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PART 3 The Marketing Mix 305
8 Product Strategy 307
The Meaning of Products and
Services 308
Types of Products 308
The Five I’s of Services 309
Classification of Products and
Services 311
Classifying Consumer Products 311
Industrial Goods Classifications 312
Service Classifications 312
9 Price 341
The Meaning of Price 342
Trends in Pricing 342
Price Transparency 343
Price or Reimbursement 345
Cost-Based Reimbursement 345
Fee-for-Service 345
Diagnostic-Related Groups 346
Capitation 346
Pay for Performance 346
Establishing the Price 347
Identifying Constraints 347
The Five Forces and Impact
on Pricing 350
10 Distribution 377
Alternative Channels of
Distribution 378
Functions in the
Channel 380
Functional Shifting 382
Channel Management 383
Intensity of Distribution 384
Intensive Distribution 384
Exclusive Distribution 385
Selective Distribution 385
Managing the Product 312
Developing the Product Line
and Mix 313
The Product Life Cycle 315
Product Life Cycle Issues 322
Modifying the Product Life Cycle 324
Branding 327
The Diffusion of Innovation 330
Conclusions 333
Pricing Objectives 351
Estimating Demand and
Revenue 352
Cost and Volume
Relationships 353
Pricing Strategies 361
Positioning Value of Price 367
The Ever-Increasing Challenge of
Pricing in Health Care 369
Conclusions 369
Vertical Marketing Systems 386
Corporate Vertical Marketing Systems 389
Administered Vertical Marketing
Systems 390
Contractual Vertical Marketing
Systems 391
Evolving Channels in Health Care 392
Disintermediation and Reintermediation:
The New Paradigms in Health Care
Channels 392
CONTENTS vii
 Channel Conflict 393
Channel Leadership 395
Using Power 396
Selected Concepts From Retailing 397
Structural Dimensions of True Retail
Markets 398
11 Promotion 413
The Communication Model 414
The Sender 414
Encoding 416
The Evolving Communication Model:
Moving to a Web 2.0 World 417
The Web as a Strategic Communication
Platform 420
The Message 420
The Channel 423
Decoding 423
Noise 424
Feedback 424
The Promotional Mix 424
12 Advertising 451
Common Classifications of Advertising 453
Product Advertising 453
Institutional Advertising 453
Developing the Advertising Campaign 454
Define the Target Audience 454
Determine the Advertising
Objectives 456
Determine the Budget 458
Develop the Message 459
Specify the Communication
Program 462
13 Sales and Sales Management
Types of Sales Jobs 489
New Business Selling 489
Trade Selling 489
viii CONTENTS
The Retail Positioning Matrix 400
Retail Mix 401
The Wheel of Retailing 404
Conclusions 405
Integrated Marketing Communications 425
Integrating Owned, Paid, and Earned
Media 425
Advertising 427
Advertising Effectiveness 427
Personal Selling 428
Public Relations 431
Sales Promotion 433
Factors Affecting Sales Promotion Use 436
The Product Life Cycle 436
Channel Control Strategies 437
Conclusions 442
Inbound Marketing 471
Evaluate the Response 472
Web 2.0 and Social Media 473
Working with Advertising Agencies 475
Alternative Advertising
Agencies 475
Agency Compensation 475
Ethics in Advertising 476
Banning Hospital Advertising 478
Conclusions 478
487
Missionary Selling 489
Technical Selling 490
The Legal Challenge to Sales 491
 The Personal Sales Process 491
Prospecting 491
Preapproach 493
Approach 494
Presentation 494
Close 495
Servicing 495
Sales Approaches 496
Stimulus-Response Sales Approach 496
The Selling Formula 496
14 Controlling and Monitoring
Controlling and Monitoring Marketing
Performance 516
Market Share Analysis 516
Sales Analysis 519
Profitability Analysis 519
Contribution Analysis 521
Variance Analysis 522
Sales Force Control 526
Appendix A A Sample Business Planning Manual 547
Why Write a Plan? 547
The Components of the Plan 548
Putting It All Together 568
Appendix B Glossary 569
Index 581
Need Satisfaction Method 497
Consultative Selling 498
Managing the Sales Function 499
Sales Force Organization 499
Sales Force Size 501
Recruitment and Selection 502
Training 505
Compensation 505
Sales Force Evaluation and Control 507
Conclusions 508
515
Advertising Control 527
Tracking Returns in the Digital Age 528
Customer Satisfaction Control 531
Components of a Measuring System 532
The Marketing Audit 533
Conclusions 541
CONTENTS ix
P R E FAC E

Few industries are as dynamic as health care. Regulation, technological changes, mergers, changes
in reimbursement—all impact the environment in which marketing strategy must be formulated.
Health care accounts for a significant proportion of the U.S. economy in such a way that the stake-
holders whom it affects all comprise segments on which marketers must be focused in terms of
planning and assessing the changing trends and forces that affect these varying groups. It is the
ever-evolving nature of this industry or profession (depending upon who is discussing health care)
that makes marketing within this field both challenging and interesting. Consumers are facing new
health care plans and are more engaged because they are interacting through social media to seek
out information on health care and clinical alternatives; consumers also interact with other individu-
als regarding their health care experiences with providers and treatment alternatives. These influ-
ences of the environmental forces and the marketplace require greater sophistication and precision
in the marketing strategies developed by health care organizations today.
Given health care’s large percentage of the gross domestic product; the concerns of price, value,
and transparency with regard to that cost; and the quality received for the dollars paid for that
service, these concerns are ever more central to stakeholders. And, these issues are central to mar-
keting in an era in which technology allows any customer group to access information regarding
these dimensions about a health care organization.
Health care marketing today is increasingly affected by two major issues that are reflected in
this text and are foremost in organizational strategy, whether it is a provider organization, phar-
maceutical company, or third-party payer. First, there is the ever-increasing impact of technology.
As briefly mentioned, technology places more information in the hands of consumers and patients,
as it most certainly does for clinicians, with the use of electronic medical records. Second, there is
the dramatic shift in population health management with accountable care systems that are
rewarded for the health of a patient population and the efficiency of the care delivered. This para-
digm shift in the health care system has dramatic implications certainly for care management but
equally important for the marketing challenges this environment represents. Successful organiza-
tions in an accountable care era must be the Amazon.coms of the health care world.
There may be no more interesting field in which to be a manager than that of health care. Two
factors allow one to make such a statement. First, health care is the most important service dealing
with people’s lives and well-being. Second, health care is always changing and evolving, affected
by a myriad of forces, and the manager is not always in control when attempting to craft a strategy
for the organization. This rapidly changing world with its new, disruptive technologies and compet-
ing service delivery models has demanded a new edition of this text.
The health care marketing field has long passed the time of debate as to whether marketing is
appropriate within this setting. However, as discussed within the text, some tactics, such as whether
salespeople should call on physicians or the role of direct-to-consumer advertising, are being

x
reexamined today. The reality is that marketing as a discipline has evolved over the past 40 years
to be a core functional area in most major health care organizations. In this revised edition of the
text, the need for utilizing marketing approaches in an era of health care reform and accountable
care organizations requires capturing patient loyalty. And, with the greater utilization of data min-
ing to identify the market segments that more heavily use and need clinical intervention, a greater
integration of marketing principles is needed in order to achieve better clinical outcomes.
Health care marketing today is a data- and technology-driven enterprise. Personal sales strate-
gies increasingly use e-visits, and more sophisticated promotional plans use social media approaches
because market research utilizes a different approach to analyzing consumer responses on social
media platforms. As this revised edition of the text underscores, no element of the marketing mix
is unaffected by dramatic changes in technology, data, health care restructuring, and the competi-
tive landscape. All of these factors require the essential elements of marketing to be refined and
reshaped in today’s new environment.

