Indian Pediatrics 1998; 35:641-645 

Medical Profession and the Pharmaceuticals: Indian Scenario

Medical profession and the pharmaceuticals have one common goal that brings them together-the treatment of the patients. Where, for the pharmaceuticals it only means drugs, for the professionals it has far wider connotations. The professionals have to play the role of counsellor, advisor and educator and to fulfil these roles, much more than drugs is required. The patients to some extent (so say the professionals) and the pharmaceuticals to much larger extent, infringe on the prescribing habits of the professionals. The pharmaceuticals vie with each other and play the one up games-manship to achieve this objective.

Some of the professionals do succumb to the marketing tactics. With the change in the perceptions and the values of society, the dividing line between the profession and the commerce is increasingly going to be thinner and interests other than those of the patients are going to take strongholds. Mercifully, still the vast multitude of professionals are scrupulous and interests other than those of the patients are non- existent in their priority and the human face still is the uppermost guiding principle in their approach.

On the contrary, pharmaceuticals because of their business compulsions have no pretensions of any human face. They are in business and they mean business. They are out whole hog to make money and therefore, follow the principles of cut throat business. And, currently the approach that rules the roost is not why his shirt is whiter than mine but to pronounce loudly in public (even if that means washing dirty linen in public) that your shirt is dirtier than mine and I shall make it (or at least make it appear) still dirtier.

It is very difficult to define a bribe. What may be bribe in one context may become a gift in another. Some times it may be akin to accepting donations for political parties, not the individual. Grey is the most sought after shade these days. Grey areas provide you the zone where you can break laws with impunity and kick ethics hard on the face. Ethics is the weapon of the weak today, the cavaliers and the smart ones care two hoots for the ethics. The pharmaceutical industry is working hard in this grey zone. In this country where rules do not deter people from doing what they like, ethics are the poor second runner. A strong argument that is advanced (I find it a very weak argument) is that the professionals can use their discretion and are not affected by the bribes. If it was so, how would you explain one brand of cefotaxime selling 20-Lac vials a month in this country and proudly flaunting this achievement on our face?

Many pharmaceutical companies give special discount to doctors. If a drug or vaccine can be sold at lower price than maximum retail price (MRP), the benefit should go to the patient. Why give rebate to the professionals and use them as commission agents? Speaks volume of the commitment of the industry! And of the professionals too!

To give you an example, the marketing strategy has pushed hepatitis B vaccine beyond all logical limits. The concerned manufacturers have generated fear psycho- sis in the name of spreading awareness. If the drug industry is so concerned about eradication of Hepatitis B from the face of the earth, they should reduce the cost of the vaccine and make it available to more needy patients. They have hiked the MRP, given lucrative offers to professionals and the net result? Doctors pocket the profit and the vaccine is out of the reach of many. Another example where there is lot of difference in the MRP and the price at which the whole seller/doctors get it is the intravenous (IV) fluids. Can we in an honest confession say that this has not led to un- necessary, unscrupulous use of IV fluids? After the advent of ORT, the need for IV fluid therapy has decreased tremendously, has the use decreased proportionately? I would again feel strongly that the easy money does influence the prescription and the practices. The role of the professionals also leaves much to be desired. How many of us will pass on the concession to the patients? When you have access to easy money it is foolish to toil hard to earn money in the modern times of cut throat competition and survival of the "smartest". There is surfeit of conferences and seminars in the country over couple of years. The pharmaceuticals are getting roped in, in a big way. More is your "pen power" (or scalpel power?) more handsome is the offer by the pharmaceuticals. The surgeons and the intensivists and the cardiologists get much better treatment than others. (I have never "qualified" beyond key rings and ball pens). If the offer is in accordance with what you write, soon the offer changes for what you can write and gradually for what you should write. If you are given air fare, five star comforts, and attractive gifts, how long can you resist the temptation? And on top of that, it wins you a label of being academician, one who attends most of the conferences, a well informed professional. It helps your improve your chances in practice. How on earth can you subscribe to this idea that the professionals remain un- affected by these strategies and the pharmaceuticals are doing it out of their love for academics or the interest of the patients. They do their market surveys, make a list of who is a "good" prescriber or a "bad" prescriber and decide their strategy. If you once get a programme sponsored they will keep coming to you to remind you of the sponsorship and their products. The organizers of the 'conferences also now issue "diktas" to write preferentially certain products and boycott others. Why can we not pay for our own learning? Why the learning has to be in outlandish, posh out- fits? And then who ultimately pays for all this extravanganza? The poor patient. The irony is that we are willy-nilly acting as an instrument in the hands of the industry to meet their ends and ignoring blatantly our basic commitment to our patients, to regard highest priority to their interests and to safeguard it against all odds. And to resist it requires the self discipline of highest order. Self discipline is the most scarce commodity these days, those who exercise it are losers at every front, the industry and the chemists hate them alike. And the in thing is to be friendly with the industry!

Another area where the relationship has now assumed different dimension is the role of the industry in providing information to the professionals. Despite the sudden upsurge in the number of seminars, symposia and conferences, for many of us 1 the sale representative is the sole source of I information. When a seller, whose basic objective beyond any shade of doubt is just to promote sales, becomes the educator, rationality is the first casualty.

