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Healthy Skepticism Library item: 20473

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.


Publication type: Magazine

Miller C
Drug ads in Third World need scrutiny
Australian Doctor 1985 Mar 628


The Medical Lobby for Appropriate Marketing is an Australian-based group operating worldwide in a quest for better pharmaceutical advertising in developing countries.

Full text:

Examples of inappropriate prescribing in the Third World can be worrying, even appalling: anabolic steroids given to starving or malnourished children; diphenoxylate-atropine combinations given to toddlers with diarrhoea and in danger of dehydration; and antibiotics promoted for infections known to be specifically resistant to the antibiotic.

While some of the poor prescribing habits are due to inadequate medical education or dispensing by non-professionals, drug advertisements can also be misleading, according to the Medical Lobby for Appropriate Marketing (MLAM).

Set up in November 1984 as the world’s first medically based international watchdog over drug and chemical promotions, MLAM has matured steadily with membership growth exceeding 140 percent during 1984. Most of its 200 members are medically qualified, PhDs or pharmacists, with 30 overseas members and about 40 lay members.

Some consumer groups, principally in Europe and North America, have earned the ire of the pharmaceutical industry because of occasional exaggerated charges. But with an eminent editorial board actively involved in day-to-day decisions, MLAM avoids any charges of harbouring a ‘ratbag’ element.

Editors include Professor Felix Bochner of Adelaide University, Dr Ian Gust of Melbourne’s Fairfield Hospital, Professor John Shaw of Sydney University and 10 other similarly qualified experts from Australia and overseas.

The goal is not to alienate pharmaceutical companies but rather work in concert, said one of MLAM’s founding members, Professor Peter McDonald, head of clinical microbiology at Flinders University.

“We’re concentrating mainly on product information given to doctors and pharmacists on ethicals. If the ad isn’t accurate or is ambiguous, then that has to be dealt with”, he said.

MLAM is concerned mainly with the situation in developing countries, but we also keep an eye on promotions here and in other Western countries”.

Regular monitoring
Suspect advertisements are culled by doctors, consumer organisations and pharmacists, and sent to MLAM editors. Some MLAM members keep a routine watch on overseas publications, particularly those from the Third World. Of the ads which have attracted MLAM’s attention, most have been from circulars, low-cost compendiums and mailers rather than medical magazines or referred journals.

All objections to an ad are carefully documented using the medical literature and then submitted to a review process for approval by other editors who may suggest additions or deletions. A form letter is then drafted and sent to members for signing and forwarding to the respective company, in much the same way that Amnesty International operates its letters campaign.

One criticism of this method is the MLAM lags behind, offering critiques of ads which may be months or years old. But Professor McDonald said that letters and pressure from doctors were preferable to other alternatives.

“A system of policing ads prior to publication has been proposed but there are many problems with delays, acceptance by medical publishers, and the cost of setting up a vetting body. The legislative approach has also been discussed but this has bureaucratic problems as well, particularly in developing countries where there are many ways of getting around regulations.

“A retrospective system of reviewing ads may not be the best, but we have to start somewhere. Also, its easy to compare acceptable from one country against ads from another country”, Professor McDonald said.

“Pharmaceutical companies are generally responsive to criticism. If they weren’t, they could look bad when new products come up for approval”.

One result of MLAM’s activites, Professor McDonald said, was that medical and pharmacist groups in Indonesia and Malayasia have been able to negotiate more effectively with drug companies because the groups can use MLAM letters as leverage.

MLAM is preparing assessments on a number of drugs, but the secretary, Dr Peter Mansfield, was reluctant to disclose brand names under consideration. He said that several promotions for analgesics, breast-milk substitutes and antibiotics had to come to MLAM’s attention, but that letters on these products were still some months away. He did disclose that MLAM was investigating the promotion of paraquat (a highly toxic herbicide) in Fiji following complaints by several doctors and a consumer organisation.

“The Achilles heel of the pharmaceutical industry is its image in the eyes of prescribing doctors. Because a reputable image takes time to build up and can be lost quickly, companies need to be seen as responsive”, Dr Mansfield told Australian Doctor.

