Point a finger at a map of the United States and try to find a state that's not competing to attract pharma and biotech business. It's nearly impossible. The story is the same in Europe and Asia. Around the world, countries, regions, and cities are trying to build their economies, and the life sciences are a key element in their plans.	

The world's hunger for economic development creates plenty of opportunity for both Big Pharma and emerging companies. But with billions of dollars in corporate investment at stake, the question is how to identify the opportunities that will pay off best. Evaluating potential new business sites is no easy task. The variables are many, and their relative value depends on who's looking and why. 	

"You have to think about it differently across the value chain," says Mark Kozin, managing partner, US, LEK Consulting. "If you're talking about research, companies are looking for world-class scientific talent. When Novartis, Merck, and Amgen move to Boston, it's because there's a critical mass of scientists there. Research is a high-cost activity, so things that are farther down the ladder such as housing and transportation don't really matter that much."	

But for manufacturing, Kozin explains, costs become more important. And if the point of a new facility is to expand sales and marketing, there's a premium on locations with high unmet patient need and the ability to influence the regulatory path. 	

Anyone who has bought an engagement ring knows the "four C's" of diamond buying: cut, color, clarity, and carat. Except for the wealthiest buyers, the ideal diamond is always a compromise-smaller but more brilliant, better in cut but less perfect in color. Similarly, there are four C's in pharma site selection: capital, clusters, capacity, and commercialization. (See "Environmental Considerations" below and "Site Selection Criteria," page 60.) This article will help pharma executives categorize site location variables according to their companies' definition of value and pick the trade-offs that best meet their needs. It also offers expert insight from all sides of the industry to help put the decision making process into perspective.	

Local, regional, and national economic development agencies continue to offer tax breaks, grants, and low-interest loans to attract companies. But savvy companies look beyond simple financial incentives. Instead of cash, they look for capital.				

Capital comes in many forms, and for many pharma companies, the most important are human and intellectual: access to quality employees and to the research and new ideas associated with universities and research centers. 		

A new study by Pennsylvania's Lehigh Valley Economic Development Corporation finds that 90 percent of pharma and biotech site consultants surveyed rank a skilled and educated work force as the number-one concern of companies choosing a new facility location. And that's true for companies of all sizes-start-up, emerging, or established.	

Nothing better exemplifies the point than Pfizer's recent multi-year, 1,000-job, $400+ million commitment to expand the company's global headquarters in midtown Manhattan. "New York may not be the cheapest place to do business," says New York City Economic Development Corporation president Andrew Alper, "but it provides the best value, with a more productive work force and proximity to the financial, legal, and advertising communities. This is a business [pharma] in which intellectual capital is so valuable that the cost of real estate and labor is overwhelmed by the quality of ideas." 	

For regions that lack New York's unique assets, training programs are useful. In its 2001 report for the Biotechnology Industry Organization, the Battelle Memorial Institute (BMI), offers details of states' initiatives. "In the past six months, we've talked to several pharma companies that are having difficulty with certain kinds of production and technician-level workers and are looking for additional support programs," says Walter Plosila, vice-president and director of BMI's technology partnership practice. He points out that several community colleges have shown interest in revamping their curricula to serve that work force, particularly one in St. Louis, Missouri and several in California. And pharma is equally interested in having such curricula to meet their work force needs.		

Clearly, what sets regions apart in their ability to attract pharma business of any kind-research, operations, manufacturing, or marketing-are their life sciences educational and professional development programs. North Carolina serves as a model for other states to follow, as companies such as GlaxoSmithKline, Biogen, Eisai, and Novo Nordisk have proven by their presence and recent expansion in Research Triangle Park. 	

North Carolina's move to strengthen its academic programs for work force development was an idea that caught on-or was already exemplified-in other areas that wanted pharma and biotech manufacturing but lacked an employee base that would allow them to compete on the research level. That's true for many locales outside the United States, such as Ireland, which has become a manufacturing powerhouse; Singapore, which is working to gain that status; and Puerto Rico, which has done so well during the past 30 years that some experts speculate the island may soon reach its saturation point.	

The focus on people and education doesn't mean that cash doesn't count. Companies, especially young ones, need access to investment capital. And investment capital often has surprisingly close ties to specific geographic locations. (See "Follow the Money.")	

That trend is supported by Joseph Cortright and Heike Mayer in "Signs of Life: The Growth of Biotechnology Centers in the United States," published by the Brookings Institution Center on Urban and Metropolitan Policy in 2002. They wrote: "The availability of venture capital is contingent in part on the presence of local venture capital firms." Venture capitalists like to play a role in the management of the companies in which they invest, down to the level of marketing, product development, and other day-to-day operations. As a result, say Cortright and Mayer, "Venture capitalists strongly prefer to invest in and work with firms located near their offices." 	

Tony Nash, chief knowledge officer for New Economy Strategies, an economic development consulting company, uses Silicon Valley as an example of a region that demonstrates the high-value companies still place on accessible venture capital. "[In the Valley], the concentration of entrepreneurial investment per capita is nearly ten times that of Boston and twenty times that of Philadelphia/New Jersey. In 2002, GrowThink Research data show that venture investment per capita for the San Jose metropolitan statistical area was $1,724. That's definitely a magnet to cash-hungry entrepreneurs." 	

Does the difference in available investment dollars mean that Boston or New Jersey/Philadelphia is less innovative? "Not really," says Nash. "The University of Pennsylvania attracts more federal research funding than any other university in the country. And the velocity and capacity of innovation within Boston's university concentration speak for themselves." There's not a simple correlation between intellectual capital and investment capital. The maturity of technology counts. So does the availability of substitute investments and the concentration of potential investors.	

In the long run, money follows opportunity. "If there is a significant mass of innovation within a new and unique technology in a region, capital will begin to reside locally," says Nash. "Austin, Texas and San Diego, California are good examples of that."	

Employees, ideas, and dollars are powerful in attracting business to a region. But when a locale has a critical mass of companies in a particular industry, the synergy enhances efficiency and accelerate innovation. Economists call such high concentrations of related businesses "clusters," and they point to them as extraordinary economic engines. For pharma and biotech companies, clusters can provide exceptional access to employees, suppliers, and innovative ideas.				

