Unholy Nexus Between Doctors, Pharmaceutical Companies, Chemists And Pathological Clinics BY ANEEK GUPTA

Unholy Nexus Between Doctors, Pharmaceutical Companies, Chemists And Pathological Clinics Unholy Nexus Between Pharmaceutical Companies And Medical Practitioners In Adopting Unethical Practices To Promote Drugs. The Space Has Been Getting Murkier With Each Passing Day As Companies Struggle To Be Ahead In The Prescriptions Race While Doctors, Ever Pampered With Goodies, Extend Their Greed By The Hour. To A Gathering Of Top Indian Drug Companies, Including A Few Honchos From Multinational Companies, Recently, Two Of The Topmost Indian Drug Regulators -- The Chairman Of National Pharmaceutical Pricing Authority And The Secretary To The Newly Carved Out Department Of Pharmaceuticals -- Urged Restraint. The Expensive Goodies (Read Bribes) Given To Doctors Add Up To The Overall Costs Of The Drug And Make It Unaffordable To The Masses. Besides, What Started As A
Token Of Appreciation
To Specialists From Drug Companies Has Snowballed Into A Major Cost Centre For Those Very Companies, Hasn't It? Most Likely, Companies Will Pay No Heed To The Cautionary Notes And The Practice Of Tempting Doctors With Gifts Than Quality Drugs Will Continue Unabated. While In Earlier Days, Doctors Were Far Less Direct Or Unwilling In Accepting Those So-Called Gifts, The Practice Has Come Full Circle And Reached A Stage Where The Number Of Prescriptions Generated Are Duly Rewarded By Way Of Foreign Travel Not Just For Doctors But Also Their Families. To Those Who Attend Scientific Conferences Abroad With A Serious Intent, This Practice Is Becoming A Joke. The Carelessness Of Drug Companies In Determining The Seriousness Of Such Conferences Could Be Gauged Easily As Cries Of Babies Are Heard In The Midst Of Scientific Presentations In Halls Packed With Researchers From Every Big University And Companies Of Repute In The World. Indian Drug Manufacturers' Association, A Group Of Indian Companies, Has Reacted And Expressed Its Desire To Discipline Companies. One Of Its Admittance To A Government Official Reads Like This:
We Fully Agree With You Regarding Avoiding Ostensible Display During Conferences, Seminars, Etc. In Fact, Our Code Of Conduct Clearly Recommends That All Conferences And Seminars Should Be Informative And Training-Centric And Other Paraphernalia Such As Gifts, Entertainment, Etc Should Be Secondary And Bare Minimum.
Idealistic Proclamation, But Will This Ever Be Followed? Not That Indian Companies Like Gifting Doctors. As Everyone Knows In The Industry, This Practice Is Borne More Out Of Compulsion Than Any Kind Of Affection Or Appreciation To The Doctor Fraternity. In The Enormously Fragmented Indian Drug Industry, The Wild Chase Is For A Select Number Of Drugs That Fetch High Revenues To Companies. Doctors Are The Last Stop For Such Companies. As Medical Representatives {Does Not Know In Details About The Drugs And Related Issues} Are Pressured By Subsequent Superiors {Does Not Know In Details About The Drugs And Related Issues} In Various Level For Reaching Monthly Targets, Doctors Make Hay. In My Several Conversations With The Field Staff Of Various Companies, The Common Refrain Is,
We Are Helpless As The Entire Industry Practices The Same Rule (Of Enticing Doctors By Gifting Or Arranging For A Fully Paid Foreign Travel), We Cannot Operate In An Island And Lose Our Market Share.
Therefore, There Is No Easy Solution And Putting Strictures Only On Drug Companies Will Not Help. The Indian Medical Association Should Step In As Well And Devise Rules That Seek To Break This Vicious Cycle. As For Drug Companies, Paying Off Doctors Will Only Burn A Big Hole In Their Profits. Some Companies Go To The Ridiculous Extent Of Offering College Expenses For Doctor's Kids As Well. There Can't Be A Bigger Bribery Than This And Being Associated With A Practice As Noble As That Of A Doctor, It Only Affirms Their Shamelessness In Accepting These Special Treatment. This Brazen Conduct Has To Stop And When It Does, Companies, Doctors And Most Importantly, The Patients Will Benefit. A Significant Percentage Of Our Patients Coming For Medical Treatment Have To Pay For The Cost Of Their Drugs, As Out Of Pocket Expenditure, Since They Do Not Carry Any Medical Insurance Cover, Whether Private Or State. Therefore, An Important Question That Arises Is Whether Patients Are Receiving Adequate Information From Their Treating Doctor Regarding The Prices Of The Various Brands Of Drugs That Are Available In The Market In Context With The Drug Prescribed To Them. The Indian Medical Council (Professional Conduct, Etiquette And Ethics) Regulations, 2002 States That Every Physician Should, As Far As Possible, Prescribe Drugs With Generic Names And He/ She Shall Ensure That There Is A Rational Prescription And Use Of Drugs. It Also Goes On To State That It Is Not Unethical For A Physician To Prescribe Drugs As Long As There Is No Exploitation Of The Patient And This Should Explicitly State The Proprietary As Well As Generic Name Of The Drug.{Here Pl Note That Most Of The Doctors Are Not Aware Of Manufacturing Processes And Details Of Non Active Ingredients In A Drug} As A Simple Exercise A Significant Percentage Of Our Patients Coming For Medical Treatment Have To Pay For The Cost Of Their Drugs, As Out Of Pocket Expenditure, Since They Do Not Carry Any Medical Insurance Cover, Whether Private Or State. Therefore, An Important Question That Arises Is Whether Patients Are Receiving Adequate Information From Their Treating Doctor Regarding The Prices Of The Various Brands Of Drugs That Are Available In The Market In Context With The Drug Prescribed To Them. As A Simple Exercise I Compared The Prices Of An Antihistaminic Namely Cetrizine (10 Mg Tablet). I Found A Four Fold Price Variation From Rs. 0.70 To Rs. 2.77. I Have Asked A Few Colleagues And They Opined That These Are By And Large Of Similar Quality. The Drug Quality Standards In India Are Regulated By The Drugs And Cosmetics Act (23 Of 1940) And We Have Drug Inspectors Whose Duty Is To Regularly Take Drug Samples For Tests Of Quality. This Makes Me Wonder Whether Doctors Should At All Have The Right To Prescribe Branded Medicines And If They Do Indeed Have This Right Then Do We Have The Right To Withhold The Information From The Consumer That The Drug Prescribed By Us To Them Is Two To Four Times Costly Than The Other Ones Available In The Market. Given The Marginalization Of The Poor And The Highly Powerful And Domineering Medical System A Patient Would Hardly Be In A Position To Give Informed Consent. The Same Holds True For India. Unfortunately India Is A Poor Country, Where For A Significant Proportion Of The Consumers, The Cost For Treatment Could Mean A Significant Expenditure. For Instance, This Difference In Price Could Be A Substantial Amount For Daily Wage Laborers. It May Be A Good Idea If Treating Physicians Could Interact With Their Patients On The Prices Of Various Brands Available In The Market. Simultaneously, It Would Be An Excellent Idea If They Could Also Take Into Consideration The Price Variations Of Various Brand Names{It Can Easily Avoided , If Doctor Prescribe Only Generic Drug Name } An Argument Given By Some In Favour Of Prescription Of Branded Drugs Is That The Prescribed Drug Is Of Good Quality. I Wonder How A Doctor Knows That? Besides Different Doctors Prescribe Different Brands.{Here Pl Note That Most Of The Doctors Are Not Aware Of Manufacturing Processes And Details Of Non Active Ingredients In A Drug}. This Should Logically Mean That All Different Brands Should Be Of Good Quality. After All A Doctor Has The Best Interest Of The Patient In Mind. Besides It Is A Fact That In Different Regions Of India Different Brands Of A Drug Are In Vogue Due To Many Reasons. Does It Mean That The Quality Of One Same Brand Of A Drug Differs In Different Parts Of India? Though The Thought That Price Of A Brand Is Related To The Quality Of A Drug Cannot Be Applied And It May Be A Good Idea To Conduct Some Quantitative Studies On This Aspect. The Nexus Between Drug Companies And Medical Professionals Is A Well Known Fact And The Sadly In India Once A Doctor Passes Out There Is Little Contact Between Them And Medical Colleges. Medical Representatives{Does Not Know In Details About The Drugs And Related Issues} Are A Major Source Of Information Pertaining To Drugs To Doctors And They Also Visit Chemist's Shops To Regularly Monitor The Prescribing Habits Of Doctors. Perhaps We Should Explore Developing Networks Where Such Issues Could Be Debated. Medical Associations Should Consider Going To Courts If They Feel That A Particular Product Is Substandard. The Government Should Also Consider The Fixing Of Maximum Permissible Price Margins Due To The Huge Asymmetry Of Information Between The Patient And The Provider. Ours Is A Noble Profession And Charging Of A Reasonable Fee For Service Is Correct But Practices As Profit Sharing Seems To Be Too Derogatory For This Noblest Of Noble Profession. Companies Find It Hard To Generate Prescriptions Based Solely On Science. Relying On Published Datasheets Issued By The Inventing Companies Reduces The Scope Of A Drug Because Of The Inconvenience Of Contraindications, Precautions, Drug Interactions, And Adverse Effects. Sometimes, For Purely Promotional Purposes Local Data Are Generated, As Happened With Letrozole, Which Was Given To Over 430 Young Women To Test Its Efficacy In Inducing Ovulation Without New Molecules, Companies Create
Novel
Products By Mixing Two Or More Medicines In A Fixed Dose Combination. Such Combinations Are Often Irrational, And Some Pose Danger. Short Term Use Of Combinations Of Quinolones With Imidazoles For Undiagnosed Diarrhoea Is Encouraging Salmonella Typhi Resistance To Quinolones. Just As Elsewhere, Gifts And Other Incentives To Prescribers Are Used By Manufacturers To Promote Their Products? And The Methods Are Often Ingenious. There Is Little Consumer Resistance To These Practices For Two Reasons: ,[object Object]

And None Had Patient Information Leaflets. Many Poor, Illiterate People In India Ask Pharmacists For Medicines For Common Problems Such As Colds, Cough, Aches, And Pains. In Order To Tap This Lucrative Market, Companies Produce
Branded Generics.
These Are Not Promoted To The Medical Profession, But To Pharmacies, Which Are Offered Huge Discounts. In The Process It Is Conveniently Forgotten That Inducing Pharmacies To Sell Prescription Drugs Without Prescriptions Is Unethical And Illegal. The Commercial Needs Of Countless, Fiercely Competing Pharmaceutical Companies Have Led Them To Depend On The Tried And Tested 3cs: ,[object Object]

And Corrupt If Nothing Else Works. It Is Easy To Find Fault With Policies Adopted Decades Ago, And The Fault May Lie In The Regulatory System Failing To Keep Pace With Innovations In The Pharmaceutical Industry. Nevertheless, The Government Has Failed In Its Duty Of Preventing Unethical Promotion That Has Already Resulted In Misery, Illness, And Death. It Appears That A Wrong Done Over And Over Again By A Large Number Of People, And Highly Educated People{Doctors} At That, Soon Becomes The Order Of The Day. Hence, Doctors Who 'Don't Fall In Line' Risk Greater Marginalization From The Mainstream. Let's Look At Some Facts In The Pathology 'Business'. Technician-Run Laboratories Are Prepared To Go To Any Lengths To Secure Their 'Business'. Although It Is Degrading For Qualified Pathologists To Compete With Technicians, There Is No Other Way Because Even Top Consultants Accept These Reports (Sometimes Even Unsigned Ones) From Technicians. We Even Have A Few Technicians Requesting Pathologists To Report Their Peripheral Smears Or Cytologies Or Even Biopsies Which Means That Even These Investigations Are Sent To Technicians' Labs And Not To Pathologists. The Flip Side Is That When It Comes To The Consultant's Own Relatives Or Friends They Always Come To A Pathologist Even For The Simplest Of Tests. What's Good Enough For Other Patients Is Not So For The Doctor's Kith And Kin. Consortium-Owned Labs Or Group Practice Set-Ups Are The 'In' Thing. Here, Doctors Invest Money Together In A Diagnostic Set-Up And Then Send Long Lists Of Investigations For Kickbacks And Incentives. (From The Layperson's Point Of View This Is Viewed As Hunting In Packs.) I Think The Main Issue Here Is The Percentage Receivable, Rather Than What Is Necessary For The Patient. It Is One Thing To Make A Project Viable, Quite Another To Burden The Patient For Your Personal Gain. Then Comes The Choice Of The Patient To Go To Any Lab. Due To The Nexus That Exists Between The Clinics And Labs, Unless A Patient Comes Back With A Report From A Particular Lab, He Is Subjected To Another Battery Of Tests With The Explanation, 'These Tests Are Wrong; Why Didn't You Go To The Other Lab?' The Poor Patient Fears The Wrath Of The Doctor And Does As He Is Told, In The Process Compromising His Right To Choose Where He Wants To Go. I Have Even Heard Of Places Where Rickshawallahs And Drugstore Owners Are Roped In To Direct Patients. This Absolutely Unethical Way Of 'Soliciting Clients' Just Proves To What Lengths We Are Now Ready To Go To Succeed In Our Profession. It Is Even More Depressing To Think How The Big Reference Labs Have Affected Small Private Set-Ups Like Mine To Compete With Their Prices, Especially When Nobody Cares About The Quality Of Reports That These Labs Have To Offer. Thus, It Is Becoming Very Difficult To Practise Pathology In A Clean Manner. It Is The Patient Who Is Being Taken For Granted All The Time. I Have Managed So Far To Keep Myself Away From These Practices But Always Get An 'Explanation' From My Male Colleagues That It's Because I Am A Woman And Don't Have To 'Support' A Family. I Think We Must Take Steps To Create A Space For Ethical Doctors To Be Able To Earn A Living While Practising Their Professions With Dignity And Self-Respect. In This, I Feel The National Accreditation Body For Laboratories Must Play An Important Role And Laboratories Must Be Licensed And Accredited. Meanwhile, To Those Who Wish To Practice Market-Medicine, I Wish You Much Happiness In Your Goings-On. But Remember What Gibbon Said: 'The First And Indispensable Requisite Of Happiness Is A Clear Conscience, Unsullied By The Reproach Or Remembrance Of An Unworthy Action.' It Was A Saying: My Doctor Gave Me Six Months To Live But When I Couldn't Pay The Bill, He Gave Me Six Months More. Regards Aneek Gupta

Unholy Nexus Between Doctors, Pharmaceutical Companies, Chemists And Pathological Clinics BY ANEEK GUPTA

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Unholy Nexus Between Doctors, Pharmaceutical Companies, Chemists And Pathological Clinics BY ANEEK GUPTA