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Healthy Skepticism International News

September 2003

Drug promotion in India

by Shabnam Minwalla

A National Seminar on Drug Promotion was held in Mumbai, India on 6 September 2003. The aim of the meeting was to discuss the findings of a qualitative study of “Promotional Practices of Pharmaceutical Firms in India” by the Forum for Medical Ethics in collaboration with the Drug Controlled General of India and funded by WHO India.

The meeting was covered in The Times of India by Shabnam Minwalla in a series of 3 reports which are reproduced with her permission below:

We do not believe that Shabnam is responsible for the first headline because her articles are very accurate but that headline is not.  The study found that pharmaceutical companies do influence prescribing but they do not have the power to dictate to doctors. By contrast, it appears that doctors sometimes dictate what gifts drug companies give.

Pharma firms dictate what doctors prescribe: Study
Shabnam Minwalla
The Times of India
11 September 2003

MUMBAI: How does a doctor decide which drugs to prescribe to his patients? If an ongoing study is any indication, the capsules and creams may be chosen less for their curative powers than their lucrative side-effects.

For, in the profit-oriented world of pharmaceuticals, doctors are routinely wooed with gifts ranging from mobile phones to sponsored weddings. These details emerged from a study on the ‘Promotional Practices of Pharmaceutical Firms in India’, conducted by the Forum for Medical Ethics in collaboration with the Drug Controller General of India and the World Health Organisation (WHO).

Over six months, a team of researchers conducted more than 100 in-depth interviews with pharmaceutical companies, doctors, chemists and medical representatives in Mumbai and came up with disturbing findings.

“Drugs are often promoted through dubious, even unethical practices,’’ said Dr Nobhojit Roy of the Forum for Medical Ethics, which released the preliminary findings at a seminar last week. “This extends from sponsored conferences in five-stars to high-value gifts like motorcycles and cars. There are even cases where pharma companies have helped doctors set up small nursing homes.’’

Such stories have long been whispered in the medical world, but have rarely been investigated. This, despite the fact that inappropriate prescriptions could lead to dangerous side effects, medical complications and needless expenses for patients. “We’ve all heard about doctors being sent for free trips to Singapore and that kind of thing, but there’s little documentation on the subject,’’ said Sunil Nandraj of WHO India.

“We see this as an exploratory study that has given clues to various trends.’’ It emerged, for example, that many Mumbai chemists demand payments from pharma companies to stock new products, while most doctors expect at least a pen or a diary from visiting med-reps. “Consultants are rewarded more handsomely than GPs, while big prescribers are also favoured,’’ said Dr Roy, while pointing out that this was likely to influence doctors and their prescription patterns.

“Medical associations have actually told pharma companies, ‘If you don’t sponsor our conference we will boycott your drugs.’ ‘’ Interestingly, nobody- not the government or medical and pharmaceutical representatives- bothered to counter these damning accusations.

“We know such practices are in vogue, but cannot do much because our legislation is silent on drug promotion,’’ said deputy drug controller Dr M. Venkateswarlu, pointing out that competition is acute in a market exploding with almost 60,000 branded formulations.

Added Dr R.K. Sanghvi of the Indian Drug Manufacturers’ Association, “Breakthrough drugs that enter the market early are promoted through scientific information. But ‘me too’ drugs and irrational formulations have to be pushed vigorously, resulting in excessive sampling, lavish conferences and obscene gifts. I recently heard of a pharmaceutical company sponsoring the wedding of a doctor’s daughter. And it is a matter of time before they give the dowry as well.’’

Concurred Dr Ketan Parikh of the Association of Medical Consultants, who observed that pharma companies were footing even birthday party bills, “Medical education is so corrupt and expensive today that you can hardly expect doctors to be saints.’’

Admittedly, the Medical Council of India has laid down a code of conduct. But given that the doctors and pharma companies have established a cozy relationship and patients rarely realise that they are pawns in a larger game, it will clearly take more than self-regulation to tackle the problem.

Is your doctor a bunny, wolf, sheep or dodo?
Shabnam Minwalla
The Times of India
12 September 2003

MUMBAI: Classifying people as bunnies, wolves, sheep and dodos may sound like a flaky party game. But it’s also serious business. “Medical representatives are sometimes trained to slot doctors into four groups,” says Dr Peter Mansfield, founder of Healthy Skepticism.