There are on records numerous examples how the pharmaceuticals "provide" us information which was not there in the original reference they had cited (One particular page was not there in Lancet which was ascribed to it by a big pharmaceutical industry, and similarly one particular graph was not there in the original article as was claimed by another bigwig).

How the information is used out of context or how there is deliberate attempt to misinformation, I have had once an opportunity to discern and to communicate to the representative. I shall like to share the experience with you. One sales representative of a company producing cloxacillin paid me a visit. In his visuals, quoting text book of Nelson, it was mentioned that the commonest pneumonia in infancy was staphylococcal (the obvious implication being that cloxacillin was the drug of choice for all pneumonias in infancy). I was not impressed. I opened the book and showed it to him, it was mentioned that of all the ages staphylococcal pneumonia was commonest in infancy. Only slightly rephrasing one sentence could do the trick! Till not very Iong ago, one reputed company was selling isoniazid in syrup from for treatment of whooping cough and innumerable children in this country received this for all varieties of hacking cough! To impress the professionals with high technical jargons they some times use the terms like minimal inhibitory concentration (MIC), etc. to give their presentation a scientific flavor. And the less discerning amongst us do get impressed. To drive home their point that their antibiotic is much more potent than another antibiotic, they will compare the MIC of these two antibiotics in question and the antibiotic with MIC of say half of the other is projected as twice as potent. Simple mathematics that!

Only those research papers which suit their needs are displayed on the visuals. I remember one pharmaceutical manufacturing "liver tonic" approach a premier institute to conduct a trial. The Head of the Department insisted on having the right to publish the outcome of the trial with him. The concerned pharmaceutical promised to return after consulting the higher-ups. They never returned!

This brings me to a very important point of this write up. Can there be any screening of the material that is presented to professionals? This is all the more important in the wake of a historical decision by the apex court of the country on 29th November 1995. Thee court has ruled that the exclusiveness of each system of medcine is to be respected and those medical practitioners who transgress their territory will be considered quack and deemed to be negligent per se without any further proof or argument. The practitioner belonging to any system of medicine if found guilty is liable to penalties under various acts. In the event of death, the doctor is liable to be punished with imprisonment for 2 years or with fine or both under section 304-A IPC. This decision is going to have repercussions on the conduct of manufacturers and their marketing teams including the sales representatives. These representatives regularly meet the medical practitioners to promote the sale of their products irrespective of the system of medicine to which the practitioners belong. Such sales representative and as well as their employers may be held liable and guilty of the offence of abetment. Under the criminal law, not only the offender but all those who abet, instigate or conspire are also liable to same punishment as the actual offender. In the case of the sales representatives, the argument that they are merely carrying out instructions 6f the employers is not legally acceptable. Under the law they are personally liable. The pharmaceutical industry should be on the alert and bear in mind that they can not continue to indiscriminately promote with impunity their products and induce doctors of one system to prescribe drugs of other system. Can the manufactures of modern medicine be effectively stopped from visiting the practitioners of other systems? Can the Indian Medical Association, Indian Academy of Pediatrics, Association of Physicians of India, or other associations take this up with the government? Can the Medical Council of India do anything about it? This will be a singularly important step in the direction of stopping the misuse of drugs and specifically the antibiotics.

After identifying the problem areas, are there any remedial measures in sight? In matters like these, the most important remedial measure is the most difficult to practise and that is exercising self discipline. Prescription of a doctor is absolutely his prerogative and he can use his sweet will to write what ever he deems right. But one should remember that the prescription of a doctor reflects his knowledge, attitude and confidence level and the doctor should use this tool to treat his patients on their merit with no other consideration what so ever.

The WHO conference of experts on the Rational use of Drugs, held at Nairobi on 25-29th November 1985, commented: "All experts spoke in favor of the application of ethical criteria in drug promotion. It was generally felt that the pharmaceutical industry has major responsibility for a with established criteria and avoiding different criteria in different countries".

In our country where there is no dearth of regulations and laws, the problem really is at the implementation level. Here are some suggestions:

• No pharmaceutical company should be allowed to use any literature to promote or advertise its products without screening by a national authority:
   

• The pharmaceutical companies should be charged a levy on their total expenses on sales promotion for research and drug development.
   

• The scientific bodies should evolve means to reduce their dependence on the drug industry for holding their conferences and seminars. Various austerity measures should be taken. The doctors should begin to think in terms of paying for their own learning.
   

• The pharmaceuticals should be re-strained from doing their own trials. The trials should be monitored by national authority and then the data should not be allowed to be presented out of context.
   

• The pharmaceuticals should promote only products relevant to the doctors' system of medicine.
   

• Rational drug therapy should be included in the medical curriculum.
   

• Some kind of prescription audit system should be evolved.
   

• No drug company should be allowed to give gifts or free samples.
   

• The doctors should be provided with periodic information regarding new drugs and medicines, some thing like British National Formulary. This should lessen the dependence on drug industry for information.

It does not behave the professionals to behave in a manner that gives an impression that they are hands in gloves with the industry. Profession and commerce need to be separated in no unclear terms. The professionals have to do a lot- of soul searching and introspection. Restoration of the dignity of the noble profession was never more required than it is today. It is really a collective responsibility to refurbish the tarnished image. Not only charity but cleaning and mopping up should also begin at home.