Drugs, Doctors and Dinners:
How drug companies influence health in the developing world

Part II
Continued from yesterday

The promotional practices of the drug industry have been described in an editorial in the British Medical Journal 3rd April 2004. "The Commercial needs of countless fiercely competing drug companies have led them to depend on the tried and tested three Cs – Convince if possible, confuse if necessary and corrupt if nothing else works". A stark example comes from an IMS Health 2007 report that attributed China’s considerably lowered growth rate in the pharmaceutical sector from 20.5 percent in 2005 to 12.3 percent in 2006, to a government’s anticorruption campaign. The campaign was introduced in the second quarter of 2006 to set limits on physician-directed promotion. This campaign lowered the sales. In this context it would have been interesting if the circular by the Director of Health Services in January 2008, instructing Heads of Public sector hospitals not to allow drug sales representatives from visiting doctors during working hours, was not withdrawn. It would then have been possible to compare drug sales in 2006 & 2007, as was done in China before and after the campaign, to see the impact of the Director General’s circular on the sales of drugs. Sri Lanka missed an opportunity.

Consumers trust doctors to act in the best interest of their patients. In a doctor: patient interaction, no outside interests should in any way influence the doctor in giving the best advice to patients. Very regrettably, consumers are unaware of the enormous influence of the pharmaceutical industry’s marketing strategies on the very health professionals they trust and rely on.

This article presents evidence from case studies and from articles in international peer-reviewed medical journals to show how the drug industry influences doctors’ prescribing habits in developing countries, including Sri Lanka.

Dr Rafik Ibrahim is an experienced general practitioner in Klang Valley in Kuala Lumpur which is the Capital city of Malaysia. Dr Ibrahim agreed to track all his interactions with drug company sales representatives from 27th July to 29th August 2007 as a case study on drug marketing to doctors in developing countries. In a span of five weeks and 17 hours of drug promotion-related interactions with drug company sales representatives, 16 multinational pharmaceutical companies and nine national generic companies and distributors visited Dr Ibrahim. This list included 10 of the world’s top 20 pharma companies. (The picture shows the promotional materials and gifts presented by drug sales representatives to Dr Ibrahim during the five weeks.)

A survey of 149 doctors in Pakistan found that there was an average of seven sales representatives visiting doctors per day. This is very much more than the number of visits Dr Ibrahim, the GP in Malaysia, had.

Dr Murad M Khan, Prof and Chairman of the Department of Psychiatry at Aga Khan University in Pakistan reported that gifts given by drug companies to doctors in Pakistan can be classified into three categories.

1. Low cost: pens, pads, diaries and calendars.

2. Medium cost: stethoscopes, books, brief cases

3. High cost: air conditioners, lap tops, desk top computers and club membership

The latest practice is: For writing 200 prescriptions of the company’s high-priced drug a doctor is rewarded with the down payment for a brand new car. Prof Khan also said, "In October 2004 Lundbeck launched the Alzheimer’s disease drug Ebixa (Generic name – memantine) in Pakistan by taking 70 doctors to a 5 star hotel in Bangkok, Thailand. How will the company recover this amount? From increased drug sales! Who will help in increasing drug sales? Physicians who went to Bangkok? Who will foot the bill? Patients and families, of course!"

How do prescribing doctors view their accepting gifts, big and small from drugs sales reps? In a number of articles that appeared recently in newspapers on the issue of generics and brand drugs, senior consultants have said that they are never influenced by the drug industry’s promotional strategies. This is true but it is not the whole truth according to the following two articles.

1. Peter Mansfield, "Accepting what we can learn from advertising’s mirror of desire", in British Medical Journal, 18th December 2004, pp 1487-8.

2. "Drug Promotion: What we know, what we have yet to learn", World Health Organization, Geneva, 2004.

These two articles analysed the views of a random sample of doctors. According to these two reports there is a sense of Unique Invulnerability that only other doctors are influenced by gifts. This theory of unique invulnerability suggests that doctors are more willing to say that other doctors are influenced more than they are themselves. This theory was also reported in an Indian study "Who rules the great Indian Drug Bazaar" by N Roy in the Indian Journal of Medical Ethics, Jan-Mar 2004. When an audience of doctors was asked if going on a drug company cruise would affect their prescription of the company’s product, the overwhelming majority responded "No". When asked if a sponsored cruise influenced the prescription practices of any doctors they knew, an overwhelming majority responded "yes".

