Health Matters issue 43 Winter 2000/01
www.healthmatters.org.uk/stories/mansfield.htmlIn 1981, an Australian medical student, Peter Mansfield, went to Bangladesh where he was horrified to find scientific medicine under attack from inappropriate pharmaceutical marketing by international drugs companies.
The challenge was to find a way to respond constructively – and that led to the Medical Lobby for Appropriate Marketing (MaLAM). Since it started 18 years ago, MaLAM has grown to over 6,000 subscribers in more than 30 countries.
Publication of international MaLAM editions, usually focusing on drug promotion in developing countries, started in November 1983, and has provided otherwise isolated doctors and pharmacists with an opportunity to contribute to worthwhile changes.
The first major success was a letter in 1986 requesting evidence to support the of a mixture of arsenic, strychnine, vitamins and alcohol as a treatment for stress promotion in Pakistan. The manufacturer announced an immediate withdrawal of that medicine. By 1991, pharmaceutical companies had undertaken to withdraw 11 drugs after receiving MaLAM letters.
In recent years, MaLAM has paid increased attention to research and education about misleading pharmaceutical promotion. It produces a newsletter that is sent to all GPs in New Zealand and is also producing teaching materials for critical appraisal of pharmaceutical promotion for the World Health Organisation.
MaLAM's major research interest is how to increase 'healthy scepticism' in doctors as a way of improving their prescribing habits. But MaLAM still campaigns on such issues as direct-to-consumer advertising of prescription-only drugs.
MaLAM emphasises that it is incorrect to blame drug companies for what is really a system problem: drug companies are obliged to maximise their profits, otherwise they get taken over – so they do whatever works to increase sales of more expensive drugs, regardless of their impact on health care.
Many countries are spending an increasing proportion of their health budget on drugs, without clear evidence of value for money. Spending decisions are strongly influenced by drug promotion so it is important to understand its effects on doctors and patients.
Doctors use promotional material produced by the drug companies as a source of health information. But drug promotion is a sophisticated applied science, and is not restricted to visits by drug company representatives, advertising and the provision of glossy handouts: Continuing medical education, control of research and illness promotion are all used to supplement more orthodox marketing techniques. Pharmaceutical companies may spend 30 to 40 per cent of their profits from sales on promotion, and they would not do that if promotion was ineffective.1
Calculations for Australia, based on the number of prescribing doctors, suggest that the industry is spending, on average, approximately half to three-quarters as much again per year on each prescribing doctor as the government spends annually on full-time medical students. Government spending on formal medical education over a doctor's medical career is dwarfed by pharmaceutical industry spending on 're-education', which favours drug over non-drug treatment.2 And the average figure masks the fact that a small number of opinion leaders have vastly more spent on them.
Taken singly, many promotional activities have only a small impact but they have a cumulative influence when repeated and/or are combined with other activities. In fact, the small impact may make the message more effective than if it attracted the attention required for conscious critical appraisal.
Those who think they are not influenced by advertising may be especially vulnerable. For example, one study found that doctors who denied that going to all-expenses-paid seminars at popular vacation sites would influence them were shown to have significantly increased their prescribing of the promoted drugs, starting immediately after they received their invitations.3
Information provided by drug companies is often unreliable. In one study, even when drug company representatives knew they were being tape-recorded, the majority contradicted approved product information at least once during visits to GPs.4 If doctors relied on drug advertisements in leading medical journals it would lead to improper treatment in over 40 per cent of cases. Many adverts show an unfair balance between benefits and adverse affects, minimise side-effects, and most make unsupported claims.5 Enforcing control over advertising is very difficult because by the time objections are processed, the sales material has already been replaced.
Drug companies also give gifts to doctors. The biggest gifts are given to doctors by analysis of their prescribing habits, publications and on personal and professional profiles garnered during visits by drug company representatives to medical practices and dispensing pharmacies. Because about 20 per cent of doctors account for 80 per cent of drug sales, it makes sense for drug companies to look after high-volume prescribers, while wooing those just out of the highest category, and ignoring doctors who prescribe the least.
Effective promotion is not restricted to offers of all-expenses-paid overseas travel. Even small gifts create obligation, and are not harmless indulgences, but a cost-effective advertising investment. Corporations get better return from the sense of obligation that is induced by gifts than they would from overt agreements to exchange services for money. Drug companies such as MSD have forbidden their own staff from accepting gifts, presumably because they know that gifts are effective.6
Career advancement in academic medicine is largely based on research performance. Research money is more readily available from drug companies than from government or non-government research funding bodies, so that drug companies are the primary source of research income in medicine.
