New Kindling For The Fires of Healthcare

I love my Kindle. It has changed how I read -- in fact, I read faster, in more places, with a greater diversity of topics.

The ability to download and carry a small New York Public library of books is amazing.

On Metro-North I read War and Peace (the new translation) one-handed while standing (try that, even in paperback). At the car repair shop, while getting my Subaru tuned, I was able to fine tune my thoughts about Andrew Jackson's presidency. And, sitting by the pool, I basked in the sun while exploring Bleak House.

The device is far more friendly to read from than my net book. And, though the internet browser is not very robust, the 3G reception is excellent.

Now what if everyone had such a device. How much easier would it be to carry around your health records, research different health states, even reach out and touch a medical professional?

Maybe webmd or Pfizer or Aetna could offer a free Kindle to everyone to help manage and answer their healthcare issues.

Okay, I confess, I was also reading Chris Anderson's Free, which I downloaded free on my Kindle.

Wouldn't a Kindle be a great freemium for healh care.

I need to ask my doctor about this.

As the cost of health care continues to rise and the government and private enterprise seeks to manage it, let's let the information and the patient devices be fee and allow the procedures and the drugs to cost what they need to cost. The more you know, I bet the more judicious the use will be.

Now that's some kindling to light the fire of healthcare.

One piece of birthday cake too many

Ever have a parent or a friend end up in the emergency room with a heart attack?

In the US, chronic diseases account for more than 75 cents of every dollar spent on healthcare, and are the #1 cause of death and disability.

Yet the amount spent in the US on prevention is $10 per person. That is about the cost of my monthly no-frills gym membership.

An ounce of prevention here is worth a pound of cure.

We can only hope that the new healthcare bill wending its way through the halls of Congress will put more of an incentive behind prevention and wellness.

As we see, the best way of moderating the cost of interventional healthcare is not to use it at all.

According to the Almanac of Chronic Disease, 4 out of 5 Americans would rather spend on preventive measures than on treating diseases after detection. Then how come my gym wasn't very crowded today? I bet there were more people at the local ER than on the elliptical this afternoon.

Let's hope that Congress gets the message and allocates more money to improve the health literacy and the coverage of the average American.

There are 46 million good reasons (the number of uninsured in America) to give more people coverage and that gym membership.

Sonia Sotomayor: Please Free the iPhone

Back in 1984, oh, all of 25 years ago (which is about the age of many iPhone users), Stewart Brand, at the first Hacker’s Convention, said, information wants to be free.

That truism has continued to be borne out over the intervening years, as company after company struggling to monetize their information and web sites. The foamy successes of some web-based successes (I will include Google, FaceBook, Wall Street Journal here) lord it over the wet troughs filled with so many failures (just too many to list).

So what about that lovely iPhone, the newly classical kouros of mobile phones?

Why is it stilled tied to one carrier? Because that was the deal that Apple made with AT&T.

Now consider the irony here:

Part of the marvelous success of the iPhone is its software architecture that allows so many applications to be created for it. The monetized Apple store is a cornucopia of creative uses digitized to mobile broad band.

But the iPhone itself? Tied to one carrier in the US. (But not overseas).

Where are the FTC and FCC when you really need them?

Capitalism is a wonderful thing in that here some manufacturers can decide what they want to sell and how they want to sell it.

I am sure that Apple knows it will sell more devices if it adds additional carriers like say my carrier, Verizon (hint, hint).

Mobile broadband will be the Next Big Thing. And if mobile broadband devices are to be truly successful than they need to be free to follow the airwaves like a bird.

(Come to think of it, how come there are now mobile phones named after birds?)

If the US government can own General Motors, why doesn’t it just take over Apple and free the iPhone? Oh yeah, Apple is making money. Well, then what are the FTC and FCC good for? What about Supreme Court decisions on Interstate Commerce?

I just got Sonia Sotomayor’s iPhone cell number. I think I will give her a ring just before her hearings.

Science advances one funeral at a time

I am going to with Max Planck and James Montier of the Financial Times.

Planck said that “science advances one funeral at a time.”

So we can now safely see that the Efficient Market Theory is dead. As we know, the EMH theory postulated that all information is reflected in current market prices. Well, as we slog our way through this financial meltdown with economic lava pulling at our heels and ankles, we recognize that the EMH theory holds less water than my grandmother’s sieve.

Hmmn, now what about clinical trials? We all would hesitate to say that science advances one funeral at a time, even though that is what sometimes happens. Max never worked at a pharmaceutical company nor was he a clinical investigator. However, his view reflects the dark underside of participating in a clinical trial.

I have recently been ruminating on rheumatoid arthritis for a client. The variability of results for the clinical trials for different drugs is astounding and confounding. As a result, it is critical to evaluate each Randomized Clinical Trial in the context of demographic and baseline disease characteristics of each population as no two trials have similar patient populations, even with similar designs.

