Desperate, Drug Makers Court Doctors in Developing Countries

In the U.S. we are accustomed to seeing exceptionally well-dressed drug company reps strolling into doctors’ offices bearing trinkets: coffee cups, note pads and pens. We also know that they take doctors to expensive dinners, and host “continuing education” junkets to warm climes. Device-makers have been known to ferry doctors to strip clubs after dinner.

But in the developing world, drug makers are pulling out all of the stops. Often there is not even a pretense that the gift will help the doctor do his job. In Kashmiri, a physician confides, “representatives of pharmaceutical  companies offer cash, refrigerators, color televisions, laptops, PCs, mobile phones, ovens, phone bills, [and even to pay school] tuition [for your] children.”

In India, a doctor from Mumbai reports:  “On sale of 1,000 samples of the drug, you get a Motorola handset. On sale of 5,000 samples you get an air cooler. On sale of 10,000 samples get a motor bike.”

In Pakistan, a survey of 149 doctors, 100 medical information officers (sales representatives) and 99 medical store personnel, found that gifts may include included air conditioners, cars, cash, home appliances and domestic cattle.   Murad M. Khan, professor & chairman of the department of psychiatry at Aga Khan University, describes the latest practice: For writing 200 prescriptions of a company’s high-priced drug, a doctor is rewarded with the down payment on a brand new car.

These are just a few of the enticements documented in a November 2007 Consumers International (CI ) study, "Drugs, Doctors and Dinners: How Drug Companies Influence Health in the Developing World." (Thanks to Gary Schwitzer, at Schwitzer Health News Blog, for calling attention to this report.) A global voice for consumers, CI is an independent not-for-profit boasting over 220 member organizations in 115 countries.

CI’s eye-popping 39-page investigation reveals how, as profits level
off in the West, drug makers are turning to the rest of the world: “The
pharma industry sees the developing world as a trillion-dollar
opportunity,” CI’s Richard Lloyd recently told the U.K. newspaper, The Independent.  But as Lloyd noted, here’s the catch:  “consumer health expenditure in these countries can ill afford to be squandered.”

In the developing world, a health care dollar that is wasted is not easily replaced.  Yet waste is rampant. According to CI, “up to half the drugs prescribed in the developing world are wrongly prescribed.” [my emphasis]

A 2005 study by the Indian National Commission on Macroeconomics and Health confirms that
as drug-makers hustle their products, doctors are prescribing drugs
that are “irrational or non-essential or hazardous.” Taking a close
look at the country’s 25 top-selling brands of medicine, listed by drug
and manufacturer, the Commission found that ten of the 25 fell into
that category (see table below.)

    “Irrational, Non-Essential or Hazardous” Products

Rank            Brand               Producer      Headquarters
1                Becosules           Pfizer               USA
3                Corex                 Pfizer              USA
9                Liv-52                Himalaya         India
11              Dexorange        Franco-Indian   India/France
12              Digene              Abbott              USA
17              Combiflam        Aventis             France
20              Polybion            E. Merck           Germany
21              Glucon-D           Heinz                USA
22              Evion E.            Merck               Germany
25              Revital              Ranbaxy            India

Even worse, in the developing world, manufacturers are flogging drugs
that regulators in the West have nixed.  For example, in 2005 the
European Medicines Agency’s Committee for Medicinal Products for Human
Use (CHMP) refused to recommend authorization
to let Novartis market a treatment for  irritable bowel syndrome known
as Zelmac (Zelnorm in the U.S.) in part because CHMP thought the drug’s
benefits did not outstrip its risks.   In the U.S. the FDA approved
Zelnorm, but only for women suffering from severe chronic irritable
bowel syndrome.  “In its ads, Novartis Pakistan does not state that
Zelnorm is recommended for women only,” CI  observes. “It is not known
how many Pakistani men are suffering from the serious side effects
associated with taking Zelnorm.”

Drug companies also appear to be pushing drugs that “have been
recalled, or are the subject of safety scares, in developed countries,”
CI continues. “Such incidents include the well reported VIOXX case,
GSK’s Seroxat and Avandia106 and AstraZeneca’s Crestor.  Despite these
scares, the drug companies continue to promote these products in . . .
markets, where pharmaco-vigilance standards are lagging.”

