THERE is an unholy alliance working against the interests of patients. Highly unethical dealings go on between the pharmaceutical and health technology industry and doctors and other health professionals. Last year, the Journal of the American Medical Association reported that 26 pharmaceutical companies paid around $33 billion in fines between 2003 and 2016 in the US. These financial penalties were slapped by the US authorities on account of various illegal activities, such as providing kickbacks and bribes, knowingly shipping adulterated or contaminated drugs to pharmacies, and marketing drugs for unapproved uses.
Transparency International reported on the corruption in the pharmaceutical sector in 2016 with the support of UKAid. It stated that in the US alone the pharmaceutical industry spends an estimated $42bn annually on promotional activities that target doctors. This is equal to an average of $61,000 per doctor.The WHO in 2010 reported that medicines account for three of the top 10 sources of inefficiency in the health system, and corruption is a leading source of inefficiency.
Most of this kind of research takes place in the US and Europe. Some of the multinational corporations are also active in most low- and middle-income countries. Despite stringent regulatory authorities and generally higher societal consciousness about the rule of law in high-income countries, the companies do not shy away from indulging in these highly unethical activities. What would the same companies do in poor countries where the relevant laws are absent or weak, regulatory authorities lack capacity, and corruption is an accepted way of life?
Local pharmaceutical companies join the MNCs in corrupting medical practice. Gullible patients pay through their nose as they buy unaffordable medicines which may not be needed in the first place or for which equally efficacious but cheaper alternatives are available. Sales representatives are given targets and they are dependent on medics for prescribing their medicines. Companies producing the same medicine compete for popular doctors through offering bigger and better incentives, which have moved from bad to worse to ugly. The word ‘unethical’ has become incapable of conveying what is going on in the medical marketplace.
I recently sat down with a group of young researchers who were concerned about this situation and were struggling to choose effective interventions to address this imbroglio. In their scoping work, they had discussed and observed what was going on between the marketing tigers and the ever-willing doctors. They spoke to both sides — the sales representatives and doctors. Their findings and examples from elsewhere are not just unethical but also horrifying:
A grand valima of a busy doctor’s son was entirely sponsored by a pharmaceutical company. The whole family and a number of friends of a popular surgeon were taken to a popular Southeast Asian beach resort for a weeklong holiday; everything was paid by a company. A sales representative told a doctor he could not give him the cash demanded but could provide an AC; the doctor told the rep to send the AC to a particular AC shop and the doctor received the money from the AC retailer.A valiant sales rep can pay for car service for a doctor, refurbishing his office, expensive private school fees, utility bills and any other imaginable expense. Depending upon individual taste and preference, some doctors have allegedly accepted drinks and more — including a full umrah package from the pharmaceutical industry. Umrah packages for spiritual cleansing at the cost of suffering patients who can’t afford the cost of the medicine — irony needs to be redefined. All this is investment for companies with huge returns on investment.
The usual argument that high prices charged by pharmaceutical companies is to recoup the high expenditures they incur on R&D is flawed. Nine out of the 10 largest pharmaceutical companies spent more on marketing than on R&D according to one study. So, high prices of medicines are also due to large sums spent by companies on the marketing of their products, a very big part of which goes into incentivising the doctors to liberally prescribe their products. And the R&D spending argument does not apply to local pharmaceutical companies, they are quite clean on this count.
How to address all this? From the global to local level, the pharmaceutical industry does not like any restrictions on its marketing practices. Despite its efforts, the WHO has not been able to produce any hard law other than a toothless and outdated Ethical Criteria for Medicinal Drug Promotion in 1988. The US and Europe have introduced stringent regulations in this connection. In 2014, the Physician Payment Sunshine Act was passed in the US, which requires companies to disclose in an online database payments of over $10 that they have made to doctors.
Closer to home, the art of unethical marketing has thrived beyond imagination and there is hardly any regulation. On Nov 17, the government of Pakistan finally issued the Ethical Marketing to Healthcare Professionals Rules, 2021, through the Drug Regulatory Authority of Pakistan. One of the stipulated functions of DRAP is to “monitor and regulate the marketing practices so as to ensure the rational use of drugs…”. It has taken the government nine years to come up with these rules after the Drap Act of 2012.
The rules are not only late; they are also lame and quite out of sync with the times. Medicines are now being promoted and sold online but these rules do not bother about this. The weakest parts of the rules deal with enforcement, contravention and punishment. These are very vague and non-committal. How they are going to be implemented is not clear and there is justified lack of hope about them changing anything on the ground. Nevertheless, now we have rules for ethical marketing. Their implementation needs to be monitored and reported regularly by civil society organisations, academia and the media. This can only ensure further strengthening of the rules and eventually some hope for impact. The reformed Pakistan Medical Council also needs to become active in this ignored area.

3 thoughts on “An Unholy Alliance
Dr Zafar Mirza, Director, Health System Development, Regional Office for the Eastern Mediterranean World Health Organization

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