Unfortunately, there is still a lot of suffering out there in RA. There are 4.5 million cases of RA in the US, EU and Japan, with 200,000 new cases diagnosed every year. Treatment goals in RA are reduction in signs and symptoms, prevention of structural damage, and induction of remission. Nothing is going to stop the pain, but, with the drugs currently available, methotrexate, Enbrel, Remicade, Humira, etc., sufferers can still enjoy a reasonably good of quality of life.

The other good news is that the pipeline of new drugs is very active with some promising new drugs.

The challenge, though, is that there is no efficient market theory. Even with all the information available, the heterogeneity of the disease itself and the diverse patient population and their individual sufferings indicate that there is no one drug cures all.

Chewing on The Cost of Living

The numbers don’t jibe with the vitriol.

Pharmaceutical companies are the general public policy whipping boy of choice for rising healthcare costs, even though drugs represent only 10% of the country’s national health care bill.

Yet, according to a Dartmouth Medical School's Institute for Health Policy and Clinical Practice, 76% of Americans blame the drug makers for the high costs. Oh, by the way, that is after those drug makers have spent over $1 billion to bring a single drug to market according to all the guidelines and “suggestions” made by the FDA.

And what about doctors and hospitals who account for 52 percent of all national health spending? Just 59% of respondents named hospitals, and 47% percent named doctors as major spending culprits. (Percentages add up to more than 100% because respondents could select as many factors as they wanted.)

There is a real disconnect between the perception of who is increasing costs and those who are actually doing it.

It is kind of like going to grocery store and complaining about rising food prices. After you go to the pharmacy, oay for those pills and then put them in your mouth, you are chewing on the cost of living.

It is so much harder to criticize or revile the costs of the doctor who is managing your chronic diabetes or high blood pressure or the hospital who is taking care of you after your angioplasty or appendectomy.

Those people who are working at Pfizer, BMS, Merck, GSK et.al do not get a free pass. And this point of perception is precisely where pharmaceutical marketing communications break down. When you need Valtrex or Flomax or Lipitor, those DTC ads are great motivators. But when you want to communicate the overall value proposition of prescription products or the industry, life sciences still struggle in developing the consumer/patient insights necessary to represent value. Here, a spoonful of the right sugar would help make the medical expenses go down.

The challenge is translating those needs and insights into getting consumers to understand the cost/ratio benefits of development and consequent patient relief or mitigation or survival.

Evidence-based medicine, costly procedures and interventions, quality of life. The actuarial buzzwords can chill the spine as fast as an epidural.

It is important, though, to spend much more time on the marketing related to get consumers/patients to understand the cost of chewing on living.

Where Niches Fear To Tread

I recently spoke at the Nicholas Hall OTC conference in Venice on the importance of knowing your customer.

At the conference, I cited three successful innovations where marketers took the brands into even more focused niches:

· Listerine mouthwash launched Listerine Pocketpaks for on-the-go oral care,
· Tylenol Extended Relief was renamed Tylenol Arthritis Pain,
· K-Y Jelly launched K-Y Massage Oil.

In all three cases, the key success factors were

· Identifying an unmet consumer need related to the main brand,
· Capitalizing on that specific and focused need,
· Leveraging the emotional connection associated with the parent brand,
· Utilizing a clear product name that identified the line extension’s usage,
· Supporting the launches with strong advertising and promotional support.

The main virtue here was sterling consumer research work that uncovered these insights and translating them into focused executions.

Now just imagine how they all combine into the same usage occasion. Hmmmnn.

The human element in Nostradmus

This past week I was speaking on how approaches to forecasting pharmaceutical compounds at CBI's Early Commercialization and Forecasting conference, and, before I spoke, I asked the audience what their most concerning issues were in forecasting.

I half-joked that our approach was called Nostradmus and I was half-right about the relational side of accurate forecasting.

The three key issues I was asked about were:

1. Addressing regulatory matters
2. Understanding competitive pipelines of drugs in development
3. Internal alignment.

Issues 1 and 2 require the same kind of effort, namely staying on top of what is going on. In terms of regulatory, it is a matter of paying attention to FDA approvals and comments, understanding how the agency's views and considerations of clinical end points are changing.

The same diligence is necessary in tracking pipelines. However, there it is not just a matter of tracking published results. It is also important to understand the different kinds of MOAs in development, what they are targeting, how are they working, to deeply appreciate what is novel and what is just me-too.

In understanding these kinds of evolving issues, you can better track game-changers and make more accurate risk-adjusted forecasts.

However, for me, the key question was alignment. You can have the absolute best checklist of approach but, if you don't have internal alignment around and support for your assumptions, it does not make a difference what you do.

That is the human element. It is not the science, not the modeling, not the data.

It is that very human relational issue that can spell success or failure in the development of a drug.

The best way to meet this issue head on is to make your assumptions as transparent as possible, and discuss them thoroughly internally so everyone precisely understands and agrees to those assumptions. In that way, you get the best minds providing their best thoughts on the best outcome.

In that way, even if it is a forecast, you will be roughly right, not just in the data but in the agreements to move forward.

