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Jan-Mar2004-12(1)
EDITORIAL
Who rules the great Indian
drug bazaar?
Nobhojit
Roy
If the one who decides does not pay, and the one who pays does not decide, will truth alone have a chance? If the one who decides does not pay, and the one who pays does not decide, and if the one who decides is ‘paid’, will truth stand any chance?
This was quoted by Dr K Weerasuriya, the WHO-SEARO
representative on Essential Drugs and Medicines, while speaking at a seminar
organised by the Forum for Medical Ethics Society (FMES) to discuss a study the
society has undertaken on drug promotion practices of pharmaceutical firms in
India. I intend to explain the purpose of the study, our impressions as we began
looking at the subject, and what we believe will be its value.
Unresolved conflicts of
interest
Dr Weerasuriya was pointing to the link between
drug promotion by companies and medical practice by health professionals.
Physicians and the pharmaceutical industry have a shared interest in advancing
medical knowledge. Nevertheless, the ethical duty of a physician is to promote a
patient’s best interests, while the primary ethic of the drug industry is to
promote its profitability.
There is often a conflict between the interests of
the patient and those of the doctor. It is unrealistic to expect that all
conflicts of interest can be eliminated. However, certain obvious measures must
be implemented if physicians want to retain the public’s trust that they still
enjoy. As an organisation, FMES works to enable medical professionals to act
according to the principles of medical ethics. These principles are: to act in
the best interest of the patient (beneficence); to protect the patient from harm
(non-maleficence); to respect the patient and foster informed choice (autonomy),
and to promote equity in health care (justice). In the context of drug
promotion, FMES must prevent the industry from placing product promotion ahead
of patient welfare, and prevent doctor from being influenced away from the
patient’s best interests.
Drug promotion and the Indian
pharmaceutical industry
Thousands of Indian companies produce 70,000 brands
of various drug formulations compared to WHO’s list of 250 essential drugs.
Drugs are sold through chemists and stockists who make a margin on the sale. The
private sector represents 80% of the health expenditure, so a doctor in private
practice is an influential prescriber. Allopathic drugs are prescribed by
registered practitioners of all systems of medicine, and also by unregistered
practitioners. Finally, customers who pay for the drugs are often uneducated,
unaware and unable to exercise their right to receive rationally prescribed
medicines. In this unregulated market, one can imagine the efforts made by
manufacturers to promote their drugs and make a profit.
WHO defines drug promotion as ‘all informational
and persuasive activities by manufacturers and distributors to induce/influence
the sale and use of medicinal drugs.’ Drug promotion has an important bearing on
the rational use of drugs; on drug price-control mechanisms, the manufacture,
availability and use of essential drugs, on equity of drug distribution and the
cost of health care—all making it a central public health issue.
In the prelude to our study, a literature search on
promotional practices was undertaken. These can be grouped under three
categories: information, incentives and trading practices.
Information
Doctors in developed countries have relatively
better access to objective sources of information to offset what the industry
promotes. For example, the BNF (British National Formulary) is a noncommercial
source of information available free to all doctors in the UK. (1). Once a
doctor in India graduates from medical school and sets up practice, there is no
legal requirement of credits for continuing medical education (CME), or for
periodic re-certification. Few doctors are interested in, and will find the time
to keep themselves abreast of the latest developments in therapeutics. The vast
majority rely on drug companies for information on new and existing products,
either through mailings or visits by their sales representatives.
(2).
There is much documentation on drug information
given to doctors in India. Most of the Indian articles deal with the accuracy of
product information as given by medical representatives, package inserts and
advertisements in medical journals. Drug advertisements in Indian medical
journals contain less information on safety and clinical pharmacology than their
American and British counterparts do(3, 4).
Gifts and incentives
Studies suggest that doctors hold a range of views
about gifts. However, smaller gifts and those useful in helping patients are
more acceptable. Doctors readily accept gifts that are smaller and socially more
acceptable. But they have double standards, and would frown if a politician
accepted a similar gift. There was also a sense of ‘unique invulnerability’,
that only ‘other’ doctors are influenced by gifts. This theory has been
confirmed in discussions organised by the FMES for students, practitioners and
healthcare administrators. When the audience was asked if going on a drug
company-sponsored cruise would affect their prescriptions towards the company’s
product, the overwhelming majority said NO. When asked if a sponsored cruise
influenced the prescription practices of at least one doctor they knew, an
overwhelming majority would say YES.
Gifts from modest product samples to exotic cruises
turn out to be a good investment for the companies, which spend huge amount of
money because they are assured of returns. However, patients disapprove of gifts
other than samples.
Trading practices
Very little published literature outside the lay
press exists on this topic, although details of trading practices are well-known
in drug-trading circles. Most members of the FMES are practising doctors, and
experience from clinical practice suggests that drug promotion is more than
shaping information or influencing doctors with gifts and incentives. We wanted
to look at trading practices which were unique to the Indian marketplace and the
Indian consumer.
Internationally, it is well known that
pharmaceutical firms have aggressive promotional tactics, but such practices
have not been documented within the Indian subcontinent, either from the point
of view of the strategies or the ethics of drug promotion. For example, people
often get medications directly from chemists and retailers, bypassing doctors
altogether, and drug companies exploit this link. The initial findings of the
study seem to suggest that the doctor’s prescription is not so powerful, after
all, in the Indian drug market. By interviewing a variety of stakeholders, from
doctors to medical representatives to chemists and manufacturers, we hope to
identify major unethical promotional practices, take note of significant trends,
and open up the field for further exploration, pointing to areas of concern and
interest. Understanding the dynamics of the Indian drug bazaar is the first step
towards regulation, ethical drug promotion and ethical medical
practice.
References
1. Lexchin J. Doctors and detailers:
therapeutic education or pharmaceutical promotion? Int J Health Serv 1989;19:
663–79.
2. Greenhalgh T. Drug prescription and
self-medication in India: an exploratory study. Social Science and Medicine
1987;25: 307–18.
3. Lal A. Information contents of drug
advertisements: an Indian experience. Ann Pharmacother 1198;32:
1234–8.
4. Lal A, Moharana AK, Srivastava S.
Comparative evaluation of drug advertisements in Indian, British and American
medical journals. JIMA 1997;95: 19–20.
Nobhojit Roy, Head, Department of Surgery, BARC Hospital, Anushaktinagar, Mumbai 400094, India. e-mail:nobsroy@yahoo.com