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August 29, 2005

PHARMA: The Industry Veteran, on what the Vioxx verdict means

After too long an absence, The Industry Veteran is back to tell us what's really the problem going on in big Pharma. It's that short-term thinking has invaded its strategic marketing. I remeber being at a meeting in 1998 where then consultant and now big cheese at United Healthcare Bill Whitely warned pharma clients about becoming so keen on being consumer companies, and I think the Veteran would agree. Here's the Veteran's restrained tone (and I'm not kidding this time!)

A recent piece in a UK newsletter got me to thinking about some implications of last week’s Vioxx verdict. The newsletter contends that the core of Big Pharma’s problems began in the 90’s when marketing rather than research began to direct the industry’s course.  I would draw some other implications from the Vioxx scandal. 

First, Merck’s malfeasance amply illustrates an argument I have made elsewhere on THCB: the Bush/Right Wing goal of an unregulated market for pharmaceuticals and most other aspects of healthcare remains delusional. Contrary to hosannas from market true believers, sick people either lack the time or the repose to make rational, profit-maximizing choices. Even if they possess such detachment, the asymmetry of information operating against them militates against rational, well informed choices. Moreover, consumers-patients have no idea of the bundled cascade of services or costs that follow from their choice of, say, a doctor or a hospital.   

A second lesson of Vioxx is that many other parties must share some blame with Merck for furthering the promiscuous overuse of COX-2 inhibitors. Physicians and their professional societies now proclaim in high dudgeon that they were unduly influenced to overprescribe the COX’s by pharmaceutical sales reps, bountiful sample packs and deceitfully published articles. In fact their current wailing amounts to an admission that clinicians and their organizations failed to fulfill their professional responsibilities. For years the societies and the state licensing boards allowed physicians to complete their continuing medical education requirements by attending company-sponsored events. The manufacturers have been only too happy to relieve physicians of the need for footing the bill to keep up with advances in their  respective disciplines. Now the same physicians and their accomplices self righteously complain that they have been influenced by promotions. Do they honestly expect us to believe or empathize with their purported shock and outrage, expressed with all the sincerity and histrionic skill of WWF wrestlers?

The third-party payers also contributed to Vioxx’s 150,000 hearts attacks and 50,000 deaths. These organizations failed to scrutinize the COX-2 studies and placed those drugs on their formularies, often without even the disincentive of higher co-payment requirements. Their coverage of the COX-2’s was not merely a result of deference to physicians’ preferences or consumers’ demands as much as it was an acceptance of bribery. Merck, Pfizer and the other manufacturers offer competing rebates on their products, thereby reducing pharmacy benefit costs for the payer organization. In such cases the HMOs’ formulary committees and their pharmacy benefit managers eagerly swallow the manfacturer’s claims of efficacy and safety.

Contrary to Drug Researcher’s arraignment of marketing as the Vioxx culprit, I would claim that Merck and other Big Pharma companies practiced short-term gouging and exploitation that are the very opposite of smart marketing. Over the past 25 years the pharmaceutical industry has  enjoyed extraordinarily high returns on equity, assets and sales, often the highest of any global industry.  The American public has permitted the industry its enormous margins because of an implicit covenant. The pharmaceutical industry’s obligations under the agreement have included the following.

(1) The industry must develop products that the public perceives as substantially improving the length and/or quality of life by advancing, each decade, the standard of care in one or another disease condition. Pharma came up short here. The number of new molecular entities that have appreciably advanced the standards of care within the last 10 years has declined considerably. The research paradigm of medicinal chemistry has already “picked the low hanging fruit” and the public correctly perceives that the industry uses a considerable portion of its research budget to develop patent-extending knockoffs.

(2)  The industry must promote its products in a restrained, professional manner. This sotto voce element of the agreement went out with the trash in April of 1997 when industry lobbyists prevailed on Congress to permit direct-to-consumer advertising on a virtually unfettered basis. The restraint and scientific rigor befitting a research-driven industry conjoined to the medical establishment soon vanished. Big Pharma’s public face was no longer esoteric or dauntingly technical in a manner to command respect. Instead it began to advertise cholesterol medications with Dr. Seuss ads and southern football coaches. Pain relievers were promoted by ice skating champions and glamorous, middle-aged models doing tai chi in the park. The public can endure such fantasy and hyperbole when it comes to soft drinks or automobiles that sell good times and sex over the intrinsic features of those products. When Pharma stooped to the same lowest-common-denominator, however, its exalted image went out with the empty bottles of Pepsi.

