Healthy Skepticism Library item: 20491

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: news

McIntosh P
Drug companies feel a watchdog's bite
The Age 1988 Jun 48

Abstract:

Philip McIntosh meets an Adelaide doctor who is trying to stop world drug abuse caused by bad marketing and misleading advertising.

Full text:

THE GIANT German pharmaceutical company Bayer produced a tonic in Pakistan containing arsenic and strychnine. Sandoz of Switzerland still promotes a drug as an appetite stimulant for children in South-East Asia.
Other companies promote antibiotics for infections that are specifically resistant to the drugs, while products are widely promoted as safe and effective when there is direct evidence to the contrary.

Examples of inappropriate marketing of medicines in developing countries are legion. In places where doctors are not as well-trained as those in developed countries and where most “prescription” medicines are sold over-the-counter without medical advice inappropriate use of drugs can have disastrous consequences.

You might think that problems like this do not apply to countries like Australia with advanced health systems. We like to think we can rely on the training and sound judgment of our doctors to prescribe the right drug for the right illness. However, the unpalatable reality for most doctors is that after graduation their main source of continuing education about drugs is not the scientific reports in medical journals, but advertisements and drug company sales representatives.

Although we might escape the worst excesses of Third World drug promotion, there is reason for concern. In a survey of advertisements in medical journals in 1985 and 1986, the Australian Society of Clinical and Experimental Pharmacologists concluded that one-third were misleading or contained unjustifiable claims.

Even more disturbing is that many of the doctors are not aware of – or are reluctant to admit – the powerful influence of drug company promotion. This was starkly demonstrated by a study published in ‘The American Journal of Medicine’ in July 1982.

A health researcher at Harvard Medical School, Dr Jerry Avorn, found that 63 per cent of a sample of US doctors believed that advertising was of “minimal importance” in influencing their prescribing. But 49 per cent believed that a heavily advertised drug was a more potent painkiller than commonly used dosages of aspirin. The researchers argued that the most likely source of this misunderstanding was advertising.

This flaw in the prescribing of doctors is not new to those who are familiar with communications theory and marketing research data. As Dr Avorn said, “Drug advertisements are simply more visually arresting and conceptually accessible than are papers in the medical literature, and physicians appear to respond to this difference”.

Some medical educators have exploited this knowledge by adopting the industry’s own marketing tactics to improve prescribing practices. One such group in Victoria reduced the cost of antibiotic drugs prescribed by hospital doctors by 21 per cent in 1986.

Compounding the problem is the sheer volume of advertising by the pharmaceutical industry, worth at least $120 million a year in Australia. Dr Harvey, a Melbourne microbiologist, says the problem of advertising is not the technical breaches. “It’s the sheer volume, the airplay that all the new and more expensive drugs get, the lack of facts, the lack of comparison, just constant barrage.”

In an editorial in ‘The Medical Journal of Australia’ in 1985, Dr Harvey and Leanna Darvall, a senior lecturer in legal studies at La Trobe University, said it was a delusion to think that a highly educated medical profession was impervious to this advertising.

“A pharmaceutical advertisement needs to be examined critically and its message should be compared with those in the scientific literature, or those promulgated by peer consensus groups, such as hospital or state drug committees,” they said.

This strategy has been adopted by Adelaide-based lobby group with modest but increasing success in Australia and overseas. The group, called MaLAM (Medical Lobby for Appropriate Marketing), was founded by a young general practitioner, Dr Peter Mansfield.

The seed of MaLAM was sown in 1982 when Dr Mansfield spent a student elective year in Bangladesh. He saw malnourished infants being fed from bottles containing “Glactose-D” (glucose and water) sold by Glaxo; it cost as much as two weeks’ meals. Thousands of drugs were available in markets without a were available in markets without a prescription, including the antibiotic chloramphenicol that was known to cause a fatal blood disease.

Dr Mansfield was a member of Amnesty International and when he returned to Adelaide he used the human rights organisation as the model for MaLAM. Each month MaLAM subscribers – doctors, nurses, pharmacists and others – receive copies of a letter addressed to drug company executives.

