At 9:14 p.m., my dog, Sofia, was asleep, the dishes were done, and the television was selling leukemia.
Not bluntly. Not with a price tag. A woman in a linen shirt stood in a field of high grass, smiling at a horizon we couldn’t see. A calm voice described a rare blood disorder most Americans will never develop. She once felt tired, the voice said. She once worried. Now she lifts her grandson and laughs.
Then the voice shifted registers.
“Serious infections… organ damage… possible fatal outcomes…”
The warnings came at auctioneer speed while the golden retriever bounded through sunlight. The price was never mentioned.
I reached for the remote and muted it. I watched the tiny white type crawl across the bottom of the screen and realized I had a question I’d never quite formed:
Why are we advertising half-million-dollar drugs to people who don’t have the disease?
Only two countries on Earth allow prescription drugs to be marketed directly to consumers on television the way Americans know them: the United States and New Zealand.¹ In most wealthy democracies, if a medication requires a physician’s gatekeeping, the persuasion ends at the clinic door.
We chose differently.
In 1997, the FDA clarified how drugmakers could meet broadcast disclosure requirements—allowing television ads that named a drug and its use so long as viewers were directed elsewhere for full risk information.² The piano music began. The lifestyle montages followed. “Ask your doctor” entered the language like a civic duty.
Since then, pharmaceutical advertising has become one of the most reliable funding streams for American television. A Government Accountability Office report found manufacturers spent nearly $18 billion on direct-to-consumer advertising between 2016 and 2018—about $6 billion a year—with spending concentrated on a relatively small number of brand-name drugs.³
The country that pays the most for medicine is also the country most aggressively sold medicine.
That is not coincidence. It is architecture.
The phrase “ask your doctor” is not just polite branding. It is a behavioral lever. In a landmark study, standardized patients—actors trained to present scripted symptoms—visited real physicians. When those patients requested a specific antidepressant by name, prescribing rates rose significantly, even in clinically ambiguous scenarios.⁴ The request shifted the dynamic. Diagnosis became negotiation.
Advertising does not need to persuade millions. It needs to locate enough.
This is why the rare-disease campaigns are the most revealing. A biologic priced at $150,000 a year does not require ten million customers. It requires a few thousand insured ones. Capture 3,000 patients and you have $450 million in annual revenue. Manufacturing cost is often a fraction of that. Pricing reflects exclusivity, leverage, and what the system will bear.
It also reflects something more subtle: attention.
Many of the most powerful campaigns do not name a drug at all.
In 2016, viewers of General Hospital watched a beloved character receive a diagnosis of polycythemia vera—a rare blood cancer. The storyline was part of a disease-awareness partnership backed by Incyte, whose drug portfolio aligned with the condition’s molecular pathway.⁵ Oncologists publicly objected that a soap opera had become a clinical funnel.⁶
No brand name flashed across the screen. No price was mentioned.
But awareness spread.
During the Rio Olympics, Mylan ran heavy “unbranded” allergy awareness advertising at the height of the EpiPen pricing controversy.⁷ The campaign urged vigilance about severe allergic reactions. It did not need to say “EpiPen.” The rescue category was already clear.
More recently, Bristol Myers Squibb launched “Could It Be HCM?”—an unbranded awareness campaign fronted by NBA player Jared Butler, urging viewers to consider hypertrophic cardiomyopathy.⁸ Alexion produced film-style awareness projects around generalized myasthenia gravis, a rare autoimmune neuromuscular disease treated with high-cost biologics in its portfolio.⁹
These campaigns do not shout. They suggest. They invite. They lower the threshold at which normal human variance feels diagnostic.
Mass advertising for rare diseases is not about the masses. It is about finding the few.
Regulators have begun to respond.
In September 2025, the FDA announced a sweeping enforcement push, issuing roughly 100 cease-and-desist notices and thousands of warning letters related to misleading direct-to-consumer drug promotion.¹⁰ The action followed a White House memorandum directing health officials to ensure ads present true “fair balance” between benefits and risks.¹¹
For context: in 2023, the agency issued a single warning letter related to promotional violations. In 2024, none.¹²
When the cop stops writing tickets, the billboards multiply.
The new enforcement wave targeted high-visibility placements. Hims & Hers drew scrutiny over a Super Bowl advertisement promoting compounded weight-loss drugs without adequate risk disclosure.¹³ Eli Lilly and Novo Nordisk received warnings related to promotional communications judged to minimize or omit serious side effects.¹⁴ These were not obscure cable spots. They were mainstream cultural events.
Regulators are not banning ads. They are trying to close gaps that allow benefit-forward narratives to float above proportional risk context.
Yet the deeper question remains unresolved.
If the defense of high American drug prices is that we subsidize global innovation, why does that innovation require mass persuasion?
Part of the answer lies on the other end of the spectrum—the miracles.
In 2019, researchers published in the New England Journal of Medicine the case of a child with Batten disease who received a customized antisense therapy—milasen—designed specifically for her genetic mutation.¹⁵ It was a triumph of precision medicine. It was also a glimpse of a future where treatments are engineered for individuals.