How drug marketing strategies influence doctors’ prescribing practices in Sri Lanka has been described in the following three articles.

1. K Jayasena, 1985 "Drug Registration and Marketing Practices", Third World Development Dialogue, 2:38-47.

2. Watkin C etal, 2003 "Characteristics of general practitioners who frequently see drug industry representatives: National Cross sectional study" In British Medical Journal, Vol. 326; 1178-9.

3. Malavige G N, "Doctor’s, Drug Companies and Medical Ethics: A Sri Lankan Perspective", Indian Journal of Medical Ethics, Jan-March 2004.

The late Prof K Jayasena of the Peradeniya University in 1985 emphasised that the import of pharmaceuticals was oriented more to profit making than to the satisfaction of the health needs of the people. To counteract this Prof Jayasena recommended that the manufacture and import of pharmaceuticals should be restricted to the 250 or so essential drugs identified by WHO.

The common conclusion from these three reports is that there is evidence that doctors in Sri Lanka may be unaware of the fact that drug companies influence their prescribing practices. Although many have argued that doctors should distance themselves from drug companies, it is easier said than done. The relationship between doctors and drug sales representatives is stronger in developing countries such as Sri Lanka, and may lead to adverse outcomes especially to consumers. These three reports support the body of evidence on biased behaviour and shows that biased doctors are more likely to:

1. Prescribe a drug if they had recently attended a sponsored event by that company

2. Prescribe a drug that is not clinically indicated.

3. Prescribe new drugs

4. Have a drug placed on a hospital formulary

5. Prescribe expensive brands of their favourite drug companies with scant regard for the expenses borne by poor consumers. For example in Sri Lanka the cholesterol lowering drug Simvastatin is available from Rs 15.00 to Rs 128.00 a tablet. The Rs 15.00 variety is equally effective but a number of patients are prescribed the expensive brands.

These reports state that drug companies grant personal favours to their best clients.

Industry’s Self Regulatory Codes

The drug industry opposes government regulation of drug promotion on the grounds that advertising and promotion are essential for informing healthcare professionals about new medicines and new uses for existing medicines.

Self regulation via the International Federation of Pharmaceutical Manufacturers Association (IFPMA) Code of Pharmaceutical Marketing Practices, supplemented by member association and company codes is the industry’s response to ensure that appropriate standards are met with.

However, according to the 2004 WHO research report referred to earlier, "Drug Promotion: what we know, what we have yet to learn", the industry self regulatory codes are inadequate since monitoring of these codes rely on complaint mechanisms which are largely inadequate because too many violations are missed. This is supported by the fact that despite the billions spent on marketing hundreds of drugs every year, IFPMA has not received a single complaint on violation of its marketing code of conduct up to 2007. (Official Website accessed 1 October 2007 at: http://www.ifpma.org/EthicalPromotion/index.aspx?5_html

Perhaps the best description of the self-regulatory industry code and the disciplinary committee was given by Andrew Chetely.

"If some one proposes that those charged with a crime could form a committee of judges, enlist colleagues and good friends as the lawyers and the jury to hear the case and pass sentence, we would dismiss the idea, as too ridiculous for words. Yet the world’s pharmaceutical industry offers just such a solution to the problem of inappropriate drug promotion".

This description of the industry’s self regulatory code and the fact that not a single complaint of violation of the IFPM marketing code was not received up to October 2007, clearly demonstrate that the industry codes can never ensure that appropriate standards of ethical marketing are maintained. It is therefore essential for governments in developing countries, including Sri Lanka, to enact and implement effective national laws on ethical drug promotion to control and regulate marketing and promotion of pharmaceuticals.

(Excerpts from, "Drugs, Doctors and Dinners: How Drug Companies Influence Health in the Developing World. Published by Consumers International, London, 31st October 2007". Consumers International is the only independent global campaigning voice for consumers. With over 220 member organization in 115 countries, CI is building a powerful international consumer movement to help protect and empower consumers every where).


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