“So bunnies are doctors who care most about their patients, wolves care most about money, sheep want to keep up with other doctors, while dodos are those who are burnt out. Once the doctor’s motivation is clear, it’s much easier to sell a new drug.”

This is just one strategy used by global pharmaceutical companies to promote their products-be they capsules for TB or pills for shyness. For, the world’s most profitable industry routinely resorts to skewed information, seminars in Seychelles and psychological tricks to push formulations to doctors. “As a result, patients often get drugs that are less effective, have more side-effects or are more expensive,” says Dr Mansfield, an Australian general practioner, who for 20 years has been trying to create global awareness about the reality behind the lab-coated facade. “That is why our motto is, ‘Improving health by reducing harm from misleading drug promotion.”

Dr Mansfield first came into conflict with pharmceutical companies as a medical student in Bangladesh in 1981. He was appalled to find a rash of irrational, even harmful, drugs in the market-including an anabolic steroid being advertised as an appetite stimulant for children.

“I didn’t have to be a senior doctor to know this was bad,” recalls Dr Mansfield, who organised a group of subscribers to bomb the offending pharma company with indignant letters. “We took on a crazy tonic marketed in Thailand by Pfizer, which had ingredients like ox-bile extract, and a Bayer’s tonic in Pakistan, which was essentially a light beer with arsenic and strychnine. We actually got a dozen products withdrawn in the ‘80s.”

Today, however, Dr Mansfield admits that he is dealing with a more sophisticated industry, which goes to great lengths to convince doctors about the benefits of new and expensive drugs. “Instead of going through research papers, most doctors are happy to believe that a new drug that is popular and recommended by experts is the best option,” says the activist, who was in the city to attend a seminar on drug promotion in India.

The problem with this reasoning, however, is that experts often toe the party line, and new drugs often mean unexpected side-effects. “Studies in the US and France have found that only three per cent of new drugs are big advances in medicine,” says Dr Mansfield, explaining why gifts and parties with scantily-clad dancing girls are necessary marketing tools.

“Social science evidence indicates that even small gifts work. So, while ethical codes in the US, for example, specify a $100 ceiling, I believe in a ‘no- gift’ policy. Most doctors across the planet accept gifts innocently, but it’s time they woke up from ‘The Truman Show’ and understood the reality.”

After years of indifference, this message has found a receptive audience. Healthy Skepticism is launching an on-line project called AdWatch, which dissects pharma ads. While Dr Mansfield is suddenly flooded with invitations to speak at medical seminars. “There’s a new wave of interest,” he says, adding that the situation has become too appalling to ignore. “Now we are trying to stay on the surfboard.”

‘Many doctors rely on skewed data’
Shabnam Minwalla
The Times of India
18 September 2003

MUMBAI: In the 24 years since Dr Arshad Gulam Mohammad graduated from medical college, much more has changed than merely the price of Crocin. About 50 per cent of the drugs he prescribes were not taught in his college pharmacology class.

“It’s a constantly changing scenario,’’ said the surgeon, pointing out that new pills, potions and surgical equipment flood the market every year.

This is a predicament faced by doctors around the world. For example, a study in the UK found that senior doctors haven’t formally studied 85 per cent of the drugs they prescribe to patients. In India, with its 60,000 branded formulations, the challenge is even greater.

How do doctors keep up with new medicines? And how do they decide whether a recent entrant is worth the hefty price tag or find out about undesirable side effects?

An study on drug promotion in India, being conducted by the Forumfor Medical Ethics, indicates that most doctors not only accept sizable gifts from pharmaceutical companies, but also swallow skewed scientific information. “It’s only possible to understand the benefits and dangers of news drugs by reading recent textbooks, research and prestigious journals,’’ said Dr Mohammad. “These sources are untainted by the profit motive.’’ But in reality, few Mumbai doctors bother to search the Internet or read medical journals.

“Most rely on medical representatives, intuition and sponsored conferences at which participants are more interested in drinking than learning,’’ said Dr V.Murlidhar of SionHospital,who was involved with the Forum study. Added Dr K. Weerasuriya of WHO, “Understanding indications, contra-indications and side-effects of drugs is crucial. Inadequate or biased information leads to poor and even dangerous usage.’’