The letters compare advertising claims with the scientific literature and the executives are asked to justify their position or to make improvements.

The letters are checked by an international editorial board of prominent medical specialists before distribution to subscribers, who number almost 500 in 30 countries. If subscribers agree with the letter they sign it and post it to the company. “So every month there’s a company that is getting lots of letters from all over the world taking issue with their advertising,” Dr Mansfield says.

MaLAM’s watchdog role is concentrated on the developing world where promotional abuses are more common and more dangerous. But even in Australia, Dr Mansfield says, doctors and the public are not well protected against misleading advertising. Although drug advertising is covered by the Trade Practices Act, he says the weakness is that the system is complaint-driven.

“Somebody’s got to complain, which means that somebody’s got to know they’ve been misled. The essence of being misled is that you don’t know you’ve been misled.”

A report on MaLAM’s activities appeared recently in the British journal ‘The Lancet’. It said that three companies withdrew products, two companies changed their products, and advertising claims for seven products were withrawn following letters from MaLAM.

Bayer said it would stop producing the tonic containing arsenic and strychnine. The Boots company had claimed in Kenya, in 1985, that there were no known conditions where the use of ibuprofen syrup for children with fever was undesirable. The company agreed this was not correct.

Pfizer will not repeat its 1987 claim that piroxicam, an anti-inflammatory drug, is “well tolerated by the ages (with a) low incidence of side effects”. Smith Kline and French has withdrawn its 1986 Pakistan advertising claim of “fast action, safety, efficacy, economy” for its anti-diarrhoeal drug. Sandoz still promotes pizotifen as an appetite stimulant for children in South-East Asia, but it now mentions that there are specific causes of failure to thrive.

None of the companies issued statements to redress their misleading claims. The report said: “Once doctors have been misled, they will stay misled until given correct information”.

Another sign that MaLAM is having an impact on large trans-national drug companies is that two of Pfizer’s most senior executives recently flew from New York to meet MaLAM personnel. Pfizer had tangled with the group over its sale of tetracycline syrups for children in developing countries.

Tetracycline is an effective antibiotic, but Dr Mansfield says it stains teeth an ugly grey for life and should never be given to children. Pfizer was still keen to sell the product, claiming that it was meant for elderly people.

Later, Pfizer came under attack by a Ralph Nader group in America over promotional claims about piroxicam (trade name Feldene), its best-selling drug. Dr Mansfield believes the criticism led to a drop in prescription for the drug, causing the company to reconsider its attitudes to critics.

The meeting took place in the office of Felix Bochner, professor of pharmacology at Adelaide University, and lasted for three hours. In diplomatic parlance there was a full and frank exchange of views. “I don’t know if they really wanted to listen to us so much as find out all about us and work out what size we were and what sort of threat we were”, Dr Mansfield says.

It is easy to be cynical and hostile towards an industry with a marketing record indicated by the excess mentioned here, but Peter Mansfield takes a firm but charitable view.

He says many of the promotional “mistakes” of the industry are not the result of wilfully wrong decisions, but arise from structural defects such as the sheer size of these trans-national corporations. Some have grown into such giant bureaucracies they do not know what their subsidiaries in far-flung parts of the world are doing.

He sees MaLAM as a watchdog over the pharmaceutical industry. “If they stray outside of claims that are scientifically justified, then we are going to bark. We are not against the pharmaceutical industry; we are against misleading advertising and drugs that shouldn’t be on the market at all.

“By temperament, I’m not inclined to say ‘These guys are evil and we want to attack them’, and I don’t think it’s going to work. What will work is if MaLAM is identified with the middle ground of the medical profession”. To foster this image of image of moderation, Peter Mansfield even shaved off his beard. “I didn’t want to look like a radical”, he said.

The pharmaceutical industry could not have a friendlier watchdog. Considering his background in Community Aid Abroad and Amnesty International, and his values as a Christian, Dr Mansfield looks like the quintessential do-gooder. “I’m actually trying to make pharmaceutical companies be nicer people, and help them to be more moral and convert them to doing the right thing. Guilty as charged. And it’s working.”