Modern medical practice depends extensively on the use of drugs and it is the function of the drug industry to supply them. In a way, the two — the medical profession and the drug industry — may be considered partners in health care. However, they differ in their objectives and guiding principles.

Medical practice must be based on scientific principles. Thus, doctors have a duty to improve themselves through continued medical education (CME). At the same time, the medical profession is service-oriented : it puts the patient before self and works for the maximum benefit of the patient (loyalty or fidelity). Beneficence (doing good) or at lease non-maleficience (doing no harm) and confidentiality are other guiding principles. The medical profession also engages in the advocacy for patients : identifying their needs and working for reallocation of time, money and personnel to satisfy them. The movements against child labour, focusing attention on the problems of the girl child, and for promotion of breast feeding are some examples of advocacy by paediatricians.

Profit, not patients

The drug industry, on the other hand, is profit-oriented and aims at giving maximum benefit to share holders. The drug industry is not bothered about consumers / patients — otherwise the market would not be flooded with irrational formulations. Confidentiality is maintained about the production and marketing strategies, and advocacy for justice is rarely considered.

The drug industry’s profits continue to increase despite escalating financial constraints. In the US, it takes $9.4 million to develop a new drug and get it approved. The only way this can be compensated for is by aggressive promotion.

Although there is some drug advertising in the lay media and although many drugs are sold unofficially over the counter, the majority of drug sales comes from doctors’ prescriptions. An estimated 20 percent of pharmaceutical companies’ budgets is spent on marketing; of this money, 20 percent is spent on training and maintaining medical representatives, 30 percent for advertising in the scientific and lay media, and 50 percent for special methods such as stalls at scientific meetings, sponsored dinner meetings for invited doctors, and the publication and distribution of books.

Unscrupulous acts

There can be no objection to the drug industry’s making a reasonable profit. What is objectionable is profiteering by unscrupulous means :

• Product information given by medical representatives may be incomplete and scanty. Yet, for many practitioners they are the only source of information about drugs.
• Help for educational activities can be acceptable if it is without strings and the activity’s organiser is the sole decider of every aspect of the programme: venue, topics, speakers, and so on. Donations should be made to the academic society, and the speaker’s expenses should be reimbursed by the professional body, not by the drug company.
• Grants should be given to professional bodies and institutions and not to individuals. The professional body/institution and the research worker must be decider of every step from project planning to report publication.
• Medical practitioners should be concerned about false advertisements in the lay media for products harmful to the health. The bans on advertisements of alcohol, infant milk substitutes and feeding bottles are examples of this concern. Drug companies advertise their products in scientific journals as well. It is very important to ensure that wrong messages are not given, and irrational products are not promoted, through advertisements in scientific journals.
• The drug industry persuades doctors to prescribe certain brands by giving gifts or providing ‘hospitality’. At times, dinner and cocktail meetings have sponsored speakers. The money does not come from the shareholders’ pockets. In our country, where 40 percent of the people live below the poverty line, the gift relationship violates the ethical principles of fidelity and non-malficience. Drug manufacturers like LOCOST, who do not engage in unethical promotional activities, are able to provide quality drugs under generic names at half the current market price, sometimes even less.

Doctors claim that they are not influenced by ‘gifts’. They forget that no profit-oriented business organisation would spend large sums of money unless there were good returns. The crippling effect of such sponsorship is evident when professional bodies feel convinced that even a one-day CME programme must be sponsored by the drug industry. They claim that delegates want comfort but apparently do not wish to pay for it even though they can certainly afford to so. So patients pay twice : once directly to the doctor and then indirectly through the drug industry.

During their medical education, doctors are never exposed to the socioeconomic aspects of heath care. They lack conviction and fall easy prey to the principle : Incur debt and enjoy your life; there is no return after you are burnt to ashes. But we are homosapiens. We must act with due consideration to others and not selfishly like animals.

It can be accepted that the drug industry also has a societal interest in having well-educated doctors with improved skills but this should not be used as a excuse for brand promotion and for squeezing money from the poor.

Institutions like the Medical Council of India, the Indian Medical Association, the Indian Drug Manufacturers’ Association, the Drug Controller of India and the judiciary should not only have suitable guidelines and laws but also monitor their application. They must have the power to enforce these rules. Unfortunately, they have neither nails to claw, nor teeth to bite, and not even a loud bark to warn.

Steps forward

The sky seems to be full of dark clouds but occasionally there is a silver lining. For example, some time around 1980, the general body of the Indian Academy of Paediatrics (IAP) took a donation for an oration made by an infant milk-substitute producer. In January 1997, the IAP resolved that “The IAP shall not accept the sponsorship in any form from any industry connected directly or indirectly with the products covered by the Infant Milk Substitutes, Feeding Bottles and Infant Food Act, 1992.”

The current dependence of the medical profession on commercial sponsorship is a result of the failure of end-organ : the doctor. If doctors are convinced and committed to their ethical responsibility, they will not yield to the unscrupulous pressures of the industry. They must learn to say ‘No’ to gifts, subsidies and hospitality; to aid with strings attached; to brand promotion; and to prescribing irrational drugs and formulations.

Consultant paediatrician, editor of the Society for Rational Therapy and Chairman for the Committee for the Protection of the Child Consumer of the Indian Academy of Paediatrics.

Based on the presentation made at the International Conference on Ethical Values in Health Care at Panchgani, January 2-4, 1998.