Healthy Skepticism Library item: 20502

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

Sweet M
Healthy Profits: Why your doctor is a pill pusher
The Sydney Morning Herald 1997 Oct 25

Full text:

There was a time, not so many years ago, when drug companies regularly paid for doctors and their spouses to fly around the world. Junkets to Monte Carlo and other exotic locations were not uncommon.

Some companies were even more blatant in their attempts to persuade doctors to prescribe their drugs. They offered cash and even frequent flier points for every prescription the doctor wrote for their product.

Times have changed, of course. The industry and medical profession now frown upon such inducements. Some medical codes of ethics discourage doctors from accepting gifts, while the industry’s code of conduct sets strict guidelines on gifts and hospitality.

But drug companies continue to exert a powerful influence on our health care. It’s just that it often goes unnoticed because it has become so much more subtle. And insidious.

Think of the last time you heard about a new wonder drug. Chances are that the news was generated by the manufacturer’s public relations machine. The media have become one of the industry’s most powerful tools for driving consumer demand and medico’s prescribing, as well as political decision-making.

The chances also are that your doctor’s decisions about whether to prescribe that drug will be based largely on information from the industry, whether direct from a company sales representive or perhaps a company sponsored conference. Or from a medical specialist who has been identified by the industry as an opinion leader” and briefed accordingly.
This is not a simple shock, horror story. The industry is vital to our health and to funding of
medical research. Where would we be without antibiotics, vaccines, new anti-HIV drugs? But there are costs to our perennial search for “magic bullets”.

Consider the growing nightmare of drug-resistant bacteria, and the influence of industry marketing on our extraordinary rates of antibiotic use, one of the world’s highest. Consider the
study, recently cited by Australian Doctor, estimating that more than 80,000 Australians are admitted to hospital each year due to adverse drug reactions, at least
some of which are due to inappropriate prescribing.

Then there’s the billions of taxpayers’ dollars spent each year on drugs. And why do we hear so
comparatively little about non-pharmaceutical ways to health, such as diet and exercise?

We shouldn’t be surprised that better health is not necessarily synonymous with an industry’s perfectly legitimate quest for profits. Many, however, might be surprised at the extent to which the industry’s goals drive our health-care system and health debate.

YOU may have heard Michael Lowy interviewed on the radio a few months
back. He’s a Sydney doctor who did a swag of interviews along the lines that having
sex is good for your mental well-being, especially if you’re depressed.

The news release that enticed many media outlets to interview Lowy also noted that some of the
medications widely used to treat depression can cause sexual problems. What it did not say –
and what was not mentioned in the media coverage – is that the release was issued on behalf of
Roche Products, which has been aggressively promoting its antidepressant, moclobemide (Auro-
rix) on the grounds that it improves sexual functioning in depressed patients.

Its campaign has included advertisements in the general media recommending that people see their doctor if they are taking antidepressants and experiencing sexual problems.
The release attracted widespread coverage, estimated in a confidential PR report to have been
worth more than $36,000 in advertising terms.

So what, you may think. Commercial interests use the media all the time in their
marketing campaigns. But drugs are different; inappropriate use of toothpaste is unlikely to kill
you. And the pharmaceutical industry recognises that distinction, in principle anyway. There
are strict limits on what companies are supposed to tell the public about prescription drugs
under the Australian Pharmaceutical Manufacturers Association (APMA) code of conduct, which describes as “unacceptable” any activity encouraging
patients to seek prescription of a specific product.

It would be unfair to single out Roche (which says that rival companies complained to the
APMA about the advertisements but they had not been found to breach the code, and that the release was unlikely to do so): media outlets receive a constant flow of material from PR companies acting on behalf of drug companies.

The public, even many doctors, do not realise the extent to which the media are used to
promote the industry’s objectives. Broadly speaking, the aims of the media – to sell papers or
win ratings – coincide with those of the industry: “break-through” stories flog both products. Media reports do not just encourage consumers to ask their doctors about new treatments; many studies have shown that they also influence doctors.
As a public relations consultant specialising in health care, Martin Palin is skilled at meeting
the needs of his media contacts for “news”. The classic package includes research being released
at a conference or on a disease awareness day, a medical expert to add credibility, and a patient
to provide the human interest angle.