(3)  The industry must not price its products beyond the reach of its core customers: the elderly.  Pharma’s lobbying group, the PhRMA, and its lackeys in the media (e.g., the Philadelphia Inquirer) still adamantly contend that Americans must pay double and triple the prices paid by Europeans and others to fund further research. For a while that argument maintained traction but the public now knows that Pharma spends considerably more on SG&A than on research while the total compensation of top executives runs from $30 million to $50 million a year. Of course the concurrent erosion of the wider, employment-based health care system has also helped take the veil off Pharma’s unconscionable pricing. As tiered co-payments became the norm, 28-year old mothers who purchase oral antibiotics for their children must now pay $20 and $30 for the same products that used to cost them only $5 or $10.

In short, Pharma has cooked its own golden goose by failing to meet expected standards for product development, by deceptively huckstering its promotions, and by using spurious rationalizations to overcharge its customers. That, ladies and gentlemen, constitutes the opposite of elementary marketing principles. Perhaps I might then differ with Drug Researcher by saying that Pharma has switched from a research-driven industry to one that is driven by bad and unethical marketing.

August 29, 2005 in Pharma | Permalink


Exactly Matthew, and why you are the only one who will call a spade a spade is beyond me, it's pathetic. Not only are you correct that the poor 28 year old single mothers' co-pays and co-insurance are going up on Rx, on the ever-eroding-dangerous-group-health-employee plans; but they are also paying with after tax dollars, no kiddin'. Employer HSA deposits are never taxed, not even FICA. Every 28 year old, broke, single parent mother is paying FICA tax, at a rate over 7%, matched by employers, there is no way out of it. In contrast, when employees use tax free HSA funds everything that's medical, vision and dental are purchased with untaxed funds, it's sweet. So basically, employers should ban together with employeee,s and partnership, and cut the IRS and the Fed's taxation, out. I like to call it compensation without taxation.

It bugs me these marketeers of "health care" can line up their tents and bribe politicians. It's so bad that when Katrina wiped out all these busineses here in Florida, back when it was only a cat 1 storm, state law requires that all employees, with businesses that have closed, lose their employer sponcered health insurance. I guess no one considers that when a company goes bust all employees shouldn't lose their health insurance and the ability of paying just co-pays and co-insurance on Rx. Some of these employees are diagnosed and their medications are hundreds of dollars a month, and rising.

The good news is the consumers are becoming empowered. Consumers want an easy, online, turn-key system that supports all administration needs. Yes, I'm taliking - Research drugs, prices and track personal prescription history. Reshearch available doctors. Compare hospital cost and quality data. Knowledge is power.

I wish I could have been at the meeting when United Health Care decided to purchase Golden Rule Insurance Company. The business model of the itty-bitty-little company wipes out the business model of the great big huge monster that will find reform a little tough to survive. Sometimes a CEO has to look in the mirrow and decide if civilization would be better without them, that's for sure. Down sizing is an art form. Lucky for shareholders that nobody is talking about stock prices and health care reform, yet.

The magic of the tax free HSA and Republican Health Care Reform, knows no bounds. Not all single parent mothers are broke, like doctors. Many mums are paying big time taxes. A woman paying 30% combined state and Federal income taxes, not CA or WI, ha ha, combined with 7.65% FICA, is a whopping 37.65%. The maxumum her employer may contribute, to her portable tax free HSA, is about $5,000 a year or $416 a month. Check it out, this woman would save $153 a month, in heavy taxes (FICA, Ferderal and State income tax) with her Employer tax-free HSA deposit and HSA health insurance is available for a non-smoking 28-year-old female and dependent child for only $62.40 in Lansing, MI. Insurance I might add, that pays 100% on Rx, after the deductible, to a lifetime max of $2 Million, per person. This hardworking single mother saves twice the amount of her own taxes with an employer HSA deposit than the cost of the health insurance, it's like magic. I tell clients and young single mothers that the HSA is a little like pulling the sword from the stone when the wolf is at your door. That usually works pretty good.

It's not magic, it's just math.

