When a new brand of insulin hit the market in India recently, doctors were quick to switch patients to it. Not long afterwards the new drug’s manufacturer took 15 physicians from Nagpur on a vacation with their families. Coincidence? Maybe so but ‘patients were fine on the old drug,’ says Vijay Thawani, Associate Professor in Pharmacology at the Government Medical College in Nagpur. Such promotional excesses abound in developing nations which have been slow to adopt regulations and even slower to enforce them. The US, Canada, Europe, Australia and New Zealand/Aotearoa have over time adopted and revised codes on drug promotion. But bribery happens in the West, too. It’s just more covert. ‘It’s becoming more subtle in all sorts of ways,’ agrees Peter Mansfield, a general practitioner and director of the international watchdog group Healthy Skepticism. ‘It creates a situation,’ adds Mansfield, ‘where physicians convince themselves it’s good for patients.’ Big Pharma has innumerable fingers in the prescribing pie. Doctors are flown to luxury resorts for lessons in public speaking, then paid well as ‘opinion leaders’ to tout the company’s product. Millions of doctors every year attend ‘continuing medical education’ events: necessary to perform their job well, but often company-sponsored junkets that let advertising cosy up to and mingle with science. In such pharma-physician relationships, it’s difficult to distinguish between the genuine and the deceptive, between the pursuit of knowledge and the pursuit of profit. Meanwhile, old-school kickbacks continue in violation of the codes and policies on drug promotion. Drug giant GlaxoSmithKline has been accused of using exotic holidays, stereos, World Cup soccer tickets and cash to bribe thousands of Italian and German doctors into prescribing its products.1 In the US last June, AstraZeneca paid a $355 million settlement for a kickback scheme where doctors billed insurance providers for drugs they received free from the company. TAP Pharmaceutical Products – a joint venture of Abbott Labs and Takeda – pulled the same trick and settled for $875 million in 2001.2
A glut of gifts
‘We have been fighting this problem for a long time,’ says a Turkish pharmacology professor. ‘Drug companies are giving refrigerators, TVs, money and women – prostitutes – as gifts to doctors in exchange for prescriptions. This is the tip of the iceberg.’3 Doctors in India and Nepal also cite refrigerators, TVs and cash as commonly offered bribes. Computers, wines and spirits are given in Kenya.3 Indian opthalmologist Prashant Agnihotri says he hears about these gifts from his fellow physicians. ‘[Drug companies] will say if you give us a million rupees’ [$21,920] business, we will send you and your family on a trip abroad.’ The problem is compounded in most developing countries by the marriage of prescription and dispensing. Sometimes doctors sell medicine to patients. Often, rather than pay doctors’ fees, patients ask pharmacists to recommend a drug. Prescription drugs are sold over the counter freely and pharmacists find themselves the recipients of refrigerators and TVs. ‘It’s well known that a dispensing doctor usually prescribes more medicines that are more expensive and for a shorter period of time, so patients have to keep coming back,’ says Dr Hans Hogerzeil of the World Health Organization’s Department of Essential Drugs and Medicines Policy. That’s not the only way a doctor can make extra cash. Some drug companies pay Turkish physicians up to $1,000 for each patient they enrol in ‘phase IV’ studies (which evaluate drugs after they have been put on the market), according to the pharmacology professor. The Canadian company Biovail recently paid American MDs $1,000 for signing up 11 patients each.4 ‘There’s no question that phase IV trials are sometimes used as a form of marketing. To get doctors to participate in a trial of a drug is often a camouflage to persuade the doctors, with some money, to prescribe the drug,’ says Arnold Relman, a former editor of the New England Journal of Medicine and professor emeritus at Harvard University. ‘The scientific value of such data is highly suspect... [and] once the patient is hooked on the drug they have to go to the drugstore and buy it.’
School for scandal
Continuing medical education (CME) provokes some of the most strident debates on pharma-physician interactions. Many doctors say drug company money is essential to keep them up-to-date on the latest research and treatments in their fields. ‘The only people providing meaningful education for doctors in developing countries are the drug companies,’ says Dennis Ross-Degnan, an associate professor at Harvard who studies pharmaceutical policy. ‘The problem is it is biased education.’ Dr Sri Suryawati, the Indonesian country co-ordinator for the International Network for Rational Use of Drugs, says drug companies are eager to sponsor medical meetings, and aren’t shy in asking for reciprocation. Consequently, hospitals holding events will often agree to use the sponsoring company’s drug for several months. This increases drug costs and sometimes causes doctors to use the wrong drugs, Suryawati stresses.
