For a start, have a look at India's pharma turf to get a picture of the ground-realities confronting brand managers today.

Ground Reality 1: Company X is simultaneously promoting omeprazole, pantoprazole, lansoprazole, and also rabeprazole.

Ground Reality 2: Company Y (it could be company X as well) has ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin and moxifloxacin.

Ground Reality 3: Company Z (again, it could be company X or Y or both) is marketing cefadroxil, cefdinir, cefixime, cefuroxime axetil, cefpodoxime proxetil, and also continuing with cephalexin.

Pity the PMT chaps trying to differentiate between look-alike SSRIs, ACEIs, ARBs - not to mention half-a-dozen statins (from atorva to pitva), a dozen' lols (from ateno to nevi), and yes, double-dozen cephalosporins. It's a crazy scene in medical madvertising. It wasn't so three decades ago.

THE GOOD OLD DAYS OF A FOCUSED PRODUCT MIX

In the really ethical era of ethical pharma marketing that lasted till the mid-1970s, the top-100 pharma companies used to have a clinically well-demarcated product mix.

Each company would ensure that there was minimal overlap between any two brands that were targetted at the same disease segment or therapy area.

Thus, almost without exception, a company's product mix would have only one analgesic brand, only one antihypertensive brand, only one antacid, and usually, only one antibiotic… Even the line-extensions that involved brand stretching were done in such a manner as to avoid clinical overlap: a plain-antacid + an antiflatulent, plain antibiotic eye drops + an ocular corticosteroid, an analgesic with an antispasmodic or a muscle relaxant, an antihypertensive with a diuretic…

What lead to the gradual shift towards an omnibus product basket - from a differentiated product mix to clinically overlapping product mix - is hard to determine. Most marketing folks point to certain 'market forces', but do not specify or isolate any particular market-force that changed the long-held concept of a clearly delineated brand portfolio.

Among the two possible developments cited by sales people are:
1) prescriber-loyal medical reps or rolling-stone product managers pressurizing the company to market an overlapping entity just because of a few prescribers shifting preferences or because of previous company's pilfered material is readily available for a quicky launch
2) introduction of the practice of selective brand promotion i.e. identifying 25 to 50 brand-loyal prescribers instead of promoting a brand to all the 250-or-so doctors on a medical rep's calling list.

Selective promotion seems to have got a further push from certain developments in market research: the arrival of retail audit and prescription audit, and the induction of data management / management information systems which were rather crude by today's standards (remember those punch-cards, Bradma-plates and telex machines of yester-years ?)

Probably the first multinatio-nal to introduce apparently overlapping brands was UK's Beecham Research Laboratories or BRL (later to morph into SmithKline Beecham, etc.)

BRL not only introduced ampicillin but also amoxycillin, cloxacillin and carbenicillin in the UK market.

But even at BRL, the clinical overlap was kept to the minimum: amoxycillin - ampicillin - cloxacillin were differentiated by the subtelities of their spectrum; with ampicillin being promoted for Salmonella and Shigella infections, amoxycillin being projected for its pharmacokinetics in purulent sputum of lower respiratory tract infections. And cloxacillin, till today, enjoys the same old status of an antistaphylococcal drug, and carbenicillin continues to be an anti-pseudomonal penicillin, this positioning having been carved by BRL way back in the early 1970's.

Brand-Blurring

In India, marketing opportunism heralding the beginnings of brand-blurring, was first demonstrated by Hoechst Pharmaceuticals when it decided to launch the then reigning antibiotic, tetracycline, as Hostacycline in a head-on competition to two well-entrenched tetracycline brands of Lederle (Achromycin), and Sarabhai-Squibb: (Resteclin), when Hoechst already had its proprietory rolitetracycline (Reverin). As a pretence to appear distinctive in the huge tetracylines' market, Hoechst also launched Hostacycline-500, claiming it to be the first twice-daily tetracycline. Soon after, Hoechst also jumped on the ampicillin bandwagon by launching Albercillin (in association with a local company, Inga Laboratories of Mumbai). Interestingly, it was Lyka and Cipla, both Indian companies, which had kick-started the ampicillin era.

Next was the turn of mighty Alembic, a pioneer in macrolides: gradually it launched all the four, hard-to-differentiate macrolides : erythromycin, roxithro-mycin, clarithromycin and azithromycin.

The process of brand-blurring gained further momentum from two parallel developments occurring alongside the introduction of macrolides.
a) the arrival in quick succession of similar-sounding cephalosporins and
b) similar-acting fluoroquinolones flooding the Indian market.

By mid 1990's, two brands of the same company were not merely clinically overlapping, but had started financially cannibalizing each other.

Meanwhile, all the tried and tested approaches of product-positioning had become irrelevant as well as impracticable, driving even a level-headed brand manager to near insanity.

Alas, the real brand-positioning travails of marketing chaps were yet to begin.

Enter the pre-WTO rush for new molecules - never mind if the newness lay in the manner of their spellings…

Mortified by the prospects of an Exclusive Marketing Rights (EMR) regime, and concerned over the drying pipe-line of new chemical entities (NCE), India's pharma giants went into an overdrive for launching as many molecules as they could source from dubious to dependable API manufacturers, from Bulgaria to China. This activity peaked in the years 2000 - 2001 when one company alone introduced 83 new products in a single calendar year. Another company could boast of having marketed 102 new products/ line extensions in the same year.

