status, a new, true ‘you'.
These stories are sanctioning themselves through the model of the rite of passage. They have appropriated the frame of the rite and packaged it forconsumption. From the point of view of Harding's conversion, the viewer isfirst called on to attend to interpersonal tensions as patterned problemsrequiring solutions, and then offered a narrative grammar that makes senseof them. Within the story, the shifts in status function as what rhetoricianKenneth Burke (1984: 126) called a ‘conversion downward' – in which thecomplex social situation of the distressed, struggling ‘you' is given a muchsimpler rationality of motivation.
Using a process vocabulary that overlaps in important ways with Turner's description of liminality, Harding attempts to characterize the way in whichone who is confronted by an evangelical who witnesses can ‘gradually cometo respond, interpret, act, as if believing [in Jesus], with or without turmoiland anxiety'. This process is not a social ritual, but rather, it is ‘a kind ofinner rite of passage' that involves acquiring a new form of ‘inner speech', a Joseph Dumit process in which one is gradually alienated from one's old voices becausethey no longer satisfy the gaps one experiences. One is cast into limbo,‘somehow in a liminal state', she says, ‘a state of confusion andspeechlessness, and begin to hear a new voice' (Harding 1987:170). Anumber of commercials explicitly elaborate this concept, where a voiceoveroffers a diagnosis and treatment and the patient says, ‘I feel like me again', ora loved one states, ‘I remember you!' These commercials and hundreds like them engage in a form of biomedical informing we might call pharmaceutical witnessing. Throughpassing on facts embedded in stories where the subject of the story ispotentially you, the viewer is put in a position of having to make sense of thestory or ignore the risk it portrays altogether.
Steve Kroll-Smith uses the self-test as an example in which the voice of experience and the voice of medicine are ‘beginning to converse outside ofthe once solid container of institutionalized medicine' (Kroll-Smith 2003:639). Kroll-Smith has studied the development, deployment and use of‘excessive daytime sleepiness' (EDS) as definite illness defined publiclythrough a Likert measure of excessive sleepiness, a self-test. He suggests that‘a person who self-diagnoses with EDS after taking [self-test] . is exercising,if only momentarily, an alternative authority [to that of modern medicine]'(Kroll-Smith 2003: 640). Calling for a both-and approach to illness anddisease, he suggests that popular media plays a crucial role in fashioningmedicine and bodily knowledge.
Stigma and social approbation are intimately associated with how persons come to think of themselves. Whereas Kroll-Smith uses contested diseases asexamples, marketers see the same media empowerment as useful foremphasizing ‘outsider' conditions and amplifying the power of the checklistover the consumer, and the consumer over the doctor. Marketers do not likestigma because they fear it will inhibit self-recognition of patient status andtherefore reduce prescription demand. They call these stigmatized diseases,‘diseases of denial', implying that individual psychology is at the heart of themarketing problem.
Diseases of denial can be broadly categorized as medical conditions thatmake patients feel excluded, rejected, devalued, inadequate, or guilty …That's one reason pharma marketers should facilitate undiagnosed oruntreated patients' self-identification and encourage them to communicatewith healthcare providers about treatment options. (Edlen-Nezin 2003) Marketers are here aligned with other sufferers who struggle to understand, accept and communicate their suffering as illnesses. Sufferersoften form their own communities online in discussion groups, and offline inmutual-help groups. In these sites, they actively invent ways of living with Pharmaceutical Witnessing their conditions (Dumit 2006; Martin 2007). Of course there are often manydifferent groups with different approaches to the same condition. Marketerswith treatments to sell actively court these groups whose interests align withtheir needs. They accelerate the circulation of these social innovations in waysthat also help sell products. The result is often a public service ‘educationaladvertising' campaign that draws attention to an illness by reifying it astreatable, and by destigmatizing it.
The marketers I have talked with regularly monitor online discussions of pharmaceuticals, they hold focus groups with patients, and some of them havehired anthropologists to conduct ethnographies of diseases. They consider oneof their greatest strengths to be finding a patient who eloquently expresses aprivate insight about an illness that accords with their mission to increaseprescriptions. Their job is then to amplify that insight so that others may cometo identify with it. Cutting and pasting is thus a fitting description of the generalcirculation and mediation of pharmaceutical experiences and practices.
Communicational media, mass media, everyday discussions and researchtechniques feed back on one another (Strathern 1992; Melucci 1996).