Pearls Before Swine Flu

I was recently quoted by Morningstar and Medical News Today on the critical lack of information and communication to the general public on the treatment options for the current H1N1 flu, also known as the misnamed "Swine Flu" outbreak.

The most basic misconception is that, unlike influenza vaccines which are preventative, medications recommended to combat the current flu outbreak, Tamiflu by Roche and Relenza by GSK are used for symptom control. This treatment means that these medications manage the symptoms and offer relief more rapidly than if the virus is left untreated. However, neither of these medications are designed to prevent or cure the illness.

In a public health emergency, people don't take the time to understand the distinctions between treatment and prevention."

In addition, while these medications are designed for symptom relief and control, their effectiveness varies in accordance with the strain of influenza. This "swine flu" is a type of Influenza A, which is an H1N1 virus strain. Therefore, treatment options should be sought out that will most effectively manage this virus.

In December 2008, The Centers for Disease Control (CDC) released a special advisory noting potential resistance to Tamiflu during the initial phase of the 2008/2009 influenza season. This advisory was based on the fact that there are various strains of influenza which could require treatment specific to their composition. 98% of Influenza A virus strains showed resistance to Tamiflu this season (2008/2009) compared to only 11% last year (2007/2008). With each flu season, viruses change and mutate, therefore the effectiveness of each drug treatment varies greatly.

There is never one vaccine that fits all outbreaks. Strains are always changing, and sometimes, when you formulate a vaccine for a seasonal outbreak, it is often easy to miss all the strains. It is like the Heisenberg Principle in vaccine formulation. The attempts to create cures can cause changes themselves over time.

Like that Heisenberg Principle, you got to stay on your toes to make sure you are hitting the right targets.

Real Shareholder Value vs. Opportunistic Value

Bristol-Myers Squibb continues to work on getting right.

CEO James Cornelius said this week that, with $9 billion on hand, BMS would continue to seek to build its pipeline through strategic acquisitions and to remain viable as an independent mid-size biopharma company.

Since 2007, following it "String of Pearls" strategy, has bought or licensed or partnered with seven different companies on developing compounds.

On one hand, those deals in unto themselves represent a good independence strategy. Look at the gyrations that the Merck/Schering-Plough deal is going through with J&J over Remicade. With so many deals done, any acquirer of BMS would find it challenging, to say the least, to unwind a host of promising partnerships. After all, a key challenge in biopharma is assigning appropriate value to promises.

The key here, though, is increasing real shareholder value vs. opportunistic shareholder value. If you do a comparison in pharma of shareholder value between companies that grew through acquisition vs. companies that grew through organic developments, you will see that mergers significantly under-performed organically developed and launched growth.

Wy-Pfi says it is all about shareholder value. But in the short term that value will be balanced on the backs of all the employees turned out onto the street. Yes, it gives Pfizer more irons to keep hot in vaccines and biologics, something Pfizer was sorely missing. But growing Pfizer value through acquisitions has not been a sustaining value strategy except for Lipitor acquired via the Warner Lambert acquisition.

All these CEOs are really smart. But for the moment James Cornelius and his strategy goes to the head of class for truly growing the company and its pipeline with a steady product-based stratgy.

Tolstoy and Pharma Mergers

As he gives the order not to defend Moscow against Napoleon’s troops and to retreat behind the city, General Kutuzov in Tolstoy’s War and Peace, keeps gnawing on the same bone of a thought: At what point, at what decision, was it already determined that Moscow had to be abandoned. Prior events simply led up to this moment and the actual decision of abandonment had been made long before.

In a very similar way it has been probably like that for Merck’s acquisition of Schering-Plough and Pfizer’s acquisition of Wyeth. Only now are those acquisitions seen as inevitable.

For years, as Pfizer struggled under loss of patents and a dearth of new products from a pipeline that looked something a sluice in the Mojave desert, the company was missing major opportunities in vaccines and biologics. Pfizer knew eight years ago that today would come, in a much sharper clarity than that afforded General Kutuzov. But still the company stuck to its knitting. And the threads separated, the fabric became coming apart. And in one action, Pfizer has jumped into two critical areas that it was never in before. As for Wyeth, it had little coming for it and so, for the sake of shareholder value, it has now run into the arms of a suitor with deeper pockets.

As for Merck, it has done a great job in recent years, overcoming the issues associated with Vioxx. However, even so, the internal growth engine were not enough. And, as for Schering, well that was just a sale waiting to happen. Merck will realize efficiencies by capturing the fullest value of Vytorin, its co-promoted drug with Schering. But that may not be enough.

Look at Pfizer’s lesson. Pfizer acquired Warner-Lambert and got the full rights to Lipitor (which held the ship steady for a number of years) and then acquired Pharmacia to get the full rights to Celebrex (well, that didn’t turn out quite the way it was hoped).

For Merck, Schering may only be a temporary stay until it gets going with something more.

