Pharmaceutical companies give globalisation a bad name

Firstly, if you want to know how big these boys are in Australia, check out the following revenue figures from 1999:

Astra Zenica – $515.3m

Bristol Myers Squibb – $387.2m

Merck Sharpe Dohme – $666.2m

Roche – $248.2m

Pfizer – $232m

Smith Kline – $463.2 (*now merged with Glaxo to become the largest worldwide)

Glaxo-Wellcome – $647.8m

Johnson & Johnson – $631m

Ricket & Coleman -$326.7m

Now, ask yourself how all these companies generate so much revenue – much of which is subsidised by us long-suffering taxpayers and the Medicare levy – and then read this rather scary report from the Boston Globe over the weekend. It is followed by an interesting piece by a local medical researcher.

People like Alan Evans, John Dawkins’s former chief of staff who now heads the pharmaceutical industry lobby in Australia, should really have a good look at themselves for working with the drug cartel in Australia.

Boston Globle Article on Drug Pushing

Pressing to sell new blockbuster drugs and buy brand loyalty, pharmaceutical companies are bombarding doctors with ever greater numbers of gifts, free meals, and drug samples, spending more than $15 billion last year just to get their message to the people who prescribe their products.

Prime in the drug industry’s sights are medical residents, doctors-in-training facing a lifetime of prescribing, whose long hours, poor pay, and inexperience can leave them hungry and vulnerable. Residents in the last few weeks could enjoy some of Boston’s best, including dinner at the Four Seasons, Red Sox tickets, or billiards and beer – all compliments of drug companies.

In return, residents usually must listen to a brief company-sponsored lecture.

”Residents are really preyed upon,” said Dr. Robert Goodman, an internist in New York who is organizing residents and other doctors to refuse drug company freebies. ”The companies are really buying a lifetime of good will from these guys by providing them with all this hospitality.”

Goodman’s ”no free lunch” campaign is part of a growing effort by doctors and hospitals locally and nationally to counter the drug industry’s pitch, ranging from restricting drug representatives’ access to residents to training their own staff to offer unbiased drug information.

Drug companies have built a powerful army to cajole doctors into using their products. Last year, about 83,000 drug representatives – double the number in 1996 – targeted residents and other doctors, showing an attentiveness that is seductive to young doctors at the bottom of their profession.

”They are among the few people around here who don’t treat you like dirt,” said Brian Green, a third-year resident at Cambridge Hospital who says he nonetheless refuses the perks.

Critics say industry marketing contributes to ballooning national spending on prescription drugs, which rose 19 percent last year to $132 billion for outpatient drugs alone, according to the National Institute for Health Care Management. Top-selling drugs are among those most heavily promoted.

But the industry’s largest trade group, Pharmaceutical Research and Manufacturers of America, says companies strive to provide accurate, comprehensive information and work within ethical guidelines established a decade ago by the American Medical Association.

”We think doctors are fiercely independent providers who make their own decisions based on the needs of their patients,” said the group’s spokesman, Jeffrey Trewhitt. ”A modest meal or a modest gift is allowed in the guidelines because we’re taking their time to educate them about our products, and doctors are very busy people.”

However, influential voices in the medical profession, including former New England Journal of Medicine editors Marcia Angell and Jerome Kassirer, as well as Public Citizen’s Dr. Sidney Wolfe, have called for shielding residents and educating them about the impact of pharmaceutical marketing. The Accreditation Council for Graduate Medical Education, which sets standards for training of residents, is discussing imposing tougher ethical standards.

”We’re worried about the environment in which residents are trained because of the intrusion of commercial interest,” said Dr. David Leach, who heads the council.

Some residents themselves are worried. ”It’s very easy to go to a drug company lunch any given day, and one could supplement one’s meals by going to a fine restaurant at least once a week,” said Dr. Ruth Potee, a second-year resident at Boston Medical Center. ”One likes to think it doesn’t affect your decisions, but it does. You feel obligated to these people who are feeding you. ”

Numerous studies have found that doctors who accept gifts or free meals or spend time with drug salespeople are more likely to prescribe expensive new drugs even when the drugs have little advantage over a cheaper generic. They are also more likely to press hospitals to add the drugs to their prescription lists.

Another study found that information provided by drug reps was inaccurate at least 11 percent of the time – promoting a more favorable view of their drug – and that most residents failed to recognize the misinformation.

Even Trewhitt, of Pharmaceutical Research and Manufacturers of America, acknowledges growing criticism about drug industry violations of ethical guidelines.

The AMA and PhRMA are jointly preparing to launch a campaign this summer to educate doctors and sales reps about the guidelines, which allow gifts of up to $100 – such as reference books or stethoscopes – provided they benefit patients. The rules also permit ”a modest meal” as part of an educational event. An informal AMA survey found that 40-50 percent of doctors weren’t familiar with the ethics code.