Turning worry into incipient action and navigating between hope and stigma thus requires precise attention to the live language of consumers aspotential patients who are struggling with a concern. Perhaps more than at anyother step, grammar matters when the personalized risk must becomeincorporated into the consumers' identity as a patient. Individual differencesamong persons thus require careful scripting in order to produce a massmarket. One marketer explained that the level of attention is increasinglyprecise: HealthMedia uses a combination of Healthcare technology and behavioralscience to design ‘action plans' that give patients tips, advice, and strategiesto obtain a healthcare ‘goal.' In essence, the action plans are the front endof a highly sophisticated customer relationship management program thatcan segment at the individual level so that each fragment of every sentencein the plan is customized and corresponds to how patients answer aconstellation of questions. (Breitstein 2004) Michel Pêcheux, in his study of language, ideology and discourse, found that motivation and identification were mediated by specific word choices(Pêcheux 1982). In the above passage, marketers manage these processesthrough empirically verified texts. Questionnaires are ‘meticulously' designedthrough ‘extensive market research'. Each question on surveys and checklistsis a psychological tool. At the conclusion of this step, concerned consumershave become worried, self-diagnosed potential patients who know what theyhave and want treatment for it. From a marketing point of view, they areempowered patients ready and motivated to see their doctor.
Joseph Dumit Convincing the Doctor, the Critical Moment
Marketers can generate significant product sales by motivating physiciansand patients to take action and by influencing their interaction. On theconsumer side, that means* providing enough information to patients so they can convince a busy, uninformed, or disinterested physician to prescribe the brand * getting more patients to fill their initial prescriptions* motivating patients to comply with their medication regimen.
With self-diagnosis accomplished, the goal of pharmaceutical promotion is still only half-way done. The potential patient must now get to the doctor,convince the doctor to diagnose and prescribe treatment, and the patientmust then take the drug and continue taking it. Marketing must now aim at‘pass-through persuasion', giving the patient the tools to convince theirdoctors. Doctors in turn, are seen as obligatory obstacles to be overcomewithout authority actually to make a diagnosis. Any resistance on thedoctor's part is seen as a lack of knowledge, of interest or of time. Thisreading may seem harsh, but it is constantly reinforced in DTC campaignsin spite of their required acknowledgement that ‘only your doctor can makethe diagnosis'. Some campaigns make doctor incompetence a direct theme,where the patient has to diagnose herself through seeing a commercial andfilling out an online checklist in order to convince the doctor of her truecondition.
The problem is that doctors also depend on these checklists which are essentially the only measure of an illness and treatment effectiveness thatotherwise is not perceptible to anyone, doctor or patient. In many cases,checklists developed in order to conduct clinical research have become bothmarketing and self-diagnostic tools (Healy 2002). This blindness anddisempowerment is all too visible in both the descriptions of emplotment ofdoctors by patients online – in which they discuss how to get what they wantfrom their doctor by saying the right things – and in commercials whichdirectly encourage such behaviour. The virtual world for the clinician isprecisely the self-identified world of the advertisement grammar. Asmembers of what Ulrich Beck calls risk society, we are prepared for the factthat many dangers are imperceptible to us, below our conscious perception,that we cannot trust our senses, but must trust instruments and othertechnologies of identification (Beck 1992).
Medical anthropologists Cheryl Mattingly, Mary-Jo Delvecchio Good and others have shown convincingly that even as they appear to be offeringpatients a choice, many doctors ask questions and phrase responses thatelicit the response that the doctor thinks is right. They have identified this Pharmaceutical Witnessing process as ‘therapeutic emplotment' (Del Vecchio Good et al. 1994; Mattingly1994). Similarly, when Martínez-Hernáez describes doctors' conversion ofpatient stories into ‘a language of facts', he was launching a critique of ‘theconversion of symptoms into physical signs; the suppression of authorship;avoidance of the message; and the meaningful intention of the complaint. Inshort, the intention of the reader comes to dominate, limiting the symptom tohis own interpretation' (Martínez-Hernáez 2000:248).
These critiques are quite perspicacious. The reification of symptoms often results in the evacuation of the meaning of suffering and delegitimates thespeaker's authority. But as patient social movements and DTC marketingshow, there is a counter-politics to this semiotics: patients often discuss insupport groups and online the possibilities to take this increasinglymechanical form of diagnosis and use it to emplot their doctors, telling themexactly what needs to be said to get what they want (Dumit 2000, 2006).
Martínez-Hernáez's notion of the ‘reader's domination' here becomes thedomination of both reader and speaker, patient and doctor, by the code oralgorithm, or symbolic domination (Melucci 1996).