PREFACE xi
INTRODUCTION

This book is divided into three main parts. Part I, “The Marketing Process,” looks first at what
marketing is, the nature of marketing strategy, and the environment in which marketing operates.
Chapter 1 provides a perspective on the meaning of marketing, how marketing has evolved in
health care, and the marketing process. Additionally, this chapter outlines how marketing health
care is evolving in light of a changing industry and the impact of technology on the four Ps. As we
move further into the 21st century, Chapter 1 begins to cover the concept of accountable care
organizations (ACOs) and the challenge of population health. Chapter 2 provides an overview of
marketing strategy and an understanding of the strategic options available to a health care orga-
nization. It also presents how having a differential advantage for a health care organization is an
important part of marketing strategy as well as the sources of that differential advantage. In health
care, a key differential advantage that is unique and has been recognized is trust, which this edi-
tion covers. In strategy, a consideration of the competition is key; an important source of new
competitors, disruptive innovations, is discussed. Three alternative strategic frameworks are pre-
sented in this chapter: the Boston Consulting Group Portfolio Matrix (BCG); the Five Forces
Model; and the Blue Ocean perspective. Chapter 3 focuses on the environment in which health
care marketing plans and strategy are formulated, and the impact that the environment has on
these plans. There are multiple dimensions of the environment to consider: technological, socio-
logical, competitive, and regulatory. Technology, a key change today, is highlighted in terms of its
impact on four dimensions: quality, cost, information, and behavior. In this edition, how health
care organizations are responding to the changing demographics of an aging population and the
cultural and attitudinal shifts in the marketplace are highlighted. The shifting demographic move-
ment to a more suburban location’s effect on health care organizations is also underscored. This
fourth edition discusses the dramatic consolidation that is occurring among insurers and provides
the government formula that is used to assess overall competitiveness in a market. The text also
presents a discussion of the HealthCare.gov health exchange website and the level of plans among
which consumers can choose on the federal exchange. An added discussion about medical tour-
ism, both international and domestic, is presented, as consumers and corporations seek to save
on the cost of care.
At the core of marketing is the consumer, which is covered in Part II, “Understanding the Con-
sumer.” The consumer can be the individual patient, the referral physician, a company buying care
for its employee base, a judge making a referral for a mental health consultation for a person under
state care, or an insurance company deciding with whom to contract. Chapter 4 provides an over-
view of consumer decision making as it pertains to both consumers and organizations. The external
search process for consumers has changed dramatically with transparency and with Web access.

xii
Multiple factors can affect a consumer’s search process. The fourth edition presents several alterna-
tive decision models that a consumer may use in making a choice. Industrial buyer behavior
involves a decision-making unit consisting of multiple participants playing different roles. Chapter
5 describes the marketing research process with primary and secondary data. Primary data is pre-
sented along the dimensions of alternative qualitative and quantitative methodologies used within
marketing research. Increasingly, organizations are using Big Data and data mining techniques to
analyze their customer base and the Web to conduct surveys; both of these concepts are discussed
within Chapter 5. The refinement of marketing strategy often occurs as a result of market segmen-
tation, which is discussed in Chapter 6. Marketing organizations have recognized that gaining
customer loyalty is the key to long-term success; this concept is the focus of Chapter 7. Loyalty is
an increasingly important concept as individuals whose health must be managed are attributed to
an accountable care organization.
The last section of this book, Part III, covers the “Marketing Mix.” The Four Ps—product,
price, place, and ­promotion—are the basis on which all organizations develop their marketing
plans and strategies. Chapter 8 reviews concepts involved in the product or service. Strategies
change over the stages of a product (service) life cycle. In the adoption of health care products
and technologies, this edition identifies the multiple criteria that affect the adoption of new ser-
vices and technologies in health care. Chapter 9 discusses pricing objectives and strategies and
how not only objective but also subjective considerations play a role in positioning an organiza-
tion. The chapter also provides an overview of the alternative reimbursement approaches that
have been utilized in health care. New pricing approaches such as reference pricing and Centers
of Excellence contracting are presented. Delivery of services is the concept of distribution covered
in Chapter 10. In today’s health care marketplace, this element of the marketing mix may well
be the most dynamic with the utilization of technology as a distribution channel. This alternative
is leading to greater conflict, a concept that is discussed in this edition of the text. Three chapters
in the text, Chapters 11, 12, and 13, are devoted to the promotional mix. Understanding the
promotional mix and the communication process is the focus of Chapter 11. A major addition is
the discussion of integrated marketing communications of earned, owned, and paid media. Now,
with the wide array of media vehicles including social media, an integrated marketing commu-
nications strategy is ever more essential. Because significant attention has been paid to the use of
push and pull strategies among physicians and pharmaceutical companies’ promotions to consum-
ers, this aspect is discussed in detail. Advertising, historically seen as the only role of marketing,
is the focus of Chapter 12. An important addition in this chapter is the discussion of evaluating
the cost of digital media. And, the importance of an inbound marketing campaign has been
included in this edition in the context of a discussion of digital media. Chapter 13, the last chapter
on the promotional mix, involves sales and sales management. Here, too, the Internet has had an
impact, changing the definition of personal selling by no longer requiring face-to-face interaction
and leading to increased use of e-detailing. Chapter 14, the final chapter, provides an overview
of control and monitoring. Measuring the outcome of marketing decisions is necessary in order
to continue to refine effective marketing strategies. This edition highlights the components of an
effective measurement system for any health care organization.
Appendix A provides “A Sample Business Planning Manual” to help readers of this text under-
stand the structure of all the components of a detailed and well-constructed business plan. Market-
ing, finance, human resources, and operational components are all part of the plan structure in
Appendix A. This appendix also includes questions throughout that need to be addressed in devel-
oping a plan for a new service to be implemented.

INTRODUCTION xiii
Chapter Organization
Readers of this book will find that six key sections appear in each chapter. These are Learning Objec-
tives, Conclusions, Key Terms, Chapter Summary, Chapter Problems, and Notes. All key terms
appear with their definitions in the glossary. At the end of the book is an index for the reader’s
convenience.

New to This Edition

For users of previous editions of this text, it may be useful to briefly highlight some of the additions
and changes that have been made throughout each chapter. As noted in the “Introduction,” these
changes reflect the ever-evolving health care environment, the growing influence of technology, and
the greater influence of population health as all may impact health care marketing.
In Chapter 1, the concept of HCAHPS is presented within the discussion of culture. This metric
is mentioned throughout the text in several chapters, as it has relevance for service delivery and
other factors relating to marketing concerns for health care organizations. A new section, titled
“The Hallmarks of a Market-Driven Planning Approach,” has been added to Chapter 1 to underscore
the difference between a market-driven and a nonmarket-driven approach. Chapter 2 has several
changes, but particularly of note is a new section titled “Avoiding Marketing Myopia”—an impor-
tant topic because health care is changing dramatically. A significant new discussion focuses on
disruptive innovations as a source of new competition. This chapter now presents the Blue Ocean
perspective for strategy. In Chapter 3, technology that is having a great impact on health care and
marketing is discussed in an expanded formulation. Since the previous edition, there has been an
appearance of domestic medical tourism, which is a significant, new alternative to international
medical tourism.
In Part II of the text, Chapters 4 through 7, several important changes and additions have
been included. Chapter 4, “Buyer Behavior,” has a new section on the factors that affect the
search process for consumers, which in today’s environment of the Web is important to consider.
As there are now social communities accessed by consumers with serious diseases, Chapter 4
includes a discussion of the “wisdom of crowds” as it relates to sites such as P ­ atientslikeme.com
and how they play into research and decision making for patients. The market research chapter,
Chapter 5, has been reorganized to better aid students in understanding the array of research
tools. The concepts of Big Data are introduced, as well as data mining in greater detail. Social
media have now been included within the context of qualitative research methods. Chapter 6,
“Market Segmentation,” now includes a discussion of micro-segmentation. Additionally, two
health care segmentation schemata are presented: One has been developed by Deloitte, while a
second—referred to as the PathValue graphic segments—has been suggested to lead to greater
­efficiency in health care. Chapter 7, “Developing Customer Loyalty,” is a chapter of increasing
importance in an era of accountable care and population health. A new discussion is added to
highlight the level of customer bonds and how to create customer bonds, which is essential in
terms of managing population health.
Part III of the text focuses on the marketing mix. In Chapter 8, “Product Strategy,” the life
cycle concept relative to proton beam therapy centers is utilized. There is an expanded discus-
sion of the attributes that affect the adoption of new services or products in the diffusion of
innovation. Chapter 9, “Price,” includes a new section titled “Trends in Pricing,” which specifi-
cally highlights three important areas affecting the pricing environment for marketing: price
transparency, consumer response, and organizational response. Another new section in this
chapter, called “Price or Reimbursement,” provides a brief description of cost-based

xiv INTRODUCTION
reimbursement, fee-for-service, diagnostic-related groups, capitation, pay-for-performance, and
HCAHPS. Chapter 10, “Distribution,” introduces the concepts of asynchronous and synchronous
value utility in health care. Another new discussion concerns disintermediation and reinterme-
diation in the channel. Chapter 11, “Promotion,” and Chapter 12, “Advertising,” begin differ-
ently from the previous edition by putting advertising in a greater historical context. A new
section has been added in terms of how digital media is valued. And, there is a shift in how
advertising agencies are being compensated. Chapter 13, “Sales and Sales Management,” has
changed substantially in this fourth edition, as technology has affected this element of the
­promotional mix. Greater detail and discussion are provided regarding e-detailing and e-sales.
A new section, “The Legal Challenges to Sales,” which highlights some of the issues around
academic detailing, has been included. Finally, as the sales process is reviewed, through each
step, the impact of technology and social media is presented. Chapter 14 has been revised with
the addition of a new section regarding the monitoring of investments in digital and web-based
investments. The second major enhancement and revision to this chapter is in the section
­“Marketing Audit.” Users of earlier editions of this text will note that there is a significant
­revision to the audit questions, which are updated to today’s health care environment.