Boston Children’s Hospital has described the research costs for such individualized programs as averaging roughly $1.6 million per case—astonishingly low by pharmaceutical standards, yet still reliant on extraordinary coordination and philanthropic support.¹⁶
The contrast is jarring.
On one side: bespoke cures built in months for a single child.
On the other: primetime commercials for six-figure therapies aimed at viewers who may not know they’re candidates.
Both exist in the same system.
And that system prices not at cost, but at leverage.
Insurance insulates patients from immediate sticker shock. Premiums absorb the difference. The signal becomes simple:
Why not ask?
The danger is not that Americans are uniquely fragile. It is that we have built an economy in which attention functions as a clinical input.
When enough viewers reinterpret fatigue, stiffness, distraction, or sadness through the lens of possibility, clinics feel the pressure. Some of those conversations save lives. Some accelerate overdiagnosis. Many are simply expensive.
Back in the living room, the news resumed. Sofia shifted and sighed.
I unmuted the television and listened to the next commercial break arrive. Another soft-lit couple. Another calm recital of catastrophic risks delivered over birdsong.
I wondered how many viewers would walk into appointments this week carrying a brand name they did not know last month. I wondered how many families with truly rare conditions were still fighting prior authorization while the awareness machine hummed.
We have built a healthcare system where miracles are real—and marketing is louder.
If we want the miracles to feel normal instead of luxurious, the solution is not silence. It is redesign.
Approve platforms once, not from scratch each time.
Pool risk so no insurer has an incentive to stall a cure.
Separate clinical education from revenue-dependent advertising.
Fund innovation transparently, and negotiate prices honestly.
Until then, the commercial break will continue doing clinical work.
And Sofia will keep sleeping through it.
⸻
Bibliography
1. Ventola, C. Lee. “Direct-to-Consumer Pharmaceutical Advertising: Therapeutic or Toxic?” Pharmacy and Therapeutics 36, no. 10 (2011): 669–684. Describes the United States and New Zealand as the only countries permitting full direct-to-consumer prescription drug advertising.
2. U.S. Food and Drug Administration. “Consumer-Directed Broadcast Advertisements; Draft Guidance.” Federal Register, August 12, 1997. Formalized how manufacturers could satisfy broadcast disclosure requirements for DTC television ads.
3. U.S. Government Accountability Office. Prescription Drugs: Medicare Spending on Drugs with Direct-to-Consumer Advertising. GAO-21-380, June 2021. Quantifies DTC advertising expenditures and concentration among brand-name drugs.
4. Kravitz, Richard L., et al. “Influence of Patients’ Requests for Direct-to-Consumer Advertised Antidepressants.” Journal of the American Medical Association 293, no. 16 (2005): 1995–2002. Randomized trial showing that patient requests significantly increase prescribing rates.
5. Molteni, Megan. “The Tricky Ethics of Big Pharma’s Soft Sell on Soap Operas.” Wired, May 2017. Reports on the General Hospital polycythemia vera storyline backed by Incyte.
6. Garde, Damian. “Drama and Diagnosis: Soap Opera Cancer Plotline Puts Incyte in Hot Seat.” FiercePharma, 2016. Describes oncologist criticism of the PV storyline as a marketing mechanism.
7. Robbins, Rebecca. “EpiPen’s Olympic Advertising Blitz.” STAT, August 2016. Details Mylan’s unbranded allergy awareness campaign during Olympic broadcasts.
8. DeAngelis, Christina. “Utah Jazz Rookie Opens Up About Heart Diagnosis in BMS Awareness Campaign.” FiercePharma, 2022. Covers Bristol Myers Squibb’s “Could It Be HCM?” unbranded awareness effort.
9. DeAngelis, Christina. “AZ’s Alexion Spotlights gMG in Awareness-Raising Film.” FiercePharma, 2023. Discusses Alexion’s documentary-style campaign around generalized myasthenia gravis.
10. U.S. Food and Drug Administration. “FDA Launches Crackdown on Deceptive Drug Advertising.” Press release, September 2025. Announces issuance of approximately 100 cease-and-desist notices and thousands of warning letters.
11. The White House. “Memorandum for the Secretary of Health and Human Services and the Commissioner of Food and Drugs.” September 2025. Directs federal agencies to ensure truthful and balanced DTC drug advertising.
12. Gardner Law Firm. “FDA Sends 100+ Cease-and-Desist Letters: A Warning to Industry on DTC Pharmaceutical Advertising.” 2025. Notes the sharp increase in enforcement compared to prior years.
13. Reuters. “U.S. FDA Chief Says Hims & Hers Super Bowl Ad Violated Drug Promotion Rules.” September 12, 2025. Reports regulatory concerns over Super Bowl weight-loss drug advertising.
14. Pharmaceutical Technology. “Lilly, Novo, Hims Get FDA Warnings About Misleading Drug Communications.” 2025. Details warning letters related to promotional communications.
15. Kim, Jong-Hee, et al. “Patient-Customized Oligonucleotide Therapy for a Rare Genetic Disease.” New England Journal of Medicine 381 (2019): 1644–1652. Describes the development and administration of milasen for Batten disease.
16. Boston Children’s Hospital. “Custom Genetic Treatments and the Future of N-of-1 Medicine.” 2022. Discusses development costs and logistical challenges for individualized antisense therapies.