In pharma, the development cycle is long but in an age when blockbusters are just as past as old Russian generals, survival is now couched in more totalitarian terms. The Putins will thrive for awhile and terrorize everyone else in the neighborhood. But until someone expands the playing field of science, delivery and treatment, the industry will continue chewing on that same bone wondering what decision was made years ago that led them to this inevitable moment.

Why is pain such a pain for P&G?

Why is pain such a pain for P&G?

This month brings the news that P&G is selling to Wyeth Thermacare, a product that established a whole new sub-segment of topical pain relief. When P&G launched Thermacare it had all the hallmarks that anyone looked for in a new brand: new technology, new name, “relatively” unmet consumer need. But, only six short years later, the brand was put on the block and jettisoned due to under-performance and a desire for brand portfolio rationalization.

For such a savvy marketer, P&G has a long inglorious history of finding pain painful as a product category.

P&G entered OTCs in 1982 by acquiring Norwich Eaton and marketing enteric-coated aspirin. Never went anywhere.

Then it teamed up with Syntex to launch naprosyn in the OTC analgesics market under the name Aleve. Much fanfare. Ballyhooed $100 million launch spend. Sold to Roche/Bayer.

Okay, so maybe systemic analgesics were too tough for this smart marketer.

Detergents, oral care, cosmetics – all deal with external structure and function claims. P&G is brilliant there.

Thermacare is external. Kind of like an OTC. Competes against Chattem’s Icy Hot and Pfizer’s (now J&J) Bengay. Maybe P&G would do well there. Nope. Sold to Wyeth, which has an extensive pain portfolio led by Advil.

Maybe P&G just doesn’t get consumer healthcare.

Pepto-Bismol, Metamucil, Vicks? All under-performers.

And you heard it here first: Someday soon P&G will sell Prilosec.

Consumer healthcare requires a different kind of sensitivity to the magic bullets that drive OTCs vs. consumer products. In OTCs, marketers sell active ingredients that actually do something to the health and wellness of the body.

These products don’t just thrive on new colors and new flavors. They live by claims supported with relevant line extensions and forays into a category adjacency. The ultimate promotion is the professional marketing of OTCs where a company markets its products to doctors based on claims derived from clinical trials published in a peer-review journals. That isn’t Home Made Simple as promoted in P&G’s online and offline magazine.

P&G knows this; it is very smart. The company regularly accomplishes feats of derring-do with Tide and Crest and Pampers.

But when it comes to products that require a higher level of scientific and regulatory understanding, P&G never gets it quite right. Prilosec was a year late because P&G hadn’t truly aligned its claims to its clinical trials.

There is a subtle difference between OTC and consumer products. OTCs demand that you really and truly understand the difference between what you do and what you say and how it affects the health of your brands and your consumers.

A Wii bit of medical advice: Try mABs

I am not going to get the Nobel Prize for this, but, I believe I have made a major scientific discovery: Wii-mABs.

Ordinarily, mABs or monoclonocal antibodies are monospecific antibodies that are identical to each other as they come from one type of immune cell that are all clones of a single parent cell. Since you can create monoclonal antibodies that specifically bind to most substances, they can then serve to detect or purify that substance. mABs are used in treatments for such diseases as rheumatoid arthritis, leukemia, and lymphoma.

So I got to thinking what I could do to help fight Wii-itis or inflammation of the elbow. I thought this would be a particularly important disease to fight given the Nintendo’s mission to turn couch potatoes into fried potatoes through the use of its motion sensitive game remote and the recent launch of its exercise-focused Wii-Fit board.

I posit that the Wii-itis or Wii elbow is a common affliction of Wii users. This injury is also common among tennis players and represents an inflammation of the elbow joint. I think it is probably under-diagnosed among Wii-ites, indicating a seriously under-treated population given the popularity of the game and a true unmet medical need.

However, upon further research, I also uncovered several other diseases associated with the Wii:

TNF-α factors, also known as, They Never Fail, which afflicts alpha males who are determined to win these games at all costs.

B cells: Small committed groups of users who try to bowl a 300 every time.

T cells: Similar to the bowlers, this group of tennis players never settles for love.

RSV proteins: These users are infected by Repeated Swinging Values caused by their single-minded desire to over and over again try to win their games.

Others have noticed a similar issue, and I would like to build on their research. In a past issue of the New England Journal of Medicine, Dr. Julio Bonis reported awakening with a sore shoulder. He was puzzled since he hadn't played any so-called sports recently, but he had played several long sessions of Wii tennis.

In the past, gamer joysticks have been known to cause arthritis, carpal tunnel syndrome, ganglion cysts and tenosynovitis.

Now, many patients can benefit from a Wii bit of exercise. The Wii console burns more calories than classic game consoles. For an average weekly use of 13 hours, 1,840 calories would be burned, that is 40 percent more than classic consoles. Plus the new Wii Fit offers ways to do yoga, balance games, aerobics and strength training.