Acknowledgments
It has been my good fortune, since my early days as an assistant professor at the Carlson School of
Management, to have had the opportunity to gain an early interest in health care and live in a vibrant
health care community. Early on, the University of Minnesota recognized the importance of studying
health care from a multidisciplinary perspective, and, while I was in the business school, I was able
to have an appointment in the Center for Health Services Research. Thus, my early years in studying
and researching health care were with a colleague, William Flexner. Bill and I began to do some of
the early writing on marketing applications within the context of health care. A good friend, Steven
Hillestad, a vice president at Fairview Health Systems at the time and later Abbott Northwestern, was
a collaborator on many challenging and interesting consulting engagements, as health care changed
from a fee-for-service to a capitated system. Steve and I also coauthored a text, Health Care Marketing
Strategy, also published by Jones & Bartlett Learning. My own education was greatly enhanced by
my professional collaboration with the American College of Physician Executives, now named the
American Association of Physician Leaders, with whom I have worked since the mid-1970s. Roger
Schenke was the visionary leader of that organization for more than 30 years and contributed greatly
to my knowledge and perspective of health care and to whom I will always be indebted. The renamed
American Association of Physician Leaders continues to grow as a major organization in influencing
the direction of health care change, not only in the United States but also globally. I have been for-
tunate to have a many-decades relationship with this professional organization.
For more than 35 years, I have had the opportunity to work with many physicians and health
care executives too numerous to mention who have always helped me understand the challenges
of this environment and, in reality, provided greatly to my ongoing education in the challenges of
health care management. Over these past years, many of these individuals kindly invited me into
their organizations to work with them or to meet with the medical staff or boards. I am always
impressed that, regardless of the country or continent—be it here in the United States, Europe,
Africa, or Asia—providers, health care organizations, and marketing issues often seem to have an
underlying similarity. There is always complexity in the reimbursement systems, the impact of social
media, the new forms of competition, and new challenges from transparency and calls for greater
quality metrics. Throughout this text, I have tried to incorporate some international examples to

INTRODUCTION xv
underscore these very same points that I have learned from so many others who have educated me
and to what I have been exposed in my travels, interactions, and work.
I cannot name all the physicians and colleagues who have personally added to my education
over these past years for fear that I would not recognize those who would deserve it. One close
friend and colleague who I must note is Rob Kauer, from Case Western Reserve University, a gifted
teacher, who passed away prematurely. We worked at many health care organizations together and
taught many health care executive seminars together. Doing research and collaborating with Rob
was great fun. And he will always be missed. I have had many good colleagues at the University of
Minnesota and the University of Massachusetts at Amherst. My recent time at Babson College has
afforded me the opportunity to meet new colleagues engaged in global entrepreneurial ventures
for which I am most appreciative. I do want to note that I have been on the Board of the Cooley
Dickinson Hospital in Northampton, Massachusetts, serving for 15 years, my last 3 years as Board
Chair, and for 9 years on the Board of Reliant Medical Group in Worcester, Massachusetts. These
experiences have further added to my knowledge and shaped my insights into what is an exciting
and challenging industry and profession.
For many years over what has now been four editions, I have had the good fortune to work
with the most professional and dedicated people at Jones & Bartlett Learning, who have been com-
mitted to ensuring this book makes a positive experience for both students and faculty. The produc-
tion of any text is no easy task. In that regard, Integra Software Services, and the good people there,
have been of the greatest help, and my appreciation for their services in producing this text goes
without saying for their fine work. At Jones & Bartlett Learning, many people contributed in so
many ways to this edition, for which I am most grateful. I want to express my gratitude to Nick
Alakel, who worked with me in the early stages of the revision process. I have to express my great
appreciation to Lindsey Mawhiney Sousa and to Merideth Tumasz, who has dealt with all the fig-
ures, exhibits, and permissions that any author knows are so critical to any text. Merideth had to
deal with my countless revisions of figures and tables and incessant questions and iterations through
many emails. On my third edition and on this new fourth edition, I was fortunate to have the
opportunity to again have the assistance and guidance of Tina Chen, who was able to keep the
process moving smoothly even when I had at times the greatest concerns over an issue or dilemma.
She was always calm, positive, and responsive. I am indebted to her for her continuous help
throughout this edition. Finally, I want to especially note my continuous appreciation to Mike
Brown, publisher at Jones & Bartlett Learning. We have had an author–publisher relationship that
goes back 20 years. Mike has been kind enough every few years to ask for another edition. And,
with this fourth edition, I now envision a few years off from sitting at the keyboard working over
another ­possible revision, which is fine with me.
Finally, and most importantly, I want to express my greatest appreciation and love to my family.
My first academic text was written when my oldest daughter was born; this text was revised as my
first granddaughter, to whom this book is dedicated, was born into a world with great new health
care possibilities. My daughters are now both professionals themselves. Both were born as various
editions and texts occurred. Sandy, my best friend and partner of more than 40 years, my wife, is
the consummate professional and, again, watches me henpeck away at another revision because I
never learned to type. My second Labrador retriever, Gracie, has patiently sat by my desk through
most days as I have worked on this edition, wondering when we are going out for a walk or to play
ball. She, too, may be most happy for my few years off from another edition.

xvi INTRODUCTION
 PART 1
The Marketing
Process

© antishock/iStock/Getty
 CHAPTER 1
The Meaning of
Marketing

© Natasa Adzic/Shutterstock
L E A R N I N G O B J E C T I V E S

After reading this chapter, you should be able to:

Define marketing and differentiate between a marketing-driven and nonmarketing-driven
process
Distinguish among marketing mix elements
Delineate between health care needs and wants
Understand the dimensions of the environment that have an impact on marketing strategy
Appreciate the ongoing restructuring of the health care industry

3
P
rimary care satellites, integrated delivery systems, managed care plans, and
­physician–hospital organizations are but a few of the elements that dominate the
structure of the health care industry today, as the government, employers, consum-
ers, providers, and health care suppliers deal with a new health care market. Added to this
environment is the reality that consumers can interact with a primary care provider through
a web-based app on their iPad or mobile device for a consult for themselves or their child on
a 24/7 basis. The marketplace of today is typified by massive restructuring in the way health
care organizations operate, health care is purchased, and health care is delivered. Competing
in this e­ nvironment will require an effective marketing strategy to deal with these forces of
change. This text focuses on the essentials for effective marketing and their implementation
in this health care marketplace. This discussion begins with an examination of what market-
ing is and how it has evolved within health care since first being discussed as a relevant
management function in 1976.

Marketing
For anyone involved in health care during the past twenty years, the term marketing generates
little emotional reaction. Yet, health care marketing—a commonplace concept today—was
considered novel and controversial when first introduced to the industry three decades ago.
In 1975, Evanston Hospital, in Evanston, Illinois, was one of the first hospitals to establish a
formal marketing staff position. Now, more than 40-some years later, marketing has diffused
throughout health care into hospitals, group practices, rehabilitation facilities, and other health
care organizations. In this text, fundamental marketing concepts and marketing strategies are
discussed. Although health care is undergoing significant structural change, the basic elements
of marketing will be at the core of any organization’s successful position in the marketplace.

The Meaning of Marketing

There are several views and definitions of marketing. The most widely accepted definition is
that of the American Marketing Association, the professional organization for marketing prac-
titioners and educators, which defines marketing as “the process of planning and executing
the conception, pricing, promotion, and distribution of ideas, goods, and services to create
exchanges that satisfy individual and organizational objectives.”1
Central to this definition of marketing is the focus on the consumer, whether that is an
individual patient, a physician, or an organization, such as a company contracting for industrial
medicine. This definition also contains the key ingredients of marketing that lead to consumer
satisfaction. Increasingly, customer satisfaction is the key issue in health care.
The Joint Commission, the industry’s major accrediting agency for operating standards of
health care facilities, requires—per its 1994 accreditation manual—that hospitals improve on
nine measures of performance, one of which is patient satisfaction. A similar requirement is
also in place for long-term care facilities. This focus on patient satisfaction is an overt recogni-
tion of the need for health care facilities to be marketing oriented and, thus, customer respon-
sive. Moreover, the Center for Medicare and Medicaid Services (CMS) requires all hospitals to
distribute to patients and publish the results of its standardized survey instrument and data
collection methodology for measuring patients’ perspectives of hospital care. This 27-item
survey underscores the focus on the consumer (patient) (see www.cms.hhs.gov