Describing himself as a “student of the media”, Palin says:
“At the end of the day if you’ve got the package, it gets a run.”
The package does not have to mention a particular product to benefit his client; just raising awareness about an issue can increase the numbers of people being diagnosed and treated.

If a newspaper mentions the general issue, say, the impact of depression, Palin will use this
coverage as leverage to get his expert onto live radio, where product names are more easily
mentioned. “One of my strategies is to give newspapers an exclusive,” Palin says. “Newspapers are incredibly influential in driving electronic coverage.”

The industry has numerous PR strategies; many of the awareness days and weeks for various diseases have been supported by drug companies. A classic example is Migraine Awareness Week, funded by
Glaxo Wellcome but run under the auspices of the Migraine Foundation.

Another popular strategy is to commission research whose results can be used to generate media coverage. Or to bring out a “prominent overseas expert” to do media interviews in between addressing meetings of health professionals. The industry has also supported many patient
groups – who make far more convincing public advocates for a drug than its manufacturer – as
well as the creation of advisory groups. A group of specialists may
be convened, and their conclusions issued to the media. The Viral Hepatitis Prevention Board,
which has issued news releases promoting hepatitis B vaccination, is mainly funded by the
vaccine manufacturer, Smith-Kline Beecham. Individual journalists are also targeted; many
medical writers (myself included) have attended overseas conferences at drug company expense.

Many of the industry’s campaigns coincide with public health goals. Not many would argue with the aims of Influenza Awareness Week, which issues media packages under the logos of the Australian Medical Association and Royal Australian College of General Practitioners. It promotes annual vaccination for high-risk groups, which reduces deaths and hospital admissions.

But media coverage rarely mentions that the week is funded by manufacturers. The campaign’s
main spokesman, Alan Hampson, is always quoted as deputy director of a World Health
Organisation collaborating centre for influenza reference and research. But he is also employed
by the manufacturer CSL.

Michael Lowy was extremely uncomfortable about his PR experience and will not be rushing to repeat it. But many doctors are happy to be involved again and again.

I have worked at one of the big PR agencies, Hill and Knowlton, mostly for pharmaceutical com-
panies, and was surprised at how many of medicine’s eminent names are involved in such
campaigns. But, from what I saw, most were not acting out of improper motives: they were glad
to co-operate if it encouraged patients to seek treatment or meant their area of concern
received greater prominence, or put pressure on governments to change policies they believed
inappropriate. Heck, some even like to get their mugs on TV.

A minority are undoubtedly also involved for personal gain, such as “honoraria” payments or
overseas trips.

Dr Linda Mann laughs, quite delightedly, when saying that she probably does not represent the
“majority” of GPs. She certainly does not seem as conservative as
many of her colleagues. Mann also differs in other ways. The practice where she works at
Leichhardt rarely sees more than two drug company reps a week.

Mann believes they are an important source of education, but has no qualms about giving them a tough time if they try to make misleading claims. “I’ve sent reps out of here so unhappy
that they’ve taken away the lunch they brought for the doctors,” she says.

Many doctors are reluctant to acknowledge that drug marketing, particularly the regular visits
from company reps, affects the way they practise medicine Mann says: “I would like to
think that they don’t influence my prescribing, but I happen to know that they do because I have
audited my own prescribing.”

Many studies have documented the influence of industry marketing on doctors (see break
out). “There’s no doubt that the biggest influence on prescribers is pharmaceutical industry promo
tion,” says Richard Day, professor of clinical pharmacology at the University of NSW and long-term advocate of the need to improve use of medicines.

Peter Mansfield is an Adelaide GP who has become notorious within the pharmaceutical industry as the tiny annoying thorn in its mega side.
Fourteen years ago, he established Medical Lobby for Appropriate Marketing (MaLAM) after being outraged that a multinational company was promoting anabolic steroids for impoverished, starving children in Bangladesh when they needed better nutrition.