One of the nation's most active life science clusters is in North Carolina's Research Triangle Park. Leslie Alexandre, DPH, president and CEO of the North Carolina Biotechnology Center, explains the kinds of needs that draw companies to a mature cluster. "They need to know that they have an ample supply of well trained workers with a strong work ethic and that they won't have any problems filling positions," he says. "For companies that have products ready to bring to the market, they need to know that there are biomanufacturing capabilities or that they will be able to develop their own in the region. Pharma companies, in particular, want to be near biotechnology companies, as biotechs are increasingly the source of new products. Many also want to be close to universities as another source of R&D."	

The big life science clusters are attractive, but they also have a down side, according to the Battelle Institute's Plosila. "After a point in time, if everybody put everything in Boston or Silicon Valley, the companies would go broke, because they would have to pay exorbitant salaries so the employees could get decent housing. It's an escalating spiral." 	

Plosila sees the industry, and especially R&D, spreading from its traditional bi-coastal homes, partly because of changes in research funding. "More and more research and testing is coming out of academic health centers wherever they are in the country, especially since NIH money is being spread more widely than it was in the past," he says. 	

Cluster building has become a highly competitive game played by states, individual municipalities, and countries-from Michigan (whose Life Sciences Corridor has attracted 50 new companies to the state) to Singapore (where Biopolis, a 2-million-square-foot biomedical complex is scheduled to open this month) to India (where the area around Hyderabad is being promoted as "Genome Valley"). In its 2002 "New Hampshire Biotechnology Business Incubator Feasibility Study," management consultants at Rainey & Associates identified trends in state-level US initiatives. Chief among them were: 	

use of tobacco settlement funds for biosciences

increased state government funding of academic bioscience research centers

increased focus on financing needs of biotech firms

growth of state biotech trade associations and networks

increased focus on work force development programs

The question today is whether state-level programs will be able to follow through on their plans and promises in a tight economy. There are attractive opportunities for companies in emerging clusters, but no one knows whether those clusters will reach maturity.	

It's easy to forget that even the most vital region can support only a finite amount of business development. Eventually, desirable employees will become scarce, the best locations will be taken, and the possibilities for further expansion will start to run out. Companies need to think about their future needs when they consider a potential site. 				

Puerto Rico, one of the most popular expansion sites, is an example of capacity overload. A lack of federal taxes made the US commonwealth attractive to pharma companies. According to Development Counselors International, 25 percent of all pharma products manufactured in the United States are shipped from Puerto Rico, and 16 of the top 20 selling medicines in the United States are produced there. In just the last four years, companies have poured nearly $2 billion into the island, creating thousands of jobs for its well trained work force. In March 2002, Amgen alone invested $800 million dollars in a manufacturing plant there.	

In addition to tax incentives, economic development agencies worked diligently to boost education and training in industrial chemistry and biotechnology. In fact, Puerto Rico offered a doctorate in industrial chemistry before any stateside university did. The legacy of "Operation Bootstrap" set up Puerto Rico as the ideal partner for the emerging pharma industry of the 1970s. And because Puerto Rico is covered under the US federal government's Homeland Security Act, it offers the same benefits and security measures as the 50 states. 	

Olga Ventura, PhD, of PharmaBioSource, an operations and site selection consulting company, says that many US pharma companies that move operations to emerging international locations such as Singapore-where companies can go for ten years without paying corporate taxes-end up returning to Puerto Rico, where they are familiar with the legal and financial structures as well as the culture and languages. 	

But as much as Puerto Rico may be in its heyday, it is, after all, an island. There's only so much room to grow. Most of the land set aside for industry is owned by the Puerto Rican Industrial Development Company and most development is moving inland, because the coastal flatlands are nearly saturated. Some facilities are already blocked from expansion.	

"Look at Wyeth in Carolina, Puerto Rico," says Rafi Maslaton, senior partner of operations management consulting company Tefen USA. "They have a Burger King in one area, McDonald's in another, a residential area behind the facility, and a major road in the front. So the facility can't grow beyond the four walls of the existing site."	

Does that mean Puerto Rico is dead as a site for pharma and biotech companies? Hardly. What it lacks in elbow room, it makes up for in a constantly improving infrastructure that includes professional development and advanced educational programs as well as an intricate network of suppliers to pharma such as plastic and glass container manufacturers, equipment calibration companies, and services from janitorial to telecommunications. There's still plenty of value on the island, but companies need to be aware of the trade-offs.	

Recently, facilities have sprouted up in places where human resources and economic advantages are not the top attractions. Instead, companies are locating in areas such as Brazil and other South American countries in which they see the best opportunities for speedy entry into the marketplace. That also goes for many European countries that represent important new markets for products currently available, for products about to enter the market, and especially for those being prepared for early clinical trials. PhRMA's 2003 annual membership survey reveals a trend in which companies are conducting more research overseas. The numbers have risen steadily since 1970, but they've grown even faster in recent years. In 2000, companies spent $4.7 billion on research outside the United States. That number grew 33.3 percent, to $6.2 billion in 2001, and tapered off to an estimated $5.7 billion in 2002.				

Leontien Ruttenberg, a Boston-based area director for the Netherlands Foreign Investment Agency, offers an explanation for that trend, saying that the regulatory environment is simpler in the Netherlands than it is in the States and that companies can measure the start-up time for Phase I trials in weeks instead of months. She adds that, although the business climate there is similar to the one in the States, there is much less litigation, which streamlines the informed consent and protocol approval processes. 	

As a result, the Netherlands also has proved attractive to contract research organizations. "Kendle and Quintiles, two of the largest CROs, confirm that it is still very easy to get a protocol approved in the Netherlands," says Ruttenberg. She adds that the Netherlands' central location and trading heritage make it a sensible place to locate European distribution centers. In fact, 62 percent of all Fortune 500 companies, including Merck, Biogen, Abbott, and Amgen, have already done so.	

By creating obstacles for companies' marketing and sales efforts, many US state governments are doing the opposite of what might help them bring in pharma business. A US Supreme Court battle ended recently in favor of a state government's right to control medication pricing. According to the decision, Maine-and other states waiting in the wings to follow its precedent-can enforce price controls on medications used by the poor and uninsured if those prices don't drop naturally within the next three years. In another case, Pfizer is pushing for Michigan's Medicaid system to drop restrictions on access to prescription medications if the state wants to keep the jobs associated with the former Upjohn facility in Kalamazoo. CEO Hank McKinnell was quoted in the April 28 issue of the Pink Sheet as saying: "I would prefer access and a pharma friendly state to tax package."								