So what is the solution: like so many sports injuries and people who suffer from such co-morbid conditions as diabetes, coronary heart disease and hypercholesterolemia, the best recommendation is changes to one’s lifestyle. In this case it is important to pursue those mABs, moderately active body breaks. In order to ensure that players get the most out of their mABs, they should actually consider reading something. Personally I am reading the new translation of War and Peace by Richard Pevear and Larissa Volokhonsky, and it is fantastic.

If you don’t take my recommendation, then please note that the august British Chiropractic Association (BCA) has advised that a Wii player to take breaks every 20-20 minutes. The BCA also says that gamers should treat a 'Wii session' like any form of exercise and warm-up adequately beforehand to prevent stiffness and possible injuries." The Association has a five-point "Wii warm-up" for the shoulders, wrists, arms, neck and back that can be downloaded from its web site at www.chiropractic-uk.co.uk.

Now excuse me, I have to return to Rock Band. I believe I have nailed Blitzkrieg Bop.

Nothing Is More Natural Than Artificial Beauty

Nothing is more natural than artificial beauty.

Are you really reducing your carbon footprint (and your wallet) when you purchase natural cosmetics from Dr. Hauschka?

According to Mark Landler in The New York Times, stars like Julia Roberts, Jennifer Aniston, Richard Gere and Robert Downey Jr. use and advocate the use of Dr. Hauschka.

Now who can argue with this A-list who, by association, have helped WALA Heilmittel the maker of Dr. Hauschka, double sales to over $150 million in the last five years. Can these stars even pronounce the name of the brand?

WALA stands for Warmth, Ashes, Light and Ashes and is based on an early 20th-century European philosophy called anthroposophy developed by Rudolf Steiner that postulates the existence of a spiritual world that can be accessed by the human intellect. The practical aspect of this philosophy was organic farming, hence the natural production of natural ingredients.

This gets even better: natural, spiritual, expensive – a trifecta for beauty. You simply can’t refuse this offer if you worry about your looks, have money to burn and want to be trendy.

I do not believe that these stars are accounting for all this sales growth. Surely there are some less beautiful people buying into this product line.

So, in the end, we have class cosmetic marketing. A cosmetic brand supported by a reason why (in this case, natural ingredients) that is promoted by glamorous stars and riding a trend.

Decade after decade, year after year, this formula works.

Or maybe I should say millennia after millennia.

After all, look at the Egyptian hieroglyphics. You won’t see any overweight, unglamorous people depicted there. Those Egyptians really looked good on their People magazine pyramid walls.

And all they ever used was natural cosmetics; probably well along the line promoted by Rudolf Steiner.

I guess the formula works. But wouldn’t it be interesting to try something truly different.

Bill Clinton - Pump Head

When I attended my daughter’s graduation from the University of Michigan last year, there was great excitement among the audience. It was just about the pride of seeing your son or daughter on their university commencement day. It was also about the fact that former president Bill Clinton was going to give the commencement address. Not a bad gig for the husband of the woman was fighting for the presidential nomination in this battleground state (remember this was when, not now).

A great applause greeted his step to the podium. Then he began to speak. The sentiments and ideas about going out into the world and making a contribution toward a better world were fairly stock commencement sentiments nicely worded.

Surprisingly, though, they weren’t nicely said. Clinton hesitated, paused over phrases, stammered. I was wondering where was the fluidity of speech, the eloquence of man known as a great campaigner and speaker. I recalled his State of the Union speeches. He didn’t sound like this then.

And this past year, as the campaign continued, there was a whole series of remarks that seemed out of context and personal attacks against former friends and supporters that didn’t ring right.

As reported by Melinda Beck in the Wall Street Journal, aides to Bill Clinton last week denied speculation that the former president's intemperate remarks on the campaign trail were due to mild cognitive damage from his quadruple-bypass surgery in 2004.

"This theory is false and is flatly rejected by President Clinton's doctors, who say he is in excellent shape...." the statement said.

But the condition dubbed "pump head" or "bypass brain" is well known to doctors but few warn patients about it.

Symptoms include short-term memory loss, slowed responses, trouble concentrating and emotional instability. As noted by Beck, in the New England Journal of Medicine in 2001, researchers at Duke University Medical Center tested 261 patients before and after bypass surgery and found that 53% of them had significant cognitive decline when they were discharged -- and 42% still suffered from it five years later.

One explanation is that when a patient's blood is pumped through a heart-lung machine during bypass, tiny air bubbles, fat globules and other particles may enter the bloodstream. The pump can also damage platelets, which form clumps, and clamping the aorta loosens bits of plaque. That debris can travel to the brain and clog tiny capillaries, forming microscopic strokes.

So we may fix the heart, but, at the same, endanger the head. Surgery is always a risk, and it helps to really understand all the complications that occur.

The best answer lies in the prevention of coronary artery disease (CAD). There are approximately 30 million people in the US and top five EU countries who suffer from CAD. And, although, mortality rates are declining due to better therapies, it still remains one of the leading causes of death in the developed countries.

Lifestyle change and the use of drug therapies like statins clearly help, and, by aggressively managing against those initial symptoms of trouble and family history, patients can defer what used to be inevitable.