Since then, agitation by his group, with a budget this year of just $18,000, has led to medicines being withdrawn and much advertising being rewritten.

Mansfield is careful about what he says for this interview, having recently been threatened with legal action after complaining about a company’s promotions. But he happily recites the selling techniques of drug reps (see breakout), including that they tend to be attractive young women who are more likely to appeal to male and female doctors. He adds: “We are more like to be influenced by people we like”.

“‘Wendy’, a former drug company rep and product manager (an attractive extrovert) disagrees with some of Mansfield’s assessments. “The guy with the beer gut in my company was the top salesman”, she says. But she adds that many doctors were happy to see her. “You’re not sick”, she says. The more you got to know them sometimes they’d see you while they had patients waiting; you’d be making the visit fun, you’d be smiling, you’d be listening to what their issues are”.

The industry also uses more subtle techniques to build relationships with doctors. Karen, a nurse, spent six months a few years back working for Merck Sharp & Dohme, in a big program that offered GPs’ patients free screening for heart disease risk factors. Those with elevated cholesterol or a combination of other risk factors were referred back to their GP. “They promoted it as a genuine, hands-off exercise, but as things developed, I felt it was more of a public relations exercise and a way of getting patients onto their [cholesterol-lowering] medication”, she says. The company emphasises the program is accredited for continuing medical education and that doctors who participate are not required to prescribe MSD drugs.

The days of extravagant gifts and hospitality for doctors are mostly gone, but the industry has turned to more subtle techniques, it targets opinion leaders, funds continuing medical education programs approved by the various medical colleges, establishes educational awards for health professionals or buys medical equipment.

The Australian Medical Association and the Royal Australasian College of Physicians have adopted codes of ethics that discourage doctors from accepting gifts and the Royal Australian College of GPs is developing guidelines. Fiona Woodard, the secretary of the APMA code of conduct subcommittee, says the code has been significantly tightened: gifts should be given only if they are brand-name reminders or part of medical education; any hospitality to doctors must now be secondary to an educational component.

But Dr Tony Jorm, an epidemiologist at the Australian National University, argues that too many doctors are still accepting gifts, which may compromise their ability to put patients’ interests first. When Jorm recently raised these concerns in The Medical Journal of Australia, there was an angry response from a Queensland GP, David Graham: “Like most rural GPs I am constantly overbooked with patients but I make time for pharmaceutical representatives whenever possible to refresh my memory about an older drug or learn about a new one. The bald fact is that each 15 minutes spent this way costs me about $30. If I get a few pens or balloons for my kids it seems little enough in exchange for me”.

Associate Professor John Turnidge, director of microbiology at the Women’s and Children’s hospital in Adelaide, says companies still occasionally invite him to football or tennis matches. “I don;t think that’s acceptable any more”, he says. “I [went] once and then felt extraordinarily guilty”. This year he knocked back an offer of free air tickets to Melbourne during the Grand Prix.

A senior specialist at one of Sydney’s big teaching hospitals recalls that he was one of many doctors to see The Power of One, courtesy of Roche, whose marketing for a new antibiotic emphasised that it needed to be given only once a day. The doctor declined to be named for this article because he wants to maintain good relations with the industry: “I don’t want to be too critical [of their tactics] because I’ve been their guest at dinners and conferences on several occasions”.

The industry also has an enormous influence on medical publications. A senior doctor has described being approached by a PR company to write an editorial for a medical journal: the company would write the article, which he could modify, thus earning $US2500. The offer reflected the growing influence of the pharmaceutical industry on medical care, he wrote in The New England Journal of Medicine. An editorial in the same journal recently dismissed the findings of an accompanying study raising safety concerns about an obesity drug. It was written by two “experts” who were later found to have a long history as paid consultants for related companies.

Closer to home, a former editor of The Medical Journal of Australia admitted, after receiving letters of complaint from doctors, that the journal had been forced by financial constraints to allow advertisements to be placed near editorial on related topics. “We all hope that an economic upturn will allow us to return to the purity of former days”, Dr Laurel Thomas wrote.

