HOW BIG PHARMACEUTICAL COMPANIES CONTROL MEDICINE Case notes on corruption
Doctors rely on information supplied, and research done, by major drugs companies: so 'Big Pharma'
directly or indirectly influences the choice of prescriptions for patients. By PHILIPPE RIVIERE
THE media just loves stories about bribery and corruption in the corridors of political power. Yet
when GlaxoSmithKline (GSK) was under scrutiny, as it was in Italy earlier this year, the media was
almost silent about it. The Italian police investigated 2,900 doctors: 37 employees of GSK Italy and
35 doctors were indicted for corruption, while 80 medical visitors were accused of making illegal
payments to doctors who agreed to prescribe GSK products rather than generic equivalents. The only
reports on this massive scandal were in the British Medical Journal (BMJ) (1) and the Guardian (2).
During the investigation, the police set up an elaborate computer system - Giove (Jupiter) - showing
how GSK commercial representatives could track prescriptions made by doctors in their pay. According
to the BMJ, 13,000 hours of phone taps give a clear picture of the relationship between
prescriptions issued and the value of presents received by the doctors. Gifts included "medical"
trips to the Monte Carlo Grand Prix or to the Caribbean, and cash payments of up to $1,700. Similar
occurences have been discovered in the United States and Germany.
* * * IN APRIL 1993 Dr Nancy Olivieri of the Sick Kids Hospital in Toronto signed a deal with Apotex
Research Inc to test a new compound, deferiprone, which promised to help patients suffering from
thalassaemia (a hereditary blood disorder) avoid heart problems caused by excess iron. She did not
suspect that her case would be the object of an inquiry and 500-page report.
Two years after trials began and the first encouraging results were published, Olivieri suspected
that deferiprone was aggravating hepatic fibrosis among some patients. She decided to have them sign
a new consent form informing them of the potential risk of side- effects, and submitted the form to
her employers. The laboratory immediately terminated the contract (without cancelling research in
other hospitals), and threatened to prosecute her if she breached a confidentiality clause she had
imprudently signed. She ignored the pressure and, as a duty to her patients, presented findings at a
conference.
Her only support over the six years of judicial and professional disappointments that followed came
from the Canadian Association of University Teachers. The head of Apotex, one of the most
influential "philanthropists" in Toronto, offered $20m to the city's university for the construction
of a new building. Because of her tenacity, Olivieri ultimately won her case and was reinstated,
with compensation for lost years of research. She also ensured that the European Commission annulled
its authorisation for the sale of deferiprone, arguing that no scientific study had looked into the
issues she had raised.
* * * A DOCTOR prescribed a patient a third generation antibiotic against acute otitis. Two days
later, her blood pressure was unnaturally low. A different doctor then told her there had been
"problems with this antibiotic before". Two days after that, she regained her strength. The
incident was not serious, and there was no proof of a link to the antibiotic, which was lucky
because the doctor had no means of noting the case. Since the Sésame-Vitale card (3) was
introduced, doctors have to connect to the net at each consultation. But there is no site on which
to record observations. If there were, the information might allow epidemiologists to detect risks
before products received market authorisation. Appeals from the Medicines in Europe Forum for
patients to be more involved in "pharmaco-vigilance" have been ignored by the European Commission.
* * * AIDS organisation Act Up-Paris has long deplored the lack of funding for the refinement of
HAART dosages for women. Most of the patients in the original HAART tests were male. Once a
product has been authorised for sale, there is no legal obligation to continue testing it or even
to monitor a sample of patients in treatment. With no legislation to make post-authorisation
testing ("phase four"😉 compulsory, laboratories choose whether to do it. The danger is that
funding will only be available for tests that boost sales of a new product. Always short of public
funds, doctors and researchers sign up to "market trials".
* * * "WE'RE not bothered about advertising," says an editor of L'Infirmière (Nurse) magazine.
"Unlike almost all other professional journals in the medical sector, we are of no interest to the
labs. Our readers are neither consumers nor prescribers of medicines. We're reasonably free to
write about what interests us: relations with patients, the state of hospitals in the third world,
the profession's problems." Medical journals are often the only source of information and even of
instruction for doctors during their careers. Yet apart from a few publications such as the
quarterly Pratiques, or Prescrire, which looks critic ally at drugs on the market, most journals
aimed at doctors are stuffed with advertising.
* * * A JOURNALIST from Paris moved to England to work as a freelance - and work was harder to get
than she had anticipated. She received, by email, this proposition: "We would like you to attend
and write about a medical meeting in London for the French media. The aim is to inform the public
about a prevalent but relatively unknown disease and about the breakthroughs in treatment." There
followed a detailed description of the disease and the new treatment's excellent results. "You
will receive £500 for attending the one-day meeting and for writing and submitting the article. I
am aware that you can't guarantee to have your story placed. However, I must stress that it is the
aim and that I expect you to do your best. The procedure will be firstly to attend, write your
story and contact editors. Then you submit your story to interested editors and tell us who they
are. You will have your freedom to chose any relevant French publication, medical journals
(Santé, Le Quotidien du Médecin), news papers, agencies such as Agence France Presse, or popular
medical websites."