4 CHAPTER 1 The Meaning of Marketing

/hospitalqualityinits/30_hospitalhcahps.asp). In January 2009, The Joint Commission posted
these results for all hospitals on its website so that consumers could search for CMS patient
satisfaction data for all hospitals and view state and national averages.2 The importance of
customer satisfaction is now a recognized and central component to the operations of health
care organizations as hospitals are financially impacted by the satisfaction of patient evalua-
tions in a system referred to as Hospital Consumer Assessment of Healthcare Provider Systems
(HCAHPS). This is a standardized survey instrument that measures patients’ perspectives on
hospital care across nine dimensions (communication with doctors, communication with
nurses, responsiveness of hospital staff, pain management, communication about medicines,
discharge information, cleanliness of the hospital environment, quietness of the hospital envi-
ronment, and transition).3

Prerequisites for Marketing

This text’s definition of marketing includes several prerequisite conditions that must exist
before marketing occurs. First, there must be two or more parties with unsatisfied needs. One
party might be the consumer trying to fulfill certain needs; the second, a company seeking to
exchange a service or product for economic gain. A second prerequisite for marketing is the
desire or ability of one party to meet the needs of another. Third, parties must have something
to exchange. For example, a physician has the clinical skills that will meet an individual
patient’s need to have a torn meniscus repaired. A consumer must have the health insurance
or financial resources to exchange for the receipt of these medical services. Finally, there must
be a means to communicate. In order to facilitate an exchange between two parties, each party
must learn of the other’s existence. It is this last aspect of health care that has formally evolved
in recent years.
Until 1975, advertising and promotion really did not exist within health care. Consider
that reality as you drive around most metropolitan communities today and look at the bill-
boards for major health care institutions or Google a particular clinical problem such as brain
tumor or cancer and look at the health care institutions whose advertisements appear as pos-
sible sources of care solutions. Health care has changed dramatically in terms of promotion.
The limitations to advertising were in the original 1847 Code of Ethics of the American
Medical Association (AMA) that placed a ban on advertising for health care services. These
ethical codes stated, “It is derogatory to the dignity of the profession to resort to public adver-
tisements or private cards of handbills inviting the attention of individuals affected with par-
ticular disease. These are the ordinary practices of empirics, and are highly reprehensible in a
regular physician.”4 Communication to facilitate exchange occurred by word of mouth. One
would consult with a physician, and that individual, in turn, recommended the physician to
other consumers who would then seek out that particular physician. Although the AMA 1957
“Principles of Medical Ethics” continued to judge the practice of soliciting of patients to be
unethical, in 1980, these prohibitions were struck down in a Second Circuit appellate court
decision in which the AMA was ordered to cease and desist from such restrictions on advertis-
ing. The court stated that such restraints violated Section 5 of the Federal Trade Commission
Act prohibiting “unfair or deceptive acts or practices in or affecting commerce.”5 The AMA
revised its code of ethics to be less stringent regarding advertising. Further legal actions between
the Federal Trade Commission (FTC) and the AMA had, by 1982, removed even those restric-
tions. The FTC believed the restriction on advertising deprived consumers of the free flow of

Marketing 5
information regarding health care alternatives and services. The FTC and the federal courts
recognized the value of communication to consumers. Communication is a prerequisite for
marketing. It is only in the last three decades that more formal means of communication have
evolved within health care and that marketing strategies have become more visible, whether
it is the formal advertising of traditional media, the personal sales representative who might
be at a trade booth displaying a new medical device at a physician specialty meeting, or on a
social media platform.

Who Does Marketing?

Traditionally, only for-profit commercial businesses in consumer or industrial settings con-
ducted marketing. In this text, they will be referred to as traditional businesses. Yet, the applica-
tion of marketing broadened in the late 1960s.
In 1969, two marketing academics—Philip Kotler and Sidney Levy—at Northwestern
University in Illinois published an article about broadening the concept of marketing. Their
writing was the first attempt to recognize that for-profit and nonprofit businesses engaged in
marketing activities. They recognized that marketing activities occurred in both service and
product businesses. At the core of these organizations’ activities was the notion of “exchange.”6
Viewing the concept of exchange as the core of marketing allowed people to consider other
areas where marketing might also be useful. Fine arts centers and museums, hospitals, and
school districts began to see the relevance of applying marketing strategies and tactics to their
settings. A consumer exchanges time and money for the pleasure of seeing a display of fine
art; a patient pays for medical services provided by a freestanding diagnostic clinic; and a school
district provides education in exchange for public support through tax levies.
The scope and nature of who markets has broadened considerably. Marketing is conducted
by individuals and organizations. Marketing is relevant to for-profit and nonprofit entities.
Although there are distinct aspects within any industry that require the modification of mar-
keting principles to fit particular needs, the core of marketing and the marketing mix is relevant
for almost every organization. Throughout this text, examples of marketing programs at busi-
nesses such as General Motors (GM) or Johnson & Johnson will be discussed, along with the
marketing programs of health care providers such as the Geisinger Health System in Danville,
Pennsylvania, or the Mayo Clinic in Rochester, Minnesota.
In health care today—as there is an increasing focus on managing an individual’s health
given the emerging nature of the health care reimbursement marketplace—it is increasingly
relevant to consider the aspect of marketing and exchange as has been discussed within a social
marketing concept. That is, the issue of exchange may well involve third parties, and the
transfer can be values, attitudes, or beliefs.7 Implicit in this concept of exchange, then, is the
recognition that marketing and, thus, social marketing involve a voluntary action on the behalf
of the individual customer or consumer that focuses on a behavioral change to improve their
health status. It is not a regulatory or enforced action being imposed on the person to change
their behavior and thus comply with some mandated action to improve their health behaviors,
for example.8 What might be considered as a difference of social marketing from marketing in
general is that social marketing has as a goal to get individuals to change their behavior in
measurable ways.9 Within this text, several examples of social marketing will be integrated
because the outcome metric may be different, but the tactical elements are similar in terms of
what will be described later as the marketing mix.

6 CHAPTER 1 The Meaning of Marketing

The Elements of Successful Marketing
Marketing Research
Within the definition of marketing is the discussion of a process of planning and executing to
meet consumer needs. Marketing requires an understanding of consumer wants and needs.
This understanding is derived through an assessment of these needs. Marketing research is a
process in which there is a systematic gathering of data from customers to identify their needs.
Within this book, Chapter 5 focuses on marketing research.

The Four Ps
The heart of marketing strategy is the development of a response to the marketplace. As noted
in the definition, marketing is the “execution of the conception, pricing, promotion, and dis-
tribution of the goods, ideas, and services.” To respond to customers, an organization must
develop a product, determine the price customers are willing to pay, identify what place is
most convenient for customers to purchase the product or access the service, and, finally,
promote the product to customers to let them know it is available.
Product, price, place, and promotion are referred to as the four Ps of marketing strategy.10
It is these four controllable variables that a firm uses to define its marketing strategy. The mix
of these four controllable variables that a business uses to pursue a desired level of sales is
referred to as the marketing mix. The definitions of the four major elements of marketing as
discussed here provide the focus of this text.

Product Product represents goods, services, or ideas offered by a firm. In this text, the term
product also will be used interchangeably with health care services and ideas. In health care,
the nature of the product has changed dramatically. Thirty or 40 years ago, one could define
the product simply as a medical procedure or as an orthotic device to correct a physical dis-
ability. In today’s climate, the discussion of the health care product includes not only these
traditional products, but also products and services. Examples of such products and services
include a contracted services organization (e.g., CEP America) that runs a hospital’s emer-
gency room, hospitalists, anesthesia services, and other necessary elements as needed by
acute care facilities; a group purchasing contract, such as that offered by Premier, Inc., an
alliance of independent hospitals in 50 states; or even a web-based consulting service such
as those provided by Carena, a private Seattle-based company that employs physicians and
nurse practitioners to do virtual consults in 11 states. And, Washington has become the 24th
state to allow reimbursement for some telemedicine services.11

Price Price focuses on what customers are willing to pay for a service. What price represents
is addressed in the definition of marketing in terms of exchanges. A company provides a
service, and customers exchange dollars for receipt of a service that satisfies their needs. For
example, an employee paying an annual premium to an insurance company and a physician
fee for an office visit both encompass exchange behaviors involving a predetermined price.
The issue of pricing for health care services has become a major concern of marketing strat-
egy as the health care environment changes, with companies shifting an increasing amount
of the responsibility to employees or consumers moving to health exchanges and being more
sensitive to the price of health care services. For many years, the price aspect of health care