One of the biggest recent medical controversies relates to calcium antagonists, which have become widely used to treat high blood pressure. But it is not know whether that are better than older, cheaper drugs at reducing heart disease and strokes, and several recent studies have raised safety concerns.

The jury is still out, but the industry has gone to enormous efforts in damage control to defend the market, estimated to be worth $US8 billion internationally. The Lancet described how a press conference at the Congress of the European Society of Cardiology two years ago was manipulated to ensure the best interpretation possible was put on what were fairly alarming results. “The European Society of Cardiology has been, until now, a creditable force in the cardiology community. Yet its pandering to the pressure exerted by a pharmaceutical company – coincidentally, one of the conference’s major sponsors – is troubling” the journal said.

The drug bulletin Prescrire International said it was bewildering that calcium antagonists were amongst the world’s most widely used drugs, yet their risk-benefit ratios were uncertain and better alternatives were available. “This inconsistency highlights the intricacy of the relationships between industry, prescribers, academics and health authorities, and the fact that ‘the patient’s best interest’ is not always the overriding factor which determines the choice of drug”.

This is particularly alarming considering the unfortunate history of another class of heart drugs, introduced in the 1980’s for treatment of abnormal heart rhythms. Pre-marketing studies showed they affected heart rhythm but had examined their effect on death rates. Many thousands of Americans died before it was realised that they increased rather than reduced deaths. In the book ‘Deadly Medicine’ by Thomas J. Moore, much of the blame for this tragedy is slated back to the close links between doctors, drug companies and regulators.

The Lancet recently criticised Bristol-Myers Squibb for putting pressure on researchers to finish early a trial of paclitaxel (Taxol) as a first-line treatment for ovarian cancer. The company argued that there was sufficient evidence of the drug’s benefits to stop the trial, although an independent monitoring committee concluded otherwise.

Medical journals have also been spitting chips over a seven year campaign by Boots Pharmaceuticals to discredit and block publication of a study showing that three competitor drugs had the same bioequivalence as its drug, Synthroid, a more expensive drug and one of Boot’s top-selling products. The study, which concluded that the four preparations are “interchangeable without loss of therapeutic efficacy in the majority of patients for treatment of hypothyroidism”, was finally published this year, with an accompanying editorial in the Journal of the American Medical Association describing the company’s campaign. Knoll Pharmaceutical, which acquired some of Boot’s prescription pharmaceuticals in 1995, wrote that it had decided to allow publication “because we gained a better understanding of the importance of supporting academic freedom and the peer review process”.

It would be naive and unfair to portray the industry as an evil giant that profits from our misery. It is extremely important in developing drugs and funding research in times when other funding sources are shrinking. Marketing is integral to a profit driven industry that spends hundreds of millions of dollars to develop a new drug. And doctors do rely on it for information. One study showed that about 85 percent of all prescriptions by physicians who graduated in medical school in 1960 were for drugs about which they had received no formal education.

But there are legitimate grounds for concern, especially as the industry is steadily expanding its domain, becoming involved in divisions of practice and, overseas, in running managed care and similar programs. This at a time when many universities and other groups that might be expected to provide some balance to the industry’s promotions are under great pressure, relying increasingly on funding from outside, such as drug companies.

When Libby Roughead worked in a Melbourne pharmacy, she was annoyed that customers would take more notice of drug advertisements than what she said. As part of postgraduate studies at La Trobe University, she analysed audio tapes of 16 encounters between drug reps and GPs.
Roughead, now a PhD student in the department of pharmacy and medical science at the University of South Australia, says the reps tended to give little information about side effects or drug interactions. They made many inaccurate statements, including recommending their products for unapproved uses. The doctor’s responses did not suggest they were critically evaluating the information.

The APMA emphasises that training for medical reps has improved greatly since that study was done in 1992-1994 and that they are now required to learn about the code. But Dr Ken Harvey, senior lecturer in public health at La Trobe University, believes much marketing is still inappropriate. “They put their hand on their heart and say they want to do the right thing”, he says, “but if you really look at what is happening in PR campaigns, advertisements and consulting rooms, they are not providing balanced, fair, objective information about their products”.