If the propaganda of the pundits, politicians and press won't tell you, Mathew will.

Reform isn't coming, reform has begun, thank God.

Posted by: Ron Greiner | Aug 29, 2005 6:59:07 AM

I agree. Companies like Merck have ignored the basic principles of doing business - treat customers with respect (by putting customers ahead of profits - if you treat your customers right, profits will come; you do the opposite, and you are dead), be concerned about creating value for them (by improving their health and doing no harm to them, in this case), and not rely on regulation to survive (if you need the help of politicians to stay in business, you are dead as soon as a new politician comes in).

Posted by: iproceed | Aug 29, 2005 8:27:10 AM

Please remember---I didn't write this! It's from the Industry Veteran, who's forgotten more about the pharma business than I will ever know

Posted by: Matthew Holt | Aug 29, 2005 9:04:56 AM

Hey, wait a minute. Industry Veteran says that "Physicians and their professional societies now proclaim in high dudgeon that they were unduly influenced to overprescribe the COX’s by pharmaceutical sales reps, bountiful sample packs and deceitfully published articles."

I agree with IV that physician marketing surely made Vioxx Merck's prime revenue driver. But I'm not aware of physicians or their professional societies admitting it. That would be a startling admission of complicity. And such conduct would violate the AMA's bylaws, which clearly state: "No physician shall ever admit to having been influenced by pharmaceutical marketing, not even a smidgen."

Can IV or anyone else provide a cite?

Posted by: TomHilliard | Aug 29, 2005 9:30:19 AM

The way the American system is supposed to work, in the "free market", is that the companies are supposed to be fully liable for what they do wrong. Large verdicts, measured by the degree of wrongdoing, are supposed to motivate the company to be responsible so that we do not have to have a massive bureaucracy watching everything they do.
The problem is, “tort reform” actually is an attack on the American free market system. We don’t have Europe-style governmental regulation, because in America, lawsuits are part of “free market” regulation. Lawsuits making companies responsible for their own wrongdoing, are intended to allow them to self-regulate. That is why “tort reform” actually is an attack on the American free market system. Insisting on no real regulation, while we’re also eliminating American-style “freedom to make a mistake”is foolish. The founding fathers allowed freedom to make a mistake but then have you have to pay for it in a civil suit. Having to pay for it is a company’s biggest incentive to “do right” in the first place.

Posted by: Tim Knight | Aug 29, 2005 9:48:58 AM

This is excellent. There was one detail I caught that I bet no one else did. The concept of "asymmetry of information" mirrors the Bush Administration concept of terror as "asymmetry of war". Bush has set the tone that validates aggressive action to correct asymmetries. I'm hoping the poor will also act to correct the asymmetry of opportunity while we're at it. ;-)

//No physician shall ever admit to having been influenced by pharmaceutical marketing//

I think Big Media deserves some credit here: the only reason know about (or "have a vague sense of?") pharma marketing to physicians is that this crops up from time to time on medical dramas on TV. However, I did notice that on recent one (House?), the pharma rep was portrayed as a normal professional instead of a Minion of Hell. This made me wonder whether show sponsorship was changing the way pharma marketing is being represented. If so, that would be a pity, because this was a case of drama giving the average TV-watching Joe/Jane an insight about the way the world worked.

Posted by: gadfly | Aug 29, 2005 9:50:28 AM

//Having to pay for it is a company’s biggest incentive to “do right” in the first place.//

Exactly. I also wonder if the reason class action lawsuits seem to be increasingly prevalant on the consumer side is that individuals have been priced out of the ability to use the law to make companies "do right". If the citizen can't afford a lawyer, or if lawyers hesitate to take on the block-and-tackle resources of a big company because they don't have the resources, then big business always escapes penalties by default. The citizen doesn't even have the money to keep "showing up" to press their claim. The combination of resources and potential pay off of a large class action is the only "incentive to do right" that's left. If you just ask big business to do right, they ignore you like a little tiny bug not worth scraping off the bottom of their shoe.

One of the things that upset me about the "Oprah" analysis of the jury was that it focused on the strategy of the Plaintiffs, which may incline people to associate this sort of approach with class actions. This takes all the nobility out of trying to make big business do the right thing. Big business set the standard for these tactics, since they have the resources to bring in all sorts of consultants: someone should be making it clear that the legal system has already been bought - class action just allows the consumer to buy in as well.