It is clearly better now to prime the heart pump into good long-term health than pay the consequences later. Yet while many patients think the surgery is a great fix (which it is), there are still many other risks that affect not just the heart but also the brain. There is no bypass there.

Get me some amoxicillin and yogurt, stat

Who doesn’t want fast, convenient, inexpensive healthcare?

So what a great idea in-store health clinics are. Big benefit to consumers/patients. Perfect sales alignment for retailers between their pharmacy counters and OTC aisles.

The number of clinics boomed in the last three years from 125 clinics to 963.

In the cosmetic business, you count distribution by how many doors you are in. The more doors, the more sales potential, filling the rack and offering access.

Think about that for health clinics. More access for sore throats, colds, rashes, blood pressure monitoring, diabetes supplies. With great convenience.

But now growth is slowing. The Wall Street Journal reports that Shopko, Meijer, and Wal-Mart and Cardinal Health’s Medicine Shoppe is actually closing units. Maybe as much as 70 clinics. And CVS is talking about scaling back their expansion plans.

Why?

Oh, it something as simple as estimating the break-even on your investment.

According to Tom Charland, for VP for Strategy at Minute Clinic, “The big mistake was for people to think they could break-even in six months. People are learning this is an 18-24-month process to get to break-even.”

Now how many product launches do you know of that break-even in six months?

Now think of how many capital-based retail fixture-based store-based assets break-even in six months?

Maybe those hard plastic theft prevention boxes that protect Gillette’s Fusion razor blades from thieves with wide and deep-sleeved coats, but not much else.

Now reality is settling in. The financial teams are making their lists and checking them twice trying to figure out what clinics have been naughty and which have been nice.

Business reality and metrics here are necessary and good.

However, they will not ultimately slow down the need for people to have access to fast and easy health care.

Compare these clinics to the current distribution of general medical practice:

• Call for the appointment
• Set in the waiting room for thirty minutes
• Speak to the doctor for 20 minutes
• Drive to the drug store to get the prescription filled
• Wait for the prescription.

One stop health care for minor ailments is a need that is here and will continue to grow.

The challenge for the retailers is to get their economics right and for drug and consumer healthcare manufacturers to get their targeting and merchandising right to help their retail partners succeed.

The patient is waiting.

The Other Guy Blinked, Part IIA

It is just a matter of time before the Rice Riots affecting developing markets turn into the Water Riots. Though I expect that that was something Noah already knew.

Those “bad” guys keep banging on the doors of the ark, seeking imitative ways to profitable salvation.

Last week, PepsiCo acquired Britain's V water to protect its European flank from Coke.

V water states that it is made from spring water, comes in different flavors and includes additives like vitamin C, zinc and ginseng.

Can anybody spell vitaminwater? The same US brand that Coca-Cola paid $4 billion to Glaceau for last year and is planning to launch overseas in such countries as, surprise, surprise, the UK.

After all, when you buy a regional brand, the easiest way to make money on your shiny new brand asset is to launch it in new geographies. The launch pipelines are pure incremental money and whatever sales you get are gravy against that expensive roast beef you purchased.

How rare is success? Actually quite frequent as long as you get the local temperature right.

The main challenge? Of yeah, when the competition is there ahead of you. Like what Pepsi just did to Coke. Nothing like landing on a foreign shore and seeing that someone was there before, like the Vikings welcoming Christopher Columbus to the new world.

This kind of strategy/counter-strategy cuts across consumer categories. Reckitt-Benckiser buys Mucinex in the US and is “banking” on rolling it out globally. What they really bought was not a unique decongestant (as guaifenesin is as old as the hills) but an advertising property called Mr. Mucinex that they better hope will play as well in Sao Paulo as it does in San Diego.

In the mean time both Coca-Cola and Pepsico are trying to defend their “water substitutes” against contamination and resource defoliation in India, as Nestle tries to gain control of new water access points in the US Pacific Northwest.

Pepsi, already owns SoBe Life Water, Gatorade sports drink and Aquafina bottled water.

The question will be do they truly believe that they can grow V water or are they just trying to pick Coke’s pocket, leaving the company with less money to invest.

Water polo anyone?

The Donnybrook Fair: Apple, Blackberry and Google

One touch of nature makes the whole world kin,
That all, with one consent, praise new-born gauds.
And give to dust that is a little gilt
More laud than gilt o’er dusted;
The present eye praises the present object.

Troilus and Cressida, William Shapespeare

The emerging battle between RIM, Apple's iPhone and Google Android have all the classic hallmarks and of a true marketing melee. That’s great to see and instructive for all.

RIM’s Blackberry, for years, has made the market for smartphones, being the corporate darling for its ease of email use. How many times have you sat in a meeting, suddenly see the flashing light on your Blackberry go from green to red and feel the need to know and to answer?

