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Healthy Skepticism International News

September 2001

We can win against DTCA.

September/October 2001 Vol 19 No 9/10   ISSN 1321-571X

We can win against DTCA.

by Peter R Mansfield
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In this editon I will tell the story of how I became involved in working on the Direct To Consumer Advertising of Prescription Only Medicines (DTCA) issue and provide four key points that have been proven useful for persuading key decision-makers against DTCA.

DTCA is legal (ie not banned yet) in the US and New Zealand and drug companies are pushing for it everywhere.

About five years ago when I started receiving reports about DTCA I just filed them.  I was very impressed with Barbara Mintzes’ Blurring the Boundaries[1] report but, to be honest, I just did not want to know about it because I was too busy with other issues.  For example I was just establishing a newsletter for all the GPs in New Zealand about misleading advertising targeting doctors called Healthy Scepticism NZ.  The newsletter is funded by PHARMAC (the New Zealand medicines purchasing agency).  They arranged for me to tour their country to promote Healthy Scepticism NZ in February 1999. On the second day they took me to meet Annette King who was then the shadow minister for health. Because PHARMAC had previously expressed their deep concern about DTCA to her, she asked for my opinion. It seemed that she wanted to make a decision one way or the other within the next 5 minutes.  I was completely unprepared.  I needed to learn more about it before I could work out my opinion.  However on the spot, based on what I knew about doctors, I mumbled something about how people’s ability to avoid being misled the advertising varied so that DTCA could be expected to exacerbate health-care inequality.  To my surprise Annette King turned to her assistant with a determined look on her face and said “We will do something about this when we get into office”.  I guess that when I used the word “inequality” I had stumbled onto something that was very important in her value system.  I came away from that meeting with the new understanding of politicians’ needs for assistance with decision-making. That lead to the conclusion that perhaps if people like me meet with key decision makers then we can make a bigger difference than I had previously realised. I was also determined to be much better prepared next time I had an opportunity like that.

It was only after the meeting with Annette King that I met with GPs throughout New Zealand who spoke of their distress about the negative impact of DTCA on health-care and that I became convinced that it was a severe problem.  I became even more convinced when I was commissioned to write reports on DTCA by the Australian Pharmacy Guild of Australia[2] and then by PHARMAC.[3] These reports have been used for government enquiries into the DTCA in both Anzac countries.  The New Zealand inquiry produced a range of options ranging from maintain status quo to a total ban.[4][5]  The Australian inquiry recommended that DTCA not be allowed.[6]

At the WHO-NGO Roundtable in Geneva, Charles Medawar made a convincing case for treating DTCA as an international public health emergency because at that time, it appeared that without urgent action there was a high risk of Europe following the US. If that happened then it would lead to enormous pressure on Africa, Asia and South America.  DTCA now met my criteria for deserving very high priority.  It was severe.  It was urgent.  There was a good chance of success.  There had been a change of government in New Zealand and Annette King was now minister of health but had been too busy with other problems to focus on DTCA.  I decided to go back to New Zealand.

Fortunately the Australian National Prescribing Service brought Charles and Barbara Mintzes to Australia for a debate about DTCA at the National Medicines Symposium.  Barbara is the world’s expert on the studies of DTCA.  She is currently doing a PhD on DTCA including a survey of the opinions of key stakeholders.  The trip to Australia gave her the opportunity to interview key stakeholders in New Zealand. It was wonderful to have the opportunity to go with her to Wellington.  Barbara is the best person to answer decision-makers questions on what the studies show about DTCA and to provide them with specific examples of advertisements that illustrate the many issues. My focus was on learning how to help politicians make decisions in accord with their values.  I learned a lot from being coached by a political adviser, Nicola Young.  We developed a list of key messages. We met with politicians right across the political spectrum but found that the same messages were just as effective with almost all of them with little need for change in emphasis. Both right and left wing politicians expressed interest in putting forward a private member’s bill to ban DTCA. About two weeks after our time in Wellington Annette King announced that she would move against DTCA. 