McKinnell's words confirm pharma's ultimate goal in its site selection decision making: that it do the best research with the best talent to create the best medicines that will benefit the most people. To do that, companies need well trained employees, a hospitable, well resourced infrastructure that allows them to expand and grow, and a business environment filled with opportunities rather than obstacles. In short, new clusters.	

"The desire among states to do economic outreach in life sciences is still very high," says Kozin. "You see areas such as the Woodlands in Texas, which came from nowhere to get a fair amount of biopharmaceutical talent in companies because it has a combination of incentives"-low location costs up front and tax incentives on the back end. 	

He adds, "I think we're in a new reality, although short term, with state and federal budgets here and the economies in Europe where governments can't afford to do as much as they were doing when they were running surpluses. But they still want these companies because they have the potential of employing a lot of high-salary people."	

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Point a finger at a map of the United States and try to find a state that's not competing to attract pharma and biotech business. It's nearly impossible. The story is the same in Europe and Asia. Around the world, countries, regions, and cities are trying to build their economies, and the life sciences are a key element in their plans.

Picking a Place to Grow

Pfizer Chairman and CEO Hank McKinnell sees the company's $58 billion blockbuster acquisition of Pharmacia as the key to Pfizer's leadership in pharmaceutical markets around the globe. But philosopher George Santayana's famous aphorism is especially poignant for the successful marriage of the two companies: "Those who cannot remember the past are condemned to repeat it." For the Pharmacia deal to meet his expectations and to escape the failure of most acquisitions, McKinnell must understand the recent history of the company he is buying. Only then can he know how to best integrate the two organizations.	

The 1995 merger of Sweden's Pharmacia AB and the USA's Upjohn was touted as a combination that would create a major force in global pharmaceuticals, but, in fact, it led to years of chaos and lost profits. From the start, leaders at the new Pharmacia & Upjohn-later just Pharmacia-battled about where to locate the new corporate headquarters. John Zabriskie (Upjohn) and Jan Ekberg (Pharmacia), both very strong-willed CEOs who didn't want to be seen as "less equal," could not agree on which of three existing business centers-Kalamazoo, Michigan; Stockholm, or Milan-they should choose. 	

As a result, they turned to the most costly of all solutions: London, which was home turf for no one and, hence, "neutral." Because they couldn't make a decision that was best for the company and its shareholders, they settled for a costly compromise. That decision added a layer of bureaucracy, further complicated the battles between top executives, and set the stage for a lack of cooperation and a fight for national identity among the company's Swedes, Italians, and Americans.	

That initial lack of collaboration spread like a wildfire throughout the merged units. Seemingly simple issues such as vacation schedules, smoking policies, and monthly progress reports became grounds for disagreement, debate, and resentment. Internal power struggles and infighting replaced the focus on business. Employees sided with their different leaders, transforming the merger into an internal civil war.	

The quick exit of top talent drained the new organization of its ability to meet its challenging financial goals. It also jeopardized the company's plans to reach critical milestones on the merger implementation timeline. 	

After many key executives jumped ship, including CEO John Zabriskie and chairman Jan Ekberg, the board finally recruited industry veteran Fred Hassan from American Home Products to stop the exodus and restore order. One of his first initiatives was to find the "right" headquarters location. 	

Hassan quickly announced a major restructuring that called for dismantling the Kalamazoo, Stockholm, and Milan facilities. In the summer of 1998, after wasted months and millions of dollars in unplanned capital expenditures, he relocated the temporary London headquarters to New Jersey. 	

Pharmacia & Upjohn's results were predictably wretched during their "integration." They issued profit warnings in every quarter of 1997, and the merger's costs quickly ballooned to more than $200 million over budget. By the end of 1997 their stock value was down 4.8 percent vis a vis the industry as a whole, whose stock prices soared over 58 percent. Consolidated net income plunged from $835 million in 1994 to just $323 million in 1997.	

By 1998, Hassan had wrestled the feuding company into submission. By the third quarter, Pharmacia finally posted an earnings increase. But the sad fact remains that, while the battles raged, the company lost almost two years of growth and shareholder wealth. Consolidated revenue remained flat from 1994 to 1997, a period during which it should have exploded in growth. What had been a marriage designed to jump-start both companies ended as a textbook case of how not to merge. The foundering ship was saved only when Hassan, a total outsider, was brought in to keep it from sinking.	

The bitter taste of the poorly managed integration is still in the mouths of many Pharmacia employees. So Pfizer has bought a company that is fraught with internal baggage. The anxiety and pain of a traumatic integration don't go away in four or five years.	

What must McKinnell do to overcome those obstacles? He must address the new integration on four fronts.	

He must clearly understand the mistakes made during the Pharmacia and Upjohn merger and take decisive steps to make sure they are not repeated. 

The integration plan must unmistakably define the operations, business practices and systems, and organization structures that will be integrated into one, as well as those that will remain autonomous.

He must implement the integration plan with blinding speed. The longer the integration takes, the more nonproductive energy is expended on internal consolidation issues. That robs the company of vital energy that should be focused on the external market, which is currently under immense competitive and political pressures. 

McKinnell must stop the talent drain that has already started. 

Within days of the deal's closing, Hassan announced he was leaving to take the top post at Schering-Plough. Dr. Gï¿½ Andro, Pharmacia's head of research and development, resigned to take the chief executive job at the UK biotech company Celltech. If McKinnell fails to take decisive countermeasures, the exit of those key executives may open the floodgates, with the most talented Pharmacia employees leaving to fall into the outstretched arms of direct competitors. McKinnell and other top Pfizer executives must quickly identify those Pharmacia employees who are critical for the success of the combined company. They must then swiftly develop relationships that build mutual commitment for a future together at Pfizer.	

Pfizer is now the largest, and is considered one of the very best, pharma companies in the industry. But to remain on top, it must not allow a mass exodus of top talent. Will Pfizer succeed with the Pharmacia acquisition? Only time will tell. One thing is certain: If McKinnell doesn't clearly understand the mistakes made during the Pharmacia–Upjohn integration, success won't come easily.	

Pfizer Chairman and CEO Hank McKinnell sees the company's $58 billion blockbuster acquisition of Pharmacia as the key to Pfizer's leadership in pharmaceutical markets around the globe.

Pfizer Can Mold Its Future by Learning from the Past

Even among industry insiders, company reputations are hard-earned and subject to change. Rating Research's (RRC) second annual Reputation Strength Study of the Pharmaceutical Industry surveyed financial analysts and industry senior executives to see how 19 companies stack up against each other and to see how their overall reputations changed from last year. (See "More than Numbers.") 	