The Elements of Successful Marketing 7

services has been a challenging variable for consumers. One health care economist likened
it to a situation in which a consumer as a shopper entered a department store blindfolded
and put clothes in a shopping cart, only to be sent a bill for the items several months later.12
In this scenario, it would be difficult to be a judicious shopper. However, there is a greater
movement to price transparency to aid consumer decision making.
Several factors are contributing to the greater role that the pricing variable plays in devel-
oping marketing strategy. In many countries, the rising cost of health care has been a major
cause of concern. Between 1990 and 2005, health care costs grew at a rate of 5.8 percent in
the United States but actually began to show signs of slowing in the latter half of the decade
to an annual increase of slightly below 4 percent. And, in this most recent decade, health care
costs have decreased even further. From 2010 through 2013, the real per capita national health
expenditure grew at an annual rate of 1.1 percent. This was the slowest rate for any 3-year
period on record and below the average rate of 4.6 percent from 1960 to 2010.13 Although this
slower growth is a positive for companies and consumers who are paying the cost either
through coverage for their employees or in the form of employee premiums, there is a down-
side to this decline in health care cost in terms of the macro environment. The slowing of the
health care sector growth had led to a decline in terms of gross domestic product (GDP) growth
by 2.9 percent in 2014. Though not all of that decline could be attributed to the slower growth
in health care expenditures, this sector of the economy is a significant factor, as the U.S. pro-
portion of GDP spent on health care had been rising faster than any other developed nation
in recent years.14
Although health care cost increases have slowed in the United States, the impact on
employers has never been larger. From 2003 to 2013, premium contributions for employers
climbed by 93 percent while premiums for family coverage increased by 73 percent. Total
premiums paid by both employers and employees rose much faster than the increase in
median household income. 15 Finally, within the health care system itself, different
approaches are being undertaken to control costs and reduce costs to employers and
­consumers in the long run. The federal government is implementing a pay-for-performance
(P4P) model through Medicare. Under this approach, financial incentives are provided
to providers to improve the quality of care they deliver and to reduce costs in the process
while meeting agreed-upon performance measures. A 2010 report by the National Confer-
ence on State Legislatures estimated that 85 percent of state Medicaid programs were to
operate such a P4P program by 2011.16 The interest in P4P models has been significant in
both the private and public sector. The programs have rewards but can also impose penal-
ties if certain goals are not met. The quality measures tend to be grouped into one of four
categories:17
•• Process measures that focus on activities that contribute to positive health outcomes.
These might be actions such as giving aspirin to a heart attack patient.
•• Outcome measures such as whether or not a patient with diabetes has it under con-
trol. This dimension is particularly controversial as many elements to control diabetes
are often felt not to be under the control of the health care organization or clinician.
•• Patient experience metrics that include patient perception of the quality of care and
their satisfaction with the service that they have received, including the communica-
tion with the clinical staff.

8 CHAPTER 1 The Meaning of Marketing

Another random document with
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kristittyä ja neljä hausaa on minun uskoani.

— Entä sinä?

Abibu, kanolaispoika, hymyili Sandersin viattomuudenilmaukselle.

— Herra, hän sanoi, — minä seuraan profeettaa, uskon vain

yhteen
Jumalaan, voimakkaaseen ja laupiaaseen.

— Se on hyvä, sanoi Sanders. — Anna nyt miesten lastata puita,

ja Joka saa pitää höyryä kuun nousuun, jolloin kaikki on valmista
lähtöön.

Kymmenen aikaan kellonsa mukaan hän kutsui neljä hausaansa,

antoi heille kullekin lyhyen karbiinin ja olkavyön. Sitten joukko lähti
maalle.

Kuningas kärsimyksineen istui majassaan, josta Sanders löysi

hänet.

— Sinä pysyt täällä, Milini, hän komensi, — eikä sinua syytetä

milloinkaan siitä, mitä tapahtuu tänä yönä.

— Mitä tapahtuu, herra?

— Ken tietää! sanoi Sanders syvällisesti.

Kadut olivat sysimustat, mutta Abibu valaisi lyhdyllä tietä. Vain

silloin tällöin he sivuuttivat majan, jossa oltiin kotona. Tavallisesti he
näkivät hiilloksen hohteesta, että asunnot olivat tyhjiä. Kerran sairas
nainen huusi heille, kun he menivät ohi. Hänen aikansa oli lähellä,
sanoi hän, eikä ketään ollut auttamassa häntä hänen vaikeana
hetkenään.

— Jumala auttaa sinua, sisar! sanoi Sanders, joka pelkäsi

syntymisen salaisuutta. — Minä lähetän naisen sinun luoksesi. Mikä
on nimesi?

— He eivät tule, sanoi kärsivä ääni. — Tänä yönä miehet lähtevät

sotaan, ja naiset odottavat suurta tanssia.

— Tänä yönä?

— Tänä yönä, herra — niin ovat messinkihenget määränneet.

Sanders maiskautti suullaan.

— Sen tahdon nähdä, sanoi hän ja jatkoi matkaansa.

Joukko tuli kylän laitaan. Heidän edessään taivaan

pronssikajastusta vasten piirtyi pienen kummun tumma muoto, ja sitä
he hakivat.

Pronssi tuli punaiseksi ja kohosi, muuttui jälleen pronssiksi tulen

hulmutessa kummun takana milloin kirkkaammin, milloin
himmeämmin. Tultuaan kukkulan harjalle Sanders näki edessään
koko näytelmän.

Metsän laidan ja kukkulan juuren välillä oli laajahko tasanko.

Vasemmalla oli joki, oikealla taas oli metsä ja suo.

Aivan tasangon keskellä paloi suuri tuli. Sen edessä, seipäillä, oli
laatikko.

Mutta ihmiset!
 Suuri piiri, istuen liikkumatta kyykyllään, vaiteliaana; miehiä,
naisia, lapsia, pienokaisia, jotka riippuivat äideissään; suuri
ihmiskehä, jonka napana oli tuli ja laatikko.

Keskellä oli aukea, josta pääsi käsiksi laatikkoon — aukea, jossa

alastomia miehiä kulki kulkueessa. Nämä pitivät yllä tulta, ja Sanders
näki heidän kuljettavan polttoainetta. Pysyen joukon takana hän
raivasi tien aukealle. Sitten hän silmäsi miehiinsä.

— On kirjoitettu, sanoi hän kanolaisten kummallisella arabian

kielellä, — että meidän on kannettava pois tämä väärä jumala.
Pääseekö kukaan meistä tästä seikkailusta elävänä, vai
kuolemmeko tässä, on Allahin vallassa, joka tietää kaiken.

Sitten hän astui päättävästi aukeata pitkin. Hän oli vaihtanut

valkean pukunsa virkapukuun, eikä joukko huomannut häntä, ennen
kuin hän tuli hausainsa kanssa laatikon luo. Tulen kuumuus oli
kauhea, polttava. Läheltä hän näki laatikon lautojen taipuneen
kuumuudesta ja raosta hän näki ohuen laakakiven.

— Ottakaa laatikko nopeasti, ja hausat kohottivat sen olkapäilleen.

Siihen asti koko ihmisjoukko oli istunut äänetönnä ihmetellen, mutta
kun sotilaat kohottivat taakkansa, kajahti vihan huuto tuhansista
kurkuista, ja miehet hypähtivät seisomaan.

Sanders seisoi tulen edessä toinen käsi kohotettuna, ja hiljaisuus

palasi.

— Isisin kansa, sanoi Sanders, — älköön yksikään liikahtako,

kunnes jumalakivi on mennyt ohi, sillä kuolema kohtaa nopeasti sen,
joka asettuu jumalien tielle.
 Hänellä oli pistooli kummassakin kädessään, ja se jumaluus, jota
hän ajatteli, ei ollut laatikossa.

Kansa epäröi liikehtien kärsimättömänä, niinkuin joukko liikehtii

epäröidessään.

Nopein askelin miehet veivät kuormansa aukeaman läpi; he olivat

jo häiriytymättä menneet melkein joukon ohi, kun eräs vanha nainen
astui esiin ja tarttui Sandersin käteen.

— Herra, herra! hän huusi, — mitä teet meidän jumalallemme?

— Vien hänet oikeaan paikkaan, sanoi Sanders, — sillä hallitus on

määrännyt minut sen pitäjäksi.

— Anna tunnus! karjui nainen, ja kansa huusi hänen mukanaan:

— Tunnus, herra!

— Tämä olkoon teille tunnukseksi, sanoi Sanders, muistaen

kärsivän naisen, — Jumalan armosta Ifabille, Adakon puolisolle,
syntyy poikalapsi.

Hän kuuli puheen sorinaa; hän kuuli viestiään kerrattavan suusta

suuhun kautta koko joukon, hän näki ryhmän naisia kiiruhtavan
takaisin kylään, sitten hän antoi käskyn marssia eteenpäin. Kuului
murinaa, ja joku syvä-ääninen mies aloitti sotalaulun, mutta kukaan
ei yhtynyt häneen. Joku — mahdollisesti sama mies — kalautti
keihästä kilpeä vasten, mutta hänen esimerkkiään ei seurattu.
Sanders tuli kylän kadulle. Hänen ympärillään oli sellainen tungos,
että hän vaivoin saattoi seurata laatikkoa. Joki oli näkyvissä; kuu
nousi kelmeänä, kultaisena pallona yli puiden, levitti hopeataan
veteen, ja sitten kuului vihan mylvintä.
 — Hän valehtelee! Hän valehtelee! Ifabille, Akadon vaimolle,
syntyi tyttölapsi.

