40 HASTINGS CENTER REPORT March-April 2018 R ebellion isn’t what it used to be. The target was a lot easier to spot in the old days, at least if you subscribed to the ideology of the counterculture. The Establishment, the Combine, the Bureaucracy, the Man: so powerful and oppressive was the en- emy that it required a proper noun. The enemy demanded that you follow the rules, suppress your individuality, and resist your desires. It was represented by the gray iconography of Eisenhow- er’s America: straight lines and perfect lawns, submissive white housewives with frozen smiles, Boy Scouts reciting the Scout oath in a church basement somewhere in Indiana. Back then, the battle lines were clear- ly drawn. It was the individual versus the institution, hip versus square, the oppressed versus the powerful. It was Randall McMurphy against Big Nurse and Hunter Thompson against Richard Nixon, accompanied by Jerry Garcia on lead guitar. Of course, that was before corporate America discovered how to put countercultural ideals to work for consumer capitalism. By the mid-’90s, as Thomas Frank wrote in his classic es- say, “Why Johnny Can’t Dissent,” those ideals had become the “official aesthetic of consumer society.” Hoody-wearing executives in Silicon Valley began to cast themselves as business radicals, disrupt- ing the staid corporate order in between visits to Burning Man. Today the sub- versive, rule-smashing individualist is such a familiar marketing trope that the very idea of cultural dissent has been de- flated. As Frank pointed out, this is not so much because the rebels have been co-opted but because there is no longer any meaningful difference between the rebels and the culture they are supposed to be subverting. Consider the recent campaign launched by Sprout Pharmaceuticals for its female libido-booster, Addyi (fibanserin). Originally developed as an antidepressant, fibanserin was rejected for approval twice by the FDA before Sprout bought it, gave it a new name, and rebranded it as the “female Viagra.” In its new incarnation as a prescription aphrodisiac, Addyi was supposed to treat “hypoactive sexual desire disorder.” The only barrier was the lack of evi- dence that Addyi actually worked. This made the task of convincing the FDA to approve the drug a challenge. Sprout scripted a strategy right out of the countercultural marketing play- book. Aided by Blue Engine Message & Media, a public relations firm, Sprout portrayed the struggle for FDA ap- proval as a fight between women and the patriarchy. Feminist activists, fed up with being told to ignore their sexual- ity, were finally demanding to be taken seriously by the medical establishment. Sprout created a fake grassroots organi- zation with a website called WomenDe- serve.org. It recruited national women’s groups as allies and paid prominent feminists to serve as spokespeople. The chief talking point for the campaign? There were twenty-six drugs to treat male sexual dysfunction but none for women. And because no scrappy un- derdog campaign would be complete without an ironic wink to the audience, Sprout created a parody YouTube ad, featuring a sexy model in lingerie who mocked television commercials for Vi- agra. The campaign was called “Even the Score,” but it might as well have been called “Sticking It to the Man.” The strategy worked brilliantly, at least for a while. The FDA approved Addyi on August 18, 2015, and two days later, Valeant Pharmaceuticals bought Sprout for a billion dollars. But that deal turned out to be the high point for Addyi. It took only a year for a commentator in the New York Times to describe Valeant’s purchase as a “co- lossal failure.” Women, apparently less easily fooled than the FDA, were not ex- actly lining up to get dosed with Addyi. Maybe it was the black-box warning that Addyi carried, or maybe it was the fact that clinicians had to pass a test for certification to prescribe the drug. But as of February 2016, according to the Times, doctors had written fewer than four thousand Addyi prescriptions. How times have changed. Thirty years ago, the only people drug compa- nies thought worth buying were doctors and politicians. But the ground began to shift in the 1980s, when HIV/AIDS activists showed everyone how powerful patient advocates could be. Of course, it didn’t hurt that many advocates were so strapped for money that they could be purchased at bargain prices. Today over 80 percent of patient advocacy groups accept money from the pharmaceutical industry, and the testimony of marginal- ized patients carries such cultural power that drug companies like Sprout are willing to fake grassroots patient move- ments. Whether you see this change as a review The Purchased Patient Advocate by Carl Elliott Health Advocacy, Inc.: How Pharma- ceutical Funding Changed the Breast Cancer Movement. By Sharon Batt. University of British Columbia Press, 2017. © 2018 The Hastings Center. Permission is required to reprint.