Poor response
“We’ve generally received adequate responses from companies over their ads, but some responses – particularly from one major multinational – have been poor. This is probably because companies did respond to criticism and the assessment method was simple and inexpensive.

“The companies are extremely powerful, and we have to stick with what is achievable. If the industry were seen as not responsive, then governments both here and abroad would notice that. As a last resort, that could prompt legislation for some regulatory body”.

Expanding its membership is MLAM’s immediate goal. Because membership subscriptions are its only revenue, resources are scarce, but the omission of endowments from other sources ensures complete editorial and financial independence. MLAM advisers include specialists, professors and medical journal editors from Europe, the US and Australasia, and more consultants are being recruited.

Another goal is to fund a full-time professional officer who can coordinate MLAM’s activities and take charge of polishing the letters. The work-load for MLAM has been enormous during the past 6 months and continues to expand.

Anticipating legal nightmares when criticising products, MLAM consulted defamation experts who advised that as long as the medical and scientific facts were adhered to strictly, then defamation was unlikely.

MLAM’s activites have had a mixed reaction from Australian firms. One medical director of a major UK-based firm said that some concerns were pertinent but that “there was a tendency to get carried away with things that happened 20 years ago”.

“Basically, I’d say we don’t view their activities happily”, he said, preferring to remain anonymous. “Not all of the pharmaceutical industry is pristine, let’s face it. But the industry here and elsewhere is highly regulated and must conform to many standards. No ads get of here without my personal approval, and that’s the same for other medical directors I know. Each ad must be scientifically and medically correct”.

The medical director said that any attempts to control drug ads on an international basis would be too complicated and unworkable. He also was critical of the group’s occasional paternalistic, Messianic attitude toward the Third World and of MLAM editors who accept drug-company money to fund university research, only to then criticise the “hands that feed them”.

Professor Garry Kneebone, MLAM editor and head of paediatrics at Flinders University, is one such doctor who has accepted research grants from the industry but he does not see that as presenting a conflict. In MLAM’s December 1984 newsletter he noted some pharmaceutical companies regarded MLAM as enfant terrible: MLAM’s aims are benign, well meaning and well intentioned, but it is clear that they are precise and pertinent to the current situation (of pharmaceutical promotions). It was salutary to realise this when a company suggested that it might need to reconsider a decision to support research for our Department now that it was recognised that I had some association with MLAM”.

During a telephone interview he said: “MLAM is not critical of the industry but is acting as an external body to review the promotion of drugs, generally ethicals. Our ideals should be the same, and it’s curious if they’re not. Promotions that are not regarded as adequate for a developing country”.

Australia’s answers

Australian companies which have received MLAM letters have provided frank answers and largely have been satisfied with MLAM’s response, according to the Australian Pharmaceutical Manufacturers Association.

“The APMA has a monitoring committee and a code, and screening of ads is done on a regular basis. Most of our complaints to companies are over minor infringements”, the APMA said.

“We haven’t had any complaints from doctors of the general public made to the APMA over Australian ads. The mechanism exists within the APMA structure for all ads to be adequately monitored”.

Just as the drug industry is concerned about its image, so is MLAM. As one editor said, “We should not be seen as opponents, but that’s been part of the response. The feedback I’ve had is: “‘Oh no, here’s another group rattling the bones about Third World problems – we wish you’d go away’”.


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Cases of wilful misrepresentation are a rarity in medical advertising. For every advertisement in which nonexistent doctors are called on to testify or deliberately irrelevant references are bunched up in [fine print], you will find a hundred or more whose greatest offenses are unquestioning enthusiasm and the skill to communicate it.

The best defence the physician can muster against this kind of advertising is a healthy skepticism and a willingness, not always apparent in the past, to do his homework. He must cultivate a flair for spotting the logical loophole, the invalid clinical trial, the unreliable or meaningless testimonial, the unneeded improvement and the unlikely claim. Above all, he must develop greater resistance to the lure of the fashionable and the new.
- Pierre R. Garai (advertising executive) 1963