Sanders kääntyi äkkiä; hänen huulensa vetäytyivät irvistykseen, ja

hänen valkeat hampaansa välkkyivät.

— Jos joku mies kohottaa keihäänsä, sanoi hän puhuen hyvin

nopeasti, — niin hän on kuoleman oma.

Jälleen he seisoivat epäröiden, ja Sanders antoi käskyn olkansa

yli.

Hetken vain joukko epäröi, sitten, kun sotilaat ottivat

jumalalaatikon olalleen, hyökkäsivät kaikki karjuen eteenpäin.

Muuan ääni huusi jotain; kuin taikavoimasta melu vaimeni,

kansanjoukko hajaantui taaksepäin ja sivuille rynnäten toinen
toisensa yli ja pyrki nopeasti pakoon.

Sanders seisoi ladattu pistooli kummassakin kädessään ja

ihmetteli suu avoinna.

Paitsi miehiään hän oli yksin, ja sitten hän näki.

Keskellä katua tuli kävellen kaksi miestä. He olivat pukeutuneet

lyhyisiin hameihin, jotka jättivät polvet paljaiksi; päässä oli suuri
messinkikypäri, ja messinkihaarniska suojeli rintaa.

Sanders katseli heitä, kun he tulivat lähemmäs, sitten hän sanoi:

— Ellei tämä ole kuumetta, niin se on hulluutta, sillä hän näki kaksi
roomalaista centuriota, raskas miekka kupeella riippuen.
 Hän seisoi vielä, ja he sivuuttivat hänet niin läheltä, että hän näki
kilvestä karkeat kirjaimet:

AUGUSTUS CAE.

— Kuumetta, sanoi hän hervottomasti ja seurasi laatikkoa laivaan.

*****

Kun laiva tuli Lukatiin, Sanders ei vielä ollut oikein selvillä, sillä
hänen ruumiinlämpönsä oli normaali eikä kuumetta enempää kuin
aurinkoa voinut syyttää harhanäyn aiheuttajaksi. Sitä paitsi hänen
miehensä olivat nähneet saman ilmestyksen.

Hän löysi valtuudet, jotka kyyhkynen oli tuonut, mutta ne olivat nyt
tarpeettomat.

— Ihmeellinen juttu, sanoi hän Carterille kertoessaan tarinaa, —

mutta otetaanpa kivi, ehkä se voi tuoda selityksen asiaan.
Centurioita — pah!

Otettuna päivänvaloon kivi näytti olevan harmaata graniittia, jota

Sanders ei ollut nähnyt ennen.

— Tässä on 'paholaisen merkkejä', sanoi hän, kun kivi

pyöräytettiin ympäri. — Mahdollisesti — ah!

Ei ihme, että hän hämmästyi, sillä kivessä oli kirjaimia, ja Carter

näki puhallettuaan tomun pois:

MARIUS ET AUGUSTUS CENT NERO IMPERAT IN DEUS DULCE

 Sinä yönä Sanders käyttelemällä unohtunutta latinaansa ja
täyttämällä kuluneet paikat arvaamalla sai kokoon seuraavan
käännöksen:

»Marius ja Augustus, Neron, keisarin ja hallitsijan,

centuriot, nukkukaa rauhassa jumalien kanssa.

»Me olemme ne, jotka tulivat Hanno Karthagolaisen löytämien

villien maiden taa…

»Marcus Septimus meni Egyptiin, ja hänen kanssaan Decimus

Superbus, mutta keisarin tahdosta ja jumalien armosta me
purjehdimme takaisin mustiin meriin… Täällä me elimme aluksemme
kärsittyä haaksirikon barbaarien kunnioittamina ja opettaen heille
sotataitoa.

»… Te, jotka tulette jälkeemme… viekää tervehdys Roomaan Cato

Hippocritukselle, joka asuu… portin luona…»

Sanders pudisti päätään, kun oli lukemisen lopettanut, ja sanoi,

että se oli »vallan kummallista».
MONROVIAN BOSAMBO

Monta vuotta ovat Ochorin miehet olleet äitelänä komediana Afrikan

siirtomaamurhenäytelmässä. Nyt ei enää voida nauraa ochorilaisille.
Eikä yön pikkutunneilla kalatulien ääressä keskusteleva pieni unelias
seurue saata ilostua kuullessaan tarinoita Ochorista ja ochorilaisista.
Kaikki tämä on tapahtunut Liberian hallituksen suosiollisella
myötävaikutuksella, vaikkakaan Liberian hallitus ei ole siitä tietoinen.

Kaikella kunnioituksella Liberian tasavaltaa kohtaan sanon, että

monrovialaiset, Liberian pääkaupungin asukkaat, ovat suuria
valehtelijoita ja varkaita luonnostaan.

Kerran, sanottakoon se valtion kunniaksi, hankittiin sotalaiva —

muistaakseni sen lahjoitti joku laivanomistaja, joka ei siitä välittänyt.
Hallitus nimitti kolme amiraalia, neljätoista kapteenia ja niin monta
upseeria kuin laivaan sopi, ja kaikilla oli mitä loistavin virkapuku.
Hallitus aikoi nimittää myös miehistön, mutta laiva ei ollut tarpeeksi
suuri, että siihen olisi mahtunut upseerien lisäksi ainoatakaan
miestä.

Kerran tämä mustan tasavallan pieni sotalaiva meni merelle,

amiraalit ja kapteenit lämmittivät ja ohjasivat sitä — tämä
jälkimmäinen oli uutta ja viehättävää.

Takaisin satamaan tultaessa eräs amiraali sanoi:

— Nyt on minun vuoroni pitää perää, ja otti ruorin.

Laiva törmäsi kariin sataman suulla ja meni pohjaan. Upseerit

pelastuivat helposti, sillä monrovialaiset uivat kuin kalat mutta
merivesi pilasi heidän kauniit pukunsa. Esitykseen, että ryhdyttäisiin
laivaa pelastamaan, hallitus viisaasti sanoi:

— Ei, emme luule sen olevan tarpeellista.

— Me tiedämme, missä se on, sanoi presidentti (hän istui

Hallituspalatsissa syöden sardiineja sormineen), — ja jos joskus sitä
tarvitsemme, on hyvä tietää sen olevan niin lähellä.

Asiassa ei olisi tehty mitään enempää, mutta Britannian

amiraliteetti sanoi, että hylky oli laivankululle vaarallinen, ja määräsi
hylyn paikalle pantavaksi poijun.

Liberian hallitus murisi jotakin kulungeista, mutta painostuksesta

(luulen sotalaiva »Dwarfin» kapteenin, joka oli kirpeäkielinen mies,
sanoneen jotakin) he suostuivat, ja paikalle asetettiin kellopoiju.

Se soi kauniisti ja rauhoittavasti — poijun kello nimittäin — ja

monrovialaiset pitivät sitä kulunkien veroisena.

Mutta kaikki monrovialaiset eivät ole v. 1821 vapautettuja

amerikkalaisia orjia, jotka ovat asettuneet Liberiaan. On myös
kansalaisia, joita liberialaiset sanovat »alkuasukkaiksi», ja näistä
huomatuimpia ovat krulaiset, jotka eivät maksa veroja, kiusaavat
hallitusta ja niistävät silloin tällöin virallisen tasavallan nenää.
 Poijun paikoilleen asettamisen jälkeisenä päivänä Monrovia heräsi
huomaten, että täydellinen hiljaisuus vallitsi lahdella huolimatta
korkeasta merenkäynnistä. Kello oli vaiti, ja kaksi ent. amiraalia,
jotka myivät kaloja rannalla, lainasi veneen ja souti tarkastamaan.
Selitys oli yksinkertainen: kello oli varastettu.

Liberian tasavallan presidentti sanoi kiivaasti;

— Tulkoon Belsebubi, joka on kaiken synnin alku ja juuri,

varastelevien krulaisten päälle!

Toinen kello asetettiin. Se varastettiin samana yönä. Pantiin vielä

yksi kello, ja veneellinen amiraaleja asetettiin vartioimaan sitä. He
istuivat läpi yön keinuen aalloilla ja yksitoikkoinen kling-klang-klong
oli musiikkia heidän korvissaan. Se soi koko yön, mutta aamulla
varhain, pimeänä hetkenä ennen auringon nousua, kellon ääni tuntui
heikkenevän.

— Veljet, sanoi yksi amiraaleista, — olemme kulkemassa kellolta

poispäin.

Mutta selitys oli se, että kello oli kulkenut heistä poispäin, sillä
puolinaisiin toimenpiteihin kyllästyneinä krulaiset olivat ottaneet koko
poijun mukaansa kelloineen ja kaikkineen, eikä vielä tänäkään
päivänä ole paikalla merkkiä osoittamassa, missä kohdin Monrovian
satamassa muinainen sotalaiva mätänee.