Oh, and who did Blackberry pass on its leg around the track? Palm, which came late to smartphones. While Blackberry software and third party apps were not as robust as Palm and even though Palm had a huge installed base of users tracking their calendars, the functionality of its email system and the alignment with corporations won that race thumbs down, even though its first devices were black-and-white and clunky.

Now we have the iPhone, a cooler piece of hardware and software than the Blackberry. But not the winner out of the gate. The functionality and ease of use (my thumbs are just too big for the accurate and fast touch screen typing) do not match the Blackberry, limiting its ability to gain a broad base of users. Who bought the iPhone first? Consumers, the bedrock of Apple users.

Now it is getting interesting:

· Apple is preparing to launch a 3G iPhone and use Microsoft corporate email technology, a needed move to get corporate IT departments to sign on to iPhones.

o But you have to wonder how much this pains the purist in Steve Jobs?

· Blackberry is also preparing a 3G version and a better piece of hardware (bigger screen, better processor with a better browser).

· Google is licensing its Android operating system, based on Linux, to gain “screen share” on cell phones globally.

Google is operating under a totally different business model, fighting on only one battlefield. They are hardware-agnostic, freeing themselves of tactical hardware tactics, desiring share of eyeballs for its many apps. Google margins should be better. Their design focused on the visual look and click-throughs as they eschew plastic, metal and processors, leaving Nokia, LG, Motorola etc to the battle of the tiny boxes.

So the battle of flanks and enfilade goes to Blackberry and iPhone as they strive to win the minds and thumbs of both consumers and corporate users. The Blackberry Pearl and Curve are okay consumer phones, but they ain’t no iPhone.

When all things about performance are equal, great design wins. In a world of parity claims about superiority, whether it is soap or cosmetics or furniture or drugs, the cool-ness factor can win. Just ask Ideo.

The real and complex battleground here will go to the winner who must strive for superiority on both hardware and software. That is not an easy task. There are a thousand different cell phone sku’s in the mobile telephone category, but few offer truly differentiated in performance. Design becomes key. Remember the success of flip phones vs. candy bars? The first Razrs vs. everything else? Even the StarTAC. What makes this new evolution so interesting between iPhone and Blackberry is that it requires a skillful combination of both performance and design.

In the thirteenth century, King John gave a license to hold an annual fair in Donnybrook, outside Dublin. By the eighteenth century, it had become a huge two-week assembly for horse dealers, fortune-tellers, beggars, wrestlers, dancers, fiddlers, and food sellers. It was known for its rowdiness and noise, particularly for the whiskey-fueled fighting that went on after dark. The traditional advice for an Irishman going to the fair was, “Wherever you see a head, hit it.” Eventually the fair was closed by the Irish government in 1855.

I don’t know if you can combine the idea of a donnybrook with a Smartphone (since smart and donnybrook seem antithetical), but that it what this category is re-shaping itself to be.

Saving Winston Churchill's Chilly Heart

Lady Nancy Astor: Winston, if you were my husband, I'd poison your tea.
Winston Churchill: Nancy, if I were your husband, I'd drink it.

Having a defibrillator at home does not protect heart attack survivors against a cardiac arrest any better than having someone at home with good cardiopulmonary resuscitation training.

Dr. Gust Bardy of the Seattle Institute of Cardiac Research and colleagues studied 7,001 people at moderate risk of sudden cardiac arrest, each of whom had a spouse or home companion willing and able to perform CPR and use an AED. He presented the results of the study of automated external defibrillators or AEDs used in the home at a meeting of the American College of Cardiology in Chicago.

In public places such as airports, AEDs have helped people survive sudden cardiac arrest, when the heart stops pumping blood. Without immediate treatment with a defibrillator or a bystander who knows CPR, most die within minutes.

As about 80 percent of sudden cardiac arrests occur at home, researchers wanted to see if putting defibrillators in the home could save lives.

One group was told to call an ambulance and perform CPR, while the other group was told to use the defibrillator first, then seek emergency help. They were followed for three years.

What a gamble to participate in this study? Will I live because I depended on skill vs. a device? What’s my risk for sudden cardiac arrest anyway? What’s the book in Vegas on my chances of the big bang and then surviving it.

Wait a moment. Wow. How much faith does it take to trust that your spouse knows enough CPR to save you vs. having the AED in your home. Or that she'll even make the attempt at all. Basically, if she fails, it is okay because it was only a clinical trial that didn't work.

Now that’s love. As you lie there on the floor, clutching your chest, you look up with pleading eyes that say save me.

And then she (oh yes, we assume it is a she) remembers all the garbage you didn’t take out, the beer on your breath when you came home at 2 am, the mess your buds made after the Giants won the Super Bowl and a thousand other slings and arrows that outrageous fortune rained down on her because of you.

"There was no mortality benefit," said Dr. Gust Bardy of the Seattle Institute of Cardiac Research, whose study was published in the New England Journal of Medicine.

No benefit? Someone still lived.

Out of 123 arrests, just 63 of those were witnessed and a defibrillator was used in just 32 people. The device, which can assess a patient's rhythm, called for a shock to be delivered in just 14 patients, and only four survived long enough to be discharged from the hospital.

