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.