Tämän varkauden suunnittelija ja toimeenpanija oli muuan

Bosambo, jolla oli kolme vaimoa. Näistä yksi, syntyään kongolainen
ja uskoton, ilmoitti asiasta poliisille, ja muodollisuuksien mukaan
Bosambo vangittiin ja vietiin korkeimpaan oikeuteen, jossa hänet
havaittiin syylliseksi »varkauteen ja valtionkavallukseen» ja tuomittiin
kymmenen vuoden pakkotyöhön.

He veivät Bosambon vankilaan, ja Bosambo haastatteli mustaa

vartijaa.

— Ystäväni, sanoi hän, — minulla on metsässä suuri ju-ju, ja jos

sinä et heti laske minua vapaaksi, sinä ja vaimosi kuolette kurjan
kuoleman.

— Sinun ju-justasi minä en tiedä mitään, sanoi vartija mietteliäästi.

— Minä saan kaksi dollaria viikossa vartijantoimestani, mutta jos
lasken sinut vapaaksi, en saa mitään.

— Tiedän paikan, johon on kätketty paljon hopeaa, sanoi

Bosambo ylpeästi. — Sinä ja minä menemme siihen paikkaan, ja me
tulemme rikkaiksi.

— Jos sinä tiesit, missä on hopeaa, miksi varastit kelloja, jotka

ovat messinkiä ja melkein arvottomia? kysyi hänen mielikuvitukseton
vartijansa.

— Huomaan, että sinun sydämesi on kivinen, sanoi Bosambo ja

meni metsäalueelle hakkaamaan puita valtion laskuun.

Neljä kuukautta tämän jälkeen sai Sanders, Isisin, Ikelin ja

Akasavan maiden pääkomissaari, monistetun kuvauksen ja
ilmoituksen:

»Sille, jota tämä koskee.

Tiedustellaan — H. Y. Liberian Presidentin julkaisemalla

kuulutuksella Bosambo Krulaista, joka pakeni pakkotyölaitoksesta
lähellä Monroviaa, tapettuaan vartijan. Hänen otaksutaan tulevan
teidän maitanne kohti.»

Seurasi kuvaus.

Sanders pani asiakirjan muiden samanlaisten joukkoon — ne eivät

olleet harvinaisia tapauksia — ja ryhtyi jälleen pohtimaan ikuista
Ochorin arvoitusta.

Nyt, niinkuin aina, ochorilaiset olivat pahassa pulassa. Koko

Afrikassa ei ole niin onnetonta kansaa kuin ochorilaiset. Fingot, jotka
olivat orjia nimeltään ja tavoiltaan, olivat julmia kuin masait
verrattuina ochorilaisiin.

Sanders oli hieman kärsimätön, ja kolmimiehinen lähetystö, joka

oli matkannut päämajaan valittamaan kansan vaivoja, tapasi hänet
epäystävällisenä.

Hän puhutteli heitä parvekkeellaan.

— Herra, ei kukaan jätä meitä rauhaan, sanoi yksi. — Isisiläiset,

ngombilaiset kaukaisista maista, kaikki tulevat luoksemme vaatien
sitä ja tätä, ja me annamme peloissamme.

— Mitä te pelkäätte? kysyi Sanders kyllääntyneenä.

— Pelkäämme kuolemaa ja kipua ja polttamista ja vaimojemme

ryöstämistä, sanoi toinen.

— Kuka on päällikkönne? kysyi Sanders hurjana.

— Minä olen päällikkö, sanoi vanhanpuoleinen mies, jolla oli

leopardinnahka yllään.
 — Mene takaisin kansasi luo, päällikkö, jos todellakin olet
päällikkö etkä vanha hävytön akka; mene takaisin ja vie mennessäsi
jumala — voimakas jumala — joka katsoo sinun etujasi ja vartioi
sinua niinkuin minä. Tämä jumala sinun pitää asettaa kyläsi laitaan
niin, että aurinko puolen päivän aikana tulee olemaan sitä
vastapäätä. Merkitse paikka, johon sinun on se asetettava, ja puolen
yön aikana sinun pitää se menoin ja uhritoimituksin asettaa
paikalleen. Ja sen jälkeen sinun ja sinun kansasi ryöstäjät joutuvat
tämän jumalan vihan alaisiksi.

Sanders sanoi tämän hyvin vakavasti, ja lähetystön jäsenet olivat

hyvin liikutuksissaan. Mutta enemmän he olivat liikuttuneita, kun
Sanders ennen heidän lähtöään antoi heille paksun seipään, jonka
päähän oli kiinnitetty lauta. Lautaan oli piirretty merkkejä.

He kantoivat aarrettaan kuusi päivää metsän läpi ja kuljettivat sitä

kanootissa neljä päivää ylös jokea, kunnes tulivat Ochoriin. Siellä se
kuun valossa ja uhraten yhden vuohen sijasta kaksi (varmuuden
vuoksi) asetettiin siten, että taulu salaperäisine kirjoituksineen oli
keskipäivällä aurinkoon päin.

Uutiset kulkevat takamaissa nopeasti, ja Isisin ja Akasavan kylissä

kerrottiin pian, että ochorilaiset olivat valkean taikavoiman erityisessä
suojeluksessa. He olivat aina olleet suojatut, sillä moni mies, joka oli
viehättynyt tappamaan ochorilaisia, oli kuollut valkoisen miehen
käden kautta.

— Minä en usko, että Sandi on tehnyt tämän, sanoi Akasavan

päällikkö. — Mennään joen poikki ja katsotaan omin silmin, ja jos he
ovat valehdelleet, pieksämme heitä kepeillä, vaikkakaan emme voi
tappaa yhtään miestä Sandin ja hänen hirmuisuutensa vuoksi.
 Niin he menivät joen yli ja marssivat, kunnes tulivat Ochorin
kaupungin näkyville, ja ochorilaiset kuullessaan akasavalaisten
olevan tulossa pakenivat metsiin ja kätkeytyivät tapansa mukaan.

Akasavalaiset etenivät, kunnes tulivat maahan pystytetylle

seipäälle ja näkivät laudan, johon oli piirretty »paholaisen merkit».

Sen edessä he seisoivat hiljaa ja peloissaan, ja sitä palvottuaan ja

uhrattuaan sille kanan (joka oli ochorilaisten laillista omaisuutta) he
palasivat.

Tämän jälkeen tuli joukko Isisistä, ja heidän täytyi kulkea

Akasavan kautta.

He toivat näille lahjoja ja viettivät yön akasavalaisten luona.

— Mitä on tämä puhe Ochorista? kysyi isisiläisten päällikkö, ja

Akasavan päällikkö kertoi hänelle.

— Voit säästää matkan itseltäsi, sillä me olemme nähneet sen.

— Sen, sanoi Isisin päällikkö, — uskon vasta nähtyäni.

— Se on pahaa puhetta, sanoivat akasavalaiset, jotka

kokoontuivat neuvotteluun. — Nämä Isisin koirat sanovat meitä
valehtelijoiksi.

Kuitenkaan ei tullut verenvuodatusta, ja aamulla isisiläiset jatkoivat

matkaansa.

Ochorilaiset näkivät heidän tulevan ja kätkeytyivät metsään, mutta

varovaisuus oli tarpeeton, sillä isisiläiset lähtivät heti takaisin. Muut
kansat tekivät pyhiinvaellusretkiä Ochoriin, ngombit, bokelit ja
metsän pikkumiehet, jotka olivat niin arkoja, että tulivat yöllä, ja
ochorilaiset alkoivat tuntea suuren tärkeytensä.

Sitten Bosambo, krulainen ja suuri seikkailija, ilmestyi näyttämölle

kuljettuaan kahdeksansataa mailia villejä maita hartaasti toivoen,
että aika pimentäisi Liberian hallituksen muistin ja toisi hänet
sattumalta maahan, jossa rieska ja hunaja vuotaa.

Bosambo oli eläissään kokenut monia. Hän oli ollut

kyökkimestarina Elder Dempster linjalla, koulumestarina
lähetyskoulussa — hän oli ylpeä siitä, että hän omisti kirjan
»Pyhimysten elämä», tunnustus edistyksestä — hänen varastossaan
oli hieman englannin kielen taitoakin.

Vieraanvarainen Ochori otti hänet vastaan sydämellisesti, ruokki

häntä manokilla ja sokeriruo'olla ja kertoi hänelle Sandin
taikuudesta. Syötyään Bosambo käveli seipään luo ja luki
kirjoituksen:

PÄÄSY KIELLETTY!

Hän ei hämmästynyt, vaan tuli takaisin syvissä mietteissä.

— Tämä taika, sanoi hän päällikölle, — on hyvä taika. Minä tiedän

sen, sillä minulla on valkean miehen verta suonissani.

