A BITTER PILL FOR DRUG COMPANIES

As a junior doctor I was exposed early to the blandishments of drug reps.
These people can be welcome to someone at the bottom of the professional
ladder, as they come with a respectful air. I cannot remember when my
doubts about the ethics of these interviews turned into frank distaste, but
after a while the introductory small talk becomes profoundly irritating.

The sales techniques vary but are designed to deliver the hardest of hard
sells. Product Y is compared hugely favourably with product Z (made by some
other company) and spurious scientific data are produced in glossy
brochures, often with the association of highly respected medical names.
There is particular persuasion to prescribe new drugs, with subtle messages
about being at the cutting edge of practice.

Sometimes moral persuasion is used: "Your patient deserves the best." Other
reps may appeal to scientific integrity: "How can you ignore these
results?" Exposure to peer pressure is a common method: "Your pharmacy has
a supply of this product; your neighbouring teaching hospital uses it
routinely; this or that eminent professor swears by it."

Drug reps are groomed to appeal to their clients; for many years I saw only
males, cast in a business mould, tending to be a little overweight,
betraying the stresses to perform and achieve which go hand in hand with
their methods. Latterly, I have been besieged by smart women with clipped
dialogue and powerdressing styles. I suspect the change took place because
I had snubbed and demolished so many men.

The interviews usually end with a little ceremony of gifts. Nowadays, when
awareness of corrupting influences is sharper, the gifts are of minimal
value but useful: pens, notepads, coffee mugs, all labelled with the
product in question. In previous years gifts were more lavish:
leatherembossed diaries, invitations to dinner at plush restaurants, even
weekends at hotels and trips abroad.

All doctors are inundated with advertisements through the post and in the
medical journals. Drug companies also sponsor research into their own
products, usually making the product available free of charge in the
process. How can the results of such research be free of bias?

It is customary for pharmaceutical companies to sponsor medical meetings.
Indeed, few educational or scientific meetings could afford to go ahead
without this support. But this interface between the commercial world and
the scientific search for truth should make us profoundly uneasy.

Medicines do have to be developed and there must be some incentive to
invest in research. But in the present system profit is the overriding
incentive. Over the years there have been instances of inappropriate
promotional practices; even more disconcerting are suggestions that
potentially harmful effects have been suppressed in order to safeguard
profits.

There is no more disturbing tale than the story of tuberculosis. TB became
treatable 50 years ago and combination treatments were developed which were
curative. However, being complex and expensive, treatment was deliverable
in western countries with sophisticated health systems but much more
difficult to provide effectively in Third World countries lacking resources
and healthcare organisations. Nevertheless, simpler and cheaper
combinations were developed which were shown to be effective in the poorest
countries, with appropriate supervision.

In spite of warnings, however, the indiscriminate sale of individual drugs
was allowed to continue. Poor, uncontrolled treatment was worse than no
treatment as it allowed resistant organisms to develop. TB became so
uncommon in the western world that it was downgraded as a priority; which
meant that support to the rest of the world was diminished.

Regrettably, apparent mismanagement has meant that drugresistant tubercle
bacilli are much commoner than before and, according to the World Health
Organisation, TB will kill more people in 1997 than in any previous year.

I hope that the leaders of our new and altruistic government will take
note. The window of opportunity for worldwide control of HIV may arrive in
the near future and may be just as disastrously lost. If the prime motive
for developing or promoting a particular medicine is profit, then profit is
what will be achieved to the detriment of other considerations.

Ideally, the motive for drug development should be analysis of need. One of
the greatest needs at present is for new and effective antimalarial drugs,
yet one has the impression that this problem tends to have a low profile
because malaria is predominantly a Third World condition and not a
lucrative prospect.

In the present political climate nationalisation is a dirty word, but a
good case could be made for a nationalised pharmaceutical industry.
Professional bodies could feed into a central watchdog committee to
determine the direction of research and development. Such a committee would
have an eye to global trends and drug development could be controlled by
need, not commercial viability.

Britain is apparently alone in allowing freedom of pricing of new drugs but
setting a target for profits, which may actually discourage cost control.
Control of prices is in any case a crude measure because costeffectiveness
is not assessed, thus neglecting the possibility of expensive but effective
drugs.

There are a number of measures which should be adopted in Britain in a
drive towards delivering better treatment to patients. I suggest the
following:

Free doctors from commercial pressures, possibly by banning drug reps from
hospitals and surgeries.

Develop national treatment guidelines. These would be particularly
important for expensive drugs.

Make available unbiased information that has been acquired within the
framework of NHS research.

Promote trials of the relative efficacy of new drugs; that is, comparing a
new drug with the best currently available of its type.

Some of the conflicts could thereby be eliminated. The watchword is motive:
let it be for better treatment, not better profits or a better government
image or other whitewash.

When we have put our own house in order we will be better placed to assist
in the global control of disease.

Margaret Cook

Margaret Cook is a consultant haematologist at St John's hospital,
Livingston, and is the wife of Robin Cook, the foreign secretary.