Bardy told reporters the rate of cardiac arrests occurring at home was lower than expected, and many occurred when the victim was alone.

And he noted that patients' spouses and companions in the control group had been well educated in how to respond to a heart-stopping event, something that could have improved survival in the group that did not have an AED.

Interestingly, the devices were also used by neighbors who borrowed one of the defibrillators to revive a family member. Two out of 7 of those people survived. Bardy said whenever the devices were used, they worked well.

AEDs for use at home cost $1,200 to $2,000 per unit. AEDs used in the study were made by Philips Medical Systems, a unit of Royal Philips Electronics, which are the only AEDs available without a prescription.

Bardy said most of the devices are purchased by the "worried well," and confessed to personally owning four.

Global Walgreen-ing

Whatever is the world coming to but the Walgreen-ing of the global mass market retail drug store distribution channel.

Global OTC manufacturers need to start thinking hard and smart about playing with global retail chain drug stores. The death knell of decline is starting to sound for independent pharmacies, and, when you couple this change in the retail distribution channel with General Sales Ledger (GSL) and Pharmacy (P) brands that provide consumers with easier access, you can start to count on

· Improved public health benefits

· Lower prices

· Great business opportunities

Nicholas Hall is a very smart and astute observer of consumer healthcare and the retail pharmacy.

Here are four data points from his latest OTC newsflash:

1. According to local press reports, the Spanish government risks being taken to the European Court in the next couple of months, in a move to change its pharmacy model to reflect EU legislation guaranteeing the freedom to set up European-wide businesses.

2. Meanwhile, a report by Dutch audit company Ecorys and the University of Maastricht, defending liberalization and deregulation, concludes that the elimination of all rules that regulate pharmacies would provide significant economic savings. The report suggests deregulation of pharmacies could improve their productivity by one-third and reduce prices by 30-40%.

3. In Japan, Drugstore chains Welcia, which has 95 stores in Shizuoka and Kanagawa, and Tokyo-based Takada are in talks to merge later this year. The merger will create Japan's ninth-largest drugstore chain, with sales of about Y130bn (US$1.2bn) and around 395 stores.

4. Speaking at a retail sector conference this week, Alliance Boots executive chairman Stefano Pessina announced that the roll-out of the Boots name in Europe. Although the Boots brand is very powerful in the UK and known elsewhere, it has not been exploited advantageously in international markets. Pessina said the brand will be developed in Europe over time, starting with Norway, where 7 of its Alliance Apotek pharmacies have been rebranded under the Boots the Chemist format, with all 125 Norwegian stores set to follow suit.

This man knows what he sees.

Now it is up to OTC manufacturers to also see these beacons of change and convert them into cogent sales, branding and distribution strategies. The pain of Wal-Mart has already been well felt in the US. Similar distribution and pricing are emerging in Europe, while, similar opportunities loom large in emerging markets like China (viz. Nep-Star) and India. The challenge will be capitalizing on this emerging wave of drug store capitalism.

Life-Profiles: The Patient Is Waiting

All of us are so similar in our differences.

It’s the Jordache, L.L. Bean, Gap, Gloria Vanderbilt, Calvin Klein and, of course, Humanity approach.

In the Wall Street Journal, Robert Lee Hotz neatly summarizes the impact and non-impact of variations in our DNA.

The Max Planck Institute reported that any one of 11 variations in a single gene can make it harder for common anti-depressants to adjust serotonin.

The University of Alabama reports that any one of 9 variations in another gene can double the risk of lupus.

The US, China and the UK have jointly launched the 1000 Genomes Project in which scientists will exhaustively detail the DNA of 1000 people from around the world, producing 60 times as much genetic detail in the three years than all of that produced in the previous 25 years.

In her book, The Human Condition, Hannah Arendt defines vita active (active life) as composed of labor, work and action in the political, social, public and private worlds.

In his book, The Human Comedy, William Saroyan illustrates how the grounded-ness of a well-rounded human support system of Homer Macauley enables him to live a full and fulfilled life

With all this data about who we intrinsically are, physically, socially and spiritually, the challenge remains on understanding and developing pills, products and ideas to continue to help us survive and thrive.

At SmartAnalyst, we are evolving an approach called Life-Profiles ™ where we can combine the best of consumer/patient, scientific and commercial research to provide pharmaceutical and consumer healthcare companies with an understanding of their ultimate target, us.

At Warner-Lambert, we used to have a saying that The Patient Is Waiting. The world is waiting for help with better vaccines, better courses of therapy and better care.

Understanding the complexities of genes and psychologies is so critical to this success that Life-Profiles is designed to help shine a light on who we are, creating a real blend of both scientific and psychological insight.

In his The Actor’s Studio, Lee Strasberg refined and taught method acting as way in which actors would recall real, personal emotions to help them get inside the personalities of their characters.

Life-Profiles is all about getting inside the life of our patients, both physically and emotionally. That is our motivation.