From my own situation, I'd like to point out that even if you file in forma pauperis, no one pays for the vast amount of paperwork (copying, printing, faxing long distance, etc.) and the physical transmission of papers. Therefore, even if the system sees you as a pauper, they allow the side with the most resources to extract a financial burden until they win by default. Therefore, even at the lowest levels, the legal system tends to deny the poor access to justice and uphold the interests of the wealthier party.

Posted by: gadfly | Aug 29, 2005 10:07:54 AM

OK, what's the solution?

I've heard no DTC advertising and no sponsoring CME. After that saves a net $6, what's next? Federalizing R&D has been proposed since it has worked so well in every other industry in which it has been tried (e.g. ?).

Do we need MORE regulation or LESS regulation? A FASTER or SLOWER FDA-approval process? CAPPED or UNCAPPED non-economic damages. Each of these diametrically opposed policies have been tried somewhere, somehow, with relatively modest success depending on how you measure them. No one here (myself included) seems to be satisfied.

Personally, I think the whole system needs to be scrapped, but that ain't going to happen. So what's Plan B?

I think the problem IS the consumer; everything else is just rearranging the proverbial deck chairs. The bottom line is that people want healthcare to be cheap, fast, and good. Any 2 of the 3 is easy, but all 3 is a monumental undertaking. How the U.S. consumer defines cheap, fast, and good, I think, is the stumbling block in the whole system.

Cheap is defined as free; fast is immediate; and, good is perfect. Since this is an impossible standard, either we try and meet it anyway, which is what has put us in the mess we find now (in my opinion), or we change the consumers' preferences (i.e. marketing...GASP!).

Other countries have struck this balance by a social contract that accepts trade-offs in these 3 goals. The U.S. has not (in general), hence, the problem we have is an inflated incremental cost of care. Arguing which country has better quality of care is fruitless, since how the end-consumer in the U.S. and the other system stakeholders define quality is different. Consumers need to be presented with a "value proposition" and make them responsible for the incremental cost of outcomes-- just like buying a Kia vs. Pontiac vs. Mercedes with various financing options available. That, my colleagues, is how a market-oriented healthcare system should work.

Alternatively, a quasi-state-run universal system can work as well (as in other countries), but not until the U.S. consumers' preferences (see above) are changed to accept the "value proposition."

But I think we can all agree that lawyers suck. Give me a "loser-pays" tort system, and I'll be satisfied.

Posted by: Joe C. | Aug 29, 2005 10:15:50 AM

// lawyers suck. Give me a "loser-pays" tort system,//

But that's the problem right there. It's becoming increasingly clear that the winner/loser in the tort system has nothing to do with right/wrong or any sort of justice. It's about who can pay the most. Even if consumers have class actions to challenge the resources of big business, the winners and losers are still being defined by how much money they can throw at the case (or risk investing in for big pay offs). That's incredibly demoralizing to average citizens, who want to believe in a guilty/wrong-pays tort system.

Posted by: gadfly | Aug 29, 2005 10:32:03 AM


I'm glad you didn't write this above// the Bush/Right Wing goal of an unregulated market for pharmaceuticals and most other aspects of healthcare remains delusional.//

Who ever wrote that has their head in the sand and refuses to accept the truth. President Bush passed sweeping health care reforms and the tax free HSAs before the Liberal Lithargic Left even knew it was on the table. Now that's what I call effective leadership.

Posted by: Ron Greiner | Aug 29, 2005 11:42:17 AM

Ron -- Please vaguely try to keep this on topic, which is pharma marketing. And I'm glad that your boy Shrub is showing such devastingly strong leadership in figuring out how to deal with the mess Cheney, Tenet, Rummy and all got him and us into in Iraq.....I am convinced that Mountain Biking is indeed the solution to all of our nation's problems--so he just needs to do more of it.

Posted by: Matthew Holt | Aug 29, 2005 12:17:40 PM

FYI gadfly

"Aysmmetrical warfare" is not a Bush administration term, or even a "neo-con one", it's actually a War College one. They just happen to use it a lot because they are fighting one, or at least blundering around attempting to.

If you're interested, look here:

The key thing to think about is that that in most aysmmetrical relationships, the group which you'd normally think would have the advantage (the team with the most aircraft carriers, lobbyists, handsome marketing professionals, whatever) actually finds itself at a significant disadvantage.