'It's common for doctors virtually to demand to be taken out by pharmaceutical reps for expensive meals'
Drug company influence is pervasive in Western CME, too. They pay for 57 per cent of American CME costs, either through direct sponsorship or exhibitor fees. The speakers are often ‘opinion leaders’ paid by Big Pharma, sometimes thousands of dollars per meeting. ‘I think people have to look carefully and should be told if the speakers are doing that for drug companies on a regular basis, if that’s a major part of how they make their living,’ says Paul McKinney, chief of general internal medicine at the University of Louisville, Kentucky. Many countries’ guidelines say the meals accompanying CME should be ‘modest’ and doctors should not bring their spouses. But the rules are regularly flouted. ‘It’s quite common for doctors virtually to demand to be taken out by pharmaceutical reps for expensive meals… It’s very, very difficult to say no,’ a doctor working for the industry says.
These bribes are changing doctors’ prescribing habits. A review paper by Ashley Wazana, then a resident at Montreal’s McGill University, found that doctors who attended pharma-sponsored CME, received free drug samples or accepted pharma funds for travel expenses were more likely to prescribe the sponsor’s drug. In a study of doctors’ and residents’ attitudes toward drug sales reps – the people who bring pizza and pens along with free samples and leaflets – McKinney found most doctors will admit their colleagues are influenced by drug promotions. Yet, somehow these same physicians deny that they, themselves, are influenced. It’s not just fat paycheques that induce physicians’ loyalties. Even those ubiquitous logo pens can change doctors’ prescribing habits. ‘Small gifts may be surprisingly influential,’ social scientists Jason Dana and George Loewenstein write in the Journal of the American Medical Association. ‘Furthermore, individuals are generally unaware of the bias, so they do not make efforts to correct for it or to avoid conflicts of interest in the first place.’ One might wonder if doctors are right to return pharma’s favour, if the most-promoted drugs also happen to be the most effective. Unfortunately, this is rarely true. Many of the most heavily promoted medicines are brand-new and barely different from what’s already on the market – except, of course, for their price. New ‘Prozac Weekly’ costs $19 per week on drugstore.com, compared to $5 for generic Prozac. Not surprising when the cost of marketing, up to $700 million for top-selling drugs, gets passed on to the consumer. There’s another danger with new drugs, says Joel Lexchin, an emergency physician who teaches health policy at York University in Toronto. ‘New drugs when they hit the market have only been tested on 5,000 to 6,000 people which means side effects that happen less frequently haven’t really been seen. Physicians and patients need to know that new drugs aren’t necessarily better and may be less safe.’ And in the Majority World especially, promotions can encourage the overuse of antibiotics, increasing bacterial resistance. So what will free medicine from the vice of industry? ‘Only a few governments have imposed regulations and that’s the only thing that works,’ Hogerzeil says. Lexchin argues: ‘[Drug promotion] should be run by an independent organization which is backed by government. There have to be meaningful sanctions for violation of any code.’ Harvard’s Dennis Ross-Degnan would focus on education. ‘The regulatory infrastructure in many countries is there and it’s accessible. I think the focus needs to be on improvement, shifting enforcement from punitive to informative.’ Medical students and residents may also be part of the solution. While some already feel entitled to handouts, others are fighting to rid their universities and hospitals of drug-company influence. In some cases, they’re supported by innovative education that teaches them to tune out promos. Getting them while they’re young may be the only way to reshape attitudes. Mansfield says many practising doctors are set in their ways. ‘Doctors tend to be socialized into thinking that it’s harmless and it’s normal. The meals and so forth are part of their remuneration package, so they don’t see it as an ethical conflict.’ And that’s just how Big Pharma likes it.
- Annette Tuffs, ‘German doctors face investigation in drugs scandal’, BMJ Vol 324, 23 March 2002; Sophie Arie, ‘British drugs giant in Italian bribery investigation’, The Guardian, 13 February 2003.
- Joshua Partlow and Marc Kaufman, ‘US, drug company settles scam charges: AstraZeneca admits free-sample scheme’, The Washington Post, 21 June 2003.
- Personal interviews.
- Gregory Zuckerman, ‘Biovail’s tactics on marketing heart medicine focus of probe’, Wall Street Journal, 24 August 2003.