Healthy Skepticism Library item: 20480

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

Protecting The Innocent From Harm: The Medical Lobby for Appropriate Marketing (MLAM)
New Doctor ?198522, 23

Full text:

In March, 1982 an Australian medical student in Bangladesh worried about a malnourished boy clutching a little bottle. The boy’s concerned parents had put their trust in western medicine. The bottle contained “Glactose – D” (glucose and water) sold by Glaxo. It cost as much as two weeks’ meals. The medical student wondered if something could be done. Thus was born the Medical Lobby for Appropriate Marketing (MLAM). The aim of this paper is to establish that inappropriate marketing exists, that it matters, and that something can be done about it.

What constitutes inappropriate marketing?
Misleading drug advertisements abound in the Third World. A classic 1982 example is Organon’s Orabolin: “Ensures normal growth, stimulates appetite, promotes optimal weight, growth in every tablet”, “safe even for children and infants”.
Orabolin is ethylestrol, an anabolic steroid.

Inappropriate marketing is of four main types”
1. Sale of products with poor risk/benefit ratios
2. Sale of products with poor cost/effectiveness ratios
3. Promotion for inappropriate indications
4. Inadequate warnings of adverse effects

1. Poor risk/benefits ratios
Pyrazolone analgesics have similar potency to paracetamol. They have been banned in Australia, UK and USA because they are not associated with fatal agranulocytosis. The incidence has not been established. In Indonesia 1985 they are sold by Hoechst, Sterling Winthrope, E. Merck, Sandoz and United American. 2

Anything over 5ml of ICI Gramoxone (the herbicide paraquat) is likely to be fatal. Even with immediate access to intensive care, mortality rates are 40-70 per cent. Death usually occurs over three days. Gramoxone is mistaken for coffee, beer or Coca-Cola. Fiji provides an example of the contrast between medical and commercial responses to paraquat. The May 1984 Fiji Med. J. reported that “during the first quarter of 1984, no less than 17 people died” and concluded that “the possibility of substituting paraquat with an alternative weedicide…. deserves honest, careful and unbiased consideration”.

In September a full page ad in the Fiji Times said “Special Announcement: Gramoxone User’s Club. Yes in addittion to lowering the price of the 5, 10, and 20 litre packs M.H. has just introduced an exclusive club for all gramoxone users”. 3

2. Poor cost/effectiveness ratios
The most common cause of death in children under three is dehydration from diarrheal disease. Oral rehydration solutions are very cheap and effective. Searle’s 1984/85 advertising for Lomotil in the Philippines states: “The No 1 prescribed antidiarrheal. Lomotil. 20 years of clinical use worldwide have confirmed the efficacy and reliabilty of Lomotil”. 4

Lomotil (diphenoxylate and atropine) obscures the symptoms of diarrheal disease but there is no evidence that it stops dehydration. Diphenoxylate is 26 times more expensive than kaolin. 5

3. Inappropriate indications
The October 1984 IIMS (Indonesia) contains a bookmark with the inscription:
“Binotal The antibiotic effective against all Grampositive and Gram negative bacteria of practical importance. Bayer”.

Binotal is ampicillin. Resistance to penicillins is a major problem in South East Asia. For example, one of Bayer’s suggested indications for ampicillin – gonorrhoea has a reported resistance rate of 30-50 percent. Staph. aureus is 60-85 percent resistant. Penicillians are among the most appropriate drugs. Unfortunately their usefulness is being undermined by overuse. 6

Although phenylbutazone is effective it is associated with a high incidence of fatal aplastic anaemia eg 250 deaths in the UK between 1964 and 1976. In August 1984 Australian doctors received a letter from Ciba-Geigy restricting indications for Butazolidin to ankylosing spondylitis, gout, pseudo-gout and acute exacerbations of rheumatoid disease unresponsive to other treatment. The letter recommended limiting treatment to one week. By contrast 1984 Butazolidin package inserts in Malaysia recommended it for “pain and stiffness in muscles and joints, lumbago, tension headache, virus infections, fever and long term treatment”. 7

3. Inadequate warnings
The Breast Mild Substitute (BMS) controversy is well known but the current situation and scale of the problem are not. During the 1980s approximately three million infants will die each year who would have lived if breast fed. It has been shown that population growth rates do not fall until after infant mortality rates improve.

Plank and Milanesi in Chile (1973) found death rates three times higher in infants fed B.M.S. 8 As wealthier Chilean parents were more likely to use substitutes, their children were more likely to die. Curiously, there have been few studies on adverse effects of B.M.S in the First World. However, Cunningham (1977) found a 2-3 increased incidence of significant illness for infants of highly educated parents in rural New York State if fed B.M.S. 9

Although not very demanding, the WHO Code of Marketing of B.M.S. is violated by almost all companies. Thanks to strenuous lobbying of the International Baby Food Action Network the code is now obeyed by Nestle, the largest manufacturer. Even so, no company’s literature even hints at the high mortality and morbidity associated with B.M.S.

How significant is inappropriate marketing?
Avorn et al (1982) used beliefs about cerebral vasodilators and propoxyphene in a fascinating study of scientific versus commercial sources of influence on prescribing behaviour. They found that Boston physicians believed that their decisions were based on their training and experience and on scientific papers and that drug ads were only a minimally important influence. However, 71 percent believed that impaired cerebral blood flow was a major cause of senile dementia and 49 percent believed that propoxyphene was more effective than aspirin. There is no scientific evidence for either belief, but those ideas were being promoted in advertisements. Avorn’s study has implications for medical education in all countries. 10

The Third World is the fastest growing market for the pharmaceutical industry. By 1980 the people of the Third World were allocating US $15 billion of their limited resources to drugs 20 percent of their money (US $3 billion) was spent on drug promotion. 11

Comparing the resources available to the industry with the resources available to unbiased sources of medical information may lead to pessimism.

However, pessimism about the prospects for health in the Third World, while fashionable, is illfounded as well as unhelpful. Skilful use of appropriate medical technology and participatory social organisation can produce dramatic improvement at very low cost. For example, the Rural Unit for Health and Social Affairs in Tamil Nadu, India, 12 measured a plumment in infant mortality from 116/1000 in 1978 to 47/1000 in 1983.

The WHO has described the proven, successful techniques under the catchcry of “Primary Health Care”. A key component of PHC is appropriate use of a limited number of ‘essential’ drugs by village health workers. Doctors can be mislead by advertisements. Village health workers are even more vulnerable. Consequently any improvement in drug marketing will have major impact on the health of people in the Third World.

Who are the Medical Lobby for Appropriate Marketing?
The medical student mentioned above, returned from Bangladesh with a few ideas. A number of his teachers and friends agreed to stick their necks out to help. The…