I have the following comments to offer in response to Dr. Srivastava's Communication:

1. There is no denying that the literature provided is informative, yet there is enough evidence to show that information is presented in a distorted form and out of context. A large majority of practitioners without any degree or training in modern medicine are not capable of discerning this. This is the target group for the pharmaceuticals.

2. The source of information is never questioned as long as the information is correct. Only when an element of business interest creeps in, one starts viewing the information under the microscope. Recently, I have come across a brochure from Dabur pharmaceuticals in which, quoting few doctors, a claim has been made about a product of theirs converting HbsAg positive into negative. The company has not heeded my request (faxed about 4 weeks ago) to provide me the un- abridged details of the study carried out by them.

3. The statement that "big prizes such as air tickets..." is wholly untrue. They are far from rare and the statement is as far away from reality as the capital city is from small towns. Certain information is difficult to document, yet majority are aware of it. A nearly 4000 delegates attended the annual Association of Physicians of India Conference at Kathmandu. From a "small" town like Raipur no less than 5 physicians were sponsored by a pharmaceutical, which included air ticket and all the staying arrangements. Everybody who has been long enough in practice knows the company who did it. Majority are aware of family pleasure trips being organized by pharmaceuticals. Not long ago, the TV highlighted an incident involving the city of Pune regarding one hematinic and how the lucrative offers had made its's sales soar.
The objection to free samples is because of certain practices. And the contention that samples are distributed free to poor people reflects half truth. Presidents of the associations getting the big prize represents just the tip of the iceberg and the pharmaceuticals are not looking for the "opinion makers", their primary search is for commercially useful people. Apart from small bribes, direct bribing is resorted to, all over the world by pharmaceutical multinationals. John Braith while in his "Corporate crime in Pharmaceutical Industry" has pro- vided an elaborate account of bribing. Some examples are illustrated below:

(i) In Italy, a dozen drug manufacturers, including some American companies banded together to back an industry sponsored bill. The companies spent $ 80,000 each, according to source, with $ 1 million to be donated to Christian democratic party. The Government fell before the bill could be enacted.

(ii) During the period 1971 to 1975, American Home Product spent $ 3.4 million in bribing 41 countries to obtain action on necessary Government clearance for granting approval. They also spent $ 38000 for an "Essential political purpose".

(iii) Park Davis paid $ 2.6 million in 14 countries to procure new product approvals.

(iv) Pfizer bribed $ 264,000 to employee of three foreign Governments. They also subscribed $ 22500 to a foreign trade association to pay to different political parties of the particular country.

(v) Roche bribed $ 14000 to two Government officials in Kenya who purchased antibacterial and tranquillizers of the company amounting to 10 years need of the country(1).

I had eschewed all these details in my write up because the manuscript was re- stricted to the Indian scenario.

4. Good ambience and comfort are not commensurate with lavish outfits and mindless extravaganza. A lecture theatre like atmosphere of a medical college can be far more congenial and conducive to learning. We may not totally do away with the support from the industry but we definitely can substantially reduce our dependence on them which ultimately gives genesis to the thought that we can not do without them. A decade ago who would have conceived of a pediatric conference without the support of baby food industry? But this has been made possible. I am shocked at the inference that "We must not feel guilty if our meetings are held at clean and comfortable places."

5. I entirely agree with the contention that quackery can be combated with legislation and education. My viewpoint only highlighted the role the industry has to play in the wake of supreme court decision.

6. I am acutely aware of the good done by the pharmaceuticals. Compared to more than 448 chemicals developed by foreign industry in the last decade (Only four of them for specific needs of a tropical country) the Indian industry has developed only a few, most of them by the public sector, Central Drug Research Institute (to name a few of them, Guggulip, Centimizone, Centbucridine, Centbutinole and Cenkhroman, a contraceptive). Few other drugs have been developed by IDPL, HCT besides two drugs from Ciba Geigy before closing its Research and Development (R&D) Center. Ranbaxy along with Cipla, Lupin and Dr. Reddy's Lab are gearing up to take up the challenge. Most of the research is reflected in what the sale representative tells you. Here are some examples, "Doctor! We, are the first company in the country to provide it in sorbitol base" "We have made a breakthrough in the management of diarrhea by launching the combination of tinidazole and norfloxacin."

7. I am aware of the R&D funds of the Indian pharmaceuticals. Compared to multinationals who spend about 10% of their budget on R&D, our companies spend only 2-4%. A large part of their research is spent on product (formulation) development, market study and development of new sales promotion techniques. And, in the ultimate analysis on whatever you spend your funds, they are recovered finally from the consumer.

8. We may continue to adopt the ostrich approach. A thorough debate is needed before we may dub certain suggestions as inappropriate. The Idea of the write up was to shake the professionals to wake up to the realities. I was not intending to deliver sermons.

9. I could not agree more on this point-we must view our relationship with the industry in a mature way.

I sincerely hope that some body will ex- plain to me the paradox outlined below. To update ourselves and to rationalize the approach we have surfeit of conferences and symposia. To make these congenial we take generous help from the industry. The industry to make the investment good pressurises us to write their products, rational and irrational. This way the exercise to rational. approach culminates in irrational approach. Now, if we subscribe to the idea that professionals do not succumb to pressures and marketing tactics, I do not believe this because the trend in the country tells us an entirely different story.
 

Sanwar Agrawal,
Consultant Pediatrician,
Child Care Clinic,
16, Shastri Market,
 Raipur 492 001,
India.

 

1. Guha A. Marketing of Medicine: Parasitolgy for profit: In: Drug Industry and the Indian People. Delhi, Delhi Science Forum and FMRAI, 1986; pp 219- 228.