This is a function of political gravity and a number of other factors. It also has to do with perception.

The larger and stronger you and your company (or your armed forces) are, the more likely you are to be perceived as threatening.

This is a big problem for the U.S. in places like Iraq and Afghanistan where people aren't likely to believe lines like:

"Oops. That precision guided missile which demolished sixteen houses and a cow was an honest mistake and we feel really badly about it."

Its also a significant problem for a large multinational corporation setting out to convince a twelve member jury people that it did no harm.

And that it really is, after all a nice friendly neighborhood corporation ...

I'd never thought about it before, but there are some interesting and possibly rather valuable comparisons to be drawn here.

Posted by: jib | Aug 29, 2005 12:21:54 PM


It works in Europe. Why is it that some have no problem coveting their health care systems, but not their tort system.

I also don't ascribe to your premise that whomever has the most money wins. [See and (full paper can be downloaded)]

Posted by: Joe C. | Aug 29, 2005 12:42:00 PM

//"Aysmmetrical warfare"//

Thanks for clarifying the definition - I actually thought it meant something quite different. I thought it meant something like guerilla warfare. Re: the conflict is asymmetrical because the conventional rules don't work or one side isn't abiding by the rules. I find the actual meaning somewhat scarier in that it takes the questionable concept of Might Makes Right and turns it into Those Little Guys Aren't Fighting Fair. Sort of a strategic inversion of moral worldview.

That said, I absolutely think that Pharma vs. Wronged Consumer is Asymmetrical Warfare. Also known as the return of the repressed moral economy of the crowd.

Posted by: gadfly | Aug 29, 2005 1:35:47 PM

Joe C. -

Thanks for the links - I'd certainly rather be living in Europe (but I may take Canada at this point), and I will read the articles with interest.

However, as a person involved in corporate Asymmetrical Litigation right now, it seems to me that money does win. The Judge had the discretion to not hear you or punish you for your lack of legal training by extending the process if they don't like clients to represent themselves. However, even if someone needs a lawyer, that's no guarantee they will get one: some people have no choice but to try to represent themselves. Apart from the legal training issue, the cost of being involved in litigation is prohibitive. As mentioned before, the cost of the paperwork involved is not subsidized for the poor. A large corporation can just force you to keep redoing the paperwork. For instance, Kaiser has just blown off my Discovery papers for the FIFTH time. I can only address this by bringing a Motion before the Judge, but every time I've tried to bring a Motion so far, the Judge has elected not to hear me over some technicality. Since I have no income, I will eventually just not be able to transmit papers anymore. Therefore, Kaiser will eventually win because they have money, and I don't.

Posted by: gadfly | Aug 29, 2005 1:43:44 PM

Jib -

//The larger and stronger you and your company (or your armed forces) are, the more likely you are to be perceived as threatening.//

Because this is all about perception, as you say, does that mean that as the stereotype of the terrorist is assimilated into the common culture, the little guy will actually be perceived as more of a public threat? (re: sneaky, subversive, etc. vs. the "sense of stability" provided by a huge corporate facade). That analogy could change how juries think. Then warfare will be asymmetric in the Might Makes Right sense again. :-(

Posted by: gadfly | Aug 29, 2005 1:53:39 PM


In the real world it's hard to get an employee group health plan anymore that pays 100% on Rx without it being an HSA qualifying plan.

Yes $30 co-pays, but this article didn't mention PLUS 30% to 50% co-insurance on Rx, which is becoming the norm. Then employees pay with after tax dollars which really increases their costs on drugs. Drugs alone can cost hundreds of dollars per month.

You go off topic when you say Americans dying to give Iraq women the right to vote is wrong. We voted on this during the election and the President beat John Kerry, thank goodness.

John Kerry wanted American taxpayers to pay claims above $35,000 for group Health Employee Plans, like Blue Cross of MA. Oh please, now tell me that big insurance companies wanted President Bush, that's just liberal propaganda and brainwashing.

It was President Clinton who said, "Most Americans have their health insurance through their employer and we should build on that system." He forgot to mention, like you, that employee group health plans cherry pick the sick people, who can't work anymore, for insurance termination, it's so cruel. Have a heart Matthew. Lucky those group plans are losing market share so fast. It's a little like Democrats in Congress.

