Drug Marketing in Mumbai

I'll be in India for a month in 2009. One purpose of the trip is to learn about medical ethics education, ethics committees and the broad landscape of health system ethics, so I've been reading ethics literature from India itself. An article on "Drug promotional practices in Mumbai: a qualitative study" in the Indian Journal of Medical Ethics caught my attention.

The authors interviewed 15 senior executives from multinational (4) and Indian (11) drug companies, 25 pharmacists - 5 wholesalers and 20 retailers (5 attached to large hospitals and 5 stand alone shops each in rich, middle class and slum neighborhoods), 26 medical representatives from Indian (9) and multinational (27) companies, and 25 physicians - 13 GPs and 12 specialists who practiced in rich, middle class and slum neighborhoods.

Here are some excerpts from the article - with my comments in italics:

1. Information and brand reminders.
"Doctors stated that they received information on new drugs primarily through visits by MRs who use flip charts for this purpose. 'These flipcharts show the benefits of their drugs over the drugs of other companies. They also provide results of studies carried out by them on the drug's efficacy.' (general practitioner in slum)

According to the doctors, MRs rarely mentioned drug interactions and adverse reactions but they were otherwise generally satisfied with the information provided and accepted the MR's role. 'Everything is told in a precise way... medical representatives are well versed with their products and quite capable of answering the doctor's questions.' (senior general practitioner in middle-class neighbourhood)"

I saw this same system in action in 1989 when I spent a day with a psychiatrist in a public clinic. He let medical representatives join him when patients and their families (no one came in alone) were in the consulting room. As described in the 2007 article, the MRs pulled flip charts out of their valises and used them to demonstrate the virtues of their products.

"The doctors did state that MRs took up time that could be spent attending to patients and MRs were aware of this. "Doctors always perceive MRs' visits as an intrusion. Every minute taken up by the MR is time which could have been spent seeing patients and making money in the clinic. Often, MRs queue up early in the morning for doctors who allow only the first three MRs to see them." (from focus group discussion with medical representatives)"

The physicians I've spent time with in the public sector were treated like Gods. After the appointment patients touched the physician's shoe as a gesture of respect. It sounds as if the medical representatives had to come as supplicants in a similar fashion.

2. Incentives.
"Some MRs said incentives had become less cost-effective over the years as each company tried to offer more expensive gifts than the others. Incentives did not work to build a doctors' loyalty to a particular brand as all companies offered incentives. So they were now increasingly based on the prescriptions generated. Two doctors practising in slum areas showed printed handouts from a drug manufacturer giving targets and incentives to meet them. They were offered a cell phone handset for prescribing 1,000 tablets, an air cooler for prescribing 5,000 tablets and a motorcycle after 10,000 tablets were prescribed."

This direct "payment" for the number of pills of prescribed is a form of fee splitting. The practice should be seen as unambiguously unethical. There's no way a patient could, or should, trust the prescribing practices of a physician who receives direct payments for prescribing a specific medication.

"Another promotional practice was to finance educational programmes and conferences. Individual doctors' travel, stay and conference fees were also paid for by drug companies. Most doctors had no objection to such support and said they could not otherwise afford these meetings that they described as informative. A small minority felt that the lack of transparency in the funding of medical programmes by drug companies was unacceptable. Nearly half the doctors and all the MRs felt that over the past decade conferences had moved out academic college auditoria to five-star hotels which served lavish cocktail dinners, all with an accompanying increase in budgets."

All of the physicians I know who work in the public sector in India have difficulty paying for educational programs and conferences. If pharmaceutical companies gave money to a central body that administered a fund independently the practice would be acceptable. But paying for specified conferences where slanted presentations may be given is marketing, not education. And while we should not begrudge five-star hotel dinners or overseas conferences for hard working physicians - they deserve R&R - for drug companies give vacations and motorcycles it creates a clear conflict of interest for the physician.

"Drug companies stated that funding medical conferences had become less cost-effective; they suggested that doctors as a group had begun to pressurise pharmaceutical companies into financing their associations' programmes and would even boycott drug companies that did not give in to their demands. 'Things have got to such a stage now with doctors actually demanding sponsorship from companies. This year (an Indian drug company) had zero participation in (a specialist association's) conference. The company is now feeling the heat in the form of infrequent prescriptions.'(senior executive of an Indian drug company)"

This form of frontier capitalism would be funny if the problem weren't so serious. Drug companies give motorcycles for prescribing 10,000 pills. Professional societies boycott medications if the drug company doesn't pay up for their conferences. This is reciprocal bribery and strongarming!

3. Trade Practices.
"Retail chemists said that the multiplicity of brands made it difficult for them to stock all drugs and they risked being left with unsold stock. They therefore stocked the drugs of those companies which were promoted well both with the chemists as well as the doctors. Hence, it made sense for MRs to be consistent in promotion with doctors as well as chemists.

It was also reported by drug companies that chemists associations [demanded]...a charge of Rs 5,000 to Rs 10,000 to the association of wholesale chemists to stock a new product. Drug companies also gave other incentives to chemists to stock their own products."

Paying physicians to prescribe their medications and pharmacies to stock them has the elegance of a military pincer attack! All that is lacking is getting the patients to ask for the product.

"...Screening camps were used to influence public knowledge about a disease and also expand the market for the drug for that disease."

With direct outreach to the public, all the marketing bases are covered - patients, pharmacies and physicians. Since few medications are paid for by insurance, that sector, which would be important in the U.S., is currently not central in India.

All of the issues described in Mumbai are present in the U.S., but in India the pharmaceutical practices are more brazen. Federal and state regulatory capacity is significantly less in India than in the U.S. Perhaps more important, organizations - medical schools, hospitals, medical societies, and more - currently have less capacity to push back against commercial forces than comparable institutions in the U.S.

But the Indian media is sinking its teeth into the issue of commercial corruption of medical decision making (see, for example, "Are your drugs boosting your doctor's lifestyle?" in yesterday's Times of India here). The same ethical drama is playing out globally, just with different timing.