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Healthy Skepticism International News

Newsletter Jul/Aug 1997

August 1997

Vol 15 Issue 7/8 News: MaLAM is overcoming some problems. Reports: An overview of promotion Part 1 First of 3 parts expanding on a report titled Healthy Profits written by Melissa Sweet for the Sydney Morning Herald.

MaLAM is overcoming some problems

We apologise for not producing this edition until November/December. We have been working our way steadily through a long list of problems.

We will now be able to produce several catch-up editions. We will then continue at the rate of one international edition every 2 months until our ongoing negotiations about funding have been completed.

Healthy Profits: An overview of promotion in Australia Part 1

This edition presents part one of an article written by Melissa Sweet, one of Australia’s most respected medical journalists, and published in the Sydney Morning Herald on 25 October, 1997. It is mostly about the situation in Australia. However, we believe it is important reading for people around the world because similar things are happening in most countries. If it is not yet happening in your country be warned. It may happen soon.

We are very impressed by Melissa Sweet’s article for many reasons. These include:

inside knowledge (she draws on her experiences in public relations (PR) as well as in medical journalism),
extensive research,
and honesty.
Melissa Sweet’s article as published appears below in our usual Times New Roman font. We have added some comments, which appear in (brackets in Ariel font).


Why your doctor is a pill pusher.

By Melissa Sweet

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 has become one of the industry’s most powerful tools for driving consumer demand and medicos’ prescribing, as well as political decision-making.

The chances also are that your doctor’s decision about whether to prescribe that drug will be based largely on information from the industry, whether direct from a company sales representative 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.

(Whilst launching the Australian National Medicines Week in July 1996, Health Minister Michael Wooldridge mentioned that inappropriate use of medicines may be costing Australia as much as $700 million per year.)

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

(In Australia the pharmaceutical industry is heavily subsidized by the Pharmaceutical Benefits Scheme (PBS). In recent years taxpayer expenditure has been soaring at up to 17% per year! The latest available figures from the PBS show that spending has increased from AUD $ 1.52 billion in the financial year 1992-93 to AUD $ 2.54 billion in 1996-7. Given that total expenditure on health has been kept relatively stable it is no surprise that there is now intense downward pressure on hospital’s and health professional’s incomes.

Expenditure on promotion by drug companies has been estimated between 10% and 17% of sales. This suggests that the drug companies allocated at least AUD $ 254 million of the taxpayer’s money to promotion during 1996-97. This does not include consideration of co-payments, prescription only drugs not subsidised by the PBS, drugs supplied by public hospitals or over the counter drugs.)

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 (many) 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 anti-depressant, moclobemide (Aurorix) 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 that $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 our 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 received a constant flow of material from PR companies acting on behalf of drug companies.

(We had complained to the APMA in June 1997 about the promotion of Aurorix (moclobemide), by Roche. In the 24 May issue of Good Weekend, the Sydney Morning Herald Magazine, there had been a full page advertisement which advised patients taking an antidepressant and experiencing sexual problems to speak to their doctor. It suggested that sexual problems might be due to the adverse effects of the antidepressant taken. The names of the advertiser and of the product were not mentioned. However, the art work used in the advertisement (including font style and colour) referred, without any ambiguity, to the current advertising campaign in medical journals for Aurorix.

We also complained about claims used in promotion to doctors asserting that Aurorix can “fulfill your desires” and that “Aurorix has been shown to improve sexual desire by 42% and anorgasmia by 28%. In contrast, with SRIs sexual function can get worse” (eg Medical Observer 30 May 1997). The reason for our concern was that none of the articles cited in the advertisement related to a comparative trial of Aurorix and SSRIs. The principle that comparative claims can only be justified by comparative trials is important. In the case of moclobemide, for all we know, comparative trials might show that it causes less adverse effects than SSRIs but such trials might also find moclobemide less effective. No one knows. The general point is that until we create an environment that encourages companies to fund proper comparative trials, no one will know which drug is the best choice for a wide range of indications.

We asked the APMA Code of Conduct Subcommittee whether it considered that the claim for Aurorix is adequately substantiated and whether Roche is allowed to run an indirect promotional campaign towards the general public.

The answer from the APMA was that the promotion “implied an inadequately substantiated comparison” and this finding was upheld, despite an appeal from Roche. We are concerned that Roche staff may still genuinely not understand that you can not justify a comparative claim without a comparative trial. We are also concerned that Roche have not been required to provide any correction. Consequently, some doctors may continue prescribing moclobemide for many years on the basis of misleading promotion.

The response to our complaint about the promotion direct to the public was even less satisfactory. Despite already receiving 3 other complaints (presumably from competitors who were losing sales) the APMA committee decided that “no linkage could be made between the advertisement and a specific prescription only product”.

It is clear that the APMA Code currently allows effective, direct to the public promotion of prescription only pharmaceuticals.)

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 “prominent overseas experts” 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, SmithKline 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 companies, 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.

(Regardless of the motives there are real problems here. There are many doctors who want to do what they can to increase the availability of resources for their favorite area. The motivation may be personal gain or empire building. An understandable concern for the welfare of the patients whom they know personally is probably a more common motivation.

However the context is one of competition for limited resources. Increased expenditure for one area is likely to be at the expense of other areas.

Given a range of competing doctors to chose from, pharmaceutical companies, understandably, will chose to support and magnify the voices of those doctors who are directly or indirectly calling for more spending on profitable pharmaceuticals. Unfortunately this will usually be at the expense of other areas. Consequently even when doctors appear to be doing the right thing for the right reason they may be contributing to harmful distortions in funding for competing areas.

Perhaps the underlying problem is expressed in the old political truism. “United we stand, divided we fall.” As long as medical politics is dominated by disunity and competition, resources will continue to flow to the much better organized pharmaceutical companies and thus away from many areas which are equal or more important for good medical care. Also, as long as medical politics are dominated by disunity and competition health professionals will not win more resources for the total health sector.

More of Melissa Sweet’s article will be published in the next MaLAM edition.)



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