I know it's hard to discuss the truth when you are trying to make a fast buck as a consultant to these merchants of death, group health plans. I think you are a little biased where I'm pretty fair and balanced.

Posted by: Ron Greiner | Aug 29, 2005 3:19:47 PM


Actually, guerrilla warfare does qualify as a form of asymmetrical warfare, as does terrorism. The two are considered closely related by the people who study such things.

The dividing line between the two is an interesting and highly political one, of course, but that is another story ... for a different blog. ;>

I may be wrong but I think the lessons of 'asymmetrical warfare' actually leave the little guy in pretty good standing.

According to the logical of the asymmetrical relationship, the big guy will always win the first fight with the massive application of force (the classic example: shock and awe) or, in the pharma context, resources (dtc spending perhaps?), but as time passes that victory will prove to be unsustainable.

That of course begs the question: "What is victory?"

Is victory seizing a market segment (or a nice little country somewhere) for temporary gain?

Or is it finding a way to win gracefully?

In a way which does not guarantee future problems?

It seems to me that pharma would do well to study the
situation in Iraq and Afghanistan very closely and try to see if the parallels make things any clearer.

That comparison isn't meant to demean or insult the industry in any way. I'm not suggesting anybody is a terrorist or making any other snarky insinuations.

I think its a legitimate point: if you have overwhelming force and an absolute advantage - you need to think very carefully and creatively about how you use that force.

Because in the end, the little guy always wins.

Posted by: jib | Aug 29, 2005 4:27:02 PM


You wrote,//It seems to me that pharma would do well to study the
situation in Iraq and Afghanistan very closely and try to see if the parallels make things any clearer.//

Please, that means nothing. I have an idea because Liberals never answer a question. You should ask Matthew to explain why he does not write about group health plans terminating cancer patients because they are too sick to work 30 hours per week. He has had plenty of time now to consider a reply so why don't you get him to write about it. He will listen to you.

Trust me, if he had an answer he would have already said it, which he didn't. Or Jib, maybe you could just answer the question yourself. Or any other Liberal is welcome to answer the question too.

Posted by: Ron Greiner | Aug 29, 2005 6:14:55 PM

Well said Ron.

Except you've made my point.

For some reason - perhaps because I used the words "Iraq" and "Afghanistan" - in my comment, you're assuming that I'm coming at this from a particular angle.

That's misperception in action, Ron.

It apparently hasn't occurred to you that its possible that I might not be saying what you think I'm saying.

As a matter of fact: you're dead wrong about where I stand. I actually (with a number of misgivings) support the war in Afghanistan, and to a lesser degree, the war in Iraq. At this point, I suspect withdrawal would mean horrors we cannot even imagine. But that's getting off topic.

My point has to do with understanding aysmmetrical power relationships and aysmmetrical challenges.

To boil things down a little bit: the U.S. is a big, powerful country, with an image problem.

As it happens pharma is a big powerful industry, with an image problem. I think we can agree on both of those things.

By comparing and contrasting we can probably figure some things out. I think we should be neutral and attempt to learn something from what is going on here:

Two very powerful entities have run into big problems.

Both have overwhelming superiority in a number of senses. They can do what they want, when they want, to whoever they want.

In basketball terms: they own the court.

Yet it seems like both are running into one problem after another after another. Whats up?

Simple answer: its tough being the biggest kid on the block. So you have to be extra careful about what you do and how you do it.

Posted by: jib | Aug 29, 2005 7:41:33 PM

// the lessons of 'asymmetrical warfare' actually leave the little guy in pretty good standing.//

In the fact of warfare yes, but in the "publicity war" no. The little guy would be in better standing with a term like "complementary warfare", which would imply a fairness in the distribution of power. In the definition you gave me, the little guy sound more scary and threatening because the big guy does not have an adequate response.

// in the pharma context, resources//

Say, using temporary inflation of stock to buy up other companies?

// in the pharma context, resources//

Isn't the gain always temporary because of patent law? The anticipation of an expiration date would deform the market right there.

// in the pharma context, resources//

Perhaps they are counting on the fickle and harried American public having a short memory? ;-)

//I'm not suggesting anybody is a terrorist or making any other snarky insinuations.//

I see what you're getting at, and it's a cool comparison.