Much DTC marketing, therefore, offers a consumer the precise language with which to accomplish this counter-emplotment. Through the focusgroups, interviews and fieldwork, marketers attempt to fuse personal storieswith the rules of diagnosis. Calibrated for maximum effectiveness, the scriptsthus simultaneously dumb down and reify the patient's experience intogeneric branded stories of suffering, and in so doing, empower them totranslate these stories into effective action in their doctors' offices — in orderto get what they ‘now' know they want. The doctors are in the end even moredumbed down and reified. For if a patient should arrive in the doctor's officesaying these words, the doctor will have little choice but to observe that thepatient has stated all the right things in the right way (Kravitz et al. 2005). Ina section called ‘Critical Moment', Realto's article describes how importantthis scripting is: All of the DTC communications for Prilosec aim at this crucial intersectionof physician and patient. The campaign primes potential gastric refluxpatients to report symptoms accurately and ask about treatment withPrilosec. (Realto 1998: 14) This situation of doctor-emplotment through witnessing was also illustrated by the Effexor XR antidepressant website (in its 2002 format). It was designedso that the first thing the viewer saw was a list of statements and was told to‘Click on the link that sounds like you'. Choices were: ‘Maybe I'm just down',‘I think I should see a doctor', or ‘I want to share my story with others'.
Clicking one of these brought up a page that did nothing other than offer thewords that best fit these feelings. There were no further instructions.
Joseph Dumit Maybe I'm Just Down
Does this sound like your situation?
Please note: The following story is fictitious and describes a general ‘After a few weeks, I knew something was wrong. Nothing really bad happened, but I was having more and more negative thoughts. At first, Ifigured it was normal to feel sad and empty (even hopeless) for a few days,maybe even a week. After all, I wondered, don't most people feel downevery once in a while? But I couldn't snap out of it. I started to get concernedthat something was seriously wrong. Why was this happening to me? Idecided to look for some answers.
‘I learned that I was experiencing the symptoms of a medical condition –depression – and that my doctor could help me feel like ‘me' again. I alsolearned that I should not feel ashamed or embarrassed because it wasbeyond my control. That's when I called my doctor.
‘It didn't happen overnight, but I really have come a long way.
Recognizing that I was experiencing the symptoms of a medical conditionand understanding that help was available was the best thing I could havedone for myself.' Do you feel sad and empty? Do you no longer feel like ‘you' anymore? Perhaps you are suffering from symptoms of depression. You may find somehelpful information in What Is Depression? or What Is Generalized AnxietyDisorder? and Symptoms of Depression or Symptoms of GeneralizedAnxiety Disorder. You might also want to use the Success Scale or seeEvaluation and Treatments for Depression.3 These pages are written in a non-reflexive manner. They are posed as fictional stories that tell your story better than you could tell it yourself. Thesituations are described in the past tense as personal testimony but they aregrammatically precise such that in repeating them you would obtain fromone's doctor exactly what you think you want. The isomorphism ofmarketing is here aligned with that of patient groups against a healthcaresystem, that for good or ill is attempting to resist the costs of increasingpharmaceutical interventions and maintenance. The net result is theaggregate increase in patients asking for and receiving prescriptions for dailymedicines. The final stage of marketing is then to have patients complete thepurchase and to continue to refill these prescriptions as long as possible.
Pharmaceutical Witnessing Companies are increasingly using physician-supplied patient starter packscontaining user leaflets, tips, FAQ advice, and patient diaries at the initialprescribing consultation to help ensure the right patient/brandcompliance from the start. Those packs create the basis of initial patientexpectations with resulting patient treatment outcomes fostering repeatbrand loyalty in terms of prescribing decision making and userpreference. (Hone and Benson 2004:104) The final stage is the payoff – one prescription purchased and hopefully many more in the future. Compliance refers to patients staying on theprescriptions they are given and refilling them. For marketers, compliancealso refers to the general gap between those who should be on life-long medsand those not.
The aim at this point is to cement a relationship between self-assessment, diagnosis and branded treatment – to integrate the pharmaceutical into theeveryday and reinforce a notion of dependent normality. The notion of a‘healthstyle', requires support from many different directions. The initial oneis through community with other patients. Second, brands are proposed asanchoring a patient's healing to future purchases. With brand loyalty comes‘product advocacy'.
Addressing those needs by providing valuable, customized informationwill not only foster product loyalty among patients, it will generateproduct advocacy. And there's nothing more powerful than patient-to-patient endorsements. Although a physician's recommendation may behighly credible, it doesn't carry the power of empathy and understandingthat a fellow sufferer typically conveys. Great brands not only becomepart of patients' health and perception of well-being, they become part oftheir lives. (Bolling 2003) Achieving this integration starts with knowing as much about patients as possible, and making sure that they understand ‘the need to take medicationdaily', ‘how to convert education to action', and to ‘associate theirmedication with being sick or well'. Above all, researchers need todetermine: ‘Do patients accept that they have a chronic disease or conditionand need to continue to take medication for it, or are they in denial that theyneed to do that?' (Bolling 2003). Contrary to writing on chronic illnesses thatstem from pain or fatigue or suffering, none of these issues are taken forgranted with these lifelong pharmaceuticals aimed at asymptomaticconditions. This explicit manipulation of unfounded fears offers insight into the Joseph Dumit single-mindedness of marketing. The war here is between companies,branded versus generic multinationals, in which patients are the means, theirminds the instruments used in waging the battle. Bolling goes torecommend: ‘Overall, the key is to increase consumers' comfort level sothey're resistant to change if faced with the option to switch' (2003:117).
