Prescribed Corruption

Let me start off with a joke taken from the book Bad Medicine: The Prescription Drug Industry in the Third World by Silverman, Lydecker, and Lee. I changed it a little bit to make the political issues more appropriate for this article but nevertheless, the message remains the same as it describes the magnitude of unfavorable views on the pharmaceutical industry.

And it came to pass that the President of the United States, the President of Iran, and the president of the pharmaceutical industry had a private audience with the Lord. Each was allowed to ask one question.

The U.S. president asked, ‘Lord, when will our unemployment problem be solved?’ The Lord pondered, then said, ‘The year 2050.’ The President of the United States walked away, crying bitterly.

The President of Iran asked, ‘When will Iranian be able to build a Nuclear Missile capable of reaching America?’ The Lord thought for a while, then said, ‘In the year 2062.’ The President of Iran walked away, crying bitterly.

Finally the president of the pharmaceutical industry asked, ‘Lord, when will the public image of our industry become favorable again?’ The Lord thought for a while and then walked away, crying bitterly.

philippines_pharmaceutical_industrySome of my readers may not be aware of this but something stinks in the pharmaceutical sales industry especially in the Third World like the Philippines. An editorial column by Amado Macasaet from the Malaya Newspaper describes the unjust practices of Unilab, the biggest drug and pharmaceutical company in the Philippines. The column describes despicable practices in its sales force such as “initiation rites” where sales-trainees are subjected to humiliation, kind of like a practice traditional in fraternities. Other practices also involve company intimidation and coercion on some of its salespeople, as well as bribery and other practices that foster a culture of corruption in Pharmaceutical Company-Physician relationships. This article will focus on this culture of corruption infesting the pharmaceutical sales industry in the Philippines.

The pharmaceutical industry is a huge and very competitive industry worldwide. In the Philippines alone, Unilab Corporation made almost Php10.66 Billion in revenue in 1999 and averages Php20 Billion in sales in 2006. Competition for pharmaceutical sales is fierce as pharmaceutical companies try vying for a bigger slice of the market share. Sales methods come in various forms such as advertisements, personal selling, trade promotion, and sponsorship. Pharmaceutical companies invest billions of dollars on its sales force in an attempt to push for increased profits. The motivation for increased profits has made physicians susceptible to corruption from many unethical sales practices coming from the pharmaceutical industry, including influence from sales representatives bearing gifts and other “enticements”.

A paper was published refuting the influence of gifts to physicians on medical prescription decisions. The article notes:

“contrary to popular belief, physicians are not easy targets readily persuaded by salespeople, but rather are tough sells as evidenced by the minimal influence of sales activities on their prescribing behavior. According to Jacobson, the most important factor explaining the limited effect of sales representatives is that physicians know they have other sources of information. Scientific papers, advice from colleagues and a physician’s own training and experience also influence prescribing practices and, he said, most physicians view these sources as far more reliable and trustworthy than salespeople.”

The study was based on the case for the United States of America; the question now is: “Does the study’s conclusion apply to doctors in Third World countries like the Philippines?”

According to a report published by the World Health Organization, there are 0.58 physicians per 1000 of the population in the Philippines. In addition, according to the Philippine Department of Budget and Management, the country merely allocated about 2.7% of total government expenditure on health care. These support Consumer International Organization’s report that health professionals in developing countries work in overstretched and under resourced sectors on low pay and in difficult conditions. Since health education does not belong to the government’s high priority list, information on medical products do not get effectively relayed to the masses. Compound the fact that a majority of the Philippine population is under-educated (having only about 28.8% pursuing tertiary education), the likelihood of the masses comprehending prescription medication technical information is low. As a consequence, the masses are left to trust the judgment of health professionals such as physicians, regarding prescription medications. The pharmaceutical companies recognize this fact that is why their sales force focus on targeting favorable leanings from physicians who prescribe medications.

One must realize that pharmaceutical “sales” does not necessarily entail merely informing physicians about products. Salespeople care more about “persuasion” rather than”information”. Salespeople persuade clients (i.e. physicians) to prescribe their products, not necessarily merely to inform them about the products. The World Health Organization actually defines drug promotion as:

“refers to all informational and persuasive activities by manufacturers and distributors, the effect of which is to induce the prescription, supply, purchase and/or use of medicinal drugs.”

These “persuasive activities” can be in the form of spending for the “entertainment” of physicians (e.g. wining and dining) and giving gifts and all sorts of â”gimmickry”. Add to the fact that sales representatives are often pressured to meet sales quotas, gifts and other forms of “entertainment” can open the floodgates of creativity all in the name of persuasion.

A paper by Taryn Vian, sponsored by USAID, notes that:

Unethical promotion of medicines is a significant problem, not only in developing countries but also throughout the world. Studies have shown that industry hospitality (e.g. all expense-paid trips to luxury resorts), gifts, and free samples all can affect physician’s judgment. Other potential causes of conflict of interest include physicians who have financial stake in pharmaceutical or medical device companies, or receive honoraria for speaking engagements, referrals, or participation in clinic-based research. The pharmaceutical industry is “not merely a provider of drugs, but” substantial purveyor of information and persuasion,” according to a recent report published in The Lancet. In 1999, the industry spent $8 billion on direct sales visits to physicians and exhibits at medical conferences.

To be fair, this article acknowledges another study in the United States that dispute the claim above. However, given the fact that the conditions in the United States are very much different from the harsh realities in the Philippines, I submit that the level of motivation for doctors to succumb to the benefits of pharmaceutical company persuasion is different, as well. In the Philippines, acceptance of unethical persuasion practices and doctor participation to such, are quite common as described in the Macasaet article.

The corruption of doctors by pharmaceutical sales people can be very dangerous to the public as drugs may be prescribed not necessarily for their (technical) merit but merely from returned favors. Because patients are left to trust the judgment of doctors, patients will tend to buy the higher cost branded products their doctors prescribe although generally speaking, these branded products have little or no additional medical value to their generic counterparts.

In the Philippines, a law was enacted to promote the use of generic drugs. This “Generics Law” was put in place in 1988 as Republic Act No. 6675. This law mandates medical practitioners such as physicians to prescribe prescription medication in its “generic term”. However, the law does not prohibit physicians to include “brand names” of drugs if they desire. This non-prohibition in the section (Sec. 6 b) of the Republic Act, I believe, defeats the purpose of promoting public purchase of the lower cost generic drugs, given that most of the population in the Philippines (who are mostly under-educated) are only left to trust the judgment of their doctors. So if a doctor were to prescribe a drug in its generic form but with a brand name for the medication included in the prescription, there is a big likelihood that the trusting patient will get the brand name that a “pharmaceutical sales representative-persuaded doctor” prescribes! The patient may end up paying for a branded prescription medication without any added medical value to its generic counterpart. The Generics Law, then, is really useless with this loophole that can easily be taken advantage of by the corrupt pharmaceutical sales representatives and the corrupted doctors.

We often hear the saying that “Doctors Know Best” when it comes to health matters. That may be true but even if we grant that doctors know what is best, it does not necessarily follow that they all can be trusted. There seems to be a need for policies to be beefed up in the Philippines to protect against the culture of corruption in the pharmaceutical sales industry.