Peter Mansfield’s group has documented many instances of inappropriate or misleading marketing. “The problem will continue as long as the drug companies continue to reward reps according to sales volumes”, he says.

Some senior medicos believe that drug marketing is contributing to the many thousands of hospital admissions and illnesses due to inappropriate use of drugs, although many other factors are also involved.

Ken Harvey says: “We’re a country that overconsumes drugs by international standards and we’re reaping the consequences of that in terms of increased adverse events”. He adds: “We teach medical students never to be the first to use a new drug, never be the last to use an old drugs. That’s precisely because side effects are less known with new drugs”. He cites the case of benoxaprofen (Opren) which was introduced to the UK in the mid ’80s and aggressively promoted for arthritic conditions but withdrawn two years later after 100 UK deaths were blamed on it, and nearly 4000 patients suffered severe side effects.

Industry marketing has a profound impact on how much we pay for our health care and in distorting the health system’s priorities. Many argue that its success in persuading doctors to switch from cheaper, older drugs to new, more expensive brands has been a big contributor to the ballooning costs of the Federal Government’s pharmaceutical benefits scheme (PBS).

“Older, cheaper drugs may receive little promotion but, if used appropriately, can deliver equivalent health outcomes for a much lower price than newer drugs”, a recent editorial in The Medical Journal of Australia noted. The Federal Health Department says it often comes under political pressure to list expensive new drugs on the PBS after companies generate public demand for the products through the media. It also believes that industry promotion often encourages doctors to prescribe drugs for uses for which they are not meant to be reimbursed.

A serious concern is the contribution of enthusiastic marketing to antibiotic overuse. Much industry promotion has encouraged antibiotic use for respiratory infections. John Turnidge notes that three-quarters of all antibiotics prescribed outside of hospitals are for these infections, 90 percent of which are viral.

“We preach rational prescribing of antibiotics”, adds Dr Jock Harkness, director of microbiology at St Vincent’s Hospital in Sydney. “The companies pay lip-service to that; their priority is to sell their drug”. Richard Day emphasises that the health system simply does not have the resources or staff to counter the industry’s promotions. That many of the big teaching hospitals do not even have clinical pharmacologists has worrying implications for patient care and medical training, he says.

There are also broader, opportunity costs to the industry’s influence, which leads to much medical research being designed to answer companies’ marketing concerns rather than the broader public interest. David Henry, professor of clinical pharmacology at the University of Newcastle, says much time and money is spent comparing competitor drugs, leaving more important questions unanswered – such as what is the best way of treating a particular disease.

Chris Silagy, professor of evidence-based care and general practice at Flinders University, notes that some of the big companies have formed a consortium to provide financial support to divisions of general practice. “Ultimately it will be used for projects that support their products”, he says. “The problem is that it leaves other questions not directly linked to pharmaceutical use, but which are incredibly important, out in the cold”. Peter Mansfield says the industry’s influence also means that medical research tends to be distorted towards finding long term treatments for common chronic diseases of wealthy people rather than cures for some of the world’s most important health problems.

The bigger picture is that we have become a society that wants a tablet to cure our every ill. It is telling, perhaps, that many in the health industry describe doctors as “prescribers”, not “care givers”.

Just think how we have all heard so much more about depression in recent years. Much of this has been generated by the marketing campaigns for antidepressants.

It’s probably fair to assume that many lives have been improved as a result of people being more willing to seek treatment. But many believe the pendulum has swung too far. Professor Beverly Raphael, the director of the NSW Centre for Mental Health in the NSW Health Department, says the issue is not clear-cut, but that on balance there may be too much focus on drug treatments and too little emphasis on psychological treatment.

Leonie Manns, executive officer of the Mental Health Coordinating Council, a coalition of consumers, carers and service providers, supports the role of drug therapies but believes they are being overemphasised, largely because of the industry’s influence on doctors. “People are starting to rely on drug treatments totally”, she says. “They are not being encouraged to make lifestyle changes”.