On one hand, the industry sees itself quite favorably. On the critical behavioral measure "perception as an excellent company," industry executives expressed positive opinions about the vast majority of rated companies. Financial analysts gave even more favorable reviews than executives on half of the surveyed companies. However, the industry has one significant vulnerability: its low scores on the measure "personally willing to support in times of controversy." The essence of the measure that asked them how willing they would be to support the company in a time of crisis is whether executives would give a particular company the proverbial "benefit of the doubt" during tough times. Even Pfizer, the company with the strongest score in the measure, attracted the support of less than half the executives surveyed. It seems clear that the issue of developing greater support-indeed trust-needs to be a central focus for the industry going forward.	

And, given the potentially turbulent times ahead, RRC believes that the industry's key players will benefit by treating overall reputation as a risk factor that they must manage. Reputation, and the intangible characteristics that constitute it, can be a vital asset-or a worrisome liability-as the industry confronts its challenges. 	

For a snapshot of the industry, RRC mapped each company into a quadrant matrix  according to its Reputation Strength Score (RSS) and its "familiarity." (See "Outlook Matrix," page 42.) An RSS is the sum of executive responses to 37 reputation components, weighted by their respective importance to overall corporate reputation. Familiarity measures the extent to which a company's public relations, advertising, and product messages have been received by those individuals who are aware of the company. RRC then labeled the four quadrants, from highest reputation to lowest, "leaders," "next generation, "traditional," and "challenged." The subset graphic in the chart illustrates how reputation changes-both good and bad-from 2002 to 2003 moved seven companies from one quadrant to another.	

This year, Merck, Pfizer, and Johnson & Johnson (J&J) dominate the "leaders" quadrant, consolidating their leadership positions. Eli Lilly and Novartis both moved into the Leaders group from their positions last year in the "next generation" and "traditional" quadrants, respectively. GlaxoSmithKline also moved squarely into the leadership quadrant from its borderline position in 2002. 	

Bayer moved out of the Leaders category, but the strength of its reputation kept it within striking distance of regaining that position. Bristol-Myers Squibb, after a string of issues relating to questionable patent protection strategies and dubious wholesale inventory practices, among others, also lost ground, moving from "leaders" to "traditional." On the positive side, Roche improved its reputation strength the most, and Novartis and AstraZeneca also made solid gains.		

Most newcomers to the 2003 rating process fall into the "challenged" group. But the challenges facing Alcon, Allergan, and Forest Laboratories involve developing a positive and distinct reputation rather than having to correct a negative one. Forest, in particular, garnered significant "neutral" responses from industry executives. Amgen began its rating history this year in the "next generation" quadran	

RRC's reputation rating process began by assessing two criteria. Based on a battery of 37 reputation components, subject to an in-depth analytic process, the first criterion explores the dimensions that emerge as most critical to driving reputation in the pharmaceutical industry. Eight dimensions emerged during last year's analysis, but this year's produced nine reputation dimensions. (See "Reputation Structure," page 44.) In descending order of importance they are:		

(See ranking charts throughout article.)	

Each of those dimensions is made up of multiple components. Competitiveness, the most important, includes intangible characteristics such as management team talent, company innovation, sufficient investment in R&D, sales force effectiveness, and the ability to attract high-quality employees, among others. Given the issues the pharmaceutical industry is dealing with, it is not surprising that "ethical behavior" is the second most important dimension this year. It captures perceptions on values such as: 			

(As a result of the increasing importance and scrutiny of ethical behavior across industries, RRC treats this area in more depth through its comprehensive Ethics Reputation Rating process. Those ratings and supporting information will be released in the near future.) 	

The third dimension, "CEO leadership" measures the ability of companies' executive managers. High performing companies are driven by high performing executives. This reputation dimension captures components such as clarity of the company's strategic direction, strength of corporate governance, its ability to form effective strategic alliances, and the effectiveness of the CEO's leadership.			

On another level, the rating process examines five key behavioral and perceptual measures that capture, at a summary level, the strength of the "reputation reservoir" a company has established. They include respondents' perceptions of the rated companies on the following measures:	

personally willing to support in times of controversy

customers willing to pay a premium for its products and services

personally willing to recommend as a place to work

perceiving the company as "excellent" overall

Generally, the strong performers from 2002 held their ground in 2003, reinforcing the reputation experts' notion that a carefully built and managed reputation will withstand the inevitable crisis or controversy. Pfizer and Merck tied for the highest "reputation strength score," followed closely by J&J. (See "Overall Reputation Rating," page 41.) All three top companies garnered exceptional scores across all nine dimensions. J&J and Pfizer ranked highest on "CEO leadership," Merck topped the "ethical behavior" list, and Merck and Pfizer tied for first in "competitiveness" (with J&J scoring fourth in that dimension). In discussing J&J, one executive said: "I think they are an excellent company and have their customer and patient base in mind, they look to the future." Another commented on Merck's ethics, noting, they "insist on everything being right."			

The financial analysts favored top performers like Pfizer and J&J, as well as Amgen and Eli Lilly. Pfizer, in particular, received strong support from analysts this year, generating favorable comments about its pipeline, management, and aggressive sales and marketing efforts. As one analyst succinctly put it, "Pfizer is the best."	

Amgen also warrants recognition in light of its strong performance in its first year in the reputation rating process. The company placed third in the dimensions of "competitiveness," "social responsibility," and "employee retention." It also captured a fifth-place ranking in "financial stability" and "manufacturing process." Executives are impressed with Amgen's innovation and view the company as "one of the best places to work in the biotech and pharmaceutical industries." 				

Financial Stability and Manufacturing Process	

The "most improved" mention goes to Roche. Its overall RSS increased by 11 points, representing improved perception in several of the 37 components measured. Wyeth, Abbott Laboratories, and AstraZeneca also improved their RSS performance. At the other end of the spectrum, Bristol-Myers Squibb dropped most drastically, from an RSS ranking of eight last year to 17th this year. (See "Compared with Last Year," page 42.) 	

Last year, analysts scored Bristol-Myers Squibb in the top group, with 77 percent support in the "personally willing to invest in" measure. But this year, support for that measure evaporated, dropping precipitously to 10 percent. More forgiving than analysts, some industry executives view Bristol-Myers Squibb's recent events as "missteps" from which a recovery is possible. As one executive noted, "The company will have a future to look forward to." 	