Todistaakseen tämän hän häväisi aivan viattoman Sierra

Leonessa palvelevan brittiläisen virkamiehen tekemällä hänet
isäkseen.

Ochori oli syvästi liikuttunut. He kaivoivat esiin tarinoita omista

urotöistään, jotka alkoivat siitä, että Tiganobeni, suuri kuningas, tuli
ammoisina aikoina pohjoisesta ja hävitti kaiken maan Isisiin asti.

Bosambo kuunteli — tarinan kertominen vei kaksi yötä ja niiden

välisen päivän, sillä Ochorin virallisella kertojalla on vain yksi
kertomatapa — ja kun se oli lopussa, Bosambo sanoi itselleen:

— Näitä ihmisiä minä olen etsinyt kauan. Minä jään tänne.

Ääneen hän kysyi:

— Ja miten usein Sandi tulee tänne?

— Kerran vuodessa, herra, sanoi päällikkö, — kahdentenatoista

kuukautena tai vähän myöhemmin.

— Milloin hän kävi viimeksi?

— Kun nykyinen kuu on täysi, kolme kuukautta sitten; hän käy

suurien sateiden jälkeen.

— Sitten, sanoi Bosambo jälleen itsekseen, — minä olen turvassa

yhdeksäksi kuukaudeksi.

He rakensivat hänelle majan, istuttivat hänelle banaanitarhan ja

kylvivät hänelle siemenen. Sitten hän pyysi vaimokseen päällikön
tytärtä, ja vaikka hänellä ei ollut millä maksaa, tuli tytär hänelle. Muut
kansat huomasivat, että vieras asui Ochorissa, sillä uutiset leviävät
nopeasti, mutta sitten, kun hän meni naimisiin, ja vielä päällikön
tyttären kanssa, oli miehen pakosta oltava ochorilainen, ja sellaisena
tuli tieto päämajaan. Sitten Ochorin päällikkö kuoli. Hän kuoli äkkiä
joihinkin tuskiin, mutta sellaiset kuolemat ovat yleisiä, ja hänen
poikansa rupesi hallitsemaan. Lyhyen hallitusajan jälkeen poikakin
kuoli, ja Bosambo kutsui koolle vanhat ja viisaat miehet ja maan
päämiehet.

— Näyttää siltä kuin Ochorin monet jumalat olisivat tyytymättömiä

teihin, sanoi hän, — ja minulle on unessa sanottu, että minä tulen
Ochorin päämieheksi. Sen vuoksi kumartakaa minua tavan mukaan,
ja minä teen teidät suuriksi miehiksi.

Luonteenomaista ochorilaisille oli, ettei kukaan vastustanut, vaikka

joukossa oli kolme miestä, jotka tapoja noudattaen olisivat voineet
vaatia päällikkyyttä.

Sanders kuuli uudesta päälliköstä ja hämmästyi.

— Etabo? kertasi hän (siten Bosambo nimitti itseään). — En

muista miestä — saako hän miehiin selkärankaa; en tiedä, kuka hän
on.

Bosambossa oli selkärankaa, juonia tai molempia.

— Hänellä on hyvin omituisia tapoja, ilmoitti alkuasukasvakooja

Sandersille. — Joka päivä hän kokoaa kylän miehet ja panee heidät
kävelemään pelebin (pöydän) ohi, jolla on monta munaa. Hänen
komentonsa mukaan jokainen mies ohikulkiessaan ottaa munan niin
nopeasti, ettei yksikään silmä sitä näe. Ja jos mies on kömpelö tai
särkee munan tai on hidas, tämä uusi päällikkö panee häpeän hänen
päällensä piesten häntä.

— Se on leikkiä, sanoi Sanders; mutta eläissään hän ei ollut

nähnyt sellaista leikkiä. Uutinen toisensa jälkeen tämän uuden
päällikön hullutuksista tuli hänen korviinsa. Joskus hän vei
ochorilaiset yöllä ulos ja opetti heille sellaisia asioita, joista he eivät
ennen olleet tietäneet mitään. Siten hän opetti heille, millä tavalla
heidän piti ottaa vuohi niin, ettei se voinut huutaa. Ja myös sen,
miten he voivat ryömiä vatsallaan tuuma tuumalta aikaansaamatta
mitään ääniä. Ochorilaiset tekivät kaiken tämän muristen ääneensä
vääryyttä ja ankaraa työtä vastaan.

— Minä repeän, ennen kuin ymmärrän tätä! sanoi Sanders

rypistäen kulmiaan, kun viimeiset tiedot tulivat. — Joillekuille muille
se olisi sodan merkki, mutta ochorilaiset!

Huolimatta käsityksistään ochorilaisten sotakuntoisuudesta hän

piti hausansa valmiina.

Mutta sotaa ei tullut. Sen sijaan akasavalaiset valittivat, että

»metsässä oli paljon leopardeja».

Leopardeista ei haittaa, ajatteli Sanders, ja akasavalaiset olivatkin

kyllin hyviä metsästäjiä lopettaakseen tämän jupakan ilman apua.
Seuraava tieto oli hälyttävä. Kahdessa viikossa nämä leopardit olivat
vieneet kuusikymmentä vuohta, kaksikymmentä säkkiä suolaa ja
paljon norsunhampaita.

Leopardit syövät vuohia, ja ehkäpä on hienostuneita leopardeja,

jotka eivät syö vuohia suolatta, mutta leopardit eivät vie
norsunhampaita edes hammastikuikseen. Sanders kiiruhti niin ollen
jokea vastavirtaan, koska pikkuasiat ovat tärkeitä seudulla, jossa
ihmiset pureksivat hyttystä, mutta nielevät kokonaisen karavaanin.

— Herra, se on totta, sanoi Akasavan päällikkö hieman

järkyttyneenä. — Nämä vuohet katoavat yö yöltä, vaikka me
vartioimme niitä, samoin suola ja norsunluu, koska me emme niitä
vartioineet.
 — Mutta leopardit eivät vie näitä esineitä, sanoi Sanders
vihaisena. —
Ne ovat varkaita.

Päällikön ällistys oli suuri.

— Kuka voisi varastaa? hän kysyi. — Ngombi on kaukana, samoin

Isisi.
Ochorilaiset ovat hulluja ja pelkureita.

Sitten Sanders muisti munaleikit ja ochorilaisten yölliset

toimitukset.

— Tahdon puhua tämän uuden päällikön kanssa, hän sanoi ja

meni joen poikki samana päivänä.

Lähettäen sananviejän ilmoittamaan tulostaan hän odotti kahden

mailin päässä kylästä, ja neuvonantajat ja viisaat miehet tulivat häntä
vastaan tuoden kalaa ja hedelmiä.

— Missä on päällikkönne? kysyi Sanders.

— Herra, hän on sairas, he sanoivat surullisesti.

— Tänään hän tuli sairaaksi, ja hän kaatui maahan voihkien.

Olemme kantaneet hänet majaansa.

Sanders nyökkäsi.

— Haluan nähdä hänet, hän sanoi.

He johtivat hänet päällikön majan ovelle, ja Sanders meni sisään.

Oli hyvin pimeä, ja pimeimmässä nurkassa makasi sairas mies.
Sanders kumartui hänen ylitseen, koetti hänen valtimoaan, tunnusteli
niskasta korvan takaa unitaudin merkkejä, mutta ei havainnut mitään
oireita. Mutta paljaalla olkapäällä, kun hänen sormensa hipoivat
miehen lihaa, hän tunsi omituisen säännöllisen arven, sitten hän
löysi toisen ja pääsi selville niistä. Liberian hallituksen vankien
polttomerkki oli hänelle tuttu.

— Arvelin sitä, sanoi Sanders ja potkaisi voihkivaa miestä lujasti.

— Tule ulos valoon, Monrovian Bosambo, sanoi hän; ja Bosambo

nousi kuuliaisesti ja seurasi komissaaria ulos majasta.

He seisoivat toisiaan katsellen useita minuutteja; sitten Sanders

sanoi
Pippurirannan murteella:

— Mieleni tekee hirttää sinut, Bosambo.

— Se on sinun ylhäisyytesi vallassa, sanoi Bosambo.

Sanders ei sanonut mitään, vaan naputteli kepillään kenkänsä

kärkeä ja katseli ajattelevana maahan.

— Kun sinä olet tehnyt näistä varkaita, niin voitko tehdä heistä
miehiä? kysyi hän hetken kuluttua.

— Luulen, että he voivat tapella nyt, sillä he ovat ylpeitä

ryöstettyään Akasavan, sanoi Bosambo.

Sanders puri keppinsä päätä niinkuin miettivä mies tekee.

— Ei varkautta eikä murhia, hän sanoi. — Päälliköt ja päällikön

pojat eivät saa enää kuolla äkkiä, hän lisäsi merkitsevästi.

— Herra, tapahtuu, niinkuin haluat.