Most doctors unquestioningly accept savvy sales pitches, people in the profession admit. “About 95 per cent of the information supplied to doctors comes directly or indirectly from the industry,’’ said Dr R.K.Sanghvi of the Indian Drugs Manufacturers’ Association, admitting that handpicked speakers at conferences and sponsored articles in journals can make even pedestrian products sound like miracle cures.

Even more central is the role of medical representatives who, rather than serving as dispensers of scientific information, have been reduced to spies and salesmen. They routinely strike deals with chemists to find out what local doctors prescribe, and then make their calls armed with this information and gifts.

“I keep hearing about training programmes for MRs, but haven’t attended a single in my 23-yearlong career,’’ said Amitava Guha, a Kolkata-based medical representative.He said that drug information is often communicated to doctors with the help of tools like cartoons and brightly coloured pop-up books.

How are these gimmicks and biased facts being countered? The Australian government, for example, has appointed a team to visit doctors and furnish them with independent information-a project that convinced many doctors to switch from aspirin to paracetemol in arthritic cases, and resulted in a sharp fall in gastric ulcers. Other countries are emphasising the importance of continuing medical education.

“In India we see the MBBS and MD as exit level exams,’’ said Dr Murlidhar. “But it’s time we realised they are just entry level exams. Only doctors who learn through their lives will be able to see through the sales pitches and biases.’’

“It’s a constantly changing scenario,’’ said the surgeon, pointing out that new pills, potions and surgical equipment flood the market every year.

This is a predicament faced by doctors around the world. For example, a study in the UK found that senior doctors haven’t formally studied 85 per cent of the drugs they prescribe to patients. In India, with its 60,000 branded formulations, the challenge is even greater.

How do doctors keep up with new medicines? And how do they decide whether a recent entrant is worth the hefty price tag or find out about undesirable side effects?

An study on drug promotion in India, being conducted by the Forum for Medical Ethics, indicates that most doctors not only accept sizable gifts from pharmaceutical companies, but also swallow skewed scientific information. “It’s only possible to understand the benefits and dangers of news drugs by reading recent textbooks, research and prestigious journals,’’ said Dr Mohammad. “These sources are untainted by the profit motive.’’ But in reality, few Mumbai doctors bother to search the Internet or read medical journals.

“Most rely on medical representatives, intuition and sponsored conferences at which participants are more interested in drinking than learning,’’ said Dr V.Murlidhar of Sion Hospital, who was involved with the Forum study. Added Dr K. Weerasuriya of WHO, “Understanding indications, contra-indications and side-effects of drugs is crucial. Inadequate or biased information leads to poor and even dangerous usage.’’

Most doctors unquestioningly accept savvy sales pitches, people in the profession admit. “About 95 per cent of the information supplied to doctors comes directly or indirectly from the industry,’’ said Dr R.K.Sanghvi of the Indian Drugs Manufacturers’ Association, admitting that handpicked speakers at conferences and sponsored articles in journals can make even pedestrian products sound like miracle cures.

Even more central is the role of medical representatives who, rather than serving as dispensers of scientific information, have been reduced to spies and salesmen. They routinely strike deals with chemists to find out what local doctors prescribe, and then make their calls armed with this information and gifts.

“I keep hearing about training programmes for MRs, but haven’t attended a single in my 23-yearlong career,’’ said Amitava Guha, a Kolkata-based medical representative. He said that drug information is often communicated to doctors with the help of tools like cartoons and brightly coloured pop-up books.

How are these gimmicks and biased facts being countered? The Australian government, for example, has appointed a team to visit doctors and furnish them with independent information-a project that convinced many doctors to switch from aspirin [like drugs] to paracetamol in arthritic cases, and resulted in a sharp fall in gastric ulcers. Other countries are emphasising the importance of continuing medical education.

“In India we see the MBBS and MD as exit level exams,’’ said Dr Murlidhar. “But it’s time we realised they are just entry level exams. Only doctors who learn through their lives will be able to see through the sales pitches and biases.’’

 

 

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