//Because in the end, the little guy always wins.//

Well, there is a certain sense that there is a relationship aspect of business, and going for the quick and easy target now at the expense of other people will destroy those relationships (and keep objectives that require a team effort out of reach). Hey, I just thought of a really cheesy analogy: this is sort of like the new kid who joins an online game who immediately ticks more experienced players off by random killing or stealing more than their share of loot. The other players hate on the newbie, and then he's banned from the game.

Unfortunately, I'm pretty much a cultural pessimist, so I don't believe the little guy always wins. Here's my model: Big Guy tries to dominate and underestimates the Little Guy's ability to resist. Little Guy gives Big Guy a taste of their asymmetrical resources. Big Guy is surprised for a minute, but then calls all his cronies in Government, Media, etc. Big Guy repairs any problems through a massive PR campaign, and their stock price bounces back after a "rough patch". Little Guy dies in ditch. Best case scenario is someone writes a commemorative poem and/or makes a serious documentary about meaningful the Little Guy's stand was, lol. :-)

Posted by: gadfly | Aug 29, 2005 11:42:33 PM

//Simple answer: its tough being the biggest kid on the block. So you have to be extra careful about what you do and how you do it.//

I think it's tougher than ever in a modern economy, where everyone is basically a dependent of the larger economic system. If you represent the system, and you try to cut off your dependents, then any breach of faith can become a bloody war for survival.

Posted by: gadfly | Aug 29, 2005 11:45:58 PM

"Contrary to hosannas from market true believers, sick people either lack the time or the repose to make rational, profit-maximizing choices"

I propose we turn over the power to recommend and make available information on health related issues to a central committee. For too long have people had the burden of responsibility when it comes to their own health. It is ridiculous to expect that people can go to trusted doctors or people close to them in their communities and form any sort of reasonable opinion on medical options and care. It is time we established standards and enforce them across the country. People are not making the right choices and are dying from them. How many children have to suffer before we stand up and protect people from themselves?

Posted by: Chad | Aug 30, 2005 3:37:24 PM

//It is ridiculous to expect that people can go to trusted doctors or people close to them in their communities and form any sort of reasonable opinion on medical options and care.//

Without transparent market information how can anyone make a reasonable decision about anything?

Of course the ability to make a decision won't help me when the EMR puts a point-of-sale guardhouse at every door, and I don't have the money for a basic antibiotics.

While you laugh at that scenario, I'd like to point out that I have a staph infection right now, and I didn't get antibiotics from the ER (the only place I could go).

Posted by: gadfly | Aug 30, 2005 5:47:54 PM

“Without transparent market information how can anyone make a reasonable decision about anything?”

Perhaps you misunderstood what I was saying. You cannot make a reasonable decision without transparent market information. That is why information on products needs to be cleared by an agency of some sort empowered by the people to decide on objective truth. I am sure when the merits of your staph infection are decided a functionary will release the antibiotics to you. I know the wait is disconcerting, and you no doubt believe you have a staph infection, but it is important that people smarter than you decide before entrusting you with a substance of such power. If you are determined to be of sufficient mental capacity, you may even be allowed to self-administer them.

Posted by: Chad | Aug 30, 2005 6:09:17 PM

//cleared by an agency//

As much as I agree with the need, I totally got a whiff of 1984 from that sentence. Anyone remember the Ministry of Truth, lol. :-)

//believe you have a staph infection//

I have a staph infection diagnosed in the ER. Maybe the correct word is "guessed" by the ER, since I didn't actually have blood tests or anything.

//people smarter than you decide before entrusting you with a substance of such power.//

Actually, I'm not a fan of antibiotics, and in the past they've made me really sick. I was just pointing out that being sick doesn't mean you get care as it is: it'll just be worse when we have point-of-sale medical center management.

I'm supposed to go back for a follow up, but I can't really imagine spending another whole day at the county hospital.

Posted by: gadfly | Aug 31, 2005 12:11:34 AM

Score three sarcasm points for the chadster.

Let them be self-administered.

Posted by: jib | Aug 31, 2005 11:25:10 AM

Gaush! scandals every where, when will they stop will the world every be able to overcome this drastic problem.

Posted by: CNA Training | Jan 13, 2011 12:08:13 AM

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