By Mikkel Brok-Kristensen & Morgan Ramsey-Elliot
If you walk into the boardroom of any major life science company, chances are you will hear talk about the growing importance of emerging and non-Western markets. The U.S., Japan and Eurozone remain the key markets for most companies, but the increasing focus on cost effectiveness and the difficulties of the general economy, make the potential for significant growth in these markets questionable. In contrast, emerging pharmaceutical markets have been growing in the double-digits and are expected to continue expanding in the years ahead, due to strong economic growth, demographic changes, and improved funding for health care.
All of this makes pharmaceutical investment in such markets an exciting prospect. Life science companies tend to be well aware of differences in regulatory frameworks, insurance schemes, and other structural issues that might impact their business in these markets. But it’s often assumed that disease treatment (and related implications for, say, portfolio management) should be essentially the same as in their home markets. After all, medicine is a science, with well-established best treatment practices. And it’s also an increasingly globalized one, with practitioners from all over the world descending on global conferences and publishing in international journals. So it’s a reasonable assumption that all other things being equal, a good doctor in Chennai or São Paulo would treat a chronic disease in the same basic way as a doctor in Minneapolis or Paris.
Despite the increasingly global nature of medicine, cultural differences continue to play a major role in how different diseases are approached and treated on the ground. And these differences can have large implications for pharmaceutical strategy. For example, in work over the past few years, we have repeatedly seen how different clients have based their strategies for treating chronic disease in Japan on American and European treatment practices. In general the mentality in the U.S. and Europe for treating these disease is: “It’s a chronic disease, so we have time to wait on drugs—the main thing is to make the patient understand, commit, and feel ownership over their disease. The first thing to focus on is making lifestyle changes, and then we can move to initiate medicines.” This common approach reflects the backward-looking perspective that is central to how lifestyle-related chronic conditions are treated in Europe and U.S. Here, when lifestyle is seen a major contributing factor the individual is often “blamed” for the situation he or she is now in, and a key step for the professional who is advising on the treatment plan is to see to it that the individual realize and accept this fact. Only after this has happened—which can take years—will the professional start medical treatment. This perspective had meant that our client’s portfolio and their positioning of their portfolio was heavily skewed toward the later phases of the treatment journey. In Japan, however, the greater deference patients have toward doctors’ orders—combined with a different outlook on disease, where a more forward-looking perspective results in little talk about past behavior but rather places the focus on the future—produces a very different (and more aggressive) approach to the use of medicines. Doctors there typically get the patient on a drug regimen immediately after diagnosis—lifestyle changes are secondary. This has had big implications for our client’s Japanese drug strategy, affecting everything from which drugs in their portfolio they focus on to how they communicate and position their products.
Medical anthropologists, members of an old and distinguished subfield of anthropology, have for decades investigated how cultural differences play a role in nearly every aspect of health care. Much of this work focuses on the local meaning of a disease—how the disease is interpreted in the local culture and its implications for care. For example, an older study (Blumhagen, 1980) of hypertension in Seattle found that the common folk interpretation of hypertension as being ”hyper-tense” was behind the high rates of noncompliance at a major clinic—when patients felt very stressed, they believed they were experiencing the disorder and took their medicine, but wouldn’t take their blood pressure drugs otherwise. Other scholarship focuses on how local cultural context affects the experience of a disease. For instance, a recent cross-cultural study by Stanford anthropologist Tanya Marie Luhrmann (2014) explored schizophrenia in the U.S., Ghana, and India, and found striking differences in the tone of hallucinatory voices. While typically harsh, aggressive, and anonymous in the U.S., voices were often playful and intimate in India. Such culturally rooted differences in the experience of symptoms have potentially important clinical implications, such as which specific drugs are prescribed to alter the experience of these voices. (For a review of this research, see: http://news.stanford.edu/news/2014/july/voices-culture-luhrmann-071614.html)
While some pharma companies do sometimes study local cultural differences as part of their business strategy, it’s still often peripheral to core strategy. But as markets outside the U.S. and E.U. become increasingly robust and competitive, it’s likely that the winners in these markets will have at their core a deep appreciation and sensitivity to local cultural practices. Such differences impact the success of everything from portfolio to communication strategy. Understanding such differences is good; for drug companies’ top lines, and also for pushing the boundaries of medical science.