Dr. Herbert Rakatansky, chairman of the AMA council that wrote the guidelines, said three recent events described to him by the Globe were typical, but apparently unethical.

On an April evening, nine residents relaxed in a smoky Boston nightclub, playing pool, downing beers, and filling their plates – all on the tab of drug giant Pfizer. For just 15 minutes, the Pfizer salesman interrupted the fun to talk about a Pfizer-sponsored study of its blockbuster arthritis pill, Celebrex, which racked up about $2 billion in sales in 2000.

A few nights later, GlaxoSmithKline treated some 60 doctors and guests to a four-course dinner at the Four Seasons, an event billed as an educational program on diagnosis and treatment of migraine. Beginning with cocktails and hors d’oeuvres, the evening moved on to tenderloin and lobster. A Harvard professor and Glaxo researcher lectured about one class of migraine drugs, focusing on Glaxo’s Imitrex. The speaker skimmed over data on side effects, despite the drug’s labeling, which warns of deaths among some users with undiagnosed heart problems.

Another Pfizer event invited residents and a guest to dinner and a Red Sox game. The price for residents: listening to a half-hour talk on Pfizer’s cholesterol-lowering drug Lipitor.

”Tickets to the Red Sox are not acceptable” under the guidelines, said Rakatansky. ”A modest meal is not going to the Four Seasons. A billiards night does not qualify as education. Since there is evidence that significant gifts will alter your behavior, you should not accept those gifts.”

Glaxo spokeswoman Mary Anne Rhyne defended the Four Seasons event, saying, ”There was some sharing of valuable information and we need to look into this further to determine if it met our policies.” Pfizer did not respond to a request for comment.

Such events are just one aspect of the marketing effort to doctors, which begins in medical school, intensifies in residency, and continues through a doctor’s career. The barrage includes one-on-one pitches in hospital hallways, lunches at departmental gatherings, sponsorship of medical conferences, and distribution of drug samples, which the firm IMS Health valued at nearly $8 billion last year.

”There’s no way they’d spend all this money unless it works,” said Dr. Colin Doherty, chief neurology resident at Partners Healthcare, who is organizing discussions to help neurology residents ”understand what they’re up against.”

On Friday, the first discussion was led by Dr. Jerry Avorn, whose department at Brigham & Women’s Hospital studies prescribing patterns. Last year, the department began monthly ”pizza rounds” for internal medicine residents as a counterpoint to drug company lunches. ”We buy the pizza and try to unhawk the drugs,” said Avorn. Next month, the department will begin training a ”sales” force of residents to discourage colleagues from overusing new drugs.

While the Brigham focuses on education, others are pressing to limit drug reps’ interactions with residents. Residents in Boston Medical Center’s internal medicine department last summer hotly debated whether to ban drug reps from their lunch gatherings. In the end, the majority voted to allow the reps to provide lunch, but to bar them from the educational part of the program. Longstanding bans on drug-company contact during work are in place at Cambridge Hospital’s medicine department and Massachusetts General Hospital’s infectious diseases and Ob/Gyn departments.

Bob Goodman would like to see more departments and doctors pledge to ”say no to drug reps and their pens, pads, calendars, coffee mugs, and of course, lunch, not to mention dinners, basketball games, and ski vacations.” Through a Web site and presentations, he is focusing on residency programs, which he sees as ”the best hope of changing the professional culture.”

But Goodman’s approach faces resistance, even among those worried about marketing masquerading as education. ”We have an obligation to physicians-in-training to ensure they are capable of dealing with this issue when they leave,” said Harold Demonaco, MGH’s director of drug therapy management. ”Allowing them access to reps in a controlled fashion with some understanding of the techniques used is perhaps a reasonable compromise.”

Alice Dembner can be reached at AD [email protected]

Cash for (no) comment’s parallel evolution in Medicine

By Renzo Researcher

An Australian-based medical researcher

Medical research is a vital and most important service to society. Governments spend considerable amounts of money (although no where near what it should spend on real research) both directly in research funding and also indirectly through tax concessions and research incentives to pharmaceutical and biotech companies. Research has many dedicated people both scientists (Ph.D’s) and medical doctors (MD’s) devoting serious portions of their lives to this very noble cause, and in the past the majority having realised little if any monetary reward for their excellence, this is especially true for Ph.D’s who don’t have a medical practice/position to fall back on. It is true in the past that University’s did offer tenure to some of its Ph.D’s, but that is a trend of the past. With the explosion of the biotech industry, there is now a veritable cornucopia of opportunities for a senior scientist with their own research groups to take their knowledge to the market place, mind you only half-lifetimes to lifetimes of work get to market, there are no short cuts or quick fixes for success in this field.