Understanding the relative importance and weighted components that comprise each dimension is extremely important, particularly to companies' understanding of their own reputational strengths and weaknesses. With these insights, a company can create an effective corporate communications strategy that reinforces its perceived strengths to key constituencies, be it the industry, customers or others. At the same time, in instances where a perceived weakness indicates a systemic problem, companies may want to implement fundamental changes. 				

Social Responsibility and Employee Retention				

As noted, "competitiveness" is the number-one reputation driver among this year's criteria. The dimension is composed of several detailed reputation components, and a company often performs better on some than on others. For instance, although Amgen, Merck, and Pfizer, lead in the dimension, they differ in specific components and areas in which they can improve. Amgen ranked 13th in "has a loyal customer base," and Merck ranked ninth in "offers innovative products and services." 	

Merck, Pfizer, and J&J emerge as "ethical behavior" leaders, performing strongly on core components such as "trustworthiness" and "transparency of financial disclosure," while BMS experienced a major decline on this dimension from 2002. Clearly, the company has reputational repair work ahead of it. As one analyst said: "BMS had fallen from grace and lost prestige and standing among its competitors and the financial community."	

Even among industry insiders, company reputations are hard-earned and subject to change. Rating Research's (RRC) second annual Reputation Strength Study of the Pharmaceutical Industry surveyed financial analysts and industry senior executives to see how 19 companies stack up against each other and to see how their overall reputations changed from last year.

Reputation: The Inside Story

Patient recruitment for clinical trials is one of the most significant bottlenecks in drug development. As a result, several organizations have called for the establishment of recruitment best practices, beginning in 2000 with the Office of the Inspector General's (OIG) report on recruiting human subjects and most recently in a Clinical Research Roundtable report published in the March 12, 2003 issue of the Journal of the American Medical Association (JAMA). (See "Call to Action," page 66.) 	

BBK Healthcare has responded with an initiative called Good Recruitment Practice. With the help of an advisory board, the consultancy hopes to have a draft available later this year with the eventual goal of having the guidelines adopted as an industry standard. This article outlines the problems that led to the need for such practices and highlights the various issues the GRPs will cover.  	

The pharma industry is under intense pressure to produce new drugs, yet development timelines are getting longer and costs are skyrocketing. According to a study from the Tufts Center for the Study of Drug Development, average clinical phase times for new biopharmaceuticals increased by 137 percent (from 31.2 to 74.0 months) between 1982 and 1989 and 2000 and 2002. Pharmaceutical Researchers and Manufacturers of America (PhRMA) reports that between 1998 and 2002, R&D spending rose from $21 billion to $32 billion, yet the number of new drugs approved dropped from 35 in 1999 to 17 in 2002. 				

With those trends, it is no surprise that the clinical R&D industry's needs can be summed up as "faster, better, cheaper." And there is little debate that improving the recruitment of clinical study participants provides fertile ground for meeting those goals. According to CenterWatch, more than 80 percent of clinical trials fail to enroll on time; 44 percent are delayed by one to six months. Time is money. According to Tufts, cutting one year from Phase III studies would save $71.4 million in the total cost of a new drug. 	

Yet, slow development times are just symptoms of more deeply seated patient and investigator recruitment problems. According to McKinsey & Company, 85–95 percent of all days delayed during clinical trials is a result of a failure to recruit patients on time. Obstacles to recruitment are complex and multifaceted:				

Critical need. The average number of clinical studies per new drug application rose from 36 to 75 between 1985 and 1988 and 1996 and 2000, according to Parexel and the MediciGroup. In the same period, the average number of patients per NDA rose 50 percent, from 3,233 to 4,850. CenterWatch predicts that, to meet expected demand, the number of respondents to clinical study promotions will have to increase sevenfold, from 2.8 million in 1999 to 19.8 million by 2005. While the level of public awareness and trust in the clinical research enterprise remains lukewarm at best, that is a tall order. 	

Lack of awareness. Many patients do not know they can participate in clinical trials and would benefit from general education about the research process. 	

A 2001 BBK/Harris Interactive survey showed that although 83 percent of Americans are willing to participate in clinical studies, only 13 percent do. The same holds true even in oncology. Fewer than 5 percent of adult cancer patients participate in clinical studies. A 2002 survey by a coalition of national cancer groups reveals why: eight of 10 cancer patients were unaware that participation is an option.	

Staff problems. Investigator and clinical staff participation is also at issue. From an investigator's point of view, clinical research has become less appealing for a variety of reasons, ranging from the complexity of budgeting and contracting to increasing legal and regulatory concerns. CenterWatch predicts a 15 percent investigator shortfall by 2005. At the same time, referring physicians, who are often crucial for meeting enrollment goals, have both a need for more information about available studies and reservations about losing patients to study investigators. 	

Risks and benefits. Meanwhile, news reports tend to focus on the triumphs of medical breakthroughs and the tragedies of clinical research. Media, as an audience, need education materials to help them describe the risks and benefits of clinical study participation. When spokespeople from the clinical research community make connections with the press and offer themselves as resources, the resulting stories are more likely to reflect balance-as in Jane E. Brody's "Ferreting for Facts in the Realm of Clinical Trials," published in the New York Times, October 15, 2002.	

Informed consent. This process continues to pose an obstacle to patient recruitment and retention. A May 2002 CenterWatch survey found that 10 percent of volunteers did not look at the informed consent form before signing it; 18 percent signed without input from their personal physician, nurse, family member, or trusted advocate; and 70 percent reported that, at the outset of the informed consent process, they didn't know what questions to ask. Improving the communication involved in informed consent should increase study participant compliance.	

Money and conflict of interest. Investigators and sponsors face additional challenges when it comes to compensation structures and potential conflicts of interest. A survey review of 37 studies by Bekelman et al. in the January 22, 2003 issue of JAMA reported a statistically significant association between industry sponsorship of a clinical study and conclusions that support the sponsor's product. Trial incentives must be carefully designed to avoid conflicts of interest. 	

Patients versus participants. The dual role of investigators who also serve as treating physicians presents another potential conflict of interest. Physicians in that dual position have a responsibility to clarify their roles for patients, who are often confused about the nature of clinical research. A recent study in the Lancet found that nearly a third of clinical trial participants didn't know the study might not help them. And nearly three-quarters failed to understand that the study was investigating nonstandard treatment. Another two-thirds didn't know they might face additional risks or discomfort. Disclosure of all types of potential conflicts of interest will help potential study participants to make fully informed decisions.	