Doctors with substantial research interests are often opinion leaders, and it is therefore in drug company shareholders' interests to influence academic doctors. Analysis of publications by researchers into blood pressure medication showed that those authors supporting the use of calcium channel antagonists were significantly more likely to have a financial relationship with manufacturers of these drugs.7
The lead role taken by drug companies in medical research also creates other problems. One is a bias towards research into drug rather than non-drug treatments. A second is the way in which pharmaceutical companies are increasingly able to control the flow of information. For example, in 1996 the Wall Street Journal revealed that Dr Betty Dong had been forced to withdraw a paper from publication because of a contract that she had signed with Boots Pharmaceuticals when they funded her research. Her research showed that the inexpensive generic form of a drug was equally effective as Boots' much more expensive patent version – which earned Boots $600m a year. Dr Dong's university initially supported her in attempting to defy the ban, but was silenced by Boots' lawyers.
Even without such contractual restrictions, the medical research system has a role in colluding with the dominance of patented over generic drugs, through the reluctance of medical journals to publish negative conclusions about differences between drugs.
A third problem concerning drug companies' role in research is the opportunity for hidden promotion in funding. Many so-called research studies are primarily designed to familiarise doctors with drugs and encourage their use, rather than to contribute to scientific knowledge. Doctors are flattered (and financially rewarded) by invitations to provide cases for, and to participate in, international, multicentred trials, without being required to make any scientific contribution to the process.
One of us (JJ) was recently approached with a request to participate in a multicentre trial of a drug for obsessive compulsive disorder. He was offered the status of 'chief investigator' if he could provide patients, even though he has no particular expertise either in the area being researched, or in drug trials.
The pharmaceutical industry has another yet more subtle way of maximising profit, which can potentially adversely influence doctors' abilities to make the best decisions for patients. Pharmaceutical companies can increase their sales by promoting illness. They sponsor or produce 'health promotion' material for doctors and their waiting rooms and alert the medical and lay community to the existence of 'new' or 'underdiagnosed' conditions like social phobia, or 'undertreated' ones like post-menopausal hormone 'deficiency'.
Doctors collude with this process by being too ready to redefine dissatisfaction with unsatisfactory predicaments as depression, or by promoting a view of health as the absence of symptoms, rather than optimal functioning. Drug companies also invest in consumer support groups, an apparently altruistic act, without any direct promotion of their product (or indeed of drug therapy).
But the real reason why companies need make no explicit link between the new diagnosis and its treatment is that their orthodox promotional programmes have already trained doctors to prescribe for these diagnoses.
One final important aspect of the ethics of drug promotion – public money funds it, since pharmaceutical drugs are predominantly paid for by the taxpayer. Drug companies therefore face different standards of accountability to producers of consumer goods for which the user pays. For most consumer products we accept that advertisers highlight the good points and hide the bad points because the consumer is deemed to be in a reasonable position to exercise his or her own judgement. But in the prescription drug market, the government exercises very little control on behalf of the taxpayer over which drugs are being bought for its money.
It is we doctors who place orders (on behalf of our patients) when we write the scripts, but we do not feel the cost. Because of this we are at risk of choosing shiny, new, expensive drugs where there is no good evidence that they are better than the old, dull, cheap ones.
1. Devlin J, Hemsley P. Management views on industry issues, pressures and consultants. Scrip Magazine. 1997;June 16:183.
2. Lexchin, J. Interactions between physicians and the pharmaceutical industry: what does the literature say? Canadian Medical Association Journal 1993, 149:1401-1407.
3. Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns: There's no such thing as a free lunch. Chest. 1992; 102: 270-73
4. Roughead EE. The pharmaceutical representative and medical practitioner encounter: implications for quality use of medicines. Masters Thesis, School of Health Systems Sciences, La Trobe University, Aug 1995.
5. Wilkes MS, Doblin BH, Shapiro MF. Pharmaceutical advertisements in leading medical journals: Experts' assessments. Annals of Internal Medicine 1992;116:912-919.
6. Pederson CA, Milburn D, Wright BAW. Selling: principles and methods (8th Ed). Homewood, Illinois: Irwin, 1984.
7. Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium-channel antagonists. New England Journal of Medicine 1998; 338:101-106.
HOME
www.healthyskepticism.org
This Web site has been
kept simple so as to load quickly and be easy to read with any browser.
Please contact Peter R Mansfield with
questions or comments about this web site.
We also welcome criticism because we believe that a complaint is a gift.
Credits
| Last modified: 18 April, 2003