Following that success Barbara invited me to visit Canada.  I was funded by HAI and assisted by the Working Group on Women and Health Protection who were funded by the women’s Issues section of Health Canada. I understand it, the Canadian national government has been unable to decide what to do about DTCA.  On the one hand the provincial governments are against it because they are responsible for a variety of drug subsidy schemes and they understand that it would drive up their costs.  On the other hand there has been strong lobbying from large drug companies, advertising companies and television companies who all hope to profit from DTCA.  Lacking clear policy from the top the bureaucrats in health Canada have been left to drift.  The strongest influence on them appears to be lobbying from the large drug companies aided by “patient groups” who have been created by or funded by the drug companies.  The bureaucrats have reinterpreted the law, contrary to the intentions of Parliament, to effectively allow the DTCA as long as individual advertisements promote the name of the drug without claims or promote claims without the name.  Several large drug companies have used advertisements that go beyond even that, but the bureaucrats have not allocated adequate resources for enforcement. Consequently, the companies feel the need to push further to see what they can get away with before their competition beats them to it.

I visited Vancouver, Victoria, Winnipeg, Toronto, Ottawa and Montreal.  I met with a wide range of stakeholders usually accompanied by at least one member of the Working Group on Women and Health Protection.

A list of activities during the tour follows (with thanks to Anne Rochon Ford):

VANCOUVER:

meetings/events:

1)    Bob Nakagawa and staff , Pharmacare (Burnaby)

2)    meeting with staff at Therapeutics Initiative’s Drug Assessment Working Group – UBC

3)    seminar sponsored by the Therapeutics Initiative, UBC

media:

1)    interview with Alicia Priest, Vancouver Sun

2)    interview with Art Hister, CKNW radio

3)    interview with Peter Warren, CKNW

 

VICTORIA:

meetings/events:

1)    Women’s Health Bureau, Ministry of Health

2)    Pharmacare Office, Ministry of Health

3)    meeting with Rick Hudson, Ministry of Health

media:

1)    interview on CBC radio, “On the Island”

2)    interview with Jodi Paterson, Victoria Times-Colonist

 

WINNIPEG

meetings/events:

1)    colloquium and Grand Rounds – Dept. of Community Health Sciences, University of Manitoba

2)    meeting with Olaf Koester and Rick Deedi (ADM) , Ministry of Health

media:

1)    press conference at Women’s Health Clinic

2)    interview with Winnipeg Free Press

 

OTTAWA

meetings/events:

1)    public policy forum (Peter, Barbara and Joel) at Tunney’s Pasture organized jointly by Women’s Health Bureau and Pharmaceuticals Directorate

2)    panel debate moderated by Dr. Carolyn Bennett, MP; panelists: Barbara Mintzes, Dr. Peter Mansfield, Mark McElwain (DTCA consultant to industry), Elizabeth Rodes (Rx&D)

3)    meeting with staff from offices in TPD related to the legislative renewal process

4)    meeting with Dr. Robert Peterson, Executive Director, Therapeutic Products Branch

5)    meeting with staff at Canadian Medical Association

6)    meeting with Judy Wasylyceia-Leis, MP and health critic for the NDP

media:

1)    interview with Laurie Fagan, CBC morning show (radio)

2)    interview at CPAC (television)

3)    interview with Bob Carty, CBC (for forthcoming program: Fall 2001)

 

MONTREAL

meetings/events:

1)    meetings with Jennifer Auchenlich (Project Genesis) and interested activists

2)    presentation to students in the Pharmaco-epidemiology Program at McGill University

3)    meeting with former McGill medical student, Ashley Wazana

4)    meeting with Pharmaco-epidemiology Research Group

5)    meeting with Dr. Gilles Hudon, Fédération des medecins spécialistes du Québec et Dr. Jacques Gagné, président de la Fondation Merck Frosst

6)    meeting with M. Claude Giroux et Mme Diane Lamarre de l’Ordre des pharmaciens du Québec

7)    meeting with Dr. Paul Saba

8)    meeting with Prof. Robert Goyer, former Dean of Pharmacy, Université de Montréal

media:

1)    interview (Peter, Barbara) with Celina Bell, ELLE (Quebec) magazine

2)    press conference with Project Genesis and the Coalition on Medical Insurance

 

TORONTO/HAMILTON

meetings/events:

1)    Grand Rounds – Family Medicine, St. Michael’s Hospital

2)    meeting with Drugs and Pharmacotherapy Ctte, Ontario Medical Association

3)    meeting with staff at Drug Programs Branch, Ontario Ministry of Health

4)    meeting with staff at Registered Nurses Associaiton of Ontario

5)    meeting with members of Medical Reform Group of Ontario

6)    meeting with Julie Tam, Canadian Drug Manufacturer’s Association

7)    meeting with Terry McCool VP, Eli Lilly

8)    meeting with Exec. Dir. and staff at Canadian Arthritis Society

9)    meeting with Susan Bowyer at ECHO (Employers’ Committee on Health Care in Ontario)

10)  rounds at Centre for Evaluation of Medicines (McMaster University))

11)  seminar for staff at Centre for Health Economics and Policy Analysis, (McMaster University)

12)  public seminar at Metro Reference Library

media:

1)    interview with Tom Walkom, Toronto Star

2)    interview with Ann Silversides for article in CMA Journal

3)    interview with Helen Branswell for Canadian Press

4)    interview with Carol Taylor, TVOntario (“The Health Show”)

 

My impression is that all that is needed to stop DTCA in Canada is for the many different groups ranging across Canadian society, who oppose DTCA, to send a united message to their Prime Minister.  These groups may include large companies such as General Motors who are upset about rising drug costs driven by DTCA in the US.[7]  I asked a journalist, Ann Silversides to write about opposition to DTCA by large companies.  Her report Looser ad rules a headache for drug plans. Direct-to-consumer advertising will send costs soaring, employers warn. was published in the major national newspaper “The Globe and Mail” on September 18, 2001.

The four key messages that appeared most important in Canada were as follows.  The first 3 are applicable anywhere.  The last would apply to many countries.  If it does not apply to your country then replace it with a statement of what you want the decision-makers in your country to do.

1 Risk:  DTCA increases the use of new drugs because DTCA is only profitable for new drugs where the companies are enabled to charge high prices by patent monopoly protection.  If you buy a new computer it will be better because of continuous small quality improvements.  Drugs are different.  With new drugs the long-term adverse effects are not known.  If we have problems then DTCA will make it much larger.

2 Cost: DTCA distorts health priorities and resources towards whatever drugs are new and thus more expensive (because of patent monopolies) at the time.  Many of these drugs have little or no advantage over older cheaper drugs and thus give less value for money. Increased sales of these expensive drugs divert scarce health resources away from more cost effective therapies.  This may mean not having access to timely emergency hospital care when you need it. (Telling the General Motors story as reported by Newsweek was very useful for making this point.)

3. Information: DTCA provides little information because the aim is not to inform but to persuade.  DTCA usually overstates the benefits and understates the harms and costs.  DTCA uses tricks that often work subconsciously to precipitate quick decisions without hearing the other side of the story.

People need access to reliable information about health issues.  Finding reliable information is like finding a needle in a haystack. DTCA just makes the haystack larger.  If people mistake DTCA for reliable information and thus stop searching then DTCA has been a barrier to finding truly reliable information.

Drug companies claim that it is beneficial to allow them to use their skills to motivate untreated people to go to a doctor.  In fact the companies skills are limited to being able to brief an advertising agency.  It is better for taxpayers to pay public health experts to brief advertising agencies for health promotion campaigns. Public health experts are:

  * better at targeting health promotion to areas of need rather than areas of profit.
  * better at appealing to those who need to be reached because they know more about them.
  * more likely to be trusted and thus more effective.
  * cheaper than the over paid staff of drug companies.

4. Enforcement: Canada already has a good law.  All that is needed is enforcement of the law as intended by Parliament.  Just say no to drug ads.

 

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