To address such diverse challenges, any solution to the bottlenecks posed by patient and investigator recruitment must be equally multidimensional and comprehensive. In particular, it seems clear that guidelines will work only if they simultaneously make recruitment more efficient and more ethical.	

Three years ago, the Office of the Inspector General called for "the development of guidelines for all parties on appropriate recruiting practices," stating that "a clearer determination of appropriate recruiting practices would be helpful for all parties-sponsors, investigators, and institutional review boards (IRBs). It is essential that this determination be made cooperatively with industry and the research community." 				

To that end, BBK Healthcare is developing principles and standards intended to improve both patient and investigator recruitment. Underlying that goal are the assumptions that clinical research studies are a critical part of the care continuum and that all patients should have access to them as healthcare options. All parties involved in conducting clinical studies share the responsibility of enhancing that perception among physicians and patients.	

The initiative, called Good Recruitment Practice (GRP), is being carried out with the help of an advisory board composed of representatives from industry and public arenas, including sponsors, physician-investigators, recruitment companies, and patient advocacy groups. BBK Healthcare also plans to present the GRP to a wide array of stakeholders to review and comment on. The long-term objective is for the guidelines to be adopted as an industry-wide standard. Such adoption would support a faster, better, and cheaper clinical recruitment process, thus yielding data of the quality required to evaluate products and secure FDA approvals. 	

Leading the advisory board is John Yee, MD, MPH, clinical faculty member at Harvard Medical School, who says, "Ultimately, this initiative is about helping patients make well informed decisions about participation in clinical research, a goal shared by all participants across the clinical research enterprise."	

Greg Koski, MD, PhD, former director of the Office of Human Research Protections, US Department of Health and Human Services, and now senior scientist at the Institute for Health Policy, Massachusetts General Hospital, is also a member of the advisory board. He says, "The creation of these guidelines is critical, especially because the industry, rather than the government, is taking a lead role. If they could be adopted by the industry as a whole, it would be an extremely positive sign and a major step toward raising the standards."	

Specific goals of the GRP initiative are to:				

reduce delays and costs in the development of drugs, devices, and other treatments

educate and empower patients to make better informed decisions about participation

support ethical behavior and decision making in dealing with investigator conflicts of interest

Reduce R&D delays and costs. The need to save time and money in the clinical R&D process is evident. The GRP approach recognizes that patient and investigator recruitment needs are rarely considered early enough in protocol design and development, leading to unforeseen difficulties and costly corrections once the study is underway. 	

Applying the science of marketing to the science of clinical research at every phase of development can save both time and money. Rather than planning protocol design, investigator recruitment, and patient recruitment as sequential steps, all elements should be considered concurrently to ensure successful study completion. 	

"We, as an industry, must improve our ability to streamline the clinical research process," says James P. Kremidas, who manages the clinical trial enrollment services division at Eli Lilly and serves as a member of BBK's GRP advisory board. "Enrollment consideration is not typically factored in early enough in the clinical study development process. The primary focus-as it should be-is the scientific validity of the study itself. But we need to understand patients' motivation to be involved in a study to determine if they would will be willing to participate in that protocol structure." 	

The GRP committee is developing the draft to include principles of study design, planning, and conduct. The guidelines address such critical components as protocol assessment, investigative site selection, investigator and patient compensation structures, and outreach programs that target audiences based on market research analysis. By creating study protocols with patient perspectives in mind and selecting investigative sites through rigorous analysis of market and site criteria that affect recruitment, the likelihood of successful enrollment can be significantly increased.	

In addition, the guidelines address the problems of declining investigator and clinical staff participation by outlining compensation packages that support investigative sites in executing the protocol in the most effective manner. 	

Educate and empower patients. To better communicate with patients and the public about clinical research, the draft GRP recommends principles and standards in patient information and communications, informed decisions, and public awareness and education.	

"We feel it is important to spend a lot of time on the telephone communicating with patients before we bring them in," says advisory board member Kathy Geissler, RN, clinical research coordinator at Rockford Gastroenterology Associates, in Rockford, Illinois. "When they come in, we go over the elements of informed consent, so they not only understand their role in the study but have a grasp of what the study is all about. We feel our patients are better informed by participating in this process, and we have a low drop-out rate because of our involvement with them." 	

Following patient information and communication guidelines would help those conducting studies to ensure clarity, balance, and lack of coercion at every step of the enrollment process-including initial outreach, informed consent, enrollment, screening, study visits, and post-study follow-up. Making potential enrollees feel respected, safe, and fully informed should increase their willingness to participate in clinical research studies. 	

Particularly important are informed consent procedures, which currently often fail to accomplish their goals. GRP principles expand informed consent to "informed decisions" and educate patients about the clinical research process and the full range of options available to them, both approved and investigational. Studies have shown that patients seldom understand the risks of participating in a clinical study or aren't aware of the safety measures in place to protect them. 	

The clinical staff at investigative sites must be equally informed. Primed with the knowledge to answer patient questions and expand patient understanding, investigators and study coordinators can enhance patient comprehension. GRP will provide principles and standards for the clinical research community in reaching out to broader audiences including media, healthcare professionals, and the public. The guidance is specific to each audience, providing objectives by which to measure the type and quality of outreach efforts. The more people understand the connection between the clinical research process and the healthcare system overall, the more likely they will be to support and participate in clinical studies.	

Support ethical behavior. The clinical research and development industry must address financial and other conflicts of interest in the system. Doing so will have a positive influence not only on investigator ethics and participation but on referring physician participation as well as public confidence in clinical study participation. GRPs will address the ethical issues involved in incentives, disclosures, and relations between investigators and referring physicians.	

According to advisory board member Matthew D. Whalen, PhD, president of Chesapeake Research Review, in Columbia, Maryland, "There continues to be a great deal of concern about conflicts of interest, including recruitment. All of us in the clinical research enterprise are, or should be, involved in the solution. The sponsor, CRO, site, IRB, or third party [such as a recruitment or PR firm] faces privacy and coercion issues among other ethical challenges. 	

"A key part of GRP is improving current standards of recruiting ethically. Additional guidance in the form of best practices is in everybody's interest. And part of developing those best practices is looking at the full range of the personal, social, and professional conflicts of interest-beyond just the financial." 	

Incentives to all involved parties must follow ethical guidelines to prevent coercion. GRP principles will provide fair and adequate guidelines. When designing compensation structures, sponsors and IRBs should evaluate whether they introduce bias. The guidelines will address bonuses to investigators or referring physicians, financial investments or stock options held by investigators in sponsor organizations, and the degree to which patient compensation supports good patient decisions.	

