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As I was nearing the end of writing this chapter, I called Ethan Watters at his home in San Francisco to ask if we should be concerned about this professional “cultural blindness,” especially at a time when Western psychiatry was being exported to more and more societies globally as a solution for their problems.

“When you look around the world to see which cultures appear to have more mental illnesses and are more reliant on psychiatric drugs,” answered Watters, “you do get the impression that we in the West are at one end of the scale in terms of being more prone to mental illness symptoms. But if that is due partly to our cultural agreement about what mental illness is, what in the world are we doing giving them all our techniques and models? Especially when other countries clearly have better recovery rates from these illnesses than we do?”

This question, for Watters, was rhetorical—he had his answer. But before we unpick what Watters knows, we first must consider one final collection of methods by which Western ideas of distress, contained in manuals like the
DSM
and
ICD
, are now infecting global populations. These methods have nothing to do with the subtle alteration of local symptom pools, but rather with the intentional exportation of Western models and treatments by the pharmaceutical industry.

4

In early 1999, the Argentinean economy went into a tailspin. Poor economic management throughout the 1990s meant that many years of mounting debt, unemployment, increasing inflation, and tax evasion culminated in a catastrophic three-year recession. By December 2001, things had become so bad in Argentina that violent riots had reached the capital, Buenos Aires. But as people were approaching breaking point, they were not only taking to the streets to express their despair, they were also turning up en masse at local hospitals, complaining of debilitating stress.

As the social suffering continued to mount in Argentina, two major pharmaceutical companies were at the same time grappling for the market share: the multinational pharmaceutical company Eli Lilly and the local pharmaceutical company Gador. What both companies knew was that mounting stress presented a great sales opportunity. As the situation deteriorated on the ground, both companies actively engaged in powerful marketing campaigns. These involved many of the marketing techniques I talked about in chapter 9, where companies learn from prescription records about which doctors their sales campaigns should target.

As both companies aggressively competed for the market share, slowly but surely a clear winner started to emerge—the local pharmaceutical company Gador. Its unlicensed copy of Prozac soon became the most widely used antidepressant in Argentina, while Eli Lilly's Prozac, which was the same price as Gador's version, strangely languished in sixth place. Was there something about Gador's marketing campaign that gave it the edge?

Professor Andrew Lakoff, an anthropologist studying antidepressant usage in Buenos Aires during the 1990s, had become particularly interested in how the two companies were marketing their chemical solutions. When I interviewed Lakoff in late 2012, it became quite clear that they had had different approaches.

“There was a legendary drug rep at Gador,” said Lakoff at the other end of the phone, “who told me that he was somewhat dismissive of the marketing strategies that purely focused on crunching numbers and data mining of prescriptions because they overlooked the essential thing—the importance of relationships, those developed between company reps and prescribers. These relationships did not just enable reps to offer incentives to doctors to prescribe Gador's products, but they also enabled reps to understand
why
doctors would prescribe a particular drug.”

This information was key because while in the United States and Europe psychiatry had shifted toward the technological or biological approach of considering mental illness to be located in the brain, Argentinean psychiatrists still largely understood mental illness as resulting from social and political problems. “Gador knew that selling drugs through images of ‘neurotransmission' and ‘selective receptors,' as Eli Lilly was doing, wasn't the best way to get psychiatrists to adopt a given drug,” continued Lakoff. “You had to approach local doctors on their own political and epistemological footing. This meant in the case of Argentina you had to appeal to the psychiatrists' more sociopolitical understanding of why patients suffered from mental disorders.”

Gador therefore developed a marketing campaign that focused on suffering caused by globalization. This campaign was clever because it capitalized on an argument that resonated with local psychiatrists about how the challenges of globalization were largely responsible for escalating economic and social misery. “So Gador took advantage of the understanding the psychiatrists had adopted about why their patients were suffering, and they used that understanding in their campaign.”

For instance, one advert featured a series of unhappy people traversing a map of the world, suffering from symptoms of globalization: deterioration of interpersonal relations, deterioration in daily performance, unpredictable demands and threats, personal and familial suffering, loss of social role, and loss of productivity.
190
Here, Gador explicitly appealed to the notion that its pills targeted the social suffering in terms of which most people articulated their distress—a message that had far greater resonance in Argentinean psychiatry than did references to neurotransmitters and serotonin levels.

Gador therefore actively deployed this deeper cultural knowledge of the local language of distress to win local doctors over to its product. “My sense is that Eli Lilly were not present on the ground in the same way Gador was,” affirmed Lakoff. “They didn't have the same long-term experts in the field doing the cultural work.” While Eli Lilly's campaign was based on bio-speak that did not resonate with Argentinean psychiatrists, Gador's message touched the heart of their sociopolitical beliefs. It was the deeper cultural knowledge Gador cultivated that helped it win the greater market share.

Let's now fast-forward a year to another pharmaceutical campaign that Ethan Watters had been separately studying in Japan, to a time when Western pharmaceutical companies were becoming far more aware that you had no hope of capturing local markets unless your marketing campaigns chimed with local cultural meanings.

We are sitting in a plush conference room in Kyoto, Japan, in which some of the world's leading academic experts in cross-cultural psychiatry are gathered.
191
The conference has been paid for and organized by GlaxoSmithKline, which has recruited experts from countries like France, Britain, United States, and Japan to discuss the topic “Transcultural Issues in Depression and Anxiety.”