In any of the major hospitals Royal Children’s, Women’s Hospital, St.Vincent’s, Royal Melbourne, Sydney etc, there are numerous research groups headed by MD’s and Ph.D’s both independent and in collaboration with each other. In general Ph.D’s do the specialist, technical and grunt work, whilst MD’s have a more global outlook and clinical interest. The combination is complementary and definitely the way to go for the future of medical research, however the despite the importance of Ph.D’s in the progress of medical research, differential treatment between the two types of Doctors is quite evident, including scholarship stipends departmental positions and grant opportunities. The elitist attitudes and the chips that many medical practitioners carry on their shoulders around the various hospital grounds of this country can in part be accredited to the arse licking behaviour of the slimy-sell your mother-drug company representatives and their cash cow employers.

The establishment of good will (arse kissing) is central in the pushing of products to MD’s, something they are renowned for. I’ve talked to many MD’s and they have recanted stories of the good ol’days when offices were known to have been refurbished in return for drug company endorsements. It may not be as blatant as that anymore, as some guidelines have been introduced, stipulating that drug company sponsorship involving doctors must come under the banner of “Educational” so that drug companies can include expenses incurred whilst buying doctors as a tax write off under the banner of advertising. This of course doesn’t impact on the extent of the carrot dangled or lavishness and expense displayed. On any given day, around the hospital that I work at, you could find a lunch sponsored by a drug company. The ones I have attended are very research based, but there are varying degrees of luncheons, the reasons (excuses) they are held for, and the extent of catering. Other displays of drug company purse strings are of course the regular dinners held. Recently a drug company took the head of the department I work under and all of his MD colleagues (Note Ph.D’s were excluded) to dinner at one of Melbourne’s finest restaurants. The evening had the obligatory educational (propaganda) course followed by copious amounts of wine and fine food. MD’S research colleagues are of course excluded from these events, as they offer no avenue of opportunity for pushing sales of their drugs. It doesn’t stop there, there are of course the trips funded to conferences, including airfare, accommodation and food all-inclusive. One meeting reflective of all that is wrong has just recently come to my attention. It is a meeting for nephrologists (kidney specialist) being held at the Versache Hotel in Queensland. I believe most nephrologists have been sent invites explaining that the meeting includes all airfares, accommodation, meals and massages for the weekend. One of my colleagues has decided that he’s not passing up the chance to go, and will be there for the first cocktail party Friday week evening. There is of course no requirement for the presentation of scientific data from the attendees. I have heard the arguments from my colleagues that all these perks are in appreciation of the doctor’s valuable the time that drug companies take, and also a way of getting the latest information.

Other drug company strategies include the profiling doctors, showering them with pens, pads, stress balls, mugs and even blatantly labeled tissue boxes. It boggles the mind to think how much money is spent on such items a year. In the department I work in there is a constant flow of such items and there is one crusty old MD, that always has young female drug representatives in short skirts come and see him, although the other doctors get a mixture of representatives.

Finances govern the ability to do research, and most money is up for grabs based on merit (applications are peer reviewed) in the form of grants offered by the Governments or Foundations. As funding into research in any field is not extensive in this country (one of the reasons our dollar sucks) an alarming trend and less apparent red flag, are the relationships that drug companies have been establishing with various clinically based laboratories. Companies will approach doctors and their laboratories, and offer them e.g. $4000 for every patient they recruit into a study involving their drug. The biggest problem with this is that if the study is negative, then the drug company has veto rights over the publication of those results in any form, and they never see the light of day. It is necessary nowadays to have to fill out a disclosure form should you want to publish anything anywhere in the scientific field.

Drug companies realise that scientific merit is the key selling factor in moving their product, and endorsement of drugs based apparently on independent academic laboratories is a sort after rubber stamp, hence the incentive for drug companies to run their own funded studies on their own terms. Another drug company strategy is to target heads of departments in hospitals, hoping to get an endorsement of a product. A prevailing ripple effect is subsequently hoped for among sub-ordinate doctors especially more junior ones.

It would probably be fair to say that most of us would jump at the opportunity to go to an all expenses paid trip to the Versache Hotel for a weekend, with the opportunity of bringing your partner at the cost of a single airfare, and so it is no surprise that doctors are humans to, and actually take these types of opportunities having only to bear with drug company rig moral. The largest problems seems to be the constant environment of temptation and persuasion created by the drug companies, the complete lack of regulation on the MD’s side and no apparent or enforced code of conduct, as well as the attitude of expectation amongst the majority of MD. There are of course the minority of doctors that do the right things, remain independent and use their funding appropriately and with out compromise.