It is essential that investigators make full disclosures to potential participants about the nature of their relationships with sponsors and, if applicable, the dual nature of their role as both physician and investigator. Some IRBs currently require those kinds of disclosures during the informed consent process.	

To address physician relations, GRP principles support physicians and investigators in placing patient interests first. Although the majority of study participants are self-referred, many still learn about clinical studies from their physicians. Improving communications between referring physicians and investigators will support that source of study participants. 	

Just as the conduct of an individual clinical study requires complex networks of communication, so does the recruitment conundrum demand the collaboration of the clinical R&D community, with its many and diverse representatives. The time is ripe for a comprehensive solution to recruitment challenges. 				

Good Recruitment Practice will provide a platform for the synthesis of the best ideas available from the disciplines of clinical research, marketing science, and health communications. The time and effort spent designing clinical studies that facilitate investigator and patient participation will contribute to successful enrollment, better compliance and retention, and faster development cycles. Ultimately, GRP will benefit patients by increasing their awareness, understanding, and trust in the clinical research and development enterprise.	

Patient recruitment for clinical trials is one of the most significant bottlenecks in drug development. As a result, several organizations have called for the establishment of recruitment best practices, beginning in 2000 with the Office of the Inspector General's (OIG) report on recruiting human subjects and most recently in a Clinical Research Roundtable report published in the March 12, 2003 issue of the Journal of the American Medical Association (JAMA).

Good Recruitment Practice = Patient Pull

During the next ten years, big pharma companies will need to launch two products a year to generate 5 percent annual growth, five products a year to hit 10 percent growth, and nine products a year to meet a 15 percent annual growth target. Clearly, the stakes are high.	

Those goals are not impossible to meet, but pharma companies must augment their core capabilities and productivity by revamping their business models. They must also improve operational effectiveness, through which they can increase process productivity while reducing administrative and infrastructure costs, and they must publicly address critical industry issues.   	

In an attempt to fit together its increasingly complex and disparate pieces, the industry has begun to transform its business model into a networked structure. (See "New Operating Models," page 74.) Although that model is emerging slowly, it is, in effect, breaking apart the traditional pharma value chain. Consider the following: 				

Nine of the top ten companies have pipelines in which 40 percent of their new chemical entities are in-licensed.

Contract research organizations (CROs) account for 20–25 percent of companies' global R&D budgets.

Contract sales organizations (CSOs) account for 10–12 percent of sales and marketing budgets.

Contract sales organizations (CSOs) account for 10-12 percent of sales and marketing budgets. Increasingly, the following functions will also be outsourced to the network: 

drug discovery, through external innovative companies and CROs

development, through contract development organizations (CDOs) or through their counterparts at pharma companies

manufacturing and supply chain, through contract manufacturing organizations (CMOs) and supply chain functions at pharma companies (See "The Source," page 78)

Accenture's studies show that, through the use of outside partners, networked companies can gain dramatic efficiencies by outsourcing:

IT operations for 30 percent improved productivity 

finance/HR operations for 20–25 percent improved productivity 

electronic learning-for a 15–30 percent reduction in training costs

Success in the networked environment requires companies to focus on their core capabilities. One approach is to use a "search and development" model that uses two or more outside research groups and keeps development, manufacturing, supply chain, sales and marketing, and supporting infrastructure in house. Another model establishes an "independent research company" to discover and develop innovations beyond the company's commercial portfolio strategy, then sell those innovations to the "best" customers it can find. Some aspects of this model are already in place in the industry. (See "Freedom to Innovate," page 76.)	

Wyeth has outsourced the majority of its clinical data management (CDM) operations to improve the time it takes to bring its new drugs to market. That effort is part of a larger program to streamline the company's protocol writing, patient recruitment, site selection, and trial management and monitoring, which, combined with CDM initiatives, will generate significant performance improvement and long-term cost savings.  	

According to Bruce Schneider, executive vice-president and chief of operations for Wyeth Research, "Recent successes in discovery have produced an explosion of data coming into CDM. It's critical that we transform our clinical development operation to handle that volume. This arrangement is a logical next step in the evolution of pharmaceutical outsourcing." 	

The industry's supply chain has been slowly becoming more efficient, but the evidence shows it can still reduce the cost of goods sold by 15–30 percent. A promising approach is to create a broad manufacturing network that combines in-house and outsourced bulk and secondary manufacturing sites and operates as a single entity, producing greater efficiencies and lowered costs and freeing existing resources for more strategic uses.								

Takeda Pharmaceuticals North America (TPNA), the US subsidiary of Japan's largest pharma company, has relied on a network of key business partners since its inception. To develop its supply chain, the company created a highly efficient, integrated, quality-control logistics infrastructure, then outsourced the function and supported it with flexible information technology that allows electronic communication with networked suppliers. 	

In a matter of months, TPNA had industry expertise in packaging, distribution, and warehousing without expending capital on buildings and equipment. That expertise shortened its operational timelines drastically to meet the needs of the company's first product launch. The network has been so successful, in fact, that TPNA has expanded it to include additional packaging and distribution/warehousing partners.	

"Our networking strategy has delivered benefits such as speed, quality, flexibility, insulation from business interruption, and cost efficiency," says Chuck Whitmer, TPNA vice-president, business operations. "Capital saved by outsourcing can be rechanneled to R&D to support new compound development, which could improve the overall level of healthcare." 	

Biotechnology companies may adopt their own slightly different model. As they grow, they face an emerging paradox: Their core capability is innovation, and growth is critical to their future, but the ability to innovate and increasing size do not always go hand in hand. In fact, a survey of biotech and pharma industry executives showed that 47 percent believe biotechs become less innovative as they grow, and 72 percent believe that emulating the traditional pharma operating model does not necessarily bring success.				

Instead, the research suggests a new operating model for growing biotechs that supports innovation, flexibility, and rapid delivery of value: an in-house innovation center interacting with a capability network of third parties. The innovation center identifies new technologies -including platform technologies as well as target identification and validation-outside the parent company and applies them to increase the speed, effectiveness, and efficiency of discovery. Third parties in the capability network provide contract development and manufacturing and sales services, supported and managed by lean, in-house "coordinating" departments.  	