All the attending experts have been flown to Kyoto first class and have all been accommodated in an exclusive city hotel. One attendee, Professor Laurence Kirmayer from McGill University, commented to Watters upon the lavishness of it all. “These were the most deluxe circumstances I have ever experienced in my life,” said Kirmayer, wide-eyed. “The luxury was so far beyond anything I could personally afford, it was a little scary. It didn't take me long to think that something strange was going on here. I wondered, what did I do to deserve this?”
192

We find a clue when we continue to scan the conference room. We notice that dotted among the attendees is a handful of people dressed so slickly and expensively that they couldn't possibly be, well, academics. But these are no ordinary company reps, either, offering the usual sales patter about the virtues of their drug. They are something else entirely, a whole new breed of company employee.

“Their focus was not on medications,” Kirmayer recalled to Watters. “They were not trying to sell their drugs to us. They were interested in what we knew about how cultures shape the illness experience.” Kirmayer said that what surprised him about these employees was their consummate capacity to understand and debate everything the experts discussed. “These guys all had PhDs and were versed in the literature,” said Kirmayer. “They were clearly soaking up what we had to say to each other on these topics.” These private scholars, these company anthropologists, were obviously there
to learn.

In order to find out what they wanted to learn, we first need some contextual background. In Japan before the 2000s, SSRI antidepressants were not considered a viable treatment for the Japanese population. The reason seemed clear: At that time in Japan there was no recognized medical category for what is termed in the United States or Europe as mild or moderate depression—the disorders most regularly treated with SSRIs. The Japanese category that came closest to depression was
utsybyo,
which described a chronic illness as severe as schizophrenia, and for which sufferers needed to be hospitalized. Thus, huge swaths of the “worried well,” who were prescribed SSRIs in Europe and the United States, simply resided outside the pool of people to whom companies could sell pills.

The challenge for GlaxoSmithKline, then, was clear: How do you get these untreated people not only to think of their distress as “depression” but as something to be helped by medications like Seroxat?

This was precisely why expensive conferences like the one in Kyoto were set up. Company officials needed to acquire a deep and sophisticated understanding of how to market the “disease” and its “cure.” They needed to learn how to convert the Japanese population to a more Anglo-American way of understanding and treating their emotional discontent. This was why Kirmayer believed he and his colleagues had been treated like royalty in Kyoto—GlaxoSmithKline need to solve a cultural puzzle potentially worth billions of dollars.
193

Once that knowledge had been gathered, GlaxoSmithKline launched a huge marketing campaign in Japan. The images of depression it popularized in magazines, newspapers, and on TV were intentionally vague, so that nearly anyone who was feeling low could interpret her experience as depression. These messages were also particularly targeted toward the young, the smart, the aspiring, and avoided dwelling on the pills' dubious efficacy as well as their many known undesirable side-effects. The ads were also focused on de-stigmatizing depression, urging people not to suffer in silence and encouraging them to take charge of their own condition and request a prescription.

Alongside the ad campaigns, about 1,350 Seroxat-promoting medical representatives were visiting selected doctors an average of twice a week, priming them to prescribe the right treatment for the new malady.
194
Furthermore, the drug company created websites and web communities for people who now believed they were suffering from depression, and these sites and communities gave the impression of being spontaneously growing grassroots organizations. Celebrities and clinicians appeared on these sites, endorsing and adding popular appeal to these online forums. What the patients and patient-caregivers using these websites did not know was that behind all this web information was GlaxoSmithKline, pulling the strings.

When I spoke to Ethan Watters about these company practices, he was frank. “To suggest to any knowledgeable audience that drug companies would do this surprises no one. But what is harder to believe was how studiously they were doing this, how directed and calculated it all was. These private scholars who worked in this world of drug companies learned everything you needed to know to market drugs successfully in Japan, and so what happened after wasn't just an ancillary outcome of two cultures colliding, or the inevitable product of globalization. This was pulling levers and doing various, nefarious things to change the cultural conception in Japan of where that line was between illness and health.”

Within a few years, the efforts of GlaxoSmithKline had more than paid off. “Depression” had become a household name, and Seroxat sales had soared—from $108 million in 2001 to nearly $300 million in 2003.
195
The companies had now learned that culturally sensitive marketing was key to disseminating their drugs, even if this meant altering an entire culture's way of understanding and responding to their emotional discontent.

As Koji Nakagawa, GlaxoSmithKline's product manager for Seroxat at the time, explained: “People didn't know they were suffering from a disease. We felt it was important to reach out to them.” The company's message was simple: “Depression is a disease that anyone can get. It can be cured by medicine. Early detection is important.”
196

What marketing campaigns like GlaxoSmithKline's seemed to achieve was a recasting of many people's emotional struggles, which had once been understood and managed in terms indigenous to the population, into a medical disease requiring pharmaceutical treatments. As Kathryn Schulz put it when writing in 2004 on such promotional practice in Japan, “… for the last five years, the pharmaceutical industry and the media have communicated one consistent message: Your suffering might be a sickness. Your leaky vital energy, like your runny nose, might respond to drugs.”
197
The depression contagion was not spreading because more people were getting sick, but because more and more were being taught to redefine their existing sufferings in these new disease-laden terms.

While these processes of medicalization were being purposefully manufactured in Japan and Argentina, they were also being rolled out in many other new markets, too. For one final telling example, let's travel now to Latvia to be a fly on the wall of a psychiatrist's consulting room sometime during early 2000.

A young woman visits her doctor complaining of “nervi”—a disorder of the “nerves” with symptoms similar to those that Western psychiatrists would classify as “depressive.” The main difference with “nervi,” however, is that in Latvia it is mostly treated by doctors attending closely to a patient's life story and investigating the possible social and political meanings of a patient's distress. Nervi is not therefore seen as a biomedical condition to be treated with drugs.