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Prescription for conflict?
A 2009 ban on doctors accepting gifts and hospitality from pharma companies has done little to end the nexus between the two who continue to treat each other right.
A rickshaw puller in Bilaspur, diagnosed with tuberculosis (TB), was prescribed medicines worth Rs 2, 000 by a private practitioner. Unnecessary drugs, including broad-spectrum antibiotics, dominated the prescription while the cost of TB medicine comprised only three per cent of the total cost, which was more than the rickshaw puller earned in a month.
This is just one instance of how medicines have come to constitute over 70 per cent of outpatient costs in a healthcare system that routinely pushes millions below the poverty line every year in India. Prescriptions like the one mentioned above are common, and often the result of doctors trying to push drugs of various companies who in turn ply them with gifts and trips to exotic places, thinly disguised as medical conferences.
The conflict of interest in the doctor-pharma nexus has serious implications for patients and patient care. The money spent by companies on doctors is added to the drug prices, pushing the numbers up, and the relationship between doctors and drug companies influence the prescribing habit of doctors. The Indian pharmaceutical industry spends around seven per cent of its turnover on marketing, an estimated Rs 4, 200 crore. Since direct advertising of prescription drugs is banned in India, most of this money is spent on wooing doctors to boost prescription and consequently sales.
The practice of giving kickbacks to doctors in the form of free travel, five-star hospitality and freebies which could be anything from pens and notepads to cars and air-conditioners had forced the Medical Council of India (MCI) to amend the Code of Ethics Regulation 2002 in December 2009 to ban doctors from accepting any kind of gifts or hospitality from the industry. Doctors protested, insisting that such practices did not affect patient care or their objective judgment. However various studies indicate otherwise. A study published in the Journal of American Medical Association in May 2009, for instance, reported that the relationships between drug detailers (medical reps) and doctors led to reduced generic prescriptions, increased overall prescription rates, rapid uptake of the newest, most expensive drugs, including those of only marginal benefit over existing options with established safety records.
It isn't just the prescription of expensive drugs that can be viewed as a conflict of interest - the doctor-pharma nexus in India can brings its combined influence to advisory boards that formulate treatment guidelines or are consulted on government policy. A recent example is the Indian Academy of Paediatrics (IAP) and its committee on immunisation. Of the Rs 27. 8 lakh fund available to the Indian Academy of Pediatrics Committee of Immunisation (IAPCOI), Rs 26. 8 lakh was contributed by vaccine manufacturers including Sanofi Pasteur, GlaxoSmithKline (GSK), Merck, Pfizer and Serum Institute. Many of its members were also advising the government on inclusion of new vaccines in the National Immunisation Programme. When details of the funding emerged, MCI secretary Dr Sanjay Shrivastava pointed out that it was illegal for associations of doctors to take funds from companies. IAP disbanded the immunisation committee and reconstituted a new one where all members had to sign conflict of interest declarations.
Dr Sneh Bhargava, chairperson of the MCI ethics committee acknowledges that the amendment to the code is an important step, but believes loopholes need to be examined. The council's ability to implement the code also needs to be ascertained. "If you don't do that, these amendments will remain on paper, " said Dr Bhargava.
Since the 2009 ban in India, the MCI has cracked down on the practice of accepting gifts and hospitality from pharmaceutical companies. The most prominent is the case of the Indian Medical Association (IMA), the largest and most powerful association of doctors in the country, signing an agreement with Pepsi to endorse Quaker Oats and Tropicana juices and another with Dabur to endorse its Odomos cream, gel and lotions. The three-year endorsement agreement, which was to extend till 2011, brought in Rs 2. 25 crore for the IMA. The MCI asked the IMA to end the endorsement and suspended the licenses of the IMA officebearers, who struck the deal, for six months.
While the MCI ban has curbed gift-giving to some extent, the practice of sponsoring lavish medical conferences continues unabated. Doctors and doctors' associations insist that without regular visits from medical representatives and industry and funding for seminars and conferences, doctors cannot keep themselves updated on the latest in medical practices and drugs. But Dr S P Kalantri of the Mahatma Gandhi Institute of Medical Sciences (MGIMS) in Sevagram argues that point, saying, "During their medical training, few doctors learn how to ask the right questions, access information, critically appraise articles and apply that information to treat an individual patient. It is time to regulate the interaction between the drug industry and medical profession and ensure that doctors learn from textbooks, journals and valid web- based resources and not from medical representatives. " Dr Kalantri successfully campaigned to end sponsorship of medical conferences by drug companies in his institution, and MGIMS continues to host medical conferences without pharma sponsorship.
Even in the US, the home of Big Pharma, over 70 per cent medical schools have tightened their conflict of interest policies by totally banning gifts to doctors by pharmaceutical companies and prohibiting their faculty from taking money to be speakers for companies. These include top medical schools such as Harvard Medical School, Stanford University, Tufts University and Boston University which have banned all gifts and sponsored on-site meals, no matter how small or inexpensive. Many medical schools have also prohibited sponsorship of on-campus educational seminars or lectures by the healthcare industry and banned participation by their faculty in programmes for and by the industry, something which continues to be rampant in India.
Moreover, in most countries there are stringent laws against companies giving kickbacks to doctors. In the US, several large drug companies have been fined billions for giving kickbacks to doctors to boost sales, including GSK which shelled our $3 billion in July last year and Abbott which agreed to pay $1. 6 billion last May. This January, the US government introduced a Sunshine Law which mandates that all drug companies have to disclose payments and other "transfers of value" to doctors and even research fees.
However in India, while doctors are penalised for taking gifts or accepting hospitality, the bribe-givers, the pharma companies, go scot free with no law to regulate them. But there is hope as the government attempts to tackle rising healthcare costs the doctor-pharma nexus, which is pushing up healthcare bills, is under increased scrutiny and regulation.
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