Summary (For those fed up with polemics)
by Carlo Fonseka

Lures, Bribes & Kickbacks

Prof. Sanath P Lamabadusuriya the pediatrician is one of the most distinguished among my former pupils. With no less than nine medical qualifications to his credit, his service to the world community has been recognised by the award of a MBE by HRH the Queen. He is extremely sharp-witted as I have sometimes learnt to my cost. For instance, at a Senake Bibile Commemoration meeting I once remarked that Prof. SB died as the result of medical negligence or conspiracy in the island of Guyana. At the end of my speech Prof. SL whispered in my ear that there are three Guyanas, British, Dutch and French and that none of them is an island. He was right. Prof. SL is also quite capable of playing the innocent when it suits his purpose. Thus he innocuously says "that if both brands (propriety and non-propriety) are of equal quality, no right-thinking doctor would prescribe the expensive drug". Here he talks as if he did not know that if the "right-thinking doctor" works in the USA, he becomes the (willing) target of the drug industry. In Dr.Marcia Angell’s book entitled The Truth About Drug Companies. How They Deceive Us And What We Can Do About It (2004), there is a chapter with the heading "The Hard Sell…Lures, Bribes, and Kickbacks". Believe it or not, this is what she reveals in this chapter about doctors in the USA " …the main target of the drug industry’s marketing efforts is … doctors. After all, they are the ones who write the prescriptions… in 2001 the industry employed some 88,000 sales representatives to visit doctors in their offices and hospitals to promote their products… usually young attractive and extremely ingratiating, they roam the halls of almost every sizable hospital in the country looking for chances to talk with medical staff and paving the way with gifts (such as books, golf balls and tickets to sporting events). In many teaching hospitals, drug reps regularly provide lunches for interns and residents while standing by to chat about their drugs. This "food, flattery and friendship" … creates a sense of reciprocity in young doctors with long prescribing lives ahead of them. They naturally feel indebted to congenial people who keep giving them gifts…drug companies pay doctors several hundred dollars a day to allow sales reps to shadow them as they see patients, a practice called "preceptorship"… it’s another way to build a relationship with the doctor and hopefully build business … Meetings with doctors in their offices are extremely valuable to drug companies and they’ve become valuable to doctors as well… There is no way to exaggerate how much a part of some doctors’ daily lives drug reps have become... Gifts to doctors are often lavish. Doctors can pretty much count on being taken to dinner in fine restaurants whenever they want… An editorial in USA Today painted a vivid but all too accurate picture: "Christmas trees. Free tickets to a Washington Redskins game with a champagne reception thrown in. A family vacation in Hawaii. And wads of cash. Such gifts would trigger a big red "bribery" alert

in the mind of just about any public official or government contractor. But not, it seems, in the minds of many doctors. They have been raking in jaw-dropping gifts from pharmaceutical firms…" (pp 126-128). Please remember that all of the above is true about doctors in America. To press a popular song of the Gypsies’ to the service of our present purpose, "Americaway ehema unath, lankaway ehema wenne ne".

Prof. SL alludes to the fact that when a doctor writes a prescription in generic names it is the pharmacist who decides which drug to dispense. Making the same point in The Island of 29th December, Dr. DPA says: "When doctors prescribe drugs using the generic names, it is common knowledge that many pharmacists decide which cheap branded drug should be issued to the patient, and it quite often happens that the pharmacist…receives an incentive from the pharmaceutical firms". Later in the same article he alleges that "depending on the incentives the pharmacist gets from the drug firm" he dispenses cheap branded drugs. On the authority of revelations in Dr. Angell’s book, when I hinted that branded-drugs-prescribing doctors like Dr. DPA get incentives from drug companies, he complained bitterly that I had caused him "pain of mind". However, he doesn’t seem to care a jot about the pain of mind he must have surely caused pharmacists in our country, when without any supporting evidence he alleged that pharmacists get such incentives from drug firms. Readers can now begin to see why doctors like Dr. DPA are so anxious to preserve the exclusive prerogative of specifying the brands that patients should receive. It has precious little to do with the welfare of patients. It has everything to do with cornering the opportunities of receiving handsome material incentives from drug companies. There is no reason why the tried and tested "food, flattery and friendship" mantra should not work in Sri Lanka.

Nowadays educated people are well aware of the corruption of the pharmaceutical industry working hand-in-glove with the medical profession, and they no longer accept and trust doctors on face value. In the teeth of such knowledge, perplexed non-medical readers may be tempted to ask: Who knows best which drugs are best for different diseases? In almost every article he has written in this debate Dr. DPA tells readers that only practising doctors know what is best for patients. Indeed on this matter he does seem "to protest too much". In Ayurveda where effective remedies are secretly handed down from generation to generation, it is possible that some practising doctors in exclusive possession of secret remedies know best

which drugs are best for different diseases. But this is emphatically not so in western medicine .The drugs used in modern medicine have been developed by the collaborative research of specialists in several related fields. As explained in Clinical Pharmacology (9th edition) by Bennett & Brown, the decisions about the use of particular drugs for the treatment of different diseases are based on evidence from:

* Systematic reviews and meta analysis

* Randomized clinical trials with definitive results

* Randomized controlled trials with non-definitive results

* Cohort studies

* Case - control studies

* Cross sectional surveys

* Case reports

Drugs so identified are licensed for the treatment of particular disorders and listed in National Formularies and their advantages and disadvantages are discussed in standard text-books written by highly qualified academicians. What non-academic clinicians like Dr. DPA are expected to do is to prescribe the drugs recommended in standard text-books. They are authorized to use the drugs listed in formularies only for treatment of diseases that are specified in the formularies. If they use it for other purposes they run the risk of being charged for malpractice. So how can Dr. DPA keep repeating ad nauseam that practising clinicians know best about drug therapy? To most of them a meta analysis is all Greek.

To the question as to who should prescribe the drugs indicated for the treatment of a given patient, the answer that Bennett and Brown give in Clinical Pharmacology is as follows: "Whenever a drug is given a risk is taken... It is often so small that second thoughts are hardly necessary, but sometimes it is substantial". The risk derives form the fact that, as the British pharmacologist William Withering famously said in 1789, "poisons in small doses are the best medicines; and useful medicines in too large doses are poisonous". When serious side-effects occur from drugs prescribed, the affected patients may accuse the doctor of medical negligence and demand compensation. This has become a matter of grave concern to doctors and they are anxious to transfer to dispensing pharmacists the time-consuming responsibility of giving instructions to patients about how to take the drugs and warning them about the possible adverse side-effects of drugs. It is in this context that Bennett & Brown say: "Doctors who seek to exculpate themselves from serious, even fatal prescribing errors, by appealing to undoubted difficulties presented by the information explosion of modern times allied to pressures of work are unlikely to get sympathy…Pharmacists and nurses stand ready and willing to relieve doctors of the burden of prescribing." If pharmacists and nurses are granted the right to prescribe, they will automatically become the recipients of lures, bribes and kickbacks offered by the drug companies. Readers will now see why various categories of health professionals are so very eager to acquire the right to prescribe drugs. Predictably doctors will fight to the death to preserve the exclusive prerogative of prescribing drugs. In our country with so few qualified pharmacists, doctors should have the exclusive prerogative of prescribing drugs. What is sad and indefensible is that they seem to be insisting on the right to prescribe exclusively by the proprietary brands of their choice. Let them fleece the rich by prescribing the proprietary brands for them because like sheep they are meant for fleecing. But please let them help the poor and the lower middle class to survive by prescribing the generic names and then specifying the proprietary brands they fancy for the benefit of the rich.