There is no free lunch in this world. Pharmaceutical companies try and catch doctors very young when they are still house officers. These young doctors then learn from pharma companies that every ill can be cured with a pill. This is concluding part of a two part series
For one thing, even hospitals have come under the latter umbrella! It is argued that ties between industry and academia are necessary for “technology-transfer”, a word invented after 1980s, when the American Government passed the Bayh-Dole Act which allowed academic institutions supported by Federal grants to patent and license new products discovered by their faculty in return for royalties. This law is cited when large-scale tie-ups go on between these two institutions. It is needless to say that we follow that rule blindly in our country. The second reason given is that academic institutions needed the money very badly. These are the main reasons why we are where we are today. The business goals of the companies influence the mission of the research institutions and also influence their final results.
One of the reasons why the cost of modern medical treatment, both medical and surgical, has skyrocketed is because the expenses incurred by the industry for its sponsored trips of medical scientists, meals in top of the range hotels, gifts, honorariums, conference and symposia expenses, consulting fees, and research grants eventually are paid by the consumer! There is no free lunch in this world. Companies try and catch doctors very young when they are still house officers. Rothman records in a report that the companies’ gifts are intended to buy the goodwill of young physicians with long prescribing lives ahead of them. Similar is the situation in many areas where the industry uses the talent of the academia for their research. Ultimately, it is a Faustian bargain.
Clinical research organizations (CROs) are mushrooming in India at alarming pace. The brokers for the western drug companies want to test their new molecules in the third world countries, as many of the western countries have banned such studies. Especially after the Northwick Park Hospital tragedy in London where, a single drug put all the volunteers into serious near fatal unknown adverse effect costing the hospital millions of pounds! These CROs are a menace to us, as we do not have the genuine informed consent in our set up with most of our patients still very poor and illiterate to understand the intricacies that are built into every new drug trial! I wonder if it is ethical to do such studies at all. Who cares for ethics these days, anyway?
In fact, there are a few “researchers” who would not have seen a single patient all their lives, but profess to the world about the drug treatment of major illnesses. The companies mainly target those diseases that are likely to be life long business for them like diabetes, high blood pressure, coronary artery disease etc. There are many guidelines all over the world for the treatment of these diseases. If one takes care to carefully scrutinize them, one quickly realizes how fallacious they are. To give an example of hypertension, there are six guidelines in all: we in India are trying to have our own guidelines, in addition. If all of them are computed together they cover just about 39% of the patients. For the rest, there are no guidelines. Young, but enthusiastic, doctors are getting frustrated looking at these. If any of the guidelines are not convenient to the drug makers, the companies get their “great brains” to refute them and have new guidelines. This happened with the American National Guidelines for high blood pressure management some time ago. (JNCV).
One could take any area for scrutiny. Anti-cholesterol drugs, anti-arrhythmic drugs, heart failure drugs, anti-hypertensive drugs, anti-diabetic drugs, pain killers, anti-cancer drugs or, for that matter, many of the procedures for surgical corrections and even some of the untested technologies like coronary care units, terminal care units, flow catheters and many other areas have their loads of skeletons in their cupboards. An unbiased audit would get these skeletons out of the cupboards. In fact, in a recent article in PLOSmedicine, Richard Smith, the former editor of the British Medical Journal and the present editor of the Cases Journal in London, showed elegantly how doctors today have become just puppets in the hands of the drug company barons.
“How much longer will medicine’s flagship educational events fly the colours of the drug industry”, asks Ray Moynihan, the editor of PLOS medicine and goes on to add, “In the heart of Manhattan Island one misty morning a few years back, I watched as hundreds of psychiatrists streamed into their flagship educational event, the annual congress. Even before arriving, they were welcomed by giant advertising billboards on the streets outside, plastered with the name of a major sponsor, Pfizer, the biggest drug company in the world and the maker of Zoloft, the world’s top selling antidepressant. Once inside, their first port of call was the huge exhibition hall, where well dressed salespeople moved among high-tech booths and hypnotic neon, exchanging pleasantries with doctors lining up to play video games and win prizes. And then, of course, there were the sponsored educational sessions. That year—2004—psychiatrists learnt about bipolar disorder over breakfast at the Marriott Marquis Hotel, courtesy of Eli Lilly. Over lunch at the Grand Hyatt they studied maternal depression, thanks to GlaxoSmithKline, and for dinner it was generalised anxiety disorder in the grand ballroom of the Roosevelt Hotel, funded by Pfizer,” in a recent article in the BMJ.
When the gulf between the industry and the academia narrows, medical students and house officers, under the constant tutelage of industry representatives, learn to rely on drugs and devices. This is more often than they should do. Young doctors learn that there is a pill for every ill and a surgical correction for every anatomic deviation from the normal. Faculty members could get distracted from their teaching commitments. Doctors get used to these company courtesies of receiving gifts and favours to further their continuing medical education. In this generation, there is always an overemphasis on drugs and devices that could ultimately work against patient interests. The Hippocratic Oath really becomes hypocrates’ oath.
It is time to do a bit of introspection before it is too late in the day for us do even that. We should see that we are not open to the charge that we are for sale. Academic medical schools should educate their students on the ills of the prevailing scenario and have to inculcate in their students the love for ethics and give them a good idea of pharmaco-economics and the ways of the business world that may be alien to them at that stage in life.
Let us not forget that 80% of the world population even today does not have any touch with modern medicine, 62% of upper middle class Americans can not afford health insurance as the premia are sky high for them, 57% of Britons do wish to have alternative systems of medicine when they are ill, despite the fact that they have the free National Health Service. Let us also remember that patients could very well live without doctors, but doctors could never survive without patients! For this write up, I have drawn heavily from my articles published earlier on similar subjects in 2001 and 2006.
“People are never satisfied. If they have a little, they want more. If they have a lot, they want still more. Once they have more, they wish they could be happy with little, but are incapable of making the slightest effort in that direction.” Anon.
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS. He is also Editor-in-Chief of the Journal of the Science of Healing Outcomes, chairman of the State Health Society's Expert Committee, Govt of Bihar, Patna. He is former Vice Chancellor of Manipal University at Mangalore and former professor for Cardiology of the Middlesex Hospital Medical School, University of London.)