More than the marketing potential or the clinical relevance of an NCE, the sole consideration in this launch-flurry was to beat two cut-off dates - January 1, 1995 as the first launch date of an NCE anywhere in the world, and January 1, 2005, as the commencement date of post-WTO / post-TRIPS era.

How to handle the promotion of today's spine-breaking brand-load?

There's a way, and though hard-to-believe at first, an honorable and a scientific way for fine-tuning the promotional message of clinically-overlapping brands - thanks to three converging developments, two in the field of medicine, and third in the relatively new domain of creative thinking with its 'Thinking Tools'.

Briefly, these three converging developments can be summarized as follows…

Firstly, clinical medicine has been getting more logical, precise and predictable day by day as a result of improved diagnostic techniques and instrumentation. Some of these techniques help in diagnosing a given illness, others serve as predictors and early markers of an impending ailment. The second development in medicine, occurring in tandem with diagnostic precision, is the formatting of clinical guidelines and algorithms for the management of most major clinical conditions and syndromes.

These guidelines and algorithms have the backing of authoritative specialist organizations and are also updated periodically, making it possible to achieve today a remarkably clear-cut patient stratification.

PATIENT STRATIFICATION - THE NEW KEY TO BRAND DIFFERENTIATION

Stratification translates into different - and differing - patient-subsets under the same disease segment. In retrospect, even BRL, while marketing several penicillins simultaneously, was resorting to patient stratification based on the ' probable pathogen' concept. Patient stratification has come a long way: more and more clinicians nowadays do not go by the conventional labels such as hypertension, angina, diabetes, depression, or schizophrenia, but perceive any clinical condition as a patient subset: a diabetic hypertensive, patient with post-stroke depression, angina in a non-MI obese individual… Even onychomycosis, the humble fungal infection of nails, has now three patient subsets!

THE THIRD DEVELOPMENT: ENTER TONY BUZAN IN THE SANCTUM SANCTORUM OF MEDICINE …

In 1970s, Tony Buzan, a UK- based learning consultant had developed a revolutionary yet disarmingly simple approach to handle intricately complex situations requiring clear-headed thinking. Tony Buzan's technique, a thinking tool called 'Mind Mapping', is a brilli-antly conceived system for capturing and differentiating ideas and insights horizontally on a single sheet of paper.

How does Mind Mapping operate?

Just take a piece of paper, have same coloured pens around, put your problem in the centre, and start plotting all the facets and aspects of the problem on lines branching out from the centre. By doing this, you are actually 'mapping' your notes, thoughts, ideas, and reactions across the page, rather than listing these in a linear fashion, as has been the prevailing practice or habit.

How does 'mapping' across the page differ from linear notes running down the page ?

Here's an excerpt from Harvard Management Communication Letter (2000) which is self-explanatory:

"Unlike linear notes, which can obscure key points, limit thought processes, and bore readers, Mind Maps track the natural progression of your brain by allowing you to connect each new thought to the ones that have come before. Linear notes or lists, on the other hand, says Buzan, deliberately cut off each idea from the ones preceding and following it, disassociating each idea from its context and stunting the natural thinking process".

MIND MAPPING AS A TOOL FOR BRAND PROFILING BASED ON PATIENT STRATIFICATION

The concluding part of this paper will demonstrate the utility of Tony Buzan's thinking tool for pharma brand managers who need to achieve a brand differential to facilitate focused promotion of apparently conflicting brands. 'Hypertension' is the disease segment selected for this demonstration because of two considerations:
a) antihypertensive drugs constitute one of the largest market segments, with the maximum number of molecules representing several categories of drugs, each category having an exclusive mode of action.
b) hypertension provides probably the widest number of patient-subsets than any other medical condition.

Before proceeding with the exercise, two assumptions are critical, though:

One, that the brand manager concerned has an indepth knowledge of the pharmacological differences between competing molecules, and Two, that the same brand manager, assisted by a competent clinician, has a lucid understanding of patient-subsets.

Remember, all 'Thinking Tools' are the equivalent of mining equipment : gold or diamonds or oil must be there to be mined and extracted.

Now, the exercise or if you like, the situation:

A large pharma organization - let's name it LPO Labs - has in its antihypertensive range the following entities:

Two beta-blockers, say atenolol and metoprolol - two ACE inhibitors, say ramipril and lisinopril; two ARBs, say candesartan and losartan ; two diuretics, say hydrochlorothiazide and furosemide ; two calcium-channel blockers say amlodipine and diltiazem; two statins, say atorvastatin and simvastatin; and two antithrombotics, say aspirin and clopidogrel; and as if this were not enough, two nitrates as well - isosorbide mononitrate and isosorbide dinitrate!

That's a mind-boggling, if not mind-blowing promotional challenge, even for the likes of Jack Trout or Tony Buzan!

To start the exercise, keep your attention glued for a while to the 'Hypertension Map' provided. You may even modify this map or make your own map of hypertension: the objective is to understand the use of thinking tool.

