issue 165 - November 1986
How to get well and stay well with only a little help from the right medicine. Dexter Tiranti diagnoses the distortions of the marketplace.
There is no more precious commodity than health. Without it, life can be hardly worth living. That is why those who trade in health are dealing with something qualitatively different from the normal commodities of the marketplace. Doctors and medicines occupy a unique position.
Since health is so priceless, there is rarely an upper limit to what someone will pay to restore strength and vigour. Who quibbles about money when listening to the fevered moans of their child? Hope and anxiety make you vulnerable to persuasion about a medicine's good effects.
All this translates into a rare luxury which few industries enjoy. Pharmaceutical corporations experience few price constraints. In the ideal world of the classical economist Adam Smith, competitive market forces would keep prices low, minimize the proliferation of similar products and keep production vaguely in line with needs. In the medicine business, this does not apply.
Market forces may not operate, but profit and loss still does. The ethics of the Hippocratic tradition rest uneasily with those of business. Yet the contradictions surface only occasionally. Take the annual general meeting of Warner Lambert's Parke Davis division which considered the following resolution: 'That the company should include the same details for the toxicity of chloromycetin in package inserts and adverts for other countries as are required by law for promotion in the US.' 97 per cent of shareholders voted against it.1
The structure of this industry is halfway to a monopoly - the top 30 companies in the world control more than 60 per cent of production. These companies jostle for an increased market share not by price cutting - far too uncouth - but diversification into new drugs and ever more ingenious methods of promotion. Promotion swallows up 20 per cent or more of sales turnover. Veteran US health campaigners Silverman, Lee and Lydecker put it this way: 'If a man should make a better mousetrap, Ralph Waldo Emerson said long ago, the world will beat a path to his door. But if the mousetrap is no better than the old, what then? Facing this dilemma the drug industry has found a remarkably satisfactory answer, double the advertising budget.'2
This near monopoly with few price constraints results in annual profits way above the industrial average. Whilst industrial earnings are generally 10-15 per cent of sales turnover, the latest drug industry figures on pages 16 and 17 of this magazine show returns of between 15 and 30 percent a year. This is nothing new. For the period 1963 to 1976 apart from two years, profit rates in the pharmaceutical industry were 45 per cent higher than the median profit rates of the 500 largest US corporations.3
But isn't the NI overstating the case again? Surely modern drugs are a blessing, one of the main reasons for the good health we enjoy in the industrialized world? This is what industry and many doctors would like us to believe. The reality is different.
The single most important cause of ill-health is poverty. Malnutrition, for instance, stems from poverty. Nutritional deficiency and immaturity were the direct cause of 6 per cent of deaths of children under five in the Third World, according to a recent Unesco study, and contributed to 57 per cent of all child deaths.4 So simple childhood diseases become fatal due to poverty. Zapping germs with modern medicines does nothing to change that nutritional weakness - a weakness which makes the mortality rate from measles 247 times higher in Ecuador than in the US.
'Disease and death in Europe in the not too distant past was strikingly similar to that in today's underdeveloped world,' points out Zimbabwean physician, David Sanders.5 In Victorian England and Wales illness and death were rife. Then came improvements in social conditions. As the graphs on this page show, the dramatic decline in death rates took place from the mid 19th century; long before any effective pharmaceuticals were available.
The wonder drug was a better standard of living. Water-related infections were reduced by efficient sewage disposal, clean tap water and safe milk. Airborne infections like tuberculosis were reduced by better housing. And underpinning all this was a better supply of good food. This is not to deny that smallpox vaccinations or more recently, antibiotics haven't been useful. But medicines do not lie at the basis of Western health. Decent living conditions certainly do.
Yet the myth endures for good reason. The belief in a medical cure is held by the weak, the poor and the infirm from Chicago to Calcutta. For they can do little to change their living conditions. Medicine, at a pinch, they might afford. The medic too is anxious to give hope. George Bernard Shaw describes the doctor's dilemma:
'When you are so poor that you cannot refuse 18 pence from a man who is too sick to pay you more, it is useless to tell him that what he and his sick child needs is not medicine but more leisure, better food and a better drained and ventilated house. It is kinder to give him a bottle of something almost as cheap as water and tell him to come again with another 18 pence if it does not cure him.'6
Decline in infectious diseases in the industrialized world
The fundamental causes of ill-health are beyond the control of doctors and their drugs. Yet recognizing this would mean questioning the validity of expensive medical care. It is not in the interests of the medical profession to be examining or confronting the social roots of illness. Anyway, they are not trained to be social workers or revolutionaries. They are trained to be scientists.
And it is medical education with its scientific bent that pharmaceutical corporations have shaped. It was discovered in the late 19th century that by-products of petroleum refinement could be used to manufacture synthetic chemicals and drugs. Production of pharmaceuticals grew with the development of the petrochemical industry. 'If doctors could be persuaded to reorient medicine towards the norm of pharmacotherapy (cure by drugs),' points out Professor of Law and Medicine Ian Kennedy, 'then clearly here were riches indeed.'7 Institutions like the Rockefeller Foundation which stemmed from Standard Oil (Exxon), donated massive sums of money to guide medical education around the turn of the century. Pharmacology became integral to the curriculum, medicine an indispensable tool of the doctor.