The report concludes: “the poor quality of information provided to
doctors in developing countries cannot be dismissed as infrequent and
isolated cases, but rather can be viewed as a systemic breach of
responsibility and ethical norms by market leaders.” This is not good
publicity for the pharmaceutical industry. And it’s a business that
could use a brighter image.

Why, then, are industry leaders playing fast and loose in the
developing world?  Desperation. This is a mature industry, and earnings
just aren’t growing as fast as they once did. Today, drug-makers have
few potential block-busters in the pipeline; most of what comes to
market is another me-too drug, no better than, and often riskier than,
medications that are already available. A breakdown of more than 1,000
new drugs approved by the US Food and Drug Administration between 1989
and 2000 revealed that more than three-quarters had no therapeutic
benefit over existing products  When the British Medical Journal
published a study rating newly patented drugs in Canada it rated only 5 percent
as “breakthrough.” Genomic research may lead to another leap
forward—but not next year.  And Wall Street is not known for its

Meanwhile, patents on prescription drugs are running out. By 2009, a
dozen of today’s top 35 branded prescription drugs will lose patent
protection, CI reports. And “expiring patents expose an estimated $157
billion worth of sales (measured in 2005 terms) to generic erosion.”

Of course, making drugs and peddling them to the public is still a
lucrative venture. But investors don’t just expect profits—they demand
sales and earnings growth, year after year after year. And as the table
below shows, growth has leveled off in recent years, falling from 14.5
percent in 1999 to 7 percent in 2006:

                           Pharmaceutical   Industry Growth 1999 to 2006

Global sales US$BN           1999    2000   2001   2002  2003  2004   2005 2006
Total world market (US$)   334      362    387    427    498    559    601   643
%Constant US$ growth      14.5      11.7  11.8   10.6   10.4   8.0     6.8   7.0

But if sales in Europe and North America are beginning to disappoint,
India’s enormous market offers hope: in 2006, pharmaceutical sales
levitated by 17.5 percent, climbing to $7.3 billion. This would be fine
if drug makers were providing Indians with the products they need—at
prices that they, or their government, can afford. But instead the
industry is bent on promoting its most expensive, high-margin
wares—drugs that often aren’t necessary, and may even do harm. A
Darwinian struggle for profits in the developing world has brought the
pharmaceutical industry to a new low.

In the British Medical Journal,
Chandra M. Gulhait of India’s Monthly Index of Medical Specialty sums
up Big Pharma’s business plan: “Fiercely competing pharmaceutical
companies [are depending]  on the tried and tested 3Cs: convince if
possible, confuse if necessary, and corrupt if nothing else works.” 

4 thoughts on “Desperate, Drug Makers Court Doctors in Developing Countries

  1. I agree that drug companies can be sketchy at times. Zelnorm was a great example since if was found to significantly increases the risk of adverse cardiac (heart attack and stroke). Ennis & Ennis is the lawyer to consult if you have suffered from a medical side effect. Zelnorm is merely one of the drugs he is involved in.

  2. It would be nice if wcould fruige this mess of ours out.It is a shame, but I think we need to regulate the drug and medical equipment suppliers.I worked for MultiCare for twnety years and observed the rip offs by vendors. Some would actually say when referring to us as that is where the money is.I have met doctors in Canada who have very big boats and niice cars.All of our friends in Canada are happy with their coverage. They have been shoked when I have told them my copay for a specialist is $40 and regular are what they are. They are even more shoked at what our drug costs are. They pay huge taxes but don’t seem to mind.Canada may not be great but neither is our system by a long ways. Far to many people are paid off,ie Congress and some the medical field one way or another. I have seen it -Tom Pitts

    • Mikie–

      I agree. Drug companies and device-makers need to be regulated. Obama is calling for price regulation of drug makers (by letting Medicare negotiate for discounts and refuse to cover over-priced drugs) in his new budget.

      I think this will happen, if not now, in 2016.