The result is that biotechs can bring their first products to market up to two years sooner than they could under the old system, protecting an estimated $1.7 billion in sales from future generic competition. Furthermore, the flexibility provided by the network allows companies to save up to $25 million in the cost of clinical development for each successful project. In sum, using such a model, growing biotech companies will have rapid access to the capabilities required to bring products to market while retaining their key attributes of innovation, scientific excellence, entrepreneurial spirit, and flexibility.	

Of course, there is no one right answer for everyone. Many successful pharma companies will continue to supply their pipelines by acquiring others and removing or paring the excess.				

Most, however, will find it increasingly difficult to be the best at everything. They will need to identify those areas in which they excel, ensure that they have complementary partners, and optimize those core capabilities. To that end, they should consider:	

their capabilities in accordance with what works best globally rather than locally

who is responsible for the process and for continuous improvement

the company's commitment to invest in those functions

They should then create new management systems-planning, monitoring, evaluation, and training-that support both accountability and integration.	

The best networked models use outside resources to optimize in-house expertise and to move their companies toward success. Companies that want a world-class research group but don't have it in-house can increase their capability through networking. 	

In the networked environment, operational excellence can also improve management performance by allowing companies to react to changes more quickly and efficiently and to make more accurate decisions. Companies can become more productive by operating their discovery, development, supply chain, and sales and marketing functions more effectively. They can decrease cycle times, increase the impact of those functions, and, by eliminating waste, increase output. They can reduce discovery timelines by employing parallel research activities such as shotgun sequencing, whole genome chips, pathway predictive tools, in silico, high throughput screening, and genotyping.			 				

Wyeth is a good case in point. To improve productivity in its discovery organization, it set goals to:	

increase annual output of small molecule and biopharma development candidates by 300 percent

decrease the time from discovery team formation to development track compound by one-third

ensure quality by defining specific compound requirements for entry into development

Teamwork issues, unclear decision-making processes, and false starts created roadblocks to achieving those goals. Furthermore, multiple cultures, born from Wyeth's many legacy companies, led to inefficiencies and anxiety about change and risk-taking. And issues regarding resource allocation and prioritization, knowledge management, and teamwork remained unresolved. Yet Wyeth also had significant assets to support the effort, including strong CEO backing, recognition that improvements could be made, leading-edge technology in many areas, and strong people and science underpinning most capabilities. 	

"The results have been profound," says Robert Ruffolo, Wyeth's president of R&D. "With a new governance model covering decision making, prioritization, and resource allocation, new advancement criteria, new processes for discovery and exploratory teams, and new team structures and leadership programs, we are meeting our stretch goals."	

In their quest to accelerate the application of scientific advances and bring better medicines to patients faster, innovative R&D organizations have focused on increasing operational efficiency and reducing time to market. The next set of challenges includes improving drug candidate screening and creating stronger patient/customer relationships to achieve higher success rates. 	

Finally, leading-edge sales and marketing capabilities can drive superior financial performance. Recent Accenture research found that, if a pharma company with $1 billion in annual sales improves its sales and marketing capabilities, it can gain a total of $135 million in extra operating margin. To accomplish that, a company should establish: 				

a highly skilled and motivated sales force (to add $45 million in operating margin)

sophisticated sales planning (to add $24 million)

excellence in customer information management (to add $32 million)

During the next ten years, big pharma companies will need to launch two products a year to generate 5 percent annual growth, five products a year to hit 10 percent growth, and nine products a year to meet a 15 percent annual growth target. Clearly, the stakes are high.

Networked Pharma

My train reading this week has been Protecting America's Health, Philip J. Hilts' enlightening history of the Food and Drug Administration. It's a book with a strong sense of how politics, people, and the uncontrollable flow of events conspire to shape institutions. It's also a good read, thanks to the author's fine eye for anecdote. Over and over, Hilts selects just the right story to capture the essence of an era in the agency's history.	

Perhaps the most striking of these tales concerns an antibiotic called Panalba, which was doing a brisk business in the late 1960s, when FDA finally got around to requiring existing drugs to prove their safety and efficacy. The problem was that Panalba was neither safe nor efficacious. The drug was a combination of two antibiotics, tetracycline and novobiocin. Not only did the novobiocin cause adverse effects in 20 percent of patients, it also counteracted the tetracycline. The company's own research said so. 	

FDA wanted Panalba off the market. But the manufacturer, which depended on the product for more than 10 percent of its revenue, fought back with doctors' testimonials, the backing of the American Medical Association (which saw efficacy testing as an attack on physicians' autonomy), and Nixon-era political hardball. The drug was ultimately withdrawn, though it cost FDA Commissioner Herbert Ley his job.	

Times change, of course. Looking back 30 years later, it hardly seems credible that the company fought so hard to keep a dangerous drug on the market. A while after the event, a Wharton professor named J. Scott Armstrong surveyed students and business people, asking what they thought of the company's actions. Ninety-seven percent called the company irresponsible. But then, Hilts explains, Armstrong tried a different approach. He led an exercise in which students played the role of company directors. An odd thing happened. Eighty percent of the role players did exactly what the company had done. And so did close to 2,000 other subjects when the experiment was repeated 90 times in ten countries. Outraged citizens became co-conspirators in the blink of an eye.	

Hilts' take on the experiment is clear from the title he gives the chapter devoted to it: "Greed and Goodness." I think perhaps he's being too simplistic. To me, Armstrong's experiment wasn't about people turning greedy. It was about people doing what they thought was expected of them-decision making on autopilot. And the lesson to take away is not that people are callous, but that it can be hard to tell when you're making up your own mind and when you're playing yes-man to the brass plaque on your door.	

That's useful to know. For most of us who lead organizations, the power to make decisions is the crucial part of our jobs. We're willing to fight colleagues or even bosses who threaten it. What Armstrong shows us is that we also need to fight against the autopilot-and that if we don't the results can be disastrous. History has a habit of repeating itself. 	

We need to make sure that this particular bit of history doesn't.	

From the Editor

My train reading this week has been Protecting America's Health, Philip J. Hilts' enlightening history of the Food and Drug Administration. It's a book with a strong sense of how politics, people, and the uncontrollable flow of events conspire to shape institutions. It's also a good read, thanks to the author's fine eye for anecdote. Over and over, Hilts selects just the right story to capture the essence of an era in the agency's history.

Pharmaceutical Executive-06-01-2003

Picking a Place to Grow

Pfizer Can Mold Its Future by Learning from the Past

Reputation: The Inside Story

Good Recruitment Practice = Patient Pull

Networked Pharma

On Autopilot

Table of Contents