Nor is this a thing of the past - pharmaceutical corporations are still involved in buttressing that close relationship between medical education and pharmaceutical treatment. Awards are granted for research, books funded for publication, prominent medical educators appointed to the boards of drug corporations. The American company Eli Lilly alone has spent over $250 million on medical schools over the past 50 years. Such a close relationship of industry with academia can result in the serious side-effects of medication being downplayed, non-drug models of healing being dismissed as quackery.
The distortion of medical teaching is particularly acute in the Third World. Bangladeshi doctors who qualified in 1980 after five years' training in Dhaka would not have had one lecture on the appropriate non-pharmaceutical treatment for diarrhoea, though this accounted for half of all children's illness and death in the country. It is because of such inadequate training that doctors globally are prescribing over $400 million worth of anti-diarrhoeal drugs a year, the vast majority of which are useless or harmful. Doctors are reluctant to use oral rehydration salts (ORS), a cheap and simple mixture of water, sugar and salt. Every year five million children die from diarrhoea, yet 3.5 million of those deaths would have been preventable by these salts. The reason, of course, is that there is little money to be made out of ORS, but a great deal to be made out of anti-diarrhoeal drugs.
Influence over physicians' thinking extends beyond the lecture room and their college notes. Heavy promotion techniques ensure it follows them into practice. From Sao Paulo, Brazil: 'There are benches on both sides of the hospital's main entrance, where more than a dozen men sit chatting and watching. They are not patients. They look healthy, and they carry large briefcases. They belong to the army of company salesmen, and the Santa Casa Hospital is their main target every morning of every day. A doctor is coming in and stops to talk to one of them. He is given a free sample of a drug and some leaflets. Soon after, he is encircled by four other salesmen. Each in his turn, with care and respect, hands the doctor drug samples. Then one of them produces a plastic bag and gives the bag to the doctor with great courtesy. More free samples and leaflets are handed over, the doctor fills up the plastic bag and leaves.'8
Simple health care solutions can be best. Changes in diet where there is an allergic reaction, herbal remedies, massage to relieve tension, hot lemon or lime drinks to relieve sore throats - all these are as relevant as ever for small problems. Yet they have become excluded in the Third World by the assumed superiority of Western medicine - and the pressing needs of the doctor with a lot of samples to sell.
There is a cruel paradox here. Whilst there is a great variety of medicines in the Third World, there are seldom enough of the useful ones. Such variety is dangerous. Variety means confused doctors. Variety means expense.
Variety in India, for example, means that there are more than 30,000 branded preparations on the market; 68 per cent of them classified as 'obsolete or therapeutically useless' by a Government drugs committee. And three quarters of them are actually harmful. By comparison, Western nations which are major drug exporters like the UK, the US and West Germany have between 6,000 and 18,000. Other nations without a drug industry to placate have limited their medicine list still further - Holland has 3,400 and Norway about 1,800. No one believes the health of the Norwegians or the Dutch suffers from this. It could be that it benefits.
If only the number of drugs were cut down, certainly in the nations of the South, there could be a concentration on producing enough of the cheaper generic drugs. Then more of those needing essential medications could get them. But to do this the market has to be regulated. There is real promise:
The World Health Organization's Essential Drugs Programme Nearly all the serious health problems of a country could be tackled by about 250 essential generic drugs, according to the WHO. The notion embodies the therapeutic ideal that medicine is prescribed only when needed, that it should be of proven therapeutic value and be acceptably safe. Doctors would have a small but comprehensive list to prescribe from and would become more familiar with each medicine, learning how to use it and what side-effects to look for.
There has been a lot of lip service to this idea, but slow progress. The notion has been coolly received by the medical profession who often see it more as a restriction on their prescribing freedom rather than as a counter to irrational prescribing (see Key Terms). And of course industry has raised its hands in horror at the idea of cheap generic drugs. The American pharmaceutical manufacturers actually took the healthcare systems Medicare and Medicaid to the High Court and successfully blocked the introduction of compulsory generic prescribing.
The Bangladesh example In 1982 an expert committee found that nearly a third of all spending on medications in Bangladesh was on unnecessary or harmful drugs. Numbers were reduced from 4,000 to 2,700. And a basic 250 generic preparations were recommended for the public hospitals and clinics. Since then, despite sniping by an international pharmaceutical industry worried that the example will be copied elsewhere, there have been solid achievements. The indigenous manufacture of essential medicines has increased from 30 to 65 per cent of all those made. Prices have gone down and the quality of the drugs has improved.