1. SLOTTING ATENOLOL / METOPROLOL

But first : A Quick Survey of Current Medical Background

Of late, beta-blockers have been loosing their long-held primacy in hypertension, and are therefore undergoing a clinical shift, being preferred in POST-MI patients where their antianginal / antiarrhythmic as well as antihypertensive benefits can be put to good use. As if through a back door, beta-blockers are also staging a comeback in heart failure (particularly metoprolol). Atenolol is hydro-philic and eliminated renally; metoprolol is lipophilic, and undergoes hepatic elimination. The controversy regarding the relevance of beta-blockers in diabetes also stands resolved as diabetics are now perceived as 'coronary equivalents', requiring antianginal cover. While diabetics have nephropathic changes, even non-diabetics have an age-related decline in kidney function, starting at age 40.

Now, re-focus on the accompanying map ("Mapping Hypertension"), and explore the possibilities for positioning / repositioning atenolol and metoprolol. The following options, among others, may occur to a brand manager doing this exercise.
- Metoprolol, alongwith a suitable regimen of an ACE-I and a diuretic for patients of heart failure
- Atenolol, as the preferred antihypertensive for post-MI patients with evidence of diabetes OR
- Atenolol in Post-MI patients with impaired liver-function
- Metoprolol as an antianginal/ anti-hypertensive / antiarrhythmic cover in elderly Post-MI patients with impaired renal function
- Metoprolol in women patients with hypertension who also have a history of migraine

2. SLOTTING LOSARTAN / CANDESARTAN

A quick survey of current medical background
Faced with…
a) increasing incidence of hypertension in younger population
b) people marrying or remarrying late-in their 40's or 50's
c) beta-blockers, diuretics, and even calcium-blockers, inducing impotence (now 'erectile dysfunction') because all three affect cardiac output.
d) young, articulate male patients with hypertension (women generally stay protected till menopause) complaining of 'reduced quality of life' - a euphemism for erectile dysfunction.
… the pharmacologists were forced into looking for alternatives to bring down BP without affecting cardiac output directly. The focus thus shifted to the Renin-Angiotensin-System (RAS), and ACE-Is were the outcome. (captopril to perindopril, and still counting ). ACE-Is however were found to induce irritant cough in up to 20 per cent patients

Pharmacologists therefore had another look at RAS, and came up with ARBs, which are largely devoid of the side-effect of cough.

Initially, the official positioning of ARBs (losartan being the prototype), was only for those patients who were well-controlled with an ACE-I, but found their cough troublesome.

'LIFE' and 'CHARMS' studies firmly established the roles of Losartan and Candesartan in many patient subsets such as diabetic hypertensives to chronic hypertensives with left ventricular hypertrophy.

Candesartan, because of its placebo-like side-effect profile and its predictable kinetics, has a sight edge over losartan.

Now, cast another focused look on the 'Map' to trigger some positioning ideas for losartan / candesartan.
- Candesartan for newly-diagnosed, young male hypertensives who may not like to exchange their raised reading of BP (hypertension has no symptoms) for cough or impotence.
- Losartan for chronic middle-aged hypertensives alongwith diabetes, who may also be having microalbuminuria. That's mind mapping in action…
- facilitating patient stratification into patient subsets
- facilitating positioning or repositioning of brands with minimal overlap

If you found the 'Mind Mapping' approach useful, you can continue with the exercise for remaining molecules, after the usual 'Quick Survey of Current Medical Background'.

Some of the positioning statements for other molecules in our example case 'LPO Labs' may evolve from the 'Map' as follows:
- Atorvastatin for all young, male hypertensives as routine prophylaxis against life-style dyslipidemiad.
- Atorvastatin for all post-menopausal hypertensives to reduce the risk of coronary disease
- Simvastatin as the ideal add-on with Ezetimibe for hypertensives with an adverse lipid profile
- Isosorbide mononitrate in ischemic hypertensives with chronic stable angina (for prophylaxis of effort-induced angina)
- Isosorbide dinitrate for chronic hypertensives with Chronic Stable Heart Failure (for improving exercise tolerance)
… and similiarly for other molecules or even their fixed-dose combinations - the more 'radiant' the mapping, and deeper your knowledge of drugs and disease, more the possibilities of arriving at well-demarcated brand positioning.

Those who wish to use the 'Mind Mapping' technique for professional presentations or for evolving brand names, or for any situation that calls for 'Whole Brain Thinking', are encouraged to read Tony Buzan's books: The Mind Map Book by Tony Buzan (1993), Plume, 320pp. and Use Both Sides of Your Brain (1989) 3rd Edition, Plenum, New York.

EPILOGUE

Those readers who are likely to comment that the patient-stratification approach to brand positioning restricts the market share, are reminded of a pharma marketing mantra particularly relevant to the current Indian scenario: "Before you aim for the share of the market, you need to get a share of the prescriber's mind."

- (The author, a Medical Copywriter and Medical Communications Consultant, offers free advice on 'Mind Mapping' to pharma brand managers from his Mumbai office. scriptamedica@gmail.com, prescription@rediffmail.com)