In liminal situations, Turner argues, we develop our grammar, ‘ways oftalking about indicative ways of communicating … We take ourselves for oursubject matter' (Turner and Turner 1992: 137). Perhaps even in subliminalmarketing experiences, we develop and refine our modes of expressivity,changing our minds in order to change our bodies. In addition to his carefulattention to the grammar and creativity of process, Turner constantlyattended to the role of the anthropological writer who must always makechoices in where to locate agency in process: in the individual, the socialstructure, or to strive for some sort of balance. Here I have portrayed thepharmaceutical marketing encounters with an emphasis on how they canconvict some people some of the time. In other work, I have stepped back,behind the focus groups to see how activists and everyday acts of creativityand resistance have shaped the terrain of the doctor-patient encounter andinvented most of the forms of informing that marketing has in turn taken upand amplified (Dumit 2006). Health activist groups today are often in a dilemma as to whether or not to accept funding from commercial, especially pharmaceutical sources.
Roddy Reid has described how even anti-smoking activists have beencaught off-guard when they are offered money by Novartis who considersthem to be helping to grow the market for nicotine patches and smokingprevention pills. Many drugs work, much of the time, for most of the people they are intended for. The issue at stake in DTC for marketers is how to continue togrow the market big enough and fast enough to keep up with investors'expectations, often stretching the evidence from clinical trials. Many of thecurrently used pills do work to modulate our bodies in ways that we may notbe able to describe completely, but which we nonetheless desire for curative,preventative, experiential or experimental reasons. However, we have fartoo little data and are not in fact collecting data as to the long-term effectsand side-effects of most drugs, as to the interactions between chronic drugs,nor of the positive dimensional effects like enhanced school performance,mood brightening, and so on. Especially consider the increasing tendency toadd drugs in treatment algorithms for the side-effects of a previous drug.
The expressivity of the commercials, websites and marketing efforts Pharmaceutical Witnessing remains my key concern. To the extent that they do posit objective self-identification of feelings and possible risks as symptoms, I wonder where,when and how self-talk adopts and deploys this new grammar within andalongside other modes. The topic of my ongoing work is the invention ofways of living within this pharmaceutical world. As much as marketingprovides potential patients with the exact words with which to emplot theirdoctors into providing them with their pills of ‘choice', people also share anddisseminate counter-strategies to avoid certain drugs, to calibrate their owndoses through splitting pills, and to explore alternative treatments,alternative diagnoses and alternative explanations. For the moment, though, the average patient, by which I mean the marketer's average, comes to experience his or her body underpharmaceutical conviction. This body is silently disordered, counter-experiential, waiting to be evaluated and measured in order to speak. Thisbody is always under construction. For more and more Americans, health isa sign of concern, health is something they must see a doctor for in order toward off the invisible risk they have been taught to worry about. Treatmentis neither an imposition or a choice, it is increasingly ordinary.
1. Consonant with Turner's distinction between liminal (pertaining to more traditional societies where rituals involve the whole social group) and liminoid(pertaining to industrial societies where individualization both flattens ritualsinto ceremonies and invents the social categories of leisure and the arts). Theprocess that Harding describes is individualized and, more importantly,antagonistic. It borders on manipulation, and is not unsurprisingly called‘brainwashing' by those who are outside of evangelical culture and see onlythe external effects of conversion. Conversion as a practice, and coming underconviction as an experience, require an extension of liminality in the directionof the sub-group or competing groups within a culture – pointed to by thefelicitous term, ‘subliminal', a term that connotes a form of liminality at a subconscious, sub-social, or social unconscious level.
2. According to his by-line, ‘Vern Realto is a virtual contributing editor to DTC Times, a composite of regular staffers and other advisors'. As a composite,Realto thus speaks the collective wisdom of the pharmaceutical marketingindustry, precisely the level of enunciation I am interested in analysing.
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2nd International Conference on Multidisciplinary Research & Practice P a g e 182 Purification of Chlorzoxazone by Adsorption A Bharucha1*, V Patel1, C Patel1, C Prajapati1, A Parmar1, V Desai1, A Sharma1 1Chemical Engineering Department, Sarvajanik College of Engineering and Technology, Surat, Gujarat Abstract: Chlorzoxazone (C7H4ClNO2) chemically 2-hydroxy