Government action in the UK Britain is moving sideways into some form of drug policy. In 1985 the UK Conservative administration took some 1,800 drugs off the National Health prescriptions list. These were expensive brand name products, where there was a generic equivalent easy to hand. In the first year there has been an estimated saving of £75 million ($112 million) on the National Health Service drug bill. Interestingly enough the furore caused by this appears to have made doctors self-conscious about over prescribing: the last year saw 18 per cent fewer prescriptions
Private action in the US Similar trends are found in the private health care system of the US. Nearly all hospitals are moving over to having a selected drug list of several hundred mainly generic drugs, from which their doctors prescribe. By the end of 1987 this should be implemented in 97 per cent of the medical institutions.
Action by consumers A final reason for optimism is the growth in proficiency and professionalism of a rag tag and bobtail army of activists and organizations, which spans continents and marches under the banner of Health Action International. They share a commitment to reduce the variety of drugs available, to curb the dangerous, the unnecessary and the expensive, to counter the influence of the pharmaceutical corporations and to campaign for better health care for the world's poor.
Make no mistake. There is real chance of progress. For the pharmaceutical companies have an Achilles heel. They are anxious to preserve an image of being the protectors of health. Adverse publicity about the dumping of dangerous medicines in distant and unregulated markets, about inflated profits and excessive promotional tricks does not help this image or their sales. Bad publicity is the powerful lever we can use to ease them into the negotiating chair. Then they can work with government health authorities and consumer groups on rational drugs policies for all. They could begin with the magic formula: 250 essential drugs.
1 'Communication by Or John Yudkin, quoted in The Struggle for Health Medicine and the Politics of Underdevelopment by 0. Sanders. Macmillan 1986.
2 'Prescription for Death - The Drugging of the Third World, Univ. of California Press. 1982.
3 'The Pharmaceutical lndustry - A Further Study in Corporate Power, by McCraine and Murray, International Journal of Health Services. 1978
4 Why the Other Half Dies: The Science and Politics of Child Mortality.
5 'The Struggle for Health - Medicine and the Politics of Underdevelopment, MacMillan 1985.
6 'The Doctor's Dilemma'
7 The Unmasking of Medicine, Paladin, 1983.
8 'Hungry for Profits by R J Ledogar, IDOC/New York 1975.'
9 Scrip pharmaceutical newsletter, No. 1119 1986.
Key terms in the pharmaceutical debate
PATENTS & TRADEMARKS allow a pharmaceutical company the right to market a newly registered drug on a monopoly basis for between ten and twenty years, depending on national patent laws. Some 5000 possible compounds are discarded for every marketable drug discovered. The length of time under patent protection allows the company to command a premium price to recoup those research and development costs. After the patent expires the drug can still maintain its high price, despite possible competition, because the trademark or brand name had become so will established in the minds of both doctor and patient that a cheaper version will not be trusted
GENERIC & BRAND NAME DRUGS do you buy the supermarket's own brand of detergent or the well known, highly advertised variety? The same issue applies to drugs. Aspirin is usually the generic name; Aspro the brand, Diazepam the generic, Valium the brand. Brand drugs are almost inevitable more expensive, costing up to 20 times the generic equivalent. Often the prices bear no relation to costs of production or the prices charged by smaller competitors. Part of the extra cost is because of the huge promotion expenses behind the brand, and the companies also claim that higher profits help to pay for r&d into new drugs (although monopoly prices should cover this).
'ME TOO' DRUGS have evolved in response to patent laws. The great majority of current r&d is looking at simple chemical manipulation of already-patented drugs to produce a 'me too' variety. This makes for cheaper testing and maintains the company's market share. To complicate matters, 'me too' research is also done by an innovating company to generate a new patent when the old patent is running out. Heavily promoted as new 'me too' drugs are of no real medical worth, keep drug prices high and confuse the doctor faced with a choice of dozens of drugs all doing the same thing. Such drugs make up the great majority of newly registered products every year.
COMBINATION DRUGS are two or more medicines within one pill. The medical logic behind this s shaky; the commercial logic far more comprehensible as they are inevitably more expensive. Combination antibiotics are particularly worrying. Individual components that are safe and effective, can be dangerous in combination. For the medicines act on each other as well as on the body, more than doubling the risk of side effects and possibly cancelling out their therapeutic effects. The Food and Drugs Administration has removed all combination antibiotics sold in Indonesia, for example. As a general rule, single ingredient medicines are much to be preferred.
THE REVOLVING DOOR SYNDROME Can account for much of the 'hands off' attitude towards the pharmaceutical industry by experts. Many consultants or employees of government drug regulatory bodies, medical education specialists and doctors will at some time move through the revolving door to be on the payroll of industry. An underpaid Ministry of Health employee in the morning can be a drug sales representative in the afternoon, a WHO head of department one year can move onto the board of directors of a pharmaceutical corporation, the next.
IRRATIONAL PRESCRIBING occurs when the wrong drug is ordered, or the right drug in the wrong amounts or at the wrong time with little or no concern for cost. Examples would be: