Freemarket freebies: drug companies make the sweetest of overtures to health practitioners. Tamar Wilner takes a critical look at this love-in - Bribery

WHEN a new brand of insulin hit the market in India recently, doctors were quick to switch patients to it. Not long afterwards the new drug's manufacturer took 15 physicians from Nagpur on a vacation with their families. Coincidence? Maybe so but 'patients were fine on the old drug,' says Vijay Thawani, Associate Professor in Pharmacology at the Government Medical College in Nagpur.

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Such promotional excesses abound in developing nations which have been slow to adopt regulations and even slower to enforce them. The US, Canada, Europe, Australia and New Zealand/Aotearoa have over time adopted and revised codes on drug promotion. But bribery happens in the West, too. It's just more covert.

'It's becoming more subtle in all sorts of ways,' agrees Peter Mansfield, a general practitioner and director of the international watchdog group Healthy Skepticism. 'It creates a situation,' adds Mansfield, 'where physicians convince themselves it's good for patients.' Big Pharma has innumerable fingers in the prescribing pie. Doctors are flown to luxury resorts for lessons in public speaking, then paid well as 'opinion leaders' to tout the company's product. Millions of doctors every year attend 'continuing medical education' events: necessary to perform their job well, but often company-sponsored junkets that let advertising cosy up to and mingle with science. In such pharmaphysician relationship, it's difficult to distinguish between the genuine and the deceptive, between the pursuit of knowledge and the pursuit of profit.

Meanwhile, old-school kickbacks continue in violation of the codes and policies on drug promotion. Drug giant GlaxoSmithKline has been accused of using exotic holidays, stereos, World Cup soccer tickets and cash to bribe thousands of Italian and German doctors into prescribing its products. (1) In the US last June, AstraZeneca paid a $355 million settlement for a kickback scheme where doctors billed insurance providers for drugs they received free from the company. TAP Pharmaceutical Products--a joint venture of Abbott Labs and Takeda--pulled the same trick and settled for $875 million in 2001. (2)

A glut of gifts

'We have been fighting this problem for a long time,' says a Turkish pharmacology professor. 'Drug companies are giving refrigerators, TVs, money and women--prostitutes--as gifts to doctors in exchange for prescriptions. This is the tip of the iceberg.' (3)

Doctors in India and Nepal also cite refrigerators, TVs and cash as commonly offered bribes. Computers, wines and spirits are given in Kenya. (3)

Indian opthalmologist Prashant Agnihotri says he hears about these gifts from his fellow physicians. '[Drug companies] will say if you give us a million rupees' [$21,920] business, we will send you and your family on a trip abroad.'

The problem is compounded in most developing countries by the marriage of prescription and dispensing. Sometimes doctors sell medicine to patients. Often, rather than pay doctors' fees, patients ask pharmacists to recommend a drug. Prescription drugs are sold over the counter freely and pharmacists find themselves the recipients of refrigerators and TVs.

'It's well known that a dispensing doctor usually prescribes more medicines that are more expensive and for a shorter period of time, so patients have to keep coming back,' says Dr Hans Hogerzeil of the World Health Organization's Department of Essential Drugs and Medicines Policy.

That's not the only way a doctor can make extra cash. Some drug companies pay Turkish physicians up to $1,000 for each patient they enrol in 'phase IV' studies (which evaluate drugs after they have been put on the market), according to the pharmacology professor. The Canadian company Biovail recently paid American MDs $1,000 for signing up 11 patients each. (4)

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'There's no question that phase IV trials are sometimes used as a form of marketing. To get doctors to participate in a trial of a drug is often a camouflage to persuade the doctors, with some money, to prescribe the drug,' says Arnold' Relman, a former editor of the New England Journal of Medicine and professor emeritus at Harvard University. 'The scientific value of such data is highly suspect ... [and] once the patient is hooked on the drug they have to go to the drugstore and buy it.'

School for scandal

Continuing medical education (CME) provokes some of the most strident debates on pharmaphysician interactions. Many doctors say drug company money is essential to keep them up-to-date on the latest research and treatments in their fields.

'The only people providing meaningful education for doctors in developing countries are the drug companies,' says Dennis Ross-Degnan, an associate professor at Harvard who studies pharmaceutical policy. 'The problem is it is biased education.'

Dr Sri Suryawati, the Indonesian country co-ordinator for the International Network for Rational Use of Drugs, says drug companies are eager to sponsor medical meetings, and aren't shy in asking for reciprocation. Consequently, hospitals holding events will often agree to use the sponsoring company's drug for several months. This increases drug costs and sometimes causes doctors to use the wrong drugs, Suryawati stresses.