Intrigued, the journalist asked for further information and was told: "This is quite a usual
practice in the sense that we would like to increase awareness about diseases that we work on. You
are free to write the article in the best way possible, we will not have any influence on the way
that it is written. None of the other journalists are from France. About 10 are from the UK and four
from Scandinavia." Another writer's work was attached as a model and the email ended: "If you can
publish the article, it will be easier for me to invite you to attend and write about other meetings
that we have."
* * * NOVELIST and doctor Martin Winckler is well-known for his opinions on the France-Inter radio
programme. On 15 May 2003 he mentioned the latest book by Philippe Pignarre, a former
pharmaceutical industry manager, which describes what Pignarre calls the crisis in the
laboratories - their chances of producing major innovations are decreasing, threatening the
sector's exceptional profitability. On a public service radio station, this does not mix well with
info-ads from the employers' organisation Les Entreprises du Medicament (LEEM), as for them
"Research advances, life progresses" according to a campaign on France-Inter, Radio Classique, and
on France Télévisions' three channels. On 4 July Winckler's broadcast was replaced, with no
explanation, by a musical interlude. On 11 July LEEM invoked its right to respond to his
"unfounded allegations". France-Inter's management then had to give awkward explanations to
puzzled listeners.
* * * TO WIDESPREAD surprise President George Bush put Randall Tobias, former CEO of Eli Lilly in
charge of the US anti-Aids fund ($15bn over five years). The leading medical research journal The
Lancet pointed out the worrying nature of this appointment on 12 July 2003: "His connections with
the pharmaceutical industry have led to concerns about whether Tobias is committed to providing
access to low-cost generic Aids drugs, or whether he will purchase patented versions so protecting
the interests of US drug companies."
The argument over pharmaceutical patents and the rigid rules governing them, which for three years
pitted Southern nations against the US, the European Union and Japan (who together consume 88% of
the world's medicines) ended, on the eve of the World Trade Organisation meeting in Cancun, with a
victory for "Big Pharma", led by the US company Pfizer. The restrictions on trade in generic drugs
ensure the large firms will keep tight control of the market.
* * * ON 23 July 2003 the House of Representatives in Washington held a highly anticipated vote on a
bill proposing to authorise imports of drugs sold at lower prices abroad than in the US (drugs as
common as the antibiotic Augmentin can cost up to three times more in the US than in Europe).
The bill transcended the usual party political divisions: 87 Republicans joined with 155 Democrats
in approving this serious challenge to the laboratories. Steven Weiss, editor of CapitalEye.org,
which specialises in analysing electoral contributions, explains who voted how. Between 1989 and
2002 those who opposed the change, as the pharmaceutical companies wanted them to, received on
average three times more campaign funding from the companies than those who supported it. In 2002
those Democrats who voted against received on average five times more than the others. Just whom do
they represent?
* * * BOMBARDED with slogans equating research with life, people rarely question the real links
between society's health needs and the priorities given to the development of products. Tropical
diseases have been forgotten since the end of the colonial era. How much research is sacrificed
because it cannot produce a big enough market, while money is spent on promoting blockbuster drugs
that make more than $1bn?
Public institutions deserve to be blamed for much of the degradation in research standards and
priorities. They train doctors and then leave them to get on with the job, often in isolation, with
few independent sources of information to update their knowledge. However, these state institutions
face a powerful and highly organised lobby that does not hesitate to use blackmail (over the use and
delivery of new treatments) and intimidation. The patient has no means other than advertising of
forming an informed opinion on the relative benefits of a treatment. The EU proposes to legalise
direct advertising to the public, which could make the situation even worse.
There have been schemes proposed for the renewed involvement of patients and doctors in health
choices, following the example of Aids sufferers, involved through their own initiatives. The first
task is to eliminate the solid intellectual barriers that the laboratories have established by
promoting scientists who develop markets while holding others back; by buying the support or
complicity of media outlets; by flattering good prescribers and denouncing as old-fashioned doctors
happy to prescribe tested older drugs. The industry, in bed with finance and in control of vast cash
reserves, polices medical thought. The petty corruption caused by these practices has infected all
levels of the social contract for the protection of public health.
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(1) Fabio Turone: "Italian police investigate GSK Italy for bribery", British Medical Journal,
February 2003. (Restricted access)
(2) Sophie Arie: "British drugs giant in Italian bribery investigation", the Guardian, 13
February 2003.
(3) A smart card issued to all social security affiliates in France, the Carte Sésame Vitale,
electronically stores details of medical records and healthcare entitlements. See
www.prescrire.org/aLaUne/dossierEur...
Translated by Gulliver Cragg